The Mini-clinical Evaluation Exercise

The Mini ClinicalEvaluation Exercise(mini-CEX)John J. Norcini, Foundation for Advancement of International Medical Education andResearch (FAIMER)

INTRODUCTION

The mini Clinical EvaluationExercise or mini-CEX is amethod for simultaneously

assessing the clinical skills oftrainees and offering them feed-back on their performance. It is asimple modification of the tradi-tional bedside oral examinationand because of that, it relies onthe use of real patients and thejudgments of skilled clinicianeducators. This article describesthe mini-CEX, recounts how it wasdeveloped, and then illustrates itsuse in the Modernising MedicalCareers (MMC) Foundation Pro-gramme Assessment.

BACKGROUND

How the mini-CEX worksIn the mini-CEX, a single facultymember observes the trainee

interact with a patient in any of avariety of settings including thehospital, outpatient clinic, andA&E. The trainee conducts afocused history and physicalexamination and after theencounter provides a diagnosisand treatment plan. The facultymember scores the performanceusing a structured document andthen provides educational feed-back. The encounters are intendedto be relatively short, about 15minutes, and to occur as a routinepart of the training programme.Each trainee should be evaluatedon several different occasions bydifferent faculty examiners.

Development of the mini-CEXFor the first four decades of itsexistence, the American Board ofInternal Medicine administered atraditional bedside oral examina-tion as part of its certification

process. By 1972, the problems ofassessing thousands of doctorsannually had become so greatthat the oral examination wasdiscontinued. In its place, theBoard asked training programmedirectors to assess the clinicalcompetence of candidates forcertification and recommendedthe use of a clinical evaluationexercise, or CEX, for trainees intheir first postgraduate year.

The CEX was based on thebedside oral examination that waspart of the certification process. Asingle faculty member evaluatedthe trainee as he or she performeda complete history and physicalexamination on a pre-selectedpatient in the hospital. Traineeswere then expected to reach diag-nostic and therapeutic conclu-sions, present their findings, andproduce a written report of the

The CEXevaluates thetraineesperformancewith a realpatient

PracticalAssessment

June 2005 | Volume 2 | No 1| www.theclinicalteacher.com THE CLINICAL TEACHER 25

patient. The faculty member thenassessed the trainees performancealong several dimensions. The CEXtook about two hours and by theearly 1990s the vast majority offirst year internal medicine train-ees in the United States were beingassessed by this method.

The CEX has at least threeimportant strengths.

It evaluates the trainees per-formance with a real patient.In medical school, the Objec-tive Structured Clinical Exam-ination (OSCE) is often usedand it does an excellent job ofassessing clinical skills. Astrainees approach entry topractice, however, their edu-cation and assessment needsto be based on performance

with real patients who exhibitthe full range of conditionsseen in the clinical setting.

The trainee is observed by askilled clinician-educator whoboth assesses the performanceand provides educationalfeedback. This enhances thevalidity of the results andensures that the traineereceives the type ofconstructive criticism thatshould result in a reduction oferrors and an improvement inquality of care.

The CEX presents trainees witha complete and realistic clin-ical challenge. They have to getall of the relevant informationfrom the patient, structure theproblem, synthesise their find-

ings, create a managementplan, and communicate this inboth oral and written form.

Despite its strengths, a grow-ing research literature throughthe 1980s and 1990s showed thatthe results of CEX were not likelyto generalise very far beyond thesingle encounter that was ob-served. This conclusion was basedon numerous studies of theassessment of doctors.

The research showed thattrainees performances withone patient were not a verygood predictor of their per-formances with other patients.Consequently, they needed tobe observed on differentoccasions with differentpatients before drawing

The CEXpresents

trainees with acomplete and

realistic clinicalchallenge

26 THE CLINICAL TEACHER June 2005 | Volume 2 | No 1| www.theclinicalteacher.com

reliable conclusions abouttheir competence. Observingeach trainee with severalpatients was also desirablefrom an educational perspec-tive, since different patientsrequire different skills fromtrainees and this significantlybroadens the range and rich-ness of feedback they receive.

The research showed that theassessors did not agree witheach other even when theywere observing exactly thesame performance. Training ofassessors is helpful to somedegree but much largerimprovements in the reliabil-ity and validity of the ratingswas achieved by includingdifferent faculty members in

the overall assessment of eachtrainee. This was also usefulfrom the perspective of edu-cation, since trainees receivedfeedback from different asses-sors, each with their ownspecialties, strengths, andperspectives.

In terms of the method itself,the CEX focused on the trai-nees ability to be thoroughwith a single new patient in ahospital setting that is unin-fluenced by time constraints.In contrast, different patientspose different challenges andthe tasks or competenciesrequired of doctors vary con-siderably depending on thesetting in which care is ren-dered. Further, most patient

encounters are much shorterthan two hours so the CEXdoes not assess the traineesability to focus and prioritisediagnosis and management.

The mini-CEX is a response tosome of the shortcomings of theCEX and it is based on the educa-tional interactions faculty rou-tinely have with trainees duringteaching rounds. As in the CEX, onefaculty member observes a trainee-patient encounter. However, theencounter is focused, lasts roughly15 minutes, and several encoun-ters are included in the overallassessment of a trainee. Theencounters will portray a broaderrange of challenges because theycan occur in a variety of settings(i.e., ambulatory/out-patient,

The assessorand traineemust agree toand record aneducationalplan of action


primary care, A&E department,and inpatient). The fact thatseveral encounters are observedincreases the quality of both theassessment and the educationalfeedback. It also offers the oppor-tunity to include different facultymembers in any one traineesevaluation.

Foundation ProgrammeAssessmentThe mini-CEX has been used in avariety of countries, specialties,clinical settings, and levels oftraining. It is currently beingevaluated as part of the NationalHealth Services ModernisingMedical Careers FoundationAssessment Programme and itsuse in this programme illustratesmany of the issues involved inimplementing the mini-CEX.

What does the mini-CEX assess?Consistent with the qualityimprovement model used in theFoundation Programme, the mini-CEX is intended to identify areasof strength and weakness. The

competencies assessed anddescriptions of them can be seenin Table 1.

What must the trainees do?Over the period of a year, thetrainees must get at least sixdifferent doctors (SpRs, SpecialistAssociate/Staff Grades, consult-ants, GPs) to assess them towardsthe end of their rotation throughdifferent posts. For example,trainees could ask a doctor toobserve them with the lastpatient on a ward round or thenext patient coming to the GPsurgery. They should be perform-ing a task routinely expected ofthem (e.g. clerking a new patient)and the six encounters must coverthe main areas of the curriculum(http://www.mmc.nhs.uk/curriculum). After the encounter,trainees keep one copy of thestructured evaluation form fortheir portfolios, give one to theireducational supervisor, and onegoes to the Trust FoundationCoordinator for forwarding to thecentral administrative centre.

What must the assessors do?The assessor must ensure that thepatient is aware of the mini-CEXand is typical of the traineesworkload. After observing theencounter, the assessor completesthe form in Table 1. As can beseen, all of the competencies arerated on a six-point scale where 1and 2 are below expectations, 3is borderline, 4 is meets expec-tations, and 5 and 6 are aboveexpectations for the end of thesecond foundation year.

The assessor is also requiredto give the trainee feedbackimmediately following theassessment. He or she must noteparticular strengths and sugges-tions for development on theform. In addition, the assessorand trainee must agree to andrecord an educational plan ofaction. This feedback structureis in line with evidence-basedgood practice.

The assessor is also respon-sible for recording informationabout the encounter itself. Thisinformation ensures that there issufficient coverage of the curri-culum, provides some notion ofthe nature and complexity of thepatients problems, and providesinformation on mini-CEX know-ledge and experience. There isalso research indicating that someof these factors are related toperformance on the mini-CEX. Forexample, previous work has shownthat assessors tend to overcom-pensate by giving higher gradeswhen the patients problems aremore complicated.

What guidance is given?Written guidance is given to boththe trainees and the assessors. Adescription of the FoundationAssessment Programme can befound at http://www.mmc.nhs.uk/. Trainees are providedwith a description of the mini-CEX, advised about whom theyshould invite to be the assessor,what they should be assesseddoing, when it should be used,

Table 1

Competence Descriptor of a Satisfactory Trainee

History Taking Facilitates patients telling of story, effectivelyuses appropriate questions to obtain accurate,adequate information, responds appropriately toverbal and non-verbal cues.

Physical Exam Follows efficient, logical sequence; examinationappropriate to clinical problem, explains topatient; sensitive to patients comfort, modesty.

Professionalism Shows respect, compassion, empathy, establishestrust; Attends to patients needs of comfort,respect, confidentiality. Behaves in an ethicalmanner, awareness of relevant legal frameworks.Aware of limitations.

Clinical Judgment Makes appropriate diagnosis and formulates asuitable management plan. Selectively orders/performs appropriate diagnostic studies,considers risks, benefits.

Communication skill Explores patients perspective, jargon free, openand honest, empathetic, agrees managementplan/therapy with patient.

Organisation/Efficiency Prioritises; is timely. Succinct. Summarises.

Overall Clinical Care Demonstrates satisfactory clinical judgment,synthesis, caring, effectiveness. Efficiency,appropriate use of resources, balances risks andbenefits, awareness of own limitations.

Routinediscussion

among facultywill improve the

quality of theassessments


and how it should work. They aregiven copies of the forms thatneed to be completed andresponsibility for having themdone in a timely fashion.

Assessors are also given writ-ten guidance that contains adescription of the mini-CEX andhow it works. They receive infor-mation about the development of

the method, its purpose, and itsplace in the overall Foundationprogramme. The competences tobe assessed are listed and des-cribed for the satisfactory trainee

Mini-Clinical Evaluation Exercise (CEX). Courtesy of Department of Health, England.


and special stress is placed on thefeedback to be given to trainees.Details of the administration arealso provided.

Although exhaustive trainingof the assessors is unlikely to beproductive, a workshop to startthe process and routine discus-sion among faculty will improvethe quality of the assessmentsand the feedback. Evidence-basedtraining should focus on fouraspects of the process.

Reducing common errors (e.g.being too severe or toolenient)

Understanding the dimensionsbeing assessed and thestandard of assessment

Improving the accuracy ofratings

Improving the detection andrecall of performance

A number of national trainingdays have been provided andfurther training is planned.

What happens with the results?Each of the rating forms isreturned to a central location andthe data are entered into thecomputer. When six encountershave been completed, the dataare collated for the whole yearand returned to the trainee viahis/her programme director. Theeducational supervisor will dis-cuss the feedback with the trai-nee. In addition, the mini-CEX

results will be incorporated intoan overall assessment profile foreach trainee.

CONCLUSION

The mini-CEX is a way of simulta-neously assessing the clinicalskills of trainees and offeringthem feedback intended to en-hance their future performance.Its validity and reliability derivesfrom the fact that trainees areobserved while engaged with aseries of real patients in differentpractice setting and judgmentsabout the quality of thoseencounters are made by skillededucator-clinicians. Its educa-tional effect is based on a signi-ficant increase in the number ofoccasions on which trainees aredirectly observed with patientsand offered feedback on theirperformance.

FURTHER READING

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The Mini-clinical Evaluation Exercise

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