Video for consultation teaching & assessment

Skilful analysis and well considered feedback help to make the best use of the registrar’s videorecorded consultations.

Video has become a mandatory part of GP training and assessment since its inclusion in summative assessment and the MRCGP examination. Pendleton and the Oxford group have defined a clear method of analysis and a set of rules for giving feedback. However, there are several other ways of analysing consultations in a formative way, and the value of each depends not on the analytical method, but on the quality of the feedback to the learner.

Feedback skills

Pendleton’s rules
  • Clarify matters of fact
  • The doctor consulting says what went well and how
  • The observers identify other things that went well and how
  • The doctor consulting says what could be done differently and how
  • The observers add to this, concentrating on ‘how’ The doctor expresses how the feedback went
  • The pair or group agree areas for development

The skills needed to give feedback are comparable to those needed for successful consulting. I believe the difficulties we all experience in giving feedback relate to our need not to destroy the other person. We often avoid areas that could be contentious or seem overcritical. Unfortunately, this often leads to a kind of cosiness, where feedback is restricted to broad comments on the consultation without clearly dissecting and potentially improving on the skills demonstrated. The most important part of feedback is offering an alternative to the skill or task being analysed. In this way the giver of feedback is also open to criticism by the receiver, and dialogue can then begin about the skills or attitudes in question.

Pendleton’s rules for organising feedback  provide a clear structure for this task. However, they are not a method for analysing consultations. The rules may be applied to any of the skills or tasks being analysed, so that each interaction is seen to be fair, and so the learner can express his or her own thoughts and feelings. Much adult learning takes place this way -facilitated rather than directly taught. As with any skill, practising the components enhances development and increases confidence. The safe environment of the trainers’ group provides an ideal setting in which to rehearse the art of feedback on videotaped consultations, while helping colleagues to improve and refine their own techniques. The many techniques for analysing consultations can be classified as task-oriented models or behaviour and skills models.

Communicate on: 

  • Performance
  • Effects on others

To enhance awareness of:

  • What (s)he does
  • How (s)he does it.
Feedback requires:

  • Courage
  • Skill
  • Understanding
  • Self respect
  • Respect for others
 Focus on:

  • Behaviour which can be changed
  • How much and when to give it
  • Being accurate and clear
Give feedback on: 

  • Behaviour, not the person
  • Observation, not inference
  • Description, not judgment
  • Sharing ideas, not giving advice
  • Exploring alternatives, not providing answers

Task-oriented models

In task-oriented models, the consultation is viewed as an amalgam of separate and definable tasks. The feedback on the consultation can focus either on whether the task was appropriate and achievable or on the skills involved in its achievement. There are several examples of these analysis tools. The RCGP model The RCGP model defines three areas of consultation interaction – physical, psychological and social. This has become standard for formative and summative assessment. It has value as a1n initial screen but is not widely used for developing higher skills.

Stott and Davies model

The suggestion of four tasks to be completed at each consultation gives a working grid from which the trainer can select specific teaching areas or the learner can identify facets that may be missing from the consultation.

The four areas are:

  • management of the presenting problem(s);
  • modification of help-seeking behaviours;
  • management of continuing problems;
  • opportunistic health promotion.
Byrne and Long model

This model suggests six phases for each consultation, each of which requires specific skills and is dependent on the previous one for orientation in the whole process:

  • establishing a relationship;
  • discovering the reason for attendance;
  • verbal and/or physical examination;
  • consideration of the condition presented or diagnosed, with the doctor and patient having varying levels of responsibility;
  • giving details of further treatment or management;
  • closing the consultation.

This model was developed from work on audiotaped consultations, a method little used now but which still holds great learning potential.

Pendleton, Schofield, Tate and Havelock model

This team describe seven tasks that together form comprehensive and coherent aims for any consultation.

  • Define the reason for attendance, including the history, the patient’s ideas, concerns and expectations, and the effects of the problem.
  • Consider other problems, including continuing problems and risk factors.
  • Choose an appropriate action.
  • Achieve a shared understanding.
  • Involve the patient in management.
  •  Use time and resources appropriately, during the consultation and long term.
  • Establish or maintain a relationship.

The method provides the trainer with a map on which significant points in the consultation can be plotted for future reference, and a rating scale to grade the achievement of each task or its components.

Nature and history
Aetiology
Patient’s ideas
Patient’s concerns
Patient’s expectations

…etc

Helman’s ‘folk model’

This puts a different slant on the consultation, so that it is viewed from the perspective of a medical anthropologist. The learner is asked whether the consultation addressed the following questions

  • What has happened?
  • Why has it happened?
  • Why to me?
  • Why now?
  • What would happen if we did nothing?
  • What should I do or whom should I consult for further help?

The views of the learner and trainer can provoke lengthy discussion.

Behaviour and skills models

Behaviour and skills models attempt to define the specific skills needed to achieve the tasks outlined in the previous models. At first they can be applied to help students and younger doctors to develop these skills in isolation and then to appreciate their application in daily practice in the hospital or community.

The Leicester Assessment Package

Consultation skills have been categorised in a number of ways, This lends itself to specific analytical tools, the most comprehensive of which is the Leicester Assessment Package, which gives structured feedback on performance and how to improve it. This method is used as often as the Pendleton mapping technique for formative assessment and teaching during the registrar year.

Consultation category Positive features Weaknesses/omissions Grade
Interview/history
Physical examination
Management …etc

The different competences are weighted for scoring purposes:

  • interviewing and history taking: 20%;
  • physical examination: 10%;
  • patient management: 20%;
  • problem solving: 20%;
  • behaviour and relationship with patient: 10%;
  • anticipatory care: 10%;
  • record keeping: 10%.

The facets of each competence are used for giving feedback. Whatever each trainer and registrar feels about the relative weightings ascribed to each competence, the method certainly encourages accurate assessment of skills and feedback.

Consultation skills
  • Welcoming: to establish and trust from the outset.
  • Questioning: includes open questions, clarification, focusing on the present, interrupting but maintaining a flow, defining patient’s meanings
  • Listening: with eye contact, recognising nonverbal cues, remembering what has been said accurately, handling written and electronic records effectively
  • Responding: clarifying problems, summarising, reflecting statements and feelings, checking understanding, defusing anger, negotiating examination
  • Explaining: using clear understandable language, with the important information first, being specific, overlapping and repeating advice and instructions, checking understanding, reinforcing with written/visual aids
  • Closing: bringing the consultation to a natural end, with clear information about the next steps, maintaining an accurate record
The Neighbour feedback record

Neighbour’s method of viewing the consultation forms a bridge between tasks and skills. His five ‘checkpoints’ follow the flow of tasks in the consultation while highlighting the specific skills needed:

  • Connecting covers rapport and listening skills.
  • Summarising involves eliciting ideas, concerns and expectations, and formulating a diagnosis.
  • Handing over relates to agreeing agendas, negotiating skills, influencing behaviour and gift-wrapping ideas.
  • Safety netting considers “what if?” issues, closing the consultation, expectations of treatment and the use of time.
  • Housekeeping reflects the doctor’s understanding of the process and feelings about it, and the effect on the next consultation.
Checkpoint Skill shown Skill suggested
Connecting

  • Verbal excuses
  • Non-verbal cues
  • Language
…etc

This format can be used very effectively for giving feedback and assessing the learner’s awareness of the areas covered. Several other feedback methods exist that provide variety of format and concentrate on specific facets of consultation teaching. The most recent development is theCalgary-Cambridge method, which combines the ‘rules of engagement’ outlined by Pendleton with theproblem-based approach of Gask et al. The method focuses on communication skills in the consultation, and can be used when learner and teacher are both satisfied that the ‘nuts and bolts’ of consulting are well developed.

Conclusion

By becoming familiar with two or three of these methods of analysis. the trainer can vary the video analysis and provide a broad picture of the registrar’s developing skills. Using these methods ensures that all aspects of the much simpler West of Scotland summative assessment tool arc covered without recourse to exam ‘coaching’. The video analysis section of the MRCGP exam has been developed by considering the mapping of tasks and identifying skills of formative work, and uniting these for the purpose of peer referencing. Eventually this tool may also become ‘summative’, but at present the two consultation examinations remain separate. Feedback is a part of our daily work as doctors, employers and teachers. Improving our skills in giving constructive feedback enhances all of these areas.

References

  1.  Pendleton D, Schofield T, Tate P, Havelock P. The consultation: an approach to learning and teaching. Oxford: Oxford University Press, 1984.
  2. Fraser R. Leicester assessment package. Leicester University.
  3. Neighbour R. The inner consultation. Lancaster: MTP Press, 1987.
  4. Gask l, Boardman J, Standart S. Teaching communication skills. A problem-based approach Postgrad Educ Gen Pract 1991; 2: 7-15..

BARRY LEWIS MB ChB, DRCOG, MRCGP General Practitioner Rochdale, Lancs. Associate Director GP Postgraduate Education Manchester University.

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