The Consultation Sieve

THE MRCGP SIEVE: A structured approach to tackling MRCGP long answer questions to maximise performance, based on the consultation

MRCGP answer plans often involve breaking down the topic in question into a number of issues, each from a different perspective. This allows the candidate to answer the question in a structured way and to consider many different viewpoints.

However, candidates often remember a list of different viewpoints such as ‘patient issues’ and ‘doctor issues’ and therefore it can become easy in an exam situation to forget one or more viewpoints from the list. Does a more structured approach exist to help maximise candidate’s performance?

Most questions involve a situation that may be faced by a GP in real life. Taking this approach one can actually address issues as centred around the consultation first, then consider other issues as they move further away from the immediate consultation issues.

The inner-circle (the consultation) considers ‘consultation issues’ – i.e. those issues that are relevant to the communication between doctor and patient, such as consultation model, reason for attendance etc. Also present within the inner circle are ‘doctor issues’ such as health, stress, running late, etc and ‘patient issues’ such as financial worries, running late etc.

The next circle (immediate environment) considers the setting in which the doctor and patient operate. To some degree where the issues are placed is arbitrary, and the circle is not exhaustive, but provides a structure for candidates to consider the issues. Listed here are practice and professional issues for doctors, and family and community issues for patients. Educational issues exist for both patient and doctor (although the issues and needs themselves differ) and this provides us with the other educational advantage with the concentric circles sieve – that the situations and issues on ‘the doctor’s side’ are mirrored in the patient’s – i.e. both leave the consultation and interact with their ‘families’ (dr=practice; pt=family) and the ‘community’ the family exists within (dr=profession; pt=community).

The third circle (wider environment) is the issues that are further removed from the immediate situation, but that still influences the other issues, such as secondary care and PCT issues, ethics, society and the media. And further still exists the miscellany of ‘wider issues’.

In an exam, the candidate can remember that there are consultation issues (dr, pt, consultation) immediate context issues (practice, profession, family, community, educational), intermediate context issues (PCT/secondary care, ethics, society, media) and wider issues. They can draw the three circles on the front page and have an instant answer plan for almost all the questions. This way the candidate can work out any categories to include in their answer plan even if they forget, as they are using a structure from first principles.

Issues list

  • Consultation Issues
        • Introductions and setting (comfortable and quiet room)
        • What type of model is most appropriate for this situation?
        • Breaking bad news
  • Doctor Issues
        • Doctor’s I,C,E
        • Health beliefs
        • Running late/ stress
        • State of health and emotional factors (guilt, satisfaction etc)
        • Sympathy and empathy
        • Self-awareness
        • Prejudice
        • ‘Heart sink’ reaction
        • Confidence in self
        • Examination and chaperone
        • Housekeeping
  • Patient Issues
        • Patient’s ICE
        • Health beliefs
        • Running late/stress/ anxiety
        • State of health and emotional factors
        • Prejudice
        • Confidence in doctor
        • Financial/ work pressure
        • Sick role
        • Housekeeping (how can we help patient to deal with effects of the consultation?)
  • Practice Issues
        • List size
        • Rural or urban setting (how does a different setting affect the problem?)
        • Dispensing or non-dispensing?
        • Continuity of care
        • Recruitment issues
        • New patient (what was previous practice like?)
        • GMS or PMS? Quality Outcomes Framework
        • Audit
        • Relationship with OOH provider
  • PHCT (Primary Health Care Team) Issues
        • How can you utilise the various members of the PHCT to help the patient?
        • Communication and confidentiality between PHCT
        • Child protection
  • Professional Issues
        • Duty of care
        • Accountability
        • Role in society
        • NSFs and NICE guidelines
        • Evidence Based Medicine
        • Resources and Theory of Justice
  • Family/Carer Issues
        • How does the patient’s family or carers affect them?
        • Power of attorney
        • Do they have a carer?
        • Are they a carer?
        • Family I,C,E (e.g. fear of losing a loved one; family expectation of doctor)
  • Community Issues
        • Ethnic/ cultural issues
        • GP role in community
        • Local workforce factors (e.g. unemployment)
        • Local schemes and support groups
        • Local charities
        • Social Services
  • Educational Issues (Doctors and patients)
        • PUNS, PENS, DUNS and DENS
        • Accessibility to information
        • Responsibility for education
  • Society Issues
        • Society’s I,C,E
        • Barriers to health care
        • Society’s role in making decisions
        • Society’s view on risk
        • Rationing
  • Legal Issues
        • Criminality
        • Responsibility
        • Case law
        • Legislation
        • MDU/MPS
        • GMC/BMA
  • Ethical Issues
        • Beauchamp and Childress’ Biomedical Ethics
        • Patient Automony
        • Beneficience
        • Non-maleficence
        • Justice
        • Utiltitarianism and Population-based medicine
        • Confidentiality
  • Media
        • The influence of the popular media on health care expectations
        • The influence of Government on health care expectations
        • Scare-mongering
  • PCT Issues
        • Resource Management
        • Service provision
        • Pharmacy issues
        • Incentive schemes
        • Quality control
  • Secondary Care Issues
        • Waiting times (and effect on Primary Care)
        • Knowledge of local services
        • Recruitment issues
        • NHS vs. Private Healthcare
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