WPBA: Clinical Examination and Procedural Skills (CEPS)

GP registrars should be completing CEPS throughout training and some CEPS must be added in each training year (ST1 and ST2 as well as ST3) that are relevant to the posts in that year. For complete clarity, if no CEPS relevant to post had been completed in a training year, this would not meet the requirements for that year.

By the end of ST3 evidence of the following must be included:

• The intimate examinations (breast, rectal, prostate, female genital, (which includes a bimanual and speculum examination) and male genital examinations). All of these must be completed and a suitably trained professional will need to observe and document performance on a CEPS evidence form.

A range of other Clinical Examinations and Procedural Skills relevant to General Practice which demonstrate clinical competence. 7 “system” GP focussed observed CEPS categories are included in the Clinical Examination and Procedural Skills section of the Portfolio (Respiratory system, Ear Nose and Throat, Abdominal system, Cardiovascular system, Musculoskeletal system, Neurological examination, Child 1- 5 years). For complete clarity, a range cannot be demonstrated with just 2 CEPS, nor could it be demonstrated with CEPS of only one type (i.e. 3 "ENT" CEPS). A suitably trained professional will need to observe and document performance on a CEPS evidence form.

CEPS cannot be assessed in a skills lab – this will not be sufficient evidence of competence. A full insurance medical examination would also not be sufficient to provide evidence of clinical competence (the extent of the examination in such a situation is determined by the insurance company and not by the clinician and may not be performed within the length of a normal GP consultation).

Once the Educational Supervisor is satisfied that the evidence provided for a specific CEPS is sufficient, that CEPS does not need to be repeated.

By the end of training the Educational Supervisor must have observed or have documented evidence from others that the GP registrar is competent in general and systemic examinations in the clinical curriculum areas.

There are intimate examinations which need to be specifically included, as these are mandated by the GMC. These include breast, rectal, prostate, male genital examination and female genital examination (which includes a speculum and bi-manual pelvic examination).

GP registrars to be observed performing the intimate examinations by a suitably trained professional. The assessor records their observation on the CEPS evidence form. If this is another doctor, they must be at ST4 level or above, or an SAS equivalent. If the assessor is another healthcare professional, such as a specialist nurse, they must confirm their role and training so that the Educational Supervisor can be satisfied that they have been appropriately trained.

A separate log entry could be written on any of these specific skills.

The intimate examinations should not be considered as a ‘minimum requirement’ on their own and they cannot by themselves demonstrate overall competence in CEPS. A range of observed assessed CEPS which are relevant to general practice are also required. 7 “system” observed CEPS categories are included in the CEPS section of the Portfolio to help meet this requirement.

These are:

• Respiratory system
• Ear Nose and Throat
• Abdominal system
• Cardiovascular system
• Musculoskeletal system
• Neurological examination
• Child 1- 5 years

This again is not an exhaustive list, nor is there a set minimum number as everyone has different needs. Performance in CEPS should be documented in the Trainee Portfolio and learning needs discussed during placement planning meetings with supervisors. The range of examinations, procedures and the number of observations will depend on a GP registrar's particular requirements and the professional judgement of their clinical and educational supervisors.

For example, a GP registrar may recognise that their learning needs to include more experience of joint examinations, or doing a new-born baby check, and discusses with their supervisor how these can be addressed. Supervisors may also recognise areas that need to be addressed by the GP registrar such as completing a mental health state examination within a GP-length consultation. These learning needs may already be known to GP registrars or supervisors, or they may become apparent during consultation with patients.

In addition, it is important to recognise the procedures that may be needed during emergency presentations in general practice. For example, setting up a nebuliser for a patient who is having an asthma attack, and explaining the procedure and process to them.

To be rated as competent in a particular CEPS, it must be performed to the standard of an independent fully qualified GP. 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, and perform it within the length of the GP consultation.

There are a set of CEPS for which evidence of competence is required by the GMC – these are breast, rectal, prostate, male genital examination and female genital examination (which includes a speculum and bi-manual pelvic examination). These are referred to as the “intimate” examinations for the purposes of grouping them together as they must all be completed. However, it is worth noting that there is no single definition of what constitutes as "intimate" examination and other examinations may be considered intimate by patients. For example, the examination of the eye with an ophthalmoscope is considered by many 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, demographic and other factors.

All GP registrars including those with a disability need to meet the requirements for WPBA, including those for CEPS. However, there will be some disabilities that means a CEPS cannot be personally performed by the GP registrar.

In these instances, GP registrars should:

• recognise when a disability prevents completion of an examination
• understand the examination required, and that it is a necessary part of the consultation
• facilitate a patient examination in a timely fashion
• demonstrate that they know what to do with the findings.

If a GP registrar feels this guidance may apply to one of their examinations (regardless of whether it is a mandatory examination or not) they should discuss this with their Educational Supervisor/Programme Director in the first instance.

As an example of how to facilitate a patient examination in a timely fashion one possible approach might be that a GP registrar who cannot personally carry out an examination refers the patient to a colleague, and then:

• instructs the colleague to examine the patient appropriately
• interprets the findings having communicated with the colleague who carried out the examination.

In a training context, to satisfy the CEPS requirement, the observer (who could be the person who performs the examination) should document on the assessment form the part of the CEPS they did observe, and document why it was necessary for the examination to be done in this way.

This should be added into the observation and feedback performance box on the assessment form.