This is an observational assessment of a pharmacist providing care for an individual patient. It is a snapshot (lasting approximately 15-20 minutes) of their practice (using a real patient), highlighting the realistic day-to-day challenges they face. The assessment will usually involve them interacting with patients, carers, nurses and doctors as appropriate. Skills and behaviours such as communication, information gathering, problem identification and decision-making can be assessed.
Whilst there is no "ideal" patient to choose for a Mini-CEX, those that provide limited opportunities for a pharmacist's input will make the SLE less beneficial for the pharmacist being assessed. Although experience has shown that in hospital practice, reviewing new patients is the most common scenario chosen for a Mini-CEX, any aspect of the patient journey could be used. The examples below are not an exhaustive list but demonstrate the variety of cases that could be used:
Initial review when a pharmacist meets a patient for the first time on a ward. A medicines reconciliation may need completing and if there are associated complexities (e.g. where a patient is prescribed medicines from different clinics) it may form the sole focus
Follow up of issues identified by an earlier patient review (e.g. interpretation of drug plasma concentrations, monitoring following the initiation of new treatments or deprescribing of existing medicines)
Consulting with a patient about their poor adherence and implementing a plan to tackle these. Elements of shared decision making could be included and the pharmacist may also have to discuss proposed changes to the patient's medicines (e.g. switching formulation due to palatability issues) with the prescriber
Responding to clinical queries raised by medical or nursing staff, e.g.
Converting medication to alternative routes / dosage forms
Advising on initial dosing of aminoglycoside or glycopeptide antibiotics or the interpretation of reported plasma concentrations of these drugs
Facilitating a safe and seamless discharge from hospital. In addition to clinically checking a discharge prescription, there should be other issues for the pharmacist to deal with, such as
Ensuring continuity of supply (e.g. for unlicensed medicines, patients on an opiate substitution programme)
Provision of information to primary care practitioners about changes made to medicines, follow-up monitoring needed or review of medicines that may no longer be appropriate for (or needed by) the patient
Dealing with an error on an out-patient prescription - as well as discussing this with the prescriber, the pharmacist may also have to consult with the patient to explain what's happening
Reviewing a patient’s INR in an anticoagulation clinic and advising on further warfarin dosing
Answering a medicines-related enquiry over the phone. The pharmacist would then outline how they plan to tackle that particular enquiry (e.g. resources to be used and the reasons why)
Structured medication review in primary care
The assessment can take place on a ward, in a dispensary, in a clinic (out-patient, ambulatory or GP practice) or in a medicines information department. Assessment dates can be pre-arranged, but unscheduled assessments can be facilitated if a suitable scenario presents itself – e.g. pharmacist asked to speak to a “demanding patient” at the dispensary hatch; during an ACAT an F1 Dr asks for advice on starting a patient on aminoglycoside therapy. If the assessment has been pre-arranged, identifying more than one potential patient / scenario can help the assessor chose one that they think will be most suitable.
Since this is an observation of practice, the assessor should position themselves carefully (to avoid being intrusive) and limit their questioning of the pharmacist to confirming how they are prioritising problems and how they can justify their proposed actions. Although interjections should be kept to a minimum (e.g. where there is a genuine clinical concern raised by the trainee’s proposed actions), other pertinent issues should be discussed afterwards, as part of the feedback for the assessment. Therefore, pharmacists need to lead the discussion to demonstrate how they synthesise information (rather than read out verbatim the content of the case notes), articulate thought processes and use clinical reasoning.
There are no minimum numbers of each type of SLE that needs to be completed. Since the tool involves a direct observation of practice and does not require the pharmacist to undertake any specific preparation, examples of when it could be used most effectively include:
During the first few weeks of a rotation to assess the pharmacist's approach to reviewing a patient in a specific clinical area. If they have moved from a cardiology ward to orthopaedic surgery, the patients will have different clinical considerations. It is important that any problems with a pharmacist's approach to reviewing patients in their new rotation are addressed early on and whilst questioning should be minimised during a Mini-CEX, the tool can be used to identify priority areas of knowledge to develop during the remainder of the rotation
If the pharmacist did not perform well during a Mini-CEX, a subsequent one can be arranged to assess how they have addressed feedback from the previous one