Introduction

Experiential learning (i.e. learning by experience) is a key component of medical professionals’ training in which acquiring professional knowledge is mainly driven by workplace experience (1). Palliative care (PC) is an interprofessional specialty that focuses on relationships and communication. It is intended to improve the quality of life of patients with incurable and often unpredictable diseases (2).
Workplace-based assessments (WBAs) emerged from the observation that the intent of an assessment should be learning. WBAs are, therefore, assessments with a primary formative intent that, according to Norci et al. (3), have the following key elements: alignment with a training program that has competence as an outcome, timely feedback on a real work-related situation, and guidance for a trainee’s learning toward a desired competency.

Typical examples of direct (single-time-point) WBAs include the mini-clinical evaluation exercise (Mini-CEX), direct observation of procedural skills (DOPS), and case-based discussions. Mini-CEX and DOPS are in-training assessments wherein a supervisor conducts an in-person assessment of a trainee’s performance. For example, a supervisor observes a trainee during the disclosure of “bad news” and then gives feedback on his or her performance. Case-based discussions: In a case-based discussion, performance in a clinical situation is assessed retrospectively. For example, a supervisor discusses the strategy to change an opioid treatment with a trainee and provides feedback on the approach the trainee uses for solving this clinical problem (3).

WBAs are well-researched educational tools with various desirable effects. Independent of the WBA type, they have shown positive effects on the quality and frequency of feedback (4). However, the acceptance of these types of assessments as standard learning practices by healthcare professionals is not universal. Key barriers to acceptance include a) lack of time, b) low feedback quality, c) an unclear setting (formative vs. summative) that leads to fear of being assessed, d) lack of supervisor training, and e) challenges in the professional relationship between a supervisor and a trainee (4, 5).
Increasingly so-called Entrustable Professional Activities (EPAs) are introduced to define tasks learners have to be capable to manage. Further, many observations of such activities can be used to “entrust” a learner to manage such activities either with direct/indirect or without supervision (6).

There are two basic medical training models: 1) the traditional time-based one in which a trainee is judged to be competent after a fixed training period, and 2) competency-based medical education (CBME), which is a learner-centered model in which a trainee’s preparedness for independent practice is evaluated after a defined level of competency is reached.

In Switzerland, PC training is strongly anchored in the traditional time-based education model. A Swiss postgraduate specialist PC training program follows this model and is governed by the Swiss Society of Palliative Care (palliative.ch) and the Swiss Institute of Medical Education (SIWF) (7). It involves three years of residency, with two years spent in a certified PC unit, an accredited theoretical course (a minimum of 140 hours), and the fulfillment of practical competencies. The Swiss Society of PC provides specific learning goals and competencies (8). Concerning WBAs, providing four WBAs per year is a mandatory requirement for accreditation as a PC training unit, but no guidance on which specific WBAs should be used is given.

Although WBAs are a main component of competency-based education, the use of WBAs in postgraduate specialist PC settings has not been summarized in the literature. To address this gap, this current review was guided by the following question: What is the current evidence regarding WBAs in PC postgraduate physician training?

Closing this gap is of interest because, on a practical level, summarizing existing evidence could provide a scientific groundwork for countries that want to shift postgraduate specialist PC training toward more competency-based education (9). The current situation in Switzerland is typical of this transition and can serve as a practical example in the discourse surrounding this topic.

Methods

This narrative review followed elements of the Scale for the Assessment of Narrative Review Articles (SANRA) (10). A detailed description can be found in Appendix 1, and the literature search is discussed in the following paragraph. To obtain an overview, an initial literature search was conducted in PubMed, Ovid, Scopus, ERIC, and PsychInfo. No limitations were set, and references up to November 2022 were included. The search focused on WBAs in postgraduate PC training using the following key search terms: PC, education, postgraduate, workplace-based assessment (as a general term), and specific types of WBAs.

After an initial search, the PubMed database was monitored for new publications on “education” in “palliative care” (search alert). Additionally, a Google Scholar search (“workplace-based assessment” AND “postgraduate training” AND “specialist PC”) was conducted in February 2024. After the initial search, emerging literature in the ongoing literature survey and specific references to underline emerging key statements were directly referenced in the text.

Information about the Swiss system is based on the official accreditation and quality requirements of the Swiss Society of Palliative Care (8). Details of the initial literature search and reference selection process can be found in Appendix 2 and a summary of the initial literature in Appendix 3.

Results

In total, 1121 papers were identified via an initial literature search conducted in November 2022. Twenty-nine papers were included after their abstracts were assessed for eligibility. An additional 24 references were found in the gray literature via crossreferencing. This resulted in 53 references, which served as the foundation for this review. Within these papers, specific evidence regarding postgraduate PC training in general was found in 31 records (11–41). The variety of papers was broad, ranging from reviews, reports, and surveys to policy papers (standards and requirements) on residency training programs. The evidence base for WBAs in specialist PC was enhanced by gray literature and personal communications; the search returned seven papers, documents, and internet websites (42–48). The literature survey and final Google Scholar search in 2024 identified three additional papers.(49–51)

Workplace-based Assessment in Specialist PC

We mainly found descriptions of the implementation of WBAs in specialist PC programs. Most of these programs followed a CBME model of training. In these programs, WBAs are the key elements of training and are, therefore, comprehensively implemented and described. In time-based systems (e.g., Switzerland), WBAs are usually considered a choice for supporting training, among others.

This review chose three CBME-pioneer countries as a comparison to the Swiss situation. Licensing bodies in Canada, the United States, and the United Kingdom provide detailed frameworks for WBAs included in their CBME programs. In Canada, the Royal College of Physicians, in cooperation with the Canadian Society of Palliative Care Physicians, provides clear frameworks for specialist PC education (24, 42, 45, 46). In the United States, the Accreditation Council for Graduate Medical Education (ACGME) provides clear guidance for PC postgraduate training (33), including ­recommendations for typical WBAs in a supplementary index (52). Similarly, the UK Royal College of Physicians provides a comprehensive curriculum (47).

In a Swiss postgraduate specialist PC training program, an in-training assessment of competencies can be done using a broad variety of methods. WBAs are an option, among others (43). In Swiss practice, Mini-CEX and DOPS are the most frequently used. For the accreditation of a training site, a minimum of four WBAs per year are required (8).

Tab. 1 and Tab. 2 provide an overview of specialist PC training WBAs in the United States, Canada, and the United Kingdom compared to Switzerland.

Discussion

We found that WBAs in postgraduate specialist PC training are described mainly in countries where the change to competency-based postgraduate education has been implemented systemically (e.g., Canada). An evaluation of these types of assessments in these settings is lacking, and the literature primarily describes implementation or normative needs (accreditation rules/guidelines). The use of structured WBAs (3) in specialist PC training seems understudied; the only publicly available evidence found in this review is the frameworks or requirements for a curriculum.

Training using WBAs appears to be a good modality in a PC setting for the following reasons: First, healthcare professionals working in PC are often confronted with highly dynamic and unpredictable settings, emphasizing the importance of assessments that take place in real-world environments. The second important aspect of continuity of care offers a natural opportunity for prolonged (multiple-time-point) formative assessments.

The primary intent of WBAs is to increase trainees’ levels of competency in their clinical work environments. Using the experiences of other specialties (53,54), postgraduate specialist training in PC can likely benefit from the introduction of WBAs. Through their communicative, high-feedback, and learner-centered nature, WBAs have the potential to improve postgraduate specialist PC training (especially if used with formative intent).

Countries that pioneered CBME (e.g., the U.S., the UK, and Canada) have a comprehensive program that includes WBAs as the primary assessment modality (see Tab. 1 and Tab. 2), proving their feasibility in these systems. The feasibility of WBAs does not imply universal acceptability, nor is there direct evidence of a training effect or usefulness in increasing the quality of care. Therefore, the lack of specific evaluations of training curricula leaves these questions open.

Swiss specialist PC training, although recently revised, remains close to a time-based model. In the current Swiss setting, only direct (single-time-point) Mini-CEX and DOPS are required; no EPAs are used in Swiss postgraduate specialist PC training (8).

Potential Roles and Impacts of WBAs as a Key Step in Shifting Specialist PC Training from Being Time-based to Competency-based:
The Swiss Example

PC is a relatively young discipline in Switzerland. The Swiss PC system, like other PC systems in Central Europe, has transitioned from a pioneering to a sustainable phase with a time-based training model of training. The reason for this could be that, over the last decade, stakeholders and policymakers have focused on introducing, positioning, and rendering the specialty sustainable at the system level. Presumably, because this achievement necessitates considerable resources, teaching and assessment modalities are left to the discretion of training facilities.

Because WBAs are central to competency-based training (55), we propose a two-step strategy for transitioning to a competency-based model. First, WBAs should be strengthened as standards in existing curricula. Second, existing curricula should evolve further with the introduction of EPAs. A detailed description of the second step is hypothetical and beyond the scope of this review. Fig. 1 summarizes this proposed two-step strategy.

Although the current revision of the specialist training program in Switzerland requires only four WBAs per year, these assessments are still one possibility among many. Therefore, an increase in their role should be considered whenever faculty members’ time resources allow it.

We anticipate several challenges during this transition at the trainee, supervisor, interprofessional team, and patient levels. Trainees and supervisors share the key challenge of additional time requirements. Recent qualitative research on residents’ experiences in CBME-based systems shows that these time requirements, particularly for administrative efforts, are a real issue (56). Together with the universal problem of staff shortages, both at the resident and supervisor levels, this might create tension between clinical responsibilities and education.
This review has several limitations. First, because of its narrative structure, it has inherent limitations regarding structure and rigor; however, we believe that, via the stringent application of SANRA quality items, this review provides a good overview from a practical perspective. Second, the contexts are confined to the United States, the United Kingdom, and Canada as examples of CBME-based systems. Switzerland can be considered an example of a transition to CBME, and many of its elements are derived from Anglo-Saxon education systems (e.g., Canada).

Conclusion

WBAs are feasible, accepted, and evaluated as formative training modalities in postgraduate training of specialties besides PC. However, although WBAs are seemingly well tailored to PC, the evaluation of WBAs in specialist PC training is lacking.

In Switzerland, postgraduate specialist PC training follows a primarily time-based model, and WBAs play only a marginal role in assessing trainees’ competencies. The transition to a CBME-based training model is ongoing. It is critical that WBAs be incorporated into Swiss (time-based) PC specialist physician training as a next step toward competency-based training.

History
Manuscript received: 24.06.2024
Accepted after revision: 22.01.2025

Abbreviations
WBAs Workplace-based assessments
PC Palliative Care
CBME Competency-based medical education
Mini-CEX Mini-clinical evaluation exercise
DOPS Direct observation of procedural skills

Appendix 1:
Scale for the Assessment of narrative Review Articles (SANRA), Detailed description according to Baethge C, Goldbeck-Wood S, Mertens S. SANRA—a scale for the quality assessment of narrative review articles. Peer Rev [Internet]. 2019 Dec [cited 2022 Dec 15];4(1):5. Available at: https://researchintegrityjournal.biomedcentral.com/articles/10.1186/s41073-019-0064-8

Appendix 2
Details of the literature search
Search terms for the initial literature search:

Pubmed
– “workplace-based assessment”[Title/Abstract] AND “postgraduate”[All Fields]
– (“palliative care”) AND (“medical education”) Filters: Review, Systematic Review
– (“palliative care”[All Fields] AND “medical education”[All Fields]) AND ((y_10[Filter]) AND (review[Filter] OR systematicreview[Filter]))
– (“Terminal Care”(mh) OR caregiver*(tw) OR bereave* OR inpatient(tiab) OR “attitude to death”(tw) OR “end of life” OR hospice* OR “terminally ill”(tw) OR palliative*(tw) OR “Advance Care” OR palliat OR advanced OR (morphine AND cancer) OR “cancer pain”)AND “Workplace based assessment”. OR “Mini-cex, Clinical Encounter Cards, Clinical Work Sampling, Blinded Patient Encounters Direct observation of procedural skills , Case-based Discussion, MultiSource Feedback”

ERIC
“Postgraduate palliative care education”

Psychinfo
– Palliative and Education

Scopus
(Title-ABS-KEY (palliative) AND education AND postgraduate)
Ongoing Literature Surveillance
PubMed search alert (11/2022 –10/2023)
“Education” AND “Palliative Care”

Specific Google Scholar search (February 2024)
Search terms (014–2024):
– “Workplace-based Assessment in Palliative Care Physicians Training”
– “Postgraduate Training in Specialist Palliative Care”