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Consulting skills for the MRCGP exam |
The main answer is that consulting well and demonstrating that ability is not as simple as it is made out to be. The two main reasons for failing are;
Most candidates know how to pass with merit because they tell the oral examiners that they consult in a patient centred way. Most insist they explore their patient's beliefs, listen actively, seek out their agendas, discover about them as human beings, examine them properly, share their understanding, involve them in their own management and share decisions with them. The current problem is that 95% of candidates tell the oral examiners this is what they do but only 10% actually demonstrate this behaviour on the submitted videotape.
There are many good books and articles written about consulting, and most VTS schemes set aside a fair amount of teaching time. Teaching and learning consulting need not be complicated. Try this simple but very effective strategy, you can learn to consult by asking yourself these ten questions after each consultation. If you can submit seven such consultations you will be in the top 10%. But remember the 15 minute rule, as many of these sort of consultations might take you longer when you first start.
Questions to ask yourself after the consultation
Of course you have to practice consulting, so use this list or something similar. Pin it up. Work on the first half of the consultation first. Have fun trying to find out what really brought your patients to see you, and be prepared for rebuffs and failures. Give yourself a prize when you first hit all ten, and start feeling smug when you do it for the second time. Then switch the camera on.
If you are happy with your ability to consult it makes no sense to fail the
exam because you have not selected the correct consultations.
The current required performance criteria are:
If you include a clear demonstration of each PC 4 times out of 7 you will get a merit, to pass 4 out of seven of all the non merit criteria is what is required.
A separate examiner marks each consultation, so there is no halo or
deleterious effect from previous consultations. Each consultation is judged on
its individual merits using the PCs as a score sheet. Your final mark is a
summation of 7 examiners making 15 decisions on each consultation. The decision
is 'is that PC present or absent in my experienced and trained opinion as a
practising GP selected for my assessment ability.' The examiners mark your tape
residentially in working groups that meet regularly to discuss standards,
calibration and have regular training sessions.
If you have not already done so read the workbook, then read it again and try to
ensure your trainer has done so too. Each PC is spelled out in some detail to
try to lessen any misunderstanding.
There are three performance criteria that seem to trouble candidates most
often - the absence of which are most frequently the cause for failure in the
video component.
These are:
While candidates who fail may do so on other criteria as well, it is very
rare for them to pass these three and fail only on others.
These criteria require a degree of patient-centredness in the consultation and
we have provided some examples and suggestions.
This is in the section of discovering the reasons for the patients
attendance. It is related to how doctors seek out their patient's agenda. Cues
later in the consultation may not be related to this search and so may not be
credited.
A cue is a sign made by the patient, which is capable of being perceived by the
doctor and can help discover why the patient has decided to attend at that time.
In deciding whether to consult a doctor about a problem, patients frequently ask themselves:
Finding answers to some of these questions by responding to cues patients
give is an important part of each consultation
For example:
A 16-year-old girl attends alone and
complains:
She then mentions:
Finding out what she thinks her mum's reasons are, and whether she agrees with them are clearly important. Responding by saying:
This clearly shows you have responded to that cue. You may decide not to respond immediately, but may return to explore this later in the consultation after finding more about other symptoms related to her periods. This is quite acceptable. |
Cues, however, may be non-verbal, but can receive both verbal and non-verbal
responses. Suppose a patient seems close to tears, you may respond by handing a
tissue and remain silent, or choose to comment:
In response to a patient attending with a painful ear, and when pointing to the ear visibly wincing, the doctor may say:
To which the patient responds:
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Responding to cues is often an important catalyst in the consultation,
demonstrating a patient-centred approach and often linking in to other
performance criteria; as in the case above by placing the complaint in a social
and psychological context. You must ensure that the technical quality of video
is good in order to demonstrate non-verbal cues and ensure that these cues are
clearly visible on the tape you submit.
You do not have to respond to every cue, but examiners expect a response to some
cues in your selection of consultations.
This is fundamental to the practice of good medicine and essential to family doctors. Good GPs know about their patients and they have gained this knowledge from consultations. Think of each consultation as producing a brick of information about that person, after a few bricks the doctor has begun to build a wall of knowledge. The MRCGP video examination expects you to demonstrate the making of a small brick of knowledge about the patient consulting you.
In placing details in a social and psychological context, it is not sufficient just to ask the patient:
Returning to the 16-year-old girl with heavy periods, she might respond to the question asking why her mum felt she should go on the pill by saying:
Asking:
She might reply:
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Let's consider another example.
A 40-year-old man shows you a tender
swelling over the dorsum of his left wrist. His opening words are:
Asking him - 'What is your job?' may just produce the reply 'I stock the shelves at a supermarket' and would not satisfy the criterion. However, asking him 'In what way has this affected you?' is an open question and more likely to produce far more information about the effects of his problem upon his life, such as:
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We now know for these two patients some of the reasons why they have presented
and have details of how these problems are impacting upon their lives. Active
listening and open questions are keys to good consulting. A consultation with
only closed questions will never provide the material you need to pass the video
module.
We have addressed three of the questions highlighted earlier that you should ask yourself after each consultation, namely:
Let's now consider a fourth - did I share in decision-making?
This is the most patient-centred of the non-merit performance criteria and is
the criterion that causes candidates most problems being the single, most common
cause of failure. Remember this comes under the element 'involving the patient
in the management plan to an appropriate extent'.
There are numerous ways of involving patients in the management of their
problems and I will use the patients we have discussed earlier to illustrate
some of these.
In the case of the girl with heavy periods, it would be appropriate to
discuss her need for contraception, including the pros and cons of starting the
oral contraceptive pill (as her mother had suggested).
The option of using mefenamic or tranexamic acid at the time of her periods or
taking norethisterone to delay her period when on holiday could also be shared
with her.
Another way of sharing management options would be to offer her the above information and the opportunity to either make a decision there and then, or to discuss this with her mother and to make her a follow up appointment.
For the man with the painful wrist, examination confirms an acute tenosynovitis.
Management options here include:
The key to this is the involvement of the patient in these decisions.
Simply saying
Is not an example of sharing and would not have been deemed to satisfy that
criterion.
The man with the painful ear has an external otitis. Discussion of the options
of longer-term management on his return from holiday, for example defined review
in the surgery, by telephone or only to see again if he has further problems,
would be examples of allowing him to decide which he felt was the most
appropriate course of action.
Below are three further patients presenting problems and diagnoses. Try to think how you might involve each patient in the management plan.
The secret of good consulting is practice, so regular recording and review of
your surgeries is vital to improve your performance.
Examiners not only want to see more candidates passing the video; we want to see
many more passing with merit.
Demonstrating at least nine examples of the merit performance criteria in the first five consultations awards the merit. When the MRCGP examiners constructed the current criteria for the video component, they based them on two main sources:
If you look at the video performance criteria you will recognise a familiar pattern:
Unfortunately, it is possible to cover all these areas badly, and so fail the exam!
The key to both passing and achieving a merit is a patient-centred approach.
This does not mean lots of small talk, or a relaxed atmosphere, or simply doing
whatever the patient asks! It is based on the fundamental belief that the
patient is a partner with the GP in the process of healthcare.
Think of it as a 'Meetings between experts', which was actually the title of a
book reporting a major UK study of GP consultations, and which provided evidence
for the value of patient-centredness.
If you can try to think of each patient as an expert in aspects of their health,
but also an expert with whom you have to collaborate in order to achieve the
best results, then the merit criteria will be easy.
Exploring the patient's health understanding
In the section on discovering the reasons for the patient's attendance, there is a sub-section 'Explore the patient's health understanding', for which the actual criterion is worded 'The doctor takes the patient's health understanding into account'. This is what the examiners will be looking for. It is not difficult! But most candidates (and most doctors) do not do it!
For example. To a patient complaining of headaches, you could ask:
- "You have had these headaches for a few weeks now and I was wondering whether you had any ideas yourself as to what they might be due to?"
This invites the patient to disclose their own, often highly relevant, health understanding, and shows that you are interested and concerned about the patient's understanding of their symptoms. They might reply:- "Well, my neck creaks a lot, but I can't see how that could cause headaches. I thought I had blood pressure, because there is a lot of aggro at work."
This reply gives you three relevant hypotheses to explore with this patient - it enables you to:
- Check their blood pressure and explain that hypertension has little to do with stress
- Discover exactly what sort of 'aggro' they are getting at work, which of course implies that you automatically meet criterion 3 about placing the complaints in a social and psychological context.
- Considering the relative contributions the stress and any musculoskeletal neck problem might be making to their headaches.
That was a fairly predictable response from a patient, but sometimes you will discover real surprises: patients are quite reluctant to volunteer information about their fears. Even with good records, you can't always know about tragedies in the patient's past. He or she may have a relative with cancer, a neighbour's child had meningitis, and a partner is in prison. You do not get this information by asking (closed) questions. You do discover it by inviting your patients to share their ideas. Try it.
Balint wrote: "If you ask questions you get answers."
Using patient's health beliefs to explain the problem
The second merit criterion follows from the first. It sits in the section on explaining the problem(s) to the patient, in the sub-section 'Tailor the explanation to the patient', and reads 'The doctors explanation takes account of some or all of the patient's elicited health beliefs.' Note the terminology, 'explain the problem(s)', and not 'diagnoses'.
Many general practice consultations are not about diagnoses in the textbook sense, but about vague symptoms, such as tiredness or pain. These don't amount to formal diagnoses, but still need to be explained. This performance criterion assumes that you have elicited this person's ideas about their symptoms, and requires you to use some of those ideas in your explanation. Again, this is not difficult!
- "You said you were under stress at work, and that your neck creaks. As you know, your blood pressure is normal, but you are tender in your neck muscles and at the base of your skull. That is how tension headaches develop. The creaking is not due to arthritis, but to the muscle tension in your neck, which is giving you headaches."
Making sure the patient understands what you have said
Following this question, if you went on to say:
- "Does that make sense? How do you feel about that?"
And the patient replied:
- "Well, partly. I can see how I get wound up at work and then these headaches get worse, but I can't see why they have gone on for so long."
Then you have fulfilled the third merit performance criteria. 'The doctor seeks to confirm the patient's understanding'. You would, I am sure, then pick up the patient's concerns, and explore further for other reasons for the headaches.
The difference between that and simply ending with 'OK?' lies in the effect. Ending an explanation with OK? almost invariably leads to agreement. People find it hard to disagree, especially with doctors.After a complex consultation you could say:
- "This has been a bit complicated, what are you going to tell your spouse about our discussion?"
This invites a summary from your patient and allows a genuine checking of understanding.
We know from research that misunderstandings about prescribing are very very common. A strategy to improve this would be to routinely ask:
- "Just before we finish could you tell me your understanding of the work and the side effects of the drugs that I have prescribed?"
This allows for an opening up of fears and misunderstandings about medication.
Maximising co-operation
Patient-centred consultations last longer, but work better. Research shows this. Patients are more likely to be concordant (to use the jargon) if they have had the opportunity to express their doubts about a treatment, or a diagnosis.
Useful phrases
There are probably only a few phrases or questions you need to use to achieve a more patient-centred approach to the consultation, for example:
- "What do you think?"
- "I am interested to know what you thought might be causing this?"
- "Any thoughts?"
However, sometimes just keeping quiet and listening is all you need to do!
For the explanation:
- "So when you said you thought . . . . . "
- "So I agree with your suggestion that . . . . ."
- "People often think (back pain needs rest) . . . . . as you did, but the evidence shows that (keeping going) . . . . . is more helpful in the long run."
And for the checking
- "Does that make sense?"
- "How do you feel about that?"
- "I don't know if that has answered all your questions . . . . ."
- "Is there anything you would like to ask me?"
Of course there are other ways of doing it, these are just some of the phrases we hear when watching recorded consultations.
Consulting skills critique proforma
Derek Blades:
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