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
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What is CEX?
Purposes of CEX
How does CEX work?
CEX settings
Who should use CEX?
CEX Competencies
CEX Form
CEX Blueprint
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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 historytaking, 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
Intermediate Stage
Early years
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Clinic
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Breaking bad news
in planned settings
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Ward
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A&E
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Dealing with a
patient/relative
complaint
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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
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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 Practice
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
Knowledge
Skills and
Performance
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Indirectly assessed
b) Apply knowledge and experience
to practice
c) Keep clear, accurate and legible
records
Safety and
Quality
Communication
Partnership &
Teamwork
** Directly assessed
a) Maintain your professional
performance
Maintaining
Trust
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
a) Communicate effectively
b) Work constructively with
colleagues and delegate
effectively
c) Establish and maintain
partnerships with patients
a) Show respect for patients
b) Treat patients and colleagues
fairly and without discrimination
c) Act with honesty and integrity
Curriculum
Knowledge
Judgement
Technique
Professional
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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:
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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:
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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)
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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
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.