People with serious illness face many decisions, both personal and medical, that can be frightening, difficult, and confusing, and they rely on their care teams to clearly communicate prognosis and treatment options over the course of their illness. Studies have shown that patients who have conversations with their clinicians about prognosis, medical and personal goals, and treatment preferences are more likely to receive goal-concordant care and experience better quality of life [1]. However, The John A. Hartford Foundation’s 2016 survey of doctors found 46 percent of physicians report not knowing what to say during conversations with seriously ill patients, and only 29 percent felt they received the necessary communication skills training to break difficult news, explore goals of care and navigate end-of-life decisions [2].
In U.S. medical schools, training in serious illness communication (along with other essential palliative care concepts and skills) is lacking, sporadic and mostly elective [3]. Aside from a few outstanding examples of longitudinal, integrated palliative care curricula (such as the University of Rochester [4] and Yale Medical School [5]), most U.S. medical students learn serious illness communication “on the fly” by observing clinicians with varying degrees of skill, and without receiving specific guidance or feedback. While the Liaison Committee on Medical Education directs medical schools to teach aspects of end-of-life care, the Association of American Medical Colleges explicitly recommends training in palliative care for all stages of illness, prognostic reasoning, shared decision-making and communication of difficult news within clinical skills curricula [6]. Medical schools face competing demands and most lack strategies and resources to integrate serious illness communication training into their required longitudinal curriculum, despite national expert-consensus competencies published in 2014 that “raised the bar” for palliative care education standards in undergraduate medical education [7].
The slow pace of curricular reform at medical schools may be related to their traditional organizational hierarchies, often constrained by resources and accreditation guidelines. In the business literature, organizational change expert John Kotter describes the strategy of a “dual operating system” or a network of energized volunteers who work within and alongside traditional hierarchies to execute a shared vision of institutional change [8]. This collaborative approach can accelerate organization change via an engine of peer support and collective expertise to drive innovation with shared results.
In this report, we describe the creation of a statewide collaboration of faculty, administrators, and students within and alongside four medical schools to promote serious illness communication skills as essential and required for all future physicians.
Of note, this approach is applicable to any area of curricular reform. In 2015, our schools convened to confront the prescription opioid epidemic at the request of the state governor and developed shared educational competencies on safer opioid prescribing and diagnosis and treatment of substance use disorder to guide undergraduate instruction [9]. In this report, we go beyond a strategy of educational competencies alone and describe our efforts to build a sustainable collaborative to address a different gap – serious illness communication training – for all students. We share our first steps in defining our mission, scope of work and educational competencies, which set the stage for curriculum mapping, novel educational design, and faculty development as next steps.