MRCGP Video assessment of consulting skills 2004

Units (broad areas) 1. Discover reasons for a patient’s attendance 2. Define the clinical problem(s) 3. Explain the problem(s) to the patient 4. Address the patient’s problem(s) 5. Make effective use of the consultation

(1) Discover the reasons for a patient’s attendance (a) Elicit the patient’s account of the symptoms which made him/her turn to the doctor: –PC 1. the doctor is seen to encourage the patient’s contribution at appropriate points in the consultation –PC 2. the doctor is seen to respond to signals (cues) that lead to a greater understanding of the problem (M)

(1) Discover the reasons for a patient’s attendance (b) Obtain relevant items of social and occupational circumstances: –PC 3. The doctor uses appropriate social and psychological information to place the complaint(s) in context

“Responds to signals (cues)” (in discovering the reasons for the patient’s attendance) “you said earlier…, tell me more about that” “you seemed upset by ……, were you?” “you mentioned your family, what do they think about this?” “I noticed the Liverpool scarf……you must be gutted ……?”

“Relevant social and psychological context” “so who’s in the family?” “how is this ……actually affecting your life?” “what exactly do you do at work?” “I know you have your daughter with cystic fibrosis, how are you coping?” “this has been a bit of a strain for you, hasn’t it?”

(1) Discover the reasons for a patient’s attendance (c) Explore the patient’s health understanding: –PC 4. The doctor explores the patient’s health understanding

“Explores the patient’s health understanding” “so what do you think it is?” or “people usually have some ideas about their illness: what have you been thinking?” “what would be your worst fear?” “what’s your theory?”

(2) Define the clinical problem(s) (a) Obtain additional information about symptoms and details of medical history (b) Assess the condition of the patient by appropriate physical or mental inspection (c) Make a working diagnosis

(2) Define the clinical problem(s) (a) Obtain additional information about symptoms and details of medical history: –PC 5. the doctor obtains sufficient information to include or exclude likely relevant significant conditions

(2) Define the clinical problem(s) (b) Assess the condition of the patient by appropriate physical or mental inspection: –PC 6. the doctor chooses a physical/mental examination which is likely to confirm or disprove hypotheses…or is designed to address a patient’s concern

(2) Define the clinical problem(s) (c) Make a working diagnosis: –PC 7. the doctor appears to make a clinically appropriate working diagnosis

(3) Explain the problem(s) to the patient (a) Share findings with the patient (b) Tailor the explanation to the patient (c) Ensure that the explanation is understood and accepted by the patient

(3) Explain the problem(s) to the patient (a) Share findings with the patient –PC 8. the doctor explains the problem or diagnosis in appropriate language

(3) Explain the problem(s) to the patient (b) Tailor the explanation to the patient: –PC 9. the doctor’s explanation takes account of some or all of the patient’s health beliefs (merit)

PC 9. “Explanation takes account of health beliefs” “I understand your concerns about the MMR vaccine: this is the best evidence we have, and there is no link with autism” “you felt the new tablets were to blame for these symptoms: that is possible, but I think they will wear off after a few weeks.” “although you feel any activity makes the fatigue worse, research shows that gradually increasing activity actually helps”

(3) Explain the problem(s) to the patient (c) Ensure that the explanation is understood and accepted by the patient: –PC 10. the doctor specifically seeks to confirm the patient’s understanding of the diagnosis (merit)

PC 11. “Seeks to confirm the patient’s understanding” “I don’t know whether that makes sense?…...” (and wait for a response!) “Is there anything you’d like to ask me?….” “What else do you want to know?……….” “What will you tell (your partner) when you get home?……...” “So just so I know you have understood, tell me what you understand about this.”

(4) Address the patient’s problem(s) (a) Choose an appropriate form of management (b) Involve the patient in the management plan to the appropriate extent

(4) Address the patient’s problem(s) (a) Choose an appropriate form of management: –PC 11. the management plan (including any prescription) is appropriate for the working diagnosis, reflecting a good understanding of modern accepted medical practice

(4) Address the patient’s problem(s) (b) Involve the patient in the management plan to the appropriate extent: –PC 12. the patient is given the opportunity to be involved in significant management decisions

Involving the patient in significant management decisions - implications (1) are relevant options available? (2) is this patient capable of making choices? (3) does this patient want to make a choice? (4) have I given sufficient information to make it an informed choice? (5) is this an appropriate strategy here? (if not, don’t try to contrive it!)

PC 12. “involve the patient in significant management decisions” “so given that choice, what would you like me to do?” “would you rather start the tablets now, or wait a few weeks and see if it settles?” “I could refer you to our counsellor, or you could contact Relate yourself: which would you prefer?” “some people prefer to adjust their inhaler dose themselves: would you?”

(5) Make effective use of the consultation (a) Make effective use of resources: –PC 13. in prescribing the doctor takes steps to enhance concordance, by exploring and responding to the patient’s understanding of the treatment (merit) –PC 14. the doctor specifies the conditions and interval for follow-up or review

Summary of changes 1)Replace “cues” with “explores health understanding” as pass criterion 2)Psychological / social information has to be “used” (not necessarily elicited) 3)PCs 8 & 9 (explain diagnosis, and appropriate language) merged 4)Re-word “options” to clarify intended meaning of “shared decision making” 5)Change “prescribing” into new merit PC on “concordance” 6)Remove “rapport”; replace with new PC on follow-up

Implications (how to pass!) 1. Understand the performance criteria 2. Practice them, so they become routine 3. Record plenty of consultations 4. Ensure technical quality 5. Select consultations (10-15 mins, new problems, include child and mental health) 6. Complete Workbook legibly (no need to type – original preferred)

FAQ’s Q. Can I edit the consultations? A. Not normally – you may only do so if what is removed is completely unrelated to the consultation (a phone call, leaving the room to collect something). The edit must be explained in the workbook.

FAQ’s Q. What if the patient has not been asked for consent before they come in? A. You cannot use that consultation for the exam. Informed written consent MUST be obtained outside the room, before the consultation starts, preferably by somebody other than the doctor.

FAQ’s Q. What if I have a “good” consultation which lasts more than 15 minutes? A. Only the first 15 minutes will be watched by the examiner.

FAQ’s Q. I saw a patient in a non-video consultation who would be very suitable for the video: may I re-enact that consultation on video? A. No. The video exam is an assessment of competence under “real” conditions, so re- enactments and role-plays are not allowed.