Mini-clinical examination method of dental students at Guilan University of Medical Sciences: A brief report evaluating caries diagnosis skills

Abstract

The Mini-Clinical Examination (Mini-CEX) is a new student assessment method. This succinct report aims to evaluate the efficacy of the Mini-CEX in enhancing dental students’ skills in caries diagnosis. This study is a brief report evaluating dental students’ skills in caries diagnosis using the Mini-CEX method at Guilan University of Medical Sciences, Iran in 2022. Fifty students were randomly divided into two equal groups by using simple sampling. The Mini-CEX group underwent three sessions at 1-week intervals, while the conventional group had a single assessment session. The scoring for the assessment was as follows: 1–3 (lower than expected), 4–6 (borderline), 7–9 (as expected), and 10 (higher than expected). An independent t-test and nonparametric Mann-Whitney test were conducted to compare the effectiveness of the Mini-CEX method versus the conventional method. The level of P < 0.05 was considered statistically significant. Significant differences were observed in three areas: determining the risk of caries (P = 0.028), detecting the speed of caries (P = 0.004), and presenting a treatment plan (P < 0.001). In addition, a significant statistical difference was noted between the third and first sessions (P < 0.001), as well as between the second and first sessions of the Mini-CEX (P = 0.001). However, no significant difference was found between the other sessions. The students’ skills showed improvement during the third session of the Mini-CEX, specifically in determining the risk of caries, detecting the speed of caries, and providing a treatment plan. However, the mean skill scores in the Mini-CEX and conventional methods did not demonstrate a significant difference.

Introduction

In the realm of educational programs, evaluation serves as a pivotal driver, facilitating the transition of education from a static state to a dynamic path. Its significance lies in discerning the strengths and weaknesses of the program, thereby reinforcing positive aspects and addressing inadequacies.[1] Effective evaluation not only enhances students’ motivation but also assists teachers in evaluating their methodologies.[2] When coupled with appropriate feedback, evaluation has the potential to evaluate students’ learning skills.[3] In general dentistry, students must pass several theoretical and practical study units. Some evaluation methods are based on students’ foundational knowledge and are presented in written or oral formats; others are designed to gauge practical skills.[4] The evaluation process for theoretical units is well-defined and structured, yet the grading approach for practical units generally lacks a clear framework, often resulting in student dissatisfaction. It is worth emphasizing that clinical evaluation methods, when complemented with constructive feedback, not only evaluate more complex cases in the traditional assessment but also promote learning.[5] Following scholarly literature, the evaluation of medical education should embody transparency, standardization, and alignment with educational objectives. Furthermore, it should continuously provide students with the necessary feedback and guidance.[6] Noteworthy, these assessment methods consist of the Objective Structural Clinical Examination (OSCE), Mini-Clinical Evaluation Exercise (Mini-CEX), and Direct Observation of Procedural Skills (DOPS).[7,8]

The Mini-CEX examination is designed to assess key clinical skills across various clinical fields.[9] A systematic review confirmed the validity and significance of the Mini-CEX method in educating students.[4] In response to the oral exam limitations, the American Board of Internal Medicine introduced the short-term clinical performance test in 1995. This test is a grading criterion for assessing six competence domains of specialized medical assistants. These domains include medical interviewing, physical examination, professionalism, clinical judgment/reasoning, communication skills/counseling, and data organization/sufficiency.[10]

A study involving students who engaged in two Mini-CEX methods revealed a significant improvement among emergency department interns. Furthermore, a study was conducted in 2020 to examine the effectiveness of the Mini-CEX method in assessing students’ performance in an X-ray panoramic report. The study indicated that the visibility and transparency of the Mini-CEX assessment contributed to the improvement of students’ performance.[11] In another study conducted at Shiraz University of Medical Sciences in 2017, it was found that descriptive tests, OSCE and Mini-CEX, are capable of evaluating high cognitive levels as well as emotional and psycho-motor domains. This has been shown to lead to an enhancement in the quality of evaluation and improvement of training.[12] Moreover, two studies indicated that the Mini-CEX and DOPS evaluation methods positively impacted students’ clinical skills. Therefore, it is strongly suggested that nursing education centers consider using these two methods to assess clinical procedures and students’ learning improvement.[13,14]

With no previous studies to guide us, this report sets out to evaluate the use of Mini-CEX in diagnosing dental caries and presenting treatment plans. This concise and brief report aims to investigate the skill level of dentistry students in the last 2 years in diagnosing caries and presenting a treatment plan using the Mini-CEX method. The first null hypothesis posits a significant difference between students’ skills from the two university entry years. The second null hypothesis asserts a notable variation in students’ abilities to diagnose caries and present treatment plans between the conventional and Mini-CEX evaluation methods. Lastly, the third null hypothesis is that there is a significant difference between the three sessions of the Mini-CEX method. The potential impact of this research on the future of dentistry education is substantial and enlightening.

Method and Material

Study design and setting

This brief report aimed to evaluate the efficacy of the Mini-CEX in improving dental students’ skills in caries diagnosis. After obtaining approval from the ethics community under the ethics code of IR.GUMs.REC.1401.537, and receiving written consent, in 2022, 50 junior and senior students from Guilan Dental School were assigned to examine patients according to the Mini-CEX and conventional methods [Figure 1].

Figure 1.

Flow diagram

Study participants and sampling

The students were randomly divided into two equal groups by using simple sampling:

• Conventional group

  In the conventional method, students of Guilan Dental School were entrusted with the responsibility to gain hands-on experience by examining patients alongside the residents of the restorative department. Each student was given the opportunity to examine a patient once, and in complicated cases, department professors would provide valuable assistance with the examination. The evaluation process was conducted within a single session.

• Mini-CEX group

  Outlined below are the key evaluation steps employed within the Mini-CEX group:

  In the first session, skills were observed for 15 minutes, followed by a 5-minute feedback.

  In the second and third sessions, observations were repeated at 1-week intervals, focusing on identifying students’ strengths and areas for improvement.

Data collection tools and technique

Both methods were evaluated based on medical interview skills, physical examination, professionalism, clinical judgment/reasoning, communication skills/counseling, and data organization/sufficiency. The assessment scoring criteria are delineated as follows:

• 1–3 (lower than expected)

• 4–6 (borderline)

• 7–9 (as expected)

• 10 (higher than expected)[13]

After collecting the evaluation forms, the data were entered into the widely recognized SPSS software version 26. Statistical indicators of average, median, standard deviation, minimum, maximum, and confidence interval of 94% of the average were used to determine the skills of caries diagnosis, as well as provide a treatment plan. When evaluating skills using software, three key metrics are often used: frequency, percentage of frequency, and 95% confidence interval; these metrics help to accurately classify the status of different skills. In examining the comparative effectiveness of the Mini-CEX evaluation method against the conventional method, an independent t-test was carried out for both individual items and the total score. In addition, the nonparametric Mann-Whitney test was employed to evaluate the proficiency levels of students regarding caries diagnosis and provide a treatment plan. To determine the effect of the Mini-CEX method, the statistical method of variance analysis based on the partial eta-squared coefficient of effect was employed. An effect size of more than 13% for partial eta-squared was considered acceptable. It is pertinent to note that the significance level of the tests was established at P < 0.05.

Ethical consideration

The students entered the study after filling out the written consent form. This study has been approved by the institutional ethics committee, with the ethics code of IR.GUMs.REC.1401.537.

Result

Fifty students participated in the study; the demographic characteristics of the two groups are presented in Table 1.

Table 1.

Demographic Characteristics of the Studied Samples

Type of evaluation (group) variable				Mini-CEX method		Conventional method		P
Sex		Male (N/P)		16 (64.0%)		11 (44.0%)		*0.156
		Female (N/P)		9 (36.0%)		14 (56.0%)
Age (M±SD)				23.84±0.69		24.20±1.15		**0.187
		2017 (N/P)		9 (36.0%)		8 (32.0%)		*0.765
Year of entry		2018 (N/P)		16 (64.0%)		17 (68.0%)
Total (N/P)				25 (100.0%)		25 (100.0%)

*χ² P. **Independent t-test P

The frequency distribution of gender, year of entry, and mean age showed no significant differences between the two studied groups (P values were 0.156, 0.765, and 0.187, respectively). However, there was a statistically significant difference in the skill of detecting the risk of decay (P = 0.028), presenting a treatment plan (P < 0.001), and detecting the speed of decay (P = 0.004) across the three evaluation sessions. The third session had the highest score, whereas the first session recorded the lowest score. In the variability comparison, the total evaluation score was 92/41%. The progression from session one to session two, and subsequently session two to session three, indicated a consistent trend of improvement in the skill levels [Chart 1].

Chart 1.

The mean skill score at three different stages

Chart 2 reveals a clear trend in the mean scores, with a decline in the following order: the third session of the Mini-CEX, the second session of the Mini-CEX, the conventional assessment, and finally, the first session of the Mini-CEX. However, a significant statistical difference was observed between the third and first sessions (P < 0.001), as well as the second and first sessions of the Mini-CEX (P = 0.001), with no significant statistical difference observed between the others.

Chart 2.

Mean total scores in different evaluation methods

One-sample t-test was utilized to compare the scores from each session of the Mini-CEX and conventional methods with the Observed Grand Mean (OGM) [Chart 3]. The results indicate a significant statistical difference between the mean score of the first session and OGM (P = 0.001), and the third session and OGM (P = 0.001), providing valuable insights that are crucial for further analysis and improvement.

Chart 3.

Comparison of the OGM with mean total score percent in different evaluation methods

Discussion

Our study aimed to investigate the impact of the Mini-CEX training method on caries diagnosis and providing a treatment plan, comparing it to the conventional treatment method in patients referred to Guilan Dental University in 2022. The findings indicated that there was no significant relationship between students’ skills and gender.[13] With the inclusion of both junior and senior students in the study, the similarity between clinical skills among these two groups could be attributed to the proximity of academic year and age, leading to the rejection of the first hypothesis. This finding aligns with a study by Habibi et al. regarding nursing colleges.[15] In contrast, Kuhpayehzadeh et al.’s[6] study indicated a significant relationship between gender and year of entry. The present study found no significant difference in the ability to address the patient’s chief complaint. Registering the patient’s chief complaint is a part of the history-taking process. The students need to be able to identify and register only the main and related complaints, disregarding the other non-essential complaints by the patient. This skill is one of the fundamental skills that students usually grasp quickly in the first semester. The close similarity in results between the use of the Mini-CEX training method and the conventional method, regardless of the student’s year of study, may be due to this quick learning in the first semester. However, Lin Niu et al. and Surekha Ramrao Rathod et al. demonstrated significant advancements in addressing patients’ chief complaints in prosthodontics and periodontology-implantology, respectively.[16,17] The findings of the present study indicate a significant relationship for caries risk detection, presenting a treatment plan, and detecting active from arrested caries, thereby confirming the second hypothesis. In addition, a significant statistical difference was observed between the second and first sessions, as well as the third and first sessions of the Mini-CEX, partially supporting the third hypothesis. The Mini-CEX approach is instrumental in identifying students’ strengths and weaknesses in clinical examinations, offering immediate feedback to enhance correct skills and rectify any shortcomings.[18] On the contrary, our study revealed that both the student and teacher were in agreement regarding the treatment plan and clinical problem, indicating no significant difference between the first session of the mini-CEX and the conventional method in caries diagnosis and treatment plan presentation. However, it is important to note the substantial difference between the first and third sessions as well as the first and second sessions of the Mini-CEX method, highlighting its effectiveness in improving students’ clinical skills. Educational methods, along with supportive feedback from the teacher, help in transferring the new clinical process to beginner learners faster and with less stress. In various studies on clinical skills in different fields, the effectiveness of the Mini-CEX method has been demonstrated. For instance, in Sureka Ramrao Rathod’s research, there was a notable improvement in dental students’ examination skills in periodontology and implantology, increasing from 27% to 66%.[17] Similarly, Lin Niu’s study showed improvement in the clinical diagnosis and physical examination skills of prosthodontists.[16] In addition, Batra et al.[18] observed enhancement in the performance of surgery residents in medical interviewing skills, physical examination, humanistic qualities/professionalism, and counseling skills.

Limitation and recommendation

The small sample size, a result of the limited number of students in the restorative department, and the time-consuming nature of the evaluation method were two significant limitations of the study. However, these limitations present an opportunity for future research that could have a profound impact. It is recommended that more studies with a larger population be conducted and that they compare with other training methods, such as DOPS. This could potentially lead to significant advancements in the field of restorative dentistry and training methods, offering hope for a more effective and efficient approach.

Conclusion

This brief report underscores the significant differences between the three Mini-CEX sessions in terms of detecting the risk and speed of decay, as well as in presenting a treatment plan. Furthermore, there was a significant difference between the first and third sessions, as well as between the first and second sessions of the Mini-CEX method. However, no significant difference was found between the other groups. According to the findings, it is recommended to implement the mini-CEX method as a replacement for traditional assessment methods across all dental procedures at various stages. These methods foster a sense of collaboration between students and instructors, shifting from the exclusively instructor-led assessment. By incorporating mini-CEX evaluation, instructors can effectively improve students’ motivation to hone their clinical skills, making them feel more included and part of the process.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.