Clinical Examination and Procedural Skills (CEPS) and Intimate Examination guidance
Competent clinical examination skills are fundamental to effective general practice.
The assessment of clinical examination and procedural skills is, therefore, an important part of GP training. You are expected to demonstrate progress in applying the skills relevant to GP in the workplace during your different posts in training. When you complete training, you must be competent to apply your skills unsupervised.
Clinical Examination and Procedural skills (CEPS) is one of the thirteen competences that are used to guide trainees and Educational Supervisors when gathering appropriate evidence to demonstrate the knowledge, skills and attitudes needed to practise as an independent GP. Relevant evidence for this competency needs to be gathered regularly throughout each review period and recorded on the ePortfolio. As with the other competences there is a set of word descriptors to help you to reflect on your progression as you acquire these skills.
Clinical examination and procedural skills should be interpreted broadly, including the range of skills that any competent general practitioner should be confident in using. There are some particular examinations that need to be specifically included as required by the General Medical Council (GMC) (see below). It is important to note that the evidence provided for CEPS as a competency should not be limited to these examinations and these five intimate examinations are not a “minimum requirement” because they are insufficient on their own to describe the Clinical Examination and Procedural Skills required by a competent GP. A Certificate of Completion of Training (CCT) cannot be recommended unless there is both evidence of competence in an appropriate range of clinical examinations and evidence of competence in these 5 intimate examinations: breast, rectal, prostate, female genital and male genital examinations.
There is no minimum number of assessments to be recorded. Instead, you will be expected to discuss your learning needs during placement planning meetings and to record your plans in the learning log and PDP. The range of examinations and procedures and the number of observations will depend on your particular needs and the professional judgement of your clinical and educational supervisors.
Mandatory requirements from the GMC for intimate examinations:
For the avoidance of any doubt, it is essential that with respect to the five intimate examinations, for which evidence of competence is required by the GMC, this needs to be robust evidence, which should normally involve observation by an appropriate colleague. If this is another doctor this means that they should be at ST4 level or above. If the colleague is another health professional - such as a specialist nurse - this means that they must confirm their role and training so that the Educational Supervisor can be satisfied that they have been appropriately trained. All this evidence needs to be clearly visible to and assessed by ARCP.
It is also important to note that this is not an exhaustive list of intimate examinations and indeed any examination can be considered intimate by some patients (for instance, a competent examination of the eye with an ophthalmoscope), but the examinations listed are those that, due to their particularly intrusive nature, need to be specifically commented on and reflected on during your training.
Evidence for CEPS can be provided by trainees or read by others in a range of places:
- CEPS evidence form (in the evidence section of the ePortfolio)
- Learning logs (there is a filter for CEPS entries)
- Mini CEX
- COT (criterion 6 refers to examination skills)
It is essential you learn how to examine patients within the general practice setting.
To be awarded your CCT, evidence for both of the following must be included:
- an appropriate range of Clinical Examination and Procedural Skills
robust evidence for the 5 mandatory intimate examinations
Educational Supervisor Reviews
The evidence will be reflected on and summarised in the ESR every 6 months along with the evidence for other competences. At each review the ES will be expected to respond to the following questions:
- For all trainees: Has the trainee demonstrated progression in their Clinical Examination and Procedural Skills, commensurate with their stage of training, during the period under assessment? Please comment specifically on breast, rectal, prostate and male and female genital examinations.
- Are there any concerns about the trainees’ clinical examination or procedural skills? If the answer is ‘yes’, please expand on the concerns and give an outline of the plan the trainee needs to follow for these to be improved.
- For those at the end of training: Is the trainee competent in breast, rectal, prostate and male and female genital examinations? Please refer to specific evidence including Learning Log entries, CEPS, COTs and CbDs etc.
Frequently asked questions
What is the range of evidence I need for CEPS?
Apart from the five mandatory examinations as required by the GMC it will be up to you to discuss your learning needs with your Educational Supervisor. The CEPS to be considered and the range of evidence required will depend on various factors such as your prior experience and the nature of your current placement. Remember that you are training to be a GP and so procedures that are unlikely to be performed in a GP setting, whilst interesting to reflect on, are not so relevant. Nevertheless all examinations and procedures have some common features such as the need to gain consent and the need to consider the comfort of the patient.
What are intimate examinations? Is there a definition?
There is no agreed definition of what constitutes an intimate examination. The five examinations for which evidence of competence is required by the GMC are generally accepted examples of intimate examinations but there are many others. For instance, the competent examination of the eye with an ophthalmoscope is considered by many, if not most, patients to be an intimate examination, especially as it requires the examination room to be darkened. Ultimately it is the individual patient who determines what is intimate or invasive for them and this will be determined by a number of possible factors including their prior experiences, their religion and their cultural background.
How many CEPS do I need to do?
There is no set number. There needs to be enough to demonstrate, to your Educational Supervisor’s satisfaction, your competence in CEPS.
What is the standard of clinical examination expected?
The standard is that of an independent fully qualified General Practitioner. As well as the technical aspects of examination and the ability to recognise abnormal physical signs, it includes the choice of examination best suited to the clinical context. For instance, a competent GP very rarely performs an extensive neurological examination but will perform a limited neurological examination as determined by the history taken from the patient.
Can CEPS be assessed in a skills lab?
Training in a skills lab and the use of manikins can be a very helpful adjunct to training in the work place. In general, and certainly in the case of the five intimate examinations as required by the GMC, this will not be sufficient evidence of competence without the demonstration that your skills can be applied in a clinical context.
Would an observed full insurance medical examination be enough evidence?
Although being observed performing such an examination might be helpful it would be unlikely to provide sufficient evidence of clinical competence. For instance, the extent of the examination in such a situation is determined by the insurance company and not by the clinician.
If I have demonstrated competence in an intimate examination does this need to be repeated?
No, if your Educational Supervisor is satisfied that the evidence you have provided for one of the five intimate examinations as required by the GMC is sufficient this does not need to be repeated. However, it is important that this evidence is recorded in such a way that you can remember where it is. The easiest ways to do this is to use the CEPS forms. At the final review before a Certificate of Completion of Training (CCT) is recommended your Educational Supervisor will need to answer a specific question in relation to these examinations.