GITalk: Communication Skills Training for Gastroenterology Fellows Improves Self-Assessed Preparedness for Serious Illness Conversations

GITalk: Communication Skills Training for Gastroenterology Fellows Improves Self-Assessed Preparedness for Serious Illness Conversations | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article GITalk: Communication Skills Training for Gastroenterology Fellows Improves Self-Assessed Preparedness for Serious Illness Conversations Alan Noll, Arpan A Patel, Rene Claxton, Robert M Arnold, Shari S Rogal, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4298423/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Despite caring for conditions associated with high symptom burden and mortality, GI fellows rarely receive communication training. Aims To describe the development, implementation, and assessment of GITalk, a novel communication curriculum for gastroenterology (GI) fellows. Methods GITalk was designed to improve the skills needed to have effective serious illness conversations frequently encountered in clinical practice. Participants practiced encounters using two cases with simulated actors. One case involved delivering news that a patient with decompensated cirrhosis will no longer be a candidate for liver transplant, and the second case involved counseling the family of a patient with moderate to severe dementia on the risks and benefits of inserting a percutaneous feeding tube for artificial enteral nutrition. Results Annual training sessions were held for four consecutive years, representing a total of 23 GI fellows. Prior to participation in GITalk, few participants reported having had prior formal teaching in serious illness conversations. Paired sample t-tests showed that participants had significantly higher mean post-training preparedness scores compared to pre-training across all 9 survey questions. 91% of participants strongly agreed with the statement: “I would recommend this training to other fellows.” 78% strongly agreed with, “This training should be required of all GI fellows.” Conclusions Participants had little formal training in serious illness conversation prior to participation in GITalk. They reported substantial improvement in their self-assessed preparedness for discussing common clinical scenarios encountered in gastroenterology. GITalk can serve as a model for improvements in the Interpersonal and Communication Skills core competency for gastroenterology trainees. Communication skills goals of care gastroenterology hepatology palliative care Figures Figure 1 Figure 2 INTRODUCTION Despite a high symptom burden, individuals living with serious illnesses affecting the gastrointestinal and hepatobiliary tracts often have substantial, unmet palliative care (PC) needs.[ 1 – 5 ] One important priority for teams caring for these patients is ensuring that they understand their condition and feel prepared for future healthcare decisions. Unfortunately, patients and families often lack a thorough understanding of their illness trajectory and infrequently participate in conversations related to advance care planning (ACP).[ 6 , 7 ] Communication around treatment decisions are often delayed and tend to take place in the inpatient setting, where mortality is high, especially in conditions such as decompensated cirrhosis.[ 8 – 11 ] One reason for such delayed and limited communication in this high-risk population may be gaps in training for general and subspecialty gastroenterology (GI) fellows. Prior studies have demonstrated low quality of communication among GI fellows when discussing end-of-life care.[ 12 ] While transplant hepatology fellows report sufficient opportunities to engage in such conversations, less than 50% report being moderately comfortable to very comfortable in assessing and managing patient concerns about dying.[ 13 ] Therefore, graduating GI fellows entering the workforce may lack training to effectively navigate conversations related to ACP and may struggle to make recommendations related to preferences for interventions such as cardiopulmonary resuscitation and gastrostomy tubes.[ 14 – 16 ] Data from other specialties suggests that communication training during fellowship can increase preparedness for engaging in conversations about serious illness and end of life care.[ 17 – 20 ] In this work, we describe the development, implementation, and assessment of GITalk, a communication curriculum for GI fellows utilizing cases commonly encountered in clinical practice. METHODS GITalk Curriculum Development The curriculum was designed to combine experiential learning with deliberate practice in cases representative of the type of serious illness conversations that GI fellows frequently encounter. The training was structured to be eight hours long and was adapted from similar trainings for fellows in other medical subspecialties. GITalk covers two main communication tasks: delivering serious news and discussing goals of care.[ 19 – 21 ] GITalk training includes a brief didactic session, demonstrations and modeling led by palliative care faculty, and opportunities to practice skills in small groups with simulated patient actors based on the REMAP framework.[ 22 , 23 ] Fig. 1 describes the communication skills associated with each component of REMAP. There are two main cases covered in the sessions with simulated actors: (1) delivering news that a patient with decompensated cirrhosis will no longer be a candidate for liver transplant due to hepatocellular carcinoma growth outside of Milan criteria, and (2) counseling the family of a patient with moderate to severe dementia on the risks and benefits of artificial enteral nutrition via percutaneous feeding tube. Authors involved in case development (ADB and RMA) collaborated with two faculty members from the GI division to obtain feedback on clinical details of the cases. Full case summaries used during training sessions are included in Supplement 1. Baseline and Post-Training Surveys . Immediately prior to participating in GITalk, fellows completed surveys asking them to report basic demographic information as well as past palliative care or communication training experience. They were also asked to rate their perceived preparedness to navigate nine end-of-life communication scenarios on a 1–5 Likert Scale (1 = not at all prepared and 5 = very well prepared) before the training session. After the training, participants again rated their perceived preparedness to lead the nine communication scenarios, as well as their satisfaction with the curriculum in 8 questions on the same Likert scale. Survey instruments were similar to other studies for nephrology, medical oncology, geriatric and palliative care fellows, but were adapted for GI fellows for this training. 18–20 Data Analysis . Survey data were collected from 2nd and 3rd year GI fellows at a single urban tertiary care center who participated in any of the four GITalk training sessions from 2019 to 2022. Each fellow completed the course once. Descriptive statistics were used for baseline characteristics of the participants and their previous palliative care or communication training experiences. Paired t -tests were used to compare self-assessed preparedness before and after training. A p -value less than 0.05 was considered statistically significant. This study was deemed exempt by the University of Pittsburgh Medical Center Institutional Review Board. All analyses were conducted in SPSS. RESULTS Sessions : Four total training sessions were held. Each session included both second and third year GI fellows. In the first two sessions (April 2019 and September 2020), all 5 components of REMAP were included in the day’s curriculum. In the latter two sessions (April 2021 and April 2022), the decision was made to limit training to the first three parts of REMAP ( R eframe, E xpect Emotion, M ap values). This change was made in response to feedback to reduce the cognitive burden on learners and to allow for increased time practicing the skills learned in the first three parts with simulated patients (see Fig. 1 ). When determining how to reduce the material covered in the one-day training, the course directors concluded that these first three steps offered the components most essential for navigating serious illness conversations. Baseline participant characteristics. Baseline participant demographic characteristics are summarized in Table 1 . Twenty-three GI fellows attended one of the four GITalk sessions between April 2019 and April 2022 and completed both pre- and post- training session surveys. The mean age of the participants was 34 years (SD ± 2.8). Most were men (61%) and in their second year of training (78%). Table 1 Baseline Participant Characteristics Total (N = 23) M ± SD or n (%) Age 33.7 ± 2.8 Gender Female 9 (39) Male 14 (61) Fellowship year Second year 18 (78) Third year 5 (22) Ethnicity Caucasian 8 (35) African American 1 (4) Asian or Pacific Islander 7 (30) South Asian 3 (13) Hispanic/Latino 3 (13) Mixed Heritage 1 (4) Note . Mean (M), Standard deviation (SD) Few participants reported having had formal teaching in serious illness conversations up until that point in GI fellowship (see Table 2 ). Specifically, only 9% of participants reported receiving training in discussing feeding tube placement for patients whom they suspect may not benefit from artificial feeding. Forty-four percent of participants reported receiving training on discussing and initiating hospice care for a patient with decompensated cirrhosis who was not a candidate for transplant. Twenty-two percent of participants reported receiving training on ACP, and 9% reported training on discussing cessation of nutrition (either enteral or parental) for patients near the end of life. None of the participants had participated in a formal palliative medicine rotation during fellowship. Table 2 Prior Palliative Care Experience at Baseline Up to this point in GI fellowship, have you received any formal teaching in…? (N = 23) n (%) Discussing insertion of a feeding tube with a patient you think may not benefit from artificial feeding? Yes 2 (9) No 19 (83) Not Sure 2 (9) Discussing and initiating hospice care for a patient with end stage liver disease who is not a candidate for liver transplantation? Yes 10 (44) No 11 (48) Not Sure 2 (9) Having conversations about advance care planning for patients with gastrointestinal disease and a combination of advanced age and/or frailty? Yes 5 (22) No 17 (74) Not Sure 1 (4) Discussing cessation of enteral nutrition or total parenteral nutrition for patients who are declining or near the end-of-life? Yes 2 (9) No 20 (87) Not Sure 1 (4) Formal palliative medicine rotation (during fellowship)? Yes 0 (0) No 23 (100) Not Sure 0 (0) Self-Reported Preparedness and Satisfaction with Training . Independent samples t -tests revealed no significant demographic differences between GI fellows in 2nd vs 3rd year of training ( p > 0.05). Paired sample t- tests revealed that across all nine end-of-life scenarios, participants reported significantly higher mean preparedness scores following training (Table 3 ). On a 5-point Likert scale, the top four mean increases in preparedness following training were in discussing 1) the role of artificial nutrition for patients with dementia (3.0 ± 1.1 to 4.4 ± 0.6); 2) prognosis of decompensated cirrhosis for patients when they were not transplant candidates (3.0 ± 0.7 to 4.4 ± 0.6); 3) role of dialysis for patients with decompensated cirrhosis who are not liver transplant candidates (2.8 ± 0.9 to 4.2 ± 0.7); 4) concerns about death and dying for a patient with advanced GI disease when death may be imminent (3.1 ± 0.9 to 4.5 ± 0.6). Reported satisfaction ranged from 4 (very good/somewhat agree) to 5 (excellent/strongly agree) across all 8 questions (see Fig. 2 ). Specifically, 91% of participants strongly agreed with the statement, “I would recommend this training to other fellows” and 78% strongly agreed with the statement, “This training should be required of all GI fellows”. Table 3 Self-Reported Preparedness Before and After training “How prepared do you feel to…” Before Training ( n = 23) After Training ( n = 23) p M ± SD M ± SD Give bad news about illness to a patient of family member? 3.7 ± 0.6 4.4 ± 0.5 < 0.001 Know how to respond when a patient becomes emotional? 3.5 ± 0.7 4.4 ± 0.6 < 0.001 Discuss the role of artificial nutrition for patients with dementia and decreased functional status? 3.0 ± 1.1 4.4 ± 0.6 < 0.001 Discuss prognosis of ESLD with patients if they ARE transplant candidates? 3.4 ± 0.8 4.3 ± 0.8 < 0.001 Discuss prognosis of ESLD with patients when they are NOT transplant candidates? 3.0 ± -0.7 4.4 ± 0.6 < 0.001 Discuss the role of dialysis for patients with ESLD who are not liver transplant candidates? 2.8 ± 0.9 4.2 ± 0.7 < 0.001 Respond to a patient who advocates for aggressive therapy despite a likely poor outcome? 2.9 ± 0.9 4.2 ± 0.7 < 0.001 Discuss death and dying with a patient who has advanced GI disease when death may be imminent? 3.1 ± 0.9 4.5 ± 0.6 < 0.001 Discuss death and dying with a patient’s family who has advanced GI disease when death may be imminent (and patient cannot participate in a discussion)? 3.1 ± 0.7 4.5 ± 0.5 < 0.001 Note . Mean (M), standard deviation (SD) and p values of an independent sample t-test between the pre- and post-training groups. DISCUSSION In this study, we report on the development, implementation, and assessment of a communication skills training for GI fellows. The core elements of the curriculum are based on the VitalTalk framework, known as REMAP, and features a combination of didactics and patient encounters with standardized patients. Such a curriculum has been implemented in multiple other specialties, including geriatrics, oncology, and nephrology.[ 17 – 20 ] Prior to GITalk, most fellows reported limited prior experience with formal communication skills training. Following training, fellows noted an improvement in preparedness across all queried end of life encounters and reported extremely high satisfaction. GITalk training was associated with a statistically significant increase in self-reported preparedness in a variety of serious illness communication competencies that were surveyed. Notable increases were seen for competencies related to discussing enteral nutrition in patients with dementia and prognosis for patients with decompensated cirrhosis. Satisfaction was uniformly high among all participants, suggesting a desire among trainees to receive such educational experiences, since they are not consistently exposed to them during training. GITalk is sustainable as evidenced by four consecutive (and ongoing) years of training within one fellowship program at a large academic center. Its success has also led to expansion of the training from a one-day course into a two-day course. Consistent with high satisfaction among participants in our data, the course has also expanded to include advanced practice providers within the GI division (data not shown as of this writing). Given that high-quality communication ideally extends beyond individual providers, such engagement across multiple types of providers is highly promising and shows that GITalk can be sustainable. Communication skills taught in GITalk aim to build skills in “primary” PC, which refers to a scenario when a clinician who is not a specialist in PC provides basic care covering the domains of PC. Primary PC skills are needed because there are not enough specialty PC providers to meet the needs of all patients with chronic GI and liver diseases.[ 24 ] Therefore, it is not ideal for core communication skills to be deferred to PC providers alone. In fact, GI providers caring for patients with serious, chronic illnesses often form longitudinal relationships with patients, making them uniquely positioned to engage in such discussions with patients. Because ACP and PC communication are iterative processes, it is important for all clinicians to have fundamental skills in these areas. Despite the novelty of this program and our findings of improvements among learners’ preparedness, this work has several limitations. This was a pilot study intended to collect preliminary data on learner satisfaction and outcomes. As such, we did not include a control group in our study design, and future incorporation of a control group will likely not be feasible since it will result in a subset of trainees not receiving valuable training. Next, post training self-rated preparedness (Table 3 ) is not an objective measure of skill and therefore may not translate into meaningful, durable changes in communication skills in actual patient care scenarios. Generalizability and reproducibility are also concerns. This training was conducted in a single center and facilitators at our center served as content experts in communication training. However, this limitation was at least partially offset by the fact that GITalk training took place over a four-year period with each year having a different set of participants. Lastly, our intervention focused on GI fellows, and there is evidence to support that attending physicians within the field would also benefit from similar trainings.[ 3 ] Therefore, the impact this kind of training might have on changes in care delivery patterns could be limited because the emphasis is on teaching trainees. However, engagement with GI subspecialty societies on these efforts could lead to involvement of a diverse group of clinicians who may stand to benefit from such opportunities and allow for scaling to a wider audience. GI fellows rarely receive training in communication and attending physicians report similar gaps in comfort and skill.[ 12 , 25 ] This trend is concerning given the high exposure to patients with serious illness faced by these providers. Perhaps due to these gaps in training, professional societies have called on training programs to develop and better incorporate communication skills within their curricula.[ 26 ] For these reasons, we believe that GITalk can potentially serve as an important starting point on how to improve GI fellowship training, particularly within the Interpersonal and Communications Skills core competency outlined by the Accreditation Council for Graduate Medical Education. Declarations Robert M Arnold is a board member of Vital Talk, section editor for UpToDate, and receives royalties from Cambridge University Press. None declared for: Alan Noll, Arpan A Patel, Rene Claxton, Shari S Rogal, and Amar D Bansal Competing Interests Robert M Arnold is a board member of Vital Talk, section editor for UpToDate, and receives royalties from Cambridge University Press. None declared for: Alan Noll, Arpan A Patel, Rene Claxton, Shari S Rogal, and Amar D Bansal Author Contribution A.N. and A.B. wrote the main manuscript text and prepared the figures. All authors reviewed and provided critical feedback to the manuscript and figures. Acknowledgement The authors would like to acknowledge Vital Talk. References Kanwal F, Gralnek IM, Hays RD, Zeringue A, Durazo F, Han SB, et al. Health-Related Quality of Life Predicts Mortality in Patients With Advanced Chronic Liver Disease. Clin Gastroenterol H. 2009;7(7):793–9. D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: A systematic review of 118 studies. J Hepatol. 2006;44(1):217–31. Beck KR, Pantilat SZ, O’Riordan DL, Peters MG. Use of Palliative Care Consultation for Patients with End-Stage Liver Disease: Survey of Liver Transplant Service Providers. Journal of Palliative Medicine. 2016;19(8):836–41. Najafian N, Sack JS, DeLisle AM, Jakab S. Advance Care Planning for Patients with Cirrhosis in a Structured Inpatient/Outpatient Hepatology Program. J Palliat Med. 2019;22(11):1445–8. Patel AA, Woodrell C, Ufere NN, Hansen L, Tandon P, Verma M, et al. Developing Priorities for Palliative Care Research in Advanced Liver Disease: A Multidisciplinary Approach. Hepatology Commun. 2021;5(9):1469–80. Kaplan A, Comisar L, Ufere NN, Jannat-Khah D, Rosenblatt R, Fortune B, et al. Understanding Prognosis: Discrepancy in Prognosis Estimates Between Patients With Cirrhosis and their Hepatologists. Clin Gastroenterol Hepatol. 2023;21(4):1005–1012.e4. Kaps L, Omogbehin L, Hildebrand K, Gairing SJ, Schleicher EM, Moehler M, et al. Health literacy in gastrointestinal diseases: a comparative analysis between patients with liver cirrhosis, inflammatory bowel disease and gastrointestinal cancer. Sci Rep. 2022;12(1):21072. Hansen L, Press N, Rosenkranz SJ, Baggs JG, Kendall J, Kerber A, et al. Life-sustaining treatment decisions in the ICU for patients with ESLD: A prospective investigation. Res Nurs Health. 2012;35(5):518–32. Patel AA, Walling AM, Ricks-Oddie J, May FP, Saab S, Wenger N. Palliative Care and Health Care Utilization for Patients With End-Stage Liver Disease at the End of Life. Clinical Gastroenterology and Hepatology. 2017;15(10):1612–1619.e4. Gupta K, Hans B, Khan A, Sohail SH, Kapuria D, Chang C. A retrospective study on use of palliative care for patients with alcohol related end stage liver disease in United States. World J Hepatology. 2022;14(9):1817–29. Tombazzi CR, Howe CF, Slaughter JC, Obstein KL. Rate of and Factors Associated with Palliative Care Referral among Patients Declined for Liver Transplantation. J Palliat Med. 2022;25(9):1404–8. Whitsett MP, Ufere NN, Patel A, Shea JA, Jones CA, Fix OK, et al. Palliative care experience and perceived gaps in training among transplant hepatology fellows: A national survey. Hepatol Commun. 2022;6(7):1680–8. Chaudhary N, Lucero C, Villanueva G, Poles M, Gillespie C, Zabar S, et al. Assessment of Abilities of Gastroenterology Fellows to Provide Information to Patients With Liver Disease. Clin Gastroenterol Hepatol. 2017;15(7):1095–1123.e3. Rogal SS, Hansen L, Patel A, Ufere NN, Verma M, Woodrell CD, et al. AASLD Practice Guidance: Palliative care and symptom-based management in decompensated cirrhosis. Hepatology. 2022;76(3):819–53. Zyl C van, Storms AD, Deen W van, Cardenas V, Ellis R, Flores A, et al. A Pilot Study of a Palliative Care Service Embedded in a Hepatology Clinic at a Large Public Hospital. J Palliat Med. 2022; Rao VL, Feld LD, Rubin DT. Discussion of Code Status in the Peri-Endoscopic Period. Am J Gastroenterol. 2018;114(3):1–3. Cohen RA, Bursic A, Chan E, Norman MK, Arnold RM, Schell JO. NephroTalk Multimodal Conservative Care Curriculum for Nephrology Fellows. Clin J Am Soc Nephro. 2021;CJN.11770720. Schell JO, Green JA, Tulsky JA, Arnold RM. Communication Skills Training for Dialysis Decision-Making and End-of-Life Care in Nephrology. Clin J Am Soc Nephro. 2013;8(4):675–80. Back AL, Arnold RM, Tulsky JA, Baile WF, Fryer-Edwards KA. Teaching Communication Skills to Medical Oncology Fellows. J Clin Oncol. 2003;21(12):2433–6. Kelley AS, Back AL, Arnold RM, Goldberg GR, Lim BB, Litrivis E, et al. Geritalk: Communication Skills Training for Geriatric and Palliative Medicine Fellows. J Am Geriatr Soc. 2012;60(2):332–7. Back AL, Arnold RM, Baile WF, Fryer-Edwards KA, Alexander SC, Barley GE, et al. Efficacy of Communication Skills Training for Giving Bad News and Discussing Transitions to Palliative Care. Arch Intern Med. 2007;167(5):453–60. Childers JW, Back AL, Tulsky JA, Arnold RM. REMAP: A Framework for Goals of Care Conversations. 2017;13(10):e844–50. Vital talk. 2023; Available from: https://www.vitaltalk.org/ Lupu D, Force AA of H and PMWT. Estimate of Current Hospice and Palliative Medicine Physician Workforce Shortage. J Pain Symptom Manag. 2010;40(6):899–911. Fricker ZP, Serper M. Current Knowledge, Barriers to Implementation, and Future Directions in Palliative Care for End-Stage Liver Disease. Liver Transplant. 2019;25(5):787–96. Shah BJ, Onken JE, Edgar L, Jou JH, Obstein KL, Pardi DS, et al. Development of Gastroenterology and Transplant Hepatology Milestones 2.0: A Guide for Programs, Faculty, and Fellows. Gastroenterology. 2021;161(4):1318–24. Additional Declarations Competing interest reported. Robert M Arnold is a board member of Vital Talk, section editor for UpToDate, and receives royalties from Cambridge University Press. None declared for: Alan Noll, Arpan A Patel, Rene Claxton, Shari S Rogal, and Amar D Bansal Supplementary Files GITalkcasesSDC.docx Cite Share Download PDF Status: Posted Version 1 posted 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. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4298423","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":294114593,"identity":"6a7209b4-a7a2-4031-b6e6-e92b1935df57","order_by":0,"name":"Alan Noll","email":"","orcid":"","institution":"University of Pittsburgh Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Alan","middleName":"","lastName":"Noll","suffix":""},{"id":294114595,"identity":"2351dbd6-fc57-44e2-ab7a-c37883891411","order_by":1,"name":"Arpan A Patel","email":"","orcid":"","institution":"University of California, Los Angeles","correspondingAuthor":false,"prefix":"","firstName":"Arpan","middleName":"A","lastName":"Patel","suffix":""},{"id":294114596,"identity":"6775d290-b4af-4ae1-854c-ba3c2c3b2da6","order_by":2,"name":"Rene Claxton","email":"","orcid":"","institution":"University of Pittsburgh Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Rene","middleName":"","lastName":"Claxton","suffix":""},{"id":294114597,"identity":"5563b2b0-18a0-439a-86e9-9da0b3f5fea3","order_by":3,"name":"Robert M Arnold","email":"","orcid":"","institution":"University of Pittsburgh Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"M","lastName":"Arnold","suffix":""},{"id":294114599,"identity":"29b879ae-72bf-45cc-8ecd-f8cf4ee715d2","order_by":4,"name":"Shari S Rogal","email":"","orcid":"","institution":"VA Pittsburgh Center for Health Equity and Promotion","correspondingAuthor":false,"prefix":"","firstName":"Shari","middleName":"S","lastName":"Rogal","suffix":""},{"id":294114601,"identity":"59a65ac3-26e8-4984-8a91-3e0f9546eb51","order_by":5,"name":"Amar D Bansal","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxElEQVRIiWNgGAWjYBACAzBZwMDYDxVgbCBOiwED48wGkrVsOECsFnP2s4c//DCwk918I/fohh8MNrIwvTiBZU9emmSPQbLxtht5aTd7GNKMCWoxOJBjxsBjwJy47UaO2W0GhsOJhLWcf2P88Y9BfeLmGWAt/4nQciPHQJrHAGi4BFjLAcJaLGe8MZOWMThuPOPMO6BfgJ6aSUiLOX+O8cc3FdWy/e25x278qLCT7SOkBQnwMMCiiSQto2AUjIJRMAqwAACS9kefZQIQiQAAAABJRU5ErkJggg==","orcid":"","institution":"University of Pittsburgh Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Amar","middleName":"D","lastName":"Bansal","suffix":""}],"badges":[],"createdAt":"2024-04-20 17:38:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4298423/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4298423/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55537960,"identity":"a12b86a5-e510-41ba-942b-48791b9b0c8c","added_by":"auto","created_at":"2024-04-29 16:46:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":30317,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eCommunication skills framework by year\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eShaded bars indicate which skills were included for the training session. In April 2019 and September 2020, GITalk covered all of REMAP. For April 2021 and 2022, GITalk was shortened to include just REM. See Results section for additional detail.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4298423/v1/9a577a104e407da1e4b03617.png"},{"id":55536713,"identity":"9730c7b0-7f4f-4d87-b272-40e2e9ad205d","added_by":"auto","created_at":"2024-04-29 16:38:21","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":18816,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eParticipant Satisfaction Rating of REMAP Curriculum\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStatements were graded according to degree of participant agreement with that statement on a Likert scale ranging from 1 (“Strongly Disagree”) to 5 (“Strongly Agree”). *Satisfaction ratings were reported on a Likert scale ranging from 1 (“Poor”) to 5 (“Excellent”). There were no responses for Likert scale 1, 2 (“Fair” or “Somewhat Disagree”), or 3 (“Good” or “Neutral”).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4298423/v1/5c52689f0f3d0976040de896.png"},{"id":55815116,"identity":"b1458ea5-0dab-4d28-9694-5d4157673d77","added_by":"auto","created_at":"2024-05-03 18:47:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":461498,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4298423/v1/c024d113-6638-4e63-813e-0bd88e3cd675.pdf"},{"id":55536716,"identity":"d4022e23-5f8b-4f47-8b53-33888e1d2cd7","added_by":"auto","created_at":"2024-04-29 16:38:21","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":18595,"visible":true,"origin":"","legend":"","description":"","filename":"GITalkcasesSDC.docx","url":"https://assets-eu.researchsquare.com/files/rs-4298423/v1/cfc6d7b0b5e449a03490e7ec.docx"}],"financialInterests":"Competing interest reported. Robert M Arnold is a board member of Vital Talk, section editor for UpToDate, and receives royalties from Cambridge University Press. \nNone declared for: Alan Noll, Arpan A Patel, Rene Claxton, Shari S Rogal, and Amar D Bansal","formattedTitle":"GITalk: Communication Skills Training for Gastroenterology Fellows Improves Self-Assessed Preparedness for Serious Illness Conversations","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eDespite a high symptom burden, individuals living with serious illnesses affecting the gastrointestinal and hepatobiliary tracts often have substantial, unmet palliative care (PC) needs.[\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] One important priority for teams caring for these patients is ensuring that they understand their condition and feel prepared for future healthcare decisions. Unfortunately, patients and families often lack a thorough understanding of their illness trajectory and infrequently participate in conversations related to advance care planning (ACP).[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Communication around treatment decisions are often delayed and tend to take place in the inpatient setting, where mortality is high, especially in conditions such as decompensated cirrhosis.[\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eOne reason for such delayed and limited communication in this high-risk population may be gaps in training for general and subspecialty gastroenterology (GI) fellows. Prior studies have demonstrated low quality of communication among GI fellows when discussing end-of-life care.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] While transplant hepatology fellows report sufficient opportunities to engage in such conversations, less than 50% report being moderately comfortable to very comfortable in assessing and managing patient concerns about dying.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] Therefore, graduating GI fellows entering the workforce may lack training to effectively navigate conversations related to ACP and may struggle to make recommendations related to preferences for interventions such as cardiopulmonary resuscitation and gastrostomy tubes.[\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eData from other specialties suggests that communication training during fellowship can increase preparedness for engaging in conversations about serious illness and end of life care.[\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] In this work, we describe the development, implementation, and assessment of GITalk, a communication curriculum for GI fellows utilizing cases commonly encountered in clinical practice.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eGITalk Curriculum Development\u003c/h2\u003e \u003cp\u003eThe curriculum was designed to combine experiential learning with deliberate practice in cases representative of the type of serious illness conversations that GI fellows frequently encounter. The training was structured to be eight hours long and was adapted from similar trainings for fellows in other medical subspecialties. GITalk covers two main communication tasks: delivering serious news and discussing goals of care.[\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eGITalk training includes a brief didactic session, demonstrations and modeling led by palliative care faculty, and opportunities to practice skills in small groups with simulated patient actors based on the REMAP framework.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e1\u003c/span\u003e describes the communication skills associated with each component of REMAP. There are two main cases covered in the sessions with simulated actors: (1) delivering news that a patient with decompensated cirrhosis will no longer be a candidate for liver transplant due to hepatocellular carcinoma growth outside of Milan criteria, and (2) counseling the family of a patient with moderate to severe dementia on the risks and benefits of artificial enteral nutrition via percutaneous feeding tube. Authors involved in case development (ADB and RMA) collaborated with two faculty members from the GI division to obtain feedback on clinical details of the cases. Full case summaries used during training sessions are included in Supplement 1.\u003c/p\u003e \u003cp\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eBaseline and Post-Training Surveys\u003c/span\u003e. Immediately prior to participating in GITalk, fellows completed surveys asking them to report basic demographic information as well as past palliative care or communication training experience. They were also asked to rate their perceived preparedness to navigate nine end-of-life communication scenarios on a 1\u0026ndash;5 Likert Scale (1\u0026thinsp;=\u0026thinsp;not at all prepared and 5\u0026thinsp;=\u0026thinsp;very well prepared) before the training session. After the training, participants again rated their perceived preparedness to lead the nine communication scenarios, as well as their satisfaction with the curriculum in 8 questions on the same Likert scale. Survey instruments were similar to other studies for nephrology, medical oncology, geriatric and palliative care fellows, but were adapted for GI fellows for this training.\u003csup\u003e18\u0026ndash;20\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eData Analysis\u003c/span\u003e. Survey data were collected from 2nd and 3rd year GI fellows at a single urban tertiary care center who participated in any of the four \u003cem\u003eGITalk\u003c/em\u003e training sessions from 2019 to 2022. Each fellow completed the course once. Descriptive statistics were used for baseline characteristics of the participants and their previous palliative care or communication training experiences. Paired \u003cem\u003et\u003c/em\u003e-tests were used to compare self-assessed preparedness before and after training. A \u003cem\u003ep\u003c/em\u003e-value less than 0.05 was considered statistically significant. This study was deemed exempt by the University of Pittsburgh Medical Center Institutional Review Board. All analyses were conducted in SPSS.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSessions\u003c/span\u003e: Four total training sessions were held. Each session included both second and third year GI fellows. In the first two sessions (April 2019 and September 2020), all 5 components of REMAP were included in the day\u0026rsquo;s curriculum. In the latter two sessions (April 2021 and April 2022), the decision was made to limit training to the first three parts of REMAP (\u003cb\u003eR\u003c/b\u003eeframe, \u003cb\u003eE\u003c/b\u003expect Emotion, \u003cb\u003eM\u003c/b\u003eap values). This change was made in response to feedback to reduce the cognitive burden on learners and to allow for increased time practicing the skills learned in the first three parts with simulated patients (see Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e1\u003c/span\u003e). When determining how to reduce the material covered in the one-day training, the course directors concluded that these first three steps offered the components most essential for navigating serious illness conversations.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eBaseline participant characteristics.\u003c/span\u003e Baseline participant demographic characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Twenty-three GI fellows attended one of the four GITalk sessions between April 2019 and April 2022 and completed both pre- and post- training session surveys. The mean age of the participants was 34 years (SD\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;2.8). Most were men (61%) and in their second year of training (78%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eBaseline Participant Characteristics\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTotal (N\u0026thinsp;=\u0026thinsp;23)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u0026thinsp;\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;\u003cem\u003eSD or n (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.7\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (39)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (61)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFellowship year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecond year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (78)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThird year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eEthnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCaucasian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfrican American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAsian or Pacific Islander\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouth Asian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHispanic/Latino\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMixed Heritage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003eNote\u003c/em\u003e. Mean (M), Standard deviation (SD)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFew participants reported having had formal teaching in serious illness conversations up until that point in GI fellowship (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Specifically, only 9% of participants reported receiving training in discussing feeding tube placement for patients whom they suspect may not benefit from artificial feeding. Forty-four percent of participants reported receiving training on discussing and initiating hospice care for a patient with decompensated cirrhosis who was not a candidate for transplant. Twenty-two percent of participants reported receiving training on ACP, and 9% reported training on discussing cessation of nutrition (either enteral or parental) for patients near the end of life. None of the participants had participated in a formal palliative medicine rotation during fellowship.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrior Palliative Care Experience at Baseline\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eUp to this point in GI fellowship, have you received any formal teaching in\u0026hellip;? (N\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDiscussing insertion of a feeding tube with a patient you think may not benefit from artificial feeding?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (83)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot Sure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDiscussing and initiating hospice care for a patient with end stage liver disease who is not a candidate for liver transplantation?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (48)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot Sure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHaving conversations about advance care planning for patients with gastrointestinal disease and a combination of advanced age and/or frailty?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (74)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot Sure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDiscussing cessation of enteral nutrition or total parenteral nutrition for patients who are declining or near the end-of-life?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (87)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot Sure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFormal palliative medicine rotation (during fellowship)?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot Sure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eSelf-Reported Preparedness and Satisfaction with Training\u003c/span\u003e. Independent samples \u003cem\u003et\u003c/em\u003e-tests revealed no significant demographic differences between GI fellows in 2nd vs 3rd year of training (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Paired sample \u003cem\u003et-\u003c/em\u003etests revealed that across all nine end-of-life scenarios, participants reported significantly higher mean preparedness scores following training (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). On a 5-point Likert scale, the top four mean increases in preparedness following training were in discussing 1) the role of artificial nutrition for patients with dementia (3.0\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;1.1 to 4.4\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.6); 2) prognosis of decompensated cirrhosis for patients when they were not transplant candidates (3.0\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.7 to 4.4\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.6); 3) role of dialysis for patients with decompensated cirrhosis who are not liver transplant candidates (2.8\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.9 to 4.2\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.7); 4) concerns about death and dying for a patient with advanced GI disease when death may be imminent (3.1\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.9 to 4.5\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.6). Reported satisfaction ranged from 4 (very good/somewhat agree) to 5 (excellent/strongly agree) across all 8 questions (see Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Specifically, 91% of participants strongly agreed with the statement, \u0026ldquo;I would recommend this training to other fellows\u0026rdquo; and 78% strongly agreed with the statement, \u0026ldquo;This training should be required of all GI fellows\u0026rdquo;.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eSelf-Reported Preparedness Before and After training\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;How prepared do you feel to\u0026hellip;\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore Training\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter Training\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGive bad news about illness to a patient of family member?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.7\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.4\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnow how to respond when a patient becomes emotional?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.4\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscuss the role of artificial nutrition for patients with\u003c/p\u003e \u003cp\u003edementia and decreased functional status?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.0\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.4\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscuss prognosis of ESLD with patients if they ARE\u003c/p\u003e \u003cp\u003etransplant candidates?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.4\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.3\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscuss prognosis of ESLD with patients when they are\u003c/p\u003e \u003cp\u003eNOT transplant candidates?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.0\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e-0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.4\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscuss the role of dialysis for patients with ESLD who are\u003c/p\u003e \u003cp\u003enot liver transplant candidates?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.8\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.2\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRespond to a patient who advocates for aggressive therapy\u003c/p\u003e \u003cp\u003edespite a likely poor outcome?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.9\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.2\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscuss death and dying with a patient who has advanced GI\u003c/p\u003e \u003cp\u003edisease when death may be imminent?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.1\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.5\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscuss death and dying with a patient\u0026rsquo;s family who has\u003c/p\u003e \u003cp\u003eadvanced GI disease when death may be imminent (and\u003c/p\u003e \u003cp\u003epatient cannot participate in a discussion)?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.1\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.5\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNote\u003c/em\u003e. Mean (M), standard deviation (SD) and p values of an independent sample t-test between the pre- and post-training groups.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this study, we report on the development, implementation, and assessment of a communication skills training for GI fellows. The core elements of the curriculum are based on the VitalTalk framework, known as REMAP, and features a combination of didactics and patient encounters with standardized patients. Such a curriculum has been implemented in multiple other specialties, including geriatrics, oncology, and nephrology.[\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] Prior to GITalk, most fellows reported limited prior experience with formal communication skills training. Following training, fellows noted an improvement in preparedness across all queried end of life encounters and reported extremely high satisfaction.\u003c/p\u003e \u003cp\u003eGITalk training was associated with a statistically significant increase in self-reported preparedness in a variety of serious illness communication competencies that were surveyed. Notable increases were seen for competencies related to discussing enteral nutrition in patients with dementia and prognosis for patients with decompensated cirrhosis. Satisfaction was uniformly high among all participants, suggesting a desire among trainees to receive such educational experiences, since they are not consistently exposed to them during training. GITalk is sustainable as evidenced by four consecutive (and ongoing) years of training within one fellowship program at a large academic center. Its success has also led to expansion of the training from a one-day course into a two-day course. Consistent with high satisfaction among participants in our data, the course has also expanded to include advanced practice providers within the GI division (data not shown as of this writing). Given that high-quality communication ideally extends beyond individual providers, such engagement across multiple types of providers is highly promising and shows that GITalk can be sustainable.\u003c/p\u003e \u003cp\u003eCommunication skills taught in GITalk aim to build skills in \u0026ldquo;primary\u0026rdquo; PC, which refers to a scenario when a clinician who is not a specialist in PC provides basic care covering the domains of PC. Primary PC skills are needed because there are not enough specialty PC providers to meet the needs of all patients with chronic GI and liver diseases.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] Therefore, it is not ideal for core communication skills to be deferred to PC providers alone. In fact, GI providers caring for patients with serious, chronic illnesses often form longitudinal relationships with patients, making them uniquely positioned to engage in such discussions with patients. Because ACP and PC communication are iterative processes, it is important for all clinicians to have fundamental skills in these areas.\u003c/p\u003e \u003cp\u003eDespite the novelty of this program and our findings of improvements among learners\u0026rsquo; preparedness, this work has several limitations. This was a pilot study intended to collect preliminary data on learner satisfaction and outcomes. As such, we did not include a control group in our study design, and future incorporation of a control group will likely not be feasible since it will result in a subset of trainees not receiving valuable training. Next, post training self-rated preparedness (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) is not an objective measure of skill and therefore may not translate into meaningful, durable changes in communication skills in actual patient care scenarios. Generalizability and reproducibility are also concerns. This training was conducted in a single center and facilitators at our center served as content experts in communication training. However, this limitation was at least partially offset by the fact that GITalk training took place over a four-year period with each year having a different set of participants. Lastly, our intervention focused on GI fellows, and there is evidence to support that attending physicians within the field would also benefit from similar trainings.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Therefore, the impact this kind of training might have on changes in care delivery patterns could be limited because the emphasis is on teaching trainees. However, engagement with GI subspecialty societies on these efforts could lead to involvement of a diverse group of clinicians who may stand to benefit from such opportunities and allow for scaling to a wider audience.\u003c/p\u003e \u003cp\u003eGI fellows rarely receive training in communication and attending physicians report similar gaps in comfort and skill.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] This trend is concerning given the high exposure to patients with serious illness faced by these providers. Perhaps due to these gaps in training, professional societies have called on training programs to develop and better incorporate communication skills within their curricula.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] For these reasons, we believe that GITalk can potentially serve as an important starting point on how to improve GI fellowship training, particularly within the Interpersonal and Communications Skills core competency outlined by the Accreditation Council for Graduate Medical Education.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003c/strong\u003eRobert M Arnold is a board member of Vital Talk, section editor for UpToDate, and receives royalties from Cambridge University Press.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNone declared for: Alan Noll, Arpan A Patel, Rene Claxton, Shari S Rogal, and Amar D Bansal\u003c/p\u003e\n\u003ch2\u003eCompeting Interests\u003c/h2\u003e\u003cp\u003eRobert M Arnold is a board member of Vital Talk, section editor for UpToDate, and receives royalties from Cambridge University Press. None declared for: Alan Noll, Arpan A Patel, Rene Claxton, Shari S Rogal, and Amar D Bansal\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.N. and A.B. wrote the main manuscript text and prepared the figures. All authors reviewed and provided critical feedback to the manuscript and figures.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to acknowledge Vital Talk.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKanwal F, Gralnek IM, Hays RD, Zeringue A, Durazo F, Han SB, et al. Health-Related Quality of Life Predicts Mortality in Patients With Advanced Chronic Liver Disease. Clin Gastroenterol H. 2009;7(7):793\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eD\u0026rsquo;Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: A systematic review of 118 studies. J Hepatol. 2006;44(1):217\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeck KR, Pantilat SZ, O\u0026rsquo;Riordan DL, Peters MG. Use of Palliative Care Consultation for Patients with End-Stage Liver Disease: Survey of Liver Transplant Service Providers. Journal of Palliative Medicine. 2016;19(8):836\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNajafian N, Sack JS, DeLisle AM, Jakab S. Advance Care Planning for Patients with Cirrhosis in a Structured Inpatient/Outpatient Hepatology Program. J Palliat Med. 2019;22(11):1445\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel AA, Woodrell C, Ufere NN, Hansen L, Tandon P, Verma M, et al. Developing Priorities for Palliative Care Research in Advanced Liver Disease: A Multidisciplinary Approach. Hepatology Commun. 2021;5(9):1469\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaplan A, Comisar L, Ufere NN, Jannat-Khah D, Rosenblatt R, Fortune B, et al. Understanding Prognosis: Discrepancy in Prognosis Estimates Between Patients With Cirrhosis and their Hepatologists. Clin Gastroenterol Hepatol. 2023;21(4):1005\u0026ndash;1012.e4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaps L, Omogbehin L, Hildebrand K, Gairing SJ, Schleicher EM, Moehler M, et al. Health literacy in gastrointestinal diseases: a comparative analysis between patients with liver cirrhosis, inflammatory bowel disease and gastrointestinal cancer. Sci Rep. 2022;12(1):21072.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHansen L, Press N, Rosenkranz SJ, Baggs JG, Kendall J, Kerber A, et al. Life-sustaining treatment decisions in the ICU for patients with ESLD: A prospective investigation. Res Nurs Health. 2012;35(5):518\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel AA, Walling AM, Ricks-Oddie J, May FP, Saab S, Wenger N. Palliative Care and Health Care Utilization for Patients With End-Stage Liver Disease at the End of Life. Clinical Gastroenterology and Hepatology. 2017;15(10):1612\u0026ndash;1619.e4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGupta K, Hans B, Khan A, Sohail SH, Kapuria D, Chang C. A retrospective study on use of palliative care for patients with alcohol related end stage liver disease in United States. World J Hepatology. 2022;14(9):1817\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTombazzi CR, Howe CF, Slaughter JC, Obstein KL. Rate of and Factors Associated with Palliative Care Referral among Patients Declined for Liver Transplantation. J Palliat Med. 2022;25(9):1404\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhitsett MP, Ufere NN, Patel A, Shea JA, Jones CA, Fix OK, et al. Palliative care experience and perceived gaps in training among transplant hepatology fellows: A national survey. Hepatol Commun. 2022;6(7):1680\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChaudhary N, Lucero C, Villanueva G, Poles M, Gillespie C, Zabar S, et al. Assessment of Abilities of Gastroenterology Fellows to Provide Information to Patients With Liver Disease. Clin Gastroenterol Hepatol. 2017;15(7):1095\u0026ndash;1123.e3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRogal SS, Hansen L, Patel A, Ufere NN, Verma M, Woodrell CD, et al. AASLD Practice Guidance: Palliative care and symptom-based management in decompensated cirrhosis. Hepatology. 2022;76(3):819\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZyl C van, Storms AD, Deen W van, Cardenas V, Ellis R, Flores A, et al. A Pilot Study of a Palliative Care Service Embedded in a Hepatology Clinic at a Large Public Hospital. J Palliat Med. 2022;\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRao VL, Feld LD, Rubin DT. Discussion of Code Status in the Peri-Endoscopic Period. Am J Gastroenterol. 2018;114(3):1\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen RA, Bursic A, Chan E, Norman MK, Arnold RM, Schell JO. NephroTalk Multimodal Conservative Care Curriculum for Nephrology Fellows. Clin J Am Soc Nephro. 2021;CJN.11770720.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchell JO, Green JA, Tulsky JA, Arnold RM. Communication Skills Training for Dialysis Decision-Making and End-of-Life Care in Nephrology. Clin J Am Soc Nephro. 2013;8(4):675\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBack AL, Arnold RM, Tulsky JA, Baile WF, Fryer-Edwards KA. Teaching Communication Skills to Medical Oncology Fellows. J Clin Oncol. 2003;21(12):2433\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelley AS, Back AL, Arnold RM, Goldberg GR, Lim BB, Litrivis E, et al. Geritalk: Communication Skills Training for Geriatric and Palliative Medicine Fellows. J Am Geriatr Soc. 2012;60(2):332\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBack AL, Arnold RM, Baile WF, Fryer-Edwards KA, Alexander SC, Barley GE, et al. Efficacy of Communication Skills Training for Giving Bad News and Discussing Transitions to Palliative Care. Arch Intern Med. 2007;167(5):453\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChilders JW, Back AL, Tulsky JA, Arnold RM. REMAP: A Framework for Goals of Care Conversations. 2017;13(10):e844\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVital talk. 2023; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.vitaltalk.org/\u003c/span\u003e\u003cspan address=\"https://www.vitaltalk.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLupu D, Force AA of H and PMWT. Estimate of Current Hospice and Palliative Medicine Physician Workforce Shortage. J Pain Symptom Manag. 2010;40(6):899\u0026ndash;911.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFricker ZP, Serper M. Current Knowledge, Barriers to Implementation, and Future Directions in Palliative Care for End-Stage Liver Disease. Liver Transplant. 2019;25(5):787\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShah BJ, Onken JE, Edgar L, Jou JH, Obstein KL, Pardi DS, et al. Development of Gastroenterology and Transplant Hepatology Milestones 2.0: A Guide for Programs, Faculty, and Fellows. Gastroenterology. 2021;161(4):1318\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Communication skills, goals of care, gastroenterology, hepatology, palliative care","lastPublishedDoi":"10.21203/rs.3.rs-4298423/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4298423/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDespite caring for conditions associated with high symptom burden and mortality, GI fellows rarely receive communication training.\u003c/p\u003e\u003ch2\u003eAims\u003c/h2\u003e \u003cp\u003eTo describe the development, implementation, and assessment of GITalk, a novel communication curriculum for gastroenterology (GI) fellows.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eGITalk was designed to improve the skills needed to have effective serious illness conversations frequently encountered in clinical practice. Participants practiced encounters using two cases with simulated actors. One case involved delivering news that a patient with decompensated cirrhosis will no longer be a candidate for liver transplant, and the second case involved counseling the family of a patient with moderate to severe dementia on the risks and benefits of inserting a percutaneous feeding tube for artificial enteral nutrition.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAnnual training sessions were held for four consecutive years, representing a total of 23 GI fellows. Prior to participation in GITalk, few participants reported having had prior formal teaching in serious illness conversations. Paired sample t-tests showed that participants had significantly higher mean post-training preparedness scores compared to pre-training across all 9 survey questions. 91% of participants strongly agreed with the statement: \u0026ldquo;I would recommend this training to other fellows.\u0026rdquo; 78% strongly agreed with, \u0026ldquo;This training should be required of all GI fellows.\u0026rdquo;\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003e Participants had little formal training in serious illness conversation prior to participation in GITalk. They reported substantial improvement in their self-assessed preparedness for discussing common clinical scenarios encountered in gastroenterology. GITalk can serve as a model for improvements in the Interpersonal and Communication Skills core competency for gastroenterology trainees.\u003c/p\u003e","manuscriptTitle":"GITalk: Communication Skills Training for Gastroenterology Fellows Improves Self-Assessed Preparedness for Serious Illness Conversations","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-29 16:38:16","doi":"10.21203/rs.3.rs-4298423/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4911d5a8-c318-4546-89ca-cfabe571cc2c","owner":[],"postedDate":"April 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-09T15:02:35+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-29 16:38:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4298423","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4298423","identity":"rs-4298423","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}