Medical-legal partnerships to enhance residency training in advance care planning

Background and Objectives: Only about one-third of adult Americans have completed advance directives for end-of-life care, and primary care physicians report that they are not always comfortable discussing advance care planning (ACP) with patients. Current approaches to teaching clinicians about ACP have limited evidence of effectiveness. With the objective of improving residents' comfort and skill discussing ACP with patients, we developed a curriculum that involved clinicians and attorneys working together to teach first-year family medicine residents (R1) about leading ACP discussions with patients.

Methods: Our curriculum consisted of a 1-hour multimedia training session on ACP followed by a series of direct in-exam room observations. Attorney and/or physician faculty observed residents holding ACP discussions with patients and provided structured feedback to residents about their performance. The initial R1 cohort observed had a series of three direct observations; the subsequent R1 cohort had two direct observations. We developed an evaluation tool with a 5-point developmental scale (beginner, novice, developing, near mastery, mastery) corresponding to the Accreditation Council for Graduate Medical Education's milestone system to score residents' performance.

Results: R1 performance improved from the beginner/novice level during the first observed ACP discussion to the novice/developing level during the second or third discussion, representing an increase in competence to that expected of a second- or early third-year resident.

Conclusion: Based on our initial experience, using medical-legal partnerships to teach residents about ACP may be more effective than previously reported approaches. Validation of our results with a larger sample is needed.