Oncological serious illness conversations in internal medicine: Residents' perspectives around challenges and solutions on the inpatient wards
Leanne Kim, Helen James, Amy Troup, Isabelle Cavan, Warren Lewin, Avian Chau, Senyo Agbeyaka, Richard Dunbar-Yaffe, Karen OkrainecIntroduction:
Internal Medicine (IM) residents often care for patients admitted for acute oncological care and are expected to lead serious illness conversations (SICs). However, they can face barriers when conducting SICs. We aimed to 1) characterize IM resident experiences with SICs; 2) determine residents' perceived barriers, compared to internists’, when facilitating SICs; 3) explore the context of these barriers, and solicit recommendations for educational improvements.
Methods:
This project was part of a larger mixed-methods quality improvement initiative conducted in 2023 at two Canadian teaching hospitals. A survey was sent to 222 IM residents and 40 internists with questions about their demographic information, prior experiences with conducting SICs, perceived barriers to engaging in SICs, and contextual factors such as hospital site and engagement of the patient. Semi-structured interviews were conducted to contextualize survey findings.
Results:
Our survey was completed by 38/222 (17%) residents and 15/40 (38%) internists. The most common barriers identified by residents were as follows: (1) their own uncertainty in estimating prognosis and their perception of patients having difficulty, (2) understanding the limitations of life-sustaining therapies, and (3) accepting a poor prognosis. In interviews conducted with 5/38 (13%) residents, they shared challenges with navigating emotional discomfort while conducting SICs with minimal experience or prior relationship with the patient.
Discussion:
The emotional weight of SICs, residents’ uncertainty about prognosis, and hidden curriculum expectations can profoundly affect residents. We identified important considerations for optimizing SIC training development for IM residents providing inpatient care for oncology patients.