Why?
This is not just change for change’s sake. While there are important external drivers, our review is primarily about the aligning our assessment strategy to the Progress+ curriculum, which was introduced in 2023, to guide learning and to ensure doctors in training have the capabilities they need as paediatric consultants in the 21st century.
Clinical examination skills should be taught and assessed in the workplace with early years doctors in training
The current MRCPCH Clinical exam was designed to mark the end of level 1 training, at the transition point from SHO to registrar in old parlance. We have valued the involvement of children and young people in our exam, but examining clinical systems on different patients, from compliant and well-rehearsed teenagers to fractious toddlers, means that the reliability of the exam is not as high as it could be. Our wonderful host examiners do a fabulous job organising the exam. And our examiners (all volunteers) give up their time, often over several weekends each year. These factors make it increasingly difficult to ensure the exam’s sustainability.
Most importantly, the MRCPCH clinical exam now sits at the end of ST4. This is at the transition between core training and specialty level training, when doctors in training have already been on the tier 2 rota as a registrar for at least a year, and marks the point of readiness for specialty level training as a more experienced and independent tier 2 paediatrician. The key clinical skills to test at this point are more complex decision-making and clinical reasoning, as well as communication with families, patients and colleagues.
Clinical examination skills are something that should be taught and assessed in the workplace with early years doctors in training to equip them to provide reliable care and to assess children and young people in their tier 1 roles. This is why we propose a new mandatory, summative assessment, Observed Assessment for Clinical Skills, more of which below.
...many elements covered in START are now approached more holistically in training
START (Specialty Trainee Assessment of Readiness for Tenures) has been a valued, mandatory formative assessment, developed to assess readiness for consultant working. It is, however, a significant expense for doctors in training and at a single point in training quite late in the pathway. Positively, as our curriculum has matured, many elements covered in START are now approached more holistically in training as a whole. This means the depth of feedback and differences in outcome are less pronounced now for START, so we need to consider what provides the best assessment for doctors in training in the future.
Significantly, both the GMC and COPMeD are not supportive of START continuing in its present form and therefore we have looked at how to transition away from it, taking the best things about it and delivering these within day-to-day training.
The current higher years assessment structure is somewhat light on assessments to drive development towards consultant capabilities, so we have taken this opportunity to review that.
What?
Workplace-based assessments (WPBAs)
Importantly, we are continuing our approach of quality over quantity: no minimum numbers of the mini-cex and CBD assessments. We would like to update these to be truly formative, so they are less formal and more part of business as usual. They should be tools to easily record learning from encounters in the clinical environment and those discussions and small episodes of practice and feedback that should be happening routinely for all doctors in training.
The development log will become the reflective log and work more in alignment with the key capabilities of the curriculum.
We have developed and piloted three new mandatory WPBAs with the valuable input from doctors in training, trainers and College faculty:
- Observed Assessment of Clinical Skills (OACS): A summative mandatory assessment designed to be somewhat akin to a DOPs (Directly Observed Procedural Skills) but for clinical systems examination. It will sit in the early years of the assessment table at ST1-2 and require that doctors in training be signed off as capable of examining a range of systems. There will be some choice but a developmental assessment will be a mandatory system to drive learning in this important and sometimes neglected area. Doctors in training will need to have their OACS signed off before sitting the MRCPCH Clinical exam.
- Professional Conversations (PC): A formative mandatory assessment and is a development of the current LEADER assessment, ensuring that the focus of the discussion is a broad leadership topic, generally not directly clinical but focusing on topics such as service development, resource management, ethical issues, management of death. There is a long list of suggestions and doctors in training will be able to choose topics relevant to their specialty training path.
- Paediatric Entrustment Assessment for Consultancy (PEAC): A mandatory summative assessment and covers capability in an area of practice typically undertaken by a consultant, examples include running a ward, conducting an outpatient clinic and other examples relevant to different specialty pathways. It's designed to be completed at ST6-7, and a variety of WBPAs and reflective logs will be brought together with local faculty feedback and a discussion with a supervisor to determine capability and an entrustable decision as well as formative feedback.
MRCPCH Clinical exam
With clinical examination skills now being assessed with OACS, the proposed clinical exam format will remain as an OSCE style circuit. But it will use role players instead of patients and the scenarios will be scored on the same domains: information gathering; clinical decision making; clinical management skills; and patient-centred relationships in healthcare.
The circuit will be standardised and more sustainable, and reliability will improve.
How?
From the outset, these changes have been developed with input and involvement from doctors in training, trainers and College staff.
We have also completed two successful WPBA pilots, a desktop exam pilot exercise and a full four-circuit face-to-face clinical exam pilot. We’re now planning a further pilot of the proposed exam format. We’d like to thank all doctors in training, trainers and examiners who have given up their valuable time to help with the pilots; it truly is appreciated. Feedback has been useful with plenty of positives to take away and suggestions for change which have been taken on board.
The consultation process, which will open later this month, will inform and help us to refine our final plans which we will present to the RCPCH Council before submitting to the GMC. Our aim is to make this submission this summer.
It is likely that the new assessments will be rolled out as optional during the 2026/27 training year before a new mandatory assessment strategy for the 2027/28 training year.
The new MRCPCH Clinical exam will follow; timing wise, this is likely to be during 2027 at the earliest. For now, START remains a mandatory part of the assessment strategy and a transition away from START will not be implemented until the other changes are in place.
We recognise that change is challenging and that many of you have experienced several changes in training over the last few years. We will work to ensure that transition plans are clearly communicated and that all implications are taken into consideration.
Our vision is of an assessment and exam structure which is sustainable, fit for the future and driving development of high-quality training, embedded in business as usual for everyone. We want to continue to be proud of UK paediatric training as a marker of excellence.
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