Writing SLEs

SLEs are supervised learning events that include

  • Mini-CEX (mini clinical evaluation exercise)
  • CBD (case-based discussion)
  • DOPS (direct observation of procedural skills)

These form part of the compulsory e-portfolio, but most aren’t taught how to complete them effectively & make them useful. As a registrar, I have sent & signed a large number and there is a great variation on what people do with them. This is my take on how to make them useful.

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What is the point of SLEs?

Workplace-based assessments were introduced to enforce structured continuous assessment with more rigorous feedback. These are then linked to the curriculum objectives to ensure your assessments cover all the things you need to know. The aim is to somewhat prioritise training over simple service provision, allowing your learning needs to be evaluated and for you to be given constructive feedback to allow advancement.

Your SLEs may be looked at under the following circumstances

  • At each meeting (with your clinical/educational supervisor)
  • At ARCP (annual review of competency progression) where your portfolio is looked at by a panel (usually without you being there) to judge whether you “pass” the year
  • You may print some off to showcase your commitment during specialty interviews
  • Potentially when a complaint is raised or you’re investigated to show whether there is a pattern of poor progression and what multiple staff members have thought about you over the years

Therefore your SLEs must indicate the growth you are undergoing as a doctor. They should highlight what you have done well & what you are looking to improve on.

How to get it right

The SLE should therefore be structured to consider all of the above circumstances. By focussing on what you did well, you become better at answering interview questions with the same focus. For example, if asked “what are some key attributes an IMT doctor needs to deal with an emergency”, instead of listing qualities you showcase with a written example how you can demonstrate the key attributes required and constantly evaluate your own performance. This means you should do far better in the interview.

Detailed Example

Mini-CEX and CBDs follow a similar format; the difference is that a CBD would be more of a discussion. Here is an example of a mini-CEX, yours doesn’t need to be this long!

Title: ABCDE assessment of an unwell patient

The “Title” allows the reader to immediately know the focus of what you have done.

Brief anonymised history: Elderly nursing home patient with dementia admitted with fall & NOF# developed delirium & hypoxia. Under the supervision of my registrar, I led the nursing & therapy team through an ABCDE assessment to evaluate the cause of the hypoxia and initiated treatment for a HAP. I communicated with the family regarding the deterioration & discussed ceilings of care helping to deal with their concerns and anger.

The “Brief anonymised history” does not include any patient identifiable details & gives as little information as is necessary to understand the patient’s issues. It is not a copied & pasted clerking or an endless list of past medical history and investigation results.

Focus of encounter: Medical record keeping, clinical assessment, investigations, treatment, follow up, professionalism

The “Focus of encounter” lists as many items as possible. This allows mapping to more curriculum items and helps you include all aspects of the case (documenting, communication, clinical assessment etc.).

Feedback based on behaviours observed: Dr Doshi promptly responded to an unwell patient competently performing a thorough ABCDE assessment. He organised appropriate investigations and appropriately empirically treated the patient for a probable HAP, whilst excluding other differentials such as a PE or COPD exacerbation. He escalated promptly, appropriately asking whether ceilings of care should be put into place in case of further deterioration overnight and ensured he handed over to the on-call team. He dealt very well with an agitated patient.

I was impressed with how he coordinated the nursing team, asking them by name to perform tasks and report back to him. I also liked how he debriefed with the MDT to ensure everyone had an opportunity to reflect on what went well and how teamworking could be improved in the future. I was also impressed with how he explained what had happened to the family and dealt with their anger that this had not been picked up sooner. His excellent bedside manner meant the family felt they had been listened to and confident in the treatment had been put in place.

An improvement would be to speak out loud the differentials he is considering, such that the whole team is aware of what is being considered. When he did this with some prompting, the nursing team then were able to suggest they could call the x-ray department to organise a portable CXR.

A further improvement would be to consider the causes of delirium more thoroughly including the indications for a CT brain.

The “Feedback backed on behaviours observed” can discuss different skills required which you can usually find in an application handbook. They tend to be quite generic so useful for all applications (e.g. leadership, communication, IT skills, clinical) the focus is different for different specialties e.g. more on practical skills for surgery.

Agreed action: Speak out loud your thought process at the next ABCDE assessment. Dr Doshi plans to do the delirium teaching session at the next FY1 teaching, using this as an opportunity to showcase the learning he will do as a result of this SLE.

I always like to use the SMART framework here. It allows for an achievable action rather than what most people write which is “improve management of x situation”.

  • Specific (defining exactly what you intend to do)
  • Measurable (be able to provide evidence that you’ve done it)
  • Attainable (actually something you can do)
  • Relevant (align with long term objectives e.g. specialty applications)
  • Time-based (have a realistic end-date e.g. by the next case or a certain time period)
S.M.A.R.T Goal Setting Practices for Project Managers
Reflection: I was very happy with how I managed to stay calm during my ACBDE assessment of this patient. I enjoyed compliments from the nursing team regarding my effective leadership and communication with them and the family. I felt very nervous dealing with my first emergency, particularly because I couldn’t remember all the causes of delirium. It was really helpful to realise that I could’ve spoken out loud that I think this patient had delirium & used the team around me to consider a full list of causes. I volunteered to do the delirium teaching for the FY1s to obtain more confidence & showcase what I have learnt.

For reflection, if you’re unsure how to construct this you can consider Gibb’s cycle. Another place for you to showcase what you did well & demonstrate that you’re looking to grow.

gibbs reflection cycle

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