How Internal Medicine Physicians Learn to Conduct Goals-of-Care Discussions: A Qualitative Study Across the Training...

Discussing goals of care (GOC) is an important component of patient-centered care. However, leading a GOC discussion requires honed communication skills and clinical judgment. Many practicing clinicians are not fully competent in discussing GOC, even in internal medicine (IM) where GOC discussions are frequently required in clinical work.

We aimed to understand the experiences of IM trainees and physicians navigating GOC discussions as a basis for insights into potential learning needs.

This was a qualitative study using individual semi-structured interviews. Interview data were interpreted using applied thematic analysis.

Thirty-four clinicians, including medical students, postgraduate year (PGY) 1-5 trainees in IM, and attending physicians in IM and critical care medicine at McGill University-affiliated academic hospitals.

Differences in conceptualizations and approaches to GOC discussions were distinguished by experience and seniority across four main themes: from concrete to abstract conceptualizations, from performative to organic approaches, from follower to leader in shared decision-making, and scaffolding learning between formal and informal development. Novices often conflated GOC with code status and were less comfortable providing guidance. Experienced clinicians showed a more nuanced understanding, greater flexibility, and willingness to make recommendations. Participants agreed that GOC skills develop as a career-long endeavor and called for a structured longitudinal curriculum to address limited formal training and early independent practice.

The way clinicians in IM understand and discuss GOC evolves substantially over the course of their careers. A structured, stage-specific curriculum is required to better facilitate this process and equip trainees with the necessary knowledge and skills in a timely fashion.