{"id":72292,"date":"2023-12-06T11:31:54","date_gmt":"2023-12-06T03:31:54","guid":{"rendered":"https:\/\/medicine.nus.edu.sg\/taps\/?post_type=issues&#038;p=72292"},"modified":"2024-04-02T08:11:39","modified_gmt":"2024-04-02T00:11:39","slug":"micro-cex-vs-mini-cex-less-can-be-more","status":"publish","type":"issues","link":"https:\/\/medicine.nus.edu.sg\/taps\/issues\/micro-cex-vs-mini-cex-less-can-be-more\/","title":{"rendered":"Micro CEX vs Mini CEX: Less can be more"},"content":{"rendered":"<p>Submitted: 28 January 2023<br \/>\r\nAccepted: 17 August 2023<br \/>\r\nPublished online: 2 January, TAPS 2024, 9(1), 3-19<br \/>\r\n<a href=\"https:\/\/doi.org\/10.29060\/TAPS.2024-9-1\/OA2947\">https:\/\/doi.org\/10.29060\/TAPS.2024-9-1\/OA2947<\/a><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Thun How Ong<sup>1<\/sup>, Hwee Kuan Ong<sup>2<\/sup>, Adrian Chan<sup>1<\/sup>, Dujeepa D. Samarasekera<sup>3 <\/sup>&amp; Cees Van der Vleuten<sup>4<\/sup><\/span><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify;\"><i><sup><span lang=\"EN-GB\">1<\/span><\/sup><\/i><i><span lang=\"EN-GB\">Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Duke-NUS Medical School, Singapore; <sup>2<\/sup>Department of Physiotherapy, Singapore General Hospital; <sup>3<\/sup>Centre for Medical Education, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; <sup>4<\/sup>Department of Educational Development and Research, Maastricht University, Maastricht, The Netherlands<\/span><\/i><\/p>\r\n<p style=\"text-align: center;\"><b><span lang=\"EN-GB\">Abstract <\/span><\/b><\/p>\r\n<p style=\"text-align: justify;\"><b><span lang=\"EN-US\">Introduction<\/span><\/b><span lang=\"EN-US\">: The mini-Clinical Evaluation Exercise (<\/span><span lang=\"EN-US\">CEX<\/span><span lang=\"EN-US\">) is meant to provide on the spot feedback to trainees. We hypothesised that an ultra-short assessment tool with just one global entrustment scale (micro-CEX) would encourage faculty to provide better feedback compared to the traditional multiple domain mini-CEX. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><b><span lang=\"EN-US\">Methods<\/span><\/b><span lang=\"EN-US\">: 59 pairs of faculty and trainees from internal medicine completed both the 7-item mini-CEX and a micro-CEX and were surveyed regarding their perceptions of the 2 forms. Wordcount and specificity of the feedback was assessed. Participants were subsequently interviewed to elicit their views on factors affecting the utility of the CEX. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><b><span lang=\"EN-US\">Results<\/span><\/b><span lang=\"EN-US\">: Quantity and quality of feedback increased with the micro-CEX compared to the mini-CEX. Wordcount increased from 9.5 to 17.5 words, and specificity increased from 1.6 to 2.3 on a 4-point scale, p &lt; 0.05 in both cases. Faculty and residents both felt the micro-CEX provided better assessment and feedback. The micro-CEX, but not the mini-CEX, was able to discriminate between residents in different years of training. The mini-CEX showed a strong halo effect between different domains of scoring. In interviews, ease of administration, immediacy of assessment, clarity of purpose, structuring of desired feedback, assessor-trainee pairing and alignment with trainee learning goals were identified as important features to optimize utility of the (mini or micro or both) CEX. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><b><span lang=\"EN-US\">Conclusions<\/span><\/b><span lang=\"EN-US\">: Simplifying the assessment component of the CEX frees faculty to concentrate on feedback and this improves both quantity and quality of feedback. How the form is administered on the ground impacts its practical utility. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><b><span lang=\"EN-GB\">Keywords<\/span><\/b><b><span lang=\"EN-GB\">:<\/span><\/b><span lang=\"EN-GB\">\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <i>Workplace Based Assessment, Mini-CEX, Micro-CEX, Feedback, Assessment<\/i> <\/span><b><span lang=\"EN-GB\"><\/span><\/b><\/p>\r\n<p align=\"center\" style=\"text-align: center;\"><strong><span lang=\"EN-GB\">Practice Highlights <\/span><\/strong><\/p>\r\n<ul>\r\n\t<li style=\"text-align: justify;\"><span lang=\"EN-US\"> <\/span><span lang=\"EN-US\">Simplifying the assessment component of the CEX frees faculty to concentrate on feedback.<\/span><\/li>\r\n\t<li style=\"text-align: justify;\"><span lang=\"EN-US\"> <\/span><span lang=\"EN-US\">A simpler form can result in better and more feedback.<\/span><\/li>\r\n\t<li style=\"text-align: justify;\"><span lang=\"EN-US\"> <\/span><span lang=\"EN-US\">Making it easy for faculty to use the form is important and increases its utility in providing feedback and assessment.<\/span><\/li>\r\n<\/ul>\r\n<p style=\"text-align: center;\"><span lang=\"EN-GB\"><\/span><strong><span lang=\"EN-GB\">I. INTRODUCTION<\/span><\/strong><\/p>\r\n<ol><\/ol>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">The Mini-CEX is one of the most widely used work-placed based assessment (WBA) tools and is supported by a large body of theoretical and empirical evidence which have shown that when used in the context of repeated sampling, it is both a valid assessment tool and is also an effective education tool in giving feedback to the trainee <\/span><span lang=\"EN-US\">(Hawkins et al., 2010; Norcini et al., 2003)<\/span><span lang=\"EN-US\">. However, in practice, the educational value <\/span><span lang=\"EN-GB\">of<\/span><span lang=\"EN-US\"> the mini-<\/span><span lang=\"EN-US\">CEX, as measured chiefly by trainee and faculty perceptions and satisfaction, varied significantly <\/span><span lang=\"EN-US\">(Lorwald et al., 2018)<\/span><span lang=\"EN-US\">. Factors affecting the educational value have been described by Lorwald et al. and categorised into context of usage, and user, implementation and outcome factors <\/span><span lang=\"EN-US\">(Lorwald et al., 2018)<\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Context<\/span><span lang=\"EN-US\"> refers to the situation in which the mini-CEX is executed, and factors which impact its actual usage, such as time needed for conducting the Mini-CEX, or the usability of the tool. Time constraint on the part of both the residents and the assessors is an especially frequent issue across multiple studies <\/span><span lang=\"EN-US\">(Bindal et al., 2011; Brazil et al., 2012; Castanelli et al., 2016; L\u00f6rwald et al., 2018; Morris et al., 2006; Nair et al., 2008; Yanting et al., 2016)<\/span><span lang=\"EN-US\">. The mini-CEX was conceived as a 30-minute exercise of directly observed assessment, and there are 6 or 7 domains which faculty are expected to assess <\/span><span lang=\"EN-US\">(Norcini et al., 2003)<\/span><span lang=\"EN-US\">. In a busy clinical environment however, what actually occurs is often a brief clinical encounter of 10-15 minutes or even less where only a few of the mini-CEX\u2019s domains were assessed <\/span><span lang=\"EN-US\">(Berendonk et al., 2018)<\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">User<\/span><span lang=\"EN-US\"> factors refers to trainee and faculty knowledge of the mini-CEX and their perceptions of its use. Studies have found that the mini-CEX is frequently regarded as a check box exercise <\/span><span lang=\"EN-US\">(Bindal et al., 2011; Sabey &amp; Harris, 2011)<\/span><span lang=\"EN-US\">. Assessor\u2019s and trainee\u2019s training and attitudes, or unfamiliarity with the WBA tools also negatively impact the educational value of the mini-CEX <\/span><span lang=\"EN-US\">(L\u00f6rwald et al., 2018)<\/span><span lang=\"EN-US\">. Reports have shown that educating faculty on the formative intent of mini-CEX can improve feedback provided <\/span><span lang=\"EN-US\">(Liao et al., 2013)<\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Implementation factors refer to how the mini-CEX is actually executed on the ground. Some studies have reported that the mini-CEX often occurs without actual direct observation <\/span><span lang=\"EN-US\">(L\u00f6rwald et al., 2018)<\/span><span lang=\"EN-US\"> or feedback provided <\/span><span lang=\"EN-US\">(Weston &amp; Smith, 2014)<\/span><span lang=\"EN-US\">. Implementation in turn affected outcome, which refers to the trainees appraisal of the feedback received <\/span><span lang=\"EN-US\">(L\u00f6rwald et al., 2018).<\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">One way of improving the educational value of the mini-CEX then might be to improve the context of its usage, by redesigning the mini-CEX to better fit the realities of the clinical workplace. In different clinical encounters, specific domains of performance are more easily and obviously observed and assessed than others <\/span><span lang=\"EN-US\">(Crossley &amp; Jolly, 2012)<\/span><span lang=\"EN-US\">. Reducing the number of dimensions the assessors are asked to rate was shown to decrease measured cognitive load and improved interobserver reliability <\/span><span lang=\"EN-US\">(Tavares et al., 2016)<\/span><span lang=\"EN-US\">. It has also been shown that using rating scales that align with the clinician\u2019s cognitive schema perform better, for instance, scales that ask the clinician assessors about the trainees ability to practice safely with decreasing levels of supervision (i.e. entrustability) showed better discrimination and higher reliability <\/span><span lang=\"EN-US\">(Weller et al., 2014)<\/span><span lang=\"EN-US\">. Compared to multidimension rating scales, global rating scales have greater reliability and validity in assessing candidates in OSCE examinations <\/span><span lang=\"EN-US\">(Regehr et al., 1998)<\/span><span lang=\"EN-US\">, assessing technical competence in procedures <\/span><span lang=\"EN-US\">(Walzak et al., 2015)<\/span><span lang=\"EN-US\"> and in simulation-based training <\/span><span lang=\"EN-US\">(Ilgen et al., 2015)<\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">We proposed therefore to replace the multiple domains with a single rating asking faculty what level of supervision the resident would require in performing a similar task, i.e. a global entrustment scale. The shorter assessment task should refocus the faculty on the feedback component, whilst still retaining the ability to identify trainee progression. One such form has been proposed by <\/span><span lang=\"EN-US\">Kogan and Holmboe (2018)<\/span><span lang=\"EN-US\">, and we designated this the micro-CEX. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">We hypothesised that these changes would improve the usability (\u201ccontext\u201d as described by Lorwald et al.) and hence improve the educational value of the assessment, measured in this study by the specificity and quality of the feedback given by faculty. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Our study aims to show therefore that the shorter micro-CEX can provide better feedback than the usual mini-CEX. We also sought to find out, from the perspective of the end-users, what other adjustments to the implementation and design of the mini or micro-CEX can be made to improve its acceptability, educational value and validity. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">The study focussed on the following questions:<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Does the micro-CEX stimulate faculty to provide more specific and actionable feedback compared to the mini-CEX?<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Can the micro-CEX provide discriminatory assessment for residents across different years of practice?<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">What are the perceptions of the faculty and residents regarding the factors affecting utility of the assessment instrument in providing feedback and assessment?<\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: center;\"><span lang=\"EN-GB\"><\/span><strong><span lang=\"EN-GB\">II. METHODS<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><i><span lang=\"EN-GB\"><\/span><\/i><i><span lang=\"EN-GB\">A. Setting and Subjects<\/span><\/i><i><span lang=\"EN-GB\"><\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">The study was conducted in the division of Internal Medicine in a 1700 bed hospital in Singapore between September and December 2018. All faculty and residents rotating through internal medicine were invited to participate via e-mail, and agreeable faculty and residents paired up. In usual practice, residents must complete at least 2 mini-CEX covering standard inpatient or outpatient encounters during each three-month internal medicine posting, hence both residents and faculty are familiar with the usual mini-CEX.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><i><span lang=\"EN-GB\"><\/span><\/i><i><span lang=\"EN-GB\">B. Design<\/span><\/i><i><span lang=\"EN-GB\"><\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">In order to evaluate for any participant reactivity affecting the CEX data (i.e. a Hawthorne effect) <\/span><span lang=\"EN-US\">(Paradis &amp; Sutkin, 2017)<\/span><span lang=\"EN-US\">, a baseline sample of 30 of the usual mini-CEX performed in the 3 months prior to the study was randomly selected and deidentified (from June to August 2018) . The quantity and specificity of feedback in these was evaluated as detailed below. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">For the study itself, faculty and residents used the usual mini-CEX as the first assessment in the first 2 weeks of the month, followed by a second assessment using the micro-CEX in the next 2 weeks. This sequence was chosen as performing the micro-CEX first might affect how the subsequent mini-CEX was performed. Cases chosen for the mini-CEX and micro-CEX were inpatient or outpatient internal medicine encounters, and faculty were simply instructed to choose cases that represented typical cases of average difficulty with no restrictions on the exact cases to be chosen.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Faculty and residents completed an anonymised survey on their experiences at the end of the study and were invited to participate in a semi-structured group interview to elicit their views regarding which aspects of the mini-CEX exercise influenced feedback and assessment (Appendix 2). Both faculty and residents were informed that the survey and interviews were part of this study and participation in either was taken to be implied consent. The workflow of the study is seen in Figure 1.<\/span><\/p>\r\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2023\/11\/OA2947-Figure-1.png\" alt=\"\" class=\"aligncenter wp-image-72293 size-full\" width=\"770\" height=\"337\" srcset=\"https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2023\/11\/OA2947-Figure-1.png 770w, https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2023\/11\/OA2947-Figure-1-300x131.png 300w, https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2023\/11\/OA2947-Figure-1-768x336.png 768w\" sizes=\"auto, (max-width: 770px) 100vw, 770px\" \/><\/p>\r\n<p align=\"center\" style=\"text-align: center;\"><span lang=\"EN-GB\">Figure 1. Study workflow<\/span><\/p>\r\n<div>\r\n<p style=\"text-align: justify;\"><i><span lang=\"EN-US\">C. Instruments<\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">The mini-CEX used in the program is based on the one described by Norcini <\/span><span lang=\"EN-US\">(Norcini et al., 2003)<\/span><span lang=\"EN-US\">.This form was hosted on the internet ( New Innovations, Ohio, USA) and could be accessed by faculty from their mobile devices or their email. The micro- CEX was hosted on an opensource online survey tool (LimeSurvey GmbH, Hamburg, Germany) and can be accessed from mobile devices. A copy of both forms is available in Appendix 1.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><i><span lang=\"EN-US\">D. Ana<\/span><\/i><i><span lang=\"EN-US\">lysis of Feedback<\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">The quality of feedback was assessed firstly by a word count, and then by grading the specificity of the feedback on a three-point scale <\/span><span lang=\"EN-US\">(Pelgrim et al., 2012)<\/span><span lang=\"EN-US\"> (Appendix 3) and finally by the presence or absence of an actionable plan for improvement. In order to avoid rater bias, the assessor for the specificity of the feedback was blinded to the source of feedback (mini or Micro CEX). The first 20 forms were independently graded by two separate assessors (OTH and AC) using the above criteria, achieving a kappa coefficient of 0.852; all subsequent forms were graded by OTH, with any uncertainty resolved by discussion between AC and OTH. Word count and specificity, as well as faculty and resident preferences between the forms, were analysed using paired samples T-test. Proportion of Feedback which showed an actionable plan was compared using a Chi-Square test. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><i><span lang=\"EN-US\">E. Semi-structured Interviews<\/span><\/i><i><span lang=\"EN-US\"><\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Faculty and residents were interviewed separately. 21 residents and 6 faculty were interviewed over 8 sessions lasting between 20 to 30 minutes each. Interviews were conducted by the investigator (OTH). The interviews were audiotaped and transcribed verbatim. Data collection ended when saturation was reached. Member checking of the transcripts was carried out. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">The inductive template analysis as described by Nigel King was used to analyse the interview transcripts <\/span><span lang=\"EN-US\">(King, 2012)<\/span><span lang=\"EN-US\">. Two transcripts were studied and coded separately by the investigator (OTH) and a collaborator (OHK). A priori themes of assessment, feedback and administration were used to structure the data so that the research question could be answered. Codes were discussed between OTH and OHK until a consensus was reached, and a codebook was created. The subsequent transcripts were coded by OTH. OHK, AC and OTH subsequently met to discuss the categories and emerging themes. NVivo 12 was used to store and manage the codes and transcripts. Results were triangulated with data from the quantitative surveys. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">For all quantitative data, an alpha of 0.05 was used as the cut-off for significance. IBM SPSS 25 (IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY) was used for calculations.<\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center;\"><strong><span lang=\"EN-GB\">III. <\/span><span lang=\"EN-GB\">RESULTS<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">The data that support the findings of this study are openly available in Figshare repository, at <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.60%2084\/m9.figshare.21862068.v1\">https:\/\/doi.org\/10.60 84\/m9.figshare.21862068.v1<\/a><\/span><span lang=\"EN-US\"> <\/span><span lang=\"EN-US\">(Ong, 2023)<\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">There were 33 internal medicine residents during the study period and 32 (97%) participated in the study; one resident declined to participate. They were paired with 39 different faculty over the three months of the study. 59 unique faculty- resident pairs completed both sets of CEX. 30.5% of the residents were in their first year of residency (R1), 47.9% in second year (R2), and 22.0% were in their third year (R3). The residents completed an average of 1.96 pairs of mini and micro CEX each. Time taken to complete the assessments was estimated by faculty to be 11.33 +\/- 6.56 min for mini-CEX vs 9.42 +\/-5.51 min for the micro-CEX (p = 0.02).<\/span><\/p>\r\n<p style=\"text-align: justify;\"><i><span lang=\"EN-GB\">A. <\/span><\/i><i><span lang=\"EN-GB\">Evaluation of Feedback in the Mini-CEX: Baseline and During Study<\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">30 de-identified mini-CEX were extracted randomly from the 3 months preceding the initiation of the study. These served as a baseline control and were compared to the feedback from the first, traditional mini-CEX done during the study (Table 1). During the period of the study, faculty using the same mini-CEX provided feedback that was more specific. Proportion of actionable feedback provided was much more in the mini-CEX done as part of the study compared to baseline controls (Table 1: 3.3% controls vs 28% study mini-CEX, p = 0.005).<\/span><\/p>\r\n<table border=\"0\" cellspacing=\"0\" cellpadding=\"0\" class=\" aligncenter\" style=\"width: 100%;\">\r\n<tbody>\r\n<tr>\r\n<td rowspan=\"2\" valign=\"top\" style=\"width: 16.2234%;\">\r\n<p>&nbsp;<\/p>\r\n<p>&nbsp;<\/p>\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<td colspan=\"3\" valign=\"top\" style=\"width: 38.4309%;\">\r\n<p align=\"center\"><b>Mini-CEX vs prior baseline control<\/b><\/p>\r\n<\/td>\r\n<td colspan=\"3\" valign=\"top\" style=\"width: 33.2447%;\">\r\n<p align=\"center\"><b><span lang=\"FR\">Mini-CEX vs Micro-CEX<\/span><\/b><b><span lang=\"FR\"><\/span><\/b><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td valign=\"top\" style=\"width: 16.7553%; text-align: left;\">\r\n<p align=\"left\">Prior baseline control mini-CEX<\/p>\r\n<p align=\"left\">(mean+\/-SD)<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 13.9628%; text-align: left;\">\r\n<p align=\"left\">Study Mini-CEX (mean +\/- SD)<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 7.71277%; text-align: left;\">\r\n<p><i>p<\/i> value<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 12.633%; text-align: left;\">\r\n<p>Mini-CEX<\/p>\r\n<p>(mean <u>+<\/u>SD<u>)<\/u><i><\/i><\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 11.9681%; text-align: left;\">\r\n<p>Micro CEX<\/p>\r\n<p>(mean <u>+<\/u>SD)<i><\/i><\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 8.64362%; text-align: left;\">\r\n<p><i>p<\/i> value<i><\/i><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td colspan=\"6\" valign=\"top\" style=\"width: 79.2553%;\">\r\n<p>Q1 in which areas did the resident do well<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 8.64362%;\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td valign=\"top\" style=\"width: 16.2234%;\">\r\n<p>Word count<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 16.7553%;\">\r\n<p>12.1 +\/-14.1<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 13.9628%;\">\r\n<p>9.5 +\/- 7.0<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 7.71277%;\">\r\n<p>0.93<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 12.633%;\">\r\n<p>9.5 +\/- 7.0<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 11.9681%;\">\r\n<p>17.5 +\/- 10.3<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 8.64362%;\">\r\n<p>&lt;0.001<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td valign=\"top\" style=\"width: 16.2234%;\">\r\n<p>Specificity*<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 16.7553%;\">\r\n<p>1.2 +\/- 1.0<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 13.9628%;\">\r\n<p>1.6 +\/- 0.90<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 7.71277%;\">\r\n<p>0.08<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 12.633%;\">\r\n<p>1.6+\/- 0.9<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 11.9681%;\">\r\n<p>2.3 +\/- 0.7<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 8.64362%;\">\r\n<p>&lt;0.001<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td colspan=\"7\" valign=\"top\" style=\"width: 87.8989%;\">\r\n<p>Q2\/3 Areas needing improvement\/ recommendations for future improvement<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td valign=\"top\" style=\"width: 16.2234%;\">\r\n<p>Word count<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 16.7553%;\">\r\n<p>3.8 +\/- 6.8<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 13.9628%;\">\r\n<p>5.7 +\/- 7.3<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 7.71277%;\">\r\n<p>0.06<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 12.633%;\">\r\n<p>5.7 +\/- 7.3<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 11.9681%;\">\r\n<p>19.3 +\/- 15.1<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 8.64362%;\">\r\n<p>&lt;0.001<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td valign=\"top\" style=\"width: 16.2234%;\">\r\n<p>Specificity*<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 16.7553%;\">\r\n<p>0.5 +\/- 0.7<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 13.9628%;\">\r\n<p>1.1 +\/-1.1<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 7.71277%;\">\r\n<p>0.01<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 12.633%;\">\r\n<p>1.1 +\/- 1.0<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 11.9681%;\">\r\n<p>1.8 +\/- 0.9<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 8.64362%;\">\r\n<p>&lt;0.001<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td valign=\"top\" style=\"width: 16.2234%;\">\r\n<p>Actionable<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 16.7553%;\">\r\n<p>1\/30 (3.3%)<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 13.9628%;\">\r\n<p>17\/59(28.8%)<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 7.71277%;\">\r\n<p>0.005<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 12.633%;\">\r\n<p>17\/59 (28.8%)<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 11.9681%;\">\r\n<p>18\/59(30.5%)<\/p>\r\n<\/td>\r\n<td valign=\"top\" style=\"width: 8.64362%;\">\r\n<p>0.84<\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<p style=\"text-align: center;\"><span lang=\"EN-GB\">Table 1. Quality and quantity of feedback in prior baseline control vs study mini-CEX, and in mini vs Micro-CEX<\/span><\/p>\r\n<div>\r\n<p style=\"text-align: justify;\"><i><span lang=\"EN-GB\">B. <\/span><\/i><i><span lang=\"EN-GB\">Evaluation of Feedback in the Micro and Mini-CEX During Study<\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Comparison of the feedback given in the mini and micro-CEX during the study is shown in Table 1. Feedback wordcount increased and was more specific with micro-CEX compared to the contemporaneous mini-CEX done by the same pair. However, there were no differences in the proportion of actionable feedback given in both forms.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><i><span lang=\"EN-GB\">C. <\/span><\/i><i><span lang=\"EN-GB\">Discrimination Between Residents in Different Years of Training<\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">The micro-CEX was able to show progression between the years of training, with a significant rise in the resident\u2019s mean score across the three years of training. On a 4 point score the mean entrustment score increased from 2.45 in the first year of training to 3.30 by the third year (p&lt;0.05). (Figure 2)<\/span><\/p>\r\n<\/div>\r\n<p style=\"text-align: justify;\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2023\/11\/OA2947-Figure-2.png\" alt=\"\" class=\"aligncenter wp-image-72294 size-full\" width=\"1599\" height=\"907\" srcset=\"https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2023\/11\/OA2947-Figure-2.png 1599w, https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2023\/11\/OA2947-Figure-2-300x170.png 300w, https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2023\/11\/OA2947-Figure-2-1024x581.png 1024w, https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2023\/11\/OA2947-Figure-2-768x436.png 768w, https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2023\/11\/OA2947-Figure-2-1536x871.png 1536w\" sizes=\"auto, (max-width: 1599px) 100vw, 1599px\" \/><\/p>\r\n<p align=\"center\" style=\"text-align: center;\"><span lang=\"EN-GB\">Figure 2. Level of entrustment vs Year of training<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Correlation of residents\u2019 year of training and grading of the mini-CEX domains was moderate (kappa 0.39 to 0.60). There was high correlation between all seven questions in the mini-CEX (kappa 0.7 to 0.8) (see appendix 4), implying that the resident\u2019s score in one domain heavily influenced the score in other domains i.e. a halo effect. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><i><span lang=\"EN-GB\"><\/span><\/i><i><span lang=\"EN-GB\">D. Faculty and Resident Preferences<\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">21 (out of total 32 participating residents, 65% response rate) residents and 25 (out of total 39 participating faculty, 64.9% response rate) responded to the survey. Faculty and residents felt that the Micro -CEX had better value for both assessment and feedback compared to the Mini-CEX (Table 2).<\/span><\/p>\r\n<div align=\"center\">\r\n<table border=\"0\" cellspacing=\"0\" cellpadding=\"0\" class=\" aligncenter\">\r\n<tbody>\r\n<tr>\r\n<td width=\"151\" valign=\"top\">\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<td width=\"104\">\r\n<p align=\"center\">Mini-CEX<\/p>\r\n<p align=\"center\">Mean <u>+ SD<\/u><\/p>\r\n<\/td>\r\n<td width=\"113\">\r\n<p align=\"center\">Micro CEX<\/p>\r\n<p align=\"center\">Mean <u>+ SD<\/u><\/p>\r\n<\/td>\r\n<td width=\"76\">\r\n<p align=\"center\"><i>p<\/i> value<\/p>\r\n<\/td>\r\n<td width=\"76\">\r\n<p align=\"center\">t-Stats<\/p>\r\n<\/td>\r\n<td width=\"81\">\r\n<p align=\"center\">Cohen\u2019s <i>d<\/i><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"601\" colspan=\"6\">\r\n<p align=\"left\">Usefulness for assessment<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"151\" valign=\"top\">\r\n<p>Faculty<\/p>\r\n<\/td>\r\n<td width=\"104\">\r\n<p align=\"center\">6.04 +\/- 1.34<\/p>\r\n<\/td>\r\n<td width=\"113\">\r\n<p align=\"center\">6.57 +\/- 0.95<\/p>\r\n<\/td>\r\n<td width=\"76\">\r\n<p align=\"center\">0.04<\/p>\r\n<\/td>\r\n<td width=\"76\">\r\n<p align=\"center\">2.23<\/p>\r\n<\/td>\r\n<td width=\"81\">\r\n<p align=\"center\">0.46<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"151\" valign=\"top\">\r\n<p>Residents<\/p>\r\n<\/td>\r\n<td width=\"104\">\r\n<p align=\"center\">6.00 +\/- 1.62<\/p>\r\n<\/td>\r\n<td width=\"113\">\r\n<p align=\"center\">6.9 +\/- 0.91<\/p>\r\n<\/td>\r\n<td width=\"76\">\r\n<p align=\"center\">0.03<\/p>\r\n<\/td>\r\n<td width=\"76\">\r\n<p align=\"center\">-2.31<\/p>\r\n<\/td>\r\n<td width=\"81\">\r\n<p align=\"center\">0.52<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"601\" colspan=\"6\">\r\n<p align=\"left\">Usefulness for feedback<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"151\" valign=\"top\">\r\n<p>Faculty<\/p>\r\n<\/td>\r\n<td width=\"104\">\r\n<p align=\"center\">6.00 +\/- 1.35<\/p>\r\n<\/td>\r\n<td width=\"113\">\r\n<p align=\"center\">6.87 +\/- 1.10<\/p>\r\n<\/td>\r\n<td width=\"76\">\r\n<p align=\"center\">0.01<\/p>\r\n<\/td>\r\n<td width=\"76\">\r\n<p align=\"center\">-3.07<\/p>\r\n<\/td>\r\n<td width=\"81\">\r\n<p align=\"center\">0.64<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"151\" valign=\"top\">\r\n<p>Residents<\/p>\r\n<\/td>\r\n<td width=\"104\">\r\n<p align=\"center\">5.43 +\/- 1.40<\/p>\r\n<\/td>\r\n<td width=\"113\">\r\n<p align=\"center\">6.81 +\/- 1.57<\/p>\r\n<\/td>\r\n<td width=\"76\">\r\n<p align=\"center\">0.09<\/p>\r\n<\/td>\r\n<td width=\"76\">\r\n<p align=\"center\">-3.82<\/p>\r\n<\/td>\r\n<td width=\"81\">\r\n<p align=\"center\">0.83<\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<p style=\"text-align: center;\"><span lang=\"EN-US\">Table 2. Perceptions of faculty and residents regarding usefulness of mini and micro-CEX for assessment and feedback<\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">*Scoring is on a 9-point Likert scale, with 1 = not useful at all &#8230;. 9 = very useful<\/span><\/p>\r\n<div>\r\n<p style=\"text-align: justify;\"><i><span lang=\"EN-GB\">E. <\/span><\/i><i><span lang=\"EN-GB\">Qualitative Data<\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Qualitative data from the semi-structured interviews was analysed to better understand what the features of the micro-CEX driving this preference were, and to look for helpful features in the CEX. Themes from the semi-structured interviews were distilled into 6 themes (Table 3):<\/span><\/p>\r\n<p style=\"text-align: justify;\"><i><span lang=\"EN-US\">1) Make it easy:<\/span><\/i><span lang=\"EN-US\"> A recurrent theme was that the micro-CEX was easier to use and the short form could be used by the bedside, on resident or faculty mobile devices. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><i><span lang=\"EN-US\">2) Immediacy is important:<\/span><\/i><span lang=\"EN-US\"> Faculty and residents both prized the ability to integrate the assessment into their daily routines, and this immediacy was very important in enhancing the value of the feedback. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><i><span lang=\"EN-US\">3) Tell us what it\u2019s for:<\/span><\/i><span lang=\"EN-US\"> Faculty and residents both expressed that the intended purpose of the forms needed to be explicit. Uncertainty in purpose of the form resulted in a perception of redundancy with the other assessments, and confusion about summative vs formative intent of the assessment inhibited honest feedback and assessment.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><i><span lang=\"EN-US\">4) Structure the form so we know what you want:<\/span><\/i><span lang=\"EN-US\"> Structuring the form with specific areas to remind them to provide narrative feedback, and what specific areas to provide feedback in, was useful. Faculty and residents both felt that the micro-CEX had better learning value than the mini-CEX.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><i><span lang=\"EN-US\">5) Choice of assessor matters depending on objective of the tool:<\/span><\/i><span lang=\"EN-US\"> Faculty and residents agreed that assessments were frequently affected by the prior experiences between the two, impacting the objectivity of assessments via both the micro-and mini- CEX. Prior engagement with the resident facilitated provision of feedback. However, for assessment purposes, residents felt that a faculty with no prior knowledge of the trainee might be more objective.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><i><span lang=\"EN-US\">6) Align assessment with learning goals:<\/span><\/i><span lang=\"EN-US\"> Many of the residents were preparing for their postgraduate medical examinations, and they found the mini-CEX exercise especially useful if it was conducted in a way similar to their examinations (the Royal College of Physicians PACES exam) \u2013 in other words, the utility of the exercise increased greatly when the assessment was aligned with the residents\u2019 own learning goals.<\/span><\/p>\r\n<\/div>\r\n<div align=\"center\">\r\n<table border=\"0\" cellspacing=\"0\" cellpadding=\"0\" class=\" aligncenter\">\r\n<tbody>\r\n<tr>\r\n<td width=\"32\" valign=\"top\">\r\n<p><b>S\/N<\/b><\/p>\r\n<\/td>\r\n<td width=\"148\" valign=\"top\">\r\n<p><b>Themes<\/b><\/p>\r\n<\/td>\r\n<td width=\"428\" valign=\"top\">\r\n<p><b>Quotations<\/b><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"32\" valign=\"top\">\r\n<p>1.<\/p>\r\n<\/td>\r\n<td width=\"148\" valign=\"top\">\r\n<p align=\"left\">Make it easy to do<\/p>\r\n<\/td>\r\n<td width=\"428\" valign=\"top\">\r\n<p>The micro-CEX was <i>\u201cmore succinct. So, it&#8217;s, it&#8217;s much easier to administer\u201d -F<\/i><\/p>\r\n<p><i>\u00a0<\/i><\/p>\r\n<p><i>\u201cIf it&#8217;s a shorter form, even though the quantity may be less maybe the fact that the quality of whatever feedback we&#8217;re given is better because they&#8217;re really giving the one or two points that really stood out to them that we need to improve on or the one or two things that we really did well\u201d -R<\/i><\/p>\r\n<p><i>\u00a0<\/i><\/p>\r\n<p>(Regarding the mini-CEX)<i> \u201cThe fact that it&#8217;s more detailed actually maybe reduces the quality of the feedback because \u2026 if you ask me for additional remarks for every single domain, then they just put nil, nil, nil because there&#8217;s no time\u201d -F<\/i><\/p>\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"32\" valign=\"top\">\r\n<p>2.<\/p>\r\n<\/td>\r\n<td width=\"148\" valign=\"top\">\r\n<p align=\"left\">Immediacy is important<\/p>\r\n<\/td>\r\n<td width=\"428\" valign=\"top\">\r\n<p>\u201cM<i>emory is also fresh because you&#8217;ve just done the case and so I think the learning value&#8217;s a lot better<\/i>\u201d <i>-R<\/i><\/p>\r\n<p>&nbsp;<\/p>\r\n<p><i>\u201cI think looking at it in terms of like a learning experience also, um, when we have that micro-CEX on the spot, ah, not only can we address, like all the points immediately, like what the resident should, um, but at the same time, ah, you can kinda go through certain topics at the same setting as well\u201d -F<\/i><\/p>\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"32\" valign=\"top\">\r\n<p>3.<\/p>\r\n<\/td>\r\n<td width=\"148\" valign=\"top\">\r\n<p align=\"left\">What is this for<\/p>\r\n<\/td>\r\n<td width=\"428\" valign=\"top\">\r\n<p><i>\u201cI think we need clear goals as to why we do these, rather than to simply check boxes.\u201d -R<\/i><\/p>\r\n<p><i>\u00a0<\/i><\/p>\r\n<p><i>\u201cThe form should come with what is the expectation of this, uh, assessment, whether it&#8217;s for assessing, or it&#8217;s for a feedback, or it&#8217;s \u2026. whether this person can work as a HO. I mean, the intention will drive how I assess\u201d -R<\/i><\/p>\r\n<p><i>\u00a0<\/i><\/p>\r\n<p><i>\u201cWe have a lot of forms, the 360 and the mini-cex and all. Sometimes maybe I personally don&#8217;t really see what the difference is sometimes or how it can help to change assessment. I think it&#8217;s just extra admin for everyone and everyone just gets fed up doing it\u201d -R<\/i><\/p>\r\n<p><i>\u00a0<\/i><\/p>\r\n<p><i>\u201cI think the assessor, sometimes they&#8217;re very nice, they know it affects your, your grading or your, your overall performance in the residency, so they try not to be too strict\u201d -R<\/i><\/p>\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"32\" valign=\"top\">\r\n<p>4.<\/p>\r\n<\/td>\r\n<td width=\"148\" valign=\"top\">\r\n<p align=\"left\">Be specific about what you want to know<\/p>\r\n<\/td>\r\n<td width=\"428\" valign=\"top\">\r\n<p>The micro-CEX had <i>\u201cI think several features currently that are really quite useful. Number one is that there is the mandatory open-ended field, um, for areas that need improvement and areas that need to be reinforced\u201d -F<\/i><\/p>\r\n<p>&nbsp;<\/p>\r\n<p>\u201c<i>I find the comments, uh, quite useful. Maybe not the grades itself, because usually people would just give, like, mod- middle-grade. But, the written comments are actually quite useful\u201d -R<\/i><\/p>\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"32\" valign=\"top\">\r\n<p>5.<\/p>\r\n<\/td>\r\n<td width=\"148\" valign=\"top\">\r\n<p align=\"left\">Choice of assessor matters depending on objective for the tool<\/p>\r\n<\/td>\r\n<td width=\"428\" valign=\"top\">\r\n<p><i>\u201cIt&#8217;s quite easy for me to, to, to, remember each of them and give them dedicated feedback\u201d -F<\/i><\/p>\r\n<p>&nbsp;<\/p>\r\n<p><i>\u201cIt should be someone that you don&#8217;t really know, but maybe in the same department. So, that it can be like, really, like a proper case scenario, yeah. Instead of grading you based on what their other impressions are\u201d -R<\/i><\/p>\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td width=\"32\" valign=\"top\">\r\n<p>6.<\/p>\r\n<\/td>\r\n<td width=\"148\" valign=\"top\">\r\n<p align=\"left\">Align assessment with learning goals<\/p>\r\n<\/td>\r\n<td width=\"428\" valign=\"top\">\r\n<p><i>\u201cSo I had this one particular case, that was a very good PACES case, that I clerked in the morning, and, we impromptu made it into a mini-CEX kind of session and, and we went in quite in depth into the discussion, and PACES that sort of stuff, and I thought that was very useful.\u201d -R <\/i><\/p>\r\n<p>&nbsp;<\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<p style=\"text-align: center;\"><span lang=\"EN-US\">Table 3. Themes with supporting quotations<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">*<\/span><span lang=\"EN-US\">1<\/span><span lang=\"EN-US\"> PACES = Membership of Royal Collage Physicians clinical examination, a required exit certification for the residents.<\/span><\/p>\r\n<div>\r\n<p align=\"center\" style=\"text-align: center;\"><strong><span lang=\"EN-GB\">IV. <\/span><span lang=\"EN-GB\">DISCUSSION<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">The most striking result from this study is that even without specific faculty training or other intervention, simplifying the assessment task alone led faculty to write longer, and more specific feedback. Faculty and residents also perceived that the feedback was better. By simplifying the assessment, the faculty\u2019s attention was shifted from grading the resident in multiple domains toward qualitatively identifying good and bad points in the encounter, providing feedback for the residents. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Proportion of actual actionable feedback in the two forms, however, was not different. This is perhaps because there was no specific faculty training for the study as we felt that the additional training itself would impact results. Specific faculty training may be needed to improve this aspect.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">A Hawthorne effect was noticed in the study <\/span><span lang=\"EN-US\">(Adair, 1984)<\/span><span lang=\"EN-US\">. The proportion of actionable feedback provided was much more in the mini-CEX done as part of the study compared to baseline controls (Table 1: 3.3% controls vs 28% study mini-CEX, p = 0.005). Word count and specificity also increased. However, despite this, we were still able to show that the micro-CEX induced faculty to provide more and better feedback.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">From the global entrustment scale used in the micro-CEX, it was possible to demonstrate progression from first year to third year of residency (Figure 2). One potential concern is loss of granularity in assessment of different domains, i.e., that we might lose the ability to identify the specific domain in which the resident is weak if we do not ask faculty to score physical examination, history taking, management etc. separately. However, we found a high correlation between the scores in all domains in the mini-CEX (kappa ranged from 0.7 to 0.8, see appendix 4), indicating a strong halo effect. This suggests that in practice, faculty are making a global assessment anyway rather than a separate assessment of separate domains. Faculty and residents perceived that the single global assessment with the micro-CEX provided better assessment. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">The messages from faculty and residents about what they perceive to be important in making the CEX work for them speak for themselves. The importance of making the form easy to administer is very intuitive; the bureaucratic impracticality of paper portfolios was pointed out long ago and e-portfolios were touted as the preferred solution <\/span><span lang=\"EN-US\">(Van Tartwijk &amp; Driessen, 2009)<\/span><span lang=\"EN-US\"> but the message here is that administrative details have significant impact on the utility of the CEX \u2013 many of the issues cited such as the number of assessments an individual assessor has to make, whether the assessor is equipped to do the assessment on the spot, or whether the assessor has prior exposure to the resident or not &#8211; are administrative and educational design details that faculty training alone cannot solve. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Our study had several limitations. <\/span><span lang=\"EN-US\">Variations in the clinical environment such as ward vs ambulatory clinic, variable workload or competing responsibilities of the faculty and residents might have affected how the CEX was administered. However, distractions in the ward do affect the performance of CEX in real life as well.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">We also note that in this study design, the mini-CEX was performed before the micro-CEX. This was deliberate as the residents and faculty were used to doing the mini-CEX on an ongoing basis so the first mini-CEX would be a \u201cusual\u201d assessment followed by the new assessment. Performing the micro-CEX first might affect how the subsequent mini-CEX was performed. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">In this study, we did not attempt to make judgements about reliability and validity of the micro-CEX as only one specific data point was obtained for each trainee. The mini-CEX is validated to be reliable\u00a0mainly in the context of repeated tests , and preferably in the context of a coherent program of assessment <\/span><span lang=\"EN-US\">(van der Vleuten &amp; Schuwirth, 2005)<\/span><span lang=\"EN-US\">. Whether the micro-CEX is able to provide equivalent robust and valid assessment compared to the mini-CEX depends on how it is used and is an area ripe for future study.<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center;\"><strong><span lang=\"EN-GB\">V. <\/span><span lang=\"EN-GB\">CONCLUSION<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Our study demonstrated that the micro-CEX has a high rate of acceptability amongst faculty and residents, as well as a measurable improvement in feedback characteristics compared to the usual mini-CEX. The context in which the form is administered in actual practice has significant impact on its utility for feedback and assessment.<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center;\"><strong><span lang=\"EN-GB\">Ethical Approval<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">The study protocol was reviewed by the hospital Institutional Review Board, who deemed this as an educational quality improvement project which did not require IRB approval (Singhealth CIRB Ref: 2018\/2696).<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center;\"><strong><span lang=\"EN-GB\">Notes on Contributors<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Thun How Ong conceptualised and designed the study, administered the interviews, analysed the data and wrote the manuscript.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Hwee Kuan Ong participated in data analysis and coding of the qualitative data.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Adrian Chan participated in data analysis and in grading of the feedback specificity.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Dujeepa D. Samarasekera provided input on initial study design and reviewed the manuscript.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">C. P. M. van der Vleuten provided guidance and input at all stages of the study, from initial study design to data analysis and manuscript writing.<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center;\"><strong><span lang=\"EN-GB\">Data Availability<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">The data that support the findings of this study are openly available in Figshare repository, at <\/span><\/p>\r\n<p style=\"text-align: justify;\"><a href=\"https:\/\/doi.org\/10.6084\/m9.figshare.21862068.v1\"><span lang=\"EN-US\">https:\/\/doi.org\/10.6084\/m9.figshare.21862068.v1<\/span><\/a><span lang=\"EN-US\"> <\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center;\"><strong><span lang=\"EN-GB\">Acknowledgement<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">The authors would like to acknowledge the contributions of the following:<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Tan Shi Hwee and Nur Suhaila who provided the administrative support that made the whole project feasible.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">The Faculty and Residents who were willing to do the extra CEX and the interviews, and who labour daily in pursuit of the ultimate goal of providing better care for our patients.<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center;\"><strong><span lang=\"EN-GB\">Funding<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">No funding was obtained for this study.<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center;\"><strong><span lang=\"EN-GB\">Declaration of Interest<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">All authors have no declaration of interest.<\/span><\/p>\r\n<p align=\"center\" style=\"text-align: center;\"><strong><span lang=\"EN-GB\">References<\/span><\/strong><\/p>\r\n<p style=\"text-align: left;\">Adair, J. G. (1984). The Hawthorne effect: A reconsideration of the methodological artifact. <i>Journal of Applied Psychology<\/i>, <i>69<\/i>(2), 334-345. <span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1037\/0021-9010.69.2.334\"><span lang=\"EN-SG\">https:\/\/doi.org\/10.1037\/0021-9010.69.2.334<\/span><\/a><\/span><\/p>\r\n<p style=\"text-align: left;\">Berendonk, C., Rogausch, A., Gemperli, A., &amp; Himmel, W. (2018). Variability and dimensionality of students&#8217; and supervisors&#8217; mini-CEX scores in undergraduate medical clerkships &#8211; A multilevel factor analysis. <i>BMC Medical Education<\/i>, <i>18<\/i>(1), 100. <span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1186\/s12909-018-1207-1\"><span lang=\"EN-SG\">https:\/\/doi.org\/10.1186\/s12909-018-1207-1<\/span><\/a><\/span><\/p>\r\n<p style=\"text-align: left;\">Bindal, T., Wall, D., &amp; Goodyear, H. M. (2011). Trainee doctors\u2019 views on workplace-based assessments: Are they just a tick box exercise? <i>Medical Teacher<\/i>, <i>33<\/i>(11), 919-927.<span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.3109\/0142159X.2011.558140\"><span lang=\"EN-SG\"> https:\/\/doi.org\/10.3109\/0142159X.2011.558140<\/span><\/a><\/span><\/p>\r\n<p style=\"text-align: left;\">Brazil, V., Ratcliffe, L., Zhang, J., &amp; Davin, L. (2012). Mini-CEX as a workplace-based assessment tool for interns in an emergency department \u2013 Does cost outweigh value? <i>Medical Teacher<\/i>, <i>34<\/i>(12), 1017-1023.<span lang=\"EN-US\"> <a href=\"https:\/\/doi.org\/10.3109\/0142159X.2012.719653\"><span lang=\"EN-SG\">https:\/\/doi.org\/10.3109\/0142159X.2012.719653<\/span><\/a><\/span><\/p>\r\n<p style=\"text-align: left;\">Castanelli, D. J., Jowsey, T., Chen, Y., &amp; Weller, J. M. (2016). 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(2013). <\/span>Development and implementation of a mini-Clinical Evaluation Exercise (mini-CEX) program to assess the clinical competencies of internal medicine residents: From faculty development to curriculum evaluation. <i>BMC Medical Education<\/i>, <i>13<\/i>, 31-31. <span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1186\/1472-6920-13-31\"><span lang=\"EN-SG\">https:\/\/doi.org\/10.1186\/1472-6920-13-31<\/span><\/a><\/span><\/p>\r\n<p style=\"text-align: left;\">L\u00f6rwald, A. C., Lahner, F. M., Greif, R., Berendonk, C., Norcini, J., &amp; Huwendiek, S. (2018). Factors influencing the educational impact of Mini-CEX and DOPS: A qualitative synthesis. <i>Medical Teacher<\/i>, <i>40<\/i>(4), 414-420. <span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1080\/0142159X.2017%20.1408901\"><span lang=\"EN-SG\">https:\/\/doi.org\/10.1080\/0142159X.2017 .1408901<\/span><\/a><\/span><\/p>\r\n<p style=\"text-align: left;\">Lorwald, A. C., Lahner, F. M., Nouns, Z. M., Berendonk, C., Norcini, J., Greif, R., &amp; Huwendiek, S. (2018). The educational impact of mini-Clinical Evaluation Exercise (mini-CEX) and Direct Observation of Procedural Skills (DOPS) and its association with implementation: A systematic review and meta-analysis. <i>PLoS One<\/i>, <i>13<\/i>(6), Article e0198009. <span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1371\/jour%20nal.pone.0198009\"><span lang=\"EN-SG\">https:\/\/doi.org\/10.1371\/jour nal.pone.0198009<\/span><\/a><\/span><\/p>\r\n<p style=\"text-align: left;\">Morris, A., Hewitt, J., &amp; Roberts, C. M. (2006). Practical experience of using directly observed procedures, mini Clinical Evaluation Examinations, and peer observation in pre-registration house officer (FY1) trainees. <i>Postgraduate Medical Journal<\/i>, <i>82<\/i>(966), 285-288. <span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1136\/pgmj.2005.040477\"><span lang=\"EN-SG\">https:\/\/doi.org\/10.1136\/pgmj.2005.040477<\/span><\/a><\/span><\/p>\r\n<p style=\"text-align: left;\">Nair, B. R., Alexander, H. G., McGrath, B. P., Parvathy, M. S., Kilsby, E. C., Wenzel, J., Frank, I. B., Pachev, G. S., &amp; Page, G. G. (2008). The mini clinical evaluation exercise (mini-CEX) for assessing clinical performance of international medical graduates. <i>Medical Journal of Australia<\/i>, <i>189<\/i>(3), 159-161.<\/p>\r\n<p style=\"text-align: left;\">Norcini, J. J., Blank, L. L., Duffy, F. D., &amp; Fortna, G. S. (2003). The mini-CEX: A method for assessing clinical skills. <i>Annals Internal Medicine<\/i>, <i>138<\/i>(6), 476-481.<\/p>\r\n<p style=\"text-align: left;\">Ong, T. H., Ong, H. K., Chan, A., Samarasekera, D. D., van der Vleuten, C. (2023). <i>Micro CEX vs Mini CEX: Less can be more<\/i> [Dataset]. <span lang=\"FR\">Figshare. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/https:\/doi.org\/10.6084\/m9.Fig%20share.21862068.v3\"><span lang=\"FR\">https:\/\/doi.org\/https:\/\/doi.org\/10.6084\/m9.Fig share.21862068.v3<\/span><\/a><\/span><span lang=\"FR\"> <\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"FR\">Paradis, E., &amp; Sutkin, G. (2017). <\/span>Beyond a good story: From Hawthorne Effect to reactivity in health professions education research. <i>Medical Education<\/i>, <i>51<\/i>(1), 31-39. <span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1111\/medu.13122\"><span lang=\"EN-SG\">https:\/\/doi.org\/10.1111\/medu.13122<\/span><\/a><\/span><\/p>\r\n<p style=\"text-align: left;\">Pelgrim, E. A. M., Kramer, A. W. M., &amp; Van der Vleuten, P. M. (2012). Quality of written narrative feedback and reflection in a modified mini-Clinical Evaluation Exercise: An observational study. <i>BMC Medical Education<\/i>, <i>12<\/i>(1), 97. <span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1186\/1472-6920-12-97\"><span lang=\"EN-SG\">https:\/\/doi.org\/10.1186\/1472-6920-12-97<\/span><\/a><\/span><\/p>\r\n<p style=\"text-align: left;\">Regehr, G., MacRae, H., Reznick, R. K., &amp; Szalay, D. (1998). Comparing the psychometric properties of checklists and global rating scales for assessing performance on an OSCE-format examination. <i>Academic Medicine<\/i>, <i>73<\/i>(9), 993-997.<\/p>\r\n<p style=\"text-align: left;\">Sabey, A., &amp; Harris, M. (2011). Training in hospitals: What do GP specialist trainees think of workplace-based assessments? <i>Education for Primary Care<\/i>, <i>22<\/i>(2), 90-99.<\/p>\r\n<p style=\"text-align: left;\">Tavares, W., Ginsburg, S., &amp; Eva, K. W. (2016). Selecting and simplifying: Rater performance and behavior when considering multiple competencies. <i>Teaching and Learning in Medicine<\/i>, <i>28<\/i>(1), 41-51.<span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1080\/10401334.2015.1107489\"><span lang=\"EN-SG\"> https:\/\/doi.org\/10.1080\/10401334.2015.1107489<\/span><\/a><\/span><\/p>\r\n<p style=\"text-align: left;\">van der Vleuten, C. P., &amp; Schuwirth, L. W. (2005). Assessing professional competence: From methods to programmes. <i>Medical Education<\/i>, <i>39<\/i>(3), 309-317. <a href=\"https:\/\/doi.org\/10.1111\/j.1365-2929.%202005.02094.x\">https:\/\/doi.org\/10.1111\/j.1365-2929. 2005.02094.x<\/a><\/p>\r\n<p style=\"text-align: left;\">Van Tartwijk, J., &amp; Driessen, E. W. (2009). Portfolios for assessment and learning: AMEE Guide no. 45. <i>Medical Teacher<\/i>, <i>31<\/i>(9), 790-801. <span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1080\/01421590903139201\"><span lang=\"EN-SG\">https:\/\/doi.org\/10.1080\/01421590903139201<\/span><\/a><\/span><\/p>\r\n<p style=\"text-align: left;\">Walzak, A., Bacchus, M., Schaefer, J. P., Zarnke, K., Glow, J., Brass, C., McLaughlin, K., &amp; Ma, I. W. (2015). Diagnosing technical competence in six bedside procedures: Comparing checklists and a global rating scale in the assessment of resident performance. <i>Academic Medicine<\/i>, <i>90<\/i>(8), 1100-1108.<span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1097\/acm.0000000000000704\"><span lang=\"EN-SG\"> https:\/\/doi.org\/10.1097\/acm.0000000000000704<\/span><\/a><\/span><\/p>\r\n<p style=\"text-align: left;\">Weller, J. M., Misur, M., Nicolson, S., Morris, J., Ure, S., Crossley, J., &amp; Jolly, B. (2014). Can I leave the theatre? A key to more reliable workplace-based assessment. <i>British Journal of Anaesthesia<\/i>, <i>112<\/i>(6), 1083-1091. <span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1093\/bja\/aeu052\"><span lang=\"EN-SG\">https:\/\/doi.org\/10.1093\/bja\/aeu052<\/span><\/a><\/span><\/p>\r\n<p style=\"text-align: left;\">Weston, P. S. J., &amp; Smith, C. A. (2014). The use of mini-CEX in UK foundation training six years following its introduction: Lessons still to be learned and the benefit of formal teaching regarding its utility. <i>Medical Teacher<\/i>, <i>36<\/i>(2), 155-163. <span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.3109\/0142159X.2013.836267\"><span lang=\"EN-SG\">https:\/\/doi.org\/10.3109\/0142159X.2013.836267<\/span><\/a><\/span><\/p>\r\n<p style=\"text-align: left;\">Yanting, S. L., Sinnathamby, A., Wang, D., Heng, M. T. M., Hao, J. L. W., Lee, S. S., Yeo, S. P., &amp; Samarasekera, D. D. (2016). Conceptualizing workplace-based assessment in Singapore: Undergraduate mini-Clinical Evaluation Exercise experiences of students and teachers. <i>Tzu-Chi Medical Journal<\/i>, <i>28<\/i>(3), 113-120. <span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1016\/j.tcmj.2016.06.001\"><span lang=\"EN-SG\">https:\/\/doi.org\/10.1016\/j.tcmj.2016.06.001<\/span><\/a><\/span><\/p>\r\n<p style=\"text-align: left;\">*Ong Thun How<br \/>\r\nAcademia, 20 College Road, <br \/>\r\nSingapore 168609<br \/>\r\n97100638<br \/>\r\nEmail: ong.thun.how@singhealth.com.sg<\/p>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<\/div>","protected":false},"featured_media":0,"parent":0,"menu_order":2,"template":"","issues_category":[12],"archive_category":[],"issue_type":[25],"volume_category":[61881],"class_list":["post-72292","issues","type-issues","status-publish","hentry","issues_category-original-articles","issue_type-past-issue","volume_category-volume-9-number-1-january-2024"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.4 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Micro CEX vs Mini CEX: Less can be more - The Asia Pacific Scholar<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/medicine.nus.edu.sg\/taps\/issues\/micro-cex-vs-mini-cex-less-can-be-more\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Micro CEX vs Mini CEX: Less can be more - The Asia Pacific Scholar\" \/>\n<meta property=\"og:description\" content=\"Submitted: 28 January 2023 Accepted: 17 August 2023 Published online: 2 January, TAPS 2024, 9(1), 3-19 https:\/\/doi.org\/10.29060\/TAPS.2024-9-1\/OA2947 Thun How Ong1, Hwee Kuan Ong2, Adrian Chan1, Dujeepa D. 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