Mini-CEX

The mini clinical evaluation exercise (mini-CEX) is a performance-based assessment method that evaluates various core competencies approved by the Accreditation Council for Graduate Medical Education (ACGME) in the United States of America. These include patient care and procedural skills(PCPS), medical knowledge(MK), professionalism(P), interpersonal and communication skills(IPCS), practice-based learning and improvement (PBLI), and systems-based practice(SBP).

This type of assessment involves having an experienced clinician observe and provide feedback on a trainee’s clinical performance. Mini CEX can be used to assess a variety of clinical skills, including history taking, physical examination, and patient communication. The advantages of using mini CEX include its ability to provide direct feedback to learners and its potential to improve learner motivation. Additionally, mini CEX has been found to be reliable and valid when compared to other assessment methods.

Introduction

Assessments are an integral component of medical education and are universally applied in evaluating various trainee competencies. This ensures that trainees are progressing as expected through their education. Conceptually, one can view the medical education system as a process of converting a “novice learner” into an “expert.” Assessment methods, in essence, serve as a means of facilitating this expected progression(Boulet and Durning 2019). As a clinician-educator, my core responsibility is to contribute to trainee education and assessment in outpatient and inpatient settings. It involves introducing rotating medical students in their third and fourth years of training to the care of adult endocrinology patients. My role as an expert in the field of endocrinology exposes me to challenging cases in this specialty.

Therefore, students assigned to my clinic are given an opportunity to evaluate complex and occasionally ambiguous endocrine cases requiring practical and sometimes unconventional approaches to clinical management. Trainees are usually required to organize historical, physical exam, and investigative (radiologic or laboratory) data in forming a diagnostic list and management plan. The assessment tool utilized in my practice is the mini-clinical evaluation exercise (mini-CEX)(Norcini et al. 2003). This formative assessment method evaluates various core competencies approved by the Accreditation Council for Graduate Medical Education (ACGME) in the United States of America.

These include patient care and procedural skills(PCPS), medical knowledge(MK), professionalism(P), interpersonal and communication skills(IPCS), practice-based learning and improvement (PBLI), and systems-based practice(SBP) (Kang et al. 2018). A nine-point rating scale is graded as follows, 1-3 (unsatisfactory), 4-6 (satisfactory), and 7-9 (superior). A sample mini-CEX form is shown in figure 1

I will review the process of assessing these core competencies through an illustrative standard mini-CEX approved by the ACGME. The benefits and limitations of this assessment method will be explored. Opportunities for improving this assessment will be discussed as well.

History of mini-CEX and work-based assessments

In addition to competency-based educational programs there is growing attention on workplace assessment in health care e.g. : The WBA assessment measures clinical competency and professional behavior in everyday practice. WBAs have been increasingly adopted in order to provide formative assessment as they require direct observation at the work. Mini-clinical evaluation exercises (Mini-CEX) are the simplest WBA and have been applied since the introduction in 1995 in both undergraduate and postgraduate programs worldwide

What is the mini-CEX?

The mini-CEX is a widely accepted tool for assessing workplace-based competencies in medical education. A medical trainee is directly observed by a supervising physician (also viewed as an expert) during a patient-physician encounter. The trainee takes a focused history, examines the patient, and discusses a clinical impression and management plan.

The supervising physician is ultimately responsible for discussing the final management plan with the patient before the end of the encounter. The supervising physician will complete the mini-CEX form and then set the stage for an interactive two-way feedback session. Conventionally, this is done soon after the clinical encounter concludes. The learner is allowed to point out both areas of weakness and acceptable competence.

This will be followed by the instructor’s critique of the clinical encounter. The aim will be to improve core competencies over time as the learner gets repeatedly exposed to varying learning scenarios. An average of scores received on various mini-CEX forms gained through formative assessments will be summarized at the end of a scheduled time interval. This in most instances, can serve as a reliable means of assessing the core competencies highlighted earlier.

 Pros and Cons of mini CEX (work-based assessment)

Disadvantages of work-based assessments in medical education

There are several potential disadvantages of using work based assessments in medical education. First, if the assessment is not well designed, it can lead to negative consequences such as decreased motivation or increased anxiety. Additionally, work-based assessments can be time-consuming and expensive to administer. Finally, there is a risk that these assessments may not be generalizable to other settings or populations.

Advantages of work-based assessments in medical education

Despite the potential disadvantages, there are also several advantages to using work-based assessments in medical education. First, these assessments can provide direct and immediate feedback to learners. Additionally, work-based assessments can be tailored to specific learning objectives. One of the benefits of using mini CEXs is that they provide a more realistic assessment of clinical skills than written exams or traditional Objective Structured Clinical Examinations (OSCEs). This is because they allow for more authentic interactions between students and patients. Additionally, mini CEXs can be tailored to specific educational objectives and skills that need to be assessed. Another advantage of mini CEXs is that they are less time-consuming and expensive to administer than full-scale OSCEs. This makes them an ideal assessment tool for medical schools with limited resources.

The usefulness of mini-CEX in medical education

The reliability, validity, improvement of future learning experiences, cost, and acceptability of this assessment tool will be explored.

The reliability of an assessment method refers to its reproducibility under various testing conditions (Van Der Vleuten 1996). It has been proposed that the time spent in completing an assessment (efficiency) is inversely proportional to its reliability(Beckman et al. 2004). The mini-CEX is designed to be short (lasting anywhere from 15 to 20minutes)(Eggleton et al. 2016), thus improving its reliability. Arguably, there is an element of subjectivity that cannot be rectified even if two evaluators assess the same clinical encounter. The assumption might be that there is low inter-rater reliability for the mini-CEX. In a study of the use of the mini-CEX in medical students, the authors showed that assessor disagreement was influenced by trivial subjective reasons such as the students grooming, preexisting learner-evaluator relationships, or the assessors’ concern for the use of seemingly derogatory labels such as “unsatisfactory” (Eggleton et al. 2016). It is worthy to note that testing conditions can also impact both the patient and student performance and thus influence the reliability of this assessment tool. Other authors have shown that the reliability of the mini-CEX can be enhanced through a considerably large sample size (Alves de Lima et al. 2007). The mini-CEX can be further improved by training clinical instructors in being more objective during clinical encounters. Also, opportunities for assessment should be instructor and not trainee initiated. The case-mix should also be diverse, from low, through medium to high levels of difficulty. This may improve the overall reliability of this assessment tool.

An assessment method’s validity refers to the test’s ability to measure what it is intended to measure. In essence, is the assessment method accurate? (Van Der Vleuten 1996).

Two measures of validity will be described, these are, content and criterion validity. Content validity refers to whether a chosen instrument appropriately assesses all the measures listed in the assessment method. In the case of the mini-CEX, these will be the core competencies previously cited in this paper (also see figure 1 in the appendix). Content validity is usually established based on expert opinion and literature review. The criterion validity, on the other hand, assesses the correlation of an assessment tool with more established assessment methods (“gold standards”)(Beaulieu et al. 2003).

The authors in a meta-analysis of 11 studies evaluating the validity of the mini-CEX were able to show that this assessment method has an acceptable content and criterion validity. This makes it a suitable assessment tool for a single measure or criterion. When assessing multiple measures, as might be required in evaluating clinical skill competence, the authors recommended using adjunctive tools to augment the mini-CEX(Al Ansari et al. 2013). Arguably, since content validity is based somewhat on expert opinion, it might be subject to a level of bias since evidence might, in some cases, be anecdotal.

On the other hand, criterion validity requires a careful comparison of the mini-CEX against a gold standard of assessment. It is, however, unclear whether a gold standard of assessment truly exists in medical education(Epstein 2007). Further studies are required to assess the validity of various methods of assessment in order to elucidate a gold standard.

Mini-CEX and cost of assessments

There are cost implications in the use of any method of assessment. These include time, human resources, processing of data, and monitoring, among others. (Van Der Vleuten 1996). The feasibility of the mini-CEX as an additional assessment tool for interns rotating in an emergency department was evaluated in a recent study. The authors were able to show that the cost to the healthcare system which served as the site of the study would be about 80,000 Australian Dollars for 36.51 hours of assessment time(Brazil et al. 2012).

This study places a monetary value on the number of hours lost by a healthcare system and highlights the challenges of balancing educational aims with healthcare costs. It has been reported that a method of assessment should not be more expensive than the process of training a student(Van Der Vleuten 1996). Based on my literature review, there are no published studies assessing a cost analysis comparing clinical training and the mini-CEX as an assessment method. Additional studies should compare cost analysis across various assessment methods in medical education. This will certainly help guide future policies in medical education.

Is the mini-CEX a practical assessment tool?

An assessment method should also be acceptable to both learners and clinical instructors(Van Der Vleuten 1996). The mini-CEX is widely accepted as an assessment method by trainees and instructors, based on several studies (Norcini et al. 2003; Gupta et al. 2017). Far from being a perfect assessment method, the mini-CEX is increasingly being used to assess workplace-based competencies. It is indeed gaining much traction in the field of medical education (Liu 2012) because it is seen as an assessment method that targets the highest level of Miller’s pyramid (Miller 1990). This further reflects its general acceptability by both learners and instructors. Since it requires a direct demonstration of competence by the learner, it can be anxiety-provoking. Anxiety may reduce performance in certain educational settings(Tian-Ci Quek et al. 2019) and be detrimental to the intended purpose of the mini-CEX. Again, allowing for random unannounced assessments might help reduce this limitation. For example, I tend to mention the need for a mini-CEX evaluation at the end of a trainee-patient encounter. This tends to reduce anxiety in the students during a clinical encounter since they have no way of knowing when the next assessment will be scheduled. For example, assessments could be two encounters in a row, on the same day, or separated by several days.

An assessment method should also improve future learning experiences. Research has demonstrated the importance of ensuring that an assessment tool mirrors professional reality as much as possible(Van Der Vleuten 1996). In my experience, the dual-feedback approach to appraising every learning and teaching experience allows for the development of both the trainee and instructor. I have experienced trainee initiated teachable moments in my role as a clinical instructor.

Conclusion

In conclusion, the role of the mini-CEX as a workplace-based assessment method was reviewed. The limitations and benefits of this assessment method were highlighted. Although a good assessment tool in medical education, further studies are required to test its validity and cost-effectiveness in medical practice compared to other assessment tools.

It is quite evident that several opportunities for assessment with the mini-CEX can also improve its reliability in the evaluation of various competencies in medical education. It is not a perfect tool, and further studies are required to optimize its use in variable learning settings.

References

Al Ansari, A. et al. 2013. The construct and criterion validity of the mini-CEX: a meta-analysis of the published research. Academic Medicine: Journal of the Association of American Medical Colleges 88(3), pp. 413–420.

Alves de Lima, A. et al. 2007. Validity, reliability, feasibility and satisfaction of the Mini-Clinical Evaluation Exercise (Mini-CEX) for cardiology residency training. Medical Teacher 29(8), pp. 785–790.

Beaulieu, J. et al. 2003. Content and criterion validity evaluation of National Public Health Performance Standards measurement instruments. Public Health Reports (Washington, D.C.: 1974) 118(6), pp. 508–517.

Beckman, T.J. et al. 2004. How Reliable Are Assessments of Clinical Teaching? Journal of General Internal Medicine 19(9), pp. 971–977.

Boulet, J.R. and Durning, S.J. 2019. What we measure … and what we should measure in medical education. Medical Education 53(1), pp. 86–94.

Brazil, V. et al. 2012. Mini-CEX as a workplace-based assessment tool for interns in an emergency department – Does cost outweigh value? Medical Teacher 34(12), pp. 1017–1023.

Eggleton, K. et al. 2016. Reliability of Mini-CEX Assessment of Medical Students in General Practice Clinical Attachments. Family Medicine 48(8), pp. 624–630.

Epstein, R.M. 2007. Assessment in medical education. The New England Journal of Medicine 356(4), pp. 387–396.

Gupta, S. et al. 2017. The Acceptability and Feasibility of Mini-clinical Evaluation Exercise as a Learning Tool for Pediatric Postgraduate Students. International Journal of Applied and Basic Medical Research 7(Suppl 1), pp. S19–S22.

Kang, D. et al. 2018. Are we meeting ACGME core competencies? A systematic review of literature on international surgical rotations. American Journal of Surgery 216(4), pp. 782–786.

Liu, C. 2012. An introduction to workplace-based assessments. Gastroenterology and Hepatology from Bed to Bench 5(1), pp. 24–28.

Miller, G.E. 1990. The assessment of clinical skills/competence/performance. Academic Medicine: Journal of the Association of American Medical Colleges 65(9 Suppl), pp. S63-67.

Norcini, J.J. et al. 2003. The mini-CEX: a method for assessing clinical skills. Annals of Internal Medicine 138(6), pp. 476–481.

Tian-Ci Quek, T. et al. 2019. The Global Prevalence of Anxiety Among Medical Students: A Meta-Analysis. International Journal of Environmental Research and Public Health 16(15).

Van Der Vleuten, C.P. 1996. The assessment of professional competence: Developments, research and practical implications. Advances in Health Sciences Education: Theory and Practice 1(1), pp. 41–67.