Ramesh Mehay Programme Director (Bradford VTS) nMRCGP in a nutshell Originally written 2007, updated Jan 2009

Aims and objectives Aims Objectives Increase our understanding of nMRCGP Help us feel more prepared for the assessments And therefore feel better! Objectives Provide an overview of nMRCGP Share understanding Share concerns (and address them?) Practise COT

Session plan Overview of the MRCGP and its components Share fears and concerns Practise some COTs in groups ?modelling (IS2 – practise some CBDs)

Background to nMRCGP nMRCGP replaces both old MRCGP and SA Based on new GP curriculum new curriculum developed by reviewing literature, very extensive consultation with doctors and patients, etc All components of nMRCGP are mapped to the competencies in the curriculum GP training now overseen by PMETB, like all other medical specialties (JCPTGP is dead)

A programme of assessment… nMRCGP WPBA AKT CSA

Components AKT (Applied Knowledge Test) machine marked test, 3x/year, at various venues CSA (Clinical Skills Assessment) OSCE-type exam, 3x/ year, Croydon WPBA (Workplace Based Assessment) recorded in e-portfolio held by GP trainee throughout the 3 years

Clinical Skills Assessment ‘Integrative assessment’ with 3 domains Data gathering, technical and assessment Clinical management Interpersonal skills 13 stations, 10 mins each, balanced selection of cases clear pass, marginal pass, marginal fail, clear fail, ‘serious concerns’ significant failure rate take early enough to have time to retake ‘Integrative assessment’ with 3 domains Data gathering, technical and assessment Clinical management Interpersonal skills 13 stations, 10 mins each, balanced selection of cases Graded as clear pass, marginal pass, marginal fail, clear fail, ‘serious concerns’ Likely to have significant failure rate Need to take early enough to have time to retake if necessary

Work Place Based Assessment: WBPA Workplace assessment: the assessment of actual working practices undertaken in the working environment

Overview of WBA What the trainee actually does Competencies demonstrated ‘when ready’ Assessment of developmental progression - guides decisions about future learning Recorded in an electronic portfolio Process is learner led - trainee has to ensure their e-portfolio covers the e-curriculum

WBA: compulsory components Case Based Discussion (CBD) Consultation Observation Tool (COT) or Mini-Clinical Evaluation Exercise (Mini CEX) Multi Source Feedback (MSF) Patient Satisfaction Questionnaire (PSQ) Direct Observation of Procedural Skills (DOPS)

WBA: local subunits OOH work booklet Clinical Supervisor’s Report (CSR) Naturally Occurring Evidence (NOE) Significant Event Review (SER) Referrals analysis Audit (Case Review, Personal Learning, Complaints)

Who makes judgements? The Trainer/Clinical Supervisor as (s)he does the assessments Educational Supervisor as he reviews the ‘whole’ thing with the trainee ARCP panels who review the whole thing when a trainee is moving up an ST grade

Case based Discussion (CBD) Structured interview designed to explore professional judgement in clinical cases Professional judgement = ability to make holistic, balanced and justifiable decisions in situations of complexity and uncertainty Attributes tested: Application of medical knowledge Application of ethical frameworks Ability to prioritise, consider implications, justify decisions Recognising complexity and uncertainty Structured interview designed to explore professional judgement in clinical cases Professional judgement = ability to make holistic, balanced and justifiable decisions in situations of complexity and uncertainty Attributes tested: Application of medical knowledge Application of ethical frameworks Ability to prioritise, consider implications, justify decisions Recognising complexity and uncertainty

CBD Competency areas CBD looks at 10 of the 12 competencies Practising holistically Data gathering and interpretation Making decisions/diagnoses Clinical management Managing medical complexity Primary Care Administration (IMT) Working with colleagues Community orientation Maintaining an ethical approach Fitness to practice (not assessed by CBD: communication skills AND maintaining performance/learning/teaching)

CBD - the process Trainee selects 3 cases, gives material to trainer 1w in advance Need balance of cases and contexts Trainer selects 2, and plans structured questions in advance 1h session = cover 2 cases 20mins case, 10mins feedback Trainer records evidence and judges level of performance (insuff evid/needs devel/competent/excellent) Need to do a MINIMUM of 6 per post All 6 before the ES meeting! (really, within 4m)

Key Points on CBD It is a STRUCTURED oral interview On what the trainee actually did And why they did that And if they considered anything else at the time So, don’t ask “what if” questions like you do in Random Case Analysis Stick to the ‘here and now’ of the case Use the question maker framework on www.bradfordvts.co.uk (click nMRCGP then click CBD)

CBD: What’s the Experience So Far? Trainees Initially anxious but less stressful than current SA Valued feedback Found it realistic Some concern re relationship with trainer Trainers Time consuming, need extra protected time Helpful structure May be more helpful for difficult trainees Concern re relationship with trainees From pilots

Consultation Observation Tool (COT) Single consultation per session Trainee and Trainer view together Trainer assesses consultation on 4pt rating scale (similar to old MRCGP/SA) No rule about consultation length Ideally at least one consultation is assessed by someone other than trainer Ideally: wide range of contexts required, including at least one child, older person, mental health problem GPR selects a single consultation per session GPR and trainer view together Trainer assesses consultation on 7pt rating scale (criteria fairly similar to old MRCGP/SA) Wide range of contexts required, including at least one child, older person, mental health problem No rule about consultation length (though this may be considered in assessment) Recommended that at least one consultation is assessed by someone other than trainer

Why Work Place Based Assessment? What was wrong with the old MRCGP or Summative Assessment? Why Work Place Based Assessment?

Miller’s Pyramid or Prism of Clinical Competence Miller’s Prism or Pyramid of Clinical Competence

What is Authentic Performance? “Testing should be as close as possible to the situation in which one attacks the problem.” “Ill-structured problems are not found in simulated and/or standardized tests.” “The variation inherent in professional practice will always elude capture by a set of rules.” Wiggins, Assessing Student Performance: Exploring the Purpose and Limits of Testing, Jossey-Bass, Inc. 1993

Relationship between tools and competency areas This says something about triangulation. So, not reaching a competency in one form of assessment can be searched for in another. Alternatively, you can validate the measures of a certain competency by comparing results in several assessment methods.

Good Assessment Instruments have: Reliability (R) Validity (V) Educational impact (E) Acceptability (A) Cost (C) (Mnemonic: CARVE) Van der Vleuten, The assessment of professional competence: developments, research and practical implications, Adv Health Sci Educ 1 (1996),

Why WPBA? High validity = Authenticity High educational impact Reliability = depends on how many you do; also some built in triangulation Reconnects assessment with learning and the workplace Assessment over entire training envelope Cost Effective and now accepted! Cost Effective because you, the trainers are doing it all!

And it gives continuous feedback “a process of monitoring student’s progress through an area of learning so that decisions can be made about the best way to facilitate future learning”

The Problem With WPBA Inter-observer variation Intra-observer variation Case specificity Inter-observer variation – the tendency of one observer to mark consistently higher or lower than another observer Intra-observer variation – the variation in one observer’s marks for no apparent reason (good day/bad day phenomenon) Case specificity – the variation in the candidate’s performance from one challenge to another, even when they seem to test the same attribute

Requirements of a high stakes performance assessment Specification Calibration Moderation Training Verification and audit (Baker, O’Neil, Linn 1991) mmm..... Here are some of the current problems that need sorting out Specification – of standards, criteria, scoring guides Calibration – of assessors and moderators Moderation – of results, particularly those on the borderline Training – of assessors including retraining Verification and Audit – through quality assurance measures and collection of reliability data

Rough Guide to Rating Scale Excellent – Smooth and efficient. Able to use knowledge, judgment and skills to adjust management appropriately to the specific patient and operative procedure. Competent – Lacks smoothness and efficiency but is able to use knowledge, judgment and skills to adjust management appropriately to the specific patient and operative procedure. NEEDS FURTHER DEVELOPMENT: Beginner – Lacks smoothness and efficiency. Able to manage the case but exhibits limited use of personal judgment and responsiveness to the specifics of the patient and operative procedure. Requires some limited coaching or attending intervention. Novice – Can only manage the case with extensive coaching and attending intervention.