title: An exploration of contextual dimensions impacting goals of care conversations in postgraduate medical education.
abstract: BACKGROUND
  Postgraduate medical trainees are not well prepared difficult conversations about goals of care with patients and families in the acute care clinical setting. While contextual nuances within the workplace can impact communication, research to date has largely focused on individual communication skills. Our objective was to explore contextual factors that influence conversations between trainees and patients/families about goals of care in the acute care setting.
  
  
  METHODS
  We conducted an exploratory qualitative study involving five focus groups with Internal Medicine trainees (n = 20) and a series of interviews with clinical faculty (n = 11) within a single Canadian centre. Thematic framework analysis was applied to categorize the data and identify themes and subthemes.
  
  
  RESULTS
  Challenges and factors enabling goals of care conversations emerged within individual, interpersonal and system dimensions. Challenges included inadequate preparation for these conversations, disconnection between trainees, faculty and patients, policies around documentation, the structure of postgraduate medical education, and resource limitations; these challenges led to missed opportunities, uncertainty and emotional distress. Enabling factors were awareness of the importance of goals of care conversations, support in these discussions, collaboration with colleagues, and educational initiatives enabling skill development; these factors have resulted in learning, appreciation, and an established foundation for future educational initiatives.
  
  
  CONCLUSIONS
  Contextual factors impact how postgraduate medical trainees communicate with patients/families about goals of care. Attention to individual, interpersonal and system-related factors will be important in designing educational programs that help trainees develop the capacities needed for challenging conversations.
authors.affiliation: Department of Critical Care Medicine and Division of Palliative Medicine, South Health Campus Intensive Care Unit, University of Calgary, 4448 Front St SE, Calgary, AB, T3M 1M4, Canada. amanda.rozedesordons@ucalgary.ca.
authors.forename: Amanda L
authors.initials: AL
authors.lastname: Roze des Ordons
authors.affiliation: Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
authors.forename: Jocelyn
authors.initials: J
authors.lastname: Lockyer
authors.affiliation: Divisions of Critical Care and Palliative Care, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Hartwick
authors.affiliation: Divisions of Critical Care and Palliative Care, University of Calgary, Ottawa, ON, Canada.
authors.forename: Aimee
authors.initials: A
authors.lastname: Sarti
authors.affiliation: Centre for Research in Assessment and Digital Learning, Deakin University, Melbourne, VIC, Australia.
authors.forename: Rola
authors.initials: R
authors.lastname: Ajjawi
mesh_terms: D002170:Canada; D003142:Communication; D004503:Education, Medical, Graduate / Q000379:methods / Q000592:standards*; D017144:Focus Groups; D006282:Health Personnel / Q000193:education*; D006801:Humans; D007388:Internal Medicine / Q000379:methods / Q000592:standards; D036301:Qualitative Research; D066107:Social Skills; D013192:Staff Development / Q000592:standards*
keywords: Communication; Context; Goals of care; Postgraduate medical education; Qualitative