The major outcome of this study, in which Mini-CEX was used to evaluate the outpatient medical interviewing ability of residents, was that the interviewing ability of students who received Mini-CEX evaluation during training was superior to that of control residents who received training alone. This result attests to the advantage of Mini-CEX in learning the critical skill of interviewing patients in the outpatient setting.
Necessity of introducing Mini-CEX evaluation in general practitioner training has been recognized in recent years. In 2011, the State Council of the People's Republic of China proposed “Opinions on Establishing a General Practitioner System” and established such a system. Clinical medicine is a discipline with strong integration of technical teaching and clinical competency with the ability of a general practitioner to convert knowledge learnt into solving clinical problems. Scientific evaluation methods and evaluation tools are important for examining training outcomes. Most traditional evaluation methods are summative assessments, are outcomes evaluations that are carried out after training has ended, and are post-hoc evaluations. However, evaluation lags for current students and is not targeted for the next cohort of students. Hence, we introduced Mini-CEX evaluation based on our study of advanced teaching models in China and other countries to observe the evaluation results of the experimental group. Others have made observations that agree with ours: Song et al. [5, 13, 14] investigated a formative evaluation in general hospitals and found that the examination results of the experimental group were higher than those of the control group. Shao et al. [15, 16] employed formative evaluation in general medicine teaching to improve teaching quality and the learning outcomes of the students.
The educational value of Mini-CEX has been generally recognized [12, 17, 18]. This study is consistent with that opinion. In the past, learning was teacher-centered, but now it has transformed to being student-centered. Residents spoke highly of Mini-CEX [19]. Residents can find their own shortcomings, so they can carry out targeted learning and exercise [20, 21]. This training model also conforms to the “learning pyramid” and “competency pyramid” theories [20]. This is likely to be the greatest advantage perceived by Chinese trainees. This is because hands-on opportunity is often limited by the strict power distance in social norms as well as the low-trust relationship between Chinese patients and junior doctors [22, 23].
In this study, the scores of the first-year and third-year residents all improved, although the scores of the two resident cohorts were different due to the difference in seniority. Therefore, a stratified analysis was further carried out, and we found that the third-year students had higher scores and made better progress. All participants improved over time, but the improvement was more noticeable in the third-year residents.
Xie et al. [24–26] found that formative evaluation can improve the practical skills of students and help hone the students’ skills and improve the teaching skills of teachers. Formative evaluation can improve teaching quality, promote teacher-student interactions, and improve clinical practice teaching, which indirectly promotes “teaching and learning improvement.” In this study, formative evaluation was carried out from the perspective of community general medicine outpatients, and consistent study results were obtained.
In summary, Mini-CEX implementation is feasible, can be carried out simultaneously with routine clinical work, and provides evaluation and feedback to trainees. The teachers can understand the learning situation of students and promptly discover problems in teaching, thereby providing a basis for adjusting the teaching plan and improving teaching methods. Moreover, students are overall satisfied with the Mini-CEX and regularly cite its advantages.
This study has limitations. The sample was limited to Wuhan Fourth Hospital, so data generalization is limited. The patients selected for Mini-CEX evaluation have various characteristics and difficulty levels, and there may be bias in post-evaluation statistical analysis. Another limitation to the present study is that only outpatient consultation ability was evaluated; future studies should consider how to train students in specific medical interviewing skills, such as using different types of questions for different clinical situations (e.g., mental illness, common diseases, or medical emergencies). Continuous exploration and revision will be required to understand how formative evaluation can be better applied in standardized resident physician training in China.