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Selecting consultations for Consultation Observation Tools

In our second article on COTs, Dr Mei Ling Denney gives guidance on choosing suitable consultations

In our second article on COTs, Dr Mei Ling Denney gives guidance on choosing suitable consultations

COTs are an opportunity for you to gather evidence under any of the 12 units of competence detailed in the e-portfolio. However five of these have been designated as particularly relevant to the COT:

• Communication and consultation skills

• Practising holistically

• Data gathering and interpretation

• Making a diagnosis/decisions

• Clinical management

It follows, therefore, that it would be a good idea to become thoroughly familiar with these before embarking on the COT (or any of the other workplace–based assessments).

As part of your preparation for COTs, try to:

• Read up on consultation models and become comfortable using at least one of them

• Arrange joint consultations with your trainer or other GPs in the practice- this enables you to critically observe more experienced GPs' consulting skills

• Ask your trainer to point you in the direction of more challenging patients for surgery consultations or visits to get practice on these

• Get exposure to more acute or chronic illnesses and learn about their management through out-of-hours work, or chronic disease management clinics

Suitable consultations

As with the MRCGP video exam, selection of consultations for assessment is important. Failure to select a variety of consultations which allow you to demonstrate competence in different areas will lessen the usefulness of the COT as a formative tool, and will not allow your trainer to collect the necessary evidence.

Registrars may either record a number of consultations on video and select one for assessment and discussion, or agree with the trainer to choose one prospective patient encounter which will be the subject of direct observation. In either case the GP registrar must ensure that the patient has given consent as per the RCGP guidelines for consenting patients. To give their informed consent, patients must be able to understand the purpose of the recording or observation, and must not be coerced into agreeing to have their consultation recorded or watched.

The RCGP's guidance on the selection of consultations states that the consultations selected should include:

• Children (aged 10 or under)

• Older adults (an adult aged more than 75 years old)

• Patients with mental health problems

As a general principle, you should be trying to practise on and select a wide variety of consultations as these will give you far greater opportunity to demonstrate the full range of competencies laid out in the ePortfolio. Although you are permitted to choose a prospective patient encounter for direct observation and assessment by your trainer, it will be easier to select pre-recorded consultations on video. Patients do not always come about the issue (whether clinical or otherwise) that you have predicted, and it may be that you find there is insufficient material or challenge in the consultation you have set aside for assessment and discussion.

The box below details some more tips for selecting consultations

COT performance criteria

The performance criteria for the COT are similar to, but not identical to, those for the MRCGP video exam. None of them are designated as ‘merit' criteria. The performance criteria are shown in the box below, and also listed with commentaries on each of the ePortfolio. The theme of patient-centredness remains, and candidates are advised to take note of this. Try to show an interest in your patients as people, discover the patient's agenda and health beliefs, and attempt to involve patients in decision making.

The COTs performance criteria (PC) are as follows:

PC1: The doctor is seen to encourage the patient's contribution at appropriate points in the consultation

PC2: The doctor is seen to respond to signals (cues) that lead to a deeper understanding of the problem

PC3: The doctor uses appropriate psychological and social information to place the complaint(s) in context

PC4: The doctor explores the patient's health understanding

PC5: The doctor obtains sufficient information to include or exclude likely relevant significant conditions

PC6: 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: The doctor appears to make a clinically appropriate working diagnosis

PC8: The doctor explains the problem or diagnosis in appropriate language

PC9: The doctor specifically seeks to confirm the patient's understanding of the diagnosis

PC10: The management plan (including any prescription) is appropriate for the working diagnosis, reflecting a good understanding of modern accepted medical practice

PC11: The patient is given the opportunity to be involved in significant management decisions

PC12: Makes effective use of resources

PC13: The doctor specifies the conditions and interval for follow-up or review

Dr Mei Ling Denney is a VTS course organiser in Cambridgeshire and an RCGP examiner

tips for selecting consultationstips for selecting consultations tips for selecting consultations

Tips for selecting consultations

 Try to show a range of patient contexts, to cover relevant units of competence as detailed in the ePortfolio – it might be helpful to look specifically for consultations which show your management of a situation, say, if you already have many that focus on history taking and interpretation of information
 Avoid very low-challenge consultations, as you are unlikely to meet many of the performance criteria
 Choose different clinical subject areas to add variety, and further help you identify any learning needs Avoid consultations where informed consent is in doubt, for example where there are language difficulties, or those concerning patients with educational subnormality Avoid very short or overlong consultations. You want to give yourself the opportunity to meet the criteria, but time management is now taken into account in performance criteria 12 on ‘resources'

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