Other strategies in observing clinical skills: The use of the mini-CEX

Looking back on my year of core clerkship, there were many different strategies used by my preceptors in order to assess my history-taking and physical exam skills. These encounters ranged from a pre-scheduled one-time complete observed hitsory and physical of one patient on the wards, to an impromptu "I will come into the room with you while you do this one". With all of the unique strategies used, it is interesting to reflect on which one I thought ended up being the most effective.

The one method that I found the most rewarding by rotation's end was the use of the mini clinical examination exercise (mini-CEX) in my family medicine rotation. In short, there were 5 scheduled days (once per week) in which one of the patients during that day (pre-determined by the clerk and preceptor) would have the encounter with the clerk observed by the preceptor.

There are several advantages I can see with this system. First, it is a snapshot of the clerk's functioning during a routine and scheduled clinic visit, instead of finding a patient anew and doing an entire history and physical (vis-a-vis ASCM2). In addition, having several opportunities spread out throughout a rotation/block allows for multiple opportunities to be observed. I think this is the biggest strength with the use of multiple mini-CEX's, in that the preceptor can assess for improvement during the rotation, and the clerk can eventually become more comfortable with this style of observation and can perform more naturally. The use of standardized mini-CEX evaluation forms makes the encounters more streamlined for the preceptors as well, who can use pre-defined competencies as a guide to assess the clerk easier and more quickly.

On the other hand, the biggest disadvantage is that of resources. Having multiple observed encounters for one clerk requires the preceptor to spend more time directly observing, which could be time spent on other clinical duties (dictating, seeing another couple of patients, catching up with administrative work, etc.). Patient comfort with having a clerk and preceptor in the room simultaneously would need to be assessed also, and it may make scheduling these observed encounters more difficult if a particular patient ends up not being comfortable with having the mini-CEX done.

Given the postives and the negatives of this strategy, I think the use of the mini-CEX in an Intenal Medicine outpatient or bedisde setting can be a very useful way of providing more and effective feedback to clerks (and potentially lower-year residents, if there is an identified need for more observation and feedback amongst PGY1's). The encounter would "feel more real" to the learner, which would allow for more comfort in performing at their best, and once it becomes an incorporated part of the curriculum, it can become easier for staff to schedule and implement. In fact, it may end up saving the preceptor time if the period spent reviewing the case and re-assessing the patient is saved by having already directly observed the encounter.

It is an interesting alternative, and perhaps a better idea is needed as to learners' perception of the mini-CEX compared to other methods of feedback. If data suggests that this method is well-accepted and implemented well, then this may be an important new step in medical education that can provide very realistic and useful educational guidance for students' clinical and bedside skills.

- Anthony

Direct Observation and Feedback in Medical Education

Looking back on my year of core clerkship, the saying "you learn from your mistakes" has definitely held true. Third year was a time of constantly entering new environments and learning new sets of skills with every new rotation. However, gauging success in a rotation was often quite difficult, since feedback was often received quite infrequently. In addition, the feedback itself often felt quite generic and was difficult to apply in the future (if I had a nickel for each time I was told to "read around my cases"...).

There are a number of different factors at play here, and I will devote a blog post to each issue individually. With the student, barriers include a reluctance to ask for additional feedback from a preceptor, and a lack of familiarity of how to ask. Staff members may be too busy during the day to supervise students at the bedside or in the ambulatory setting in order to give adequate feedback. Likewise, there may be a lack of familiarity of how to give appropriate feedback. Finally, the curriculum itself may lend itself to an inability to obtain appropriate feedback. While there are significant efforts being made to ensure all students are observed once doing a history and physical examination at the bedside during their Internal Medicine rotation, could there be further system-level changes that can foster an environment of more observation and feedback?

My clerkship years have been filled with very diverse experiences. With that, I have had some rotations with a great deal of observation and feedback built into the rotation, while others have very little opportunities. Yet in other rotations I was observed often, but was not receiving appropriate feedback. I firmly believe that a medical student's comfort in being observed and asking for or receiving feedback plays a large role in their perceived performance in a rotation, as well as their perception or enjoyment of that block. Most importantly, I think it causes significant avoidable stress in a medical student's clerkship; it is for this reason that I will be focusing on this topic throughout my CEEP selective. It starts with identifying the issues and barriers, and establishing new practices that make increased observation and feedback the norm.

- Anthony