MRCGP Video – Flow Diagram of Consultation Technique – Basic Formula
Hints and Tips for Passing the MRCGP Video
Purpose
The MRCGP video is designed to test consulting skills and specifically ‘patient-centredness’. Patient-centredness can be defined as
· exploring the patients ideas and agenda (answering the questions – what does the patient think the problem is?, what do they [or family or friends] think the treatment or management should be?, how is this problem impacting on their home or work life?)
· involving the patient in management decisions (giving the patient sufficient information [about possible diagnoses, investigation and treatment options] to make an informed choice and respecting their decision)
Patient-centredness is not empathy [showing understanding of the patient’s predicament] or sympathy [suffering with the patient]. However asking questions about the patient’s ideas and concerns gives the patient a sense that you are interested in them and are attempting to understand them and their perspective. Therefore on the basis of asking these questions you may be rated as an empathetic or understanding doctor by the patients.
In general, the MRCGP video does not attempt to test your clinical acumen but it is still advisable to only include videos where you feel your management was safe and appropriate.
For 2004, two additional testing areas were added. These are
· encouraging concordance (checking the patients understanding of any medication prescribed – dose, dose regime, side effects and concerns) [currently only a merit criterion]
· follow-up arrangements and safety netting (specified when and under what circumstances further medical review is necessary). This is a required criterion to pass and because it nearly always falls at the end of the consultation it is having the effect of limiting the duration of tapes to 15min per consultation [the maximum duration the examiner will watch].
What you will need to submit
The current regulations require you to submit seven consultations in VHS video format. One consultation should be of a child (under 10y) and one should have a significant psycho-social element.
For MRCGP you do not need to submit the consent forms or display the time on the tape [unlike summative assessment].
Submission Options
It is likely you will be completing summative assessment at the same time you are taking MRCGP. Your options are
· Single route – submit a single tape for MRCGP and summative assessment. This tape will be marked by the MRCGP examiners and if you pass MRCGP video component then you will automatically pass summative assessment. If the tape fails MRCGP it will be passed to a summative assessment assessor for review against the summative assessment criteria.
· Dual route – submit 2 separate tapes – one for MRCGP and one for summative assessment [two hours of surgery consulting averaging 8-10 consultations].
· Simulated surgery for summative assessment and tape for MRCGP – Leicester simulated surgery unit run regular simulated surgery assessments and offer an evening of training in advance.
Tapes for MRCGP can be submitted twice a year – April for summer exam, October for winter exam. This provides something of a challenge in Nottingham because these dates fall 3 months after the start of your 6-month attachments. Some defer submission of the tape until 3-months after completion of training.
Technical Aspects
It is usual in order to generate an adequate tape for MRCGP that you will require many (happy!) hours of video consulting to produce seven consultations with which you are happy. Therefore it is important that the process of videoing in the practice is straightforward - this covers the consent process by the receptionists, through to the ease of operation of the camcorder and video recorder.
In Kegworth we use a wall mounted camcorder as feed into a TV/video unit with a remote. This allows ease of record on/off function, review of picture framing and allows direct recording onto VHS cassette.
Whatever the setup in your surgery you need to be familiar and confident with use of the system.
Gremlins will invariably frustrate you some of the time. But try to make this as infrequent as possible.
Sound quality is more important than visual quality on the video. As an examiner, it is much easier to mark a blurred image with good sound quality than the opposite.
Personal Aspects
Experience of video recording amongst Nottingham VTS registrars is generally suboptimal. Everyone should be encouraged to do as much recording as possible even in the first six-month attachment.
Lack of familiarity with video recording produces several barriers which need to be overcome to allow the potential of the process as a teaching and learning tool to be realised. It is important that you achieve a reasonable comfort level in the following areas
· Acceptance of what you sound and look like
· Acceptance of another person e.g. trainer watching you on video
Achieving acceptance in these areas is important because it then allows more accurate self-reflection on your performance and allows you to make use of feedback from a third party. Almost without exception the standard of your consulting is very high and at the outset you will display many positive behaviours. It will also become rapidly apparent to you that you have a distinct style [a pattern of behaviours and communication that is special to you].
This pattern has been developed over many years and has proved to work for you in many varied settings. It is important that you do not attempt to deconstruct this pattern of consulting because that could be destructive. What is needed usually is subtle additions to your usual pattern to bring it more in line with the flowchart displayed on the front and allow you to achieve the performance criteria for MRCGP.
As always in feedback to yourself it is important to identify the positive aspects perhaps using the MRCGP performance criteria template as a benchmark.
The most common area of deficit is ‘exploring the patient’s reasons for attendance’. In many respects this is expected because history taking is based around the clinical method with a prescribed structure.
· ‘What is the problem?’[sorethroat]
· ‘How long have you had it?’ ‘Where does it hurt’ ‘Does it hurt anywhere else?’ ‘What other symptoms have you?’
The clinical method is symptom based questioning which allows the doctor to make a clinical assessment. This remains an important component of the ‘patient-centred model’ but, in addition, you need to find out more about the patient’s reason for attendance and perspective. This can be considered a more ‘lay’ approach to consulting. In other words what you might have said to someone before you were taught the clinical method or before you presumed to have some clinical knowledge or expertise.
So if your friend tells you they have a sore throat – perhaps you might proceed as follows
· ‘I’ve got a sore throat’ [you – ‘oh dear’(acknowledgement and sympathy always helps!)
· ‘What do you think is going on? (explore their ideas – what they think it is) – they could respond with ‘well the last time I felt like this I had tonsillitis’
· What did you do last time? (explore their ideas – what they think they should do about it) – ‘the doctor gave me some antibiotics but it took a week to get better; I felt really lousy’
So it isn’t rocket science! But even small changes in patterns of our behaviour take quite a lot of practice. And that emphasises why it is useful to do as much videoing as early as possible in your registrar posts.
MRCGP Performance Criteria
We’ll look at these in blocks which might help with feedback and conceptualising the consultation model used.
I Exploring Patients Reasons for Attendance
This section covers the first four performance criteria
· PC1 The Dr is seen to encourage the patient’s contribution at appropriate points in the consultation.
· PC2 The Dr is seen to respond to signals (cues) that lead to a deeper understanding of the problem [merit]
· PC3 The Dr uses appropriate psychological and social information to place the complaint(s) in context.
· PC4 The Dr explores the patient’s health understanding.
At the end of this section you want to be able to be able to describe to yourself
· Why has the patient come to see me?
· What do they (or others) think or fear might be happening?
· What ideas do they (or others) have about how we might proceed?
· How is the problem or concern affecting them in their life (home/work/school)?
This is often most easily achieved at the outset of the consultation when you have not influenced or disrupted the patient by asking clinical method questions, or by a temptation to interrupt and dismiss some of the patient’s ideas. However, it can be achieved at any point in the information gathering part of the consultation. Some clinicians find it very difficult when presented with a clinical symptom not to explore in further detail using the standard clinical method. For them it can sometimes be easier to do a symptom enquiry and then go back to exploring the patient’s ideas.
Time and an unpressured feel is often important to allow patients to tell their story and disclose their concerns.
Start with ‘How can I help you?’ Patient will usually give a brief statement in response e.g. sorethroat and pause. In standard clinical method the doctor then asks clarifying medical questions e.g. how long have you had it? Etc.
In this situation that often interrupts the patient’s story and interferes with exploring the patients ideas and concerns.
So recommend you prompt the patient to ‘Tell me more’ and passively listen for the next 1-2minutes (‘golden minute’). Passive listening involves non verbal facilitation e.g. look interested, relaxed posture and verbal facilitation ‘ahah…ahah..’
Whilst doing this try to imagine you have a few boxes into which you wish to collect and put information.
You’re trying to answer the questions
· What does the patient think is going on?
· What do they think we should do about it?
· How is it affecting them at home, at work, at school?
And last and least at this stage
· Is there any information they give that helps me make a clinical diagnosis?
With most patients by 1-2min you’re beginning to get a feel for these points.
You may wish then to pick off those areas that haven’t been answered by using the questions
· What do you think is going on/the problem? [do not accept I don’t know or that’s why I’ve come to you Dr; particularly in slightly confrontational men because they’re almost certainly is an underlying concern] Probe gently further with ‘Did anyone else have any suggestions?’ or ‘What does your wife/partner/mother think?’
· What did you think we might do to help you? Or ‘What treatment did you think might help?
· How is it affecting you at home/in your work?
By this stage (approx 2-5min into consultation depending on complexity) you should have a fairly clear view why the patient has attended.
You may wish to make a summarising statement before moving on to the next [clinical] part of the consultation. This is particularly important in two situations
1. Where a patient has given all the information unprompted – you need to demonstrate to the examiner that you have defined the reasons for attendance. If you have not asked direct questions cos your passive listening technique was so effective and the patient is clear and articulate about their reasons – then it is necessary to provide evidence to the examiner.
2. To confirm you and the patient have the same understanding.
This is done by making a statement such as ‘So just to recap – you have a sorethroat which you think is tonsillitis cos you’ve had it previously and for which antibiotics were previously effective. Is that right?’
So let us look at the individual performance criteria in more detail.
1. The Dr is seen to encourage the patient’s contribution at appropriate points in the consultation.
This performance criterion is achieved by nearly everyone. It is easy to achieve by simple passive listening techniques – smile, appear interested, relaxed posture and say ahah! Done skilfully a lot of detail you require for other performance criteria will just ‘fall out’.
Active listening techniques help throughout the consultation. These are techniques which probe the patient’s verbal and non-verbal cues further and also techniques which clarify and summarise what has been said to confirm shared understanding. In active listening the following behaviours are usually displayed
· Simple prompts – after patient’s opening phrase doctor says ‘tell me more’ or simple ahah..ahah.
· Reflection of words e.g. Patient ‘I feel miserable’ Doctor ‘miserable..[followed by pause]’ – prompts patient to tell more about particular key thought or word.
· Reflection of emotion e.g. doctor notices patient looks sad and thinks might be relevant to consultation, so says ‘you look sad.’ Patient may burst into tears and say ‘I’ve never felt so low and depressed’ – so leads doctor to explore further – ‘tell me more etc’
· Delayed reflection – a patient mentions a phrase earlier in their story which you don’t pick up at the time but come back to later to probe further. E.g. the patient says, ‘I have this pain and it is really affecting me at work.’ The patient goes on to tell you more about the pain. Later doctor says, ‘Earlier you said the pain was really affecting you at work, tell me more…’
· Clarifying and summarising statements – are very useful to move from one section of the consultation to the next. They can usefully signal closure of one part of the consultation to the patient and allow checking of shared understanding e.g. doctor says to patient ‘so let me just check with you what we’ve covered so far….please correct me if I get it wrong. You started with a sorethroat last week, which is like the tonsillitis you previously had and antibiotics helped last time, is that right?’