1. Clinical Examination and Procedural Skills The Introduction of CEPS The assessment of psychomotor skills in WPBA for the MRCGP examination
MRCGP WPBA Core Group

2. ‘Integrated DOPS’ The proposal for change from
mandatory to Integrated DOPS :
The assessment of DOPS will no longer be recorded as a single test on a mandatory list.
2. DOPS will be integrated within the existing framework of the Trainee ePortfolio and become Clinical Examination and Procedural skills (CEPS).
The move from mandatory to integrated DOPS may be seen as a paradigm shift within WPBA - from a prescribed and limited mandatory list to a much broader learner-centred and patient-centred PUNs and DENs approach.
There is no longer a prescribed list of clinical examinations or procedural skills which must be demonstrated.
Similarly there is no prescribed minimum number of assessments to be recorded.
Trainees are expected to discuss their learning needs during placement planning meetings and to record their plans in the learning log and PDP. The range of examinations and procedures and the number of observations will depend on the needs of the trainee and the professional judgment of the educational supervisor. There is still a recommendation that the intimate examination skills should be considered as essential for all trainees.
These essential procedural skills should include
breast examination
female genital examination
male genital examination
prostate examination
rectal examination
It will be for the trainee and their educational supervisor to assess the need for training and devise ways of achieving it as guided by the GP curriculum. Assessment should reflect that integral nature both in the regular ‘low stakes’ assessment for learning and in the cumulative ‘high stakes’ assessment of learning.
Assessments of integrated DOPS are made by clinical supervisors and other senior colleagues (including senior nurses and trainees more senior than ST4). The assessments are an integral part of the overall competences of data gathering, diagnosis, clinical management and in some cases the ethical aspects of consent and autonomy.

3. Recording Integrated DOPS in the ePortfolio
New professional competence also called Clinical Examination and Procedural Skills
New Learning Log category called ‘Clinical Examination and Procedural Skills’
Included as part of the COT (criterion 6)
Specifically addressed by 3 questions for the ES as a summary of progress in the ESR.
Changes to MSF
Changes to CSR
New evidence form for assessor to document observations
1. A new clinical competence will be introduced called Clinical Examination and Procedural Skills. It will eventually appear in the list of diagnostic competences after data gathering but initially will sit below the current competencies below fitness to practice.
2. Clinical examinations and procedural skills are documented by the trainee within their learning log. As with all log entries these will need to be linked to the relevant curriculum heading and will need to include a range of entries from specific areas, for example cardiovascular/ respiratory / children / elderly and patients with Mental Health problems. Log entries will require reflection on any communication, cultural or ethical difficulties encountered
3. The wording of the COT will change slightly to refer specifically to clinical examination and procedural skills.
It is expected that the trainees supervisors will also observe the trainee performing DOPS and this can be documented within the log using a new specifically designed form. If the examination included the need for specific consent then “Maintaining an Ethical Approach” would be appropriate. If the procedural skill was necessary for patient management, for example administration of medication by injection or immunisation then “Clinical Management” would be appropriate. The logs could be linked to these in addition to Clinical Examination and Procedural skills.
4. As part of the ESR process the trainee will be asked to make their own assessment of their examination and procedural skills when they also relate to these competences of Clinical management and Maintaining an ethical approach.
5. Progress in psychomotor skills will be specifically addressed by 3 questions for the CS orES as a summary of progress in the CSR and ESR.
Where an educational or clinical supervisor has significant concerns about a trainee’s performance in any of these areas it is recommended that these are recorded as an Educator Note in the ePortfolio so that this can be referred to if necessary at the next periodic review. Equally, where an educational or clinical supervisor considers that significant progress has been made an Educator Note might similarly be useful.
[A specific feedback form will replace the formal Skills form and allow formative feedback on examination and procedural skills any appropriate team members. It asks for feedback in performance and areas for future development.]

4. 1. New professional competence also called Clinical Examination and Procedural Skills
‘Clinical Examination and Procedural Skills’ becomes a new and additional competency to be completed by trainees in the same manner as the current twelve competencies.

5. New Competence: Clinical Examination and Procedural Skills
Insufficient Evidence
Needs Further Development
Competent
Excellent
From the available evidence, the doctor’s performance cannot be assessed.
[placed on a higher point of this developmental scale]
Chooses examinations broadly in line with the patient’s problem(s)
Chooses examinations appropriately targeted to the patient’s problem(s)
Proficiently identifies and performs the scope of examination necessary to investigate the patient’s problem(s)
Identifies abnormal signs but fails to recognise their significance
Has a systematic approach to clinical examination and able to interpret physical signs accurately
Uses an incremental approach to examination, basing further examinations on what is known already and is later discovered
Suggests appropriate procedures related to the patient’s problem(s)
Varies options of procedures according to circumstances and the preferences of the patient
Demonstrates a wide range of procedural skills to a high standard
Demonstrates limited fine motor skills when carrying out simple preocedures
Refers on appropriately when a procedure is outside their level of skill
Actively promotes safe practice with regard to examination and procedural skills
Observes the professional codes of practice including the use of chaperones
Identifies and discusses ethical issues with regard to examination and procedural skills
Engages with audit quality improvement initiatives with regard to examination and procedural skills
Performs procedures and examinations with the patient’s consent and with a clinically justifiable reason to do so
Shows awareness of the medico-legal background to informed consent, mental capacity and the best interests of the patient
Helps to develop systems that reduce risk in clinical examination and procedural skills
This slide gives the word pictures for the new competency which will appear after data gathering in the diagnostic section of the ESR eventually but will initially sit below the existing competencies.
This competency is about the trainee’s performance in Clinical Examination and Procedural Skills

6. IPUs – Indicators of Potential Underperformance:
Fails to examine when the history suggests conditions that might be confirmed or excluded by examination
Patient appears unnecessarily upset by the examination
Inappropriate over examination
Fails to obtain informed consent for the procedure
Patient or trainee shows no understanding as to the purpose of examination.
The IPU is a tool to help clinical and educational supervisors identify potential underperformance in their trainees. This tool is now incorporated into the ePortfolio alongside the competency framework and can help to identify behaviours that signpost potential underperformance. The observations and the wording is designed to aid recognition of IPU and to enable formative feedback and targeted training.

7. New Competence: Clinical Examination and Procedural Skills
Genital and Intimate Examinations
Insufficient evidence
Needs further development
Competent
Excellent
By the end of training the trainee must have demonstrated competence in breast examination and in the full range of male and female genital examinations
The intimate examination is conducted in a way that does not allow a full assessment by inspection or palpation. The doctor proceeds without due attention to the patient perspective and feelings
Ensures that the patient understands the purpose of an intimate examination, describes what will happen and explains the role of the chaperone. Arranges the place of examination to give the patient privacy and to respect their dignity. Inspection and palpation is appropriate and clinically effective.
Recognises the verbal and non-verbal clues that the patient is not comfortable with an intrusion into their personal space especially the prospect or conduct of intimate examinations. Is able to help the patient to accept and feel safe during the examination.
The slide gives the specific performance criteria for the conduct of intimate examinations
Insufficient Evidence:
By the end of training the trainee must have demonstrated competence in breast examination and in the full range of male and female genital examinations. Full range of female and male genital examinations would be expected to include things like rectal, prostate, female genital and male genital.
Needs further development
The intimate examination is conducted in a way that does not allow a full assessment by inspection or palpation. The doctor proceeds without due attention to the patient perspective and feelings
Competent
Ensures that the patient understands the purpose of an intimate examination, describes what will happen and explains the role of the chaperone. Arranges the place of examination to give the patient privacy and to respect their dignity. Inspection and palpation is appropriate and clinically effective
Excellent
Recognises the verbal and non-verbal clues that the patient is not comfortable with an intrusion of their personal space especially the prospect or conduct of intimate examinations. Is able to help the patient to accept and feel safe during the examination.

8. 2. New Learning Log Category
Clinical Examination or Procedural Skill performed (please specify, if a genital or intimate examination)
Reason for physical examination and physical signs elicited (was this the expected finding?)
Reflect on any communication or cultural difficulties encountered 
Reflect on any ethical difficulties encountered, (to include consent)
Self assessment of performance (to include overall ability and confidence in this type of examination)
Learning needs identified
How and when are these learning needs going to be addressed ?
These are the questions that will appear on the new learning log category screen
Examples of evidence:
A review of referral letters and the response letters back from the hospital may provide evidence of correct clinical abnormalities assessment and identification. They may also show appropriate examination in relation to the clinical scenario.
Random case review and surgery debriefs may show appropriate examination relating to the patient problem and a focused rather than complete examination of specific areas.
Directly observed consultations and videos will allow demonstration of all areas from examination selection, focused performance, communication, consent, ethical, cultural consideration and subsequent management using the findings elicited.
Models allow for detection of abnormalities and correct process of examination and procedural skills.
At the beginning of a placement there should be a specific discussion between the educational or clinical supervisor and the trainee aimed at agreeing which clinical and procedural skills need to be developed during that placement. This should form the basis of a Personal Development Plan (PDP) entry.
In a general practice placement we recommend that in the first few joint surgeries educational and clinical supervisors specifically but informally assess the trainee’s attitudes and approach to clinical examination. If necessary this might lead to further PDP entries where needed.

9. Consultation Observation Tool Criterion 6
3. Included as part of the COT / MiniCex
New wording in italics
Consultation Observation Tool Criterion 6
This competence will be about both the appropriate choice of examination, and performance when directly observed . A mental state examination would be appropriate in a number of cases. Intimate examination should not be recorded (on video), but directly observed. The observer may also choose to write an assessment form.
The recommendation is that about half of the consultations assessed using the Consultation Observation Tool (COT) should be done on live, rather than recorded, cases and where possible those done live should target cases where the examination technique of the trainee can be observed and assessed under criterion 6.
In addition Case Based Discussions are a useful way of assessing and giving formative feedback on a registrar’s knowledge of, and attitudes towards, the ethical considerations surrounding clinical examination of patients in general, and intimate examinations in particular.

10. 5. Three Questions in the ESR
1. Are there any concerns about the trainee’s clinical examination or procedural skills?
If the answer is, “yes” please expand on the concerns and give an outline of a plan to rectify the issues.
2. What evidence of progress is there in the conduct of genital and other intimate examinations
(at this stage of training)?
Please refer to specific evidence since the last review including Learning Log entries, COTs and CBDs etc.
 3. What does the trainee now need to do to improve their clinical examination and procedural skills?
The Clinical and educational supervisors will be asked 3 questions within the skills log section of the review.
In particular the ES is required to comment on the trainee’s skills in conducting intimate examinations.
Trainees and Educational supervisors are required to comment on the evidence of progression in Examination and procedural Skills within the 6 monthly ESR.
This will occur within the trainee’s and ESs assessment of the competencies.
They will also be asked to advise on learning objectives before the next ESR
A trainee will need to be competent for licensing in Clinical Examinations and Procedural Skills to obtain their Certificate of Completion of training  
It is the responsibility of both the trainee and their trainer to ensure that there is sufficient evidence of competence recorded in the ePortfolio

11. Discussion
Assessment of progress Longitudinal approach v. cross-sectional Workplace based Learning Expert judgements of experienced trainers The intimate examination and the invasion of personal space Integrated needs based agenda for learning v. Disjointed prescribed ‘tick box’ lists.
Integrated DOPS The broad assessments that we make of communication and consultation skills, data gathering and decision making all draw on a wide range of direct observations and discussions. There are aspects of clinical care such as red flag symptoms, the psychological context and hidden agendas which are all integrated into our assessments and none have a separate and distinct check list. So it is with the examination we use as part of our clinical assessment. The clinical examination and procedural skills are integral to detecting or confirming diagnosis and implementing management plans.
Mandatory DOPS enabled the assessment of a skill at a single point in time.
Integrated DOPS allows for a longitudinal view of professional development.
In WPBA the trainer and the trainee need to provide evidence of progression in examination and procedural skills throughout the GP training programme
Burden of assessment
Integrated DOPS will ease the burden of assessment.
The educational and clinical supervisors are no longer required to present evidence for their professional opinion about every trainee’s examination skills. The ESR no longer has a ‘Skills screen’, instead the educational supervisor will be asked if they have any concerns about the appropriateness and skills of physical examination. They will only be required to give more evidence if there is a problem - just as they would if a trainee kept omitting to check for red flags or ignored the patient's feelings or social context.
Expert judgement
The assessment of competence in this wide range of skills must be entrusted to the experience and discretion of the clinical and educational supervisors. There is a wide range of procedural skills relevant for general practice but there is not yet a clear consensus about which should be the core skills. However there is agreement that skills in the intimate examinations are essential to competent general practice. The learning needs of individual trainees will vary enormously. The stage of training the previous experience the learning opportunities of each training post will all have a bearing on the learning agenda.
 Workplace based learning
There is a move away from WPB Assessments towards WPB Learning. The GMC and AoME are collaborating on a generic model of Supervised Learning Events (SLEs). This accumulation of low stakes events will form the evidence base for a more summative assessment of progress (AoP). The six monthly ESR provides the record of progression in all the professional competencies. Integral to this progress is the acquisition of skills such as IT, consultation, and DOPS
Invasion of privacy
In the consultation process there was a clear consensus that special attention should be given to the development of competence in the intimate examination. The intimate examination is synonymous with the pelvic examinations for both sexes and these clinical skills are formally assessed in the foundation years. It has also been recognised that for many patients the act of touching and the invasion of one’s private space is just as discomforting. GPSTs should be able to demonstrate continuing progress in these broad clinical skills during the training programme.

12. ‘CEPS’ - Implementation
Time constraints
Assessment of intimate examinations
Gold standard for GP
Contractual requirements
Video v. direct observation
Trainers as DOPS assessors
Managing the change
Guidance and training for trainers
The full physical examination
Communication skills during examination
The skills lab
‘Rational’ examination
‘Rational’ procedural skills
Assessment of intimate examinations
The time spent in observing trainees conducting intimate examinations will again depend on the skill level and learning needs of the trainee at any given stage of the training programme.
Gold standard for GP
There is no agreed gold standard or prescribed list of core skills for DOPS. But a detailed reading of the GP curriculum indicates how clinical skills are integral to good GP practice.
Video v. direct observation
Video recording of many clinical examinations, especially musculo skeletal and neurological examinations, are suitable for integrated DOPS. However, the intimate examination in all its forms must be directly observed.
The full physical examination
The full physical examination as might be conducted for an insurance medical has been suggested as a convenient method of assessment for DOPS. There may be merit for this approach in the early days of a GP post but it would not be the optimal method for the assessment of progress and the careful selection of examinations appropriate to the clinical context. 
The skills lab
Similarly the skills lab may have a place in assessing progress in a trainee needing special support. Before completion of training, that trainee should be able to demonstrate
‘Rational ‘ examination
Rational prescribing has been developed to balance clinical need with financial constraints. There are increasing financial constraints on laboratory and imaging investigations and it is for the GP to make a ‘rational clinical assessment’ before referring patients to hospital. Effective examination enhances rational clinical assessment.
[The consultation process has indicated that there is a debate to be had by the GP educational community to determine what and how much is enough assessment of psychomotor skills in general practice.]