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Mini clinical evaluation exercise as evaluation tool of communicative and cooperative skills in the outpatient clinic

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Jesper G Eriksen at Aarhus University Hospital
Jesper G Eriksen
Dorit Simonsen
Dorit Simonsen
Dorit Simonsen
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Lars Bastholt at Odense University Hospital
Lars Bastholt
Knut Aspegren
Knut Aspegren
Knut Aspegren
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Abstract

In the revised Danish medical specialist training increased focus has been placed on competences which are hard to evaluate such as communication skills. Mini-CEX seems promising as an evaluation tool. Our aim was to test: 1) whether mini-CEX was useable in the evaluation of communicative and cooperative skills and 2) whether mini-CEX would provide reproducible data. Twenty-one residents were evaluated by mini-CEX by trained observers. Seventeen residents had at least two observations within a short period of time and these data were used to estimate the mini-CEX reproducibility. In addition to the residents, the nurses who assisted them in the outpatient clinic answered a questionnaire regarding the mini-CEX satisfaction. Observations had a median duration of 20 minutes (10-60 minutes) and the overall median duration of feedback was 15 minutes (5-60 minutes). Time used for feedback was halved from the first to the following feedback sessions. No significant clinical differences were observed between the scorings performed by the residents themselves and the observers, or the nurses of the outpatient clinic and the observers. In general, the residents were satisfied with the mini-CEX evaluations. The mini-CEX is a promising tool for the evaluation of communicative and cooperative skills.
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UGESKR LÆGER 171/12 | 16. MARTS 2009 1003
VIDENSKAB OG PRAKSIS
| ORIGINALARTIKEL
væsentlig information, når lokal gentamicinbehandling over-
vejes som alternativ, idet der her findes en velkendt risiko for
samtidigt høretab. Man bør således være tilbageholdende
med gentamicin hos patienter med en god hørelse.
Med hensyn til kontrol med svimmelhedsanfald er resulta-
terne af vestibulær neurektomi sammenlignelige med eller
bedre end gentamicininstillation [17].
Vi har tidligere demonstreret god effekt af vestibularis-
overskæring, idet ophør af svimmelhedsanfald var resultatet
for 88% af patienterne [4]. I denne opfølgende opgørelse do-
kumenteres 100% anfaldsfrihed. Man kunne tilskrive denne
forbedring en akkumuleret erfaring med det kirurgiske ind-
greb, hvilket taler for en fortsat centralisering af behandlin-
gen. Det er herunder væsentligt, at patienter, behandlere og
foreninger orienteres om muligheden og om resultaterne, idet
behandlingen i flere tilfælde har afhjulpet svær invalidering
og forhindret eksklusion fra arbejdsmarkedet.
Resultaterne er i øvrigt sammenlignelige med internatio-
nale referencer [9-14], hvorunder der desuden foreligger god
evidens for en vedvarende effekt [9, 10, 13, 14].
SummaryMartin Nue Møller, Pr. Cayé-Tomasen & Jens H. Thomsen: Vestibular nerve section in the treatment of morbus MénièreUgeskr Læger 2009;171:xxxxIntroduction: Vestibular nerve section in the treatment of Mb. Ménière was introduced in Denmark in 1980. This treatment is
centralised at Gentofte Hospital and we have previously published the results from 1980-1996. We here present the updated results from 2000-2007 with a total of 18 patients.
Material and methods: Systematic review of case journals and questionnaires regarding postoperative satisfaction, vertigo control and influence on daily activities.
Results: All patients achieved total vertigo spell control. In total 15 patients (83%) indica ted satisfaction with the operation. Sixteen patients (89%) reported that vertigo had no, mild, or moderate influence on their daily activities. The difference between pre- and postoperative functional level
was highly significant. Expected consequences of unilateral ablation in the form of imbalanced gait or lingering sensation of dizziness occurred to varying degrees in 14 patients (78%). Complications: Two patients developed postoperative liquorrhoea an d one patient partial facial palsy.
Conclusion: The results demonstrate that vestibular nerve section causes vertigo spell control and improved daily functional levels in patients with severe and otherwise untreatable Mb. Ménière. These results are in accordance with international publications. New prospects in vestibular reha-
bilitation promise significant reductions of the postoperative imbalance. Continued centralisation of the surgical intervention is recommended, as is providing patients with information of the positive results of this treatment
Korrespondance: Martin Nue Møller, Øre-næse-halskirurgisk Afdeling E,
Gentofte Hospital, DK-2900 Hellerup. E-mail: MANUMO02@geh.regionh.dk
Antaget: 26. oktober 2008
Interessekonflikter: Ingen
Litteratur
1. Frazier CH. Intrakranial division of the auditory nerve for persistent aural
vertigo. Surg Gynecol Obstet 1912;15:524-9.
2. McKenzie KG, Intracranial division of the vestibular portion of the auditory
nerve for Ménière’s disease. Can Med Assoc J 1936;34;1127-52.
3. Thomsen J, Berner B, Tos M. Vestibular neurectomy. Auris Nasus Larynx
2000;27:297-301.
4. Thomsen J, Tos M. Surgery of acustic neurinomas. Preliminary experience
with translabyrinthine approach. Acta Neurol Scand 1977;56:277-90.
5. Committee on Hearing and Equilibrium guidelines for the diagnosis and
evaluation of therapy in Ménière’s disease. Otolaryngol Head Neck Surg
1995;113:181-5.
6. Glasscock ME 3rd, Thedinger DA, Cueva RA et al. An analysis of the retrolaby-
rinthine vs the retrosigmoid vestibular nerve section. Otolaryngol Head Neck
Surg 1991;104:88-95.
7. Magnan J, Bremond G, Chays A et al. Vestibular neurectomy by rectrosigmoid
approach: technique, indications and results. Am J Otol 1991;12:101-4.
8. Thomsen J, Stougaard M, Becker B et al. Middle fossa approach in vestibular
schwannoma surgery. Postoperative hearing preservation and EEG changes.
Acta Otolaryngol 2000;120:517-22.
9. Pappas DG Jr, Pappas DG Sr. Vestibular nerve section: long-term follow-up.
Laryngoscope 1997;107:1203-9.
10. Gavilán J, Gavilán C. Middle fossa vestibular neurectomy. Long-term results.
Arch Otolaryngol 1984;110:785-7.
11. Silverstein H, Jackson LE. Vestibular nerve section. Otolaryngol Clin North
Am 2002;35:655-73.
12. Perez R, Ducati A, Garbossa D et al. Retrosigmoid approach for vestibular
neurectomy in Ménière's disease. Acta Neurokir (Wien) 2005;147:401-4.
13. Tewary AK, Riley NR, Kerr A. Long-term results of vestibular nerve section.
J Laryngol Otol 1998;112:1150-3.
14. Wazen JJ, Spitzer J Kasper C et al. Long-term hearing results following ves-
tibular surgery in Ménière’s disease. Laryngoscope 1998;108:1470-3.
15. Teufert KB, Berliner KI, De la Cruz A. Persistant dizziness after surgical treat-
ment of vertigo: An exploratory study og prognostic factors. Otol Neurotol
2007;28:1056-62.
16. Hillier SL, Hollohan V. Vestibular rehabilitation for unilateral peripheral ves-
tibular dysfunction. Cochrane Database of Systematic Reviews 2007;(4):
CD005397.
17. Hillman TA, Chen, Arriaga MA. Vestibular nerve section versus intratympanic
gentamicin for Ménière’s disease. Laryngoscope 2004;114:216-22.
18. House JW, Doherty JK, Fisher LM et al. Ménière's disease: prevalence of con-
tralateral ear involvement. Otol Neurotol 2006;27:355-61.
Mini-clinical evaluation exercise til evaluering
af kommunikation og samarbejde i ambulatoriet
Originalartikel
Læge Jesper Grau Eriksen, sygeplejerske Dorit Simonsen,
læge Lars Bastholt, læge Knut Aspegren, læge Claus Vinther,
sygeplejerske Kirsten Kruse & læge Troels Kodal
Odense Universitetshospital, Onkologisk Afdeling R,
Sydvestjysk Sygehus i Esbjerg, Parenkymkirurgisk Afdeling, og
Region Syd, Den Lægelige Videreuddannelse
Resume
Introduktion: I speciallægeuddannelsen er der fokus på svært
målbare kompetencer som kommunikation og samarbejde. Mini-
Clinical Evaluation Exercise (mini-CEX) er standardiseret direkte
observation ved brug af et observationsskema, og vi ville teste om
mini-CEX: 1) Var anvendeligt til at evaluere yngre lægers kompe-
tencer i patientkontakt og 2) Var egnet til at give reproducerbare
informationer.
Materiale og metoder: 21 yngre læger blev evalueret med mini-
CEX af trænede observatører. I alt 17 læger havde mere end to ob-
servationer med kort interval. Disse blev brugt til at vurdere repro-
ducerbarheden af data. Læger og sygeplejersker udfyldte også et
spørgeskema vedrørende tilfredsheden med at evaluere med mini-
CEX.
Resultater: Observationerne tog 20 minutter (10-60). Feedback
blev foretaget lige efter og tog 15 minutter (5-60). Tiden til feed-
back blev halveret ved næstfølgende evalueringer af samme læge.
Der var stor intern konsistens i data for såvel læger som observatø-
rer. Der var ingen klinisk signifikant forskel mellem lægens egen-
vurdering og observatørens vurdering, hvilket også var tilfældet
mellem ambulatoriepersonalets vurdering og observatørens vurde-
ring. Der var fra lægernes side stor tilfredshed med anvendelsen af
mini-CEX.
Konklusion: Mini-CEX er et effektivt og accepteret formativt evalu-
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eringsredskab til at vurdere lægers evner til kommunikation og
samarbejde med personale og patient i ambulatoriet.
I den nye speciallægeuddannelse er der via målbeskrivelserne
øget fokus på andre kompetencer end de direkte behand-
lingsrettede kvalifikationer. Disse kompetencer er vanskelige
at vurdere, og derfor er der behov for at afprøve mere struktu-
rerede fremgangsmåder. Til evaluering af den direkte patient-
kontakt er der flere mulige evalueringsredskaber [1]. Optimalt
set bør metoden være enkel og let tilgængelig, reproducerbar
og informativ for såvel den uddannelsessøgende som vejleder.
Mini-clinical evaluation exercise (mini-CEX) blev udviklet i
USA i 1995 for at vurdere kliniske færdigheder hos medicin-
studerende og læger under uddannelse. Mini-CEX er i dag ac-
cepteret af American Board of Internal Medicine [2, 3] og af Royal
College of Physicians i England [4]. Erfaringer har vist, at det ta-
ger 15-20 minutter at udfylde og evaluere med mini-CEX, li-
gesom redskabet er brugbart til evaluering over tid [3]. Ske-
maet er valideret i forhold til andre amerikanske måleredska-
ber [5], og reproducerbarheden er høj ved mange, gentagne
målinger, selv når det sker med forskellige observatører [6].
På Onkologisk Afdeling i Odense og Organkirurgisk Afde-
ling i Esbjerg indgik man i efteråret 2005 et samarbejde med
det formål at teste, om mini-CEX er et redskab, der i praksis
kan anvendes ved evalueringen af uddannelsessøgende lægers
kompetencer i kommunikation og samarbejde, og om redska-
bet er egnet til at give reproducerbare informationer.
Materiale og metoder
Mini-CEX-skemaet kan ses i pdf-versionen af artiklen på
www.ugeskrift.dk. På forsiden af mini-CEX-skemaet er der
trykt en vejledning, og der er plads til at angive, hvor evalue-
ringen har fundet sted samt til at gradere kompleksiteten af
konsultationen. På bagsiden kan følgende vurderes på en 9-
punkts skala: Anamnese og objektiv undersøgelse, empati og
professionel adfærd, klinisk dømmekraft og vurdering, pa-
tientvejledning og rådgivning, organisation og samarbejde,
samt den generelle kliniske kompetence. Endelig er der plads
til at angive forbrugt tid samt en overordnet vurdering af læ-
gen samt dennes tilfredshed med evalueringen. Et til tre point
er under det forventede niveau, 4-6 er det forventede niveau,
mens 7-9 point betegnes som over det forventede niveau.
Derved sikres, at lægen vurderes i forhold til det forventede
niveau på undersøgelsestidspunktet. Skemaet er udarbejdet
ud fra tilsvarende amerikanske skemaer men tilpasset danske
forhold og specialet klinisk onkologi. En regelret validering
har således ikke fundet sted, men skemaerne har været afprø-
vet over en periode på et år for at samle erfaringer før projekt-
periodens start.
Mini-CEX-evalueringerne foregik i ambulatoriet på Organ-
kirurgisk Afdeling i Esbjerg og på Onkologisk Afdeling i
Odense. Tilstede var observatøren, den uddannelsessøgende
samt den sygeplejerske, der bistod ved konsultationen. Obser-
vation og feedback foregik ens på de to afdelinger med den
ene forskel, at observatøren i Odense ikke deltog aktivt i kon-
sultationen, mens observatøren i Esbjerg også fungerede som
sygeplejerske. Alle patienter blev informeret om tilstedeværel-
sen af observatøren og fik mulighed for at afstå fra deltagelse.
Under konsultationen vurderede observatøren samtalen
og udfyldte mini-CEX-skemaet. Efterfølgende udfyldte også
lægen skemaet. Skemaerne blev umiddelbart efter gennem-
gået punkt for punkt i en samtale mellem den uddannelsessø-
gende og observatøren (feedback).
Lægen og ambulatoriesygeplejersken fik også udleveret
korte spørgeskemaer, som omhandlede lægens og sygeplejer-
skens oplevelse af evaluering med Mini-CEX til vurdering af
selve evalueringsprocessen. Dette skema skulle udfyldes efter
konsultationen og blev afleveret til observatøren inden for få
dage efter observationen. Alle udtalelser fra spørgeskemaerne
blev kategoriseret og optalt af en af forfatterne (KA) sammen
med en uafhængig forsker.
Fra 1/10 2005 til 30/9 2006 indgik i alt 21 uddannelsessø-
gende læger i projektet. Lægerne var alle ansat på afdelin-
gerne ved projektets start eller blev ansat under forløbet. Del-
tagelse var frivillig. Til denne del af undersøgelsen blev alle
superviseret en gang og 17 mindst to gange med under to
ugers interval – i alt 47 observationer. Femten læger fra
Odense og seks fra Esbjerg.
Statistik
Data blev bearbejdet ved brug af deskriptiv statistik, nonpara-
metriske test og Fishers eksakte test. En tosidet p-værdi < 0,05
blev betragtet som signifikant. Chronbachs alfa blev brugt til
at beregne bedømmelsernes interne konsistens. En værdi over
0,7 blev betragtet som udtryk for acceptabel reliabilitet [7].
Den »rå« alfa er et udtryk for, hvor stærkt variable er relateret
og jo højere værdi jo mere konsistent test, mens den standar-
diserede alfa er et udtryk for kovariansen mellem distributio-
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nen af to variable, som det er muligt at vurdere, da der arbej-
des med sammenlignelige skalaer. Data blev bearbejdet i sam-
arbejde med en ekstern statistiker.
Resultater
Alle evalueringer foregik i ambulatoriet, og der var tale om
forskellige typer konsultationer (forundersøgelse, informa-
tion om behandling, kontrol, efterbehandling m.v.). Lægerne
beskrev kompleksiteten af konsultationen som »let« i 17 af 46
tilfælde (37%), »moderat« i 52% (24/46), mens kun fem kon-
frontationer (11%) blev betegnet som »svære«. I et tilfælde var
kompleksiteten ikke scoret. Der var intet mønster, i hvordan
konsultationerne blev scoret af den enkelte læge, ligesom for-
delingen i lette og svære konsultationer var ensartet fordelt
mellem første- og andengangskonsultationer. I lighed med er-
faringer fra andre [3] var der en ikkesignifikant tendens til at
læger med svære konsultationer scorede højere end læger, der
blev vurderet på lettere konsultationer. Der var ingen signifi-
kant forskel mellem lægens og observatørens vurdering af
konsultationens kompleksitet. Den interne konsistens vurde-
ret med Chronbachs alfa er vist i Tabel 1.
Observationstiden tog mediant 20 minutter med variation
fra ti til 60 minutter. Der var ingen forskel mellem observa-
tionstiden ved første og efterfølgende konsultationer. Feed-
back på observationen blev foretaget umiddelbart efter og tog
for alle observationer mediant 15 minutter (5-60 minutter).
Første gang den uddannelsessøgende fik feedback, tog det
mediant 20 minutter (7-60 minutter) mod 10 minutter (5-20
minutter) ved efterfølgende observationer. Der var en ikkesig-
nifikant tendens til, at konsultationerne tog lidt længere tid på
Onkologisk Afdeling end på Kirurgisk Afdeling, mens der
ikke var reel forskel på feedbacktiden.
Blandt de 47 observationer var der ingen signifikante for-
skelle på, hvordan lægen og observatøren scorede kategori-
erne anamneseoptagelse, empati og professionel adfærd, klinisk
dømmekraft og vurdering, patientvejledning og rådgivning samt ge-
nerel klinisk kompetence, mens der i kategorierne objektiv under-
søgelse (p = 0,02) og organisation og samarbejde (p = 0,01) var
signifikant forskel på observatørens og lægens scoring, idet
observatørerne vurderede lægerne lidt bedre, end lægerne
vurderede sig selv. Denne forskel var dog baseret på en forskel
på mindre end et halvt point på den anvendte 9-punkts skala,
hvorfor den ikke kan betragtes som klinisk signifikant.
For 22 observationer var det muligt at undersøge forskelle
mellem ambulatoriesygeplejerskens og observatørens scoring
af lægen. På alle kategorier undtagen organisation og samar-
bejde (p = 0,03) var der ingen signifikant forskel i scoringerne.
Den signifikante forskel på organisation og samarbejde var
igen baseret på, at sygeplejerskerne vurderede lægerne lidt
bedre, end lægerne vurderede sig selv (mindre end et halvt
point og dermed ikke klinisk signifikant).
De efterfølgende spørgeskemaer om selve processen blev
besvaret ved 81% af observationerne for lægernes vedkom-
mende, mens ambulatoriesygeplejerskerne besvarede skemaet
ved 80% af observationerne. Eksempler på spørgsmål og svar
er præsenteret nedenfor.
Uddannelsessøgende læger
Lægerne blev spurgt: »Hvordan var det at deltage i undersø-
gelsen?« Ud af 45 kommentarer handlede 31 (69%) om vær-
dien af at få feedback: »Godt at få kommentarer til min sam-
tale og ideer til forbedringer«. En læge skriver: »... tænker ikke
over, at der observeres under konsultationen og rart med
feedback efterfølgende«. En anden læge er mere ambivalent:
»Man føler sig noget eksponeret, men rart at få konstruktiv
kritik«. En tredje mente: »God idé, at det er en sygeplejerske.
Det fjerner lidt af det faglige pres«.
»Når du fik feedback, mener du, at du blev bedømt retfær-
digt? Ja/Nej, fordi:« blev besvaret af samtlige læger med »Ja«,
og 26 havde yderligere kommentarer. Metodens pålidelighed
var emnet i 35% af tilfældene: »Det var professionelt«. »Uvildig
bedømmelse, god tid til at tale om eventuelle forbedringer«.
Til det positive udfald bidrog sandsynligvis, at flere af læ-
gerne, var enige med bedømmerne. »Deres evaluering passede
med min«. I alt 54% af kommentarerne handlede om værdien
af feedback: »Blev gjort opmærksom på ting jeg ikke var be-
vidst om, som jeg forhåbentligt kan huske at bruge«.
»Har du haft nytte af den feedback, du fik?«. Alle lægerne
besvarede dette spørgsmål med »Ja«. Der var 23 kommentarer,
hvoraf 76% handlede om, hvor lærerigt det var at deltage og
værdien af feedback. »Ja meget. Fået redskaber til at komme
lidt videre i meget besværlige samtaler«. »Ja, jeg oplever at få
konstruktiv kritik, som jeg kan bruge i fremtidige situationer«.
Evaluerende ambulatoriesygeplejersker
»Var det svært at bedømme lægen? Hvis ja, hvorfor?« blev i de
fleste tilfælde besvaret med »Nej«. Men fra de 45 observationer
var der fem tilfælde, hvor spørgsmålet blev besvaret med »Ja«.
Motiveringen var enten, at patienten ikke var egnet til seancen,
eller at sygeplejersken ikke følte sig fortrolig med metoden.
Tabel 1. Intern konsistens beregnet ved Chronbachs
alfa. Ambulatorie- Sygeplejerske- Lægernes egen-
sygeplejersker, Odense observatører (n=2) evaluering (n=21)
Antal observationer . . . . . . . . . . . . . . 22 47 47
Cronbachs »rå« alfa . . . . . . . . . . . . . 0,64 0,86 0,77
Cronbachs alfa - standardiseret . . . . . 0,74 0,88 0,80
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Andet spørgsmål var: »Var det svært at forstå målene i
mini-CEX-skemaet? Hvis ja, angiv hvilket, og kommenter«.
Fra de 36 besvarelser fremgår det, at der stort set ikke var no-
gen problemer med forståelsen, men en sygeplejerske skrev
»... jeg havde ikke så meget tid til at sætte mig ind i det«.
Til spørgsmålet »Kan du tænke dig at denne måde at eva-
luere uddannelsessøgende læger på kan blive rutine frem-
over?«. svarede alle »Ja« og kommenterede værdien af meto-
den: »På denne måde bliver det legalt for sygeplejersker at
vejlede/evaluere yngre læger«. »Det giver anledning til en
tværfaglig samtale – og mulighed for refleksion!«.
Diskussion
Vi ønskede med dette projekt at vurdere, om mini-CEX er et
brugbart værktøj til vurdering af kommunikative og samar-
bejdsmæssige færdigheder; to af de syv roller, som den ud-
dannelsessøgende læge skal mestre.
De største bekymringer ved det valgte design var, at der
deltog flere observatører, og at undersøgelsen var udført på to
principielt forskellige afdelinger. For at minimere forskellene
afdelingerne imellem bistod observatøren i Odense i oplærin-
gen af observatøren i Esbjerg. Observatøren i Esbjerg skulle
tillige udføre sygeplejeopgaver, men det influerede dog ikke
på, at hun var til stede under hele samtalen med mulighed for
at fokusere alene på denne. At der var tale om to meget for-
skellige afdelinger, afspejledes også af tendensen til længere
konsultationer i onkologisk regi sammenlignet med kirurgisk
regi. De variable, der blev undersøgt i denne mini-CEX (med
undtagelse af objektiv undersøgelse), er dog alment relevante
for kommunikation, uanset hvilket speciale der er tale om.
Der var en stor intern konsistens i data inden for såvel ob-
servatørernes som lægernes egenvurdering vurderet ved både
»rå« og standardiseret Chronbachs alfa. Dette tyder på stor re-
producerbarhed i evalueringerne både inden for den enkelte
variable og også mellem de forskellige variable i mini-CEX.
For ambulatoriesygeplejerskerne i Odense lå Chronbachs »rå«
alfa under 0,7, hvilket formentlig skyldes, at sygeplejerskerne
ikke var trænede i denne form for observation og evaluering
af uddannelsessøgende læger.
Reproducerbarheden blev underbygget af en stor overens-
stemmelse mellem observatørernes og lægernes scoringer in-
den for den enkelte observation, hvilket tyder på en stor enig-
hed om, hvordan konsultationen forløb. Overraskende var det
dog, at der i Odense-data, hvor også den tilstedeværende am-
bulatoriesygeplejerske evaluerede den uddannelsessøgende,
var en stor overensstemmelse mellem ambulatoriesygeplejer-
skens og observatørens vurderinger. Dette kunne tyde på, at
det er muligt at træne rutinerede sygeplejersker på relativt kort
tid til at score uddannelsessøgende læger med samme præci-
sion som trænede observatører. Vores data kan dog ikke un-
derbygge den hypotese, ligesom det ikke er muligt at sige no-
get om forskellen i kvaliteten af den efterfølgende rådgivning.
Den tid, som mini-CEX tager fra det daglige arbejde, ligger
i den efterfølgende evaluering. Erfaringer fra USA har påpe-
get, at evaluering med mini-CEX tager 15-20 minutter [3].
Dette var i overensstemmelse med vores data, der for alle ob-
servationer tog 15 minutter omend med stor variation. Inte-
ressant var det dog, at den mediane tid til feedback var 20 mi-
nutter ved første evaluering mod mediant 10 minutter ved ef-
terfølgende evalueringer. Dette tyder på, at mini-CEX er en
evalueringsmetode, som kan indpasses i ambulatoriepro-
grammet – specielt ved gentagende evalueringer.
Da projektet foregik over en relativ kort periode for den
enkelte læge, var det ikke muligt at sige noget om progressio-
nen i evnen til kommunikation og samarbejde. Nyere data ty-
der på, at der skal mere end ti observationer til, for at metoden
kan bruges summativt [8], men dette forhindrer ikke at den
bruges formativt. Alene det, at skemaet skal udfyldes og disku-
teres af såvel lægen som observatøren, sikrer, at den uddannel-
sessøgende får vurderet sine evner til at sikre et optimalt møde
mellem behandler og patient [9] samt får feedback baseret på
observerede handlinger. At metoden er egnet til dette, under-
støttes af de kvalitative data, der peger på høj accept af mini-
CEX både hos lægerne og observatørerne. Alle deltagere
mente, at metoden kan blive standard i uddannelsesforløbet
for læger. Lægerne fandt, at den systematiske feedback og læ-
ring fra mini-CEX var stor, ligesom sygeplejerskerne angav, at
metoden gør det legitimt for dem at vejlede læger.
SummaryJesper Grau Eriksen, Dorit Simonsen, Lars Bastholt, Knut Aspegren, Claus Vinther, Kirsten Kruse & Troels Kodal:Mini Clinical Evaluation Exercise as evaluation tool of communicative and cooperative skills in the outpatient clinicUgeskr Læger 2009;171:xxxxIntroduc-
tion: In the revised Danish medical specialist training increased focus has been placed on competences which are hard to evaluate such as communication skills. Mini- CEX seems promising as an evaluation tool. Our aim was to test: 1) whether mini-CEX was useable in the evaluation of commu-
nicative and cooperative skills and 2) whether mini-CEX would provide reproducible data.
Material and methods: Twenty-one residents were evaluated by mini-CEX by trained o bservers. Seventeen residents had at least two observations within a short period of time and these data were used to estimate the mini-CEX reproduci bility. In addition to the residents, the nurses who as-
sisted them in the outpatient clinic answered a questionnaire regarding the mini-CEX satisfaction.
Results: Observations had a median duration of 20 minutes (10-60 minutes) and the overall m edian duration of feedback was 15 minutes (5- 60 minutes). Time used for feedback was halved from the first to the following feedback sessions. No significant clinical differences were observed between
the scorings performed by the residents themselves and the observers, or the nurses of the outpatient clinic and the observers. In general, the residents were satisfied with the mini-CEX evaluations.
Conclusion: The mini-CEX is a promising tool for the evaluation of communicative and cooperative skills.
Korrespondance: Jesper Grau Eriksen, Odense Universitetshospital,
Onkologisk Afdeling R, DK-5000 Odense C.
E-mail: jesper@oncology.dk
Antaget: 22. oktober 2008
Interessekonflikter: Ingen
Taksigelser: Tak til professor, dr.phil. Peter Allerup, Danmarks Pædagogiske Uni-
versitet, for hjælp til den statistiske bearbejdning af data.
Litteratur
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2. Norcini JJ, Blank LL, Arnold GK et al. The Mini-CEX (Clinical Evaluation Exer-
cise). A preliminary investigation. Ann Intern Med 1995;123:795-9.
3. Norcini JJ, Blak LL, Duffy D et al. The Mini-CEX: a method for assessing clin-
ical skills. Ann Intern Med 2003;138:476-81.
4. Wragg A, Wade W, Fuller G et al. Assessing the performance of specialist regis-
trars. Clin Med 2003;3:131-4.
5. Durning SJ, Cation LJ, Markert RJ et al. Assessing the reliability and validity of
the Mini-Clinical Evaluation Exercise for internal medicine residency training.
Acad Med 2002;77:900-4.
6. Norcini JJ, Blank LL, Arnold GK et al. Examiner differences in the Mini-CEX.
Adv Health Sci Educ Theory Pract 1996;2:27-33.
7. Yu CH. An introduction to computing and interpreting Chronbach Coefficient
Alpha in SAS. SUGI 2001;246-26:1-6. www2.sas.com/proceedings/sugi26/
p246-26.pdf (1. marts 2008).
8. Alves de Lima A, Barrero C, Baratta S et al. Validity, reliability, feasibility and
satisfaction of the Mini-Clinical Evaluation Exercise (Mini-CEX) for cardiology
residency training. Med Teach 2007;29:785-90.
9. Hauer KE. Enhancing feedback to students using Mini-CEX (Clinical Evalu-
ation Exercise). Academic Med 2000;75:524.
1
Mini-CEX kan bruges til evaluere alle situationer, hvor den uddannelsessøgende interagerer med patienter eller andre
personalegrupper. Princippet bygger på direkte observation af den uddannelsessøgende, dvs, at vejleder eller kolleger
observerer den uddannelsessøgende udføre forskellige handlinger og samtidig eller umiddelbart derefter udfylder skemaet
og giver den uddannelsessøgende feedback på handlingen.
Det aktuelle skema anvendes til vurdering af kontakt mellem uddannelsessøgende læge og patienter, og det åbner mulighed
for fokus på forskellige punkter i denne kontakt.
Nedenfor er anført stikord, som beskriver, hvad man har tænkt sig skulle vurderes under de enkelte punkter.
• Anamnese: Inviterer patienten til at fortælle; effektiv og relevant brug af spørgsmål til at indsamle præcis,
relevant og nødvendig information. Passende brug af non-verbal kommunikation.
• Objektiv undersøgelse: Systematisk (logisk og relevant), balance mellem screening og diagnostiske us.,
informerer patienten, udfører us. med hensyntagen til patientens komfort.
• Empati og professionel adfærd: Viser respekt og opnår god kontakt, fortrolighed, reagerer passende på
patientens følelser, ydmyg, engageret.
• Klinisk dømmekraft og vurdering: Selektivt ordinerer/udfører diagnostiske tests, overvejer relevans,
ulemper/risici og fordele.
• Patientvejledning og rådgivning: Forklarer rationale bag undersøgelser/behandling så patienten kan tage
stilling, samtykke, vejleder/rådgiver/uddanner omkring undersøgelse/behandling.
• Organisation og samarbejde: Prioriterer, modtager/søger og giver information, punktlig, pligtopfyldende.
• Generel klinisk kompetence: Syntetiserer klinisk problemstilling, klinisk problemløsning, effektiv og virksom..
Uddannelseslæge: Dato:
Bedømt af (læge):
Sygehus/Hospital: Afdeling:
Lokaliteter: Ambulatorium
Kemodagafsnit Strålebehandling Sengeafsnit
Alder: Mand: Kvinde:
Patient: Patientproblem/diagnose:
Anamnese: Diagnostik:
Fokus: Objektiv undersøgelse: Information:
Kompleksitet: Let: Moderat: Svær
Anamnese: Diagnostik:
Fokus: Objektiv undersøgelse: Information:
Kompleksitet: Let: Moderat: Svær
Med forventet niveau tænkes på det faglige niveau man vil forvente af en yngre læge der har gennemført en
introduktionsstilling i onkologi.
2
Anamneseoptagelse (ikke observeret: )
1 2 3 4 5 6 7 8 9
Under forventet niveau Forventet niveau Over forventet niveau
Objektiv undersøgelse (ikke observeret: )
1 2 3 4 5 6 7 8 9
Under forventet niveau Forventet niveau Over forventet niveau
Empati og professional adfærd (ikke observeret: )
1 2 3 4 5 6 7 8 9
Under forventet niveau Forventet niveau Over forventet niveau
Klinisk dømmekraft og vurdering (ikke observeret: )
1 2 3 4 5 6 7 8 9
Under forventet niveau Forventet niveau Over forventet niveau
Patientvejledning og rådgivning (ikke observeret: )
1 2 3 4 5 6 7 8 9
Under forventet niveau Forventet niveau Over forventet niveau
Organisation og samarbejde (ikke observeret: )
1 2 3 4 5 6 7 8 9
Under forventet niveau Forventet niveau Over forventet niveau
Generel klinisk kompetence (ikke observeret: )
1 2 3 4 5 6 7 8 9
Under forventet niveau Forventet niveau Over forventet niveau
Mini-CEX forbrugt tid: Observation: Min. Feedback: Min.
Tilfredshed: Bedømmers tilfredshed med Mini-CEX:
Lav 1 2 3 4 5 6 7 8 9 Høj
Uddannelsessøgendes tilfredshed med Mini-CEX:
Lav 1 2 3 4 5 6 7 8 9 Høj
... More than half of the studies (11 out of 18) calculated a coefficient of around or higher than 0.9. While an acceptable value is considered above 0.7, two studies calculated a coefficient of less than 0.7 (0.64 in Eriksen et al. 2009 and0.58 in Paravicini andPeterson 2015). We could not find any special characteristics in these studies except one. ...
... In general, results of the qualitative studies showed that mini-CEX was considered a very useful assessment instrument and a useful teaching tool (Alves de Lima et al. 2010), and overall satisfaction was high among both trainees and assessors (Brazil et al. 2012). They believed that it is a valuable assessment strategy and can be an adjunct to in-training assessment (Alves de Lima et al. 2005;Brazil et al. 2012;Gupta et al. 2017;Joshi et al. 2017), liked the realism (Alves de Lima et al. 2010), felt quite comfortable with it (Alves de Lima et al. 2005), believed they were judged fairly (Eriksen et al. 2009;Hill et al. 2009), and preferred it over long case as a summative exam (Hill and Kendall 2007). On the other hand, some studies have shed light on the drawbacks of mini-CEX. ...
... Pernar showed that the use of the mini-CEX resulted in a twice as many qualitative feedback comments compared to the global assessment (Pernar et al. 2011). Many studies found that a kind of feedback had been provided in the majority of mini-CEX encounters (96% in Eriksen et al. 2009;85.3% in Lin et al. 2012;74.9% in Liao et al. 2013;and 92.6% in Chang et al. 2017), but the accuracy and usefulness of the feedback provided was questioned by many studies. One study, for instance, found that in 22.7% of cases the positive aspects of performance were not identified and in 28.2% of cases no suggestion for development was made; and still in 49.7% of cases no plan of action had been developed (Fernando et al. 2008). ...
The utility of mini-Clinical Evaluation Exercise in undergraduate and postgraduate medical education: A BEME review: BEME Guide No. 59
Article
Full-text available
Background: This BEME review aims at exploring, analyzing, and synthesizing the evidence considering the utility of the mini-CEX for assessing undergraduate and postgraduate medical trainees, specifically as it relates to reliability, validity, educational impact, acceptability, and cost. Methods: This registered BEME review applied a systematic search strategy in seven databases to identify studies on validity, reliability, educational impact, acceptability, or cost of the mini-CEX. Data extraction and quality assessment were carried out by two authors. Discrepancies were resolved by a third reviewer. Descriptive synthesis was mainly used to address the review questions. A meta-analysis was performed for Cronbach’s alpha. Results: Fifty-eight papers were included. Only two studies evaluated all five utility criteria. Forty-seven (81%) of the included studies met seven or more of the quality criteria. Cronbach’s alpha ranged from 0.58 to 0.97 (weighted mean = 0.90). Reported G coefficients, Standard error of measurement, and confidence interval were diverse and varied based on the number of encounters and the nested or crossed design of the study. The calculated number of encounters needed for a desirable G coefficient also varied greatly. Content coverage was reported satisfactory in several studies. Mini-CEX discriminated between various levels of competency. Factor analyses revealed a single dimension. The six competencies showed high levels of correlation with statistical significance with the overall competence. Moderate to high correlations between mini-CEX scores and other clinical exams were reported. The mini-CEX improved students’ performance in other examinations. By providing a framework for structured observation and feedback, the mini-CEX exerts a favorable educational impact. Included studies revealed that feedback was provided in most encounters but its quality was questionable. The completion rates were generally above 50%. Feasibility and high satisfaction were reported. Conclusion: The mini-CEX has reasonable validity, reliability, and educational impact. Acceptability and feasibility should be interpreted given the required number of encounters.
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... Even though there are many studies where mini-CEX is being used for work-place assessment of post-graduate residents, [10,11] there are hardly any studies using mini-CEX for assessment of the communication skills of interns. [12,13] 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. [10] There were significant differences between male and female interns in the various skills of mini-CEX. ...
Assessment of communication skills of interns in pediatrics using mini-clinical evaluation exercise
Article
Full-text available
  • Jan 2021
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.
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... 6,17 Sin embargo, se debería poner más énfasis en el tiempo dedicado a la devolución dada la importancia que tiene. En este sentido el tiempo de 8 minutos parece insuficiente, comparado con los 15 minutos del estudio de Eriksen et al., o los 17 minutos reportados por Alves de Lima, et al. 18,8 El puntaje de competencia global medio para los residentes de primer año fue 6,57, para los de segundo año 6,87 y para los de tercer año 7,3; observándose una diferencia estadísticamente significativa, de modo que el Mini-CEX permitió discriminar entre los diferentes niveles de competencia global entre los residentes de los diferentes años, lo que coincide con otros estudios y reafirma la validez del instrumento. [5][6][7][8] Wiles et al., evaluaron a médicos en formación en neurología, en la Universidad de Cardiff en el Reino Unido, encontrando que el puntaje de competencia global y de habilidades de comunicación aumentaron con significancia estadística con cada año de entrenamiento. ...
Evaluación de las competencias clínicas en una residencia de pediatría con el Mini-CEX (Mini-Clinical Evaluation Exercise)
Article
  • Aug 2011
Objetivo. Evaluar las competencias clínicas de los residentes de pediatría con la implementación del Mini-CEX, determinando su validez, confabilidad, factibilidad y la satisfacción de docentes y de residentes.Métodos. Participaron 14 docentes y 8 residentes. Se utilizó el Mini-CEX, método basado en la observación directa del desempeño del residente durante su práctica diaria, por parte de un docente.Resultados. Se realizaron 181 observaciones, media de 12,92 observaciones por cada docente. Cada docente evaluó a 5,78 residentes. Hubo una media de 22,6 evaluaciones por residente. Las observaciones se realizaron en consultorios externos 38,7%, internación pediátrica 19,3%, neonatología 17,1%, sala de recepción del recién nacido 14,4% y en internación conjunta 10,5%. Los puntajes promedios fueron: profesionalismo 7,15; entrevista 6,64; examen clínico 6,67; criterio clínico 6,70; asesoramiento 6,79 y organización 6,73. Los puntajes de competencia global variaron de acuerdo a los años de experiencia. Primer año 6,57; segundo 6,87 y tercero 7,3; p= 0,004. El puntaje de satisfacción de los docentes fue 7,89 y de los residentes 7,74. El tiempo de duración de las observaciones fue de 28,35 minutos. El coeficiente alfa de Cronbach fue de 0,97 lo que indica elevada confabilidad del método de evaluación. El ANOVA de puntajes de competencia global de todos los docentes mostró diferencias estadísticamente signifcativas, p <0,0001. Conclusiones. La implementación del Mini-CEX fue factible, bien aceptada por residentes y docentes, permitió valorar los diferentes niveles de desempeño de los residentes.
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Uso do Mini-Clinical Evaluation Exercise (Mini-CEX) na residência médica: uma revisão de escopo
Article
Full-text available
  • Mar 2024
Resumo Introdução: Com a evolução do ensino médico para currículos baseados em competências, fez-se necessária uma readequação dos currículos e dos métodos de avaliação, com maior enfoque sobre o cenário de prática profissional e, portanto, na utilização de ferramentas como o Mini-Clinical Evaluation Exercise (Mini-CEX). Objetivo: Este estudo teve como objetivo avaliar o uso da estratégia Mini-CEX como método de avaliação nos programas de residência médica. Método: Trata-se de uma revisão de escopo, cuja estratégia de busca realizada no PubMed resultou em 578 artigos. Após aplicar a metodologia do Instituto Joanna Briggs para inclusão e exclusão, foram selecionados 24 estudos transversais. Resultado: Selecionaram-se artigos referentes a estudos realizados entre 1995 e 2021, em diversos continentes, diferentes programas de residência, e cenários ambulatorial, internação e de emergência. O Mini-CEX mostrou-se aplicável no contexto da residência médica, pois trata-se de uma avaliação observacional direta do atendimento realizado pelo médico residente nos diversos cenários de atuação, como ambulatórios, internações e emergências. Trata-se de uma avaliação com tempo de observação variando de dez a 40 minutos e que permite a abordagem de vários aspectos do atendimento médico, como anamnese, exame físico, raciocínio clínico e aconselhamento, além de possibilitar a realização de um feedback sobre o desempenho dos residentes. Conclusão: O Mini-CEX constitui uma ferramenta de fácil aplicabilidade e promove alto grau de satisfação dos envolvidos, podendo ser utilizada de forma rotineira nos programas de residência médica.
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In-training assessment: The Danish experience
Article
  • Apr 2011
Editors' introduction Following a report from the Danish National Committee on Postgraduate Education, Denmark was one of the first developed countries to embark on a journey of developing competency-based training in postgraduate medical education. Traditionally there have been no formal summative or formative assessments in postgraduate medical education in Denmark, with the exception of the appraisal between trainees and their tutors. In this chapter, Ringsted gives a cross-specialty account of anaesthesia and internal medicine in child and adolescent psychiatry, detailing how significant centralized efforts were made across these three specialties to adopt an outcome-based training model, structured on the CanMEDS framework. This included validation of the Canadian framework within the Danish context and the development of tailored outcomes and in-training assessments based on individual specialties, characteristics and tasks. Finally, Ringsted describes the generic lessons learnt from the implementation and evaluation of this outcome-based model in Denmark. Introduction In-training assessment (ITA) in postgraduate medical education was introduced in Denmark in 2001, after a report from a Danish National Committee of Postgraduate Education, which recommended a number of innovations regarding structure, process and content of the training, including the introduction of outcome-based education and ITA (Ministry of Health, 2000). Following this report, a reform of postgraduate education was initiated in 2003. Until then, there had been no assessment of postgraduate trainees in Denmark, apart from regular appraisal meetings between trainees and their tutors.
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Assessment of clinical competence in a pediatric residency with the Mini-Clinical Evaluation Exercise (Mini-CEX)
Article
  • Aug 2011
Assess the clinical competence of pediatric residents with the implementation of Mini-Clinical Evaluation Exercise (Mini-CEX), determining its validity, reliability, feasibility and satisfaction of examiners and residents. 14 examiners and 8 residents of pediatrics took part. The Mini-CEX, a method based on direct observation of residents during their daily training, was used. A nine-point rating scale was used in order to evaluate their skills regarding medical interviewing, physical examination, professionalism, clinical judgment, counselling, organization, overall competence and satisfaction with the method. 181 observations were made, an average of 12.92 observations per examiner (range-2-39). Each examiner assessed 5.78 residents, (range 2-8). There was an average of 22.6 assessments per resident, range (18-30). The observations took place in outpatient clinic 38.7%, pediatric inpatient unit 19.3%, neonatal intensive care unit 17.1%, neonatal reception unit 14.4% and rooming-in 10.5%. The mean scores were: professionalism 7.15; interviewing 6.64; physical examination 6.67; clinical judgment 6.70; counselling 6.79 and organization 6.73. The overall competence score varied according to experience levels. Mean scores were: first-year residents 6.57; second-year residents 6.87 and third-year residents 7.3; p= 0.004. The score related to examiners's satisfaction was 7.89 and that of the residents was 7.74. The duration of the observation period was 28.35 minutes. Cronbach alfa coefficient was 0.97 showing the high reliability of the assessment method. The ANOVA score for overall competence of all examiners showed statistically significant differences, p <0.0001 in relation to stricter or more lenient judgment to evaluate skills. The implementation of the Mini-CEX in the Pediatrics Residency was feasible and positively accepted by residents and examiners. It allowed the assessment of different levels of performance among residents according to their experience, in every clinical setting of a pediatrician's practice. The variability criteria among examiners and the lack of constructive criticism are matters to be dealt with in future investigations.
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An introduction to computing and interpreting Cronbach Coefficient Alpha in SAS
Article
Full-text available
In spite of the ease of computation of Cronbach Coefficient Alpha, its misconceptions and mis-applications are still widespread, such as the confusion of consistency and dimensionality, as well as the confusion of raw Alpha and standardized Alpha. To clarify these misconceptions, this paper will illustrate the computation of Cronbach Coefficient Alpha in a step-by-step manner, and also explain the meaning of each component of the SAS output. INTRODUCTION Reliability can be expressed in terms of stability, equivalence, and consistency. Consistency check, which is commonly expressed in the form of Cronbach Coefficient Alpha (Cronbach, 1951), is a popular method. Unlike test-retest for stability and alternate form for equivalence, only a single test is needed for estimating internal consistency. In spite of its ease of computation, misconceptions and mis-applications of Cronbach Coefficient Alpha are widespread. The following problems are frequently observed: 1. Assumptions of Cronbach Alpha are neglected by researchers and as a result over-estimation and under-estimation of reliability are not taken into consideration. 2. Some researchers believe that the standardized Alpha is superior to the raw Alpha because they believe standardization can normalize skewed data. This problem also reflects the confusion of covariance matrix with correlation matrix. 3. Additionally, some people throw out difficult or easy items based on the simple statistics of each item without taking the entire test into account. 4. Further, when a survey or test contains different latent dimensions, some researchers compute the overall Alpha only and jump to the wrong conclusion that the entire test or survey is poorly written. 5. On the other hand, when a high overall Alpha is obtained, many researchers assume a single dimension and do not further investigate whether the test carries subscales. 6. Several researchers use a pretest as the baseline or as a covariate. However, a low Alpha in the pretest may result from random guessing when the subjects have not been exposed to the treatment (e.g. training of the test content). Judging the reliability of the instrument based on the pretest scores is premature. 7. Last but not least, quite a few researchers adopt a validated instrument but skip computing Cronbach Coefficient Alpha with their sample. This practice makes subsequent meta-analysis of mean difference and Alpha impossible. To clarify these misconceptions, this paper will illustrate the computation of Cronbach Coefficient Alpha in a step-by-step manner, and also explain the meaning of each component of the SAS output. WHICH RELIABILITY INFORMATION SHOULD I USE? One could compute Cronbach Coefficient Alpha, Kuder Richardson (KR) Formula, or Spilt-half Reliability Coefficient to examine internal consistency within a single test. Cronbach Alpha is recommended over the other two for the following reasons: 1. Cronbach Alpha can be used for both binary-type and large-scale data. On the other hand, KR can be applied to dichotomously scored data only. 2. Spilt-half can be viewed as a one-test equivalent to alternate form and test-retest, which use two tests. In spilt-half, you treat one single test as two tests by dividing the items into two subsets. Reliability is estimated by computing the correlation between the two subsets. The drawback is that the outcome is affected by how you group the items. Therefore, the reliability coefficient may vary from group to group. On the other hand, Cronbach Alpha is the mean of all possible spilt-half coefficients that are computed by the Rulon method (Crocker & Algina, 1986).
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Retrosigmoid approach for vestibular neurectomy in Meniere’s disease
Article
Full-text available
  • Apr 2005
Background. Vestibular nerve section is considered to be the most effective surgical procedure to control intractable symptoms secondary to Menière’s disease (MD). This study was developed to analyze the adequacy of retrosigmoid vestibular neurectomy in terms of vertigo control, hearing preservation and clinical complications of this procedure. Methods. A retrospective review was carried out on 14 patients affected by definite unilateral MD who underwent vestibular neurectomy via the retrosigmoid approach. Findings. One patient was lost from follow-up; another one had only a short postoperative observation. At follow-up performed on 12 cases, no patients reported any crisis of acute vertigo. Four patients were free from any vestibular symptoms, while 8 reported some slight gait disturbances. Hearing function was preserved in 10 patients and improved in 2. 1 year postoperative vestibular function was absent at the side operated on and unchanged on the other side in all the cases. Conclusions. Vestibular neurectomy via the retrosigmoid approach can be considered a safe and effective procedure in relieving medically refractory vertigo in Menière’s disease, while preserving hearing.
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The Mini-CEX: A Method for Assessing Clinical Skills
Article
  • Mar 2003
Objective: To evaluate the mini-clinical 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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Long-term hearing results following vestibular surgery in Meniere's Disease
Article
  • Oct 1998
  • LARYNGOSCOPE
The purpose of this study is to evaluate the long-term hearing changes following vestibular surgery in patients with Meniere's disease. Study This is a retrospective analysis of patients operated on in a tertiary referral center setting. Preoperative, postoperative, and 3- to 9-year postoperative audiograms were analyzed in two patient groups. Twenty-one patients underwent posterior fossa vestibular neurectomy (VN) and five, mastoid endolymphatic sac decompression and shunt (ELS). All frequencies, four-frequency pure-tone averages (PTAs), spondee thresholds, and speech recognition scores were compared for operated ear against nonoperated ear of VN subjects. The results were subjected to a covariance analysis. VN and ELS patients whose hearing deteriorated from "serviceable" (PTA < or =70 dB hearing level) and speech recognition > or =30%) to nonserviceable status were compared using nonparametric statistics. Progressive hearing loss beyond the rate of change of the normal contralateral ear was evident in all patients. Serviceable hearing dropped from 81% to 43% of patients an average of 4 years following VN. VN patients have significant hearing deterioration over time in the operated ear. This finding suggests that continued postoperative medical management is necessary for patients undergoing VN.
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Surgery of acoustic neuromas. Preliminary experience with a translabyrinthine approach
Article
  • Nov 1977
Inspired by the works of William House, the authors formed an otoneurosurgical team in order to improve the results after surgery for acoustic neuromas. This paper deals with the preliminary results obtained with the translabyrinthine approach in 13 patients with acoustic neuromas. In 9 patients it was possible to remove the tumor totally with this approach, in 4 patients a second suboccipital operation was necessary to secure total removal. One small, 7 medium and 5 large tumors were encountered. The facial nerve was preserved in 83 per cent of the patients. One patient with a large tumor died after the second suboccipital operation. The relation between size of the tumor and the outcome of the operation is stressed, and in order to reduce the number of large tumors it is suggested that all patients with unilateral hearing loss should be suspected of having a neuroma, until the diagnosis has been disproved. It is concluded that the surgery for acoustic neuromas is otologic-neurosurgical teamwork, and that the treatment should be centralized.
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An analysis of the retrolabyrinthine vs. the retrosigmoid vestibular nerve section
Article
  • Feb 1991
Vestibular neurectomy is gaining widespread acceptance as a primary means of controlling medically refractory vertigo. However, debate continues over the adequacy of vestibular neurectomy within the cerebellopontine angle, long-term control, and the most appropriate surgical approach. To address these issues, we retrospectively reviewed 118 patients who underwent vestibular neurectomy between October 1984 and January 1988. Forty-two patients who underwent a retrolabyrinthine approach and 44 patients who underwent a retrosigmoid approach completed a written questionnaire and provided a recent audiogram. According to American Academy of Otolaryngology-Head and Neck Surgery guidelines, complete or substantial vertigo control was achieved and maintained in 95% of patients in both surgical groups. Hearing, tinnitus, and fullness results over the long term are variable. The advantages and disadvantages of the various vestibular neurectomy approaches will be detailed. On review of our results and surgical experience, we now prefer the retrosigmoid approach.
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Vestibular neurotomy by retrosigmoid approach: Technique, indications, and results
Article
  • Apr 1991
  • Am J Otol
During the past 15 years, 96 retrosigmoid vestibular neurotomies have been used in the surgical management of incapacitating Meniere's disease for the control of vertigo and preservation of hearing. This posterior approach of the pontocerebellar angle gives the best view on the acousticofacial nerve bundle, through a 2 x 2 cm suboccipital craniotomy immediately behind the mastoid and sigmoid sinus. Then the vestibular nerve is easily identified, separated from the cochlear nerve and sectioned, the facial nerve not being at risk, as it lies much deeper. Actually, the majority of authors agree that vestibular neurotomy is the most effective surgical treatment in relieving disabling vertigo (96% of cases) with serviceable hearing, but few surgeons know that the retrosigmoid approach is simpler and more reliable than the middle fossa or retrolabyrinthine approaches, with a low incidence of complications. The purpose of this paper is to emphasize the routine use of the retrosigmoid approach.
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Middle Fossa Vestibular Neurectomy: Long-term Results
Article
  • Jan 1985
  • Arch Otolaryngol
• Middle fossa vestibular neurectomy is especially useful for treatment of Meniere's disease. We treated 59 cases of Meniere's disease with this technique and followed them up for at least ten years. Middle fossa vestibular neurectomy was effective against vertigo in Meniere's disease in 100% of the cases with unilateral involvement. Hearing, as well as tinnitus and hyperacusis, showed a clearly favorable evolution after vestibular neurectomy. The excellent long-term effects of this procedure on vertigo and low incidence of complications make middle fossa vestibular neurectomy one of the most effective surgical treatments for Meniere's disease. (Arch Otolaryngol 1984;110:785-787)
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The Mini-CEX (Clinical Evaluation Exercise): A preliminary investigation
Article
  • Dec 1995
To gather preliminary data on the mini-CEX (clinical evaluation exercise), a device for assessing the clinical skills of residents. Evaluation of residents by faculty members using the mini-CEX. 5 internal medicine training programs in Pennsylvania. 388 mini-CEX encounters involving 88 residents and 97 evaluators. A mini-CEX encounter consists of a single faculty member observing a resident while that resident conducts a focused history and physical examination in any of several settings. After asking the resident for a diagnosis and treatment plan, the faculty member rates the resident and provides educational feedback. The encounters are intended to be short (about 20 minutes) and to occur as a routine part of training so that each resident can be evaluated on several occasions by different faculty members. The encounters occurred in both inpatient and ambulatory settings and were longer than anticipated (median duration, 25 minutes). Residents saw either new or follow-up patients who collectively presented with a broad range of clinical problems. The median evaluator assessed two residents and was generally satisfied with the mini-CEX format; residents were even more satisfied with the format. The reproducibility of the mini-CEX is higher than that of the traditional CEX, and its measurement characteristics are similar to those of other test formats, such as standardized patients and standardized oral examinations. The mini-CEX assesses residents in a much broader range of clinical situations than the traditional CEX, has better reproducibility, and offers residents greater opportunity for observation and feedback by more than one faculty member and with more than one patient. On the other hand, the mini-CEX may be more difficult to administer because multiple encounters must be scheduled for each resident. Exclusive use of the mini-CEX also prevents residents from being observed while doing a complete history and physical examination. Given the promising results and measurement characteristics of the mini-CEX, however, the American Board of Internal Medicine encourages the use of this method in conjunction with or as an alternative to the traditional CEX.
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