What is the CPX?

The Clinical Practice Examination (CPX) is a standardized patient-based performance exam, which assesses the application of students’ clinical skills to patient care.  This cumulative exam includes seven cases similar to those faced in outpatient practice.  Each case includes a unique patient encounter and a written patient note or oral case presentation. The entire exam takes approximately four and a half hours to complete.

What Skills Are Assessed?

The following skills are assessed during the CPX:       

• history-taking                      
• information sharing                                         
• physical examination                           
• interpersonal communication
• diagnostic decision-making 
• diagnostic interpretation                                
• management                                                     

What are the Purposes of the CPX?

The purposes of the CPX are to:                         

1)  provide a standard and objective measure of medical students’ clinical skills at the end of the third year of undergraduate medical education.

2)  provide students with additional information about their readiness to move on to graduate medical education.

3)  provide the School of Medicine with information about group performance in          order to assist in the refinement of existing curricula and in the development of new instruction.

4)  provide students with experience participating in an extended performance assessment as practice for Step 2A of the USMLE.

What Happens on the Day of the CPX?

Each student will complete a total of 7 patient cases.  Each case includes two components: 1) patient encounter; 2) written patient note OR oral case presentation

At the beginning of your designated session, you will participate in a brief group orientation.  During this time, you will be given detailed instructions about the examination.

Before entering each patient room, you will be given a chart describing that patient, the setting, and the expectations for the encounter.  You will then have 15 minutes to complete the patient encounter.  You may also be asked to complete a sub-station before or after the patient encounter where you may interpret lab cultures or demonstrate procedural skills.  Following the patient encounter, you will have an additional 15 minutes to complete the computer-based patient note OR orally present your patient, findings, and plan to a resident.

The entire examination will take approximately four and a half hours.  Snacks will be provided mid-way through the CPX.

What Role Should I Portray During the CPX?

Students will take the role of PGY1 residents working in various ambulatory settings, such as a primary care doctor’s office, emergency room, or walk-in clinic. 

Keep in mind that you may interact with a single patient, a patient and a family member, or you may even be asked to interview a patient over the   telephone.  You may also be required to view and interpret cytological findings and present these results to a patient.

Where Do the Cases come from?

The cases for the CPX are representative of common types of clinical encounters experienced in primary care settings.  They are also typical of the types of cases that will be included in the USMLE Step 2A. 

Specific cases are created and/or reviewed by the Faculty Advisory Committee, made up of UVA Clerkship Directors and other clinical faculty. These faculty assure that the cases represent problems with which students should be familiar by the end of the third year.

How Are My Skills Evaluated?

Your performance on the seven cases will be assessed in the following manner:

1. After each encounter, your standardized patient will enter information about your performance into a computer. This information will be converted into a numeric percent-correct score for history-taking, information sharing, and physical examination. Interpersonal communication scores will be computed by averaging the seven numeric rating scale scores from all patients.  The criteria used for each skill area are established by the Clerkship Directors.
2.   You will write a patient note for six cases using the USMLE Step 2 CS format.  For grading efficiency, the note is written on the computer, but paper copies will also be available for hand-written notes if requested.  Physcians grade patient notes using a patient note rubric that evaluates history and physical exam written findings as they are related to the differntial diagnosis and follow-up plan.   The scale used to grade the patient note is a standard five-point Likert, ranging from poor to excellent.
3. .  One case will be evaluated by a trained resident physician.  Your clinical reasoning and oral presentation skills will be reviewed and on an oral presentation rating scale.  The scale used for each encounter is a standard five-point Likert, ranging from ‘poor’ to ‘excellent’.

What Are the Criteria For Passing the CPX?

Students will receive a separate score for each component of the CPX.  Students must pass both components.  The criteria for passing each component are as follows:

1. Students must score above the 16th percentile of the class on three or more cases to pass the patient encounter component.  [Note that the cases are scored separately, which means that it is possible for all students to pass the CPX.]
2. Students must receive a minimum average numeric ranking of ‘fair’ on the patient note and oral presentation.

What if I don‘t do well on a particular case?

Not doing well on one case will not affect whether you pass the CPX!  The criteria have been set so that weak performance on one or even three cases will not justify a recommendation for remediation.  Therefore, during the CPX, do not let one poor performance on a given case influence your performance on other cases. 

What if I don‘t Pass the CPX?

Student performance on the CPX will be reported as Pass or Not Meeting Passing Criteria.  Students who do not meet passing criteria may be given an opportunity to pass a retest in the fall after reviewing their CPX results.  Other students interested in polishing their skills in a performance exam may also be invited to participate in the CPX retest.  Sudents who continue to perform below passing criteria will meet with the Associate Dean for Student Affairs to plan appropriate clinical experiences in the fourth year.  The student’s plan is subject to approval by the Student Promotions Committee and must be completed prior to January of the fourth year.

What are Some Common Mistakes Students Make During the CPX?

1. Not performing all important physical examination procedures.
2. Assuming that no physical signs or symptoms will be present because the case is a simulation.  This is not true!
3. Taking a disorganized and/or incomplete history from the patient.
4. Narrowing too quickly to a specific diagnosis when more assessment is needed.
5. Ruling out alternatives prematurely. 
6. Forgetting to include follow-up in the management plans.
7. Forgetting to wash your hands in view of the patient.
8. Requesting labs, tests, and procedures that are unwarranted or unjustified.

What Should I bring to the CPX?

Please wear your white coat and bring the following medical instruments: Stethoscope, Reflex Hammer, Tuning Fork. 

You are not permitted to bring medical references and/or resources into the CPX; however, several reference books will be made available during the post-encounter stations.  You will not have access to the Internet during the CPX.

When Will I Complete the CPX?

Students are excused from ALL clerkship duties on the date that they are scheduled to complete the CPX.  Students are also excluded from on-call duties the evening prior to the CPX session. 

What if I’m on an Out-of-Town Rotation?

Students who are attending away rotations are required to return to Charlottesville to complete the CPX.  These   students are scheduled during a weekend session.  In order to compensate for the weekend session, these students are relieved one additional weekday (Friday or Monday).  In order to accommodate the students’ travel time, they are also relieved one half-day (Friday evening / Monday morning).  The details of these accommodations should be made by the individual clerkship rotation.

What If I Have Questions or Concerns Regarding the CPX?

If you have scheduling question or concerns, contact:

Ornuma Wawsri

Assistant Coordinator, CSTAP

ow2p@virginia.edu     (434) 924-5809 Office

All other questions or concerns can be relayed to:

Anne Chapin

Assistant Professor in Medical Education

Coordinator, Clinical Skills Training and Assessment Program

achapin@virginia.edu  (434) 243-9477 Office