Background:  Numerous influential groups have emphasized the need for hospice and palliative medicine (HPM) skill-building and knowledge accrual for generalist clinicians (1-3). This has led to an expansion of HPM-related resources in graduate medical education (GME) and continuing medical education (CME) since the 1990s. Despite these efforts, non-palliative care clinicians continue to report poor HPM knowledge and skills (4,5). One reason why is traditional educational formats (textbooks, Grand Rounds didactics, clinical workshops, etc.) are limited in HPM by the ‘confidence-knowledge gap’ – most clinicians have limited insight into their actual performance and knowledge in HPM-related skills (6,7). Both over-confidence and the perception of fixed incompetence interferes with successful learning (6,7). Innovative educational tools that take advantage of educational opportunities as they occur in clinical training are needed to improve HPM educational outcomes. 

What is Just-in-Time Teaching (JiTT)?  JiTT is an educational strategy conceived in 1996. The original format consists of preparatory, out-of-classroom assignments that link to in-class work (8). When preparing each upcoming lesson, the instructor reviews and incorporates insights gained from the students’ responses from these assignments. In this way, the course content automatically adjusts to the learners’ needs. More recently, JiTT has expanded beyond classrooms and into clinical education. While the “traditional” JiTT is based on setting up preparatory assignments and questions to motivate learning, “clinical” JiTT takes advantage of actual clinical scenarios as opportunities for teachable moments. Educators who anticipate and identify these opportunities can leverage their inherent educational tension (the learner’s sense of a “need to know”) and create an active, customized learning experience (9,10).

Evidence:  While the majority of JiTT research comes from basic science, there are supporting data for GME and CME (11-16). For example, a JiTT educational video on how to splint an injured extremity improved medical student motivation to learn and knowledge retention compared to more traditional classroom and textbook instruction (13). Additionally, JiTT has been shown to be a feasible and effective educational strategy for rotators on a busy inpatient HPM and hematology/oncology service (14,17). 

Implementation: Modifications to the “traditional” JiTT method are necessary considering the single learner or small group model which applies to most HPM learning. Successful “clinical” JiTT requires engagement from both learners and educators to be on the lookout for teachable moments in which the learner is struggling with a clinical dilemma and thereby motivated to learn. In contrast, more traditional medical education models (didactics, independent reading, etc) does not provide this active partnership and thereby valuable learning opportunities can be missed. Providing a pocket card to offer a concise framework for leading a serious illness discussion immediately prior to real serious illness discussion is one example of a “clinical” JiTT tool. Since not all clinical learners are accustomed to this active format of teaching, the concept and intent of JiTT should be explained upfront. 

Tips when designing a “traditional” JiTT curriculum:  For classroom JiTT, the thoughtful development of preparatory assignments is crucial. These assignments should be concise and include thought-provoking questions eliciting complex answers to relevant issues. Characteristics of quality assignments include:

• They should build upon prior knowledge and experience. Reflecting upon what we covered about cancer-related cachexia, how does medically administered nutrition affect the quantity and quality of life of a cachectic cancer patient? 
• They should contain enough ambiguity to lead learners to self-reflect and seek out supplemental information not explicitly covered already. What are your thoughts on when medically administered nutrition should be utilized and avoided for patients with advanced cancers?
• A summary question should be included which assesses whether there are general concepts still unclear to the learner: After completing this assignment, what concepts are still unclear to you?

Tips when incorporating “clinical” JiTT into clinical rotations:  The first step is to identify HPM-related scenarios or clinical issues that learners will likely encounter during their rotation and have relevant content prepared ahead of time. Once the educator identifies a teachable moment, they can engage the learner by using prepared questions in the style of JiTT assignments (see above). Based on the learner’s response, the educator can then identify the educational need and target it via shared resources. Evidence-based reference materials which are easy to access at the time of need (smart phone apps or online platforms) are available for HPM-specific CME or GME (see references 18-21). Additional strategies to incorporate JiTT principles into the daily clinical schedule include: 

• Ask learners to complete preparatory assignments prior to the start of the rotation (e.g., a knowledge pre-test). Responses are reviewed to shape the learner’s educational goals and objectives.
• Utilize the interdisciplinary team during morning rounds to generate interprofessional perspectives and problem solving to care dilemmas encountered by the learner. 
• Set a dedicated time at the end of the clinical week to engage in learning sessions framed upon recent, challenging cases. 
• Utilize standardized patients and/or role-playing exercises to create in-the-moment, targeted feedback for essential experiences that leaners may not reliably encounter during their rotation.
• Reach clinicians on other clinical teams with relevant content via concise, evidence-based resources that can be linked into consultation notes, team rooms, email, phone apps, etc. (9,15,18).

References: 

1. Institute of Medicine. Approaching Death: Improving Care at the End of Life. Washington, DC: IOM, 1997
2. World Health Organization. Cancer Relief and Palliative Care. Geneva: WHO, 1990
3. Billings AJ, Block S. Palliative care in undergraduate medical education: status reports and future directions. JAMA 1997;278: 733-8
4. Billings ME, Curtis JR, Engelberg RA. Medicine Residentsʼ Self-Perceived Competence in End-of-Life Care. Academic Medicine. 2009;84(11):1533-1539. doi:10.1097/acm.0b013e3181bbb490. 
5. Head BA, Schapmire TJ, Earnshaw L, et al. Improving medical graduates’ training in palliative care: advancing education and practice. Adv Med Educ Pract. 2016;7:99-113. Published 2016 Feb 24. doi:10.2147/AMEP.S94550
6. Krautheim V, Schmitz A, Benze G, et al. Self-confidence and knowledge of German ICU physicians in palliative care – a multicentre prospective study. BMC Palliative Care. 2017;16(1). doi:10.1186/s12904-017-0244-6. 
7. Davis DA, Mazmanian PE, Fordis M, Harrison RV, Thorpe KE, Perrier L. Accuracy of Physician Self-assessment Compared With Observed Measures of Competence. Jama. 2006;296(9):1094. doi:10.1001/jama.296.9.1094. 
8. Simkins, Scott P., et al. Just-in-Time Teaching: across the Disciplines, across the Academy. Stylus Publishing, 2010.
9. Weissman DE. Fast facts: the Veg-o-Matic of palliative medicine education. J Palliat Med. 2011 Aug;14(8):892-3.
10. Hoffman KG, Donaldson JF. Contextual tensions of the clinical environment and their influence on teaching and learning. Med Educ. 2004 Apr;38(4):448-54.
11. Kessler D, Pusic M, Chang TP, et al. Impact of Just-in-Time and Just-in-Place Simulation on Intern Success With Infant Lumbar Puncture. Pediatrics. 2015;135(5). doi:10.1542/peds.2014-1911. 
12. Nishisaki A, Donoghue AJ, Colborn S, et al. Effect of Just-in-time Simulation Training on Tracheal Intubation Procedure Safety in the Pediatric Intensive Care Unit. Anesthesiology. 2010;113(1):214-223. doi:10.1097/aln.0b013e3181e19bf2. 
13. Cheng Y-T, Liu DR, Wang VJ. Teaching Splinting Techniques Using a Just-in-Time Training Instructional Video. Pediatric Emergency Care. 2017;33(3):166-170. doi:10.1097/pec.0000000000000390. 
14. Sam J, Pierse M, Al-Qahtani A, Cheng A. Implementation and evaluation of a simulation curriculum for paediatric residency programs including just-in-time in situ mock codes. Paediatrics & Child Health. 2012;17(2). doi:10.1093/pch/17.2.e16. 
15. Schuller MC, Darosa DA, Crandall ML. Using Just-in-Time Teaching and Peer Instruction in a Residency Program’s Core Curriculum. Academic Medicine. 2015;90(3):384-391. doi:10.1097/acm.0000000000000578.
16.  Mangum R, Lazar J, Rose MJ, Mahan JD, Reed S. Exploring the Value of Just-in-Time Teaching as a Supplemental Tool to Traditional Resident Education on a Busy Inpatient Pediatrics Rotation. Academic Pediatrics. 2017;17(6):589-592. doi:10.1016/j.acap.2017.04.021.
17. Rodenbach R, Kavalieratos D, Tamber A, et al. Coaching Palliative Care Conversations: Evaluating the Impact on Resident Preparedness and Goals-of-Care Conversations. Journal of Palliative Medicine. 2020;23(2):220-225. doi:10.1089/jpm.2019.0165.
18. Claxton R, Marks S, Buranosky R, Rosielle D, Arnold RM. The Educational Impact of Weekly E-Mailed Fast Facts and Concepts. Journal of Palliative Medicine. 2011;14(4):475-481. doi:10.1089/jpm.2010.0418. https://jittdl.physics.iupui.edu
19. Fast Facts and Concepts. Accessible at www.mypncow.org/fast-facts/  Last accessed January 8^th, 2021
20. Vital Talk App.  Accessible at www.vitaltalk.org/vitaltalk-apps/  Last accessed January 8^th, 2021
21. Kossman DA, Wolfrom SD, et al.  Just-in-time interdisciplinary education for hospice care of ventricular-assist device patients. Journal of Palliative Medicine 2019; 22(9):1167-1169.

Version History: first electronically published in January 2022; originally edited by Sean Marks MD

Authors Affiliations:  University of Minnesota Medical School, Minneapolis, MN; Health Partners Regions Specialty Clinics, St. Paul, MN

Conflicts of Interest: None to report