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)
  • LEARN (learning encounter and reflection note)
  • LEADER (clinical leadership, work-based review)
  • DCT (developing the clinical teacher)

These form part of the compulsory e-portfolio. There is lots of conflicting information regarding how may are required, and this will often vary by trust. Guidance for FY2 is that you need a minimum of 5 unique SLEs to map to the first five learning outcomes. Although if you aim for 5 per rotation as a rule of thumb you will end up with more than enough to map to the curriculum sufficiently.

Despite their importance, they are often not taught or explained well. Often you have to explore them yourself and work out how to use them through trial and error. This guide aims to offer more information surrounding the SLEs, including where and how you can potentially use them.

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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 (mapped) 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.

When to use each type of SLE

Mini CEX

This is one of the SLEs that you will probably being using the most it is a very good option when you carried out an aspect of medical care. This could include things like an A-E approach, family discussion or breaking bad news. It covers more detailed clinical assessment and action than just a more straightforward DOP. These are perfect to map to the HLO 1 section when evidencing your skills which have developed throughout your time as a Foundation Doctor.

CBD

This is the other main SLE you will probably be completing often. This is perfect for evidencing informal teaching discussions and personal growth resulting from these. Often these will be following discussions with your seniors regarding an aspect of care, i.e ways of communicating or the knowledge and background of the speciality you are currently working in, e.g. ECG interpretation. Finding different ways to creativity use these to cover weak points in your portfolio is especially useful towards the end of the year before ARCP.

DOPS

One will probably be more familiar with this from medical school as it will be your standard skills. Excellent for simple skills like suturing or NG tube. For slightly more unique skills like a baby check, try to discuss with a senior to turn in a Mini-CEX or CBD as these are typically more favourably looked upon.

LEARN

This is a more formal way of reflecting and will be a very good option if you have performed and discussed the event with a senior, as they will be able to sign off the experience with you. This is slightly different to a normal reflective form that you can complete be yourself due to the slightly more formal nature of the form.

If the worst were to happen and you are involved in an adverse event or death, then this form could be incredibly useful and form part of a debrief with your seniors. It will provide a very good framework for you to acknowledge and analyse the situation.

LEADER

This form is great if you have created a teaching programme, or lead an audit as it allows you to display a different area of medicine that you may not normally consider. The process of medical leadership is vital for a medical career and should not be overlooked if possible. This allows a great framework to consider in detail what you have done and how it benefited the team you are working in. This is a much longer form compared to some of the others and therefore will require additional time and effort to complete. Whilst not necessary it definitely makes your portfolio stand out from the crowd. Other scenarios you could use this form in include, leading an acute medical situation (e.g. cardiac arrest, met call).

DCT

This form is perfect to complete alongside the other teaching opportunities that you may have already added to your portfolio. It allows for an overview of all the teaching to be collected, along with acknowledgment of the feedback. It is also a really good way to summarise a number of individual teaching sessions as a whole and again will look better than many individual teaching certificates.

Your SLEs may be looked at under the following circumstances

  • At each meeting (with your clinical/educational supervisor), typically at the start and end of your rotations
  • 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. Always try to include your thoughts and feelings as this will make your reflection a lot more detailed and you will really see a growth in the way you approach stressful and acute situations as you move towards the end of the year.

gibbs reflection cycle

Key Points

  • Consider these SLEs early in each block and try to get them completed and signed off early so you do not have to worry about them
  • After the first block, map the SLEs to learning outcomes so you can focus on areas lacking in evidence
  • Don’t be afraid to ask FY2s or other seniors from help and SLE opportunities
  • Try to focus on getting more senior grades to sign these, ideally registrar and above (some CT sign offs are fine)
  • Chase people to sign these off you, they do not count if not signed

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