Vocational awe is (not) enough: Learnings from early adopters of serious illness communication.

Context: As part of a broader institutional initiative, the serious illness care program was implemented in a multi-site academic primary care practice. After 2 years, a minority was observed to be documenting serious illness conversations routinely.

Objectives: We aimed to learn about the motivations and actions of clinicians who routinely conducted and documented serious illness conversations.

Methods: We identified primary care early adopters of serious illness communication: 17 of 228 physicians (roughly 8%) who were documenting at least 1-2 conversations every 1-2 months for a year. Fifteen physicians agreed to participated in semi-structed interviews and which were then analyzed with thematic analysis.

Results: Early adopters successfully integrate serious illness conversations into clinical practice by using four strategies that amplify vocational awe: their deep sense of their professions core value. Three strategies focus on positive aspects of serious illness communication: (1) reflecting on the meaningful impact of serious illness conversations on clinical care; (2) feeling a resonance between serious illness communication and their personal identity and values; and (3) identifying with the medical community's sense that serious illness communication contributes to good clinical care. The fourth strategy is to minimize system limitations using a range of tactics that include accepting time shortages and streamlining workflow.

Conclusion: Vocational awe is a powerful driver for engaging in serious illness communication; however, without system-level resource support, it does not sustainably motivate most clinicians. Serious illness communication needs to be a part of routine healthcare with appropriately allocated time, compensation, and workflow support.