|ORIGINAL RESEARCH ARTICLE
|Year : 2014 | Volume
| Issue : 3 | Page : 262-268
Introduction of Mini-CEX in undergraduate dental education in India
Lecturer, Department of Oral Medicine and Radiology, STES's Sinhgad Dental College and Hospital, Pune, Maharashtra, India
|Date of Web Publication||26-Feb-2015|
759/100, Pramathesh Apts, Prabhat Road, Lane No. 2, Pune - 411 004, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Some assessment methods of clinical learners have limitations so that students might not reflect their performance in actual clinical situations. Educational research has so far not yielded a single 'gold-standard' performance assessment tool. Mini-CEX (clinical evaluation exercise) is an instrument intended for work-based assessment of actual clinical performance, including a range of skills like communication and humanistic qualities. It involves direct observation of real patient encounters followed by one-on-one structured feedback sessions between assessors and the trainees. Mini-CEX has already found wide acceptance in medical education but is largely untested in dental education. Methods: Twelve dental undergraduate students underwent one mini-CEX encounter each. Four teachers performed the roles of assessors, directly observing the students and rating their performance using the standardized mini-CEX rating form. A systematic feedback session then took place, following which students' and teachers' perception of the mini-CEX was sought through structured questionnaires. Results: Almost all students appreciated that their communication skills were assessed, but some felt that the presence of a teacher was intimidating. They felt that the constructive feedback helped them reinforce the skills that they did well. The assessors found planning for mini-CEX time consuming and also felt that that their presence had an impact on the students' performance. However, teachers reported that the mini-CEX allows them to assess students' professionalism and communication skills, which are important in dentistry. Discussion: Data from this pilot study supports the use of mini-CES in dental education, but still the need for wider studies remains. It also explains the ways in which undergraduate dental students and teachers find the mini-CEX useful and how it could be improved and used more effectively.
Keywords: Assessment, dental education, evaluation, feedback, mini-CEX, questionnaire
|How to cite this article:|
Behere R. Introduction of Mini-CEX in undergraduate dental education in India. Educ Health 2014;27:262-8
| Background|| |
Formative assessment is an instructional intervention evaluating performance and identifying trainees' strengths and weaknesses in order to reveal performance gaps, that is, differences between desired and actual performance. ,, Although assessment of clinical competence is receiving increasing attention in educational research, it has not yet yielded a single 'gold-standard' performance assessment tool that can confidently be said to be both reliable and valid.  The mini-CEX (clinical evaluation exercise) designed to conduct work-based assessment of clinical performance was originally developed in 1995 , in the USA for the evaluation of Internal Medicine residents' clinical skills. The principal characteristics of mini-CEX are direct observation of real patient encounters, applicability in a broad range of settings and immediate structured feedback to the learner after the encounter. ,
Undergraduate dental education in India is currently going through a transitional period, with the old curriculum changing to satisfy the revised regulations released by the Dental Council of India in 2007. These new regulations envisage a dental graduate competent to investigate, diagnose and manage oral diseases prevalent in India. Two generic skills every dental practitioner must exhibit are (i) clinical evaluation and diagnosis and (ii) acquisition and interpretation of dental radiographic images.  Oral Medicine and Radiology is one of the clinical subjects in the five-year undergraduate curriculum. Training in this subject is introduced in the third year of the course. By the end of the third clinical posting (each posting is of 12 working days), students are expected to be competent in the above two skills. Formative assessment consists of allocating a case to every student, who then records the case history, examines the patient, makes a provisional diagnosis, advises and makes a periapical radiograph, and interprets it. At the end of the allotted time, students present the case findings, diagnosis, the radiograph and their report. These are evaluated by the faculty, and marks are awarded. Each of these procedures is made up of several sub-skills, which the students are expected to perform correctly and in a systematic manner. 
This traditional method of assessment only considers the final outcome, not how the students have reached it. The teachers do not observe the actual performance of the procedures by the students. This impacts both the 'validity' and the 'reliability'. Moreover, communication skills are rarely assessed, there is very little scope for direct feedback, and some important skills may not be tested at all. Students may also feel dissatisfied by not receiving personal attention from the faculty and be confused about which particular skill is being tested.  Norcini has summarized the primary weak areas of the traditional assessment method, namely, lack of assessment of a large variety of cases, examination by a very limited number of examiners and testing of only a few competencies: These all lead to a lack of reproducibility of scores. 
Mini-CEX, in contrast, has the potential to be a more practically suited assessment tool in situations involving patient-doctor interactions and where communication skills and professionalism are important. Mini-CEX formalizes the supervisory interaction between teachers and students, and promotes teaching interactions. As teachers are asked to observe their students, students have to take responsibility for the case, and teachers learn more about their students' skills and decision-making processes. The structured nature of the rating form means that teachers give feedback across a broader range of topics and are more inclined to address issues that otherwise may not be addressed in evaluation. However, the assessment can be perceived as "threatening" to students and may alter how they perform, and also change the nature of the collegial relationship between the teacher and the student by strongly emphasizing the 'assessor' role of the teacher. 
A search of two databases, namely, PUBMED (search term: Mini-CEX [dentistry or dental]) and ERIC (search term: Mini-CEX dentistry dental) done by the author on September 19, 2013 did not yield a single article where mini-CEX was administered to assess dental students anywhere in the world. Upon using Google Search, the author came across only one instance where mini-CEX was administered to 4 th year dental students during their Periodontology posting.  Although not peer-reviewed, it was presented as a paper at the ICERI Conference in 2012. This demonstrates that educational research in this area is scarce.
Thus, the goal of this pilot study was to introduce mini-CEX as a tool for formative assessment of students in the subject of Oral Medicine and Radiology and study the perception of both students and faculty towards this method of assessment.
| Methods|| |
This pilot study was carried out in the Department of Oral Medicine and Radiology at STES's Sinhgad Dental College and Hospital, Pune between August and October 2012. It was approved by the Institutional Review Board and exempted from ethical review. To sensitize the faculty to mini-CEX, an orientation session was first conducted. A presentation was made to the entire faculty of the department and hand-outs were distributed. The faculty was made familiar with the mini-CEX rating form (Annexure 1).
A study carried out by Weller  analyzing the experience of mini-CEX in anesthesia department found that defining the standard of performance was problematic for trainees and assessors. In Weller's study, some specialists were unsure if they should be hard or lenient, and they wanted more guidance on judging the level of performance. Therefore, the author of the current pilot study felt the need to prepare a provisional checklist for deriving criteria for assessment. This provisional checklist was distributed to the faculty for their suggestions on any changes that could be made to it. The checklist was then fine-tuned and finalized [Table 1]. The faculty was also shown a video demonstrating the entire mini-CEX process. A few doubts expressed were discussed and clarified, namely, whether the assessors could interrupt the interaction, whether they could signal to the trainee that the allotted time was up, and whether they were supposed to always remain outside the direct line-of-sight of the trainee. Cook  has demonstrated that assessor training does not necessarily improve inter-assessor reliability or accuracy of mini-CEX scores. Thus, we did not feel a need to carry out a formal training workshop for the faculty.
A similar orientation session was conducted for 12 students in the first term of the fourth year of the Bachelor of Dentistry (BDS) course who were posted in the department. A presentation was made to the students and hand-outs were distributed. They were made familiar with the mini-CEX rating form. They were also shown a video demonstration of the entire mini-CEX process. All 12 students voluntarily agreed to be a part of this pilot study. They were informed that results were known only to the research team, and as such had no impact on their formal assessment.
The 12 students were randomly divided into four groups of three students each. One assessor was assigned to each group. It may be noted that under ideal circumstances, a student should undergo at least one mini-CEX with every assessor. However, this being only a pilot study and due to the necessity of conducting the traditional examination at the end of the posting, each student in a group underwent only one mini-CEX encounter with their group assessor. Therefore, there were a total of 12 mini-CEX encounters.
Every attempt was made to select 12 cases of equal complexity. Each mini-CEX encounter lasted roughly 20 min, exception for one case where the student exceeded the time limit. The assessor directly observed the student and with the help of the checklist, rated the student's performance under the following six domains using the mini-CEX rating form (Annexure 1):
Each student was also rated for his/her 'Overall Clinical Competence,' which was a global score, for which there were no checklist-determined guidelines. After the student-patient interaction was complete, a systematic feedback session of about 10 min took place in a separate room. The assessor first explained to the student the things that were done well, followed by the things that could be done better. These suggestions were put in writing on the mini-CEX rating form. The assessor and the student then agreed on a specific educational plan for the student to improve in the weak areas. Both the assessor and the student then carefully went through the completed rating form and signed it.
After such structured feedback was given to the students as part of the mini-CEX, feedback was voluntarily obtained from them with a structured questionnaire: All 12 students participated. Voluntary feedback was also obtained from the four faculty with another structured questionnaire. Since the purpose of this pilot study was not to compare the results obtained by mini-CEX with that of the traditional examination, no such comparison was made.
| Results|| |
Twelve students in the first term of the fourth year of the BDS course posted in the Department of Oral Medicine and Radiology underwent one mini-CEX encounter each.
Perceptions of students toward mini-CEX
After completion, their perception of this method of assessment was sought through a structured questionnaire (Annexure 2). Perceptions were categorized for three areas: Mini-CEX orientation, mini-CEX implementation and feedback. Results reported here are the opinions of participants, and words in quotation marks are direct quotes from trainees (T), and a number for which trainee the quote is attributed to.
All the students felt that the mini-CEX orientation session was adequate to understand the basic working of this assessment method.
Students were quite expressive with their responses related to this category. Ten out of the twelve students felt that the entire mini-CEX session was well organized. However, only seven students agreed that the cases were of equal complexity. "Each case is different. Some might get a very easy case and others a complex one" (T3). Ten students agreed that the skills chosen to be assessed during the mini-CEX were taught during previous postings and nine said that a wide range of skills was chosen to be assessed. The students particularly appreciated that their communication skills were assessed. "Mini-CEX was a new format of examination of our communication skills…" (T5); "I liked the mini-CEX format as I learnt to improve my communication skills" (T1).
The most inconsistent response was obtained for the time required for the students to finish the mini-CEX. Four students felt that they needed more time; four felt that the time was enough and the remaining four remained neutral. "Got opportunities, but could not manage time" (T10). "Time given was enough…" (T7). Likewise, there was the same split of opinion on whether the mini-CEX was a more stressful experience than the traditional format. "Mini-CEX was not stressful but an opportunity for us to correct our mistakes and improve weak areas" (T2); "It was stressful as a lot of things had to be examined in a short period of time".
Eight out of twelve students said that a teacher's presence during the mini-CEX was frightening. Other responses ranged from "Teacher's presence was not frightening, but we were made more alert…" (T8) to "Presence of a teacher was initially a little frightening but one gets accustomed to it in no time".
Ten students agreed that mini-CEX provided more opportunities than the conventional format to demonstrate skills.
The feedback session of the mini-CEX was most appreciated by the students. All students felt that the constructive feedback helped reinforce the skills that they did well, and helped them identify weak areas. "The immediate feedback helps because we immediately correlate the case and the way we approached it and the way we could have" (T9). "It was an interesting experience because of the immediate feedback" (T12). All but one student agreed that the feedback motivated them to learn further. Nine out of the twelve students were satisfied that the rating reflected their level of performance. "May be the performance at that time was not good due to stress or lack of time but we may be good during our regular postings or other times" (T4).
Overall, the students were found to perceive mini-CEX positively - "Mini-CEX was a new format of examination of our communication skills as well as our handling efficiency. This made us aware about the points and skills in which we were lacking" (T7). "Mini-CEX has helped me to improve my skills, motivated me to learn some basic areas which will help me in the future" (T6); "It was a good experience. Helps us learn our strengths and weak points" (T2).
Perception of faculty toward mini-CEX
Four faculty members assessed three mini-CEX encounters each. Their perceptions of the mini-CEX are presented according to their understanding of the mini-CEX, the mini-CEX planning and implementation, perception of mini-CEX as an examiner, and overall impression of mini-CEX. Direct quotes from individual assessors are shown with (A) and a number for the specific assessor.
All the assessors felt that the mini-CEX orientation session was adequate to understand the working of mini-CEX.
Mini-CEX planning and implementation
All assessors agreed that planning the mini-CEX process requires more time and thinking than traditional evaluation methods. However, all also felt that a major advantage of mini-CEX over other newer methods of assessment like OSCE (Objective Structured Clinical Examination) is that no additional manpower, equipment, instruments, materials or patients are required. However, two assessors felt that more time was required to conduct a mini-CEX encounter. "It does require a little more effort on the assessor's behalf to conduct mini-CEX" (A2).
Perception of mini-CEX
All assessors agreed that their presence had an adverse effect on the performance of the student. "The students' activities appeared more orchestrated at the time" (A4). No faculty found it boring to be an assessor, but two found it to be a tiring exercise.
Overall impression of mini-CEX
- All the assessors seconded almost all the literature-reported advantages of mini-CEX: They found that this method allows assessment of a student's attitude and communication skills, which are very important in all professions and especially in dentistry
- They agreed that the mini-CEX format allows for more opportunities for improvement by providing immediate focused feedback, which also acts as a motivating factor to students for further learning
- There was mutual agreement that mini-CEX provides an opportunity to develop a specific, individually tailored educational plan for a single student, targeting specific weak areas.
| Discussion|| |
The goal of this pilot study was to introduce mini-CEX as a tool for formative assessment of students in the subject of Oral Medicine and Radiology, and to study the perception of both students and faculty toward this novel method of assessment.
As only 7 out of the 12 students agreed that the cases allotted to them were of equal complexity, perhaps in hindsight more time and attention should have been given to case selection by the principal investigator. All students particularly appreciated that their communication skills were assessed. However, there was a divergence of opinions on the statements: "You needed more time for your mini-CEX encounter" and "The mini-CEX was more stressful than previous format". Perhaps, if a 5-level Likert scale was used, there would be a better chance of not having equal responses and hence a representative opinion may have emerged.
An important component of the mini-CEX is the structured one-on-one feedback that takes place immediately following the student-patient encounter. This was greatly appreciated by all students. Research on formative assessment and feedback suggests that these are powerful tools to change trainees' behavior. ,,, From several studies we know that trainees do not benefit from feedback in the form of mere numerical marks, ,, but that feedback should preferably be narrative and specific, explicating where more work needs to be done. Additionally, feedback can be made more effective when recipients receive guidance on how to turn feedback into concrete steps to improve their performance. The feedback session in the mini-CEX involves first reinforcing those skills that were done well, and then discussing the areas where improvement is possible. The trainee and assessor then agree on a individually tailored educational plan to bring about this improvement and formalize it with their signatures. Positive effects of narrative feedback have been reported by various authors like Overeem  who found higher satisfaction with such feedback, and Govaerts  who suggested that narrative feedback can improve in-training evaluation. Archer  additionally concluded that feedback should not be exclusively trainer-driven but a two-way process in which trainers provide comments and at the same time encourage trainees to self-reflect on their performance. Archer's model for effective feedback includes: Self-monitoring (reflection on action) supported by external feedback and linkage with personal goals (action plan) in a coherent process rather than a series of unrelated events. 
One student response exposed a limitation of this pilot study, namely, "the grading was evaluated on the basis of just one patient, which was not fair. We could have gotten much better grades if evaluated on the basis of at least three cases. After the first feedback session, we could have improved on the next two cases" (T8).
The overall perception of trainees toward mini-CEX was positive and they felt that this assessment method was a good experience would motivate them to improve in specific areas. Lee  found similar views among 110 postgraduate year-1 (PGY1) general medicine residents. The students in our study also provided valuable suggestions like implementing mini-CEX in the third year of the curriculum rather than the fourth year, and using mini-CEX as a replacement for the short case first rather than directly the long case.
All assessors agreed that organizing and implementing the mini-CEX required more planning and involvement than traditional assessment. A review of published literature on the feasibility of mini-CEX reveals that results are both negative and positive.  Wilkinson  attributes feasibility problems to lack of time and the fact that the procedure is experienced as time consuming. Alves de Lima  blames poor feasibility on inadequate implementation. These studies conclude that assessment instruments must be well integrated within the curriculum and part of the routine of practice, and additionally propose that workshops are a better way to implement an instrument than written instructions. Clearly, further studies are needed to unravel the instruments' feasibility issues.
Two out of four assessors found it to be a tiring exercise possibly because they were asked to carry out more than one mini-CEX in a single day. All assessors felt that being an examiner for mini-CEX was more time-consuming than the traditional method of evaluation. This could be attributed to the fact that for this particular pilot study, the mini-CEX encounters took place in addition to conventional assessment.
All assessors agreed that their presence impacted the trainees' performance. Weller  similarly found that trainees altered their behavior because they were being directly observed and assessed.
Learning experience of the author
Much more conceptualization, planning and wider support from colleagues is required in educational research. It also appears to be more qualitative than quantitative. On account of the short duration of the postings, implementing mini-CEX in addition to conventional assessment posed administrative problems. Selecting cases of equal complexity was a daunting task. The presence of a teacher definitely had an impact on the students' performance. The feedback session was the most favored part of the mini-CEX, but was possible only because direct observation of the student's performance took place during the student-patient encounter.
Limitations of this study
This study did not examine whether mini-CEX actually improved learning, clinical skills and ultimately the quality of patient care. Given the formative nature of this instrument, effects on learning and performance should be the prime objective of this type of assessment. Existing research typically evaluates perceptions of users, and although the outcomes are overwhelmingly positive, they do not provide compelling evidence for learning effects. This study also did not collect feedback from patients. As they were the real "subjects" of the mini-CEX, their perception about it could have thrown up some new perspectives. Studies have shown that evaluation of performance by patients draws attention to different aspects of performance than is elicited by evaluation of consultations by health professionals.  Moreover, if such patient feedback could be incorporated and discussed in the mini-CEX feedback session, rather than simply be passed on to the trainees in a written format, it would be more significant in stimulating trainees' interest and in improving the quality of patient care.  Lastly, this study was done in a single institution and with only one discipline.
| Conclusions|| |
To the best of the author's knowledge, this is only the second investigation of the introduction of mini-CEX into dental education anywhere in the world. Dentistry is a unique specialty as it involves training and assessment of a wide range of procedures performed by undergraduate students with actual patients. This makes it ideal for implementation of mini-CEX as a tool for formative assessment. Moreover, since fear of dentists/dental treatment is widely recognized, it is important that dental students develop sound communication and counseling skills to allay patient fears and anxiety. Currently, there is no formal evaluation of these skills in the dental curriculum. Mini-CEX can bridge this gap in formative assessment.
The data arising from this pilot study supports the implementation of novel assessment methods such as mini-CEX to improve the learning experience for undergraduate dental students. Our pilot study goes some way to understanding why students and teachers find mini-CEX useful, how it could be improved, and the barriers to using it more effectively. Furthermore, we identify potential content for assessor training, both to optimize the quality and educational value of the assessments, and to maximize the opportunity to improve the educational knowledge and skills of assessors. But before the verdict on the scope of mini-CEX in dental education can be announced, more studies on its feasibility for other disciplines and procedures in dentistry need to be carried out.
| Acknowledgments|| |
The author thanks the faculty of the Institute of Medical Education Technology and Teachers' Training, MUHS Regional Centre, Pune, India and Dr. Shailesh Lele (Professor and Head, Department of Oral Medicine and Radiology, STES's Sinhgad Dental College and Hospital, Pune, India) for mentorship throughout the project; the faculty of the Department of Oral Medicine and Radiology for their cooperation and the students who consented to participate in the project, all at STES's Sinhgad Dental College and Hospital, Pune, India.
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