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The AAMC lists “presenting palliative care (including hospice) as a positive, active treatment option for a patient with advanced disease” as one of its minimum competencies for medical students. Yet few physician trainees are provided with formal end-of-life care training (Sullivan AM, Lakoma MD and Block SD. J Gen Intern Med. 2003 Sep;18(9);685-95).

I decided to do something about this knowledge gap during my first year as a faculty member at the University of Utah in the Division of Geriatrics. Each month four internal medicine interns rotate through geriatrics. The interns spend the month in a variety of clinical settings and also have multiple brief (30-60 minutes) interactive teaching activities or lectures dispersed throughout their days.

I decided to use my 30-minute block of time to teach the interns about the Medicare Hospice Benefit. I created a snazzy handout, met the interns at 8:00 am, and shared the hospice information with them. The interns did their best to pay attention, but listening to facts about the Medicare Hospice Benefit at 8 am (despite the snazziest of handouts) turned out to be the Ambien of learning experiences.

“Necessity is the mother of invention” and my need was to keep the interns awake at 8 am to learn about a very important topic – so I created the Medicare Hospice Benefit (MHB) Game. The Game is a competency-based educational tool designed to evaluate physician trainee’s knowledge of the MHB and their comfort describing services provided by the MHB while educating them in an interactive format.

The format of the game is very simple. There is a set of cards that have
statements about the Medicare Hospice Benefit that are either true or false. The
interns sort the cards into a true and false pile. Once they finish sorting
the cards I pass out the answer sheet and ask them to circle the items
they missed. I warn them that the questions are difficult and require significant
knowledge about the hospice benefit. They shouldn’t feel discouraged if their
answers are incorrect as the goal of the game is to spark discussion. At the end
of the game I have the interns pick a prize, “smartees” or “dum dums” candies,
based on how they feel after the game or, more likely, which candy is more
appetizing at 8 am.

I found it interesting that the quality of the discussions with the interns was
inversely proportional to their scores. So, of course, I made the questions
harder. The discussions improved to the degree that the 30-minute interactive
teaching session turned into an hour.

The game focuses on hospice regulations and covered services, which may seem tedious or irrelevant to the interns at first. To help them understand the importance of the game questions I spent a little time having them role-play. The interns would pretend to be my doctor and I would pepper them with questions about the hospice regulations they just learned from the game:

“Dr. Smith if I go on hospice can I continue to see you?”
“Will I have to be DNR?”
“I am getting palliative radiation, can that continue on hospice?”
“Who will pay for my medications?”
“Isn’t hospice for people that have six months to live, what happens if I live longer than that?”
“Can I still go to the hospital?”
“Do I have to move to a hospice unit?”

I have created a PowerPoint version of the game entitled “Are you smarter than a medical intern? The why, what and how of the Medicare Hospice Benefit.” I use the PowerPoint version in large group settings. The only drawback to this version is it can require more man-power (the presence of a “Vanna White” assistant to pass out the prizes is helpful).

The Medicare Hospice Benefit card game and facilitator guide is currently available on the MedEd portal and POGOE:

I have not yet submitted the PowerPoint presentation but plan to do so shortly.

I encourage you to play the game and see if you can beat the intern’s scores. I may even send a bag of smartees or dumdums to the person who posts the highest score!

by: Shaida Talebreza Brandon

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