The research team conducted individual semi-structured interviews with thirty-four clinicians spanning the entire training continuum, from medical students to postgraduate year one through five residents in internal medicine, and on to attending physicians in internal medicine and critical care medicine at McGill University-affiliated academic hospitals. The interviews were interpreted using applied thematic analysis, a rigorous qualitative method that allows researchers to identify recurring patterns in how participants describe their experiences. What emerged was a developmental arc, a story of how understanding of goals-of-care discussions transforms as clinicians gain experience and seniority.

The analysis organized its findings into four central themes that map the trajectory from novice to expert. The first traces a shift from concrete to abstract conceptualizations of what a goals-of-care discussion actually is. Less experienced trainees frequently conflated goals-of-care conversations with code status discussions, reducing a rich, patient-centered dialogue to a narrow question about resuscitation preferences. For these novices, the task was often perceived as a form to be completed, a checkbox in the admission paperwork rather than an exploration of what matters most to a patient facing serious illness. More senior clinicians, by contrast, described goals of care in abstract and contextual terms, framing these conversations as ongoing negotiations that integrate prognosis, patient values, family dynamics, and clinical uncertainty.

The second theme captures a parallel movement from performative to organic approaches. Early trainees described following scripted frameworks, reciting standardized phrases, and treating the conversation as a performance to be evaluated by a supervising attending. This performative orientation, while a reasonable starting point, left them rigid and easily thrown when a patient or family member deviated from the expected script. Experienced physicians described something fundamentally different: an organic, responsive conversation that flexes to the emotional and informational needs of the moment. They spoke of reading the room, pacing the disclosure of difficult information, and weaving goals-of-care discussions naturally into the fabric of clinical care rather than isolating them as discrete, formulaic events.

The third theme, from follower to leader in shared decision-making, addresses one of the most consequential differences between junior and senior clinicians. Novices were markedly less comfortable offering guidance and tended to position themselves as passive facilitators, presenting options without direction and hoping the patient would choose. This hesitation, the researchers suggest, may reflect both a lack of clinical confidence and an incomplete understanding of prognosis. Attending physicians, drawing on years of accumulated judgment, demonstrated a greater willingness to make recommendations, to share their expert opinion while still honoring patient autonomy, and to steer the conversation toward medically appropriate and patient-aligned decisions. This evolution from deference to directed guidance represents a core component of what experts mean by clinical judgment in serious illness communication.

The fourth theme concerns how learning itself happens, described as scaffolding between formal and informal development. Participants agreed almost universally that goals-of-care skills develop as a career-long endeavor, shaped far more by observation, feedback, and lived clinical experience than by structured instruction. Formal training on this topic was described as limited, fragmented, and often arriving too late. Trainees reported watching senior colleagues conduct these conversations, debriefing afterward with attendings when circumstances allowed, and gradually building competence through repetition and reflection. Yet the study found that many trainees were expected to lead goals-of-care discussions independently early in their training, before adequate scaffolding had been established, raising pointed concerns about patient care and trainee distress.

The implications of this developmental mismatch are significant. Internal medicine is, by the nature of its patient population, a specialty where goals-of-care conversations are frequently required. Hospitalized patients with advanced illness, uncertain prognoses, and complex family situations present these dilemmas daily. If junior physicians are being sent into these encounters with a conceptualization limited to code status and a performative, script-dependent approach, both patients and trainees are being underserved. Prior research cited by the authors, including studies of residents’ code status discussion skills and randomized trials of simulation-based communication training, has shown that these skills can be taught, but the new findings suggest that isolated interventions may not be enough. What is needed, the authors argue, is a structured, stage-specific, longitudinal curriculum that meets learners where they are in their development.

Such a curriculum would look markedly different at each stage. For medical students and early residents, the priority would be building accurate conceptual foundations, decoupling goals of care from code status, and introducing frameworks that emphasize eliciting patient values before discussing interventions. For mid-level residents, deliberate practice with simulated patients and observed conversations with structured feedback could accelerate the shift from performative to organic approaches. For senior residents and early attendings, coaching on recommendation-giving and prognostic communication would support the transition to leadership in shared decision-making. The study’s participants themselves called for exactly this kind of sequenced, longitudinal design, echoing broader movements in medical education such as competency-based frameworks and longitudinal coaching programs that have been adopted in Canada and elsewhere.

The study also carries a broader message about the nature of expertise in medicine. Communication skills are often treated as soft skills, assumed to be absorbed along the way rather than rigorously taught. This research demonstrates that the growth from novice to expert in goals-of-care discussions follows a describable, predictable developmental progression, one that can be anticipated and supported rather than left to chance. The differences in conceptualization, approach, and decision-making role between junior and senior clinicians are not merely matters of personality or confidence. They reflect distinct cognitive and professional stages, each with its own learning needs. Recognizing this progression allows educators to design training that is developmentally attuned, rather than one-size-fits-all lectures delivered at a single point in training.

As populations age and chronic serious illness becomes an ever-larger share of medical practice, the ability to conduct skillful, compassionate goals-of-care conversations will only grow in importance. This study, funded by the Fédération des Médecins Résidents du Québec Research Grant and presented in preliminary form at the International Conference on Residency Education in Ottawa, provides a roadmap for how the medical education community might respond. By treating goals-of-care communication as a career-long developmental arc with structured support at every stage, training programs can ensure that physicians arrive at these pivotal bedside moments not as anxious novices clutching a script, but as confident, nuanced clinicians capable of guiding patients and families through the most consequential decisions of their lives.

Subject of Research: How internal medicine physicians develop goals-of-care discussion skills across the training continuum

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

Article References: Lee, C. B., Snell, L., Li, K. X., Jayaraman, D., & Nugus, P. (2026). How Internal Medicine Physicians Learn to Conduct Goals-of-Care Discussions: A Qualitative Study Across the Training Continuum. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10696-w

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10696-w

Keywords: goals of care, internal medicine, medical education, communication skills, qualitative study, shared decision-making, code status, residency training, palliative care, clinical judgment, longitudinal curriculum, physician development