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Indian Pediatr 2017;54: 284-287 |
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Implementation of a
Mini-Clinical Evaluation Exercise (Mini-CEX)Program to Assess
the Clinical Competence of Postgraduate Trainees in Pediatrics
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*Sumaira Khalil, *Anurag Aggarwal and * #Devendra
Mishra
From Departments of *Pediatrics and #Medical
Education, Maulana Azad Medical College, New Delhi, India.
Correspondence to: Dr Devendra Mishra, Department of
Pediatrics, Maulana Azad Medical College, Delhi 110002. India. Email:
[email protected]
Received: August 14, 2016;
Initial review: November 05, 2016;
Accepted: January 11, 2017.
Published online: February 02, 2017.
PII:S097475591600043
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Objective: To implement Mini-CEX, a Workplace-based assessment tool,
for formative assessment of clinical skills of final year pediatric
post-graduate residents.
Methods: All final-year postgraduate residents at
the Department of Pediatrics of a public medical college in India
underwent mini-CEX assessment by rotation among six faculty members.
Outcome was assessed by an anonymous questionnaire-based feedback from
the participating students and faculty members, collected after the
completion of all the mini-CEX encounters.
Results: 20 final year postgraduate students (12
males, 15 MD and 5 DCH) were assessed. Data gathering (68.7%) and
counseling (63.3%) were the most common areas assessed. 84% and 58% of
the students and faculty, respectively were satisfied with their
Mini-CEX encounter (score > 8 on a 10-point Likert scale). 90% of
the participating students felt that Mini-CEX should be included as a
routine in postgraduate teaching. All six faculty thought they had a
good experience, but 50% were unsure whether it was a valid method of
assessment.
Conclusions: The involved faculty and residents
had high satisfaction levels with mini-CEX evaluation. Mini-CEX has a
potential to be incorporated in the formative evaluation of postgraduate
pediatric students as part of the workplace-based assessment.
Keywords: Assessment, Competency-based medical education,
Teaching methods, Workplace-based assessment.
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T he method of postgraduate medical student
evaluation in our country is restricted to an annual examination [1],
with or without evaluation of a log book/internal assessment. Eighty
percent of the students are assessed more for their presentation skills
rather than clinical skills as they are actually observed later during
presentation, and not while taking history or carrying out physical
examination [2]. Mini-Clinical Evaluation Exercise (Mini-CEX) is a brief
and rapid observation of core clinical skills in a doctor-patient
encounter lasting only 10-15 minutes [3]. It is a Workplace-based
assessment (WPBA), in which the performance of the student is evaluated
during a focused clinical interaction, followed by a focused feedback
[1]. A variety of clinical skills like data collection, history taking,
physical examination, clinical judgment, counseling, overall competence,
organization and efficiency can be assessed by Mini-CEX. Mini-CEX has
shown to have a better reliability score than Objective Structured
Clinical Examination (OSCE) or Long-case based examination of the same
duration [4].
Published data across countries shows that less than
25% of the students are actually assessed during a clinical encounter
with a structured format [5]; though very little data is available from
India [6,7]. Thus, we planned this study with the primary objective to
implement Mini-CEX as a tool for formative assessment of clinical skills
of final year pediatric post-graduate residents. The secondary
objectives were to sensitize our faculty and residents about Mini-CEX;
and also to assess the feasibility of using Mini-CEX as formative
assessment tool for pediatric post-graduate residents.
Methods
This cross-sectional study was carried out from
August 2015 to January 2016 in the pediatric department of a teaching
hospital in India, following approval from the Institutional ethics
committee. For the sake of uniformity in the theoretical and practical
knowledge of the participants, only final year residents (III year
Doctor of Medicine {MD} students and II year Diploma in Child Health
{DCH} students) were enrolled in the study after an informed consent.
Those who had attended less than 20 months (DCH students) or 30 months
(MD students) of clinical training in the department, and those having
pre-existing additional pediatric qualifications (DNB, DCh, MRCPCH) were
excluded from the study.
An audio-visual presentation was shown to sensitize
all the faculty and residents of the department about the basic
principles and methodology of mini-CEX. Six faculty members interested
in participating volunteered for conducting the mini-CEX and providing
feedback. The faculty volunteers were trained in the conduct of the
mini-CEX sessions. An external expert took a session on art of giving
effective feedback.
One encounter with each of the six different teachers
was planned for each student, thereby ensuring that all the students are
rotated through all the teachers. A weekly schedule with the names of
the student and teacher was displayed on the departmental notice board,
and also mailed to all teachers. Two faculty members had the additional
responsibility of coordinating the conduct of the sessions. The place of
encounter and the types of cases were decided in advance by the student
and the teacher together.
The standard nine-point scale format of mini-CEX was
used for rating the students, employing the structured assessment form
by the American Board of Internal Medicine [8]. The focus of the
encounter, the complexity of the case to be discussed; and the
competency on which the encounter will focus was informed to the student
before each session by the concerned faculty. The focus areas assessed
were Data-gathering, Diagnosis, Therapy and Counseling. Each student was
assessed for seven competencies which were medical interviewing skills,
physical examination skills, professionalism, clinical judgment,
counseling skills, organization, and overall clinical competence. The
assessor provided an unstructured feedback to the resident immediately
after the encounter, written feedback were provided on the form by both
the resident and the faculty regarding their overall satisfaction with
the encounter. Students who missed any of the Mini-CEX evaluations were
personally contacted for re-scheduling the encounter at a convenient
time. No additional efforts were made if the student missed two such
re-scheduled encounters (total three opportunities) during the study.
Data on satisfaction with the encounter was collected
from the mini-CEX form. An anonymous questionnaire-based feedback was
designed for participating students and faculty members, and was used
after the completion of all the mini-CEX encounters. The data were
entered in an Excel sheet, and the final data was analyzed with
Microsoft Excel program.
Results
A total of 20 final year postgraduate students (15 MD
and 5 DCH; 12 males) were assessed. There were 112 (93.3%) Mini-CEX
encounters conducted by six faculty members (3 Assistant Professor, 2
Professors and 1 Senior professor); 7 (5.8%) of these encounters needed
re-scheduling. Eighty-one sessions were conducted in the Outpatient
department, 17 in Inpatient wards, and 14 in the Casualty department;
all sessions were directly observed throughout by the faculty member.
The complexity level of cases was rated as moderate in 61, low in 29 and
high in 22 cases. The mean (SD) time taken for each encounter and
observation time were 17.7 (2.57) min (range, 15-35 min) and 12.4 (2.13)
min (range, 10-22 min), respectively.
Data-gathering (68.7%) and counseling (63.3%) were
the most common areas assessed (Table I). Out of the
competencies assessed, students scored least in counseling (median score
3.9, range 3-7) and professionalism (median score 4.5, range 3-7),
whereas they scored highest in medical interviewing skills (median score
5.3, range 4-8) and physical examination skills (median score 5.3, range
4-8). Eighty-four percent and 58% of the students and faculty,
respectively were satisfied with their Mini-CEX encounter (score
ł 8 on 10-point
Likert scale).
Table I Details of Mini-CEX Encounters (N=112)
|
No.(%) |
Focus-area assessed |
|
Data gathering |
77 (68.7) |
Diagnosis |
68 (60.7) |
Therapy |
42 (37.5) |
Counseling |
71 (63.3) |
All 4 areas assessed |
14 (12.5) |
Single area assessed |
34 (30.3) |
Competency assessed |
|
Professionalism |
112 (100) |
Interviewing skills |
99 (88.4) |
Clinical judgment |
94 (83.9) |
Physical examination |
86 (76.7) |
Organization |
96 (85.7) |
Counseling skills |
90 (80.3) |
Overall competence |
110 (98.2) |
Ninety percent of the participating students felt
that Mini-CEX changed their attitude towards teaching and it should be
included as a routine in postgraduate teaching. Only 25% thought that it
induced anxiety in them (Table II). On assessment of
faculty perception of Mini CEX, all (100%) thought they had a good
experience and the teacher’s feedback would improve students’
performance, whereas 50% were unsure whether it was a valid method of
assessment (Web Table I).
Table II Perceptions of Participating Pediatric Residents Regarding Mini-CEX (N=20)
Feedback* |
Agree |
Disagree |
|
No. (%) |
No. (%) |
Adequate time provided for the encounter |
20 (100) |
0 |
Improvement in residents’ performance# |
14 (70) |
3 (15) |
Adequate time provided for feedback# |
15 (75) |
2 (10) |
Conducted in a non-threatening environment |
20 (100) |
0 |
Induced excessive anxiety in the residents |
5 (25) |
15 (75) |
Valid method of assessment of clinical skills |
17 (85) |
3 (15) |
Changed my attitude towards teaching |
18 (90) |
2 (10) |
Useful as a routine method in PG training |
18 (90) |
2 (10) |
*The ‘strongly agree’ and ‘agree’, and ‘strongly disagree’ and
‘disagree’ responses have been clubbed as ‘Agree’ and
‘Disagree’, respectively. #’Unsure’ responses have
not been depicted. |
Discussion
In this cross-sectional study of 112 mini-CEX
encounters among six faculty and 20 final-year pediatric post-graduate
students, the tool was found to be feasible to conduct with a high
acceptability among both faculty and residents. Initial scheduling
problems could be resolved with the use of additional faculty to
coordinate the schedule.
Mini-CEX has been previously studied among a variety
of settings in medical schools outside India and has shown good
acceptability [9,10]. Indian experience with the tool is primarily
limited to only four specialties, Ophthalmology [6], Dentistry [11],
Obstetrics and Gynecology [12], and Pediatrics [5,7]; all reporting good
acceptability by the participants. However, previous studies had certain
lacunae like varying evaluator status (faculty and senior residents)
[5], low completion rates [5,12], limited to 1-2 settings [5,12], one
faculty evaluating a single competency [12] or a single learner [6]. We
obviated many of these and documented a high completion rate. The high
acceptability by both the evaluators and the residents was similar to
the previous studies [5-7,12].
One major advantage of Mini-CEX is that it has an
in-built mechanism of providing instant feedback by evaluator on the
performance of the learner, which is reportedly the single most
important influence on achievement [13], in addition to building a
strong student-teacher relationship [14]. In our study, all faculty
members perceived that instant feedback has a positive impact on the
students’ future performance. This could be one of the major positives
of incorporating this tool for formative assessment of postgraduate
students.
The major limitation of this study was the small
number of faculty members involved, as only volunteering faculty members
were included. Another problem was the initial difficulties in
scheduling the encounters, with either the student (patient-care, other
academic activity or personal problems) or the faculty (administrative
work or other academic responsibilities) missing the scheduled session.
This was handled by deputing two faculty members as coordinators to
ensure timely conduct of the sessions as per schedule. Thus, we could
achieve a high rate of completion of planned encounters (93.3%),
utilizing only faculty members as evaluators.
The high satisfaction with the mini-CEX tool by both
faculty and residents in this and other Indian studies is an encouraging
signal in the light of the thrust of MCI towards Competency-based
medical education and Workplace-based assessment [15]. Adoption of
Mini-CEX as a component of WPBA will have the additional advantage of
immediate feedback for students, thereby enhancing learning and
improving their future performance [15]. There is a need for feasibility
and acceptability studies of this tool among residents and faculty of
other specialties among Indian medical colleges.
Acknowledgments: Dr Seema Kapoor, Dr Mukta Mantan,
and Dr Ashish Jain who volunteered to be the faculty and conduct the
Mini-CEX sessions. The study was conducted as a part-requirement of the
Advanced Course in Medical Education by the third author at MCI Nodal
Center, CMC, Ludhiana.
Contributors: SK: conceived the study-idea,
coordinated and conducted the Mini-CEX sessions, did the literature
search, analyzed the data, and prepared the initial draft of the
manuscript; AA: conducted the Mini-CEX sessions, provided intellectual
inputs and assisted in preparation of manuscript. DM: planned the study
and supervised the conduct of the sessions, provided intellectual inputs
in the preparation of the manuscript, and will be the guarantor. All
authors approved the version to be published.
Funding: None; Competing interest: None
stated.
What This
Study Adds?
• Reference percentile charts of total and
regional lean body mass among Indian urban adolescents are
generated.
• There is increase in total and regional lean body mass with
age and pubertal progression in Indian adolescents in both
genders.
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