Assessment of clinical examination and procedural skills (CEPS) is an important part of GP training.
Evidence for CEPS can be provided via CEPS evidence forms, learning logs, criterion 6 of the consultation observation tool, a clinical supervisor’s report, questions relating to CEPS in the educational supervisor’s review and multisource feedback. This article focuses on the CEPS learning log.
Evidence of skill development
While the CEPS assessors' form is for a suitably qualified clinician to complete after observing trainees perform and interpret a physical examination or undertake a procedural skill, the learning log is for trainees to reflect on what they have done and how they might improve in the future.
When trainees meet their clinical supervisor to discuss their learning needs during placement planning meetings, they should agree the examinations and procedures they need for their development as GPs and discuss the learning opportunities available to them during the rotation.
By recording these in their PDPs, and by logging their skills acquisition in CEPS learning logs, trainees gather evidence of skill development. When trainees complete training, they must be competent to apply their skills unsupervised.
To obtain a Certificate of Completion of Training, trainees must have evidence of competence in five intimate examinations: breast, rectal, prostate, female genital and male genital examinations. However the range of examinations and procedural skills is not limited to these five and should include a range of skills that any competent general practitioner would be confident in using.
An example learning log
Look at the CEPS learning log below and consider the following questions - these are questions that trainers will be considering when assessing your log entries:
- What evidence does this learning log provide of the trainee's progression in their development of specific examination and procedural skills?
- Is there anything in the learning log that gives concern about the trainee’s clinical examination or procedural skills?
- In this account, is there evidence of the trainee's understanding of the medicolegal aspects (including consent) of examining patients or performing procedures? How did the trainee deal with patients who were unable to give consent personally or with patients who refused examinations or procedures?
- Did the trainee comment on whether the patient's socio-economic status affected their expectations of the clinical examination or procedure?
Subject title: Hip examination in the newborn
Clinical Examination or Procedural Skill performed: Ortolani and Barlow manoeuvres
Observer name: Dr S W
Observer position: Paediatric SpR (ST4)
State reason for physical examination or procedure performed. Describe physical signs elicited (to include whether this was the expected finding): As the paeds SHO, I need to perform my share of newborn and infant physical examinations (NIPE), for example on pre-term babies, whom the midwives cannot screen. As a GP, I will also do six-week baby checks.
Both newborn and six-week baby checks include hip screening using Ortolani and Barlow manoeuvres, which I need to practise before doing independently. I asked the Paeds SpR who taught me the Ortolani and Barlow manoeuvres to observe my first hip examination before I started doing them myself.
Prior to examining the hips, I asked about risk factors for developmental dyplasia of the hip (DDH), such as a first degree relatives with DDH, breech presentation after 36 weeks, club foot or twins.
I undressed the baby taking care to keep her warm. I looked for leg length and skin fold symmetry. I was able to abduct both legs fully. There was no palpable clunk when I performed the Ortolani and Barlow manoeuvres; no clunk was what I expected in a normal examination. My SpR checked my technique and said it was good. He concurred with my assessment that the hips were not dislocated.
Reflect on any communication or cultural factors: This was mum's second child and she expected an examination of her baby prior to being discharged. I explained that I would be examining the baby's hips and described what I was looking for. I did not discuss why my registrar was present, nor did mum ask.
Reflect on any ethical factors (to include consent): I explained that I was performing a screening examination, that I was looking for hip problems, which if left undetected, could cause complications later but if detected early, could be investigated and treated to prevent these complications. Mum gave verbal and written consent.
It was relatively straightforward to explain screening for DDH to a second time mum who speaks English. I wonder how easy it is to obtain consent from non-English speaking mums who do not have any experience of baby screening examinations, especially as the Ortolani and Barlow manoeuvres look painful?
Self assessment of performance (to include overall ability and confidence in this type of examination or procedure): I was methodical and thorough. I placed my hands in the correct position. I felt the hips move and now understand the sensation of normal hip movement. I haven't felt an abnormal hip as yet.
Learning needs identified: To gain confidence with feeling a range of 'normal hip movement' and to be able to do the hip examinations more quickly and slickly.
How and when these learning needs will be addressed: Even though midwives do most of the checks, I could offer to do more checks to improve my hip screening technique.
As the trainer reading this CEPS learning log, I would reference this entry in my educational supervisor’s review as evidence of the trainee's progression in their development of specific examination and procedural skills (competence 13).
The trainee has also discussed her risk assessment, that is, the data-gathering she does prior to undertaking the examination.
She discussed obtaining informed consent from the mum and gave a good explanation of why hip screening is done. Had she explored the ethics of screening (in this or a separate log entry) and expanded on the possible harms of Ortolani and Barlow manoeuvres, or the chances of a problem being missed by this examination, she would have scored more highly.
The trainee discussed the mother’s expectation of baby screening and reflected on how mothers from a different cultural background could view Ortolani and Barlow manoeuvres with suspicion. To score more highly, she could discuss what she would opt to do in such a situation.
The trainee could also discuss what she would do if the hip screening uncovered a problem, thereby providing evidence of knowing how to manage the results of hip screening.
- Dr Naidoo is a GP trainer in Oxford. She has written three books on how to pass the CSA. The latest book CSA Practice Cases for the MRCGP was published in January 2016.
- RCGP information on Workplace Based Assessment Competences
- RCGP information on CEPS
- GMC. Consent: Patients and doctors making decisions together, paragraph 18. 2008
Picture: Science Photo Library