Workplace-Based Assessment

Clinical Evaluation Exercise (CEX)

These slides have been prepared to facilitate discussion on the use of the CEX. The suggested practical group exercise at the end is designed to be used with a training video.

Overview

• What is CEX?• Purposes of CEX• How does CEX work?• CEX settings• Who should use CEX?• CEX Competencies• CEX Form• CEX Blueprint

• How many CEXs?• CEX validity and reliability• Preparation for the CEX• During the CEX• After the CEX• Group exercise• Further Reading• Acknowledgements

What is CEX?

• Mandatory workplace assessment for learning

• A consultation or patient-trainee interaction which is observed and critiqued by a trainer/assessor

• Covers a range of clinical problems relevant to the stage of training and specialty

• Evaluates the trainee’s clinical and communication skills, judgement and synthesis

• The focus of the discussion can be on any or all of history-taking, examination, diagnosis, explanation, consent and management

Purposes of CEX

• To provide feedback to help the trainee improve their clinical judgement, decision making and professional skills

• To encourage a reflective approach to learning

• To help the trainee build evidence of their progress

• CEXs form one of the indicators that inform the AES’s end of placement report for the ARCP

• Individual CEXs are not designed to sign off independent practice.

CEX Competencies

1. History taking skills

2. Physical examination skills

3. Diagnostic skills and underlying knowledge base

4. Management and follow-up planning

5. Clinical judgement and decision making

6. Communication and listening skills

7. Organisation and time management

How does CEX work?

• The trainee selects a patient consultation, representative of their normal case mix

• The assessor observes the trainee undertaking the consultation

• The trainee presents findings

• The assessor and trainee discuss the consultation using the CEX form as a guide

• The assessor provides feedback on progress, covering strengths, exploring development needs and agreeing action plans within a feasible timescale.

• The assessor records the feedback on the CEX form and provides a rating against competencies

• Takes as long as the consultation itself with 10-15 minutes feedback

CEX settings

Early years

• Clinic

• Breaking bad news in planned settings

• Ward

• A&E

• Dealing with a patient/relative complaint

Intermediate Stage

• Clinic

• Guiding a junior in

clinic

• Breaking bad news in

unexpected settings

• Leading a ward round

• Ward – severely ill

patients and their

relatives

• A&E – severely ill

patients and their

relatives

• Dealing with a dying

patient

Final Stage

• Leading a clinic

• Guiding a junior in

clinic

• Breaking bad news in

complex /highly

sensitive settings

• Leading a ward round

• Ward – emergency

• A&E – emergency

• Interviews with

patients/relatives

• Dealing with a dying

patient

• Conflict resolution

Who should use CEX?

Trainee• CEX is applicable to trainees in all training stages

Assessor• Consultants• Trainee’s current AES• Senior trainees, more advanced than the assessee• Senior SAS grade surgeons• Other senior healthcare professionals

Assessors must have received training in the tool and be expert in the clinical problem/task

CEX Form

•Assessed against the end point for the stage of training• Summary of clinical problem• Focus of encounter• Complexity of the case• Competency areas• 3-point rating scale• Not assessed for areas not

in remit or not observed• Area for written feedback• 4-point global summary• Trainee can add reflection• Trainee can link to syllabus

CEX blueprint 

Good Medical PracticeCurriculum

Knowledge Judgement Technique Professional

Knowledge Skills and Performance

a)  Maintain your professional      performance  * *  ** **b)  Apply knowledge and experience      to practice ** **  ** **c)  Keep clear, accurate and legible     records ** **  ** *

Safety and Quality

a) Put into effect systems to protect patients and improve care  * *  *  b)  Respond to risks to safety  * *  * * c)  Protect patients and colleagues     from any risk posed by your     health

   *Communication Partnership & Teamwork

a) Communicate effectively  * ** ** ** b)  Work constructively with     colleagues and delegate     effectively

   c)  Establish and maintain     partnerships with patients   *  **  ** ** 

Maintaining Trust

 

a) Show respect for patients  *  **  ** **b)  Treat patients and colleagues     fairly and without  discrimination  *  **  ** **c)  Act with honesty and integrity  *  *  * *

Assessment blueprints help to ensure that assessment methods are mapped to the domains of the curriculum and Good Medical Practice.

A single method will cover some domains and the range of assessments should cover all domains

** Directly assessed

* Indirectly assessed

How many CEXs?

• To be used throughout surgical training

• The number will vary according to the trainee’s needs and should be agreed with the trainee’s AES

• The majority should be completed with the CS in each placement (with at least one with the AES)

• The JCST Quality Indicators state that training posts should offer at least 40 WBAs per year, of which the CEX should be of an equal proportion to other WBA methods. This is checked at the ARCP

• Each surgical specialty or training region may also recommend a specific number of CEXs

CEX validity and reliability

Validity and reliability is enhanced by:

• Assessor training and trainee induction• Linking to Learning Agreement objectives• Use as an assessment for learning• Using frequently throughout training• Using a range of assessors who are qualified and trained• Use in different settings with different clinical problems• Increasing the complexity of the case according to the

trainee’s competence and progression • Feedback addressing trainee development needs• Triangulation with other assessment methods• Trainee reflection on feedback

Preparation for the CEX

Trainee:• Arrange the case and CEX with the assessor well in

advance• Arrange to have the form to hand, either printed or online• Reflect on the case beforehand

Assessor:• Receive training in the tool• Ensure it is a case with which you have expertise and be

familiar with the medical notes

Both:• Ensure the patient has consented to the observation• Make suitable time so that there are no distractions• Agree the focus of the assessment

During the CEX

Trainee:• Conduct the consultation as you would normally

Trainer:• Observe the encounter, using the CEX form as a guide but do

not be limited by the areas listed• Discuss the encounter with the trainee, give the trainee the

opportunity to give their view first• Summarise the feedback including what was done well and

what needed to be improved• Expand on areas that were less than satisfactory• Include suggestions for remedial steps and agreed actions• Ensure the form captures feedback and areas observed

After the CEX

Trainee:• Upload feedback to the portfolio accurately in good time• Reflect on the case and feedback received• Follow up action plans

Trainer:• Validate the assessment in good time• If necessary, follow up on any actions agreed• Discuss the trainee’s needs with the AES if necessary

Group exercise

Purpose: To practice rating CEX, discuss best practice and enhance consistency

Technique: With a group of new and experienced trainers:

1. Group discusses the meaning of the CEX competencies

2. Group views a CEX video (see ISCP CEX example videos) https://

www.iscp.ac.uk/surgical/assessment_observation.aspx (pause at point of feedback in order to discuss the trainee’s performance)

3. Each trainer completes the CEX Form ratings and writes feedback comments based on the video

4. Group compares ratings and discusses written feedback

5. Each trainer reflects on whether they would adjust their ratings/comments in light of discussion

Repeat the exercise with another video (alternatively a role play).

Further discussion:• Different applications for early years and higher training• Use of scenarios in a simulated setting to help trainees practice skills

Further reading

1. ISCP Guidance notes on using the CEX https://www.iscp.ac.uk/static/public/cex_guidance.pdf

2. ISCP Tips for using CEX

https://www.iscp.ac.uk/static/public/cex_tips.pdf

3. CEX Form

https://www.iscp.ac.uk/static/public/cex_form.pdf

4. Academy of Medical Royal Colleges: Improving Assessment

http://www.aomrc.org.uk/doc_view/49-improving-assessment

Acknowledgements

The CEX was originally designed by John Norcini and promulgated by the American Board of Internal Medicine

Norcini JJ, Blank LL, Arnold GK, Kimball HR. The mini-CEX (clinical evaluation exercise): a preliminary investigation. Ann Intern Med 1995; 123(10):795-799.