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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 17
| Issue : 4 | Page : 825-829 |
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Mini clinical evaluation exercises (mini CEX) as formative assessment tool in pediatric postgraduate education: Its feasibility and acceptability
Sunil Pathak1, Pooja Patel1, Manish Rasania1, Prashant Modi2
1 Department of Pediatrics, Smt. B.K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth (Deemed to be University), Vadodara, Gujarat, India
2 Department of Pediatrics, Smt. B.K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth (Deemed to be University); Department of Pediatrics, Parul Institute of Medical Sciences and Research, Parul University, Vadodara, Gujarat, India
| Date of Submission | 01-Jan-2022 |
| Date of Acceptance | 30-Sep-2022 |
| Date of Web Publication | 10-Feb-2023 |
Correspondence Address:
Dr. Prashant Modi
Department of Pediatrics, Parul Institute of Medical Sciences and Research, Parul University, Waghodiya, Vadodara, Gujarat
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jdmimsu.jdmimsu_47_22
Background: Although there is an increasing emphasis on workplace-based assessment (WPBA) during postgraduate medical education, the current assessment relies mainly on summative assessment. Formative assessment is less valued and done only to fulfill regulatory requirements. Various methods have been described for WPBA; mini-clinical evaluation exercise (mini-CEX) is one of them. Mini-CEX is incorporated well in Western countries, but in India, it is rarely used. Aim and Objectives: The objective is to assess acceptability and feasibility of Mini-CEX as a formative assessment tool during pediatric postgraduation. Methodology: Twenty-one postgraduates and 10 faculty participated in the study. A total of 93 sessions were conducted, 65 with 3rd year and 28 with 2nd year residents. The perception of faculty and students about feasibility and acceptability was taken by a prevalidated questionnaire based on the Likert scale. Epi-Info 7.2.2.6 was used for data analysis. Percentage, ratio, mean, and median were calculated. The qualitative data were pooled, and conclusions were derived. Results: Ninety percent of faculty agreed mini-CEX can be adopted as a formative assessment tool, it is feasible with current time limit and existing faculties. Ninety percent of faculty opined that mini-CEX will not have an adverse impact on current teaching–learning and assessment activity and it had a positive impact on their attitude toward postgraduate teaching. 70% of residents found that it is a useful method. Conclusions: Mini-CEX is a useful formative assessment tool, feasible and can be adopted in postgraduate medical education.
Keywords: Mini-clinical evaluation exercise, teaching–learning and assessment, workplace-based assessment
How to cite this article:
Pathak S, Patel P, Rasania M, Modi P. Mini clinical evaluation exercises (mini CEX) as formative assessment tool in pediatric postgraduate education: Its feasibility and acceptability. J Datta Meghe Inst Med Sci Univ 2022;17:825-9 |
| Introduction | |  |
The undergraduate and postgraduate medical student teaching–learning evaluation in India is restricted to an annual examination, with or without evaluation of a logbook/internal assessment. Most of the time, students are assessed more for their presentation skills rather than clinical skills as they are evaluated later during the presentation and not while taking a history or carrying out a physical examination. The formative feedback approach is used infrequently. The western literature suggests that less than one-fourth of medical students are observed during a clinical encounter using a structured approach. Even at the postgraduate level, about 80% of trainees are never observed during their actual work.[1]
Workplace-based assessment (WPBA) has emerged as an attractive concept to fill in this gap in the field of medical education. It has many advantages as the assessment is conducted in a real environment under direct observation, it resembles the day-to-day clinical experience, and its focus is more on actual performance. Although it can be used both for formative and summative assessment, its strength lies in use for formative assessment to enhance learning. Since its introduction, too many methods have been developed, and mini-clinical evaluation exercise (mini-CEX) is among one of them.
Mini-CEX is a short and rapid observation of clinical skills in a doctor–patient encounter lasting only 10–15 min. It is a WPBA where the performance of the student is evaluated during a focused clinical interaction it is followed by feedback.[2] Feedback is an important part of learning, de-learning, and relearning. In Miller's pyramid, the highest level of assessment is “does,” i.e., the student is assessed while performing an actual clinical task in an authentic setting.[3] Thus, feedback, feedback content, and the way of providing feedback during the learning phase become very important to reach the optimum level, i.e., “Does.”[4] Feedback is an integral part of mini-CEX, which stimulates the students' learning.[5] Despite it seems appealing, WPBA has not achieved a uniform level of acceptability and there are issues related to the feasibility of carrying out multiple assessments in busy clinical practice and by utilizing multiple assessors to ensure reliability.[6] This study was conducted to evaluate the feasibility and acceptability of mini-CEXs as a formative assessment tool in pediatric postgraduate education.
| Methodology | | |
Study design
It was a prospective Educational Interventional study conducted at the Department of Pediatrics, Smt. B. K. S. Medical Institute and Research Centre, Vadodara, Gujarat, India. Thirty-one (21 residents and 10 faculties) participants were enrolled in the study. First-year residents of the department were excluded from the study. The study was conducted with patients from the pediatrics outpatient department (OPD), ward, neonatal intensive care unit (NICU), and pediatric intensive care unit (PICU).
Method
This study was started after approval from Sumandeep Vidyapeeth Institutional Ethics Committee. Prior written consent of participants was taken. All the Faculty and Residents (R2, R3) working in the department of pediatrics were invited to participate in the study. The details and format of the study were explained to the residents and faculty in the department of pediatrics before starting the study. Sensitization and training program were conducted for the participants regarding mini-CEX and feedback.
Mini-CEX was planned in such a way that each student has exposure to each participant faculty in the department. It was done to eliminate any bias of the assessor. Before each encounter, students were explained the area of skill to be assessed. Each encounter was conducted on a patient new to the residents. Each encounter had a different complexity level and different areas of skill assessment. The level of complexity was decided by the assessor. The whole plan of events was shared with residents and faculties in advance. During each encounter, the postgraduate residents were assessed on various clinical skills. This includes history taking, performing a physical examination, clinical judgment/diagnosis, counseling of patient relatives, overall competence, and organization efficiency related to major areas of the curriculum. The whole process was observed and recorded by the assessor in standard mini-CEX format by the American Board of Internal Medicine (ABIM).[7] Permission to use mini-CEX format by ABIM has been obtained. Each competency is graded on a scale of 1–9. The score of 1–3 was graded as unsatisfactory, 4–6 as satisfactory, and 7–9 as superior.
Separate feedback from residents was taken. Resident feedback included 8 items. Feedback was taken regarding whether they liked the overall process, their perception of the whole process in comparison to traditional methods of assessment, improvement in resident's performance, their perception of the validity of method as an assessment of clinical skills, the level of anxiety, environment during the assessment and the adequacy of time provided for each encounter. Their comments were also sought after each encounter if they wanted to add other points if they feel so.
Faculty feedback included 10 items. Feedback was taken on a Likert scale of 1–5, regarding the feasibility and acceptability of mini-CEX. Their comments were also requested after each encounter, if they want to add other suggestions for further improvement.
The resident and faculty were asked to give their feedback on a Likert scale of 1–5. Both feedback formats were peer-reviewed and pre-validated (internal as well as external peer group) for standardization, modifications were done according to the suggestion before its administration in the actual study. Feedback was taken online using Google forms.
Data analysis
Data so collected were entered into the Excel sheet. Data analysis was done using Epi Info 7.2.2.6 software. Percentage, ratio, and mean were calculated. The qualitative data were pooled, and conclusions were derived.
| Result | | |
A total of 21 (10 third-year and 11 second-year) residents and ten consultants participated in the study. Nineteen were MD and 2 were diploma students. A total of 93 mini-CEX encounters were conducted. Sixty-five (69.8%) encounters were with 3rd year and 28 (30.2%) with 2nd year students. Twenty-nine (31.18%) encounters were observed by professors, 30 (32.25%) by associate professors, 12 (12.90%) by assistant professors, and 22 (23.65%) by senior residents. Thirty-four (36.55%) encounters were conducted on OPD patients, 38 (40.86%) on ward patients, and 21 (22.58%) on intensive care patients (NICU and PICU). Regarding the complexity of cases, 22 (23.65%) cases were of high complexity, 62 (66.67%) were moderate, and nine (9.67%) were of low complexity. In 45 (48.38%) encounters, a major focus was on data gathering, 20 (21.50%) on diagnosis, 9 (9.67%) on therapy, and 19 (20.43%) on counseling [Table 1].
In each encounter, average 5.75 competencies were observed (535/93). Out of 93, overall competency 93 (100%) were observed in each encounter, followed by professionalism 90 (96.77%), organization skills 84 (90.32%), interviewing skills 77 (82.79%), physical examination 72 (77.44%), clinical judgment 65 (69.89%), and counseling skills 54 (58.06%). The distribution of competencies observed is depicted in [Table 2].
The average time taken by the assessors for observation was 14.96 min (6–30 min), while the average feedback time was 7.492 min (2–15 min).
Most of the faculty (nine, 90%) agreed with (i) time provided for assessment was adequate, (ii) can be added as a routine formative assessment, (iii) can be adopted as teaching–learning and assessment tool, and (iv) it can be incorporated in the current working time limit. Eighty percent of faculty agreed that numbers of faculties are enough to adopt mini-CEX as a formative assessment tool. Six (60%) agreed that (a) It requires more commitment than traditional methods and (b) it is difficult to examine students more frequently. Nine (90%) of faculty disagree with mini-CEX will have an adverse impact on the current teaching–learning and assessment activity in the department and it needs extra facilities and equipment to support this activity. All faculty (100%) agreed that mini-CEX has a positive impact on their attitude toward postgraduate teaching [Table 3].
Five faculty members have also given their suggestions in the comment section of feedback. Almost all agree that it is a good method of formative assessment. It gives a better overview of students' learning and understanding. One faculty commented that it should be blinded [Table 4].
Out of 21 residents, 20 responded with their feedback. All residents (100%) agreed that it made them aware of their weaknesses. Ninety percent agreed that adequate time was provided for encounter, and it helped them in improving their clinical skills. Seventeen (85%) residents agreed that the environment during the encounter was conducive and time taken for feedback was adequate. Fourteen (70%) residents agreed that it is a useful method. Only 55% agreed that it is a valid method. There was mixed feedback that it induced excessive anxiety 40% agreed, 35% disagreed, and 25% were of no opinion/neutral [Table 3].
Seven residents have also given their suggestions in the comment section of feedback. Most of them agreed that it helped in realizing their strengths and weaknesses. It also helped them in improving their clinical skills. Surprisingly, similar to one faculty member's suggestion, one student also suggested that there should be blinding “There should be blinding. Like Resident and observer must not know each other. Otherwise, bias will be there.”
| Discussion | | |
Today, we all are striving for competent professional in every field, whether it is medicine, engineering, sports, or social science. Our role as teacher is to ensure that our students should achieve relevant competency in their respective field to be locally relevant and globally competent. Workplace-based assessment is one of the ways that help us to guide our students to overcome their weakness and become competent.
Through this study, we introduced mini-CEX as innovative WPBA in our institute. It can be inferred from the current study that it is feasible to use mini-CEX as formative assessment of postgraduate residents. In the current study, the majority of faculty were of opinion that it can be incorporated into the current working time limit, numbers of faculties are adequate to adopt as formative assessment tool. They were of opinion that mini-CEX will not have an adverse impact on the current teaching–learning and assessment activity in the department, and it does not require extra facilities and equipment to support this activity. On the contrary, majority of faculty were of the opinion that more commitment is required than traditional methods, and it is difficult to examine students more frequently, which is higher (60% vs. 22%) than the study by Joshi et al.[8] It may have occurred because this intervention was conducted in addition to current teaching and learning activities (TLA) in the department. Therefore, they had to reschedule their routine activities and additional efforts were made. Once the mini-CEX is incorporated in routine TLA activity, probably this extra commitment part will be taken care of.
All faculties agreed that mini-CEX has changed their attitude toward PG teaching and almost all agreed to adopt it as routine formative assessment methods in the department. While almost all residents were of opinion that feedback made them aware of areas of weakness and helped in improvement in their performance. Forty percent of residents found that it induced excessive anxiety among them, being observed by faculty during their interviewing/examining of the patient. A similar finding (33.33%) was reported by Joshi et al.[8] They also feel that it is useful as a routine method in PG training. Therefore, making it an acceptable method of formative assessment. There are some modifiable factors that can improve the acceptability of WPBA with some genuine effort in this direction. These factors include sensitization of students and faculty, creating an environment of mutual trust and proper training of faculty in providing feedback.[9] This can reduce the amount of anxiety among students. A meta-analysis by Hattie showed that the efficacy of feedback is maximum when information was provided around a specific task.[10] Another meta-analysis by Veloski et al. showed a beneficial effect of feedback in majority of studies.[5] Despite its proven significant role to promote learning, the use of feedback on the basis of observed performance does not occur frequently.[11],[12],[13]
Regarding blinding as suggested by faculty member and one student, the assessment by multiple faculty reduces the bias. Its format is made to provide feedback for improving student learning. Evidence shows that not merely feedback, the type of feedback and the way it is given has major influences on its effectiveness.[14] Yes, training of faculty in providing feedback as suggested by Singh and Sharma and creating conducive environment will help in improving acceptability.[1]
| Conclusions | | |
Mini-CEX is feasible and acceptable as a formative assessment tool. Mini-CEX will not have any adverse impact on current TLA activity if it is properly aligned with current academic activities in the department. Gradually, it will have a positive impact on the attitude of faculty toward postgraduate teaching leading to further improvement in the academic achievements of students. Making residents aware of their strengths and weaknesses, it further enhances trust between students and teachers. It, in turn, leads to open and free interaction between them, therefore, it will lead to a better and competent physician.
Limitations
This study was conducted over very short period; therefore, the full potential of this tool cannot be realized. To utilize and understand it fully, it should have been continued over at least one whole term. It should have been planned in such a way that student progression can be observed over the period.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 11. | Kassebaum DG, Eaglen RH. Shortcomings in the evaluation of students' clinical skills and behaviors in medical school. Acad Med 1999;74:842-9. |
| 12. | Holmboe ES, Yepes M, Williams F, Huot SJ. Feedback and the mini clinical evaluation exercise. J Gen Intern Med 2004;19:558-61. |
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[Table 1], [Table 2], [Table 3], [Table 4]
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