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The Mini-CEX: A Method for Assessing Clinical Skills

John J. Norcini, PhD; Linda L. Blank; F Daniel Duffy, MD; and Gregory S. Fortna, MSEd
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From the Foundation for Advancement of International Medical Education and Research and the American Board of Internal Medicine, Philadelphia, Pennsylvania.

Disclaimer: This research was supported by the American Board of Internal Medicine but does not necessarily reflect its opinions.

Acknowledgments: The authors thank the following participants: Edward Bollard, MD, and Richard J. Simons Jr., MD, Penn State College of Medicine and Milton S. Hershey Medical Center; R. Michael Buckley, MD, Pennsylvania Hospital; Rand David, MD, Elmhurst Hospital Center and Mt. Sinai School of Medicine; William Farrer, MD, Seton Hall University; Susan D. Grossman, MD, and Cynthia Wong, MD, St. Vincent's Catholic Medical Center of New York, Staten Island Region; Sheik N. Hassan, MD, Howard University Hospital; Eric Holmboe, MD, National Naval Medical Center; Brenda Horwitz, MD, Temple University Hospital; Stephen J. Huot, MD, PhD, Yale Primary Care Internal Medicine Residency; Gregory Kane, MD, Jefferson Medical College; David G. Kemp, MD, Easton Hospital; Nayan Kothari, MD, Robert Wood Johnson Medical School; Frank Kroboth, MD, University Health Center of Pittsburgh, Montefiore University Hospital; Jeanne Macrae, MD, State University of New York Health Center at Brooklyn; Dragica Mrkoci, MD, The George Washington University Medical Center; Richard S. Rees, MD, New York Harbor Veterans Affairs Health Care System Medical Service; Steven Reichert, MD, Englewood Hospital and Medical Center; David G. Smith, MD, Abington Hospital; Sara L. Wallach, MD, Monmouth Medical Center; Frederick K. Williams, MD, Washington Hospital Center; Jack Boulet, PhD; William Burdick, MD; Danette McKinley; and Gerald P. Whelan, MD, Educational Commission for Foreign Medical Graduates.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: John J. Norcini, PhD, Foundation for Advancement of International Medical Education and Research, 3624 Market Street, 4th Floor, Philadelphia, PA 19104; e-mail, jnorcini@faimer.org.

Current Author Addresses: Dr. Norcini: Foundation for Advancement of International Medical Education and Research, 3624 Market Street, 4th Floor, Philadelphia, PA 19104.

Ms. Blank, Dr. Duffy, and Mr. Fortna: American Board of Internal Medicine, 510 Walnut Street, Suite 1700, Philadelphia, PA 19106-3699.

Ann Intern Med. 2003;138(6):476-481. doi:10.7326/0003-4819-138-6-200303180-00012
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Objective: To evaluate the miniclinical evaluation exercise (mini-CEX), which assesses the clinical skills of residents.

Design: Observational study and psychometric assessment of the mini-CEX.

Setting: 21 internal medicine training programs.

Participants: Data from 1228 mini-CEX encounters involving 421 residents and 316 evaluators.

Intervention: The encounters were assessed for the type of visit, sex and complexity of the patient, when the encounter occurred, length of the encounter, ratings provided, and the satisfaction of the examiners. Using this information, we determined the overall average ratings for residents in all categories, the reliability of the mini-CEX scores, and the effects of the characteristics of the patients and encounters.

Measurements: Interviewing skills, physical examination, professionalism, clinical judgment, counseling, organization and efficiency, and overall competence were evaluated.

Results: Residents were assessed in various clinical settings with a diverse set of patient problems. Residents received the lowest ratings in the physical examination and the highest ratings in professionalism. Comparisons over the first year of training showed statistically significant improvement in all aspects of competence, and the method generated reliable ratings.

Conclusions: The measurement characteristics of the mini-CEX are similar to those of other performance assessments, such as standardized patients. Unlike these assessments, the difficulty of the examination will vary with the patients that a resident encounters. This effect is mitigated to a degree by the examiners, who slightly overcompensate for patient difficulty, and by the fact that each resident interacts with several patients. Furthermore, the mini-CEX has higher fidelity than these formats, permits evaluation based on a much broader set of clinical settings and patient problems, and is administered on site.


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Appendix Figure.
The mini–clinical evaluation exercise (mini-CEX) form.

Dx = diagnosis; ED = emergency department; min = minutes; R-1 = first-year resident; R-2 = second-year resident; R-3 = third-year resident.

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