Overview

1. Workplace-Based AssessmentClinical 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.

2. Overview 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? • Purposes of CEX • How does CEX work? • CEX settings • Who should use CEX? • CEX Competencies • CEX Form • CEX Blueprint

3. 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

4. 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.

5. CEX Competencies • History taking skills • Physical examination skills • Diagnostic skills and underlying knowledge base • Management and follow-up planning • Clinical judgement and decision making • Communication and listening skills • Organisation and time management

6. 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

7. 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

8. 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

9. 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

10. CEX blueprint 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Group exercise Purpose: To practice rating CEX, discuss best practice and enhance consistency Technique: With a group of new and experienced trainers: • Group discusses the meaning of the CEX competencies • 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) • Each trainer completes the CEX Form ratings and writes feedback comments based on the video • Group compares ratings and discusses written feedback • 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

17. Further reading • ISCP Guidance notes on using the CEX https://www.iscp.ac.uk/static/public/cex_guidance.pdf • ISCP Tips for using CEX https://www.iscp.ac.uk/static/public/cex_tips.pdf • CEX Form https://www.iscp.ac.uk/static/public/cex_form.pdf • Academy of Medical Royal Colleges: Improving Assessment http://www.aomrc.org.uk/doc_view/49-improving-assessment

18. Acknowledgements The CEX was originally designed by John Norcini and promulgated by the American Board of Internal Medicine NorciniJJ, Blank LL, Arnold GK, Kimball HR. The mini-CEX (clinical evaluation exercise): a preliminary investigation. Ann Intern Med 1995; 123(10):795-799.