1. MRCGP VIDEO Dr Ramesh Mehay, Bradford VTS

2. Aims: For participants to: become familiar with the MRCGP performance criteria Be able to assess their own videos (MRCGP stylee) explore collaborative ways of working on consultation skills

3. MRCGP video 7 consultations – at least one with a child under 10 years of age, and at least one with a significant social or psychological dimension only the first 15 minutes of a consultation will be assessed

4. MRCGP marking 14 performance criteria (PC), 10 pass and 4 merit must display each PC at least 4 times in the 7 consultations each consultation marked by a different marker

5. Preparing for the recording Choice of camera Positioning of camera Trial recording Consent 3-way consultations

6. DISCOVER THE REASONS FOR THE PATIENT'S ATTENDANCE PC1: the doctor is seen to encourage the patient's contribution at appropriate points in the consultation “active listening” appropriate use of open questions “you mentioned headaches, tell me a bit more about those” silence, reflecting, and facilitation. “what do you mean by dizzy?” “looking back at it now, how do you feel about it?” It is not demonstrated by simply letting the patient talk!

7. What is active listening? Active Listening is a communication skill which involves both the sender and the receiver in the communication process. Active listening involves: communicating verbally and nonverbally practising “uninterrupted” listening restating the message observing the sender’s nonverbal signals

8. Why practice active listening? Helps us understand others better Show others we respect them Allows us to receive accurate messages Enables us to respond appropriately

9. OBTAIN RELEVANT ITEMS OF SOCIAL AND OCCUPATIONAL CIRCUMSTANCES PC2: the doctor uses appropriate psychological and social information to place the complaint(s) in context (1/5 TH FAILURES) The competency is demonstrated when the doctor uses this information in understanding the problem. Occupational cause/effect of the problem, family stressors (APPROPRIATE) A simple way to address this PC is to ask yourself, “what else do I need to know about this person as a person?” “so were you worried that if you keep getting back pain you will end up taking too much time off work and therefore be at risk of losing your job?”

10. EXPLORE THE PATIENT’S HEALTH UNDERSTANDING PC3: the doctor explores the patient's health understanding (1/4 FAILURES) previously a “merit” criterion; it is always possible bluntly asking “what do you think is the matter?” is likely to generate the reply “I don’t know: you’re the doctor!”. “You’ve told me that you’ve had this for three weeks now. I am sure if I had it for 3w I’d start having thoughts about it. What thoughts did you have? What do you think might be going on?” pt: “Do you think it might be an allergy dr?”; dr: “what makes you think it might be?” The PC will be achieved if the candidate asks appropriately about health beliefs, and the patient discloses some such belief, so persistence may be necessary!

11. OBTAIN ADDITIONAL INFORMATION ABOUT THE SYMPTOMS, AND OTHER DETAILS OF MEDICAL HISTORY PC4: the doctor obtains sufficient information to include or exclude likely relevant significant conditions (1/3 RD FAILURES) = “differential diagnoses” that would threaten life or health difficult for very minor conditions for most problems there are certain “medical” questions that do need to be asked, for the consultation to be considered “safe”. Closed focussed questions : “so, with these headaches, do you vomit with them? Changes in your vision?” etc Can you think of others? Suicide in depression, malignancy in chronic cough, change in bowel habit, dysphagia, weight loss etc

12. ASSESS THE PATIENT BY APPROPRIATE PHYSICAL AND MENTAL EXAMINATION PC5: the physical/mental examination chosen which is likely to confirm or disprove hypotheses that could reasonably have been formed OR is designed to address a patient's concern choice of examination, not about competence in performing it rationale to the examination, (e.g. “now I’d like to examine your chest, to see whether there is any bronchitis”). sometimes the rationale will be self-evident

13. MAKE A WORKING DIAGNOSIS PC6: the doctor appears to make a clinically appropriate working diagnosis forms the basis for the subsequent competencies, of explaining, and managing the condition. examiners will infer it from the explanation, but also write it in the workbook. not necessarily be expressed as a “disease”

14. SHARE THE FINDINGS WITH THE PATIENT PC7: the doctor explains the diagnosis in appropriate language avoid medical jargon use words the patient is likely to understand. try and use their own words if appropriate

15. CHOOSE AN APPROPRIATE FORM OF MANAGEMENT PC 8 : the management plan (including any prescription) is appropriate for the working diagnosis, reflecting a good understanding of modern accepted medical practice management = drugs or other means commonly accepted good practice evidence-based

16. INVOLVE THE PATIENT IN THE MANAGEMENT PLAN PC9: the patient is given the opportunity to be involved in significant management decisions (2/3 RD FAILURES) Discuss management choices so patient to be able to make an informed choice = SHARED DECISION MAKING e.g. drug, non-drug, referral, watchful waiting, investigations, time off work etc Not all patients will so wish the competency can be demonstrated without the patient actually making a choice “How would you feel about seeing a stress counsellor” as opposed to “I am going to refer you to a stress counsellor”

17. MAKE EFFECTIVE USE OF RESOURCES PC10: the doctor specifies the conditions and interval for follow- up or review (1/3RD FAILURES) “safety-netting” “if it is not improving in two days, come back and we’ll see you the same day” “can I see you again in one week, but sooner if you are worried” In a low-risk situation, a routine review, such as three months, might be appropriate. The competence would not be demonstrated unless there was a reference to further contact.

18. DISCOVER THE REASONS FOR THE PATIENT'S ATTENDANCE PC1: (Merit) the doctor is seen to respond to signals (cues) that lead to a deeper understanding of the problem being sensitive both to what they say, how they say it, and sometimes what they don’t say. watching their face, “body language” You may also find cues in the records “you said earlier you felt low. Can you expand on that?” “I can see you look worried about that” “you seem rather low” pt: “I’ve felt low this week”; dr: “low?” This PC is only demonstrated when as a result of the doctor’s response to the cue, some additional information is elicited, leading to a “deeper understanding of the problem”.

19. SHARE THE FINDINGS WITH THE PATIENT PC2: (Merit) the doctor's explanation incorporates some or all of the patient's health beliefs This PC requires that the doctor incorporates one or more of the patient’s ideas (about the nature or cause of their problem) into their explanation. “this rash is called psoriasis, and is caused by overactive cells in the skin, but it is probably not affected by what you eat” (having elicited food concerns earlier) “so your irritable bowel syndrome is very likely to be related to the stress you were telling me about earlier”

20. ENSURE THAT THE EXPLANATION IS UNDERSTOOD AND ACCEPTED BY THE PATIENT PC3: (Merit) the doctor specifically seeks to confirm the patient’s understanding of the diagnosis checking that your explanation has been understood should be routine not demonstrated by “is that clear?” to which the answer is usually “Yes doctor”. better “I don’t know whether that makes sense, is there anything you want to ask me?”, or “how would you explain your condition to someone else?”

21. MAKE EFFECTIVE USE OF RESOURCES PC4: (Merit) in prescribing the doctor takes steps to enhance concordance, by exploring and responding to the patient’s understanding of the treatment recent evidence that most patients do not adequately understand their treatment, nor take it as intended. There are two elements 1. exploring the patient’s understanding of the treatment (analogous to PC which explores their understanding of the diagnosis) 2. a reactive explanation of the treatment in the light of this.

22. MRCGP results May 2004 17% of single route candidates failed MRCGP 22% of non-SR candidates failed more on single route on www.nosa.org.uk and www.rcgp.org.ukwww.nosa.org.uk www.rcgp.org.uk 65% of those who failed did not demonstrate “The patient is given the opportunity to be involved in significant management decisions.”

23. Other failing criteria: “The doctor specifies the conditions and interval for follow up or review.” (35%) “The doctor obtains sufficient information to include or exclude likely relevant significant conditions.” (28%) The doctor explores the patient’s health understanding.” (24%) “The doctor uses appropriate psychological and social information to place the complaint(s) in context.” (21%)

24. Group process and tasks: establish ground rules GPR offering the tape as a gift Purpose of feedback Balanced feedback Descriptive feedback Suggestions for change (constructive) Rehearsal of alternatives

25. Role of facilitator: Helping group to establish and keep to the ground rules Protecting the GPR offering the tape; thanking them Balanced, constructive & descriptive feedback Showing how easy it is to get some of the criteria in everyday consultations Resolving dilemmas or uncertainties – performance criteria keeping group to task modelling teaching, including summarising learning points, checking with learners Timekeeping Evaluate your session A word with the registrar