L. J. Taylor1, S. K. Johnson2, T. C. Campbell2, A. Zelenski2, J. Tucholka1, M. Nabozny1, M. Schwarze1 1University Of Wisconsin,Surgery,Madison, WI, USA 2University Of Wisconsin,Medicine,Madison, WI, USA
Introduction: Surgeons bear responsibility for the conduct of preoperative discussions about end-of-life care, yet surgical training provides little formalized communication instruction. Best Case/Worst Case is a communication framework designed to help surgeons structure challenging decision-making conversations with frail older adults who have acute surgical problems. We initially used a one-on-one resource intensive format to train surgeons to use this framework that was difficult to scale for wide-spread dissemination. Our objective was to use implementation science to streamline training and generate an implementation package to teach groups of surgeons to use Best Case/Worst Case. We sought to test and refine this implementation strategy with surgical residents.
Methods: We initially trained 25 attending surgeons using intensive didactic instruction and one-on-one coaching with standardized patients. We used the conceptual framework developed by Proctor to iteratively revise the training to build a less resource-intensive program to teach groups of surgeons. This new training program includes an instructional video, role-play, and small-group coaching. We then trained residents in general surgery, vascular surgery, and urology at a single institution. After training, participants completed a standardized assessment of competence and a survey to evaluate implementation outcomes including feasibility, fidelity, acceptability, adoption, and appropriateness. We used these results to evaluate and refine the training program to construct a final implementation package.
Results: We used training completion rates to assess feasibility; of the 42 eligible participants, 24 completed the 2-hour training. We measured fidelity of tool enactment using a standardized post-training assessment; residents scored a mean of 13.2 points (range 11-15) using a checklist of 15 essential Best Case/Worst Case elements. Elements residents most commonly missed were breaking bad news and making a treatment recommendation. Regarding acceptability, adoption, and appropriateness, 100% report Best Case/Worst Case is better than what they usually do to help patients make decisions, 50% are using the tool with patients 2 months after training, and 67% strongly agree that the Best Case/Worst Case approach is suitable to help patients make value-laden choices.
Conclusion: We developed an implementation package to train groups of surgeons to use the Best Case/Worst Case framework. Our findings suggest that training can be implemented with high fidelity and the tool is acceptable to end users. We learned valuable lesson which were incorporated within the implementation package including the importance of buy-in from local surgical leadership to increase participation, tool elements that need emphasis during training, and specific guidance to facilitate success of the role-play component. Future study will evaluate the effect of this implementation package at other institutions.