Using Visual Technology in
Advance Care Planning Education
®
Craig M. Klugman PhD, Jonathan Gelfond MD PhD, Kristy Kosub MD, Diane Ferguson RN BSN
The University of Texas Health Science Center at San Antonio
Introduction
Over the last 20 years, many publications have reported the
need for training medical students in advance care planning
(ACP).1-8 Challenges to an effective curriculum range from lack
of physician knowledge and skill, discomfort with such
conversations, and lack of practice opportunities. Several
innovative programs have been tried. Torke et. al developed a
half-day workshop after which students reported increased skills
in breaking bad news, discussing advance directives, and
managing pain.9 Gallagher et. al administered a 70-minute
curriculum consisting of a short lecture followed by 2
standardized patient (SP) sessions. SPs and student selfassessments were recorded. The data suggests the program
may be helpful. 10 Mueller et. al taught a 10-hour bioethics
course that included advance directives. One month after the
course, students self-reported feeling more knowledgeable and
confident about advance care planning.11 The only control group
study was conducted by Green & Levi. In a required ethics
course, students were assigned to either a pen-paper packet or
a computer-based tool. The results of pre/post tests show that
students in the computer group learned more factual knowledge
and had increased confidence.12
Results
73 SP encounters
reviewed (47=intervention
group, 26=control group)
Statistical or correlative
significance found for
positive increase in
Suggestive Impacts on
Video Analysis Data
Label
Control
Intervention Total
Head Nod (A >90%; B=50%; C<10% of time)
A
15 (57.69) 37 (78.72) 52 (71.23)
B
6 (23.08)
8 (17.02)
14 (19.18)
C
5 (19.23)
2 (4.26)
7 (9.59)
Total
26
47
73
Body language
o Head nodding
o Using hand gestures
Affirms SP's Choice to Discuss ACP (A=>4 times; B=
once; C=None)
A
7 (26.92)
22 (46.81) 29 (39.73)
B
17 (65.38) 17 (36.17) 34 (46.58)
C
2 (7.69)
8 (17.02)
10 (13.7)
Total
26
47
73
Vocal Communication
o Displaying vocal
confidence
o Use of lay language
instead of medical
Student hand gestures (A=>90%; B=50%; C=<10% of
time)
A
8 (30.77)
24 (52.17) 32 (44.44)
B
11 (42.31) 20 (43.48) 31 (43.06)
C
7 (26.92)
2 (4.35)
9 (12.5)
Total
26
46
72
Professional Approach
o Affirming patient choice
to have advance care
planning conversations
o Using questions instead
of lecturing in speaking
with patient
o Asking if patient has a
living will or advance
directive
o Closing the interview
with plans for follow up
and providing further
resources
Other
o SP score directly
correlated to time spent
in session
o Students self report
more comfort in ACP
Pval
Student displays vocal confidence (A=Yes; B= No)
A
21 (80.77) 45 (95.74) 66 (90.41)
B
5 (19.23)
2 (4.26)
7 (9.59)
Total
26
47
73
Student uses lay language more than medical
(A=>90%; B=50%; C=<10% of time)
A
5 (19.23)
20 (42.55) 25 (34.25)
B
13 (50)
20 (42.55) 33 (45.21)
C
8 (30.77)
7 (14.89)
15 (20.55)
Total
26
47
73
0.08
0.06
0.01
0.09
0.09
Student explains options (A=Yes; B=No)
A
10 (38.46) 30 (63.83) 40 (54.79)
B
16 (61.54) 17 (36.17) 33 (45.21)
Total
26
47
73
0.07
Student asks if SP has living will (A=No; B=Yes)
A
4 (15.38)
1 (2.13)
5 (6.85)
B
22 (84.62) 46 (97.87) 68 (93.15)
Total
26
47
73
0.05
Student closes interview with follow up and
resources (A=Follow up Planning & Resources;
B=Resources only; C=Nothing)
A
3 (11.54)
18 (38.3)
21 (28.77)
B
11 (42.31) 23 (48.94) 34 (46.58)
C
12 (46.15) 6 (12.77)
18 (24.66)
Total
26
47
73
0.003
Materials and Methods
At the UT Health Science Center San Antonio School of
Medicine, every third-year medical student (n=220) takes part in
a 2-hour ethics session during his/her internal medicine (IM)
clerkship. The session consists of: (a) 1-hour conversation about
ethical and professional issues the students have encountered
or observed; (b) 15-minute viewing of award-winning Advance
Directives video; (c) 45-minute discussion of video and advance
care planning.
All students complete an objective structured clinical
examination (OSCE) using standardized patients (SPs) during
the IM clerkship. One OSCE encounter requires the student to
discuss advance directives with a SP in the role of patient. All
encounters are video-taped. Two-third of the students have the
OSCE 1 to 2 months after the ethics session (experimental
group) and one-third have the OSCE 1 month before the ethics
session (control group). Both groups have access to an article
about having advance care planning conversations with their
patients. SPs complete an evaluation of the students’ skills and
students complete a self-assessment of their comfort with endof-life conversations.
We looked at video and assessment results for one calendar
year March 2011-March 2012, covering parts of two medical
school classes. Every third video (by alphabetical order) was
reviewed and coded for body language, terminology, behavior,
and knowledge content. These 73 interviews were coded by a
single rater. Every fifth video was viewed by a second rater and
their answers compared. Any discrepancies were discussed and
the video provided final arbitration.
We analyzed the self-assessment, standardized patient scores,
and coded elements for correlation, Chi-Square, and Fischer
Exact Test using R Statistics (ver 2.15.1).
Filming of family debate in Advance Directives film (2010)
Conclusions
Although other teaching sessions have used more time, this data
shows that even a short 2-hour advance care planning session in
the MS3 year during a clinical rotation can have an affect on the
student’s skills. In particular students are more likely to use a
questioning, rather than lecture, style and to have follow up plans
that provide patients with further resources. Students also are
more likely to have increased comfort in end-of-life conversations
which is evident to patients through tone of voice, hand gestures,
using lay language, and asking questions about the patient’s
experience with advance directives. We propose that more
teaching hours and experiences would lead to a greater affect.
This study had several limitations. The sample size of 47 is very
small and the two groups were not evenly divided (66%
intervention vs. 34% control). Even though many of the results
show borderline significance, all of the results trend in the direction
of the intervention having a positive influence. In addition, this
study was at 1 school, taking place over part of 2 separate class
years.
References
1.
Billings JA, Bock S (1997). Palliative care in undergraduate medical education: status report and
future directions. JAMA 278: 733-738;
2. Field MJ, Cassell CK (1997). Approaching death: Improving care and the end of life. Institute of
Medicine Report. Washington DC: National Academy Press.
3. Sullivan AM, Lakoma MD, Block SD (2003). The status of medical education in end-of-life care: A
national report. J Gen Intern Med 18:685-695.
4. Barnard D, Quill T, Hafferty FW, Arnold R, Plumb J, Bulger R, Field M (1999) Preparing the
ground: contributions of the preclinical years to medical education for care near the end of life.
Working Group on the Pre-clinical Years of the National
5. Consensus Conference on Medical Education for Care Near the End of Life. Acad Med 74:499–
505
6. Schonwetter RS, Robinson BE (1994) Educational objectives for medical training in the care of
the terminally ill. Acad Med 69:688–690
7. Sullivan AM, Lakoma MD, Billings JA, Peters AS, Block SD, Faculty PC (2005) Teaching and
learning end-of-life care: evaluation of a faculty development program in palliative care. Acad Med
80:657–668
8. Sullivan AM, Lakoma MD, Block SD (2003) The status of medical education in end-of-life care: a
national report. J Gen Intern Med 18:685–695
9. Torke AM, Quest TE, Kinlaw K, ELey JW, Branch WT (2004). A workshop to teach medical
students communication skills and clinical knowledge about end-of-life care. J Gen Intern med 19:
540-544.
10. Gallagher TH, Pantilat SZ, Lo B, Papadakis MA (1999). Teaching medical students to discuss
advance directives: A standardized patient curriculum. Teaching & Learning in Medicine 11(3):
142-147.
11. Mueller PS, Litin SC, Hook CC, Creagan ET, Cha SS, Backman TJ (2010). A novel advance
directives course provides a transformative learning experience for medical students. 22(2): 137141.
12. Green MJ, Levi BH (2011). Teaching advance care planning to medical students with a computerbased decision aid. J Canc Edu 26: 82-91
ACKNOWLEDGEMENTS: The authors wish to acknowledge Alvand Sehat and Nicole Manley
for their assistance in this project.