Internal Medicine Resident Barriers to Advance Care Planning in the Primary Care Continuity Clinic

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Background: While primary care providers regularly engage in Advance Care Planning (ACP) conversations, it is not well known what challenges resident physicians face to achieving this core competency. Objectives: We aimed to assess resident perceptions of barriers and potential interventions to outpatient ACP. Methods: We distributed an electronic survey to Internal Medicine and Medicine-Psychiatry residents at our institution in 2022. Questions addressed outpatient ACP barriers and potential interventions in several domains: structural issues, personal knowledge, and communication skills. We reported results using descriptive statistics and Wilcoxon rank-sum tests, comparing responses by residency year (interns vs upperyears). Likert-scale responses were dichotomized to a “not at all or slightly” vs “moderate or extreme” barrier or helpful intervention. Results: Of 149 residents, 71 completed the survey (48%). Highest scoring barriers were structural, including 1) lack of clinic time (99%), 2) need to prioritize other medical problems (94%), and 3) lack of patient continuity (62%). Highest scoring interventions included the ability to schedule dedicated ACP visits with themselves (96%) or another clinician (82%). Interns were statistically significantly less confident in their ability to conduct ACP, and more likely to report lack of knowledge (i.e., not understanding ACP, patient prognosis, or how to complete paperwork, P <.05). Conclusions: Residents report significant structural barriers to outpatient ACP, including limitations in time, continuity, and competing medical priorities, that may warrant greater program attention to interventions such as clinic schedules and work-flow. Additional trainings may be most beneficial if targeted to the beginning of intern year.






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Dussault, Nicole, Elissa Nickolopoulos, Katherine Henderson, Patrick Hemming, Alex Cho and Jessica E Ma (2023). Internal Medicine Resident Barriers to Advance Care Planning in the Primary Care Continuity Clinic. American Journal of Hospice and Palliative Medicine. pp. 104990912311546–104990912311546. 10.1177/10499091231154606 Retrieved from

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Alex Han Cho

Associate Professor of Medicine

Population health; telehealth; primary care; implementation science; applied genomics; health behavior; patient self-management; health policy.


Jessica Ma

Assistant Professor of Medicine

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