"Observational studies have suggested that communication about end-of-life care is associated with decreased intensity of care, increased quality of life, and improved quality of dying. In addition, interventions that focus on communication about palliative and end-of-life care, using palliative care specialists, have demonstrated improved quality of life, decreased symptoms of depression, and reduced intensity of care at the end of life," according to background information in the article. "Simulation-based training improves skill acquisition, but effects on patient-reported outcomes are unknown."

J. Randall Curtis, M.D., M.P.H., of the University of Washington, Seattle, and colleagues conducted a trial to examine whether a communication skills-building workshop aimed at internal medicine (n = 391) and nurse practitioner (n = 81) trainees, using simulation during which trainees practiced skills associated with palliative and end-of-life care communication, had any effect on patient-, family-, and clinician-reported outcomes. Participants were randomized to the 8-session, simulation-based, communication skills intervention (n = 232) or usual education (n = 240).

The primary outcome was patient-reported quality of communication (QOC). Secondary outcomes were patient-reported quality of end-of-life care (QEOLC) and depressive symptoms and family-reported QOC and QEOLC.

The researchers received 1,866 patient evaluations completed by 1,717 patients evaluating 345 trainees; and 936 surveys completed by 898 family respondents, evaluating 295 trainees. Analysis of the data indicated that the intervention was not associated with improvement in QOC or QEOLC. After adjustment, comparing intervention with control, there was no difference in the QOC or QEOLC score for patients or families, but it was associated with increased depression scores among patients of post-intervention trainees.

"These findings raise questions about skills transfer from simulation training to actual patient care and the adequacy of communication skills assessment," the authors write.

Improving Communication With Patients -- Learning by Doing

In an accompanying editorial, Jeffrey Chi, M.D., and Abraham Verghese, M.D., of the Stanford University School of Medicine, Stanford, Calif., write that there are many possible reasons for the unexpected results of this study.

"Patients and families are not formally trained to evaluate communication skills. Additionally, the acquisition of skills was tested over the course of a 10-month period following workshop participation and not immediately following specific end-of-life discussions. It is possible that the improvement in participants' skills was not enough to make a measurable difference to patients; conversely, it is possible that trainees did not recall training and so were not able to apply the communication skills."

"The study by Curtis et al provides an important lesson about the nature of pedagogy [teaching or training] in medicine: new and innovative ways are needed to teach skills, and continued measurement, reassessment, and validation are needed to determine if those teaching methods have succeeded. The final arbiter is of course the patient and patient outcomes. Much work remains to be done."