Transcript The Consulting Skills Component: The Video

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)
2)
3)
4)
5)
6)
Replace “cues” with “explores health understanding” as
pass criterion
Psychological / social information has to be “used” (not
necessarily elicited)
PCs 8 & 9 (explain diagnosis, and appropriate language)
merged
Re-word “options” to clarify intended meaning of
“shared decision making”
Change “prescribing” into new merit PC on
“concordance”
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 reenactments and role-plays are not allowed.