Training principle of the month 10: Assessment is used as a learning tool

It is easy to see assessments as a tick box exercise, rather than as the learning tools they were originally intended to be. This month we hear about how assessments can be used effectively through a variety of case studies, a conversation with Head of School for London School of Paediatrics and a training presentation.
RCPCH Progress+ Training principle of the month
Last modified
2 September 2022

From children and young people

We think it's important you have children, young people and families involved in RCPCH assessments. We've been trying out new ways to do this for MRCPCH exams and RCPCH START (assessments) - thinking about using emojis, and having children and young people write questions and give feedback.

In 2019, we shared ideas on all parts of the Progress curriculum, which can help know what's important to us in your assessments.

See RCPCH Progress - what the domains mean to children and young people

Get the elephant out - video

One of the challenges of being a paediatrician is you have to be good at a lot of different things.

Dr Parisut Kimkool sat down with Dr Jonathan Round, Head of School at London School of Paediatrics, to discuss how to use assessments effectively in this video.

Assessments in action

Sometimes seeing worked examples makes it easier to understand how to put things into practice. Dr Hannah Davies, Dr Daniel Evans, Dr Patrick Joseph Mullaly and Dr Jennifer Williams have put the following cases together.

Be opportunistic! - case study

Setting: Children's Assessment Unit (CAU)

Assessment type: Mini-CEX (Clinical Evaluation Exercise)

Participants: Paediatrics ST1-3 and Paediatric Consultant

What happened? An 18-month-old male is referred in by the GP with a petechial rash to his face and neck. The paediatric trainee covering CAU notices the consultant is free and asks them to observe them taking a clerking in the patient.

Following a quick initial review, the trainee and consultant are happy the child is not critically unwell, and the assessment can take place safely. The trainee proceeds to take a detailed history from the carer. Over the course of the history taking, the trainee correctly addresses all possible red flag symptoms and determines that the child has had several episodes of vomiting and diarrhoea over the last two days, with the petechiae appearing this morning. The trainee proceeds to examine the patient and summarise their findings to the consultant. The trainee proposes a management plan but, given how well the child looks, remains uncertain about how far to take investigation of the petechiae and whether to start antibiotics.

While the trainee was taking the history from the carer, the carer became incredibly upset. The GP had mentioned meningitis to them, and they were very worried about this. The trainee listened to their concerns and calmly reassured them. The consultant was impressed with the trainee’s ability to handle this unexpected event.

How can this scenario support the trainee learning? The trainee discusses the case with the consultant in CAU once a management plan has been started. The consultant recognises that the trainee had independently assessed the patient, had come up with sensible differential diagnoses and settled on a reasonable primary diagnosis, had planned appropriate investigations, and had started a management plan based on their primary diagnosis. The consultant then proceeds to address some of the knowledge gaps and directs the trainee’s attention to recent studies of petechiae in children.

The consultant completed two mini-CEX’s for the trainee - one for Domain 4 on patient management, and another for Domain 2 on communication.

Any practical tips​?  The most efficient way to completing a portfolio without dedicating lots of extra time at home is to utilise everyday scenarios for multiple types of assessments. The truth is we demonstrate many domains daily but fail to get them formally assessed. Stop. It’s time to make portfolio work for you. As Tom Clancy put it, “Every person you meet - and everything you do in life - is an opportunity to learn something!”

Assessments should be tailored to the needs of the trainee - case study

Setting: Resus Bay, Paediatric Emergency Department

Assessment Type: Leader CBD (Case Based Discussion)

Participants: A paediatric emergency medicine (PEM) sub-specialty ST6 supervised by a PEM consultant, alongside a resuscitation team (PEM nurses, paediatric registrar, paediatric SHO)

What happened? The emergency department is pre-alerted to the imminent arrival of an acutely unwell 6-year-old with shortness of breath. The PEM ST6 is asked to lead the resuscitation under the guidance of the PEM consultant. They call all the paediatric team to help, predicting a very unwell child based on the pre-alert. The PEM registrar then proceeds to lead the team as they manage the acute presentation.

Following a successful resuscitation and safe transfer to the ward for ongoing care, the PEM ST6 and consultant discuss the management of the case, with a particular focus on the skills employed when leading a team.

How did this support training and trainees​? This scenario specifically addressed Domain 6 on leadership and team working, by enabling the trainer and trainee to shape the discussion and feedback after the event to a multitude of different leadership and team-working qualities within the scenario. The simulated scenario specifically enables the trainee to test these skills and a reflective discussion after this will allow them to identify where improvements may be made.

Any practical tips​? Learning conversations must be dynamic. The areas of focus for the discussion during the assessment can be tailored to support the trainees specific learning needs. Therefore, the same resuscitation may have different learning points for different trainees. It is important for a trainee to reflect regularly on their own skills, so they can assist the trainer in directing feedback to the aspects they wish to develop. Similarly, trainers may identify aspects of learning that the trainee may need to develop but have not recognised themselves.

Assessments can showcase development - case study

Setting: Neonatal Intensive Care Unit

Assessment type: DOPS (Directly Observed Procedural Skills)

Participants: A Paediatric ST2 being supervised by a neonatal sub-specialty ST7, who is in turn being supervised by a neonatal consultant.

What happened? A 30-week gestation neonate was admitted to the neonatal unit and were subsequently screened for sepsis. A few days later the baby deteriorated and needed intubation. A consultant neonatologist, a neonatal ST7 and a paediatric ST2 were present. This was used as an opportunity for the ST2 to attempt intubation, having witnessed several beforehand. The ST7 supervised the ST2 for the intubation, while the consultant supervised the ST7. After an unsuccessful attempt by the ST2 they were intubated by the registrar under the consultant’s supervision.

How did this support the training and trainees? Despite the attempt being unsuccessful, the ST2 demonstrated several key skills that showed they were ready to intubate, including adequate preparation, deciding on team roles, and ensuring there were contingency plans in place. They received feedback from the ST7 about how they could improve their technique for a future attempt. A DOPs for intubation was completed, which the ST2 reflected on. This DOPS was linked this to Domain 3 on clinical procedures.

Any practical tips? It is important for trainees to be proactive in seeking learning opportunities and to have them documented in the form of assessments when possible. In this case, it is also worth noting that an unsuccessful attempt at a procedure is still a useful DOPs to have on record, as a future successful attempt at the same procedure will now clearly demonstrate progress.

Also, when there are several seniors present, there are ample learning opportunities for the assessors too! In this case, for example, having a consultant witness the ST7 lead and supervise junior colleagues, opens options for a formal assessment to take place for the ST7.

A single event can offer multiple assessment opportunities - case study

Setting: Community Paediatric Clinic

Assessment type: Safeguarding CBD

Participants: A senior paediatric trainee and a paediatric consultant.

What happened? A child is seen by the paediatric registrar for a child protection medical as part of a community paediatrics rotation. The supervising consultant is asked to sit in on the consultation to observe the injuries, and it’s been prearranged that they will conduct a child protection CBD on this consultation. The outcome of this medical requires the child to have further investigations which demonstrates further injuries, and these results need discussion with other agencies including social services and police as well as parents. The registrar leads on organising the multi-disciplinary teamwork.

How did this support training and trainees? This scenario specifically addresses Domain 9 on safeguarding. Safeguarding cases can require a significant amount of work liaising between agencies and with parents and so is a perfect opportunity for a trainee to take a leadership role under the consultant’s supervision and complete a safeguarding CBD.

Other assessment opportunities can emerge from a single case. Often reports are required for court proceedings which can be prepared by a trainee in conjunction with a supervisor and so is an opportunity for a DOC (Discussion of Correspondence) assessment. These cases are usually discussed at departmental Peer Review which is a prime occasion for a trainee to present the case to colleagues and obtain a mini-CEX. 

Any practical tips? All of this represents work that many trainees are already undertaking and by normalising including assessments in our day to day work we can maximise the educational value of common scenarios and get recognition the for the hard work we are already doing! This is also an example of a common situation with multiple opportunities to use assessments to structure and record a trainee’s development. 

What's the evidence? - training presentation

Educational strategies need to be evidence-based in much the same way that clinical strategies do. Dr Assim Javaid and Dr Jong Eun Song have created the following presentation for you to use locally, which explains the evidence base for using assessments as learning tools. Download as a PowerPoint presentation or PDF below.

Find out more about what to expect from Progress+

This month we heard from trainee Dr Parisut Kimkool (ST5, London North West Deanery), and several trainees from Wales Deanery - Dr Hannah Davies (ST5), Dr Daniel Evans (ST2), Dr Assim Javaid (ST6), Dr Patrick Joseph Mullally (ST3), Dr Jong Eun Song (ST2) and Dr Jennifer Williams (ST5).