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Abstract
Conservative care, a comprehensive treatment path for advanced kidney disease most suitable for individuals unlikely to benefit from dialysis, is underutilized in the United States. One reason is an absence of robust education about this approach and how to discuss it with potential candidates. To address this need, we developed a multimodal conservative care curriculum for nephrology fellows. This curriculum consists of four online modules that address essential concepts and communication skills related to conservative care. It is followed by an in-person, interactive, “flipped classroom” session facilitated by designated nephrology educators at participating Accreditation Council for Graduate Medical Education nephrology training programs. Curriculum effect was assessed using surveys completed by participating fellows immediately before and following the curriculum and for participating nephrology educators following flipped classroom teaching; 148 nephrology trainees from 19 programs participated, with 108 completing both pre- and postcurriculum surveys. Mean self-reported preparedness (measured on a five-point Likert scale) increased significantly for all ten concepts taught in the curriculum. The mean correct score on eight knowledge questions increased from 69% to 82% following the curriculum (P<0.001). Fellows rated the curriculum highly and reported that they plan to practice skills learned. For the 19 nephrology program educators, the mean perceived preparedness to teach all curriculum domains increased after, compared with before, facilitating the flipped classroom, reaching significance for seven of the ten concepts measured. Data suggest that fellows' participation in a multimodal curriculum increased knowledge and preparation for fundamental conservative care concepts and communication skills. Fellows rated the curriculum highly. Educator participation appears to have increased preparedness for teaching the curriculum concepts, making it likely that future education in conservative care will become more widespread. Herein, we describe the curriculum content, which we have made publicly available in order to encourage broader implementation, and its effect on participating fellows and the nephrology educators who facilitated it.
Introduction
Conservative care, defined as medical management without dialysis, is an appropriate advanced kidney disease treatment for patients unlikely to gain meaningful benefit from dialysis. Grounded in palliative care principles, conservative care is associated with improved symptom management, receipt of care that aligns with patient values and priorities, and higher utilization of hospice services at end of life compared with those undergoing dialysis (1⇓–3). Despite these attributes and nephrology guidelines promoting patient-centered care (4⇓–6), conservative care appears underutilized in the United States compared with other Western countries (7⇓⇓⇓⇓⇓⇓–14). Kidney failure data from the US Department of Veterans Affairs, for example, reveal that 41% of elderly patients over the age of 85 were receiving or preparing for dialysis, despite the presence of high comorbidity (7).
Among the likely reasons for this trend is a dearth of education about and comfort in discussing conservative care with patients who may derive benefit (15⇓–17). Education in primary palliative care skills, particularly those focused on discussing prognosis and goals of care, may lead to higher utilization of conservative care. Although nephrology fellows report limited teaching about and comfort in performing these tasks (18,19), we found that education improves primary palliative care skills in nephrology trainees. Following NephroTalk, a multiday training course, fellows gained an average of 3.8 communication skills for delivering bad news and responding to emotion (20).
In-person courses such as NephroTalk, however, are resource intensive, requiring skilled communication facilitators and simulated patients. Accordingly, scalable interventions, such as online courses, are necessary to broaden the effect of communication skills training in nephrology. With support from the American Society of Nephrology (ASN) William and Sandra Bennett Clinical Scholars Program, we created a multimodal “NephroTalk conservative care curriculum” for nephrology fellows, consisting of an online component followed by an in-person flipped classroom session. This curriculum aims to (1) improve fellows' preparedness in core conservative care concepts and tasks and (2) provide educational materials and approaches to a community of nephrology educators interested in teaching these concepts and tasks to nephrology fellows. This article describes the curriculum design, content, and evaluation of the effect it had on fellows' knowledge and preparedness in conservative care as well as educators' comfort and preparedness to teach these concepts and skills.
NephroTalk Conservative Care Curriculum Overview
The curriculum has two primary components: (1) an online portion to be completed independently by each fellow followed by (2) an in-person, flipped classroom session convened at each participating training program led by a designated local nephrology educator (Figure 1).
Conservative care curriculum components. REMAP framework: “R” is reframe why the status quo is not working, “E” is expect emotion and empathize, “M” is map the future, “A” is align with patient’s values, and “P” is plan treatments that match patient values. CC, conservative care; TLT, time-limited trial dialysis.
The online component consists of four modules, each approximately 30 minutes in duration, that address the following: (1) description of conservative care and relevant outcomes, (2) identification of patients who may benefit from conservative care, (3) learning how to elicit patient values to guide treatment decisions for conservative care, and (4) learning how to make a recommendation for conservative care and a time-limited trial (see https://www.nephro-talk.com). Experts in online curriculum development (M.K.N.) and palliative care education (R.M.A.) guided module production. Videos were produced at the University of Pittsburgh’s Innovative Design for Education and Assessment Laboratory. Fellows viewed the modules independently, or in one instance as a group, at their own pace and with the opportunity to revisit previously viewed content.
Threaded throughout the modules are communication skill demonstrations with two simulated patients, each with serious illness, who are approaching kidney failure. Modules 3 and 4 present a previously published communication framework, REMAP (“R,” reframe why status quo is not working; “E,” expect emotion and empathize; “M,” map the future; “A,” align with patient’s values; “P,” plan treatments that match values), for discussing treatment decisions with seriously ill patients that incorporates elicited patient values and priorities (21). Fellows observe two nephrologists (R.A.C. and J.O.S.) having shared decision-making discussions with each patient using REMAP, in which one patient elects a time-limited dialysis trial and the other chooses conservative care. The curriculum also includes “worksheet moments,” in which the fellows are intermittently prompted to answer questions or engage in exercises on topics addressed.
After completing the online curriculum, a 1-hour in-person, interactive flipped classroom session, designed to reinforce online learning, was convened at each participating institution. These were led by locally identified nephrology faculty educators, whom we characterized as palliative care “champions.” During the session, the trainees worked as a group to apply the recently learned REMAP framework to a patient vignette provided (Supplemental Material).
To prepare for session teaching, champions attended a conference call with curriculum developers. Additionally, they were provided a facilitator guide (Supplemental Material), a novel patient case (Supplemental Material), and PowerPoint slides for session use (Supplemental Material). The facilitator guide, informed by adult learning principles, explained the different steps for executing the session, coaching tips, and proposed timing of session components. It also contained several open-ended questions, designed to coalesce trainee learning, for champions to pose at the session conclusion: “what surprised you about the curriculum,” “what are you still curious about,” and “what will you take forward into clinical practice?” Champions opted to facilitate the session alone or to recruit a palliative care faculty member as a cofacilitator.
Recruitment and Curriculum Implementation
During the 2018 ASN Kidney Week Training Program Director Meeting, we presented a brief overview of the curriculum and invited Accreditation Council for Graduate Medical Education (ACGME) nephrology training programs to participate in the curriculum. Consenting programs then identified the local champion charged with overseeing the curriculum and facilitating the flipped classroom. Over the following 3 months, 19 US ACGME–accredited nephrology training programs (Ascension St. John Hospital, Baylor, Duke, Emory, Henry Ford Hospital, Johns Hopkins, Medical College Wisconsin, Medical College South Carolina, Mount Sinai Medical School, New York Medical College, Oregon Health Sciences University, University of Chicago, University of Colorado, University of Kentucky, University of Massachusetts, University of Texas Southwestern, University of Washington, Vanderbilt, and Yale) participated, each designating a champion educator and providing email addresses of current nephrology fellows. A brief curriculum description and invitation to participate voluntarily were then emailed to the fellows, who were informed that participation would have no direct bearing on fellowship training or standing. After 177 fellows completed a precurriculum survey, they received a link to the online curriculum to be completed within 3 months. At the conclusion of the classroom at each program, fellows were emailed a postcurriculum survey. The classroom session was scheduled at least 3 months after initiation of the online component at each program. This study was approved by the University of Pittsburgh Institutional Review Board under exempt criteria for educational setting.
Curriculum Evaluation
Two surveys measured the effect of the curriculum on nephrology fellows, done before and immediately after curriculum completion. The presurvey included a baseline assessment of prior formal teaching on conservative care and communication skills for conversations with patients about this option (Table 1). Fellows' perceived preparedness for ten conservative care concepts and communication skills was measured at baseline and after the classroom session. Preparedness was measured on a one to five Likert-type scale (one is “not at all prepared,” and five is “extremely prepared”) for the following: defining conservative care, identifying which patients benefit most from conservative care, describing how long a person can survive with conservative care, describing factors associated with poor survival on dialysis, knowing the effect that geriatric syndromes have on dialysis outcomes, knowing how to respond when a patient becomes emotional, knowing a communication framework for eliciting patient values and priorities to guide treatment decisions, and knowing how to incorporate patient values into a recommendation for conservative care or a time-limited dialysis trial. Fellows also answered eight knowledge questions (Supplemental Material) about conservative care topics and communication skills before and after the curriculum. The first question asked about survival with conservative care; questions 2–4 queried about differences in outcomes (subjective well-being, symptoms, and access to hospice) for conservative care compared with dialysis. Questions 5–8 dealt with acknowledging emotions arising during conversations, asking patients' illness understanding before providing information, identifying expected changes in survival and function on dialysis, and knowing specific prognostic variables related to survival on dialysis. Postsurvey open-ended questions included asking what fellows will do differently in caring for patients, what aspect of the online curriculum was especially useful, describe a change that could improve the curriculum, and identify one to two future kidney palliative care topics about which they wish to learn more.
Baseline characteristics of fellows and champions
The champions completed a survey after teaching the classroom session, measuring perceived preparedness to teach the ten conservative care concepts and communication skills after, compared with before, participating in this educational intervention. Ratings were on a one to five Likert-type scale (one is “not at all prepared,” and five is “extremely prepared”). Fellows' and champions' pre- and postsurvey data were stored securely in REDCap data management system (22). SAS University Edition and Microsoft Excel: Microsoft Office Professional Plus 2016 were used for statistical analyses. Paired sample t test was used to compare self-rated pre- and postcurriculum preparedness to use and teach selected conservative care skills among nephrology fellows and faculty champions, respectively, as well as pre- and postintervention knowledge evaluation scores for fellows. F tests were used to determine whether the t test for equal or unequal variances was appropriate for each item. Inductive qualitative analysis was used to identify emergent themes among postintervention survey free response items (23).
In total, 148 fellows (84%) completed the survey and received a link to the online component. Among those, 108 (73%) completed the postsurvey. The majority of fellows (60%) were men, with 45% first-year, 47% second-year, and 8% third-year trainees (Table 1). The majority of participants reported having only one to two formal teaching sessions (lecture or small group discussion) on conservative care concepts or communication skills prior to the curriculum (Table 1).
Fellows were asked to evaluate preparedness for specific conservative care concepts and communication skills before and after the curriculum (Table 2). Mean perceived preparedness on a five-point Likert scale significantly increased for all ten conservative care concepts taught in the curriculum (range, 1.0–1.4 points; P<0.001). Mean correct score on the eight-question knowledge evaluation increased from 69% to 82% following the curriculum (P<0.001). The majority of fellows (75%) completed three-quarters to all of the modules. Fellows rated the curriculum very highly (Table 3), including the relevance of the online modules to nephrology training. They appraised favorably the usefulness of specific module facets, including communication skills demonstrations, worksheets, prognosis exercise, and the treatment recommendation exercise. Fellows also rated the classroom session highly, including the group exercise applying the REMAP framework. Mastering how to communicate conservative care with patients, appraised as very important, was rated more highly than mastering renal tubular acidosis.
Fellows' self-rated preparedness pre- and postcurriculum
Fellows' satisfaction with curriculum
When fellows were asked about an especially useful curriculum aspect, the primary themes noted were (1) learning a structured approach to discussing goals of care, (2) understanding prognostic data for conservative care and dialysis, and (3) demonstrations of communication skills used with patients. The most commonly mentioned constructive feedback included shortening the curriculum, adding more written content to supplement the modules, and providing more complex patient cases.
When fellows were prompted to identify one curriculum-related skill or concept they intend to practice, the most common themes that emerged were (1) recognizing and responding to patient emotions, (2) eliciting patient goals before discussing treatments, (3) asking permission before providing prognostic information or a treatment recommendation, and (4) recognizing conservative care as a valid treatment option. The three most frequently noted palliative care topics they wished to learn more about were delivery of conservative care and symptom management, time-limited dialysis trials, and dialysis withdrawal and end of life.
The majority of the 19 champions (Table 1) were women (58%), with most practicing nephrology for 5–10 years. Five had training in both palliative care and nephrology, and one had dual training in nephrology and geriatrics. Ten enlisted a local palliative care subspecialist to cofacilitate. All champions responded to the postclassroom survey (Table 4). Mean perceived preparedness to teach increased after, compared with before, curriculum exposure and achieved significance for all domains except the following: defining conservative care, describing which patients benefit most from conservative care, and factors associated with poor survival on dialysis.
Champions' self-reported preparedness pre- and postcurriculum
Those champions who enlisted palliative care colleagues found them to be a valuable addition, with one noting, “Our palliative care colleagues were able to provide additional insight, anecdotes, and strategies that I believe the learners felt were helpful.” The champions commented that fellows appeared to be excited about and reported more confidence in using communication skills. Champions also reported learning more about relevant communication skills that they plan to use frequently in clinical practice. For future curriculum topics, they suggested developing more educational material regarding implementation of conservative care and symptom management, time-limited trials, and how to discuss dialysis withdrawal.
Conclusions
We have developed a multimodal curriculum designed to teach conservative care concepts and communication skills. This was piloted at 19 ACGME nephrology training programs with 148 fellows participating. These findings suggest that education improves nephrology fellows' comfort with and willingness to discuss and recommend conservative care. After completion, fellows’ attitudes indicated the importance of conservative care, with the majority planning to implement specific approaches and communication skills taught in the curriculum. Both the online modules and flipped classroom were rated highly by respondents.
Our use of online education and a flipped classroom session aligns with a shift in medical education toward more active and innovative teaching methods. The curriculum is grounded in the Knowledge, Process, and Practice mode that promotes adult learning concepts (24). Consistent with this model, online content is deliberately concise and includes simulated patient interview demonstrations. Worksheet activities encourage reflection, followed immediately by putting learning into practice. As an example, for one worksheet, fellows were asked to write treatment recommendations for either conservative care or a time-limited trial on the basis of provided medical information and values for two different patients. As part of the flipped classroom, fellows as a group applied skills learned independently online to an additional case exercise provided.
Currently, conservative care is not an equally considered and routinely recommended treatment option compared with dialysis and kidney transplantation. Practice patterns suggest dialysis often remains a default decision despite patient preferences for nondialytic treatment (25⇓⇓⇓–29). We deliberately enlisted nephrology champions to address this issue with the intention of improving conservative care education among these educators. Consequently, a community of nephrology educators skilled in practicing and teaching conservative care has been established. Ten of the 19 educators partnered with a local palliative care educator, thus creating future opportunities for palliative care integration and collaboration within nephrology and a model that can be replicated at other programs. Nephrology educators described feeling empowered by the curriculum. One shared the comment, “Conservative care wasn’t taught to me, so it’s really helpful to know that there is a community that is filling that gap and that what I’m teaching is in line with that.”
The curriculum design and the study findings have several strengths. The curriculum was developed with several fundamental education principles in mind that promote active learning: presentation of content in discrete segments, consistent with cognitive load theory; individual pacing of modules and the ability to repeat material as desired, cohering with learner centeredness; questions posed throughout the modules, coherent with reflective practice; and a flipped classroom session consistent with interactive, spaced education (30⇓⇓⇓⇓⇓–36). Although self-selected, the participating institutions were diverse geographically and by type of nephrology training program, including both academic institutions and a couple of community hospitals, thus making the findings more generalizable for American trainees. On the basis of responses to questions posed before and after the curriculum, fellows gained knowledge of the content and perceived greater confidence about conservative care concepts to which they had limited exposure prior to the curriculum. Fellows found the curriculum important, compelling, and easy to navigate. They also indicated an intention to practice specific approaches taught in the curriculum when they encounter medically complex patients with advanced kidney disease and an eagerness to embrace other related curricular topics. Another strength is that as a result of facilitating the curriculum, nephrology champions felt more confident to teach the conservative care concepts. For nephrology educators elsewhere who elect to implement the curriculum that includes the flipped classroom (either in person or virtually), partnering with a palliative care subspecialist may prove particularly beneficial.
These findings have several limitations. First, the knowledge questions were assessed immediately after the program and may not reflect sustained learning. Second, the self-assessed improvement in concepts and skills does not measure actual competencies or changes in behavior or patient outcomes. Such measurements were beyond the scope of this pilot. Third, the self-selected nature of program participation may further bias results. Finally, the lower response rate for the postcurriculum survey may have biased results in a more favorable light. Future research would benefit from measurement of patient satisfaction or clinical outcomes following access to the curriculum.
In summary, we have created a robust curriculum for nephrology fellows that increased fellows' knowledge and preparation for conservative care concepts. This curriculum may improve nephrology fellows’ attitudes about conservative care and their ability to identify and discuss conservative care with patients who would likely benefit from this approach. We anticipate that as a consequence of pilot participation, many more rising nephrologists will be equipped with the capacity to discuss conservative care effectively. This will make it likelier in the coming years that this treatment option will be deployed with greater frequency and that patients, in general, will ultimately undergo treatments for kidney failure that are more value concordant. Our goal is to create a community of nephrology clinicians skilled in practicing and teaching conservative care. To further this possibility, we have made the curriculum and its supporting materials publicly available to nephrology educators to encourage additional programs to consider its implementation. This accessible curriculum also allows learners to return to the materials as often as they wish, to refresh their knowledge and skills. Going forward, we intend to expand the curriculum to include other fundamental palliative care topics related to the care of seriously ill patients with kidney disease and have these taught by a growing community of nephrology educators.
Disclosures
R.M. Arnold reports employment with the University of Pittsburgh Medical Center Health System, receiving honoraria from American Academy of Hospice and Palliative Medicine and UpToDate, and serving as a scientific advisor or member of VitalTalk. A. Bursic reports employment with the University of Pittsburgh Medical Center. E. Chan reports employment with the University of Pittsburgh Medical Center. R.A. Cohen reports employment with Beth Israel Deaconess Medical Center and receiving Emory University honoraria for nephrology grand rounds, University of North Carolina honoraria for renal and palliative care grand rounds, Vanderbilt University honoraria for renal grand rounds, honoraria from VitalTalk for course teaching, Yale University honoraria for renal grand rounds, and honoraria from DynaMed. M.K. Norman reports employment with the University of Pittsburgh. J.O. Schell reports employment with the University of Pittsburgh Medical Center; receiving honoraria from UpToDate; and receiving salary support as a palliative care advisor from Dialysis Clinic, Inc.
Funding
Funding for this study was provided in part from the American Society of Nephrology William and Sandra Bennett Clinical Scholars Program (to J.O. Schell).
Acknowledgments
The authors acknowledge Rakan Alseghayer for the NephroTalk website and design.
Supplemental Material
This article contains supplemental material online at http://cjasn.asnjournals.org/lookup/suppl/doi:10.2215/CJN.11770720/-/DCSupplemental.
Supplemental Material. Knowledge test questions and answers, NephroTalk postconservative care curriculum session, NephroTalk values handout to practice making recommendation, and NephroTalk facilitator guide.
Footnotes
Published online ahead of print. Publication date available at www.cjasn.org.
- Copyright © 2021 by the American Society of Nephrology
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