|Year : 2021 | Volume
| Issue : 3 | Page : 134-139
Assessment of communication skills of interns in pediatrics using mini-clinical evaluation exercise
Bindu T Nair, Vandana Negi, Abhishek Prakash
Departments of Paediatrics, Army College of Medical Sciences, New Delhi, India
|Date of Submission||24-May-2020|
|Date of Decision||03-Aug-2020|
|Date of Acceptance||24-Aug-2020|
|Date of Web Publication||29-Oct-2021|
Dr. Bindu T Nair
Department of Paediatrics, Army College of Medical Sciences, Delhi Cantt., New Delhi - 110 010
Background: Interns who would be the future doctors are not being observed for communication skills at their workplace. The Mini-clinical evaluation exercise (mini-CEX) can be used as a “Work Place Based Assessment” (WPBA) tool for the assessment of the communication skills of the interns and also for giving immediate feedback. This study was done to evaluate the acceptability, feasibility, and effectiveness of mini-CEX for improving the communication skills of interns in Pediatrics. Materials and Methods: It was a prospective interventional study which was conducted in the Department of Pediatrics. Forty interns and six faculty who volunteered participated in the mini-CEX encounters. The structured assessment mini-CEX form by the American Board of Internal Medicine was used. Each intern faced six assessment sessions on mini-CEX forms with each of the faculty. At the end of the internship rotation, the perceptions of the interns and faculty were gathered by an anonymous validated questionnaire containing both close-ended (using 5-point Likert scale) and open-ended questions. Statistical Analysis Used: The descriptive data were analyzed on the Statistical Package for the Social Sciences (SPSS) version 23. also done. Qualitative data of open-ended questions were done by thematic analysis. Results: Most interns (87.5%) and all faculty (100%) felt that mini-CEX helped them in achieving good communication skills. Comparison between the 1st and the 6th encounter of mini-CEX showed an increase in the mean score values for all skill competencies, and this improvement was statistically significant (P < 0.001). Conclusions: Mini-CEX is an acceptable, feasible, and effective WPBA tool for communication skills training of interns in pediatrics.
Keywords: Communication skills, interns, mini-clinical evaluation exercise, pediatrics, perception
|How to cite this article:|
Nair BT, Negi V, Prakash A. Assessment of communication skills of interns in pediatrics using mini-clinical evaluation exercise. Sahel Med J 2021;24:134-9
|How to cite this URL:|
Nair BT, Negi V, Prakash A. Assessment of communication skills of interns in pediatrics using mini-clinical evaluation exercise. Sahel Med J [serial online] 2021 [cited 2021 Nov 28];24:134-9. Available from: https://www.smjonline.org/text.asp?2021/24/3/134/329519
| Introduction|| |
Communication skills of doctors have a significant impact on patient care and correlate with improved health-care outcomes of society. Undergraduate medical students are not imparted with communication skills training. Interns who would be the future doctors are not being observed for communication skills at their workplace. Workplace-based assessment (WPBA) is being increasingly used as a method of assessing communication skills and can be used for interns as well., Hence, this project was done to evaluate the feasibility of using mini-clinical evaluation exercise (mini-CEX) as a WPBA tool for assessment and providing immediate feedback to the interns on their communication skills.
| Materials and Methods|| |
The study design inolves prospective interventional study.
Pediatric Department, Army College of Medical Sciences, Delhi Cantt, New Delhi – 110010.
The duration of the study was from March to December 2019.
Forty interns who came for internship rotation in pediatrics from April to August 2019 (8 interns per month) were enrolled. Six faculty members who volunteered for participation were included. Informed written consent was taken from the 40 interns and 6 faculty participating in the study.
First, ethical clearance for the study was obtained from the Institutional Ethics Committee, Base Hospital, Delhi Cantt, India (IEC BHDC No./32 of 2019 dt 05 April 2019). Orientation sessions were conducted to sensitize and train the participating faculty and the interns to mini-CEX. This comprised a combination of a mini-lecture with the power-point presentation, role-play, videos of mini-CEX on simulated patients, and cinema education clips with focus on history taking, counseling and breaking bad news. The principles and methodology of mini-CEX were explained in detail, and any doubts were clarified. They were also given hand-outs and literature on mini-CEX for further reading.
The structured mini-CEX assessment form by the American Board of Internal Medicine was used for the mini-CEX sessions. The guidelines for the assessment of communication skills and giving structured feedback during mini-CEX encounters were based on “how the intern builds a relationship, opens the discussion, gathers information, understands the patient's perspective, shares information, reaches agreement and provides closure.” These guidelines were adapted from “Kalamazoo Essential Elements Communication Checklist” (adapted)., Permission from both the American Board of Internal Medicine and Kalamazoo Consensus Group for the use of the concerned tools was taken.
The mini-CEX encounters were conducted either in the neonatal intensive care unit (NICU), outpatient department (OPD), inpatient ward, or emergency department of the Pediatric Department. Informed consent was obtained from the patients/patients' attendants before the mini-CEX sessions were conducted. The mini-CEX assessment form has 7 skills which are to be observed. Out of these 7 skills, only 3 skills, namely “history taking” (Point 1), “humanistic qualities/professionalism” (Point 3), and counseling skills (Point 5) were considered for evaluation during the encounters. Point 7 of the mini-CEX assessment form was modified to “overall communication skill competence” instead of “overall clinical skill competence.”
Each intern had 6 mini-CEX assessment encounters with six different faculty. Each assessment session using the mini-CEX rating form was for 15–20 min, and thereafter, unstructured oral feedback was given to the interns in the next 5 min. We tried to keep varied assessment sessions for the interns like history taking, communicating the risks and prognosis of the illness, breaking bad news, taking informed consent, and counseling about therapy. The time interval between two encounters was 4–5 days.
For each assessment session, the faculty recorded the date, the complexity of the patient's problem on a 3-point scale (low, moderate, and high) and the setting (OPD, pediatric inpatient ward, NICU, or emergency department). The time spent on observing the assessment session and giving feedback was also recorded. The faculty also noted whether the focus of the assessment session was history taking, humanistic qualities/professionalism, or counseling.
The mini-CEX rating form had a nine-point scale in which score 1–3 was unsatisfactory, 4–6 was satisfactory, and 7–9 was superior. Each intern was rated by all the assessors once, and an average of the scores was taken. The scores of mini-CEX assessment forms obtained by the interns in the 1st encounter were compared with those of the 6th encounter and analyzed.
At the end of the rotation of the internship, the interns completed an anonymous feedback questionnaire, which was validated by the Medical Education Unit (MEU) members and subject experts of the department. Feedback questionnaires were also taken from the participating faculty after all the mini-CEX encounters were completed. Mini-CEX scores and feedback data were entered periodically, whenever possible.
The scores of mini-CEX assessment forms obtained by the interns in the 1st encounter were compared with those of the 6th encounter and analyzed. At the end of the rotation of internship, the participating interns completed an anonymous feedback questionnaire, which was validated by the MEU members and subject experts of the department. The faculty also filled the feedback questionnaire after all the mini-CEX encounters were completed. The questionnaires contained both close-ended (using a 5-point Likert scale as a response scale ranging from 1 = strongly disagree to 5 = strongly agree) and open-ended questions to elicit their perceptions regarding the use of mini-CEX as an assessment and feedback method for communication skills of interns in pediatrics.
Data were collected from mini-CEX rating forms and prevalidated feedback questionnaires from interns and faculty. The data were analyzed on the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, Version 23.0. IBM Corp., Armonk, NY). Descriptive statistics, frequency, and percentages were calculated for all categorical variables. Appropriate tables and figures (Pie and Bar Diagrams) were projected for the data. “Paired t-test” was applied to compare the scores of the 1st and 6th mini-CEX encounters, and P < 0. 001 was taken as significant. Qualitative data of open-ended questions were done using thematic analysis.
| Results|| |
A total of 40 interns and 6 faculty participated in the study. Forty interns who came for internship rotation in Pediatrics from April to August 2019 (8 interns per month) had mini-CEX sessions with six different faculty. Thus, there were a total of 240 encounters of 40 interns with 6 faculty members each. Out of the 40 interns who participated in the project, 19 (47.5%) were males and 21 (52.5%) were females [Figure 1]. Out of the 240 mini-CEX encounters, participating faculty classified 5 cases (6.07%) as high complexity, 77 (32.08%) cases as moderate complexity, and rest 158 (65.83%) as that of low complexity [Figure 2].
|Figure 2: Complexity of cases of mini-clinical evaluation exercise encounters|
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The areas focused upon in the various mini-CEX encounters were history taking/interviewing skills in 116 (48.33%) cases, counseling about the disease in 22 (9.17%) cases, immunization counseling in 42 (17.5%), drugs counseling in 33 (13.75%), taking consent before procedure/investigations in 22 (9.17%) cases and breaking bad news in 5 (2.08%) cases [Figure 3]. Male interns scored better in “Medical Interviewing Skills” while female interns scored better in “Counselling skills.” Male interns also scored better on “Humanistic Qualities/Professionalism” than female interns. The score of female interns was higher in the Overall communication skills competence [Table 1]. However, none of these findings were statistically significant.
|Figure 3: Focus areas of mini-clinical evaluation exercise encounters assessed|
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|Table 1: Comparison of mean score rating of mini-clinical evaluation exercise competencies of male and female interns|
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The perception of the interns about using mini-CEX in the assessment of communication skills and giving feedback are shown in [Figure 4]. 87.5% interns agreed or strongly agreed that the mini-CEX helped them in achieving good communication skills, made them confident in history taking and was a good method for assessing communication skills. 85% of interns agreed or strongly agreed that it helped them in improving their counseling skills. 85% of students felt that it was an effective tool for feedback. 87.5% interns felt that it was not a time-consuming process, and 82.5% interns felt that it was a feasible WPBA exercise. 85% of interns felt that mini-CEX could be incorporated as a means of assessment in the medical curriculum, and 85% felt that the program should be continued during internship rotation.
|Figure 4: Perception of interns about using mini-clinical evaluation exercise in the assessment of communication skills|
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Feedback from interns for the open-ended questions (verbatim):
- With every succeeding encounter, I wanted to do better. I was clearly told what is right or wrong in my communication skills and that made me motivated to overcome my shortcomings
- Getting immediate feedback from faculty reinforced understanding of the mistakes I had committed
- Getting feedback from the faculty enhanced learning better than reading from books/interne.
- I felt anxious on knowing that my whole encounter with the patient was being observed
- I was getting conscious when I was being taught counseling in front of the patient.
The perceptions of faculty who participated in the mini-CEX encounters about using it in the assessment of communication skills and giving feedback to interns are as shown in [Figure 5]. All faculty (100%) felt that min-CEX made interns confident in communicating with patients and helped in improving the communication skills of interns. 83.3% of faculty agreed or strongly agreed that mini-CEX is a satisfactory method of assessing communication skills competency in interns and also was an effective tool for feedback on assessment skills. 66.6% of faculty felt that it is a feasible exercise and is not a time-consuming process. All faculty (100%) felt that the program should be continued and should be incorporated in the undergraduate medical curriculum for interns.
|Figure 5: Perception of faculty about using mini-clinical evaluation exercise in the assessment of communication skills|
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Feedback from the faculty for the open-ended questions (verbatim)
- Feedback stimulated self-reflection in the interns and improved their motivation to do better in the next encounter
- Besides learning communication skills, the interns' knowledge on the topic also increased
- It should be used as part of the certification for the internship
- I felt it difficult and exhausting to do the sessions on a busy day, especially with a lot of administrative and academic responsibilities
- It was a very lengthy process
Comparison between the 1st and the 6th encounter showed an increase in the mean mini-CEX score values for all skill competencies, and this improvement was statistically significant (P < 0.001) [Figure 6].
|Figure 6: Comparison of scores between 1st and 6th mini-clinical evaluation exercise encounter. Improvement in scores significant, P < 0.001|
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| Discussion|| |
Communication skills of doctors have a significant impact on the well-being of patients and are associated with improved health-care outcomes. Even then, there is no structured training or assessment in communication skills for undergraduates or interns. The new Competency-Based Medical Education Curriculum which has been introduced stresses on Attitude, Ethics, and Communication module and teaching communication skills to the students. Communication skills cannot be taught by just didactic lectures.
Repeated WPBA and immediate feedback on varied patient encounters such as getting informed consent, history taking or medical interviewing, dealing with emotions of patients with critical illnesses, empathy, breaking bad news, etc., have to be done.
In the present study, the communication skills of interns in real patient settings were assessed using mini-CEX during their pediatric internship rotation. Mini-CEX can be used for both assessments as well as giving immediate feedback. Even though there are many studies where mini-CEX is being used for work-place assessment of post-graduate residents,, there are hardly any studies using mini-CEX for assessment of the communication skills of interns., In the study, the average time for observation was 15.28 min, and for immediate feedback was 5.98 min in the mini-CEX encounters. However, the average time taken for observation and feedback was 21 min and 8 min, respectively in a study by Kogan et al.
There were significant differences between male and female interns in the various skills of mini-CEX. Male interns scored better in “Medical Interviewing Skills” and “Humanistic Qualities/Professionalism skills”, while female interns scored better in “Counselling skills.” However, this difference was not statistically significant. The score of female interns was higher in the “Overall Communication Skills” competence. Thus, female interns showed more empathy and communicated better with patients as we see in the overall communication skills competence. Similar findings were found in other studies also showed that female interns have a tendency to communicate with higher degrees of empathy. There was also a recent meta-analysis that showed that female physicians displayed better patient-centered communication behaviors like empathy, collaborative communication skills and also gave more psychosocial information to the patients.,
Mean scores of all 3 skill competencies-Medical Interviewing skills, Humanistic Qualities, Counselling skills, and “Overall Communication Skill Competence” showed improvement over successive encounters, which was statistically significant. Mean scores of mini-CEX were higher for “Medical Interviewing Skills” (6.28) and “Counselling skills” (6.33) than for “Humanistic Qualities” which was 6.12 [Figure 6]. The encounters for each intern were at an interval of approximately 4–5 days. By the end of the pediatric internship rotation, the interns developed adequate confidence and felt that they had improved their communication skills. This was displayed in the mini-CEX scores between the first and sixth encounter.
The analysis of feedback questionnaires after the mini-CEX encounters from the interns and faculty showed that both the interns and faculty were satisfied with the mini-CEX sessions. Most (87.5%) of the interns felt that it improved their communication skills. Similar results were found in another study by Pfeiffer also. Hundred percent of faculty felt that there was an improvement in the communication skills of the interns since the time mini-CEX sessions were started in the department. They perceived that mini-CEX made them very confident to effectively communicate with real patients.
The interns felt that being given immediate feedback really helped them in improving their communication skills. Most interns were comfortable about the process though some expressed anxiety about these encounters with real patients. Similar results were obtained in another study. Another systematic review study also concluded that interns' individual personality, the environmental setting of the facilitation session and the context in which the feedback was being given had a great impact on the reaction of the interns to the sessions. Overall both the interns and faculty found it to be a satisfactory tool for assessment of communication skills as in other studies also.
Interns felt that the immediate constructive feedback from the faculty improved their confidence while dealing with patients in the real setting. At times, they found the mini-CEX sessions challenging and over-whelming while communicating with the patients. They mentioned that immediate constructive feedback helped them to clarify doubts on dealing with difficult patient encounters.
In response to the open-ended questions, the interns expressed their enthusiasm to have more such sessions. The interns felt that such mini-CEX encounters should be carried out in other clinical departments also as it would help them in their future clinical practice. Though few interns felt anxious that they were being observed in front of the patients and were getting conscious of the feedback being given immediately.
In response to the open-ended questions, faculty felt that besides improving the communication skills, it also enhanced the knowledge of the interns. The interns were also stimulated by the feedback and they had self-reflection about their performance. They were motivated to do better in the next encounter. Though few faculties felt that the sessions were a very lengthy process. They found it difficult and exhausting to do the sessions on a busy day, especially with a lot of administrative and academic responsibilities.
On reviewing literature, studies have shown that for the effective doctor-patient relationship, it is essential to teach communication skills longitudinally to medical undergraduates in all phases of the medical curriculum. Lately, there has been a lot of research on communication skills as it has become one of the key requirements for medical undergraduates to groom themselves to become doctors of greater competence.
| Conclusion|| |
Mini-CEX is an effective WPBA tool to assess communication skills of the interns. Interns showed consistent statistically significant improvement in Mini-CEX scores over time. This tool enables the faculty to give immediate feedback to the interns on the deficiencies observed in the communication skills
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rider EA, Hinrichs MM, Lown BA. A model for communication skills assessment across the undergraduate curriculum. Med Teach 2006;28:e127-34.
Modi JN, Anshu -, Chhatwal J, Gupta P, Singh T. Teaching and assessing communication skills in medical undergraduate training. Indian Pediatr 2016;53:497-504.
Norcini J, Burch V. Workplace-based assessment as an educational tool: AMEE Guide No. 31. Med Teach 2007;29:855-71.
Norcini JJ, Blank LL, Duffy FD, Fortna GS. The mini-CEX: a method for assessing clinical skills. Ann Intern Med 2003;138:476-81.
Joyce BL, Steenbergh T, Scher E. Use of the kalamazoo essential elements communication checklist (adapted) in an institutional interpersonal and communication skills curriculum. J Grad Med Educ 2010;2:165-9.
Makoul G. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med 2001;76:390-3.
Likert R. A technique for the measurement of attitudes. Arch Psychol 1932;140:1-55.
Parker SM, Clayton JM, Hancock K, Walder S, Butow PN, Carrick S, et al
. A systematic review of prognostic/end-of-life communication with adults in the advanced stages of a life-limiting illness: patient/caregiver preferences for the content, style, and timing of information. J Pain Symptom Manage 2007;34:81-93.
Kogan JR, Bellini LM, Shea JA. Implementation of mini CEX to evaluate medical student's clinical skills. Acad Med 2002;77:1156-7.
Hill F, Kendall K. Adopting and adapting the mini-CEX as an undergraduate assessment and learning tool. Clin Teach 2007;4:244-8.
Sahana KS, Qadiri GJ, Saldanha PR. End of pediatric posting assessment of medical interns at a teaching hospital from Coastal Karnataka. J Nepal Pediatr Soc 2018;38:90-3.
Eriksen JG, Simonsen D, Bastholt L, Aspegren K, Vinther C, Kruse K, et al
. Mini clinical evaluation exercise as evaluation tool of communicative and cooperative skills in the outpatient clinic. Ugeskr Laeger 2009;171:1003-6.
Bylund CL, Makoul G. Empathic communication and gender in the physician-patient encounter. Patient Educ Couns 2002;48:207-16.
Marteau TM, Humphrey C, Matoon G, Kidd J, Lloyd M, Horder J. Factors influencing the communication skills of first-year clinical medical students. Med Educ 1991;25:127-34.
Smith RC, Lyles JS, Mettler JA, Marshall AA, Van Egeren LF, Stoffelmayr BE, et al
. A strategy for improving patient satisfaction by the intensive training of residents in psychosocial medicine: a controlled, randomized study. Acad Med 1995;70:729-32.
Pfeiffer C, Madray H, Ardolino A, Williams J. The rise and fall of student's skill in obtaining a medical history. Med Educ 1998;32:283-8.
Malhotra S, Hatala R, Courneya CA. Internal medicine residents' perceptions of the Mini-Clinical Evaluation Exercise. Med Teach 2008;30:414-9.
Miller A, Archer J. Impact of workplace based assessment on doctors' education and performance: A systematic review. BMJ 2010;341:c5064.
Balamurugan PV, Jayapriya B, Geetha K, Lourdu JA. Teaching and assessment of clinical skills in interns using the mini clinical evaluation exercise (Mini-CEX) in a South Indian medical college – A pilot study. IOSR J Dent Med Sci 2017;16:69-73.
Kurtz S, Silverman J, Draper J. Teaching and Learning Communication Skills in Medicine. 3rd
ed.. Abingdon, Oxon: Radcliffe Publishing Ltd.; 2013. p. 1-305.
Amini M, Kojuri J, Lotfi F, Karimian Z, Abadi AS. Research priorities in medical education in the Eastern Mediterranean Region. East Mediterr Health J 2012;18:687-92.
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