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The "AIMST University Mini-CEX Model" for Authentic Simulation of Clinical

Skills Learning

Preprint · January 2021

DOI: 10.13140/RG.2.2.12893.23521

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Sethuraman K Raman
AIMST University 08100 Malaysia
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 The “AIMST University Mini-CEX Model” for Authentic Simulation of Clinical Skills Learning

– Sethuraman, KR. Dated 17th January 2021

Introduction

The lockdown in Malaysia since 18th March 2020 has created a sudden vacuum in the face to face
learning opportunity of clinical skills. We had to design and deliver authentic learning of clinical-skills in a
simulated environment in the faculty of Medicine, AIMST University. This is a gist of the principles we
have followed to achieve that to the best of the collective ability of the faculty.

Based on our recent success in utilising modified mini-CEX format to conduct final year clinical
examination in the long case and short case formats, we anticipate that the present model will be
equally satisfying in achieving intended outcomes.

Guiding Principles in Brief

Structuring of Clinical Teaching-Learning (through years 3 to 5 of MBBS) has been done by adopting
RIME framework.1 We have been following the RIME model since 2019.

Briefly, it is to teach and learn,

o recording (R) clinical history and physical examination in year-3,

o interpreting (I) the clinical case details and the investigation reports in year-4, and
o planning management (M) of the case and how to give follow up advice by patient education (E) in
year-5 of the MBBS course.

RIME framework is primarily for structured evaluation of students’ progress through clinical years. By
backward design principles of outcome based learning2, RIME framework guided our focus during
clinical sessions for the clinical years 3 to 5 of MBBS.

Choice of the Mode of Teaching-Learning

This has been based on the predominant domain as per the revised Bloom’s taxonomy 3 and Miller’s
prism/pyramid.4 Academic freedom was given to each clinical unit to base their choice of the level of
clinical experience based on availability of resources, feasibility and priorities. The guiding principle for
the choice of learning experience was Dale’s cone of experience.5

For example, the clinical units with access to real ambulatory cases arranged to get the cases to the
simulated bedside discussions. Other units, used hybrid models to the extent possible combining,

i) standardised patients, who could give clinical history in a consistent manner,

ii) normal volunteers for the students to practice physical examination, and
iii) high fidelity simulators to learn perceptual skills of visual, auditory and tactile senses.

Creating Ambulatory care and In-patient Environment

Due to the pandemic created recurrent and unpredictable disruptions in hospital based clinical training,
it has now become necessary for us to create ambulatory care and inpatient care simulated
environments. That would enable the students to learn the clinical skills of ambulatory care and
inpatient case management that they normally learn during the final year of MBBS through ‘shadow
housemanship’.

Ambulatory Care Simulation6

Ambulatory (outpatient) care is medical care provided on an outpatient basis, including diagnosis,
observation, consultation, treatment, intervention, and rehabilitation services. The goal is to learn the
skills of focussed case assessment and advising the patient on home based management of the problem.

It is feasible to use some of the clinical students to play the roles of ambulatory cases with a bit of
guidance and coaching on key features of the case scenario. The others would then interact with them
in layperson’s language to elicit the case history. Several symptoms do not have any abnormal physical
findings and are diagnosed based on history alone. These are easy to begin the program of ambulatory
care simulation.

An example of ambulatory care simulation from my efforts during 1990-1996:

 Preparatory day: Five case scenarios where the patient has either normal physical finding or
minimum of findings were chosen in chest pain, viz., intercostal myalgia, herpes zoster of intercostal
nerve (pre-eruptive phase), stable effort-angina, reflux oesophagitis, pleurodynia (Devil’s grippe).
 Five students, who volunteered for this session, were individually coached on the syndrome which
each of them had to play the patient’s role. They got a handout or a reference to look up to learn
more about the condition they had to act out the next day.
 The rest of the students were asked study ‘approach to a case of chest pain or chest discomfort” and
come to play the role of doctors or supervisors.
 Simulation day: On the next day, during the initial briefing session, each case was allotted to a
student, who played to role of the ambulatory care doctor and another student, who played the role
of a peer-supervisor to ensure that the “doctor” and the “patient” interacted in lay person’s
language. I recommended them to converse in vernacular.
 The ambulatory care interview went on for around 15-20 minutes, after which they all assembled
for debriefing session. Each case in turn was presented by the ‘doctor’ concerned. The case scenario
was then analysed to arrive at the probable diagnosis and differential diagnosis, if any. The peer
supervisors added their remarks on the fidelity of the interaction among the role players. Finally, the
clinical instructor highlights the key features of the case and how to manage such cases as
outpatients.
 At the end of the debriefing, the clinical instructor summarises the approach to chest
pain/discomfort in ambulatory settings and the ‘red flags’ that should alert us to admit the patient
for observation or further investigations.

Similarly, I used to conduct sessions on musculo-skeletal aches & pains, abdominal aches & pains,
headache, breathing difficulty (with simulated physical findings), diarrhoea/dysentery/’loose bowel’.
The additional benefit of this method proved to be the realisation among the participating students on
the importance of eliciting history in initial case assessment.7

In-patient Care Simulation

Goal: 8 The student will be able to evaluate and manage adults hospitalized with acute illness and
convey this information facilely on patient care rounds.

Objectives: 8

o Obtains, records, and communicates an accurate history and physical exam.

o Utilizes supplemental laboratory and diagnostic studies to support the most likely diagnoses.
o Interprets the clinical information by prioritizing a problem list
o Begins to demonstrate reasoned therapeutic decision-making for basic core problems.
o Presents patients in the context of daily care rounds (brief SOAP presentation) and new patient
presentations (comprehensive ‘long-case’ model).
o Documents clear and accurate admission and progress notes on each patient.

Proposed “AIMST University Model” of simulated In-patient environment:

Cognitive realism is more important than physical realism in creating authentic learning environment.9
Therefore, each clinical unit will plan sustainable and practicable in-patient simulation based on the
principles of design stated earlier. We propose to create a 3 or 4 bedded in-patient cubicle.

On day-0, the briefing is done on the objectives of the in-patient simulation exercises, which would
spread over 3 to 5 days. The students who play the roles of in-patient cases will be initially coached on
case details. From day-1, they would plan to narrate their daily progress until they are discharged. The
clinical conditions will be chosen from the common diseases prevalent in Malaysia.

On day-1, the rest of the students would be allotted a new patient for clerking. Appropriate Mannequins
or videos will be supplemented to present the physical findings of the patient allotted. After an hour of
clerking, the clinical instructor will take ward rounds and analyse each case presentation in detail,
especially focussing on differential diagnosis, further investigations and initial treatment plan.

On day-2, the daily progress report, and the lab reports & images will be the basis for discussions. The
focus will be narrowing the diagnostic possibilities, planning further work up if needed, and modifying
treatment plan based on test results. This may go on for a day or two more as planned by the unit.

On the final day of the simulation exercise, the students will discuss discharge plans and instructions to
the patients.

Evaluation of the Ambulatory and In-patient simulation

Evaluation of the learning outcomes will be done on daily basis, using the RIME evaluation format
already available with the major clinical units. In addition, feedback will be obtained from the students,
from the role-players and from the clinical instructors on the usefulness of the simulated clinical
environment in achieving the expected outcomes.
 Summary

AIMST University Model of Mini-CEX to simulate out-patient and in-patient settings is based on
evidence-based educational principles. It is expected to keep the learners engaged in clinical
environment until they can resume face-to-face learning in the real healthcare settings.

References

1. RIME with Reasons. ASTU Web Portal. https://www.atsu.edu/pdf/rime-with-reasons.pdf

2. Planning a Course: Learning Outcomes and Backward Design. Office of Instruction & Assessment. The
University of Arizona web portal. https://oia.arizona.edu/content/290
3. Revised Bloom’s Taxonomy. IOWA State University. https://www.celt.iastate.edu/teaching/effective-teaching-
practices/revised-blooms-taxonomy/
4. Miller’s Pyramid of Assessment (handout). Ben.edu portal. https://www.ben.edu/college-of-education-and-
health-services/nutrition/upload/assessment_and_feedback_for_residents_and_students-1.pdf
5. Dale’s Cone of Experience (Handout). Queens University.
https://www.queensu.ca/teachingandlearning/modules/active/documents/Dales_Cone_of_Experience_sum
mary.pdf
6. Dent J. Learning in ambulatory care, in Walsh K. Oxford Textbook of Medical Education (online), 2013.
DOI:10.1093/med/9780199652679.003.0019
7. Sethuraman KR. Innovations in Clinical Education (a project report submitted to IGNOU, Delhi as a part
fulfilment for PGDHE) 1996. Unpublished monograph.
8. Inpatient Clerkship Goals and Objectives. University of Iowa web portal:
https://medicine.uiowa.edu/internalmedicine/education/undergraduate/inpatient-clerkship/goals-and-
objectives
9. Herrington, J., Oliver, R. & Reeves, T. (2003). 'Cognitive realism' in online authentic learning environments. In
D. Lassner & C. McNaught (Eds.), Proceedings of World Conference on Educational Multimedia, Hypermedia
and Telecommunications 2003 (pp.2115-2121). Chesapeake, VA: AACE. Available at
http://ro.ecu.edu.au/ecuworks/3253 ; PDF available at
https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.856.3299&rep=rep1&type=pdf

Additional Reading on Mini-CEX

Mortaz Hejri S, Jalili M, Shirazi M, Masoomi R, Nedjat S, Norcini J. The utility of mini-Clinical Evaluation
Exercise (mini-CEX) in undergraduate and postgraduate medical education: protocol for a systematic review.
Syst Rev. 2017;6(1):146. Published 2017 Jul 18. doi:10.1186/s13643-017-0539-y available at
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5516345/

About the Author: Dr KR Sethuraman is the Dean and Senior Professor of Medicine and Medical
Education in the Faculty of Medicine at AIMST University, Malaysia (www.aimst.edu.my)

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