Most medical educators are familiar with the mini-CEX, developed by the ABIM and used extensively across US medical schools to facilitate direct observation and feedback of residents and medical students, particularly in internal medicine. In this study by Donato et al, investigators analyze direct observation of internal medicine residents documented with the use of a different tool, the Minicard. The Minicard is similar to the mini-CEX in that observation of multiple domains of patient interaction can be documented, but uses behaviorally anchored scales of “poor” to “excellent” rather than numeral ratings of 1 to 9. In doing so, the Minicard is actually not so “mini,” and not a “card,” but consists of 12 items spanning multiple pages. How does it perform? Of 3715 Minicards collected over a 6 year period (reflecting 73 residents in inpatient and outpatient settings), the majority of the rating range was used and scores increased over the course of the training. The authors also highlight their findings that the rating of “marginal” was given with relatively high frequency (8% of observations for first year residents and 2% for third year residents) compared to reports from prior studies using the mini-CEX (0 or 0.5% of observations), and that action-oriented feedback was documented in 50% of the encounters compared to 8% reported in a prior study using the mini-CEX.
Should we then all switch to the Minicard? Not so fast. It’s worth noting that there was extensive faculty development plus financial incentives (yes!) involved: the authors report that completion of 1 Minicard per learner per week was 1 of 3 educational metrics used to calculate incentive pay, approximately $4000/year. But a more important issue to keep in mind is that the actual tool used is likely much less important than developing and promoting a culture of high quality feedback that is not just enforced, but embraced, by faculty and trainees. — Sarang Kim, MD