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Why consider the Mini-CEX? Year 4 OSCE 2011 Overall Results

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Using the Mini-Clinical Evaluation Exercise (Mini-CEX) as an assessment tool for medical students April 29, 2011. Why consider the Mini-CEX? Year 4 OSCE 2011 Overall Results. Number sitting OSCE 248 Number passing 245 (98.8%). Competency Domains. What is mini-CEX?.

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Using the Mini-Clinical Evaluation Exercise (Mini-CEX) as an assessment tool for medical studentsApril 29, 2011
why consider the mini cex year 4 osce 2011 overall results
Why consider the Mini-CEX?Year 4 OSCE 2011 Overall Results
  • Number sitting OSCE 248
  • Number passing 245 (98.8%)
what is mini cex
What is mini-CEX?

Structured 10 min observation of a student performing specified tasks during routine practice

Feedback session (10 min)

Completion of a standardized one-page rating form

mini cex types of tasks
Mini-CEX: Types of tasks

Focused history

Physical examination


advise patient regarding management options

provide appropriate education

make recommendations that address patient’s concerns

Clinical reasoning skills

diagnostic and therapeutic skills

Case presentation

implementing a mini cex
Implementing a Mini-CEX


Familiarize yourself with the mini-CEX rating form and definition of the components of the student’s performance you will be rating

Schedule the mini-CEX

1-2 / week

Allow 20 minutes for each assessment

Obtain patient permission

implementing a mini cex1
Implementing a Mini-CEX

Select the patient encounters to be observed

Year 3 “must see” list of medical conditions

new or existing medical problem

acute vs. chronic illness

different age groups and both genders

different clinical settings (e.g. office, hospital) if possible

Ask the student to perform the task without prompting about the possible diagnosis

perform an abdominal examination

Not: examine the patient for possible appendicitis

assessment process
Assessment Process

Avoid interrupting the student during the patient encounter

no questions, comments or suggestions

if you want to follow-up findings with patients, do this after the student is finished

Conduct immediate feedback (10 minutes)

Complete rating form

Discuss rating or comments with student

mini cex feedback
Mini-CEX: Feedback



Limited to key issues



Descriptive, not judgmental, e.g.

“you did not examineX”

NOT “you were way off base”

mini cex feedback1
Mini-CEX: Feedback

Two-way process (inter-active)

Start by asking the student some questions

how they felt they did with the patient

what findings they found

what they think is the most likely diagnosis

why they ordered a particular investigation or suggested a particular treatment

Answers can stimulate specific feedback and also guide ratings of performance

feedback challenge
Feedback challenge
  • Easy when the student does well
  • More difficult when the performance is poor
    • do not hesitate to point out area of weakness
    • multiple assessments with multiple examiners (reliability)
    • sampling performance across the spectrum of clinical situations (validity)
mini cex feedback closing the loop
Mini-CEX: FeedbackClosing the loop

Provide a recommendation

interviewing/ examination/ counselling skills/ management/ presentation

Develop a specific action plan

allows student to act on the recommendation

example of use of mini cex
Example of use of Mini-CEX


  • A man presents with abdominal pain
  • The student performs a focused abdominal examination (10 minutes)
  • The preceptor notices that the student did not examine the inguinal areas adequately
  • Feedback is given
    • the preceptor demonstrates the correct technique
    • recommends a review of hernias in clinical skills textbook
    • suggests plan to practise exam technique
summary key features of the mini cex
Summary: Key features of the Mini-CEX

Direct assessment of actual patient care

Allows assessment of performance

good evidence supporting mini-CEX’s validity and reliability

cumulatively can infer student’s competence

Can be incorporated into daily activities

efficient use of resources

Allows immediate and substantive feedback

assessor s training
Assessor’s training

Paper-based orientation

Familiarize with the process, specific observation task and ratings form

All assessors who participated received this form of training

Workshop* - video-based training

Videos exemplifying three levels of performance

Rated at the end on the form by all participants

*(Modeled after ABIM/NBME ‘Direct observation of Competence Training Program’, Holmboe et al., 2004)

effects of training
Effects of training

Assessors of the post-graduate trainees

Raters not trained in workshop were more lenient:

3.17 vs. 2.31

6.17 vs. 4.85

8.29 vs. 7.38

Both the scenario and training-group effects were significant


Generalizability-theory approach to reliability

Allows for estimating the variance-components attributable to the different factors of the measurement situation

Calculating G-coefficient (reliability coefficient)

Modeling the effect of changes in these factors (e.g., number of items needed to achieve certain level of precision)

Number of mini-CEXs needed was the main factor followed through all studies (in one case, the effect of blueprinting was also explored)