In this study, we report on the development, implementation, and assessment of a communication skills training for GI fellows. The core elements of the curriculum are based on the VitalTalk framework, known as REMAP, and features a combination of didactics and patient encounters with standardized patients. Such a curriculum has been implemented in multiple other specialties, including geriatrics, oncology, and nephrology.[17–20] Prior to GITalk, most fellows reported limited prior experience with formal communication skills training. Following training, fellows noted an improvement in preparedness across all queried end of life encounters and reported extremely high satisfaction.
GITalk training was associated with a statistically significant increase in self-reported preparedness in a variety of serious illness communication competencies that were surveyed. Notable increases were seen for competencies related to discussing enteral nutrition in patients with dementia and prognosis for patients with decompensated cirrhosis. Satisfaction was uniformly high among all participants, suggesting a desire among trainees to receive such educational experiences, since they are not consistently exposed to them during training. GITalk is sustainable as evidenced by four consecutive (and ongoing) years of training within one fellowship program at a large academic center. Its success has also led to expansion of the training from a one-day course into a two-day course. Consistent with high satisfaction among participants in our data, the course has also expanded to include advanced practice providers within the GI division (data not shown as of this writing). Given that high-quality communication ideally extends beyond individual providers, such engagement across multiple types of providers is highly promising and shows that GITalk can be sustainable.
Communication skills taught in GITalk aim to build skills in “primary” PC, which refers to a scenario when a clinician who is not a specialist in PC provides basic care covering the domains of PC. Primary PC skills are needed because there are not enough specialty PC providers to meet the needs of all patients with chronic GI and liver diseases.[24] Therefore, it is not ideal for core communication skills to be deferred to PC providers alone. In fact, GI providers caring for patients with serious, chronic illnesses often form longitudinal relationships with patients, making them uniquely positioned to engage in such discussions with patients. Because ACP and PC communication are iterative processes, it is important for all clinicians to have fundamental skills in these areas.
Despite the novelty of this program and our findings of improvements among learners’ preparedness, this work has several limitations. This was a pilot study intended to collect preliminary data on learner satisfaction and outcomes. As such, we did not include a control group in our study design, and future incorporation of a control group will likely not be feasible since it will result in a subset of trainees not receiving valuable training. Next, post training self-rated preparedness (Table 3) is not an objective measure of skill and therefore may not translate into meaningful, durable changes in communication skills in actual patient care scenarios. Generalizability and reproducibility are also concerns. This training was conducted in a single center and facilitators at our center served as content experts in communication training. However, this limitation was at least partially offset by the fact that GITalk training took place over a four-year period with each year having a different set of participants. Lastly, our intervention focused on GI fellows, and there is evidence to support that attending physicians within the field would also benefit from similar trainings.[3] Therefore, the impact this kind of training might have on changes in care delivery patterns could be limited because the emphasis is on teaching trainees. However, engagement with GI subspecialty societies on these efforts could lead to involvement of a diverse group of clinicians who may stand to benefit from such opportunities and allow for scaling to a wider audience.
GI fellows rarely receive training in communication and attending physicians report similar gaps in comfort and skill.[12, 25] This trend is concerning given the high exposure to patients with serious illness faced by these providers. Perhaps due to these gaps in training, professional societies have called on training programs to develop and better incorporate communication skills within their curricula.[26] For these reasons, we believe that GITalk can potentially serve as an important starting point on how to improve GI fellowship training, particularly within the Interpersonal and Communications Skills core competency outlined by the Accreditation Council for Graduate Medical Education.