Improving Clinician Communication Skills (ICCS)

Inclusion Criteria:

Physician:

* all internal medicine residents at either University of Washington (UW)or the Medical University of South Carolina
* who have a clinical rotation allowing implementation of the intervention.

NP Student:

* All NP Students at UW or MUSC
* in programs that train them to work with the following patient types:
* Adult patents with Cancer or other chronic, life-limiting illnesses
* Older Adults
* Adults Primary Care Patients

Patient:

One or more of the following diagnostic criteria:

* Advanced Cancer;
* Chronic obstructive pulmonary disease (COPD) with FEV1 values \< 35% predicted and/or oxygen dependent;
* Restrictive lung disease with a TLC \< 50% predicted;
* Congestive heart failure with an ejection fraction \<30% or functional deficits matching New York Heart Association Class III or IV heart failure;
* End stage liver disease including Child's Class C cirrhosis, MELD score ≥ 18, a variceal bleed, refractory ascites, or spontaneous bacterial peritonitis (SBP);
* a Charlson Comorbidity Score point value ≥6;
* in-patients with a University HealthSystem Consortium (UHC) Risk of Mortality score of major or extreme;
* OR hospitalized patients ≥ 80 years.

Family:

* The ability to speak English well enough to be able to complete the study procedures
* AND no significant dementia or delirium that would limit the family member's ability to complete instruments.

Nurse-evaluators:

* are working in the hospital or clinic with the resident or NP student enrolled in the study.

Exclusion Criteria:

* less than 18 years,
* significant dementia, delirium, or psychosis;
* the inability to speak English well enough to be able to complete the study procedures.