Resident perceptions of a novel virtual serious illness communication skills curriculum incorporating medical management: qualitative analysis of participant group interviews

Introduction

Emergency medicine (EM) and internal medicine (IM) physicians care for seriously ill and acutely decompensating patients in settings such as the emergency department (ED) or inpatient wards. High-quality care of these patients involves providing goal-concordant care, or treatment that aligns with the patient’s known goals and values (1). There are several potential barriers to delivering goal-concordant medical care to seriously ill acutely decompensating patients.

First, physicians working in acute care settings often fail to identify potential imminent death in a timely manner (2,3). One would need to consider imminent death in the initial differential diagnosis on presentation and then confirm whether it matches the clinical picture, potentially moving quickly if time is short. Early recognition of imminent death can profoundly impact a patient’s clinical course. For example, timely recognition of imminent death is associated with fewer in-hospital deaths and more deaths in a preferred place (4).

Second, even when clinicians caring for seriously ill patients promptly recognize that imminent death may be occurring, they must have the skills necessary to conduct serious illness communication (SIC)-discussions about prognosis, goals, values, and care preferences for patients with serious illnesses (5,6). Most residents initiate and lead SIC alone, and their skill development often occurs through self-reflection after unsupervised patient interactions with some contributions from modeling of communication by staff physicians (7-9). In contrast, structured SIC training is associated with increased frequency, earlier timing, and higher quality of documented serious illness conversations, as well as reduced healthcare costs and healthcare utilization at end-of-life (EOL) (10-13). Opportunities for structured training might include observed role modeling of practicing clinicians, traditional lectures, structured role-play with colleagues, simulation-based training with trained facilitators and actors, or “just-in-time” training, which occurs when training is conducted immediately before an encounter (14). An alternative to traditional lectures, the flipped classroom (FC) is a pedagogical model in which educators assign didactic material to be completed before the face-to-face portion when the material is actively applied. This approach facilitates interactive learning in a collaborative learning environment (15).

Third, the care of patients in the ED and wards often focuses on rescue and resuscitation (16-18). This makes SIC tasks even more complex. Clinicians must (I) make the correct diagnosis by formulating a differential diagnosis and choosing appropriate tests; (II) develop a prognosis; and (III) communicate this prognosis to the patient/caregiver. Leaders in EM and IM education have recognized the importance of these skills for graduates in their respective fields (19-21). Kraus et al. surveyed directors and associate directors of over 100 EM residency programs about the importance and presence of specific competencies in graduating residents. Management of the imminently dying was one of the largest reported gaps between their rated importance and existing skill level (21). Additionally, “task switching”, or the ability to multitask during these complex clinical scenarios, is so vital that it is recognized as a milestone for EM residents by the Accreditation Council for Graduate Medical Education (ACGME) (22). Despite this consensus, it remains unclear whether combining SIC and clinical management tasks into a single curriculum is a feasible approach to this material.

This paper aims to explore IM and EM resident perceptions of an entirely virtual SIC curriculum that required participants to assess and manage clinically decompensating seriously ill patients while simultaneously utilizing SIC skills. We hypothesized that a simulation-based curriculum involving both types of tasks would be perceived as effective and realistic. We present this article in accordance with the SRQR reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-25-72/rc).

Methods

SIC curriculum overview

Our curriculum, “Managing Acute Decompensation in Life-limiting Illness” (MADLI), was developed by physician educators representing hospice and palliative medicine (D.K. and L.J.M.), EM (A.H.W. and K.J.), and primary care (M.S.E.). It consists of three components: a didactic video, a simulated patient (SP) encounter, and a structured group interview (Figure 1). Each component is described below.

Figure 1 Curriculum structure. The MADLI curriculum began with a 20-minute video didactic presentation, which participants viewed asynchronously at least 7 days prior to a 60-minute simulated patient encounter. This was immediately followed by a 60-minute group interview. All components were conducted via Zoom. MADLI, Managing Acute Decompensation in Life-limiting Illness.

Our goal was to replicate a clinical scenario in which physician trainees must evaluate a patient in an acute care setting who demonstrates early signs of dying but is stable enough not to require immediate intensive care. We aimed to develop an SP case that allowed clinicians the time and space to practice newly taught communication skills. We focused on skills related to discussing prognosis, eliciting patient/caregiver understanding, goals, and values, and recommending medical care aligned with this information. We adapted the training framework used by VitalTalk (23), a national non-profit organization dedicated to teaching SIC skills to all clinicians. This framework incorporates evidence-based methods, including role-playing in small groups using SPs and caregivers (24,25).

MADLI was initially designed as an in-person activity at the Yale Center for Healthcare Simulation. However, in Spring 2020, all teaching at Yale School of Medicine transitioned to remote learning due to the coronavirus disease 2019 (COVID-19) pandemic. Therefore, we adapted the curriculum for remote delivery via Zoom while preserving the original educational objectives and content.

Video lecture

At least 7 days before their scheduled simulation day, participants were emailed an invitation to participate in our “flipped curriculum”—a 20-minute recorded slideshow lecture presented by one of the study authors (D.K.) and reviewed by three other authors (M.S.E., L.J.M., K.J.). The lecture, which participants watched asynchronously, covered an organized approach to SIC which included “NURSE” (Naming, Understanding, Respecting, Supporting, and Exploring) statements to respond empathically to patient and caregiver emotions (26) and the “REMAP” (Reframe why the status quo isn’t working, Expect emotions and empathize, Map out patient values, Align with the patient’s values, and Plan medical treatment to match patient values) model (27).

Simulation encounter

We developed a new case (Appendix 1) based on our team’s combined expertise in using healthcare simulation to teach SIC skills (28). The case was as follows: Sam Flynn is a patient with a diagnosis of Stage IV lung cancer who presents to the ED from a short-term rehabilitation facility. He is accompanied by his wife, who is worried about new symptoms of acute decline, including decreased oral intake, rapidly decreasing functional status, new confusion, and uncontrolled pain and dyspnea. Medical workup would reveal progression of his cancer, with chest computed tomography demonstrating “new endobronchial tumor obstructing the right main bronchus with a metastatic lesion eroding the aorta”. The case was reviewed by and piloted with two Hospice and Palliative Medicine fellows who provided feedback about their experience and suggestions for improvement before implementation with study participants.

During the simulation encounters, the patient was represented by a photograph of a high-fidelity simulation training mannequin, which was used as the virtual background of the actor playing his wife (Figure 2). The patient’s wife was played by a trained actor with years of experience in our SIC program. The actor underwent additional training with our team to modulate responses based on the effectiveness of the residents’ communication skills. One study investigator (D.K.) facilitated all simulation groups, while another investigator (K.J.) played the nurse role.

Figure 2 Simulated family member video screen. Simulated family member, Mrs. Flynn (played by Susan Kulp), as seen by the resident participants during the simulated patient encounter. A photo of a high-fidelity simulation mannequin was used as her Zoom background to represent the patient. This image is published with the participant’s consent.

The facilitator began each simulation encounter by leading the group through the objectives and case description. The residents were given three objectives: (I) perform a focused history and physical exam to develop a differential diagnosis; (II) communicate diagnosis and prognosis to the patient’s surrogate decision-maker; and (III) propose a treatment plan that respects the patient’s values, goals, and priorities. The facilitator emphasized that these objectives were a collective responsibility for the group and not necessarily tasks to be divided among individual residents. As the case unfolded, residents could request physical exam, laboratory, and imaging findings for the case.

To standardize the simulation experience across the resident groups, we developed a faculty and actor training document (Appendix 2), which outlined the anticipated progression of the case, dividing it into three “acts” with both SIC and medical management components. It was reviewed and approved by all authors to guide the actions of the facilitator, simulated family member, and faculty member in the nurse role. It described the likely steps the trainee might take in each portion of the case. It also suggested the emotional tone and language of the simulated family member at different points. For example, in the first act, we predicted that residents would assess the simulated family member’s understanding of the patient’s serious illness after completing the history and physical. The document also contained scripted lines the faculty facilitator and simulated nurse could deliver to advance the encounter if needed. For example, the registered nurse (RN) would start Act II by saying, “Doctor, his oxygen saturation is slowly dropping again. It is now down to 88%.” If the resident had not ordered any imaging 5 minutes into Act II, the RN was to ask, “Doctor, what do you think about an X-ray or CT scan?”

Each resident was invited to lead one act while their colleagues observed and took careful notes. At the halfway point of each act, the facilitator paused the simulation for debriefing and self-reflection. The facilitator led the group through constructive feedback, helping the residents identify a skill they were interested in practicing further. The residents briefly re-entered the simulation to practice that specific skill (29). After each resident completed their act, the next resident entered the simulation, continuing the case from where the previous resident left off.

Group interview

To better understand the residents’ clinical reasoning and perceptions of the curriculum’s strengths and areas for improvement, one study author (D.K.) conducted in-depth, open-ended interviews with each group of residents immediately after their simulation encounter. The investigator who conducted the group interviews drew on experience facilitating small groups in similar SIC courses, which provided a strong foundation in active listening, probing for participant reflections and managing group dynamics. The interview guide was developed collaboratively with an experienced qualitative researcher (A.H.W.), who provided coaching and mentorship during the process. A prepared interview guide (Appendix 3) was used to conduct the semi-structured group interviews. Questions included “Can you walk me through your thought process during the simulation case?” and “How would you describe the realism of the case?” The interviewer was never in a direct clinical supervisory role with study participants outside the study, and interview/simulation performance data were not shared with residency program leadership. All interviews were audio and video recorded and professionally transcribed verbatim. Transcripts were reviewed manually to verify accuracy.

Residents from all post-graduate year (PGY) levels of the EM and IM residency programs at a large, urban, academic teaching hospital were invited to participate via program-wide email invitations offering a $75 gift card for study participation. EM residents were also offered credit toward their residency program’s didactic education requirement. Residents volunteered to participate during their non-clinical time. No participants were excluded or dropped from the study. Recruitment continued until thematic saturation from our qualitative analysis was achieved. A total of six sessions were scheduled, with three participants per group in the first four sessions and two participants per group in the last two sessions.

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The Yale University Institutional Review Board reviewed the study protocol and deemed it exempt, as it involved normal educational practices and research on the effectiveness of instructional techniques. Written informed consent was obtained from each participant before each simulation encounter and group interview.

Statistical analysis

Data were analyzed using the qualitative analysis software Dedoose (Version 9.2.4 web application for managing, analyzing, and presenting qualitative and mixed-method research data, 2023).

We used qualitative thematic analysis to explore learners’ decision-making during the simulation and their perceptions of the virtual MADLI curriculum. In accordance with a thematic analysis approach, codes were derived from the text in an inductive manner rather than being pre-determined by the researchers (30). Two authors (D.K. and S.T.) independently coded the first two group interview transcripts. Through an iterative process, they collaborated closely to develop a codebook of agreed-upon parent and child codes. This codebook was then used by D.K. and S.T. to code the remaining transcripts. Objectivity was ensured by the triangulation of transcripts with group interview notes and the use of two coders (a medical student and palliative medicine attending) (31). The coders met regularly over the course of 6 months where they openly discussed their biases. All transcripts were reviewed and discussed in depth to ensure agreement between the two coding authors. The parent codes were organized into themes and subthemes, which were subsequently reviewed and agreed upon by all authors. Quotations that best represent each theme were chosen to provide additional context.

Results

We reached data saturation with 16 residents completing the MADLI curriculum and participating in group interviews. All data collection occurred between December 2020 and April 2022. Group interviews lasted an average of 35 minutes. Most participants (88%) were EM residents. Senior residents (PGY3 and PGY4) represented 50% of our sample (Table 1).

Analysis of group interview transcripts yielded three major themes: (I) simulation unmasked moral challenges in clinical decision-making for complex EOL scenarios in emergency settings; (II) simulation facilitated safe practice and identification of knowledge gaps for SIC skills; and (III) task switching and case realism were virtual SIC curricular elements that promoted learner engagement and practical learning. We discuss key concepts from each theme in detail below. A complete list of representative quotations supporting each theme is in Table 2.

Theme 1: simulation unmasked moral challenges in clinical decision-making for complex EOL scenarios in emergency settings

Subtheme 1: prognostication as a challenging but critical skill for effective SIC

Residents described factors at play in determining the patient’s prognosis, carefully considering whether there were reversible causes. Several residents astutely recognized that the patient might be dying but struggled with the severity of illness and how that may impact the intensity of medical interventions in their subsequent treatment plan.

“My biggest goal was figuring out if this is something that he’s acutely dying from and that we need to have a really significant goals of care move towards comfort measures only. Or is this something that might be reversible? You know, is he suffering from mild pneumonia and he’s altered from that? Or is he a little hypoglycemic in the setting of poor PO intake? Does he just need a couple antibiotics and some close observation? Or does he need a thrombectomy from a massive PE (pulmonary embolism)? Or are his lungs full of blood, you know? So, I didn’t know what was happening, but I was curious to know which of the two main categories we were going in. Was this imminent death or something that we could work with for a little bit longer?” (P7, EM, PGY3)

As evidence of a short prognosis, one resident (P14, EM, PGY4) referenced the patient’s reported physical exam and computed tomography (CT) scan findings demonstrating a tumor eroding the aorta. They described the challenge of incorporating this information into the conversation in an effective way.

Subtheme 2: careful deliberation around decision to intubate

Residents described the complex factors involved in their thinking around the role of critical care in this case. They recognized mechanical ventilation as a pivotal decision point. One resident described how they weighed the burdens and the benefits of intensive medical interventions, including the potential impact on the patient’s future quality of life.

“Yeah, [I would] avoid intubation or chest compressions that aren’t going to change the outcome. Especially if someone wants them to go peacefully, or the idea that once they get on a machine, they can’t come off the machine. Do they really want to live on a machine?” (P5, EM, PGY1)

Another resident (P12, EM, PGY4) determined that the patient’s respiratory status was relatively stable in the moment, which allowed them time for SIC tasks.

Subtheme 3: ambivalence around the use of morphine for dyspnea

Several residents expressed ambivalence toward using morphine for symptom control despite recognizing it as a therapeutic modality that could provide benefit to the SP, given concerns that it may hasten the patient’s death.

“I did think about morphine for shortness of breath, and I admit that I sort of chickened out because I was like, I don’t want to do anything that’s going to worsen his respiratory drive and make it a little bit more urgent to intubate. I’m like, I think I need a little more time for this conversation. I don’t know if that was the right move or if there’s a relatively low risk of harming that for the benefit of improving their work of breathing.” (P9, IM, PGY2)

Theme 2: simulation facilitated safe practice and identification of knowledge gaps for SIC skills

Subtheme 1: importance of proactively assessing surrogate understanding

Residents appropriately recognized the importance of assessing the patient’s wife’s understanding of his illness as one of the first steps in a SIC.

“I think big things for me were really getting her understanding of how progressive the disease was and the prognosis. And then trying to understand what they had discussed in the past in terms of measures for this patient.” (P13, EM, PGY1)

One resident (P8, EM, PGY1) reflected on the challenge they encountered when the patient’s wife shared her understanding that his cancer treatment was on hold but that he could resume chemotherapy in the future. Eliciting this information early in the encounter was effective for the resident as it highlighted the gap in understanding that needed to be addressed.

Subtheme 2: discomfort with communicating prognosis

One resident (P13, EM, PGY1) recounted how their focus changed to determining the best way to share the prognosis when they recognized the severity of the patient’s condition.

“As the interventions failed and the patient got progressively sicker, then my focus shifted to ‘how do I tell this woman that I think this patient’s time is short. Which I feel extraordinarily uncomfortable doing because I don’t feel like I know that.” (P13, EM, PGY1)

Another resident (P4, EM, PGY3) explained the challenge of balancing specificity and ambiguity when discussing prognosis.

Subtheme 3: challenge of aligning with unrealistic goals

The caregiver in the simulated encounter shared that one of her husband’s goals was to attend their daughter’s wedding, a month away. After recognizing the extent of the patient’s clinical decompensation, residents described their approach to aligning with the caregiver around the patient’s goals and hopes, especially when they believed them to be unrealistic and unattainable.

To work through this challenge, residents reframed the status quo as not working, the first step in the “REMAP” cognitive framework introduced in the didactic video. One resident (P9, IM, PGY2) described their internal negotiation process to establish a new, attainable shared goal by continuing to “map the patient’s values”, a step represented by the “M” in the REMAP framework.

“Looking at the patient’s medical history, I think it’s clear that there’s a lot of backstory and that this patient might not do well. Initially, I was trying to think, ‘One of the goals is to get him to his daughter’s wedding in a month. How can we make that happen?’ As the case went on it became clear that that was not possible. I thought, ‘Okay, what’s the next step that we can shoot for that’s a reasonable, attainable goal?’” (P9, IM, PGY2)

Theme 3: task switching and case realism were virtual SIC curricular elements that promoted learner engagement and effective learning

Subtheme 1: case perceived as realistic

Residents shared that the simulated encounter felt realistic and similar to scenarios they encountered in their daily medical practice, allowing for useful practice of essential SIC skills in a controlled environment. One participant (P14, EM, PGY4) described a challenge of initiating SICs with patients without established rapport.

“Unfortunately, I think this was very realistic in terms of when we come in [in the ED]. We don’t have a personal connection to the patients initially, and we’re certainly not part of their day-to-day treatment team. And we usually end up meeting them in extremis.” (P14, EM, PGY4)

Subtheme 2: inclusion of medical management increased simulation value

Several residents identified the combination of medical management and communication tasks to be a welcome challenge that elevated the value of the simulation encounter. They expressed that task switching required in the simulation encounter was reflective of their clinical experiences in these settings.

“I like the fact that medicine was also incorporated in this because there’s a lot of task switching. It’s not just going to be having this conversation.” (P3, EM, PGY1)

Subtheme 3: preferences for timing of curricular elements

Residents recognized the value of having teaching materials prior to the simulation day. One resident (P15, EM, PGY2) described the inclusion of asynchronous materials that can be reviewed before the simulation encounter as more effective than traditional approaches.

“I always appreciate any time something is simulated or any time you’re working on new skills, having asynchronous learning materials. Sometimes, it’s incorporated into the SIM time, and I feel there are many different ways to communicate that information, so I appreciated that. I felt like it was a more effective tool for me.” (P15, EM, PGY2)

Residents also expressed a desire to participate in MADLI earlier in their training to maximize the benefits provided to them.

Discussion

To our knowledge, this was the first study to develop, implement, and evaluate qualitative learning outcomes of a simulation-based curriculum to teach and practice SIC skills in the context of an acutely decompensating patient for an interdisciplinary group of resident physicians. This was also novel for its integration of SIC and clinical medicine within a single, unfolding case, conducted entirely via Zoom and featuring an FC component. Residents participated in a three-part curriculum, which included an asynchronous didactic video, a small group SP encounter, and a post-encounter group interview. We found that the simulations unmasked critical moral challenges related to effective communication and medical management during EOL scenarios. The experience was instrumental for practicing SIC skills in a realistic scenario.

Our resident participants found the curriculum valuable and realistic despite the absence of an in-person component. This study builds on prior virtual SIC curricula for post-graduate medical trainees. For example, Crossman et al. utilized teleconferencing software to teach similar content (NURSE and REMAP) to EM residents. However, their approach relied on peer role-play and excluded medical decision-making tasks or trained actors portraying patients or family members (32). In contrast, MADLI curriculum participants worked with an actor specifically trained in SIC skills, a feature residents highlighted as a major contributor to the realism of the case.

Overall, participants recognized the importance of assessing patient and caregiver understanding of the serious illness prior to giving information. Residents described the differential diagnoses they considered during the simulation encounter, with several mentioning imminent death as a possibility. At appropriate points, they recognized the patient’s tenuous clinical status and weighed the implications of escalating medical management to involve critical care interventions. Residents also identified the challenge of responding to the caregiver’s unrealistic expectations honestly without compromising trust. These results expand on the work of Uy et al., who studied transcripts of simulated encounters in which EM and IM physicians cared for a clinically unstable patient and found that 82% of physicians elicited the patient’s intubation preferences, but only 38% explored the patient’s broader values (33). Our study facilitated a deeper exploration of the clinician’s thought process driving these decisions.

Simulation curricula that teach skills specifically focused on the care of the acutely decompensating and potentially dying patient are sparse. Of those with this focus, most utilize patient cases in which the prognosis or expected trajectory is clear (34,35). In one study, investigators intentionally designed an uncomplicated case so that learners would “focus on palliative issues rather than emergent resuscitation and stabilization” (35). In contrast, MADLI participants were challenged to use their medical knowledge and diagnostic skills. The outcome of our simulation encounter was dependent on the learner’s ability to elicit critical pieces of information. The case was written so that the caregiver would, by default, express a desire to pursue intensive treatments in hopes that the patient could receive further chemotherapy. However, we intentionally designed the case to allow the trajectory to change if the residents used the skills taught in the didactic video to elicit the underlying goals and values. Therefore, unlike other virtual SIC curricula, MADLI required participants to integrate several higher-level tasks, including acute medical management, prognostication, and complex SIC skills within a single virtual simulation encounter. Additionally, our study differs due to its focus on a patient who is clinically stable yet remains at high risk of sudden clinical decompensation. This design enabled physician trainees to recognize and act on opportunities to elicit values using a structured approach (27) to provide goal-concordant medical care without reflexively escalating the intensity of care.

Our qualitative study contributes to the literature by highlighting that participants found this integration of both skill areas very useful, as it made the simulation more reflective of actual clinical practice. These results suggest that future simulation-based curricula focused on acutely decompensating patients should prioritize opportunities for trainees to task switch between communication and clinical management to achieve clinical competency.

Limitations

Our study has several limitations. First, its single-site design may limit generalizability to other training institutions. Second, while we aimed to limit selection bias by recruiting a diverse group of participants from different backgrounds and levels of experience, recruitment through a single investigator (D.K.) with a known role in clinical palliative care may have influenced participants’ expectations, leading them to anticipate themes related to caring for seriously ill and dying patients. Additionally, our sample includes a higher proportion of EM residents, whose greater baseline exposure to simulation-based training than their IM colleagues may have shaped their perceptions of our curriculum. Lastly, our study outcomes were limited to assessing perceived value, which is categorized into Level One of Kirkpatrick’s training model (36). To increase the evaluative rigor, future iterations of this curriculum should incorporate objective performance assessment tools and other evaluative methods.

Challenges and future directions

We encountered challenges in participant recruitment, which were more pronounced among IM than EM residents. We suspect that the greater flexibility granted by the shift schedule of EM residency made it more feasible for EM residents than for IM residents to participate on their days off. For institutions interested in adapting the MADLI curriculum, we recommend obtaining buy-in from residency program leadership to designate it as a prioritized learning activity with dedicated training time for residents to participate.

A second challenge pertains to the resource intensity required to implement MADLI. If adapted using our exact model, at least two faculty members and one SP would be needed for every three trainees. However, institutions can adjust the structure of MADLI to match their available resources.

For educators planning virtual SIC curricula, we recommend our FC approach, which emphasizes the importance of completing preparation activities before simulation (37). This design improves knowledge acquisition (38-41) and maximizes valuable simulation time, which may be limited by other factors, including cost, availability of actor(s), etc. We suspect that the asynchronous component would also facilitate similar in-person curricula, creating greater learner accountability, engagement, and time efficiency.

Consistent with prior survey research (42), we found that IM and EM residents desire additional training to strengthen their prognostication skills and have knowledge gaps around the use of opioids for symptomatic dyspnea management. Therefore, we suggest that educators planning SIC curricula for these trainees incorporate didactic material focused on these skills. Further research is needed to identify the most effective teaching method (didactic versus debrief) and timing (pre-simulation versus post-simulation) of teaching that addresses these knowledge gaps.

Conclusions

In summary, MADLI presents a novel approach to teaching SIC skills within an acute clinical decompensation patient scenario to groups of combined EM and IM residents using virtual simulation and an FC model. The MADLI simulation was designed to allow the practice of both medical management and SIC tasks, thus creating an effective SIC curriculum with high resident engagement. Residents perceived this learning as effective, realistic, and valuable.

Acknowledgments

We would like to thank Susan Kulp for her role as “Mrs. Flynn” in the MADLI pilot curriculum and her invaluable contributions as an actor and co-teacher in our other SIC skills workshops.

Footnote

Reporting Checklist: The authors have completed the SRQR reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-25-72/rc

Data Sharing Statement: Available at https://apm.amegroups.com/article/view/10.21037/apm-25-72/dss

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-25-72/prf

Funding: This work was funded by a Rosenkranz Award for Pedagogical Advancement from the Yale Poorvu Center for Teaching and Learning (to D.K.).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-25-72/coif). D.K. reports funding of the Rosenkranz Award for Pedagogical Advancement from the Yale Poorvu Center for Teaching and Learning. A.H.W. reports receiving NIH and AHRQ federal research grants, and serving on the editorial boards of Annals of Emergency Medicine and Academic Emergency Medicine Education & Training, as well as on the Research Committee of the Society for Academic Emergency Medicine. K.J. reports receiving up to $3,000 per year in travel reimbursement from the Department of Emergency Medicine to attend national meetings, and serving as an unpaid member of the Ethics Committees of ACEP and SAEM. M.S.E. reports receiving payment for medical expert review of legal cases, unrelated to the submitted work and receiving support to attend professional conferences from his employer, Yale University. L.J.M. reports serving as a Director-at-Large Board Member for the American Academy of Hospice and Palliative Medicine, with paid travel and lodging for two board meetings annually. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The Yale University Institutional Review Board reviewed the study protocol and deemed it exempt, as it involved normal educational practices and research on the effectiveness of instructional techniques. Written informed consent was obtained from each participant before each simulation encounter and group interview.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Sanders JJ, Curtis JR, Tulsky JA. Achieving Goal-Concordant Care: A Conceptual Model and Approach to Measuring Serious Illness Communication and Its Impact. J Palliat Med 2018;21:S17-27. [Crossref] [PubMed]
2. Christakis NA, Lamont EB. Extent and determinants of error in physicians' prognoses in terminally ill patients: prospective cohort study. West J Med 2000;172:310-3. [Crossref] [PubMed]
3. Gunasekaran B, Scott C, Ducharlet K, et al. Recognising and managing dying patients in the acute hospital setting: can we do better? Intern Med J 2019;49:119-22. [Crossref] [PubMed]
4. Abarshi EA, Echteld MA, Van den Block L, et al. Recognising patients who will die in the near future: a nationwide study via the Dutch Sentinel Network of GPs. Br J Gen Pract 2011;61:e371-8. [Crossref] [PubMed]
5. Vermeir P, Vandijck D, Degroote S, et al. Communication in healthcare: a narrative review of the literature and practical recommendations. Int J Clin Pract 2015;69:1257-67. [Crossref] [PubMed]
6. Lakin JR, Koritsanszky LA, Cunningham R, et al. A Systematic Intervention To Improve Serious Illness Communication In Primary Care. Health Aff (Millwood) 2017;36:1258-64. [Crossref] [PubMed]
7. Tulsky JA, Chesney MA, Lo B. See one, do one, teach one? House staff experience discussing do-not-resuscitate orders. Arch Intern Med 1996;156:1285-9. [Crossref] [PubMed]
8. Schmit JM, Meyer LE, Duff JM, et al. Perspectives on death and dying: a study of resident comfort with End-of-life care. BMC Med Educ 2016;16:297. [Crossref] [PubMed]
9. Burke G, Melvin L, Ginsburg S. "Patients Are the People Who Teach Me the Most": Exploring the Development of Communication Skills During Internal Medicine Residency. J Grad Med Educ 2023;15:59-66. [Crossref] [PubMed]
10. Ma C, Riehm LE, Bernacki R, et al. Quality of clinicians' conversations with patients and families before and after implementation of the Serious Illness Care Program in a hospital setting: a retrospective chart review study. CMAJ Open 2020;8:E448-54. [Crossref] [PubMed]
11. Lakin JR, Neal BJ, Maloney FL, et al. A systematic intervention to improve serious illness communication in primary care: Effect on expenses at the end of life. Healthc (Amst) 2020;8:100431.
12. Lakin JR, Arnold CG, Catzen HZ, et al. Early serious illness communication in hospitalized patients: A study of the implementation of the Speaking About Goals and Expectations (SAGE) program. Healthc (Amst) 2021;9:100510. [Crossref] [PubMed]
13. Myrhøj CB, Bernacki R, Bjerre-Bertelsen S, et al. Serious illness conversations and quality of end-of-life care in patients with hematological malignancies-a retrospective quality improvement study. Support Care Cancer 2025;33:814. [Crossref] [PubMed]
14. Rock LK. Communication as a High-Stakes Clinical Skill: "Just-in-Time" Simulation and Vicarious Observational Learning to Promote Patient- and Family-Centered Care and to Improve Trainee Skill. Acad Med 2021;96:1534-9. [Crossref] [PubMed]
15. Hurtubise L, Hall E, Sheridan L, et al. The Flipped Classroom in Medical Education: Engaging Students to Build Competency. J Med Educ Curric Dev 2015;2:JMECD.S23895.
16. Green L, Capstick A, Oyebode J. Iatrogenic suffering at the end of life: An ethnographic study. Palliat Med 2023;37:984-92. [Crossref] [PubMed]
17. Gunaga S, Zygowiec J. Primary Palliative Care in the Emergency Department and Acute Care Setting. Cancer Treat Res 2023;187:115-35. [Crossref] [PubMed]
18. Bailey C, Murphy R, Porock D. Trajectories of end-of-life care in the emergency department. Ann Emerg Med 2011;57:362-9. [Crossref] [PubMed]
19. Shoenberger J, Lamba S, Goett R, et al. Development of Hospice and Palliative Medicine Knowledge and Skills for Emergency Medicine Residents: Using the Accreditation Council for Graduate Medical Education Milestone Framework. AEM Educ Train 2018;2:130-45. [Crossref] [PubMed]
20. Kezar CE, Lawton AJ. Defining Key Elements of a Clinical Experience in Hospice and Palliative Medicine for Medical Residents in the United States. J Med Educ Curric Dev 2024;11:23821205241228027. [Crossref] [PubMed]
21. Kraus CK, Greenberg MR, Ray DE, et al. Palliative Care Education in Emergency Medicine Residency Training: A Survey of Program Directors, Associate Program Directors, and Assistant Program Directors. J Pain Symptom Manage 2016;51:898-906. [Crossref] [PubMed]
22. The Accreditation Council for Graduate Medical Education. Emergency Medicine Milestones. 2021. Accessed September 20, 2024. Available online: https://www.acgme.org/globalassets/pdfs/milestones/emergencymedicinemilestones.pdf
23. Arnold RM, Back AL, Tulsky JA. VitalTalk: Intensive Small Group Training—Addressing Goals of Care (P02). Journal of Pain and Symptom Management 2016;51:307.
24. Kelley AS, Back AL, Arnold RM, et al. Geritalk: communication skills training for geriatric and palliative medicine fellows. J Am Geriatr Soc 2012;60:332-7. [Crossref] [PubMed]
25. Grudzen CR, Emlet LL, Kuntz J, et al. EM Talk: communication skills training for emergency medicine patients with serious illness. BMJ Support Palliat Care 2016;6:219-24. [Crossref] [PubMed]
26. VitalTalk. Responding to Emotion: articulating empathy using NURSE statements. 2024. Available online: https://www.vitaltalk.org/guides/responding-to-emotion-respecting/
27. Childers JW, Back AL, Tulsky JA, et al. REMAP: A Framework for Goals of Care Conversations. J Oncol Pract 2017;13:e844-50. [Crossref] [PubMed]
28. Ellman M, Kozhevnikov D, Segar N, et al. Advancing primary post-graduate palliative care training: developing an integrated competency-based curriculum for internal medicine residents. 13th World Research Congress of the EAPC, Barcelona, Spain.
29. Kissane DW, Bultz BD, Butow PN, et al. editors. Oxford Textbook of Communication in Oncology and Palliative Care. 2nd edition. Oxford: Oxford University Press; 2017:434.
30. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005;15:1277-88. [Crossref] [PubMed]
31. Shenton AK. Strategies for ensuring trustworthiness in qualitative research projects. Educ Inf 2004;22:63-75.
32. Crossman ME, Stobart-Gallagher M, Siegel M. Determining Goals of Care During the COVID-19 Pandemic: A Virtual Course for Emergency Medicine Residents. Cureus 2021;13:e14558. [Crossref] [PubMed]
33. Uy J, White DB, Mohan D, et al. Physicians' decision-making roles for an acutely unstable critically and terminally ill patient. Crit Care Med 2013;41:1511-7. [Crossref] [PubMed]
34. Hayley DC, Kalender-Rich JL, Mack J, et al. Development of a Hybrid Simulated Patient Experience to Practice Care of the Dying Older Adult. MedEdPORTAL 2018;14:10777. [Crossref] [PubMed]
35. Goldonowicz JM, Runyon MS, Bullard MJ. Palliative care in the emergency department: an educational investigation and intervention. BMC Palliat Care 2018;17:43. [Crossref] [PubMed]
36. Kirkpatrick DL, Kirkpatrick JD. Evaluating Training Programs: The Four Levels. 3rd edition. San Francisco, CA, USA: Berrett-Koehler; 2006.
37. Dong C, Szarek JL, Reed T. The Flipped Classroom and Simulation: a Primer for Simulation Educators. Med Sci Educ 2020;30:1627-32. [Crossref] [PubMed]
38. Graham KL, Cohen A, Reynolds EE, et al. Effect of a Flipped Classroom on Knowledge Acquisition and Retention in an Internal Medicine Residency Program. J Grad Med Educ 2019;11:92-7. [Crossref] [PubMed]
39. Liu KJ, Tkachenko E, Waldman A, et al. A video-based, flipped classroom, simulation curriculum for dermatologic surgery: A prospective, multi-institution study. J Am Acad Dermatol 2019;81:1271-6. [Crossref] [PubMed]
40. Uther P, Van Munster KA, Briggs N, et al. Introducing early-phase medical students to clinical paediatrics using simulation and a flipped-classroom. J Paediatr Child Health 2019;55:1107-12. [Crossref] [PubMed]
41. Chiu HY, Kang YN, Wang WL, et al. The Effectiveness of a Simulation-Based Flipped Classroom in the Acquisition of Laparoscopic Suturing Skills in Medical Students-A Pilot Study. J Surg Educ 2018;75:326-32. [Crossref] [PubMed]
42. Lamba S, Pound A, Rella JG, et al. Emergency medicine resident education in palliative care: a needs assessment. J Palliat Med 2012;15:516-20. [Crossref] [PubMed]