Clinical Examination and Procedural Skills (CEPS) and Intimate Examination guidance

Summary

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:

Five mandatory intimate examinations. A suitably trained professional will need to observe and document your performance on a CEPS evidence form.
A range of Clinical Examination and Procedural Skills relevant to General Practice.

Introduction

Competent Clinical Examination and Procedural Skills are fundamental to effective general practice. Relevant evidence for this capability needs to be gathered regularly throughout each review period and recorded in your ePortfolio. As with the other capabilities there are a set of word descriptors to help you reflect on your progression as you acquire these skills.

Which skills need to be assessed

There are five intimate examinations, which need to be specifically included, as these are mandated by the GMC. These include breast, rectal, prostate, male genital examinations and female genital examination, to include speculum examination and bimanual pelvic examination. You need to be observed performing these 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. If the colleague is another health professional - such as a specialist nurse - they must confirm their role and training so that your Educational Supervisor can be satisfied that they have been appropriately trained. You may also decide to write a log entry on any of these specific skills but this would be in addition to the CEPS evidence form.

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 observed, and commented on during your training.

The five mandatory examinations are not a 'minimum requirement' and cannot by themselves demonstrate overall competence in CEPS. A range of CEPS which are relevant to general practice are also required. This again is not an exhaustive list, nor is there a set minimum number as everyone has different needs. You are expected to document your performance in CEPS in your learning log and /or discuss your learning needs during placement planning meetings with your supervisor. The range of examinations, procedures and the number of observations will depend on your particular requirements and the professional judgement of your clinical and educational supervisors.

For example, you may recognise that your learning needs are joint examinations, the examination of the eye or doing a newborn baby check and if needed, you can discuss with your supervisor how these can be addressed. Your supervisor may also recognise areas that need addressing such as how to do a neurology examination within a GP-length consultation or examine a diabetic patients feet correctly.

You may already be aware of specific CEPS you want to address but these can equally become apparent during your consultations with patients.

In addition, it is important to recognise the procedures you may need during emergency presentations in General Practice; for example can you explain to a patient who is having an asthma attack what you are going to do, set up and start them on a nebuliser?

Completion of CEPS

These can occur in a variety of ways and these include;

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)
MSF
CSR

You will not be able to be signed up as competent in CEPS by your Educational Supervisor during your final review, unless there is observed evidence of the 5 mandatory intimate skills and a range of CEPS relevant to General Practice. This will also be reviewed at your ARCP and an unsatisfactory outcome given if these are not present.

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:

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 rectified.
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, male genital and female pelvic examinations.
For final review only: Is the trainee competent in breast, rectal, prostate, male genital and female pelvic examinations? Please refer to specific evidence including Learning Log entries, CEPS, COTs and CbDs etc.

Useful links

CEPS information for trainees and supervisors [PDF]

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.

What if I am unable to complete a CEPS due to disability?

All GP trainees regardless of whether they have a disability need to meet the required competences to ensure patient safety is maintained. This though includes having the insight to recognise when your disability prevents an examination from being completed, understanding which examination is needed and that it is a necessary part of the consultation, being able to facilitate your patient having the examination in a timely fashion and demonstrating that you know what to do with the findings.