Consultation Observation Tool (COT)

The COT is one of the tools used to collect evidence for the Trainee’s e-Portfolio as part of the Workplace Based Assessment component of the MRCGP exam.

Selecting consultations for COT COTs can be done either by observation of recordings or direct observations of patient consultations. The resulting discussion and feedback provides evidence for the trainee’s e-Portfolio. It is inadvisable for a consultation to be longer than 15 minutes as effective use of time is one of the performance criteria.

Patient consent The patient must give consent, in accordance with the guidelines for consenting patients.

Collecting evidence from the consultation Relate your observations to the WPBA competence framework and COT criteria. Make an overall judgement and provide formal feedback, with recommendations for further development.

Numbers required A minimum of 6 COTs in each of ST1 and ST2. A minimum of 12 COTs in ST3.

Detailed guide to the Performance Criteria

PC1 Encourages the patient’s contribution The doctor is seen to encourage the patient’s contribution at appropriate points in the consultation. This competence is particularly looking for evidence of a doctor’s active listening skills, the ability to use open questions, to avoid unnecessary interruptions, and the use of non- verbal skills, in exploring and clarifying the patient’s symptoms. Evidence should be sought that the doctor can encourage a contribution from a patient when encouragement is needed.

PC2 Responds to cues The doctor is seen to respond to signal (cues) that lead to a deeper understanding of the problem.

PC3 Places complaint in appropriate psychosocial contexts The doctor uses appropriate psychological and social information to place the complaint in context. Trainee’s are expected to consider relevant psychological, social including occupational aspect of the problem: these may be known beforehand, or offered spontaneously by the patient, or elicited. The trainee should use the information in exploring the problem eg ‘How does your backache affect you life as a builder?’

PC4 Explores patient’s health understanding The doctor explores the patient’s health understanding. This competence incorporates exploring the patient’s ‘Ideas, concerns and expectations’ in the context of ‘Discover the reason’s for the patient’s attendance.

PC5 Includes or excludes likely relevant condition The doctor obtains sufficient information to include or exclude likely relevant significant conditions.

PC6 Appropriate physical or mental state examination The physical/mental examination chosen is likely to confirm or disprove hypotheses that could reasonably have been formed, OR is designed to address a patient’s concern.

PC7 Makes an appropriate working diagnosis The doctor appears to make a clinically appropriate working diagnosis.

PC8 Explains the problem in appropriate language The doctor explains the problem or diagnosis in appropriate language. There must be evidence of an explanation of the patient’s problem and the findings should be shared with the patient. Excellent registrars will incorporate some of all of the patient’s health beliefs considered in PC4. It is unlikely that this competence could be demonstrated in the absence of PC4. Essentially it requires a reference back to the patient-held ideas during the explanation of the problem/diagnosis.

PC9 Seeks to confirm patient’s understanding The doctor specifically seeks to confirm the patient’s understanding of the diagnosis. This should be an active seeking out of the patient’s understanding. Questions such as ‘Tell me what you understand by that’ or ‘What does the term angina mean to you?’ and a dialogue between the doctor and patient ensuring that the explanation is understood and accepted are essential.

PC10 Appropriate management plan The management plan (including any prescription) is appropriate for the working diagnosis, reflecting a good understanding of modern accepted practice. Management must be a safe plan even if it is not what you would do. Investigations and referral should be reasonable. The prescribed medication (if any) should be safe and reasonable, even if not you preferred choice.

PC11 Patient is given the opportunity to be involved in significant management decisions The doctor and patient should engage in shared decision making. This may involve establishing the conditions for shared-decision making such as the patient’s willingness to be involved (at least 1/3 are unwilling), their ability to make decisions (some are not able), and the evidence base on which any decisions are being made. The registrar should be rewarded for addressing any of these aspects of the competence: they do not need to take the patient right through to a decision.

PC12 Makes effective use of resources

PC13 Conditions for interval and follow up are specified The doctor specifies the conditions and interval for follow-up or review.