The Palliative Care Clinical Evaluation Exercise (CEX): An Experience-Based Intervention for Teaching End-of-Life Communication Skills

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Academic Medicine (Impact Factor: 2.93). 07/2005; 80(7):669-76. DOI: 10.1097/00001888-200507000-00009
Source: PubMed


To pilot test the "Palliative Care Clinical Evaluation Exercise (CEX)," a new experience-based intervention to teach communication skills in giving bad news and discussing code status. The intervention allows faculty to observe, evaluate, and give feedback to housestaff in their discussions with patients and families.
In 2002-03, the intervention was piloted among 60 first-year residents in the categorical Internal Medicine Residency Programs at the University of Pittsburgh. The authors collected feasibility measurements at the time of intervention, and interns' attitudes were measured before and one week after intervention and at the end of the intern year.
Forty-four residents (73%) completed the intervention. Discussions averaged a total of 49.5 minutes (SD 24.1), divided among 12.7 minutes (SD 7.5) for prediscussion counseling between the resident and faculty observer, 25.6 minutes (SD 16.1) for the resident-patient discussion, and 12.1 minutes (SD 5.7) for postdiscussion feedback. Residents rated the Palliative Care CEX favorably (>3 on a five-point scale) on ease of arranging the exercise, educational value, quality of the experience, effect on their comfort with discussions, importance to their education, and value of preceptor feedback. Self-ratings of communication competence showed improvement one week after the intervention.
The Palliative Care CEX is feasible and positively valued by residents. The findings from this initial pilot study support the value of further efforts to refine the intervention, to confirm its feasibility in other settings, and to validate its use as an educational and assessment tool.

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    • "yes resident questionnaires (telephone survey and written questionnaire) (Han et al., 2005) most residents rated the Palliative Care CEX very highly (>4 on five-point scale) among several dimensions: -educational value, -overall quality of the experience, -preceptor " s effectiveness in creating a positive learning experience, -improvement in comfort with discussions, -importance of formal instruction in end-of-life communication, -value of preceptor feedback). the study provides support for the feasibility in this setting. "
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    ABSTRACT: We reviewed the literature on instruments for work-based assessment in single clinical encounters, such as the mini-clinical evaluation exercise (mini-CEX), and examined differences between these instruments in characteristics and feasibility, reliability, validity and educational effect. A PubMed search of the literature published before 8 January 2009 yielded 39 articles dealing with 18 different assessment instruments. One researcher extracted data on the characteristics of the instruments and two researchers extracted data on feasibility, reliability, validity and educational effect. Instruments are predominantly formative. Feasibility is generally deemed good and assessor training occurs sparsely but is considered crucial for successful implementation. Acceptable reliability can be achieved with 10 encounters. The validity of many instruments is not investigated, but the validity of the mini-CEX and the 'clinical evaluation exercise' is supported by strong and significant correlations with other valid assessment instruments. The evidence from the few studies on educational effects is not very convincing. The reports on clinical assessment instruments for single work-based encounters are generally positive, but supporting evidence is sparse. Feasibility of instruments seems to be good and reliability requires a minimum of 10 encounters, but no clear conclusions emerge on other aspects. Studies on assessor and learner training and studies examining effects beyond 'happiness data' are badly needed.
    Full-text · Article · Mar 2011 · Advances in Health Sciences Education
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    • "Most assess trainees' history-taking, physical examination, and communication or counseling skills, and many include multiple skill domains. Some tools focus on more specific clinical skills, such as palliative care or cardiac auscultation (Han et al. 2005; Torre et al. 2005). Most tools employ numerical rating scales supported by adjectives/ adverb anchors. "
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    ABSTRACT: Direct observation of medical trainees by their supervisors with actual patients is essential for trainees to develop clinical skills competence. Despite the many available tools for direct observation of trainees by supervisors, it is unclear how educators should identify an appropriate tool for a particular clinical setting and implement the tool to maximize educational benefits for trainees in a manner that is feasible for faculty. Based on our previous systematic review of the literature, we provide 12 tips for selecting and incorporating a tool for direct observation into a medical training program. We focus specifically on direct observation that occurs in clinical settings with actual patients. Educators should focus on the existing tools for direct observation that have evidence of validity. Tool implementation must be a component of an educational program that includes faculty development about rating performance, providing meaningful feedback, and developing action plans collaboratively with learners. Educators can enhance clinical skills education with strategic incorporation of tools for direct observation into medical training programs. Identification of a psychometrically sound instrument and attention to faculty development and the feedback process are critical to the success of a program of direct observation.
    Full-text · Article · Jan 2011 · Medical Teacher
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    • "The hallmark of palliative end of life care is holistic, relationship-centered, and compassionate care of people living and dying with life-threatening conditions and their families. A number of curricula (Bednash & Ferrell, 2000; Emanuel et al., 2002; Back et al., 2003; Liao et al., 2004; Browning & Solomon, 2005; Ferrell et al., 2005; Han et al., 2005; Ogle et al., 2005; Sullivan et al., 2005; Paice et al., 2006; Kelly et al., 2008) using different teaching methods (Williams et al., 2001; Browning & Solomon, 2005; Fryer-Edwards et al., 2006; Ferrell et al., 2007; Weissman et al., 2007; Meyer et al., 2009) have been developed to give health care professionals the knowledge and skills to care for dying people. "
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    ABSTRACT: Health care professionals report a lack of skills in the psychosocial and spiritual aspects of caring for dying people and high levels of moral distress, grief, and burnout. To address these concerns, the "Being with Dying: Professional Training Program in Contemplative End-of-Life Care" (BWD) was created. The premise of BWD, which is based on the development of mindfulness and receptive attention through contemplative practice, is that cultivating stability of mind and emotions enables clinicians to respond to others and themselves with compassion. This article describes the impact of BWD on the participants. Ninety-five BWD participants completed an anonymous online survey; 40 completed a confidential open-ended telephone interview. Four main themes-the power of presence, cultivating balanced compassion, recognizing grief, and the importance of self-care-emerged in the interviews and were supported in the survey data. The interviewees considered BWD's contemplative and reflective practices meaningful, useful, and valuable and reported that BWD provided skills, attitudes, behaviors, and tools to change how they worked with the dying and bereaved. The quality of presence has the potential to transform the care of dying people and the caregivers themselves. Cultivating this quality within themselves and others allows clinicians to explore alternatives to exclusively intellectual, procedural, and task-oriented approaches when caring for dying people. BWD provides a rare opportunity to engage in practices and methods that cultivate the stability of mind and emotions that may facilitate compassionate care of dying patients, families, and caregivers.
    Full-text · Article · Dec 2009 · Palliative and Supportive Care
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