Assessing Clinical Competence with the Mini-CEX

This is the first draft of an article that I published in The Clinical Teacher mobile app.

Introduction

The assessment of clinical competence is an essential component of clinical education but is challenging because of the range of factors that can influence the outcome. Clinical teachers must be able to make valid and reliable judgements of students’ clinical ability, but this is complex. The more valid and reliable a test is, the longer and more complicated it is to administer. The mini Clinical Evaluation Exercise, or mini-CEX was developed in response to some of the challenges of the traditional clinical evaluation exercise (CEX) and has been found to be a feasible, valid and reliable tool for the assessment of clinical competence.

Assessment of competence

Competence in clinical practice is defined as the “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individuals and communities being served” (Epstein & Hundert, 2002). The assessment of competence can take a range of forms in clinical education, but this article will only discuss competence around the physical examination of patients.

Teaching physical examination skills is a unique challenge in clinical education because of the many variables that impact on how it is conducted. Consider how each of the following factors plays a role in the quality of teaching and learning that happens; the teachers’ own clinical skills; trainees’ prior knowledge, skills and interest; availability of patients with the necessary findings; patient willingness to be examined by a group of doctors and trainees who may not have any impact on their clinical care; the physical environment which is usually less than comfortable; and trainee fatigue level. In addition, the session should be relevant to the student and have significant educational value, otherwise there is the risk that it will degenerate into a “show and tell” exercise (Ramani, 2008).

This article will demonstrate how the mini-CEX provides a structured way to achieve the following goals of clinical assessment (Epstein, 2007):

  • Optimise the capabilities of all learners and practitioners by providing motivation and direction for future learning
  • Protect the public by identifying incompetent physicians
  • Provide a basis for choosing applicants for advanced training

The mini-Clinical Evaluation Exercise

The mini-CEX is a method of assessing the clinical competence of students in an authentic clinical setting, while at the same time providing a structured means of giving feedback to improve performance. It involves the direct observation of a focused clinical encounter between a student and patient, followed immediately with structured feedback designed to improve practice. It was developed in response to the shortcomings of both the traditional bedside oral examination and initial clinical evaluation exercise (CEX) (Norcini, 2005).

In the mini-CEX, the student conducts a subjective and objective assessment of a patient, focusing on one aspect of the patients presentation, and finishing with a diagnosis and treatment plan. The clinician scores the students’ performance on a range of criteria using the structured form, and provides the student with feedback on their strengths and weaknesses. The clinician highlights an area that the student can improve on, and together they agree on an action the student can take that will help them in their development. This can include a case presentation at a later date, a written exercise that demonstrates clinical reasoning, or a literature search (Epstein, 2007).

The session is relatively short (about 15 minutes) and should be incorporated into the normal routine of training. Ideally, the student should be assessed in multiple clinical contexts by multiple clinicians, although it is up to the student to identify when and with whom they would like to be assessed (Norcini, 2005). Students should be observed at least four times by different assessors to get a reliable assessment of competence (Norcini & Burch, 2007). The mini-CEX is a feasible, valid and reliable assessment tool with high fidelity for the evaluation of clinical competence (Nair, et al., 2008).

The mini-CEX is a good example of a workplace-based assessment method that fulfils three requirements for facilitating learning (Norcini & Burch, 2007):

  1. The course content, expected competencies and assessment practices are aligned
  2. Feedback is provided either during or immediately after the assessment
  3. The assessment is used to direct learning towards desired outcomes

Structure of a mini-CEX form

Each of the competences in Table 1 below is assessed on 9-point scale where 1-3 are “unsatisfactory”, 4 is “marginal”, 5-6 are “satisfactory”, and 7-9 are “superior” (Norcini, et al., 2005). In addition to the competences documented below, there is also space for both student and assessor to record their experience of the assessment, indicating their satisfaction with the process, time taken for the encounter and experience of the assessor.

Table 1: Competencies and descriptors of the mini-CEX form

Competence

Descriptor of a Satisfactory Trainee

History taking

Facilitates patient’s telling of story, effectively uses appropriate questions to obtain accurate, adequate information, responds appropriately to verbal and non-verbal cues.

Physical exam

Follows efficient, logical sequence; examination appropriate to clinical problem, explains to patient; sensitive to patient’s comfort, modesty.

Professionalism

Shows respect, compassion, empathy, establishes trust; Attends to patient’s needs of comfort, respect, confidentiality. Behaves in an ethical manner, awareness of relevant legal frameworks. Aware of limitations.

Clinical judgement

Makes appropriate diagnosis and formulates a suitable management plan. Selectively orders/ performs appropriate diagnostic studies, considers risks, benefits.

Communication skill

Explores patient’s perspective, jargon free, open and honest, empathetic, agrees management plan/therapy with patient.

Organisation/efficiency

Prioritises; is timely. Succinct. Summarises.

Overall clinical care

Demonstrates satisfactory clinical judgment, synthesis, caring, effectiveness. Efficiency, appropriate use of resources, balances risks and benefits, awareness of own limitations.

Role of the assessor

The assessor does not need to have prior knowledge or experience with assessing the student, but should have some experience in the domain of expertise that the assessment is relevant for. The patient must be made aware that the mini-CEX is going to used to assess a student’s level of competence with them, and they should give consent for this to happen. It is important to note that the session should be led by the trainee, not the assessor (National Health Service, n.d.).

The assessor must also ensure that the patient and assessment task selected is an appropriate example of something that the student would reasonably be expected to be able to do. Remember that the mini-CEX is only an assessment of competence within a narrow scope of practice, and therefore only a focused task will be assessed. They should also record the complexity of the patient’s problem, as there is some evidence that assessors score students higher on cases of increased complexity (Norcini, 2005).

After the session has been completed, the assessor must give feedback to the student immediately, highlighting their strengths as well as areas in which they can improve. Together, clinician and student must agree on an educational action that the student can take in order to improve their practice. It is also recommended that assessors go on at least a basic workshop to be introduced to the mini-CEX. Informal discussion is likely to improve both the quality of the assessment and of the feedback to students (Norcini, 2005).

Advantages of the mini-CEX

The mini-CEX also has these other strengths:

  • It is used in the clinical context with real patients and clinician educators, as opposed to the Objective Structured Clinical Exam (OSCE), which uses standardised patients.
  • It can be used in a variety of clinical settings, including the hospital, outpatient clinic and trauma, and while it was designed to be administered in the medical field, it is equally useful for most health professionals. The broader range of clinical challenges improves the quality of the assessment and of the educational feedback that the student receives.
  • The assessment is carried out by a variety of clinicians, which improves the reliability and validity of the tool, but also provides a variety of educational feedback for the student. This is useful because clinicians will often have different ways of managing the same patient, and it helps for students to be aware of the fact that there is often no single “correct” way of managing a patient.
  • The assessment of competence is accompanied with real, practical suggestions for improvement. This improves the validity of the score given and provides constructive feedback that the student can use to improve their practice.
  • The process provides a complete and realistic clinical assessment, in that the student must gather and synthesise relevant information, identify the problem, develop a management plan and communicate the outcome.
  • It can be included in students’ portfolio as part of their collection of evidence of general competence
  • The mini-CEX encourages the student to focus on one aspect of the clinical presentation, allowing them to prioritise the diagnosis and management of the patient.

Challenges when using the mini-CEX

There is some evidence that assessor feedback in terms of developing a plan of action is often ignored, negating the educational component of the tool. In addition, many students often fail to reflect on the session and to provide any form of self-evaluation. It is therefore essential that faculty training is considered part of an integrated approach to improving students’ clinical competence, because the quality of the assessment is dependent on faculty skills in history and physical exam, demonstration, observation, assessment and feedback (Holmboe, et al., 2004a). Another point to be aware of when considering the use of the mini-CEX is that it doesn’t allow for the comprehensive assessment of a complete patient examination (Norcini, et al., 2003).

Practice points

  • The mini-CEX provides a structured format for the assessment of students’ clinical competence within a focused physical examination of a patient
  • It is a feasible, valid and reliable method of assessment when it is used by multiple assessors in multiple clinical contexts over a period of time
  • Completion of the focused physical examination should be followed immediately by the feedback session, which must include an activity that the student can engage in to improve their practice

Conclusion

The mini-CEX has been demonstrated to be a valid and reliable tool for the assessment of clinical competence. It should be administered by multiple assessors in multiple clinical contexts in order for it to achieve its maximum potential as a both an assessment and educational tool.

 

References and sources