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This 2.5-hour rater-training workshop is modified from that developed by Drs. Ravi Sidhu, Rose Hatala, and Gordon Page at the University of British Columbia, and is based on the Direct Observation of Competence Training program developed by Holmboe et al at the American Board of Internal Medicine (Holmboe, 2004).*
The accompanying videos contain nine taped patient encounters and three taped feedback encounters for use in the workshop. For each type of patient encounter, three different performances are depicted, which can be used at different points in the workshop:
NOTE: All patients and candidates in the following videos are paid actors
A history taking encounter for a patient with angina complicated by anaemia (scenarios 1-3)
A physical examination encounter for a patient with shortness of breath (SOB), fatigue, and productive cough (scenarios 4-6)
A counselling encounter with a patient with high cholesterol – A treatment counselling session (scenarios 7-9)
For each of these three types of encounters, a feedback session is shown with one candidate:
Feedback for scenario 2 – the feedback session for one of the history taking encounters
Feedback for scenario 5 – the feedback session for one of the physical examination encounters
Feedback for scenario 8 – the feedback session for one of the counselling encounters.
Workshop program
1. Introduction (10 minutes)
a. Overview/history of the mini-CEX – outline the background (changes in the health care system, expectations of patients, current assessment techniques – for example, OSCEs, Miller’s pyramid) leading to the proposed use of the mini-CEX.
b. Discuss the purpose of, and program for, the workshop.
2. Looking at clinical performance: What is being assessed? (about 20 minutes)
Notes for facilitators
a. Show scenario 3 – history taking for chest pain. Then have a brief discussion about what aspects of performance were seen in the encounter (in an attempt to get the participants to be analytical and less tacit in their observations), what was good, not so good. Suggest that the participants begin to think about how they would rate this person.
Notes for assessors and IMGs
a. Watch scenario 3 – history taking for chest pain. Then discuss what aspects of performance were seen in the encounter, what was good, not so good. Think about how you would rate this person.
b. Show scenario 6 – physical examination for shortness of breath (SOB), fatigue, cough – repeat discussion as in (a) above.
c. Show scenario 9 – counselling for raised cholesterol level – repeat discussion as in (a) above.
d. Then give out the mini-CEX rating form – discuss its background, the meaning of the rating categories – referencing the definitions on the form.
3. Frame of reference and feedback session (about 90 minutes)
Frame of reference training: Ask the assessors to watch the following scenarios in the order as outlined in this training program. These encounters display varying levels of proficiency. After each scenario, ask them to independently score the scenario on the mini-CEX form and then discuss the ratings as a group. Start the discussion by asking the group to announce their overall ‘grade’ – fail, borderline or pass, and to explain ‘why’, and then pursue the ratings of individual competencies. Discuss their ratings and the reasons for any differences that exist across assessors, highlight what they agree was done well and not so well.
Please note: the structure of this session is to firstly address the frame of reference training for each type of patient encounter (that is, watch the scenarios, score individually and then discuss) and to then watch the taped feedback encounter relevant to that type of encounter.
History taking encounters
Show the following scenarios:
Scenario 1
Ask participants to score; discuss their ratings
Scenario 2
Ask participants to score; discuss their ratings
Providing feedback
Show Feedback for scenario 2.
Ask participants for their comments on the feedback provided. Record key points raised about effective feedback on the whiteboard.
Physical examination encounters
Show the following scenarios:
Scenario 4
Ask participants to score; discuss their ratings
Scenario 5
Ask participants to score; discuss their ratings
Providing feedback
Show Feedback for scenario 5
Ask participants for their comments on the feedback provided. Record key points raised about effective feedback on the whiteboard.
Counselling encounters
Show the following scenarios:
Scenario 7
Ask participants to score; discuss their ratings
Scenario 8
Ask participants to score; discuss their ratings
Providing feedback
Show Feedback for scenario 8, the feedback session for the counselling scenario. Ask participants for their comments on the feedback provided. Record key points raised about effective feedback on the whiteboard.
4. Providing feedback – a summary (10 minutes)
Provide a summary related to giving effective feedback (refer to the comments collected on the whiteboard and RG7 of this course)
5. Wrap up (10 minutes)
Recap the main points from the session and summarise the assessors’ involvement in mini-CEX assessment in the future.
Notes for facilitators on the recorded scenarios
These notes should assist facilitators in using the videos below for training.
Case information for scenarios 1–3: Taking a history
60-year-old male retired accountant who presents to an outpatient clinic complaining of intermittent chest pain that he has had for many months.
Scenario 1
This interaction displays the poor communication of the candidate through:
Using closed questions with apparent disinterest in the patient’s responses. The only positive response the candidate gave was saying ‘good’ to exercise;
Ignoring the patient’s specific concern regarding his father’s illness. The candidate moved quickly off the reported symptom of indigestion rather than following this up and asking more questions which might have identified melaena;
Giving a brief and technical explanation of the patient’s condition;
Failing to establish rapport;
Failing to allow the patient to talk;
Appearing non-caring and not responding to the patient’s calls for understanding. This is a situation where empathy is clearly called for.
Because of her ‘shotgun’, rapid fire, closed questions, the candidate did not process the information given in an appropriate way to generate and test diagnostic possibilities (or hypotheses). Although the candidate did make the diagnosis of angina, her performance is very unsatisfactory.
Rating:
Overall: a very unsatisfactory performance
Scenario 2
The candidate was pleasant throughout the interview. In some ways, the candidate was thorough – he asked about risk factors, including family history, hypertension, cholesterol, and other vascular disease (for example, claudication looking for peripheral vascular disease), disease in the distribution of the carotid (asked about visual changes, episodes of weakness) and other cardiac symptoms (heart failure, peripheral oedema)
The candidate then went on to a mini systems review but used double-barreled or multiple questions, such as indigestion, vomiting, bowel problems. The systems review sought a history of joints.
The candidate did not appear to be thinking in a problem-solving mode (if presented with indigestion and melaena, the link between joint disease and other symptoms might be non-steroidal anti-inflammatory medication). The candidate appeared to be operating in a data gathering mode and collecting data without thinking about its significance – for example, having heard of the elbow symptoms, he didn’t ask about non-steroidal medication.
When the patient asked for an explanation, the candidate avoided responding by saying that it was ‘too early’ and spoke of the need for tests, even though he appeared to have had a good idea of what was happening.
Rating:
Overall: Borderline unsatisfactory
Scenario 3
The candidate uses good open-ended questions, uses good listening techniques, picks up on patient cues – for example, indigestion; identifies potential impact of the family history, particularly the father’s death on his perception of own illness and prognosis and makes appropriate empathic statements in this regard.
Very satisfactory description of likely diagnoses using appropriate lay language.
Rating:
Overall: This represents a very satisfactory performance.
Case information for scenarios 4–6: Physical Examination
60-year-old male presents to clinic with the main complaint of shortness of breath (SOB), fatigue, and productive cough. He is unsure but thinks he has been slowly getting more short of breath over the last year or so. He is a smoker, having consumed 25 a day between the ages of 20 and 55 years. He has noticed some mild ankle oedema in the last 2 months. He is otherwise well and is on no medication.
He was diagnosed with Inflammatory Bowel disease 20 years ago and this has been stable since an ileostomy 15 years ago.
The doctor has taken his history and the patient has been asked to go into the examination room and strip to the waist prior to being examined.
Scenario 4
The candidate assessed the cardiovascular system including looking at the JVP and for ankle oedema. The candidate also listened to several areas of the lung posteriorly. It was a fairly methodological approach but the observing assessor wasn’t sure what the candidate was looking for and how the findings impacted on her working diagnosis.
Rating:
Physical examination techniques were very satisfactory.
The overall rating was satisfactory but there is uncertainty about her clinical reasoning (this might be good if she was looking for the right things). This would be elicited in the interview and a debrief at the end of the physical examination.
Scenario 5
The candidate was respectful of patient and was thorough to such an extent that she was overly inclusive in examination components. Given the presentation¸ she did not need to look in his ears or feel glands in neck. This may indicate that she isn’t testing a working hypothesis.
Technique: evidence suggests that vocal fremitus is inferior to vocal resonance – applied hand vertically instead of horizontally in rib spaces. Examination of the abdomen was satisfactory but was unnecessary. The assessor would want to ask her what she was thinking in the interview afterwards.
Rating:
Technique: satisfactory but overly inclusive
Overall: Need have a clear view of diagnostic possibilities and use clinical reasoning to identify those features that should be sought on physical examination.
Scenario 6
The candidate’s technique appeared to be very satisfactory.
The candidate appeared to be generating hypotheses and testing them – all aspects of the examination were done appropriately to testing hypotheses, including recording the peak flow. The candidate should have repeated peak flow at least twice more but there is a reasonable assumption that he would refer for detailed lung function tests.
Rating:
Overall: very satisfactory.
Case information for scenarios 7–9: Counselling for high cholesterol
46-year-old female returning to clinic for follow-up and counselling for her hyperlipidemia. She has a strong family history of heart disease. At the last test, her LDL cholesterol was 7.2 mmol/l. She is recently divorced and works as an administrative officer in the city. She smokes about 10 cigarettes a day and has ignored past advice to stop smoking. She has no regular exercise.
Scenario 7
This candidate demonstrates poor communication skills as evidenced by:
not involving the patient,
using short statements with little explanation
not checking understanding
unsettling the patient
using statistics and jargon that the patient doesn’t understand
having few pauses
poor eye contact and therefore missing cues from patient
telling the patient what to do instead of negotiating a plan
grossly inadequate explanation of the side effects.
Rating:
Overall rating: Very unsatisfactory
Scenario 8
The candidate engaged the patient and gave options. Smoking and exercise were addressed but not in enough detail. Further information/advice would be needed, for example, gradually increase fitness level. The important side effect of statins (myositis) was covered. The concern about weight gain was inappropriately dismissed by the candidate.
The candidate approached the encounter in a disorganised way and focused more on the medication and less on lifestyle issues.
Rating:
Interviewing skills: very satisfactory
Organisation: less than satisfactory
Overall: satisfactory
Scenario 9
The candidate engaged the patient; checked understanding; actively involved the patient in negotiating a plan; acknowledged that lifestyle changes are important, would need further appointment and arrived at a mutual agreement to talk about these at the next appointment; checked understanding again at the end of the interview; offered to see the patient again. The candidate did address risk factors but could have been a little clearer in terms of immediate and long term risks.
