Teaching Pediatric Cardiology Fellows to Communicate Serious News:  A Pilot Study

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Crafts, Christopher Teng, Margaret Irwin, Angela M. Feraco, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4456463/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Oct, 2024 Read the published version in BMC Medical Education → Version 1 posted 4 You are reading this latest preprint version Abstract Background Pediatric cardiology fellows often deliver serious news to families. Effective clinician-patient communication is the basis of strong therapeutic relationships and improves health outcomes, increases patient adherence, and enhances patient satisfaction. Communication training improves physicians’ communication skills, ability to deliver serious news, and meet the informational and emotional needs of patients and family members. However, there is little data surrounding pediatric cardiology fellows competencies or training in communication skills. Methods Pediatric cardiology fellows participated in a 3-hour communication training session. The session used VitalTalk methodology and was facilitated by two VitalTalk facilitators. Fellows spent 1 hour learning the skills of delivering serious news and responding to emotion and 2 hours in role play with standardized actors followed by a brief group wrap-up activity. Participants took an anonymous, electronic pre- and post-survey as well as an 8-month follow-up survey via REDCap. Participants were asked about their preparedness and comfort performing certain communication skills and leading challenging conversations specific to pediatric cardiology. Response options utilized a combination of 0 (low comfort/preparedness) to 100 (high comfort/preparedness) point scales and multiple choice. Results 9 fellows participated in the training and 100% completed all three surveys. Eight were first-year fellows and 1 was a third-year fellow. Finding the right words, balancing honesty with hope, and clinical and prognostic uncertainty were the top three factors that contributed to making conversations difficult. Following the course, there was a significant increase in fellow preparedness to communicate a new diagnosis of congenital heart disease, discuss poor prognoses, check understanding, and respond to emotion as well as an increase in fellow comfort responding to emotions. Four fellows reported using the skills from this training course in various clinical settings at 8-month follow up. Conclusions Communicating serious news effectively is a skill that can be learned in a sustainable way and is essential in the field of pediatric cardiology. Our study demonstrates that an interactive, VitalTalk course can improve preparedness and comfort to deliver serious news in a cohort of pediatric cardiology trainees. Future studies are needed to evaluate translation of skills to clinical practice and durability of these skills in larger cohorts. Communication delivering serious news fellowship education medical education Figures Figure 1 Figure 2 Introduction Effective clinician-patient communication is the basis of strong therapeutic relationships and has been shown to improve health outcomes, increase patient adherence to medical recommendations, and enhance patient satisfaction with care [1-8]. Conversely, poor communication may undermine the alliance between patients and families, interfere with delivering effective clinical care, and is often cited as the reason for patient dissatisfaction [4,5,8]. Consequently, the Accreditation Council for Graduate Medical Education (ACGME) has made communication a core curricular competency for graduate medical trainees. The ACGME tasks residency and fellowship programs with training effective communicators who can engage in shared decision-making with their patients and families and participate in end-of-life (EOL) discussions and care plans [9]. Effective communication is an essential skill for clinicians in pediatric cardiology. Clinicians must lead conversations disclosing the diagnosis of congenital heart disease (CHD), discussing options for invasive cardiac procedures, supporting families in the setting of prognostic uncertainty, and facilitating EOL care discussions for patients across a wide age range, from fetuses to adults. Numerous studies have highlighted areas for improvement in communication between cardiology clinicians and patients, CHD diagnosis to EOL discussions [10-13]. A recent study revealed discrepancies between parents of children with advanced heart disease and their physicians regarding the adequacy of communication, receipt of conflicting information, and the most effective way for parents to receive information [11]. This study concluded that communication training for physicians caring for children with CHD could be an important intervention to address these challenges. Communications skills training improves physicians’ global communication skills [14-15], as well as their ability to deliver serious news [15-16], respond to patient emotional cues [15-16], check patient understanding [17-18], and meet informational and emotional needs of patients and family members [19]. Yet despite the essential role of strong communication skills in pediatric cardiology and the recognized effectiveness of communication training, there are limited studies assessing the effectiveness of formalized communication training for pediatric cardiology fellows. Our objective was to develop and evaluate a communication skills training course aimed at teaching pediatric cardiology fellows how to effectively communicate serious news and respond to patient and family emotions. We hypothesized that a role play-based course, specific to pediatric cardiology trainees, would improve the preparedness and comfort of participating pediatric cardiology fellows in delivering serious news with patients and families. Material and Methods This single-arm longitudinal study was conducted at Boston Children’s Hospital from July 2023 to April 2024. The half-day communication training was delivered during fellow bootcamp, a month at the start of training dedicated to learning the fundamentals of pediatric cardiology prior to starting clinical rotations and patient care. Course Description: The VitalTalk -based course was developed in collaboration with faculty and fellows from the Department of Cardiology at Boston Children’s Hospital and from the Department of Psychosocial Oncology and Palliative Care and Pediatric Care at Dana-Farber Cancer Institute. VitalTalk provides an evidence-based methodology to train clinicians in communication skills with seriously ill patients that includes didactic sessions to teach skills, demonstrations of skills to learners, and role-plays with trained actors playing the role of the patient [20, 21]. The role play sessions were facilitated by faculty who completed the VitalTalk Faculty Development Course, each with extensive experience in facilitation and communication course design. Two local actors, both of whom had previously participated in communication training sessions, met with faculty for a 2-hour training session the week before the course. A 3-hour, interactive course was developed consisting of (1) a brief (20 minute) didactic outlining the communication skills of delivering serious news and responding to emotion, (2) a demonstration of the skills by faculty facilitators, (3) role play with experienced actors, and (4) a brief, facilitated group wrap-up activity. Each learner had the opportunity to participate in at least one role play with an actor. Learners identified a goal for the encounter, had the opportunity to “time out” during the encounter as needed to ask for help, and received feedback from the group on “what was going well.” After identifying a stuck point and brainstorming a response, the learner “replayed” a moment within the communication encounter. The faculty facilitator guided the learner in debriefing the re-winded scenario to identify a learning point for future practice. All learners remained engaged throughout the role plays by observing and recording the encounter through written notes and providing specific, positive feedback during the debrief. We developed two, unique cases for the simulation experiences that were specific to pediatric cardiology. The first case was a toddler diagnosed with acute viral myocarditis requiring escalation to mechanical circulatory support. The second case was an infant with single ventricle congenital heart disease who required a prolonged inpatient admission for failure to thrive and poor feeding. The objectives of both scenarios were to succinctly deliver a clinical update or “headline” to the parent and subsequently recognize and attend to their emotions that arose. Each case included a short clinical vignette for the fellow learner followed by a detailed character description for the actor portraying the child’s parent/ caregiver. Character descriptions included emotions they might express, personal history of the character, tone of the environment, underlying fears they might have, and an explanation of the clinical scenario for someone without medical training. The scenarios were provided to the actors in advance of the training session and a pre-course rehearsal allowed for exploration of the character and for mutual exchange between course faculty and actors to ensure the objectives of the case and expectations were clear. This training procedure for the actors has been previously described [22]. Evaluation : The training session was evaluated by administering surveys at three points in time immediately prior to the session, immediately following the session to be completed within 2 weeks of the training, and then approximately 8 months after the training. The surveys were modeled after a successful example in the literature [23] and were reviewed by experts in palliative care and cardiology for content and face validity. The surveys were anonymously completed via REDCap. In the first survey (pre-course), participants were asked about their prior experience with formal communication training, preparedness and comfort with communication skills, and preparedness and comfort leading challenging conversations specific to pediatric cardiology. In the second survey (post-course), participants were again asked about their preparedness and comfort performing certain communication skills, preparedness and comfort leading challenging conversations specific to pediatric cardiology, and reactions to the course. In the final survey (medium-term follow-up), participants were asked about their application of the training course in clinical practice. Response options utilized a combination of 0 (low comfort/preparedness) to 100 (high comfort/preparedness) point scales, multiple choice, and open-ended options. Survey instruments and the two clinical cases used for the training are available upon request to the corresponding author. Statistical Analysis : Responses to all surveys and demographic questions were tabulated. We conducted descriptive analysis using both mean and standard deviation (SD) as well as median and interquartile range (IQR). A Wilcoxon signed ranks test was used to assess change in fellow preparedness and comfort from the pre-course assessment to the post-course assessment. A p-value less than 0.05 was considered statistically significant. All analyses were carried out using IBM SPSS Statistics for Windows, version 29.0.0.0 (IBM Corp., Armonk, N.Y., USA). Results Participant Demographics, Prior Communication Training, and Comfort with Communication : Basic participant characteristics are shown in Table 1. Eight first year fellows and one third year fellow participated in the training session. The response rate on all three surveys was 100%. Most fellows characterized their previous training sessions as helpful (mean 74±18, 0 = not helpful, 100 = very helpful). All fellows felt that fellows should be allowed to lead the communication during challenging encounters. Using a scale from 0-100 where 0 is very difficult and 100 is very easy, fellows found that discussions regarding surgical/procedural complications (mean 16±15), new diagnosis with a poor prognosis (mean 20±14), new diagnosis with significant morbidity (mean 21±21), and redirection of care (mean 21±17) to be the most challenging. Discussions with the highest scores were those regarding a new diagnosis with good prognosis (mean 69±30) and care conferences (mean 53±17). The top three factors that most contributed to difficult communication encounters included that it is “hard to find the right words” (67% of respondents), “difficult to balance honesty with hope” (78% of respondents), and uncertainty (78% of respondents). Comparison of Pre-Course and Post-Course Comfort and Preparedness : Median preparedness and comfort for almost all queried scenarios increased after the training session (Figures 1 and 2). The increases were significant in preparedness to discuss a new diagnosis of congenital heart disease, preparedness to discuss a new diagnosis with a poor prognosis, preparedness to check understanding, preparedness to respond to emotion, and comfort with responding to emotion. Median and interquartile values for the pre-course and post-course survey and p-values are shown in Table 2. Fellows agreed that the training was important to their training as a pediatric cardiologist (mean 85±17, 0 = strongly disagree, 100 = strongly agree), and that they would use the skills taught in the session in their clinical practice (mean 81±18, 0 = strongly disagree, 100 = strongly agree). 8-month Follow-Up : A summary of the 8-month follow-up survey questions is shown in Table 3. Four of the 9 (44%) fellows indicated they used the communication skills taught in the course in clinical practice since the training session. All fellows felt more prepared to have serious conversations with their patients after the course. Finally, 56% (5/9) of fellows noted they would handle a past clinical encounter differently following exposure to the communication skills course. Some examples of such clinical encounters included discussing a new diagnosis or clinical deterioration with a family and communicating with colleagues. Discussion Communication is a vital skill for pediatric cardiology providers, who care for seriously ill children and their families. Using validated techniques and methodologies, provider communication is a skill that can be effectively taught [14-19] and utilized. However, few studies have evaluated communication curricula in pediatric cardiology providers [24]. In this single-site, longitudinal assessment of a pediatric cardiology-focused communication training session, we confirmed that communication skills can be taught, as evidenced by a significant increases in participant preparedness or comfort to discuss new diagnoses of congenital heart disease, check patient and caregiver understanding, and respond to patient and caregiver emotions. Most of our learners had experience with formal communication training sessions in the past, perhaps representing a trend in medical education to recognize the importance of communication training. Despite this prior experience, learners still benefited from the course suggesting that communication is a longitudinal skill that requires contextualization as learners progress through their training. This study builds on previous evaluation of a similar curriculum in pediatric cardiology fellows [24] by identifying the types of conversations by which fellows feel most challenged. These included conversations that center on poor prognosis and significant morbidity. Future training should be tailored to focus on these difficult encounters and to evaluate if this is unique to pediatric cardiology. Furthermore, our study demonstrates that the skills learned from the course have been actively applied in diverse patient encounters and that the improvement in preparation to have serious conversations is sustainable over at least an 8-month period. Although 4 of the 9 fellows reported using the skills taught in their training and many more felt improved comfort at medium-term follow up, 5 of the 9 fellows reported not using the skills. This raises the concern that further work is required to reinforce the skills taught in the communication course. Our results suggest future directions could include training all members of the care team in this methodology in order to foster a shared language and approach, offering refresher sessions to remind learners of their new skills, or tailoring training sessions to translation of skills outside of the acute setting. Our study has several important limitations including the small sample size and reliance on self-reported outcomes of comfort and preparedness as well as self-reported behavior change. In review of the literature, no standardized assessment tool existed to evaluate the impact of this course. Therefore, we developed a survey tool to evaluate this course. Finally, our participants were primarily first year fellows who had very little pediatric cardiology training prior to the session. While little clinical knowledge of pediatric cardiology was required to participate in the course, this could have contributed to starting pre-course values being lower than if fellows with more cardiology experience also participated. Conclusions Our study demonstrates the success and feasibility of implementing a communication curriculum with pediatric cardiology trainees and that communication skills can be both taught and utilized by the learner in a variety of scenarios. Future studies will be needed to assess these findings in larger cohorts of learners and the impact these trainings have on family perception of provider communication. Abbreviations ACGME - Accreditation Council for Graduate Medical Education CHD - congenital heart disease EOL - end-of-life IQR - interquartile range SD - standard deviation Declarations Clinical trial number not applicable as this was not a clinical trial. Ethics approval and consent to participate IRB approval was obtained from the Boston Children’s Hospital IRB. Informed consent was obtained from all study participants when they completed the surveys. Consent for publication The authors listed have all provided consent for this study to be published in its current state. Availability of data and material Data collected during this study is available upon request. Materials used for the VitalTalk session are also available upon request. Competing interests None of the authors have competing interests or relevant financial disclosures. Funding Funding for this project was partially supported by grants from the Joseph Middlemiss Foundation and the Dorothy & Howard Dulman Fund. Authors' contributions LC, CT, EB, and CR conceptualized the evaluation. LC, CT, EB, MI, AF, JS, AL were involved in training course development. AF, JS, and AL taught the training course. LC collected data and was involved in quantitative analysis. LC, CT, EB, MI, AF, JS, AL were involved in writing, revising, and reviewing the manuscript. Acknowledgements: None Authors' information (optional): Please see title page. References Meyer EC, Ritholz MD, Burns JP, Truog RD. Improving the quality of end-of-life care in the pediatric intensive care unit: parents’ priorities and recommendations. Pediatrics . 2006;117(3):649-657. doi:10.1542/peds.2005-0144 Meyer EC, Sellers DE, Browning DM, McGuffie K, Solomon MZ, Truog RD. Difficult conversations: Improving communication skills and relational abilities in health care. Pediatr Crit Care Med . 2009;10(3):352-359. doi:10.1097/PCC.0b013e3181a3183a Contro N, Larson J, Scofield S, Sourkes B, Cohen H. 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Delivering Serious News in Pediatric Cardiology–A Pilot Program. Pediatr Cardiol [Internet]. 2024;(0123456789). Available from: https://doi.org/10.1007/s00246-024-03440-w Table Table 1 : Subject Characteristics Characteristic n (%) Year of Fellowship 1 st year 8 (89) 3 rd year 1 (11) Previous Formal Communication Training (Y) Medical student 8 (89) Resident 5 (56) Type of Communication Training as Resident Formal lectures 4 (80) Role play with other trainees 4 (80) Standardized actors as patients 4 (80) Case scenarios 4 (80) Responsible Group for Communication Training as Resident Palliative care 4 (80) General pediatrics 1 (20) Should Fellows Lead Challenging Communication Encounters? Yes 9 (100) No 0 (0) Table 2: Change in Median Preparedness and Comfort Following Session Question Pre-Course Median (IQR 25%-75%) Post-Course Median (IQR 25%-75%) Wilcoxon signed-rank p-value How prepared* do you feel: Discussing a new diagnosis of congenital heart disease 23 (1-60) 52 (31-72) 0.021 Discussing a poor prognosis 34 (12-65) 66 (41-78) 0.015 Checking a patient or caregiver’s understanding 67 (55-77) 81 (65-98) 0.033 Responding to a patient or caregiver’s emotions 64 (56-72) 76 (68-90) 0.028 Discussing various treatment options including palliative care with families 50 (29-69) 44 (29-65) 0.889 Obtaining parental consent for a central line placement in the ICU 63 (13-92) 60 (34-85) 0.575 Disclosing that a patient can no longer be discharged from the hospital for inadequate weight gain 78 (56-92) 88 (73-96) 0.069 Discussing a new diagnosis of a moderate VSD in an infant 47 (12-84) 66 (25-89) 0.293 Performing prenatal counseling for a diagnosis of HLHS 6 (0-31) 24 (5-52) 0.108 Disclosing to a family that a patient had a stroke following hemodynamic cardiac catheterization 2 (0-41) 19 (4-52) 0.236 Discussing transitioning off mechanical support for a patient who is too sick to be listed for transplant 5 (2-33) 18 (0-57) 0.674 How comfortable^ do you feel: Discussing a new diagnosis of congenital heart disease 43 (16-56) 50 (29-75) 0.263 Discussing a poor prognosis 33 (4-44) 32 (27-68) 0.214 Checking a patient or caregiver’s understanding 50 (67-87) 65 (82-95) 0.139 Responding to a patient or caregiver’s emotions 68 (57-76) 85 (77-94) 0.015 Discussing various treatment options including palliative care with families 20 (13-51) 39 (21-63) 0.236 Obtaining parental consent for a central line placement in the ICU 62 (20-98) 63 (26-93) 0.866 Disclosing that a patient can no longer be discharged from the hospital for inadequate weight gain 77 (37-99) 76 (67-94) 0.374 Discussing a new diagnosis of a moderate VSD in an infant 40 (9-69) 75 (21-80) 0.213 Performing prenatal counseling for a diagnosis of HLHS 12 (0-36) 14 (0-47) 0.553 Disclosing to a family that a patient had a stroke following hemodynamic cardiac catheterization 19 (1-34) 9 (3-53) 0.398 Discussing transitioning off mechanical support for a patient who is too sick to be listed for transplant 16 (1-25) 10 (3-58) 0.260 *Prepared scale from 0 (very unprepared) to 100 (very prepared) ^Comfort scale from 0 (very uncomfortable) to 100 (very comfortable) Table 3: Follow-Up Survey Question n (%) Have you used your communication training in clinical practice? Yes 4 (44) How many times? Several times 2 (50) Weekly 1 (25) Once 1 (25) In what clinical environment? Cardiology clinic 2 (50) Inpatient floor 3 (75) Cardiac intensive care unit 2 (50) Cardiology consult service 3 (75) No 5 (56) Have you felt more prepared having serious conversations with patients after the training course? Yes 9 (100) No 0 (0) Have you felt more comfortable having serious conversations with patients after the training course? Yes 6 (67) No 3 (33) Do you think a refresher course would be helpful? Yes 8 (89) What format? Emailed content 1 (13) Brief didactic during fellowship conference 7 (88) Role play with standardized patients 1 (13) Online, self-paced module 1 (13) No 1 (11) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 07 Oct, 2024 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 18 Jun, 2024 Editor assigned by journal 18 Jun, 2024 Submission checks completed at journal 18 Jun, 2024 First submitted to journal 21 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Blume","email":"","orcid":"","institution":"Boston Children's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Elizabeth","middleName":"D.","lastName":"Blume","suffix":""},{"id":315895190,"identity":"7894f472-e037-4c9c-9fb6-4a3dcbf25592","order_by":7,"name":"Christina Ronai","email":"","orcid":"","institution":"Boston Children's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Christina","middleName":"","lastName":"Ronai","suffix":""}],"badges":[],"createdAt":"2024-05-21 17:45:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4456463/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4456463/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-024-06078-7","type":"published","date":"2024-10-07T15:57:55+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60354892,"identity":"b721e697-adf3-41bd-b9f0-610105526d71","added_by":"auto","created_at":"2024-07-15 23:54:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":44214,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChange in Median Preparedness Following Session\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4456463/v1/3846d726e74303a6a6017b07.png"},{"id":60354893,"identity":"249ff046-baf4-410e-913c-048ddf10b39f","added_by":"auto","created_at":"2024-07-15 23:54:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":43467,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChange in Median Comfort Following Session\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4456463/v1/97ae49ecfeb5ddbd6cf84082.png"},{"id":66597222,"identity":"1d9470dc-22b2-41e1-a47d-39077afb6611","added_by":"auto","created_at":"2024-10-14 16:08:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":560446,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4456463/v1/7e4d5f37-87f1-4a01-ad8f-4a6857b0e9bb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Teaching Pediatric Cardiology Fellows to Communicate Serious News: A Pilot Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEffective clinician-patient communication is the basis of strong therapeutic relationships and has been shown to improve health outcomes, increase patient adherence to medical recommendations, and enhance patient satisfaction with care [1-8]. Conversely, poor communication may undermine the alliance between patients and families, interfere with delivering effective clinical care, and is often cited as the reason for patient dissatisfaction [4,5,8].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsequently, the Accreditation Council for Graduate Medical Education (ACGME) has made communication a core curricular competency for graduate medical trainees. The ACGME tasks residency and fellowship programs with training effective communicators who can engage in shared decision-making with their patients and families and participate in end-of-life (EOL) discussions and care plans [9].\u003c/p\u003e\n\u003cp\u003eEffective communication is an essential skill for clinicians in pediatric cardiology. Clinicians must lead conversations disclosing the diagnosis of congenital heart disease (CHD), discussing options for invasive cardiac procedures, supporting families in the setting of prognostic uncertainty, and facilitating EOL care discussions for patients across a wide age range, from fetuses to adults. Numerous studies have highlighted areas for improvement in communication between cardiology clinicians and patients, CHD diagnosis to EOL discussions [10-13]. A recent study revealed discrepancies between parents of children with advanced heart disease and their physicians regarding the adequacy of communication, receipt of conflicting information, and the most effective way for parents to receive information [11]. This study concluded that communication training for physicians caring for children with CHD could be an important intervention to address these challenges.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCommunications skills training improves physicians\u0026rsquo; global communication skills [14-15], as well as their ability to deliver serious news [15-16], respond to patient emotional cues [15-16], check patient understanding [17-18], and meet informational and emotional needs of patients and family members [19]. Yet despite the essential role of strong communication skills in pediatric cardiology and the recognized effectiveness of communication training, there are limited studies assessing the effectiveness of formalized communication training for pediatric cardiology fellows. Our objective was to develop and evaluate a communication skills training course aimed at teaching pediatric cardiology fellows how to effectively communicate serious news and respond to patient and family emotions. We hypothesized that a role play-based course, specific to pediatric cardiology trainees, would improve the preparedness and comfort of participating pediatric cardiology fellows in delivering serious news with patients and families.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003eThis single-arm longitudinal study was conducted at Boston Children’s Hospital from July 2023 to April 2024. The half-day communication training was delivered during fellow bootcamp, a month at the start of training dedicated to learning the fundamentals of pediatric cardiology prior to starting clinical rotations and patient care.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCourse Description:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe \u003cem\u003eVitalTalk\u003c/em\u003e-based course was developed in collaboration with faculty and fellows from the Department of Cardiology at Boston Children’s Hospital and from the Department of Psychosocial Oncology and Palliative Care and Pediatric Care at Dana-Farber Cancer Institute. \u003cem\u003eVitalTalk\u003c/em\u003e provides an evidence-based methodology to train clinicians in communication skills with seriously ill patients that includes didactic sessions to teach skills, demonstrations of skills to learners, and role-plays with trained actors playing the role of the patient [20, 21]. The role play sessions were facilitated by faculty who completed the \u003cem\u003eVitalTalk\u003c/em\u003e Faculty Development Course, each with extensive experience in facilitation and communication course design. Two local actors, both of whom had previously participated in communication training sessions, met with faculty for a 2-hour training session the week before the course.\u003c/p\u003e\n\u003cp\u003eA 3-hour, interactive course was developed consisting of (1) a brief (20 minute) didactic outlining the communication skills of delivering serious news and responding to emotion, (2) a demonstration of the skills by faculty facilitators, (3) role play with experienced actors, and (4) a brief, facilitated group wrap-up activity. Each learner had the opportunity to participate in at least one role play with an actor. Learners identified a goal for the encounter, had the opportunity to “time out” during the encounter as needed to ask for help, and received feedback from the group on “what was going well.” After identifying a stuck point and brainstorming a response, the learner “replayed” a moment within the communication encounter. The faculty facilitator guided the learner in debriefing the re-winded scenario to identify a learning point for future practice. All learners remained engaged throughout the role plays by observing and recording the encounter through written notes and providing specific, positive feedback during the debrief.\u003c/p\u003e\n\u003cp\u003eWe developed two, unique cases for the simulation experiences that were specific to pediatric cardiology. The first case was a toddler diagnosed with acute viral myocarditis requiring escalation to mechanical circulatory support. The second case was an infant with single ventricle congenital heart disease who required a prolonged inpatient admission for failure to thrive and poor feeding. The objectives of both scenarios were to succinctly deliver a clinical update or “headline” to the parent and subsequently recognize and attend to their emotions that arose. Each case included a short clinical vignette for the fellow learner followed by a detailed character description for the actor portraying the child’s parent/ caregiver. Character descriptions included emotions they might express, personal history of the character, tone of the environment, underlying fears they might have, and an explanation of the clinical scenario for someone without medical training. The scenarios were provided to the actors in advance of the training session and a pre-course rehearsal allowed for exploration of the character and for mutual exchange between course faculty and actors to ensure the objectives of the case and expectations were clear. This training procedure for the actors has been previously described [22].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eEvaluation\u003c/u\u003e:\u003c/p\u003e\n\u003cp\u003eThe training session was evaluated by administering surveys at three points in time immediately prior to the session, immediately following the session to be completed within 2 weeks of the training, and then approximately 8 months after the training. The surveys were modeled after a successful example in the literature [23] and were reviewed by experts in palliative care and cardiology for content and face validity.\u003c/p\u003e\n\u003cp\u003eThe surveys were anonymously completed via REDCap. In the first survey (pre-course), participants were asked about their prior experience with formal communication training, preparedness and comfort with communication skills, and preparedness and comfort leading challenging conversations specific to pediatric cardiology. In the second survey (post-course), participants were again asked about their preparedness and comfort performing certain communication skills, preparedness and comfort leading challenging conversations specific to pediatric cardiology, and reactions to the course. In the final survey (medium-term follow-up), participants were asked about their application of the training course in clinical practice. Response options utilized a combination of 0 (low comfort/preparedness) to 100 (high comfort/preparedness) point scales, multiple choice, and open-ended options.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSurvey instruments and the two clinical cases used for the training are available upon request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eStatistical Analysis\u003c/u\u003e:\u003c/p\u003e\n\u003cp\u003eResponses to all surveys and demographic questions were tabulated. We conducted descriptive analysis using both mean and standard deviation (SD) as well as median and interquartile range (IQR). A Wilcoxon signed ranks test was used to assess change in fellow preparedness and comfort from the pre-course assessment to the post-course assessment. A p-value less than 0.05 was considered statistically significant. All analyses were carried out using IBM SPSS Statistics for Windows, version 29.0.0.0 (IBM Corp., Armonk, N.Y., USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cu\u003eParticipant Demographics, Prior Communication Training, and Comfort with Communication\u003c/u\u003e:\u003c/p\u003e\n\u003cp\u003eBasic participant characteristics are shown in Table 1. Eight first year fellows and one third year fellow participated in the training session. The response rate on all three surveys was 100%. Most fellows characterized their previous training sessions as helpful (mean 74±18, 0 = not helpful, 100 = very helpful). All fellows felt that fellows should be allowed to lead the communication during challenging encounters.\u003c/p\u003e\n\u003cp\u003eUsing a scale from 0-100 where 0 is very difficult and 100 is very easy, fellows found that discussions regarding surgical/procedural complications (mean 16±15), new diagnosis with a poor prognosis (mean 20±14), new diagnosis with significant morbidity (mean 21±21), and redirection of care (mean 21±17) to be the most challenging. Discussions with the highest scores were those regarding a new diagnosis with good prognosis (mean 69±30) and care conferences (mean 53±17). The top three factors that most contributed to difficult communication encounters included that it is “hard to find the right words” (67% of respondents), “difficult to balance honesty with hope” (78% of respondents), and uncertainty (78% of respondents).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eComparison of Pre-Course and Post-Course Comfort and Preparedness\u003c/u\u003e:\u003c/p\u003e\n\u003cp\u003eMedian preparedness and comfort for almost all queried scenarios increased after the training session (Figures 1 and 2). The increases were significant in preparedness to discuss a new diagnosis of congenital heart disease, preparedness to discuss a new diagnosis with a poor prognosis, preparedness to check understanding, preparedness to respond to emotion, and comfort with responding to emotion. Median and interquartile values for the pre-course and post-course survey and p-values are shown in Table 2. Fellows agreed that the training was important to their training as a pediatric cardiologist (mean 85±17, 0 = strongly disagree, 100 = strongly agree), and that they would use the skills taught in the session in their clinical practice (mean 81±18, 0 = strongly disagree, 100 = strongly agree).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e8-month Follow-Up\u003c/u\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA summary of the 8-month follow-up survey questions is shown in Table 3. Four of the 9 (44%) fellows indicated they used the communication skills taught in the course in clinical practice since the training session. All fellows felt more prepared to have serious conversations with their patients after the course. Finally, 56% (5/9) of fellows noted they would handle a past clinical encounter differently following exposure to the communication skills course. Some examples of such clinical encounters included discussing a new diagnosis or clinical deterioration with a family and communicating with colleagues.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCommunication is a vital skill for pediatric cardiology providers, who care for seriously ill children and their families. Using validated techniques and methodologies, provider communication is a skill that can be effectively taught [14-19] and utilized. However, few studies have evaluated communication curricula in pediatric cardiology providers [24].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this single-site, longitudinal assessment of a pediatric cardiology-focused communication training session, we confirmed that communication skills can be taught, as evidenced by a significant increases in participant preparedness or comfort to discuss new diagnoses of congenital heart disease, check patient and caregiver understanding, and respond to patient and caregiver emotions. Most of our learners had experience with formal communication training sessions in the past, perhaps representing a trend in medical education to recognize the importance of communication training. Despite this prior experience, learners still benefited from the course suggesting that communication is a longitudinal skill that requires contextualization as learners progress through their training.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study builds on previous evaluation of a similar curriculum in pediatric cardiology fellows [24] by identifying the types of conversations by which fellows feel most challenged. These included conversations that center on poor prognosis and significant morbidity. Future training should be tailored to focus on these difficult encounters and to evaluate if this is unique to pediatric cardiology.\u003c/p\u003e\n\u003cp\u003eFurthermore, our study demonstrates that the skills learned from the course have been actively applied in diverse patient encounters and that the improvement in preparation to have serious conversations is sustainable over at least an 8-month period. Although 4 of the 9 fellows reported using the skills taught in their training and many more felt improved comfort at medium-term follow up, 5 of the 9 fellows reported not using the skills. This raises the concern that further work is required to reinforce the skills taught in the communication course. Our results suggest future directions could include training all members of the care team in this methodology in order to foster a shared language and approach, offering refresher sessions to remind learners of their new skills, or tailoring training sessions to translation of skills outside of the acute setting.\u003c/p\u003e\n\u003cp\u003eOur study has several important limitations including the small sample size and reliance on self-reported outcomes of comfort and preparedness as well as self-reported behavior change. In review of the literature, no standardized assessment tool existed to evaluate the impact of this course. Therefore, we developed a survey tool to evaluate this course. Finally, our participants were primarily first year fellows who had very little pediatric cardiology training prior to the session. While little clinical knowledge of pediatric cardiology was required to participate in the course, this could have contributed to starting pre-course values being lower than if fellows with more cardiology experience also participated.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur study demonstrates the success and feasibility of implementing a communication curriculum with pediatric cardiology trainees and that communication skills can be both taught and utilized by the learner in a variety of scenarios. Future studies will be needed to assess these findings in larger cohorts of learners and the impact these trainings have on family perception of provider communication.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACGME - Accreditation Council for Graduate Medical Education\u003c/p\u003e\n\u003cp\u003eCHD - congenital heart disease\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEOL - end-of-life\u003c/p\u003e\n\u003cp\u003eIQR - interquartile range\u003c/p\u003e\n\u003cp\u003eSD - standard deviation\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eClinical trial number not applicable as this was not a clinical trial.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eIRB approval was obtained from the Boston Children\u0026rsquo;s Hospital IRB.\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all study participants when they completed the surveys.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eThe authors listed have all provided consent for this study to be published in its current state.\u003c/p\u003e\n\u003cp\u003eAvailability of data and material\u003c/p\u003e\n\u003cp\u003eData collected during this study is available upon request.\u003c/p\u003e\n\u003cp\u003eMaterials used for the VitalTalk session are also available upon request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eNone of the authors have competing interests or relevant financial disclosures.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eFunding for this project was partially\u0026nbsp;supported by grants from the Joseph Middlemiss Foundation and the Dorothy \u0026amp; Howard Dulman Fund.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eLC, CT, EB, and CR conceptualized the evaluation.\u003c/p\u003e\n\u003cp\u003eLC, CT, EB, MI, AF, JS, AL were involved in training course development.\u003c/p\u003e\n\u003cp\u003eAF, JS, and AL taught the training course.\u003c/p\u003e\n\u003cp\u003eLC collected data and was involved in quantitative analysis.\u003c/p\u003e\n\u003cp\u003eLC, CT, EB, MI, AF, JS, AL were involved in writing, revising, and reviewing the manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: None\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; information (optional): Please see title page.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMeyer EC, Ritholz MD, Burns JP, Truog RD. 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Parent-Provider Communication in Hospitalized Children with Advanced Heart Disease. \u003cem\u003ePediatr Cardiol\u003c/em\u003e. 2022;43(8):1761-1769. doi:10.1007/s00246-022-02913-0\u003c/li\u003e\n\u003cli\u003ePinto NM, Patel A, Delaney RK, et al. Provider insights on shared decision-making with families affected by CHD. \u003cem\u003eCardiol Young\u003c/em\u003e. Published online 2021. doi:10.1017/S1047951121004406\u003c/li\u003e\n\u003cli\u003eArya B, Glickstein JS, Levasseur SM, Williams IA. Parents of children with congenital heart disease prefer more information than cardiologists provide. \u003cem\u003eCongenit Heart Dis\u003c/em\u003e. 2013;8(1):78-85. doi:10.1111/j.1747-0803.2012.00706.x\u003c/li\u003e\n\u003cli\u003eGoelz T, Wuensch A, Stubenrauch S, et al. Specific training program improves oncologists\u0026rsquo; palliative care communication skills in a randomized controlled trial. \u003cem\u003eJ Clin Oncol Off J Am Soc Clin Oncol\u003c/em\u003e. 2011;29(25):3402-3407. doi:10.1200/JCO.2010.31.6372\u003c/li\u003e\n\u003cli\u003eAlexander SC, Keitz SA, Sloane R, Tulsky JA. A controlled trial of a short course to improve residents\u0026rsquo; communication with patients at the end of life. \u003cem\u003eAcad Med\u003c/em\u003e. 2006;81(11):1008-1012. doi:10.1097/01.ACM.0000242580.83851.ad\u003c/li\u003e\n\u003cli\u003eBack AL, Arnold RM, Baile WF, et al. Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. \u003cem\u003eArch Intern Med\u003c/em\u003e. 2007;167(5):453-460. doi:10.1001/archinte.167.5.453\u003c/li\u003e\n\u003cli\u003eBays AM, Engelberg RA, Back AL, et al. Interprofessional communication skills training for serious illness: evaluation of a small-group, simulated patient intervention. \u003cem\u003eJ Palliat Med\u003c/em\u003e. 2014;17(2):159-166. doi:10.1089/jpm.2013.0318\u003c/li\u003e\n\u003cli\u003eGibon A-S, Merckaert I, Li\u0026eacute;nard A, et al. Is it possible to improve radiotherapy team members\u0026rsquo; communication skills? A randomized study assessing the efficacy of a 38-h communication skills training program. \u003cem\u003eRadiother Oncol J Eur Soc Ther Radiol Oncol\u003c/em\u003e. 2013;109(1):170-177. doi:10.1016/j.radonc.2013.08.019\u003c/li\u003e\n\u003cli\u003eSullivan AM, Rock LK, Gadmer NM, Norwich DE, Schwartzstein RM. The Impact of Resident Training on Communication with Families in the Intensive Care Unit. Resident and Family Outcomes. \u003cem\u003eAnn Am Thorac Soc\u003c/em\u003e. 2016;13(4):512-521. doi:10.1513/AnnalsATS.201508-495OC\u003c/li\u003e\n\u003cli\u003eBack AL, Arnold RM, Baile WF, Tulsky JA, Barley GE, Pea RD, et al. Faculty development to change the paradigm of communication skills teaching in oncology. J Clin Oncol Off J Am Soc Clin Oncol. 2009 Mar;27(7):1137\u0026ndash;41.\u003c/li\u003e\n\u003cli\u003eVitalTalk. Accessed May 9, 2024. www.vitaltalk.org\u003c/li\u003e\n\u003cli\u003eLawton AJ, Greco L, Airaldi R, Tulsky JA. Development of an Actor Rehearsal Guide for Communication Skills Courses. BMJ Support \u0026amp;amp;amp; Palliat Care [Internet]. 2024 Jan 9;spcare-2023-004509. Available from: http://spcare.bmj.com/content/early/2024/01/09/spcare-2023-004509.abstract\u003c/li\u003e\n\u003cli\u003eFile W, Bylund CL, Kesselheim J, Leonard D, Leavey P. Do pediatric hematology/oncology (PHO) fellows receive communication training? \u003cem\u003ePediatr Blood Cancer\u003c/em\u003e. 2014;61(3):502-506. doi:10.1002/pbc.24742\u003c/li\u003e\n\u003cli\u003eDas N, Brown A, Harris TH. Delivering Serious News in Pediatric Cardiology\u0026ndash;A Pilot Program. \u003cem\u003ePediatr Cardiol\u003c/em\u003e [Internet]. 2024;(0123456789). Available from: https://doi.org/10.1007/s00246-024-03440-w\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e: \u003cstrong\u003eSubject Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.32692307692308%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.673076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.32692307692308%\" valign=\"top\"\u003e\n \u003cp\u003eYear of Fellowship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.673076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.32692307692308%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003csup\u003est\u003c/sup\u003e year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.673076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e8 (89)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.32692307692308%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003csup\u003erd\u003c/sup\u003e year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.673076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e1 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.32692307692308%\" valign=\"top\"\u003e\n \u003cp\u003ePrevious Formal Communication Training (Y)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.673076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.32692307692308%\" valign=\"top\"\u003e\n \u003cp\u003eMedical student\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.673076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e8 (89)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.32692307692308%\" valign=\"top\"\u003e\n \u003cp\u003eResident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.673076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e5 (56)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.32692307692308%\" valign=\"top\"\u003e\n \u003cp\u003eType of Communication Training as Resident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.673076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.32692307692308%\" valign=\"top\"\u003e\n \u003cp\u003eFormal lectures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.673076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e4 (80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.32692307692308%\" valign=\"top\"\u003e\n \u003cp\u003eRole play with other trainees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.673076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e4 (80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.32692307692308%\" valign=\"top\"\u003e\n \u003cp\u003eStandardized actors as patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.673076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e4 (80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.32692307692308%\" valign=\"top\"\u003e\n \u003cp\u003eCase scenarios\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.673076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e4 (80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.32692307692308%\" valign=\"top\"\u003e\n \u003cp\u003eResponsible Group for Communication Training as Resident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.673076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.32692307692308%\" valign=\"top\"\u003e\n \u003cp\u003ePalliative care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.673076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e4 (80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.32692307692308%\" valign=\"top\"\u003e\n \u003cp\u003eGeneral pediatrics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.673076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e1 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.32692307692308%\" valign=\"top\"\u003e\n \u003cp\u003eShould Fellows Lead Challenging Communication Encounters?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.673076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.32692307692308%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.673076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e9 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.32692307692308%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.673076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Change in Median Preparedness and Comfort Following Session\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"852\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuestion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-Course Median\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(IQR 25%-75%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-Course Median\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(IQR 25%-75%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\"\u003e\n \u003cp\u003e\u003cstrong\u003eWilcoxon signed-rank p-value\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow prepared* do you feel:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003eDiscussing a new diagnosis of congenital heart disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e23 (1-60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e52 (31-72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003eDiscussing a poor prognosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e34 (12-65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e66 (41-78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003eChecking a patient or caregiver\u0026rsquo;s understanding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e67 (55-77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e81 (65-98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003eResponding to a patient or caregiver\u0026rsquo;s emotions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e64 (56-72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e76 (68-90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.028\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003eDiscussing various treatment options including palliative care with families\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e50 (29-69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e44 (29-65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.889\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003eObtaining parental consent for a central line placement in the ICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e63 (13-92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e60 (34-85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.575\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003eDisclosing that a patient can no longer be discharged from the hospital for inadequate weight gain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e78 (56-92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e88 (73-96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.069\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003eDiscussing a new diagnosis of a moderate VSD in an infant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e47 (12-84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e66 (25-89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.293\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003ePerforming prenatal counseling for a diagnosis of HLHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e6 (0-31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e24 (5-52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.108\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003eDisclosing to a family that a patient had a stroke following hemodynamic cardiac catheterization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e2 (0-41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e19 (4-52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.236\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003eDiscussing transitioning off mechanical support for a patient who is too sick to be listed for transplant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e5 (2-33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e18 (0-57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.674\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow comfortable^ do you feel:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003eDiscussing a new diagnosis of congenital heart disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e43 (16-56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e50 (29-75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.263\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003eDiscussing a poor prognosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e33 (4-44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e32 (27-68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.214\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003eChecking a patient or caregiver\u0026rsquo;s understanding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e50 (67-87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e65 (82-95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.139\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003eResponding to a patient or caregiver\u0026rsquo;s emotions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e68 (57-76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e85 (77-94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003eDiscussing various treatment options including palliative care with families\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e20 (13-51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e39 (21-63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.236\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003eObtaining parental consent for a central line placement in the ICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e62 (20-98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e63 (26-93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.866\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003eDisclosing that a patient can no longer be discharged from the hospital for inadequate weight gain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e77 (37-99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e76 (67-94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.374\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003eDiscussing a new diagnosis of a moderate VSD in an infant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e40 (9-69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e75 (21-80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.213\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003ePerforming prenatal counseling for a diagnosis of HLHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e12 (0-36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e14 (0-47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.553\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003eDisclosing to a family that a patient had a stroke following hemodynamic cardiac catheterization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e19 (1-34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e9 (3-53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.398\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"63.689776733254995%\" valign=\"top\"\u003e\n \u003cp\u003eDiscussing transitioning off mechanical support for a patient who is too sick to be listed for transplant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp\u003e16 (1-25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.396004700352526%\" valign=\"top\"\u003e\n \u003cp\u003e10 (3-58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.870740305522915%\" valign=\"top\"\u003e\n \u003cp\u003e0.260\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Prepared scale from 0 (very unprepared) to 100 (very prepared)\u003c/p\u003e\n\u003cp\u003e^Comfort scale from 0 (very uncomfortable) to 100 (very comfortable)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Follow-Up Survey\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuestion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eHave you used your communication training in clinical practice?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e4 (44)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eHow many times?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eSeveral times\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e2 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eWeekly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e1 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eOnce\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e1 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eIn what clinical environment?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eCardiology clinic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e2 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eInpatient floor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e3 (75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eCardiac intensive care unit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e2 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eCardiology consult service\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e3 (75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e5 (56)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eHave you felt more prepared having serious conversations with patients after the training course?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e9 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eHave you felt more comfortable having serious conversations with patients after the training course?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e6 (67)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e3 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eDo you think a refresher course would be helpful?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e8 (89)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eWhat format?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eEmailed content\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e1 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eBrief didactic during fellowship conference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e7 (88)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eRole play with standardized patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e1 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eOnline, self-paced module\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e1 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"80.21978021978022%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.78021978021978%\" valign=\"top\"\u003e\n \u003cp\u003e1 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Communication, delivering serious news, fellowship education, medical education","lastPublishedDoi":"10.21203/rs.3.rs-4456463/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4456463/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePediatric cardiology fellows often deliver serious news to families. Effective clinician-patient communication is the basis of strong therapeutic relationships and improves health outcomes, increases patient adherence, and enhances patient satisfaction. Communication training improves physicians\u0026rsquo; communication skills, ability to deliver serious news, and meet the informational and emotional needs of patients and family members. However, there is little data surrounding pediatric cardiology fellows competencies or training in communication skills.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePediatric cardiology fellows participated in a 3-hour communication training session. The session used \u003cem\u003eVitalTalk\u003c/em\u003e methodology and was facilitated by two \u003cem\u003eVitalTalk\u003c/em\u003e facilitators. Fellows spent 1 hour learning the skills of delivering serious news and responding to emotion and 2 hours in role play with standardized actors followed by a brief group wrap-up activity. Participants took an anonymous, electronic pre- and post-survey as well as an 8-month follow-up survey via REDCap. Participants were asked about their preparedness and comfort performing certain communication skills and leading challenging conversations specific to pediatric cardiology. Response options utilized a combination of 0 (low comfort/preparedness) to 100 (high comfort/preparedness) point scales and multiple choice.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003e9 fellows participated in the training and 100% completed all three surveys. Eight were first-year fellows and 1 was a third-year fellow. Finding the right words, balancing honesty with hope, and clinical and prognostic uncertainty were the top three factors that contributed to making conversations difficult. Following the course, there was a significant increase in fellow preparedness to communicate a new diagnosis of congenital heart disease, discuss poor prognoses, check understanding, and respond to emotion as well as an increase in fellow comfort responding to emotions. Four fellows reported using the skills from this training course in various clinical settings at 8-month follow up.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eCommunicating serious news effectively is a skill that can be learned in a sustainable way and is essential in the field of pediatric cardiology. Our study demonstrates that an interactive, \u003cem\u003eVitalTalk\u003c/em\u003e course can improve preparedness and comfort to deliver serious news in a cohort of pediatric cardiology trainees. Future studies are needed to evaluate translation of skills to clinical practice and durability of these skills in larger cohorts.\u003c/p\u003e","manuscriptTitle":"Teaching Pediatric Cardiology Fellows to Communicate Serious News: A Pilot Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-15 23:54:45","doi":"10.21203/rs.3.rs-4456463/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-18T12:01:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-18T10:01:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-18T09:58:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2024-05-21T17:43:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4e071f54-102d-40e5-b6b7-c3f2788680e1","owner":[],"postedDate":"July 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-14T16:03:09+00:00","versionOfRecord":{"articleIdentity":"rs-4456463","link":"https://doi.org/10.1186/s12909-024-06078-7","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2024-10-07 15:57:55","publishedOnDateReadable":"October 7th, 2024"},"versionCreatedAt":"2024-07-15 23:54:45","video":"","vorDoi":"10.1186/s12909-024-06078-7","vorDoiUrl":"https://doi.org/10.1186/s12909-024-06078-7","workflowStages":[]},"version":"v1","identity":"rs-4456463","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4456463","identity":"rs-4456463","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}