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
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