Assessment of postgraduate dental students using mini-clinical examination tool in periodontology and implantology.

INTRODUCTION: Mini-clinical examination (mini-CEX) is a new assessment tool that observes the student using a standard rating form. The aim of this study was to evaluate the feasibility and usefulness of the mini-CEX as an assessment and feedback tool in the postgraduate setting in periodontology.
MATERIALS AND METHODS: Eight postgraduate students and two evaluators were included in this study carried out for 4 months during which the students were made to appear for four encounters evaluated on a standardized nine-point Likert scale. Feedback was obtained from the students about this assessment after the fourth encounter.
RESULTS: Sixty-three percent of the students felt that mini-CEX is better than the conventional assessment tools. Seventy-five percent of the students felt that this type of mini-CEX assessment helped improve the student-teacher relationship and student-patient relationship. Sixty-three percent of the students were satisfied with this assessment pattern and were willing to face more encounters as it helped them improve their competencies. Seventy-five percent of the students agreed that they felt anxious on being observed while taking cases.
CONCLUSION: The training and assessment of a wide range of procedures make dentistry unique. Good communication skills and counseling can allay patient's fear and anxiety. This structured way of assessment of clinical skills and feedback provides good clinical care and helps improve the quality of the resulting information which would induce confidence, improve clinical competencies, and alleviate the fear of examination among the students.

INTRODUCTION

Assessment is an important input for improving quality of education. This is especially so for helping students acquire good clinical skills during all phases of their learning as postgraduate students. The reason for dissatisfaction with traditional assessment is its lack of direct observation. A long case for example is assessed without actually observing the student taking the history or performing the physical examination. Mini-clinical examination (mini-CEX) is a snapshot observation of a clinical encounter. As the name indicates, it is briefly lasting for only 10–15 min. Traditional assessment has very little scope if any, for providing feedback to the trainee. Even when it is provided, it is not based on direct observation, is not in the vicinity of the performance, and is not reliable because of dependence on a single examiner.[1]

The most important issue is to build validity. Miller's pyramid provides a useful model for assessment of clinical competence. Mini-CEX assesses the trainee at higher levels of Miller's pyramid. In 1990, Miller represented the elements of clinical competence as a pyramid structure. Its base represents the knowledge components of competence: “know” (basic facts) followed by “knows how” (applied knowledge). The “shows how” indicates requirements by the qualifying physician and “does” represents performance of the professional in real clinical practice. Assessment of the highest level of Miller's pyramid requires observation of the physician's routine clinical work [Figure 1].[2]

Figure 1

Miller's pyramid. OSCEs – objective structured clinical examinations, MCQ's – mulitple choice questions

In the mini-CEX, the evaluator observes the student using a standard rating form. At the end of the observation, the evaluator provides a focused feedback to the students. Mini-CEX rating has also a good correlation with the other measures of clinical competence providing validity evidence.

Mini-CEX is a relatively new entrant in the Indian dental scenario. There have been some studies in the western countries which use the mini-CEX in the postgraduate setting but very few in India. The main purpose of this study was to expose the postgraduate student as well as the faculty to utility of formative feedback and how it can be assessed for better learning. The aim of this study was to evaluate the feasibility and usefulness of the mini-CEX as an assessment and feedback tool in the postgraduate setting in periodontology.

MATERIALS AND METHODS

This study was carried out in the Department of Periodontology and Implantology between July 2015 and October 2015. Institutional ethical committee clearance was obtained. All the students and the faculty members who consented to be a part of this study were sensitized with this assessment tool with audio-visual aids and made familiar with the mini-CEX rating form and anonymity was promised.

Two evaluators (A and B) alternated their turns at evaluation each month such that each student underwent at least two mini-CEX sessions with each evaluator. However, this is a FAIMER fellowship project and constricted time period for this project was only 4 months.

Thirty-two cases of equal complexity were selected for the students. In the first encounter, students exceeded the time limit which subsequently reduced to roughly 20–25 min. The postgraduate students examined the patients who came for periodontal treatment. Each student was observed by an evaluator both for the diagnosis and treatment planning. The evaluators were the teachers of the Periodontology Course who received instructions on this new form of assessment and were assisted by the study coordinator.

The evaluators evaluated the students for seven clinical competencies using the standardized mini-CEX form and gave the feedback to the students. The form used a standardized nine-point Likert scale with rating span from 1 to 3 (unsatisfactory); 4 to 6 (satisfactory); and 7 to 9 (superior) [Table 1 and Figure 2]. Each student faced four clinical encounters, and after the each clinical encounter, the student immediately presented an assessment and treatment plan.

Table 1

Rating skills and its description

Figure 2

Rating skills

At the time of the fourth encounter, students were asked to give their feedback on the assessment given by the evaluator and experience with encounter.

RESULTS

Postgraduate students showed satisfactory performance in different clinical skills, namely medical interviewing, CEX, professionalism, clinical judgment, and organization.

In-patient setting consisted of examination, diagnosis, and treatment planning of patient problem with the moderate complexities. The problems covered a broad range of presenting symptoms which included gingival bleeding, mobility of teeth, sensitivity, oral malodor, and pain. Routine physical examination consisted of chief complaints and history of present illness, plaque index, gingival index, and periodontal parameters such as probing pocket depth and clinical attachment level.

The medical interviewing skill improved from 41% to 68% over the first encounter to fourth encounter. The physical examination skill improved from 37% to 66% while a similar growth in skills was seen in the professionalism and communication and counseling skills 43%–63% and 40%–71%, respectively. Clinical judgment and organization and efficiency improved from 40% to 73% and 42% to 78%, respectively. The overall performance showed a drastic improvement from 40% to 81% from encounter 1 to encounter 4 [Table 2].

Table 2

Rating of the clinical skills of the four encounters

The student's feedback regarding the mini-CEX was also positive as it helped them develop a better insight about patient examination and decision-making in diagnosis. It induced confidence and reduced examination fear among them. Seventy-five percent of the students felt that this type of mini-CEX assessment helped improve the student–teacher relationship as well as the student–patient relationship. Sixty-three percent of the students were satisfied with this assessment pattern and were willing to face more encounters as it helped them improve their competencies. Sixty-three percent of the students felt that mini-CEX is better than the conventional assessment tools. Seventy-five percent of the students agreed that they felt anxious on being observed while taking cases [Table 3].

Table 3

Percentage feedback questionnaire for students

In our study, the staff was unaware of the existence of any workplace assessment program before sensitization and agreed to improve learning in the clinical competencies of the students by giving them effective feedback about their presentations which was not a part of their routine. Twenty percent of the staff agreed to include the mini-CEX program as a part of their routine [Tables 4a and b].

Table 4a

Percentage feedback questionnaire for staff

Table 4b

Likert scale for the feedback questionnaire of the staff

The mean time taken for observation or examination reduced from encounter 1 to encounter 4 from 43.75 to 29.37 min. A similar reduction was seen when time was assessed for feedback of evaluators which reduced from 15.62 to 10.62 min [Table 5].

Table 5

Mean of time for observations and feedback for evaluators

The evaluator's satisfaction improved from a low of 50%–78% over the four encounters. The trainee's satisfaction improved from 55% to 74% over the same period [Table 6].

Table 6

Satisfaction of trainees and assessors in four encounters

DISCUSSION

The comparison of student mini-CEX scores between the first and fourth encounter of clinical practice evidenced an improvement in all competencies evaluated supporting the validity of this assessment method. The greatest score was in the overall performance followed by organization and efficiency, clinical judgment and counseling skills, and diagnosis and examination.

The overall growth in the student's skill was seen to improve from a low of 40%–81% over encounter 1 to encounter 4. Hence, the evident advantage of the mini-CEX tool is direct observation of the evaluators and longitudinal tracking of the student and allows the correction and strengthening of actions or attitudes in performance.[34]

Previous studies demonstrated mini-CEX to be a valid technique for assessing the students by standardizing the patient examination and standardized oral examination, diagnosis, and treatment planning.[56] Norcini et al. observed that assessment of the student–patient relationship in due course of encounters was slightly biased toward the case difficulty and several patient interactions for each student. Therefore, in our study, we overruled this biasing by standardizing the level of complexity of patient problem.[7]

Our study showed that on the basis of a 10-point scale executed by our examiners, the medical interviewing skill improved from 41% to 68% over the first encounter to fourth encounter. The physical examination skill improved from 37% to 66% while a similar growth in skills was seen in the professionalism and communication and counseling skills as 43%–63% and 40%–71%, respectively. Clinical judgment and organization and efficiency improved from 40% to 73% and 42% to 78%, respectively. The overall performance showed a drastic improvement from 40% to 81% from encounter 1 to encounter 4.

The postgraduate students agreed that the mini-CEX was a better assessment tool when compared with the conventional assessment tools. The results were in accordance with Lima et al., who stated that mini-CEX is a valid and reliable instrument and promotes direct observation and constructive feedback on real patient encounters in the clinical workplace.[8] They even agreed that they felt anxious on being observed while they take case histories, which eventually diminished over multiple encounters. Similar findings were reported by Behere where he found that the students were frightened in the teacher's presence during mini-CEX but got accustomed to it with time.[9]

According to Little et al. in 2001, patients of doctors who took a patient-centered approach were more satisfied, more enabled and had greater symptom relief and lower rates of referral.[10] Feedback on the student–patient interaction proved to be an invaluable learning tool in our study.

The staff realized the need for an effective feedback after the presentation and was willing to include the mini-CEX in their postgraduate curriculum. This was found to be in accordance with Kogan and Hauer, who successfully correlated and implemented mini-CEX in undergraduate medical training programs, and thus, we have implemented the same for postgraduate students in this study.[11]

Consistent with the previous work, the examiners as well as the trainees were satisfied with the new format and their satisfaction was correlated with their evaluation and their time spent in observing the trainee and the patient complexity. Future research should focus on at least two issues, first, recognizing that there is no gold standard to judge performance, and second, monitoring which can impact rating accuracy.

CONCLUSION

To the best of our knowledge, this is the first study of the implementation of mini-CEX into postgraduate dental education in the subject of periodontology. Our experience makes us believe that mini-CEX is an acceptable and practical tool in the postgraduate setting. The training and assessment of a wide range of procedures make dentistry unique. Good communication skills and counseling can allay patient's fears and anxiety. This structured way of assessment of clinical skills and feedback for the provision of good clinical care will help improve the quality of the resulting information and also help in learning from different perspectives which would induce confidence, improve clinical competencies, and alleviate the fear of examination among the students. Hence, we can conclude that:

The students showed great improvements in medical interviewing skill, physical examination skill, professionalism, communication and counseling skills, clinical judgment, and organization and efficiency skills as well as in overall performance

Mini-CEX emerged as a promising tool that overpowered the conventional methods of assessment

The students developed confidence and better insight about patient examination and decision-making in diagnosis

It not only improved the student–teacher relationship but also improved the student–patient relationship and worked toward their incompetency

Fear for examination among postgraduate students reduced over the period of encounters.

Limitations of the study

The patients were not asked to report for a feedback

This study was done in a single department with one discipline only

A small sample size was taken to conduct the study

Numbers of evaluations were limited per student.

Recommendation

Mini-CEX can be a useful tool to evaluate the clinical competencies of the students. It can be used from time to time in all subjects of dentistry to increase the efficiency of the student and thus should be incorporated in the dental curriculum in India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.