COT to Calgary Cambridge

Triangulation of the COT criteria with Calgary Calgary Cambridge Criteria. This assists in focussing on the specific behavioural skills that the learner may need to address.

The COT criteria are derived from the summative old MRCGP video criteria, so may not necessarily be the appropriate springboard for the behavioural change needed when developing communication skills.

This table points to the Calgary Cambridge criteria for each COT criterion (although in practice most Calgary-Cambridge criteria will apply in some way to each COT criterion, it is not a straightforward linear relationship!). Each learning need may, therefore, cascade into other Cal-Cam areas, and the skill of the educator is in developing this.

Some issues to consider when teaching COT to cal-cam

The COT criteria for performance competencies whereas Calgary Cambridge criteria are behavioural skills

  • Be discriminatory about which Calgary Cambridge criteria to teach on. You are likely to have identified many areas to tackle: for focus in on a small number of areas is probably the best approach, including other issues for later.
  • There are diverse ways of tackling the issues
    • Watch it all
    • Watch Part Of It
    • Focusing on topics
    • Doing the to the positive stuff
    • What do you need help with?
    • Stop-start – microteaching
  • Formative and summative assessment go on at the same time
  • CO T is developmental. It is designed to get t that he GPR to show the competencies
  • Use Calgary Cambridge to identify the skills needed
  • The opposite of “competence” is not “incompetence” in this situation, rather it is “in training”. Competence is only achieved at The end of three years of training for most GPRs. Showing one of your own videos at the start of training could demonstrate to the GPR that established doctors still have areas for development.
  • One approach is to complete the COT form with the GPR. The discussion could become coercive. This can be prevented by
    • What did you see?
    • What I saw was… Followed by discussion
  • COT is formative, so there is no fail
  • COT is not a sequence of events, Calgary-Cambridge tends to be.
  • Buddying trainers – using another trainer to also do COTs with your GPR aids benchmarking

A. Discovers the reasons for the patient’s attendance.

1 Encourages the patient’s contribution
  • 3. Demonstrates interest and respect attends to patient’s physical comfort
  • 4. Identifies the patient’s problems or the issues that the patient wishes to address with an appropriate opening question (e.g. “What problems brought you to the hospital?” or “What would you like to discuss today?” or “What questions did you hope to get answered today?”)
  • 5. Listens attentively to the patient’s opening statement, without interrupting or directing patient’s response
  • 6. Confirms list and screens for further problems (e.g. “so that’s headaches and tiredness; anything else……?”)
  • 7. Negotiates agenda taking both patient’s and physician’s needs into account
  • 8. Encourages patient to tell the story of the problem(s) from when first started to the present in own words (clarifying the reason for presenting now)
  • 9. Uses open and closed questioning techniques, appropriately moving from open to closed
  • 10. Listening: listens attentively, allowing the patient to complete statements without interruption and leaving space for the patient to think before answering or go on after pausing
  • 11. Facilitates patient’s responses verbally and non-verbally e.g. use of encouragement, silence, repetition, paraphrasing, interpretation
  • 12. Picks up verbal and non-verbal cues (body language, speech, facial expression, affect); checks out and acknowledges as appropriate
  • 13. Clarifies patient’s statements that are unclear or need amplification (e.g. “Could you explain what you mean by light-headed”)
  • 14. Periodically summarises to verify own understanding of what the patient has said; invites the patient to correct interpretation or provide further information.
  • 17. Actively determines and appropriately explores:
    • patient’s ideas (i.e. beliefs re cause)
    • patient’s concerns (i.e. worries) regarding each problem
    • patient’s expectations (i.e., goals, what help the patient had expected for each problem)
    • effects: how each problem affects the patient’s life
  • 18. Encourages patient to express feelings
  • 19. Summarises at the end of a specific line of inquiry to confirm understanding before moving on to the next section
  • 20. Progresses from one section to another using signposting, transitional statements; includes the rationale for the next section
  • 23. Demonstrates appropriate non-verbal  behaviour
    • eye contact, facial expression
    • posture, position & movement
    • vocal cues e.g. rate, volume, tone
  • 24. If reads writes notes or uses computer, does in a manner that does not interfere with dialogue or rapport
  • 25. Demonstrates appropriate confidence
  • 26. Accepts legitimacy of patient’s views and feelings; is not judgmental
  • 27. Uses empathy to communicate understanding and appreciation of the patient’s feelings or predicament; overtly acknowledges the patient’s views and feelings
  • 28. Provides support: expresses concern, understanding, willingness to help; acknowledges coping efforts and appropriate self-care; offers partnership
  • 29. Deals sensitively with embarrassing and disturbing topics and physical pain, including when associated with a physical examinationInvolving the patient
  • 30. Shares thinking with the patient to encourage patient’s involvement (e.g. “What I’m thinking now is….”)
  • 31. Explains the rationale for questions or parts of a physical examination that could appear to be non-sequiturs
  • 32. During the physical examination, explains the process, asks permission
  • 33. Chunks and checks: gives information in assimilable chunks; checks for understanding, uses patient’s response as a guide to how to proceed
  • 34. Assesses patient’s starting point: asks for patient’s prior knowledge early on when giving information; discovers the extent of patient’s wish for information
  • 35. Asks patients what other information would be helpful e.g. aetiology, prognosis
  • 36. Gives explanation at appropriate times: avoids giving advice, information or reassurance prematurely
  • 42. Checks patient’s understanding of the information given (or plans made), e.g. by asking the patient to restate in own words; clarify as necessary
  • 44. Provides opportunities and encourages the patient to contribute: to ask questions, seek clarification or express doubts; responds appropriately
  • 45. Picks up verbal and non-verbal cues, e.g. patient’s need to contribute information or ask questions; information overload; distress
  • 46. Elicits patient’s beliefs, reactions and feelings re information given, terms used; acknowledges and addresses where necessary
  • 53. Contracts with patient re next steps for patient and physician
  • 59. Encourages questions about and discussion of potential anxieties or negative outcomes
  • 63. Elicits patient’s beliefs, reactions, concerns re opinion
  • 66. Obtains patient’s view of the need for action, perceived benefits, barriers, motivation
  • 67. Accepts patient’s views, advocates alternative viewpoint as necessary
  • 68. Elicits patient’s reactions and concerns about plans and treatments including acceptability
  • 70. Encourages patient to be involved in implementing plans, to take responsibility and be self-reliant
  • 71. Asks about patient support systems, discusses other support available

ie most criteria! Others could be included too….

2 Responds to cues
  • 10. Listening: listens attentively, allowing the patient to complete statements without interruption and leaving space for patient to think before answering or go on after pausing
  • 11. Facilitates patient’s responses verbally and non-verbally e.g. use of encouragement, silence, repetition, paraphrasing, interpretation
  • 12. Picks up verbal and non-verbal cues (body language, speech, facial expression, affect); checks out and acknowledges as appropriate
  • 33. Chunks and checks: gives information in assimilable chunks; checks for understanding, uses patient’s response as a guide to how to proceed
  • 45. Picks up verbal and non-verbal cues, e.g. patient’s need to contribute information or ask questions; information overload; distress
  • 52. Checks with the patient: if plans accepted; if concerns have been addressed

Practically, responding to cues occurs at every stage of the consultation.

3 Places complaint in appropriate psychosocial contexts
  • 5. Listens attentively to the patient’s opening statement, without interrupting or directing patient’s response
  • 6. Confirms list and screens for further problems (e.g. “so that’s headaches and tiredness; anything else……?”)
  • 11. Facilitates patient’s responses verbally and non-verbally e.g. use of encouragement, silence, repetition, paraphrasing, interpretation
  • 17. Actively determines and appropriately explores:
    • patient’s ideas (i.e. beliefs re cause)
    • patient’s concerns (i.e. worries) regarding each problem
    • patient’s expectations (i.e., goals, what help the patient had expected for each problem)
    • effects: how each problem affects the patient’s life
  • 18. Encourages patient to express feelings
  • 43. Relates explanations to patient’s illness framework: to previously elicited ideas, concerns and expectations

…and others…

4 Explores patient’s health understanding
  • 10. Listening: listens attentively, allowing the patient to complete statements without interruption and leaving space for the patient to think before answering or go on after pausing
  • 17. Actively determines and appropriately explores:
    • patient’s ideas (i.e. beliefs re cause)
    • patient’s concerns (i.e. worries) regarding each problem
    • patient’s expectations (i.e., goals, what help the patient had expected for each problem)
    • effects: how each problem affects the patient’s life
  • 18. Encourages patient to express feelings
  • 43. Relates explanations to patient’s illness framework: to previously elicited ideas, concerns and expectations
  • 56. The final check that patient agrees and is comfortable with the plan and asks if any corrections, questions or other items to discuss

…and others…

B. Defines the clinical problem

5 Includes or excludes likely relevant significant condition
  • 4. Identifies the patient’s problems or the issues that the patient wishes to address with an appropriate opening question (e.g. “What problems brought you to the hospital?” or “What would you like to discuss today?” or “What questions did you hope to get answered today?”)
  • 10. Listening: listens attentively, allowing the patient to complete statements without interruption and leaving space for the patient to think before answering or go on after pausing
  • 10. Listening: listens attentively, allowing the patient to complete statements without interruption and leaving space for the patient to think before answering or go on after pausing
  • 11. Facilitates patient’s responses verbally and non-verbally e.g. use of encouragement, silence, repetition, paraphrasing, interpretation
  • 12. Picks up verbal and non-verbal cues (body language, speech, facial expression, affect); checks out and acknowledges as appropriate
  • 13. Clarifies patient’s statements that are unclear or need amplification (e.g. “Could you explain what you mean by light-headed”)
  • 14. Periodically summarises to verify their own understanding of what the patient has said; invites the patient to correct interpretation or provide further information.
  • 15. Uses concise, easily understood questions and comments, avoids or adequately explains jargon
  • 16. Establishes dates and sequence of events

This focuses a lot on active listening.

6 Appropriate physical or mental state examination
  • 29. Deals sensitively with embarrassing and disturbing topics and physical pain, including when associated with a physical examination
  • 30. Shares thinking with the patient to encourage patient’s involvement (e.g. “What I’m thinking now is….”)
  • 31. Explains the rationale for questions or parts of a physical examination that could appear to be non-sequiturs
  • 32. During the physical examination, explains the process, asks permission

Information gathering criteria will define whether the examination is appropriate.

7 Makes an appropriate working diagnosis
  • 33. Chunks and checks: gives information in assimilable chunks; checks for understanding, uses patient’s response as a guide to how to proceed
  • 34. Assesses patient’s starting point: asks for patient’s prior knowledge early on when giving information; discovers the extent of patient’s wish for information
  • 35. Asks patients what other information would be helpful e.g. aetiology, prognosis
  • 36. Gives explanation at appropriate times: avoids giving advice, information or reassurance prematurely
  • 47. Shares own thinking as appropriate: ideas, thought processes, dilemmas
  • 48. Involves patient by making suggestions rather than directives
  • 49. Encourages patient to contribute their thoughts: ideas, suggestions and preferences
  • 50. Negotiates a mutually acceptable plan
  • 51. Offers choices: encourages patient to make choices and decisions to the level that they wish
  • 52. Checks with the patient: if plans accepted; if concerns have been addressed

C. Explains the problem to the patient

8 Explains the problem in appropriate language
  • 33. Chunks and checks: gives information in assimilable chunks; checks for understanding, uses patient’s response as a guide to how to proceed
  • 34. Assesses patient’s starting point: asks for patient’s prior knowledge early on when giving information; discovers the extent of patient’s wish for information
  • 35. Asks patients what other information would be helpful e.g. aetiology, prognosis
  • 36. Gives explanation at appropriate times: avoids giving advice, information or reassurance prematurely
  • 37. Organizes explanation: divides into discrete sections; develops a logical sequence
  • 38. Uses explicit categorization or signposting (e.g. ‘There are three important things that I would like to discuss. First …‘; ‘Now, shall we move on to …‘)
  • 39. Uses repetition and summarizing to reinforce information
  • 40. Language: uses concise, easily understood statements; avoids or explains jargon
  • 41. Uses visual methods of conveying information: diagrams, models, written information and instructions
  • 42. Checks patient’s understanding of the information given (or plans made), e.g. by asking the patient to restate in own words; clarify as necessary
  • 43. Relates explanations to patient’s illness framework: to previously elicited ideas, concerns and expectations
  • 44. Provides opportunities and encourages the patient to contribute: to ask questions, seek clarification or express doubts; responds appropriately
  • 45. Picks up verbal and non-verbal cues, e.g. patient’s need to contribute information or ask questions; information overload; distress
  • 46. Elicits patient’s beliefs, reactions and feelings re information given, terms used; acknowledges and addresses where necessary
D. Addresses the patient’s problem
  • 47. Shares own thinking as appropriate: ideas, thought processes, dilemmas
  • 48. Involves patient by making suggestions rather than directives
  • 49. Encourages patient to contribute their thoughts: ideas, suggestions and preferences
  • 50. Negotiates a mutually acceptable plan
  • 51. Offers choices: encourages patient to make choices and decisions to the level that they wish
  • 52. Checks with the patient: if plans accepted; if concerns have been addressed

9 Seeks to confirm patient’s understanding

10 Appropriate management plan
  • 48. Involves patient by making suggestions rather than directives
  • 49. Encourages patient to contribute their thoughts: ideas, suggestions and preferences
  • 50. Negotiates a mutually acceptable plan
  • 51. Offers choices: encourages patient to make choices and decisions to the level that they wish
  • 52. Checks with the patient: if plans accepted; if concerns have been addressed
  • 53. Contracts with patient re next steps for patient and physician
  • 54. Safety nets, explaining possible unexpected outcomes, what to do if the plan is not working, when and how to seek help
11 Patient is given the opportunity to be involved in significant management decisions
  • 51. Offers choices: encourages patient to make choices and decisions to the level that they wish
  • 64. Discusses options eg, no action, investigation, medication or surgery, non-drug treatments (physiotherapy, walking aides, fluids, counselling, preventive measures)

E. Makes effective use of the consultation

12 Makes effective use of resources
  • 4. Identifies the patient’s problems or the issues that the patient wishes to address with an appropriate opening question (e.g. “What problems brought you to the hospital?” or “What would you like to discuss today?” or “What questions did you hope to get answered today?”)
  • 6. Confirms list and screens for further problems (e.g. “so that’s headaches and tiredness; anything else……?”)
  • 33. Chunks and checks: gives information in assimilable chunks; checks for understanding, uses patient’s response as a guide to how to proceed
  • 51. Offers choices: encourages patient to make choices and decisions to the level that they wish
  • 64. Discusses options eg, no action, investigation, medication or surgery, non-drug treatments (physiotherapy, walking aides, fluids, counselling, preventive measures)

…for example. Using the whole of the Calgary Cambridge model

13 Conditions and interval for follow up are specified
  • 52. Checks with the patient: if plans accepted; if concerns have been addressed
  • 53. Contracts with patient re next steps for patient and physician
  • 54. Safety nets, explaining possible unexpected outcomes, what to do if the plan is not working, when and how to seek help
  • 55. Summarises session briefly and clarifies plan of care
  • 56. The final check that patient agrees and is comfortable with the plan and asks if any corrections, questions or other items to discuss

COT to Calgary Cambridge teaching session

 

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