MEDICINE: the CEX life of junior doctors

“…not everything that can be counted counts, and not everything that counts can be counted.” – 1957, William Bruce Cameron, Informal Sociology


It’s been a year since I passed the FRCA Primary (I’ll explain what this is shortly). As such, I thought this topic was a good one to start the medical component of this blog.

For doctors, assessment doesn’t stop at medical school. The various Colleges (e.g the Royal College of Physicians, Royal College of Surgeons) are responsible for setting standards within their respective specialties

To that end, a variety of acronyms are used to test trainees. ‘Trainee’ means a fully qualified doctor on a training scheme to be a consultant. (It is not a medical student.)

Firstly, there are exams:

  • SOE (Structured Oral Examination) – a short semi-structured viva.
  • OSCE (Observed Structured Clinical Examination) – a multi-station practical exam on anything from procedures on dummies to communication to anatomy
  • SAQ (Short Answer Question) – short essays
  • MCQ (Multiple-Choice Questions)

Then there are workplace-based assessments (WBAs):

  • CBD (case-based discussion) – the trainee has a structured discussion with an assessor around a case in which they were involved.
  • Mini-CEX (mini clinical examination) – assessor watched the trainee take a history and/or perform an examination and then provides feedback.
  • DOPS (direct observation of procedural skill) – assessor watches the trainee perform a procedure.
  • MSF (multi-source feedback) – the doctor is assessed by 15-20 peers of varying disciplines who comment on competence and professionalism.

Tired of the acronyms yet? This is not exhaustive.

First, let’s talk exams.

You can’t revise at 5am

These exams are hard. Referred to as Fellowship or Membership exams depending on College, failure rates of 40-50% are commonplace in many (possibly most) specialties. They are mandatory to become a consultant.

They’re expensive. Anaesthetists pay £1935 (320 + 590 + 470 + 555) and GPs £2131 (489 + 1642) but this doesn’t include revision courses and retakes.

There is debate about the relevance of some content. (Do I really need to know how a horse hair hygrometer works to be a competent anaesthetist?) But this is not the full story.

Simply, doctors are allocated little or no time to study. As such, one ends up revising on night shifts and at weekends. As an example, the FRCA (Fellowship of the Royal College of Anaesthetists) examinations are split into two sets – Primary and Final.

The general advice is to set aside 6 months for each component. Not 6 months off work – 6 months of your social life on top of a rota working 2 in 7 weekends.

Organise your own exam room

Doctors also need to complete WBAs (including the CEX in the title). There is some issue as to the validity of these. They’re designed to be formative (to aid learning) not summative (to assess competence) but are used for the latter nonetheless.

Rather than being organised by supervising consultants, junior doctors arrange assessments themselves. To my mind, this is akin to asking an A-level students to administer their own exam.

Arguably, it’s an assessment of the ability to find a willing consultant, rather than ability as a clinician.

The sheer volume of WBAs has grown. Anaesthetists need an assessment every other day on top of exams. This doesn’t include reflection, supervisor meetings, personal development plans, probity statements…

The electronic or e-portfolio should make this easier. It doesn’t. Each assessment has to be linked to the correct part of the syllabus in order to pass an appraisal. Doctors have failed to progress due to clerical rather than clinical errors.

Oh, just stop being so whiny

On top of the issues leading to the junior doctor strikes, the number of these assessments is slowly increasing. Assessment does need to happen but the attitude of ‘more, more’, of ignoring the time required to pass exams and a lack of engagement from some consultants adds to what is already a stressful job.

Anaesthetics might be oversubscribed but the last thing we need is another reason for doctors avoid general practice or leave emergency medicine.