Narrative Approach to Goals of Care Discussions: A Novel Curriculum

J Pain Symptom Manage. 2019 Dec;58(6):1033-1039.e1. doi: 10.1016/j.jpainsymman.2019.08.023. Epub 2019 Aug 28.


Context: Innovative patient-centered approaches to goals of care (GOC) communication training are needed. Teaching a narrative approach, centered on the patient's unique story, is conceptually sound but has not been evaluated with respect to objective skills attainment. We developed a curriculum based on a novel, easily-remembered narrative approach to GOC, the 3-Act Model, and piloted it with a cohort of internal medicine (IM) interns.

Objectives: To describe the development of the 3-Act Model curriculum and to assess its impact on the GOC communication skills of IM interns.

Methods: The curriculum was developed with input from multidisciplinary experts, IM residents, and patient/family representative. Notable elements included instrument development with validity evidence established, determination of proficiency standards, and creation of role-play scenarios. In two three-hour workshops, interns participated in role-plays as both providers and patients, before and after teaching (which included narrative reflection, didactics, and video demonstration).

Results: 22 interns played the role of provider in five unique scenarios; 106 proficiency ratings were analyzable. Interns objectively rated as proficient increased from 30% (pretest) to 100% (final role-play). By the end of the training, 96% of interns strongly agreed or agreed that they felt ready to independently lead basic GOC discussions and the percentage who strongly agreed increased with successive role-plays. All interns indicated they would recommend the training.

Conclusion: This pilot demonstrates that the 3-Act Model is teachable and appreciated by learners. This GOC curriculum is the first based on a narrative approach to demonstrate objective skills improvement.

Keywords: Communication skills curriculum; assessment tool; graduate medical education; narrative medicine; primary palliative care; role-play learning.

MeSH terms

  • Adult
  • Clinical Competence
  • Cohort Studies
  • Communication
  • Curriculum*
  • Education, Medical, Graduate
  • Educational Measurement
  • Family
  • Female
  • Health Personnel
  • Humans
  • Internship and Residency
  • Male
  • Narration
  • Palliative Care / organization & administration*
  • Patient Care Planning*
  • Patient-Centered Care / organization & administration
  • Patients