Can I leave the theatre? A key to more reliable workplace-based assessment.

BACKGROUND: The value of workplace-based assessments such as the mini-clinical evaluation exercise (mini-CEX), and clinicians' confidence and engagement in the process, has been constrained by low reliability and limited capacity to identify underperforming trainees. We proposed that changing the way supervisors make judgements about trainees would improve score reliability and identification of underperformers. Anaesthetists regularly make decisions about the level of trainee independence with a case, based on how closely they need to supervise them. We therefore used this as the basis for a new scoring system. METHODS: We analysed 338 mini-CEXs where supervisors scored trainees using the conventional system, and also scored trainee independence, based on the need for direct, or more distant, supervision. As supervisory requirements depend on case difficulty, we then compared the actual trainee independence score and the expected trainee independence score obtained externally. RESULTS: Compared with the conventional scoring system used in previous studies, reliability was very substantially improved using a system based on a trainee's level of independence with a case. Reliability improved further when this score was corrected for case difficulty. Furthermore, the new scoring system overcame the previously identified problem of assessor leniency and identified a number of trainees performing below expectations. CONCLUSIONS: Supervisors' judgements on trainee independence with a case, based on the need for direct or more distant supervision, can generate reliable scores of trainee ability without the need for an onerous number of assessments, identify trainees performing below expectations, and track trainee progress towards independent specialist practice.

Mini-clinical evaluation exercise in anaesthesia training.

BACKGROUND: The Mini-Clinical Evaluation Exercise (Mini-CEX) is a workplace-based assessment tool of potential value in anaesthesia to assess and improve clinical performance. Its reliability and positive educational impact have been reported in other specialities, but not, to date, in anaesthesia. In this study, we evaluated the psychometric characteristics, logistics of application, and impact on the quality of supervision of the Mini-CEX in anaesthesia training. METHODS: A Mini-CEX encounter consisted of a single specialist anaesthetist observing a trainee over a defined period of time, completing an online Mini-CEX form with the trainee, and providing written and verbal feedback. We sought trainee and supervisor perspectives on its value and ease of use and used Generalizability Theory to estimate reliability. RESULTS: We collected 331 assessments from 61 trainees and 58 assessors. Survey responses strongly supported the positive effect of the Mini-CEX on feedback, its relative feasibility, and acceptance as a potential assessment tool. In this cohort, we found variable assessor stringency and low trainee variation. However, a feasible sample of cases and assessors would produce sufficiently precise scores to decide that performance was satisfactory for each trainee with 95% confidence. To generate scores that could discriminate sufficiently between trainees to allow ranking, a much larger sample of cases would be needed. CONCLUSIONS: The Mini-CEX in anaesthesia has strengths and weaknesses. Strengths include: its perceived very positive educational impact and its relative feasibility. Variable assessor stringency means that large numbers of assessors are required to produce reliable scores.

Polymorphic fibrillar assembly of human amylin.

Human amylin forms fibrillar amyloid between pancreatic islet cells in patients with non-insulin-dependent (type 2) diabetes mellitus. Fibrillar assemblies also form in vitro in aqueous solutions of synthetic human amylin. We now report on the structural polymorphism of these fibrils. The thinnest fibril, referred to as the protofibril, has an apparent width of 5 nm but is only rarely observed by itself. These protofibrils spontaneously assemble into higher order fibrillar structures with distinct morphologies. Prominent among these is an 8-nm fibril with a distinct 25-nm axial crossover repeat which is formed by left-handed coiling of two 5-nm protofibrils. Coiling of more than two 5-nm protofibrils results in cable-like structures of variable width depending on the number of protofibrils involved. Lateral (side-by-side) assembly of 5-nm protofibrils is also observed and produces ribbons which may contain two, three, four, or more protofibrils and occasionally large single-layered sheets. The mass-per-length (MPL) of the 5-nm protofibril is 10 kDa/nm. This has been established in two ways: first, the 8-nm fibril, which is formed by coiling two 5-nm protofibrils around each other, has an MPL of 20 kDa/nm. Second, higher order fibrils differ by increments of 10 kDa/nm. Hence, about 2.6 human amylin molecules (3904 Da) are packed in 1 nm of protofibril length. Similarities exist between amylin fibrils and those formed from other amyloid proteins, suggesting that the in vitro assembly of synthetic protein may serve as a useful model system in advancing our understanding of amyloid formation in disease.