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Mini-CEX discriminates between pre-existing levels of seniority, requires considerable sampling to achieve sufficient reliability, and was not feasible within the current circumstances, but it was considered a valuable assessment tool as indicated by the evaluators' and residents' satisfaction ratings.

The CREATE-ECLA Randomized Controlled TrialThe CREATE-ECLA Trial Group Investigators* See also pp 427 and 489.

The study was designed to illustrate how residents perceive the Mini Clinical Examination Exercise as an assessment tool and its influence on their approach to learning and studying. A phenomenographic approach was applied. All 16 residents from a cardiology training program in Buenos Aires were included. Results show that in all cases residents demonstrate an intrinsic interest in the subject matter. They show self-regulating strategies when required to select, relate and make critical appraisals of their own. They consistently demonstrate an aim to build a relationship between individual experience and their chosen topic. The residents feel comfortable because it melts with their routine. Residents find the Mini Clinical Examination Exercise to be a useful assessment tool with a favorable influence towards a constructive approach to study and learning.

Reliability estimations of workplace-based assessments with the mini-CEX are typically based on real-life data. Estimations are based on the assumption of local independence: the object of the measurement should not be influenced by the measurement itself and samples should be completely independent. This is difficult to achieve. Furthermore, the variance caused by the case/patient or by assessor is completely confounded. We have no idea how much each of these factors contribute to the noise in the measurement. The aim of this study was to use a controlled setup that overcomes these difficulties and to estimate the reproducibility of the mini-CEX. Three encounters were videotaped from 21 residents. The patients were the same for all residents. Each encounter was assessed by 3 assessors who assessed all encounters for all residents. This delivered a fully crossed (all random) two-facet generalizability design. A quarter of the total variance was associated with universe score variance (28%). The largest source of variance was the general error term (34%) followed by the main effect of assessors (18%). Generalizability coefficients indicated that an approximate sample of 9 encounters was needed assuming a single different assessor per encounter and assuming different cases per encounter (the usual situation in real practice), 4 encounters when 2 raters were used and 3 encounters when 3 raters are used. Unexplained general error and the leniency/stringency of assessors are the major causes for unreliability in mini-CEX. To optimize reliability rater training might have an effect.

An application-directed learning style predominates in this group of residents. Information regarding learning styles can provide foundations upon which arguments can be made for changes in education that are traditionally not evidence-based.

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