Enhancing Feedback to Students Using the Mini-CEX (Clinical Evaluation Exercise)

Objective: Medical students and residents are rarely observed by attending physicians performing history and physical examinations in realistic clinical encounters. To address this problem at the residency level, the American Board of Internal Medicine and residency program directors developed and validated the clinical evaluation exercise (CEX) as a method of assessing residents' history-taking and physical examination skills. Subsequently a mini-CEX was designed as a short, easy form to use in focused first-time or follow-up encounters in any clinical setting.1. We have used the mini-CEX with medical students to augment the feedback they receive from their attendings regarding their clinical skills. Description: At the University of California, San Francisco, we introduced the mini-CEX into the core internal medicine clerkship in 1999 to ensure that each student is observed by an attending physician at least once conducting a focused history and physical examination. Each student and ward attending pair are instructed to complete the mini-CEX during the first half of the clerkship, spending 15–20 minutes on the encounter and 15 minutes on feedback. After the clinical encounter, the student immediately presents an assessment and plan, and the attending gives feedback. The attending evaluates the student's history and physical examination, clinical judgment, humanism, and overall clinical competence as a student, using the standardized mini-CEX two-page form. The form uses a standardized nine-point scale, with a ratings span from 1–3 (unsatisfactory), 4 (marginal), 5–6 (satisfactory), to 7–9 (superior). Because the primary goal of the exercise is to provide “real time” constructive feedback, the results do not contribute to the clerkship grade. Results with the first 22 students at two of our sites showed that the mean time that the attendings spent observing students was 30.9 minutes (range 10–105), and the mean time for feedback was 15.4 minutes (7.5–37). The mean student performance rating was 7.9. The mean rating for students' satisfaction with the format (7.5) exceeded the mean rating for the evaluators' satisfaction (6.0). Discussion: The nationally developed mini-CEX for residents functions well for medical students as a learning tool and is easily adapted to an inpatient internal medicine clerkship. The exercise serves as a standardized format for an attending to use to observe a student at the bedside, hear the student's assessment, and critique the interaction in a nonthreatening, non-graded situation. The benefits of the mini-CEX include the breadth of skills evaluated in a short time, assurance that students are receiving feedback, low cost, and opportunity for attendings and clerkship site directors to identify students with deficiencies early in the rotation in order to facilitate remediation. Although the reproducibility of a single encounter per student is limited, we are not using the exercise to evaluate or grade an individual student's competence but rather to improve the process of attendings' observation and feedback. The mini-CEX will become a required component of the core internal medicine clerkship for all students at our institution, and it could be repeated in additional inpatient or ambulatory encounters to further enhance feedback and improve the reliability of the scores.