Truth Disclosure at the End of Life: A Qualitative Study of Internal Medicine Residents in the United Arab Emirates

Background Respect for patient autonomy has become the guiding biomedical ethical tenet in the West; yet, moral values are contextual and culturally relevant. In the collectivist society of the Middle East, families and physicians have historically believed that concealing truth about a terminal illness is more ethical and compassionate. Recent studies reveal a trend toward truth disclosure. Objective To gain insight into resident experiences with, and barriers to, truth disclosure in terminally ill patients in the United Arab Emirates (UAE). Methods Focus group interviews were conducted with first through fourth year internal medicine residents and recent graduates at two large academic medical centers in the UAE. Qualitative thematic content analysis was used to identify themes related to communication and truth telling in end-of-life care. Results Residents revealed that non-disclosure of medical information in serious illness is a common practice in UAE hospitals. Barriers to truth telling include family objection, deficits in medical training, and inconsistently implemented institutional guidelines. Conclusion Educational and policy interventions are needed to improve physician-patient communication, decrease patient-family-physician tension, and alleviate trainee moral distress.

Resident Perspectives on Palliative Care at an Urban Teaching Hospital

Background There has been an increasing need to address end of life (EOL) care and palliative care in an era when measures to extend life for terminal illnesses are often initiated without consideration of quality of life. Addressing the barriers for resident physicians to initiate EOL conversations with patients is an important step towards eliminating the disconnect between patient wishes and provider goals. Purpose To assess resident physician perspectives on initiating palliative care conversations with terminally ill patients at an urban teaching hospital. Methods This paper solicited the experiences of pediatric, general surgery, and internal medicine residents through an anonymous survey to assess exposure to palliative care during training, comfort with providing palliative care, and barriers to implementing effective palliative care. Results 45% of residents reported exposure to palliative care prior to medical training. Ninety-three percent of these residents reported being formally introduced to palliative care during medical training through formal lecture, although the majority reported also being exposed through either small group discussions or informal teaching sessions. Time constraints and lack of knowledge on how to initiate and continue conversations surrounding EOL care were the greatest barriers to effectively caring for patients with terminal illnesses. Residents concurred that either attending physicians or hospital-designated palliative care providers should initiate palliative care discussions, with care managed by an interdisciplinary palliative care team; this consensus demonstrates a potential assumption that another provider will initiate EOL discussions. Conclusions This study evaluated the current state of physician training in EOL care and provided support for the use of experience-based training as an important adjunct to traditional didactic lectures in physician education.

Perceptions of Residents on the Microlearning Environment in Postgraduate Clinical Training

Background. Teaching hospitals are the primary locus of training for residents, and the afforded microlearning environments can affect their level of satisfaction, competence, and learning processes. Since limited attention has been directed towards evaluating the microlearning environment, how Saudi postgraduate residents perceive it remains unknown. Objectives. This study evaluated the microlearning environments for major clinical specialties in a tertiary care teaching hospital. It also investigated the association between satisfaction levels and the age and gender of the participants, as well as their stage and specialty. Methods and Methods. A questionnaire-based, observational study was conducted using a prevalidated HEMLEM tool for data collection. Data were collected using the QuestionPro® survey tool and analyzed using SPSS version 23 software. A one-way ANOVA and t-test were performed to compare different subgroups. Results. In total, 129 residents participated in the study, representing a response rate of 87.16%. The overall mean value for microlearning environment satisfaction was 50.21. Females scored higher relative to males. Maximum satisfaction with the microlearning environment was observed in the age group 25–30 years and among internal medicine residents. Conclusion. Overall, a satisfactory score on the HEMLEM tool was recorded, suggesting the majority of residents are satisfied with the microlearning environment at KFHU. Supervisors, program directors, and curriculum planners could use our findings to further improve the educational climates within their training specialties.

Development and Evaluation of Resident-Championed Point-of-Care Ultrasound Curriculum for Internal Medicine Residents

Introduction: Point-of-care ultrasound (POCUS) is a powerful clinical tool that has seen widespread adoption, including in Internal Medicine (IM), yet standardized curricula designed by trained faculty are scant. To address the demand for POCUS education at our institution, we created a resident-championed curriculum with support from skilled faculty across multiple specialties. Our objective was to teach postgraduate year (PGY)-3 IM residents the basics of POCUS for evaluation of the pulmonary, cardiac, and abdominal systems through resident-developed workshops. The goal of acquisition of these skills was for resident education and to inform decisions to pursue further patient testing. Methods: Three half-day workshops were created to teach residents how to obtain and interpret ultrasound images of the pulmonary, cardiac, and abdominal systems. Workshops were comprised of didactic teaching and practical ultrasound instruction with expert supervision of clinicians within and outside of IM. Residents were asked to complete a written survey before and after each workshop to assess confidence, knowledge, and likelihood of future POCUS use. Results: Across the three workshops (pulmonary, cardiac, and abdominal), 66 sets of pre- and post-workshop surveys (32 pulmonary, 25 cardiac, and 9 abdominal) were obtained and analyzed. Confidence in and knowledge regarding POCUS use increased significantly across all three workshops. Likelihood of future use increased in the cardiac workshop. Conclusions: We implemented a resident-championed POCUS curriculum that led to improved attitudes and increased knowledge of POCUS for PGY-3 IM residents.

Retaining interest in caring for underserved patients among future medicine subspecialists: Underserved Medicine and Public Health (UMPH) program

Background Accessing subspecialty care is hard for underserved patients in the U.S. Published curricula in underserved medicine for Internal Medicine residents target future-primary care physicians, with unknown impact on future medicine subspecialists. Methods The aim was to retain interest in caring for underserved patients among Internal Medicine residents who plan for subspecialist careers at an urban university hospital. The two-year Underserved Medicine and Public Health (UMPH) program features community-based clinics, evening seminars, reflection assignments and practicum projects for 3–7 Internal Medicine residents per year. All may apply regardless of anticipated career plans after residency. Seven years of graduates were surveyed. Data were analyzed using descriptive statistics. Results According to respondents, UMPH provided a meaningful forum to discuss important issues in underserved medicine, fostered interest in treating underserved populations and provided a sense of belonging to a community of providers committed to underserved medicine. After residency, 48% of UMPH graduates pursued subspecialty training and 34% practiced hospitalist medicine. 65% of respondents disagreed that “UMPH made me more likely to practice primary care” and 59% agreed “UMPH should target residents pursuing subpecialty careers.” Conclusions A curriculum in underserved medicine can retain interest in caring for underserved patients among future-medicine subspecialists. Lessons learned include [1] building relationships with local community health centers and community-practicing physicians was important for success and [2] thoughtful scheduling promoted high resident attendance at program events and avoided detracting from other activities required during residency for subspecialist career paths. We hope Internal Medicine residency programs consider training in underserved medicine for all trainees. Future work should investigate sustainability, whether training results in improved subspecialty access, and whether subspecialists face unique barriers caring for underserved patients. Future curricula should include advocacy skills to target systemic barriers.

Addressing Sickle Cell Disease Implicit Bias in Internal Medicine Residents

Introduction: Throughout the years, patients with sickle cell disease (SCD) have been subjected to biases and stigmas that have affected their care, which then leads to them experiencing greater pain and a lower quality of life. Literature continues to show that patients suffer from their pain being discounted during hospitalizations. In the previous year, our group showed that our internal medicine residents had negative implicit biases (IB) toward patients with SCD. Frameworks and trainings exist for addressing different aspects of IB; however, none exists to address implicit biases on the individual level. We developed an implicit bias module (SOAR) for residents to complete to help address negative IB toward patients with SCD. Methods: Twenty-three 2 nd and 3 rd year internal medicine residents went through the SOAR module for addressing IB twice. The SOAR framework assisted the residents in self-identification of the IB, observing when the IB occurs, creating an action plan to address the IB, and repeating the steps for maintenance. SOAR framework is heavily based on methods from cognitive behavioral therapy. The SOAR sample case for residents involved a patient with SCD requiring pain medication. Residents were surveyed on their initial forming thoughts, in this case the IB, emotions, and intensity of the IB or emotion before and after going through the module. A 10-point Likert scale (10 = high/1=low) was used to judge intensity of the IB or emotion. Results: Residents had a range of initial thoughts such as: failure, suspicion and opioids, pity and boring admission, chronic pain and dread of confrontation, and frustration, with an average belief of 7/10 in that thought. Their emotions initially included: frustration, sadness, shame, guilt, worry, and pessimism with an average belief of 5.5/10 in that emotion. After completing SOAR, the average belief in the initial IB decreased to 4.3/10. Emotions changed to feelings of regret and sadness with an average intensity of 6/10. 75% of the residents found the lecture helpful, 92% stated they believed it is important to address implicit biases, and 100% stated that they would use SOAR framework to address their own negative implicit biases. Discussion: The IB module is based on cognitive behavioral therapy techniques and uses concepts typically reserved for automatic thoughts such as in patients with depression or anxiety. We substituted automatic thoughts for IB. It is important to address negative IB that affect our patients and their care. We have attempted in this module to address IB on a personal or individual level for residents. The SOAR criteria helped focus on improving conscious efforts to overcome IB. This training is not enough for addressing all the faults in the medical system that perpetuates biases and health inequities toward patients with SCD or any other medical condition. It can be used to supplement other methods such as education about influences and patient outcomes, increasing awareness, and making systemic changes. Limitations in this study include voluntary participation in the survey during the module leading to a different number of respondents answering each question as well as being underpowered. Conclusion: Individual or personal strategies can be used to effectively address implicit biases we hold. Addressing implicit biases may help decrease the negative impact these biases have on patients and improve quality of care for patients with SCD. Disclosures No relevant conflicts of interest to declare.

P.133 ‘Building Your Neurology Acumen’: a flipped classroom approach to strengthen Internal Medicine residents’ neurological skills

Background: Rotating internal medicine (IM) residents do not feel adequately prepared to approach patients with neurologic issues. The purpose of this project was to conduct a needs assessment to determine the optimal components and delivery of a neurology curriculum for internal medicine residents. Methods: We utilized a mixed-methods design and recruited participants through a combination of purposive and convenience sampling. We conducted interviews with IM residents (n=12) and focus groups with neurology residents (n=7) and neurology staff (n=8). IM residents completed entry- and post-call surveys while on a neurology rotation. Results: Themes according to Kern’s framework for curriculum development: 1. Problem: Discomfort and perception of under-preparedness amongst IM trainees 2. Needs Assessment: What the learners (stakeholders) think they need to know vs. what their teachers want them to know vs external requirements (Royal College) 3. Goals/objectives: What content is relevant for clinical requirements vs assessments? 4. Methods and setting: Didactic vs bedside vs virtual 5. Implementation of the curriculum 6. Evaluation and feedback Conclusions: Our findings illustrate a possible mismatch between internal medicine residents’ needs and neurologist teachers’ expectations in teaching neurology. Addressing learners’ needs could enhance neurology knowledge and sense of preparedness when encountering patients with neurologic issues.

Addressing Transition to Practice: Assessing Perceived Effectiveness of a Competency Based Change to On-Call Responsibilities of Senior Cardiology Residents

Background There has been a paradigm shift in residency training over the last several years wherein Competency by Design (CBD) is being integrated to replace more traditional time-based models of training. The Residency Program Committee (RPC) for the Cardiology training program at Dalhousie University in Halifax, Canada addressed the Transition to Practice stage by approving a trial of adjusting the resident call responsibilities to reflect the transition to CBD curriculum. The goal of this adjustment was three-fold: i. Gradually increase accountability of the senior cardiology resident as they transition to practice; ii. Address a gap in training that allows the senior resident to have a gradual transition to the role of a practicing cardiologist while on call; iii. Allows further evolution of skills and abilities. Methods A survey was administered to the practitioners involved in this competency-based change to the call responsibilities. Surveys were distributed to the final year Cardiology Residents, Staff Cardiologists, and Senior Internal Medicine residents to assess their experience and opinions of the current, competency-based change of the on-call curriculum. The survey consisted of eleven questions, of which, four were assessed on a Likert scale and 3 were yes/no questions. Results Four PGY6 cardiology residents, five senior internal medicine residents and eleven staff cardiologists completed the survey. Amongst those who completed the survey there was agreement that the change to the on-call responsibilities improved cardiology residents’ skills, accountability and preparedness to practice. All groups felt the changes were useful for the cardiology training program. There was mild negative effect of perceived accountability by the internal medicine residents. Conclusion Overall the change in call structure led to improved perceived preparedness to practice amongst the cardiology residents and addressed a gap in the Transition to Practice phase of CBD training. This study provides some evidence to the potential benefit of CBD and specifically in the benefits towards transitioning to practice.