迷你臨床演練評量Mini-Clinical Evaluation Exercise (Mini-CEX)

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大綱 什麼是什麼是迷你臨床演練評量迷你臨床演練評量 如何實施如何實施迷你臨床演練評量迷你臨床演練評量

Key Elements in Curriculum The goals of the programThe goals of the program Content to be taught and learnedContent to be taught and learned Sequence of implementationSequence of implementation Teaching stategies to achieve the goalsTeaching stategies to achieve the goals Description and allocation of resourcesDescription and allocation of resources AssessmentAssessment Detailed plan for evaluation and Detailed plan for evaluation and

adjustmentadjustment

Student Assessment

Medical record auditsMedical record audits Diary, Logbook, PassportDiary, Logbook, Passport Direct observation (Mini-Direct observation (Mini-

CEX, OSCE/SP)CEX, OSCE/SP) Model, Patient simulatorModel, Patient simulator Case presentationCase presentation Computerized patient Computerized patient

simulation Exam.simulation Exam. Oral Exam.Oral Exam. Essay questionEssay question Multiple choice questionMultiple choice question

DOES

Framework of Assessment

KNOWS

SHOWS HOW

KNOWS HOW

George E. Miller: Acad Med 1990

Teacher Reasoning During Case Presentations and Five Microskills for Clinical Teaching

Diagnose Learner1. Ask for a commitment2. Probe for underlying reasoning

Diagnose Patient

Teach3. Teachgeneral rules4. Provide positive feedback5. Correct errors

Neher, JO, Gordon, KC, Meyer, B, and Stevens, N. A Five-step "MicroskiIls" Model of Clinical Teaching. Journal of the American Board of Family Practice. 5:419 424, 1992.

ACGME (Accreditation Council of Graduate ACGME (Accreditation Council of Graduate Medical Education)Medical Education) Clinical competenceClinical competence

ABIM (American Board of Internal Medicine)-ABIM (American Board of Internal Medicine)-NBME (National Board of Medical Examiner)NBME (National Board of Medical Examiner)

Mini-CEXMini-CEX

Mini-CEX

Mini-CEX ABIM (American Board of Internal Medicine)ABIM (American Board of Internal Medicine)發展推薦的評量工具發展推薦的評量工具

可行性很高可行性很高 , , 教師學員皆認同教師學員皆認同(Norcini JJ, et al. Ann Med 1995)(Norcini JJ, et al. Ann Med 1995)

於於 2121 所醫院進行前導研究所醫院進行前導研究 , , 頗獲好評 頗獲好評 (Norcini JJ, et al. Ann Med 2003)(Norcini JJ, et al. Ann Med 2003)

信效度優於傳統評量方法 信效度優於傳統評量方法 (Duming SJ, et al. Acad Med 2002)(Duming SJ, et al. Acad Med 2002)

可適用於醫學生可適用於醫學生(Hauer KE. Acad Med 2000 & Kogan JR. (Hauer KE. Acad Med 2000 & Kogan JR.

Acad Med 2002)Acad Med 2002)

Mini-CEX A attending physicianA attending physician A traineeA trainee A patient A patient Any time, Any placeAny time, Any place Direct observation of routine activityDirect observation of routine activity

(15-20 min) (15-20 min) Assessment and Feedback Assessment and Feedback

(5-10 min)(5-10 min)

Feasibility Some interns report that these are the first times they have Some interns report that these are the first times they have

been directly observed and given immediate feedback about been directly observed and given immediate feedback about their interaction with patientstheir interaction with patients(Stephen Huot, MD/Yale Primary Care Residency, New Heaven, (Stephen Huot, MD/Yale Primary Care Residency, New Heaven, CT) CT)

The trainees have reported the experience to be not only The trainees have reported the experience to be not only evaluative and also informativeevaluative and also informative

(Sheik Hassan, MD/Howard University Hospital, Washington, (Sheik Hassan, MD/Howard University Hospital, Washington, DC)DC)

Both evaluators and residents expressed their high Both evaluators and residents expressed their high satisfaction with the mini-CEX evaluation system and consider satisfaction with the mini-CEX evaluation system and consider it an improvement in evaluating clinical skillsit an improvement in evaluating clinical skills

(Dragica Mrkoci, MD/George Washington University Medical (Dragica Mrkoci, MD/George Washington University Medical Center, Washington DC)Center, Washington DC)

Reliability & Validity Reproducibility coefficients and standard Reproducibility coefficients and standard

errors of measurementerrors of measurement(Norcini JJ, et al. Ann Med 1995)(Norcini JJ, et al. Ann Med 1995)

Correlational validityCorrelational validity (Duming SJ, et al. Acad Med 2002) (Duming SJ, et al. Acad Med 2002)

Consequential validityConsequential validity (Norcini JJ, et al. Ann Med 2003)(Norcini JJ, et al. Ann Med 2003) Construct validityConstruct validity (Holmboe ES, et al. Acad Med 2003)(Holmboe ES, et al. Acad Med 2003)

Medical Interviewing Skills Starts with open-ended questionsStarts with open-ended questions Progresses with specific questionsProgresses with specific questions Does not ask multiple questionsDoes not ask multiple questions Does not ask presumptive/leading questionsDoes not ask presumptive/leading questions Does not interrupt patientDoes not interrupt patient Asks for clarification if necessaryAsks for clarification if necessary Logic sequencing of questionsLogic sequencing of questions Segment summarySegment summary

Lane JL & Gottlieb RP. Structured Clinical Observations. Pediatrics 2000

Physical Examination Skills Washes handsWashes hands Minimizes discomfortMinimizes discomfort Preserves modestyPreserves modesty Explains to parent what doingExplains to parent what doing Explains to child what doingExplains to child what doing Sequence matches cooperation levelSequence matches cooperation level Build rapportBuild rapport Correct techniqueCorrect technique

Lane JL & Gottlieb RP. Structured Clinical Observations. Pediatrics 2000

Humanistic Qualities/Professionalism My Dr. seems to take a personal interest in meMy Dr. seems to take a personal interest in me Even my problem is small, my Dr. is concernedEven my problem is small, my Dr. is concerned I have confidence in my Dr.’s decisionsI have confidence in my Dr.’s decisions My Dr. respects my beliefsMy Dr. respects my beliefs I would talk to my Dr. if something troubling meI would talk to my Dr. if something troubling me My Dr. takes an interest in my home lifeMy Dr. takes an interest in my home life My Dr. is easy to talk toMy Dr. is easy to talk to My dr. seems to know what I am going through when I My dr. seems to know what I am going through when I

tell him/her about a problemtell him/her about a problem

Hauck FR, et al. Humanism in Physicians. Family Med 1990

Clinical Judgment Formulating a D.D. using history and physical Formulating a D.D. using history and physical

examinationexamination Developing a prioritized problem list to select testsDeveloping a prioritized problem list to select tests Applying principles of sensitivity, specificity, and pretest Applying principles of sensitivity, specificity, and pretest

predictive value probabilitiespredictive value probabilities Assessing risks, benefits, and costs of treatment optionsAssessing risks, benefits, and costs of treatment options Involving patient in decision makingInvolving patient in decision making

Goroll AH, et al. Reforming core clerkship. Ann intern Med 2001

Counseling Skills The patent’s role in decision makingThe patent’s role in decision making AlternativesAlternatives Pros (benefits and cons (risks) of the alternativesPros (benefits and cons (risks) of the alternatives Uncertainties associated with the decisionUncertainties associated with the decision As assessment of the patient’s understanding of As assessment of the patient’s understanding of

the decisionthe decision An exploration of the patient’s preferencesAn exploration of the patient’s preferences

BRADDOCK CH, et al. Informed decision making. JAMA 1999

Organization/Efficiency Clinical practice guidelines: systemically Clinical practice guidelines: systemically

developed statements to assist practitioner and developed statements to assist practitioner and patient decision about appropriate healthcare for patient decision about appropriate healthcare for specific clinical conditionspecific clinical condition

The practice guideline is a management plan that The practice guideline is a management plan that enables healthcare providers to make sequential enables healthcare providers to make sequential decisions about testing or therapy in a given decisions about testing or therapy in a given clinical situationclinical situation

Gerszten PC. Neurosurg Focus. 1988

Overall Clinical Competence Opening/closing the interviewOpening/closing the interview

Introduce self; calls patient by name; Shakes hands entering; Introduce self; calls patient by name; Shakes hands entering; Shakes hands leaving Shakes hands leaving

Relationship skillsRelationship skills Listens carefully (nods, “mm-hm”); Reflects and legitimizes Listens carefully (nods, “mm-hm”); Reflects and legitimizes

patient’s feelings or concerns; Offers partnership, support, or patient’s feelings or concerns; Offers partnership, support, or praisepraise

Personal mannerPersonal manner Appearance; Good eye contact; Appropriate body language, Appearance; Good eye contact; Appropriate body language,

facial expression, and tone of voice; Use silence facial expression, and tone of voice; Use silence appropriatelyappropriately

Lane JL & Gottlieb RP. Structured Clinical Observations. Pediatrics 2000

Limitations of Mini-CEX

Teacher’s rating biasTeacher’s rating bias Evaluate “shows how” not “does”Evaluate “shows how” not “does” Lack of timeLack of time Culture differencesCulture differences Reliability and ValidityReliability and Validity Halo effect across the competenciesHalo effect across the competencies

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