Having recently had a supervisor review there are some really important features of how to use the RCGP ePortfolio that I wished I had been more mindful of. One of the GP ST2 had mentioned these in our induction lectures but some where along the line I must have taken my eye of the ball.
So what is the aim of the ESR? It is to evidence the trainee has covered the breadth of the curricullum as well as evidence the attainment of particular competencies. It isn't looking at the clinical skills (which the clinical supervisor looks at in terms of the particular rotation) but more about how a trainee applies themselves to the situation.
For example I had a palliative care patient which referenced nicely to the curricullum statment for palliative care. However it was also used as evidence for working in teams (with McMillan/Marie Curie), communication skills, and practicing holistically. So the first thing to remember is to make sure that each entry has an easy reference "HEADLINE" e.g. "22.6.12A Palliative Care *Comm skills *holistic practice" implying the date, this is Case A on that date, and that it is evidence towards those competencies aplying reflective practice as talked of before in order to generate a learning need to add to the personal development plan (PDP) - of which 1 or 2 should be met a month bearining in mind that the closer you complete them to the learning event the more chance of the experience cementing the knowledge being assimilated. The aim is for about three cases a week like this.
One of the mistakes I made was listing a whole bunch of cases e.g. a morning theatre list or a ward round and this really made it hard to use these entries as evidence as it was laborious to identify clearly the specific evidence used to meet a competency. A further mistake was that sometimes in my entries it was unclear who had made "the decision" e.g. a senior or myslef which is useful in order for the evidence to be considered robust enough. One tip was that when discussing a case e.g. in a professional conversation I could have highlighted the medical complexity of the case and been clear what my plans had been and how the senior colleuges had felt about/engaged with them. A further mistake I made was simply recording subtely different cases with the view that it was their subtle differences which implied complexity but actually medical complexity relates only to one particular patients management. Including this, there were 4 competency areas that really shocked me as to what they had been trying to ask for and what I had delivered so it is vital to really get to know these different competencies.
So when evidencing medical complexity one must look to the competency definition which includes managing co-morbidity, uncertainty and risk as well as having an approach to health and not just illness. At a basic level this means being positive about a patients health, prioritising managment based on risk, and drawing conclusions managing health problems seperately. The competency begins to be met when the trainee identifies the implications of co-morbidity, managing both acute and chronic conditions of a patient, explaining risk to the patient to enable them to engage in its managment, and finally encourages recovery and rehabilitation as well as health promotion and disease prevention strategy. To excell on this one, the trainee has to be able to manage the acute and chronic issues over time, co-ordinating a team based approach to rehabilitation, care, cure, palliation or health promotion, and finally anticipates and uses strategies to manage risk/uncertainty such as monitoring, outcomes assessment and feedback to minimise risk. Interestingly the way GP's are being paid is changing to reflect this ability to create health through quality.
The second interesting competency was practicing holistically - which I thought meant taking into accoun their social and psychological situations. However it also means more than this in the sense that it is important to utilise other community services and supports and not just yourself. It also means recognising how the condition will impact carers and family and hence involving them in the discussions and plans (not just informing them of the outcomes of plans) and then organising this care recognising the doctors limited ability to intervene in these matters. When making plans it is key to understand the influence of the cultural and socio-economic backgrounds and use this to generate practical solutions to the problems.
Ethics shows us the difference between a curriculumm (a broad scope of an educational programme including content, processes and experiences) and a syllabus (a list of topics to cover). The reason it shows this is because of the tension in that there is inherent conflict e.g. in providing a person centred approach i.e. a consultation looking at treament vs. a community approach i.e. telephone triaging at the time. Social expectation and political influence challenges the curricullum and creates tension by changing how refferals could be authorised to happen, aiming to prescibe cheaper generic medications, and serving different agendas. In my own competency assesment I noted how in one situation I felt something was wrong but did not have the skill and knowledge to affirm the feeling and expertly debate the case with a senior. In the competency itself it suggests not only identifying the conflict - which I sort of recognised inmyself but also take action to discuss them.
The fourth and final competency area of interest was communication skills which I will address later.
Suffisive to say that the competency are the core of the eportfolio which shouldn't just be seen as a way of revising for the AKT/CSA - IT IS a different beast!
THe Best way of seeing how the curriculum relates to the competencies is http://www.rcgp.org.uk/GP-training-and-exams/~/media/Files/GP-training-and-exams/Curriculum-2012/RCGP-Curriculum-Introduction-and-User-Guide-2012.ashx
Thursday, 18 October 2012
Monday, 8 October 2012
Clear, Caring and Convincing - a novice guide to the CSA
As per the RCGP website the Clinical Skills Assessment (CSA) is a summative assessment of a doctor’s ability to integrate and apply clinical, professional, communication and practical skills appropriate for general practice. Simulating a typical NHS surgery clinic the CSA assesses a range of scenarios from general practice relevant to most parts of the curriculum which can also target particular aspects of clinical care and expertise.
Lets not forget its got to be done in 10 minutes!
There is cummalative pass mark (clear fail to clear pass - 0-3 marks) of 13 cases; with the threshold depednign on the days mix of cases. There are feedback statements which higlgiht areas for improvement for future exams. And the reason I am so interested in when I had been on the A&E locum circuit I met many people who had failed this exam and came out of GP land (you get 4 hances to sit the exam) and I dont want to be back there because in A&E you dont get to follow patients through and become the smae doctor a patient sees because the shift nature of the job. So it is important and ifficult to pass.
We recently had a practice session on doing a CSA style OSCE - I even volunteered for one of the cases - and it was the first taste of taking the examination to the next level. We watched 4 caes being attempted twice each - fatigue, depression and nitts as well as a staff complaint. In the CSA the cases are done stratified according to difficulty, age, type (telephone/visit/surgery) and type (psychological, preventative, acute/chronic/undifferentiated, examination) - so dont forget your doctors bag!
As a Gp trainee one can start on 30 minute consultations but the aim is to get down to 5-10 minutes mark (including checking and requesting investigation then initiating or modifying managment plans). The CSA however is focused on the history taking element and even if one does not know the complete in's and out's of the managment of a condition (tested in the applied knowledge test) one can still achieve some degree of success by demonstrating efficient and relevant data gathering [proficient exam/investigation choice and interpretation], good interpersonal skills [recognised communication technniques to understand patients illness exprience whilst ethiically developing a shared approach to management], and developing a safe managment plan (which may include looking up the condition, having a chat with a partner/senior, organising/instigating a critical event analysis, writing to or calling a patient back, or organising follow up with good safety netting e.g. if A happens do X or if B happens do Y) [structured and flexible approach to decision making; ability to deal with multiple complaints and comordbidites; ability to promote a positive approach to health].
When I saw other people do their consultations (I was one of the GP ST1's in a group dominated by the skiled ST3's with the CSA around the corner) I was impressed by their ability to appear very calm, and provide tangible managment plans. I also found, after doing my own consultation where I only got to the beginning of management before my 10 minutes were up, that they had time managed very well.
So what were the key lessons I drew from the day?
1. Time managment and consultation style influence the score more than the clinical knowledge for this exam so therefore I need to become aware of how to maximise these skills and demonstrate them. This is what the rest of the blog will devlop as a theme.
2. Some times nothing is wrong with the patient and they need to be reassured e.g. a patient with tiredness who had a new family and recently returned to work was tired - nothing was found to be clinically wrong on the tests so it was all about how you "sold" the management plan.
For example one trainer suggested that to inspire patients and reassure them he had metaphors to help the patient to visualise their situation in order to understand and relate to it. for example with the patient above he would say that she has differen pieces to her unique puzzle such as her children, her job and her inability currently to enjoy the hobbies which she previously used to keep fit with such as swimming at lunch time but that they way the pieces fitted together at the moment meant she was tired. He suggested she could go away and think how these pieces could better fit tgether e.g. part time work etc. and discuss this with her family. He would make her an appointment in 3 months to see how things are going but otherwise she could come back and seem him if anything else worried her.
I love this analogy and find it a really good tool.
3. A very insteresting point that an ST3 raised was that he had to constantly kick himself to ask the patient what they wanted to do - he was so used to hospital work where the patient is told what to do that he found it a struggle to just take that bit of extra time and negotiate. Funily enough one of the participants used the phrase at the end of his consultation (at least he got there unliek me!) "here's what we are going to do..."
A different trainer chared another excellent analgoy - the doctors job is only to offer the right menu to the patient a highlighting the benefits and risks of the different options but not to pick the dish :)
4. A fourth general point fomr the practice was that it was important to quickly "get to it" e.g. you sound depressed would you like help with this? Rather than talk around the topic. However the danger of this too early means you may come across as rushing the patient. Equally it may be too hasty to say too early on "is there anything else?" (often patients come with 2 or 3 agendas they want to deal with and the risk is that if you say this question at the end you may find a another problem you dont have time to help solve) as it may appear as if the condition they have presented is not worthy of your time or not big/impressive anugh to be seen with or again that you are uncaring as if you want to move off the topic.
The other important learning points from the day were drawn from the brilliant professional actors:
1. They suggested that some people were unclear as to what was being communicated. These difficulties in them recieving the message came from simple things such as doctors speaking to fast or not giving the patient enough time to process information and feel comfortable to ask questions and check they've understood, ranging to more difficult communication errors such as an unclear thought (one doctor asked a patient to comb the knits onto "the paper" as if he had already reffered to one but hadn't made clear that it could be any paper and the relevance of doing it was so no live knits could be seen) or a shaky unclear managment plan (one doctor suggested that the mother of child with knitts brought her in but then said she may not need to).
The trainer explained that the key here was to sign post clearly what was being done. So in the example above the doctor should have made clear exactly which was it - does he want to see the daughter or not; bearing in mind as long as he can explain the reaosning there is no wrong answer - and emphasise this in his closing summary of the plan.
2. They suggested that the doctors came across as cold and uncaring - too focused on gathering the clinical (biological) data and in too much of a rush to provide the cold information on the managment options. Interestingly - when in the above case of nits the doctor asked to see the daughter the mother had felt reasured the doctor cared and this was important to her. Being talked "at" - rather than "to" for example when being told about how depression can be treated where as it may have been better to ask what the patient felt like she would like or what options she knew about (however avoiding asking two or more questions or then quickly answering with ones own response before the patient has a chance to reply.
So bringing all of this together using the flanagans and Dr ross model from http://www.pennine-gp-training.co.uk/csa-case-scenarios-written-by-our-gpsts-for-their-csa-work-groups.htm combined I think the following is useful:
1. Welcome patient and introduce yourself
2. Start with big open question and fascilitate golden minute (cue handling)
3. Explore psychosocial (Social Hx:Work, family, driving, alcohol, smoking)
- mindful that in the second half of the consultation later you should relate the patients;
> ideas to your explanation of diagnosis and differentials
> concerns to the prognosis
> expectations to mangement (investigation, watchful wait, lifestyle change, medication, refferal)
4. Focussed questions & Red Flags Focused systemic enquiry, Red flags, PMH, DH, FH
7. Examination (focused /2 minutes)
8. Explanation & Rx option sharing +/- safety netting (no later than 8 mins into the consultation)
9. Shared decision making/management plan
10. Closure – checking understanding -/+safety net /follow up
And smile, be nice, be beliveable.
Indicators of good performance
Data Gathering
1. Organised and systematic in gathering information from history taking, examination and investigation
2. Identifies abnormal findings or results and/or recognises their implications
3. Data gathering does appears to be guided by the probabilities of disease
4. Undertakes physical examination competently, or use instruments proficiently
Clinical management
1. Makes appropriate diagnosis
2. Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice
3. Follow-up arrangements and safety netting are adequate
4. Demonstrates an awareness of management of risk and health promotion
Interpersonal skills
1. Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues.
2. Develops a shared management plan or clarify the roles of doctor and patient
3. Uses explanations that are relevant and understandable to the patient
4. Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination
So there you have it - a true beginners interpretation of the exam!
Lets not forget its got to be done in 10 minutes!
There is cummalative pass mark (clear fail to clear pass - 0-3 marks) of 13 cases; with the threshold depednign on the days mix of cases. There are feedback statements which higlgiht areas for improvement for future exams. And the reason I am so interested in when I had been on the A&E locum circuit I met many people who had failed this exam and came out of GP land (you get 4 hances to sit the exam) and I dont want to be back there because in A&E you dont get to follow patients through and become the smae doctor a patient sees because the shift nature of the job. So it is important and ifficult to pass.
We recently had a practice session on doing a CSA style OSCE - I even volunteered for one of the cases - and it was the first taste of taking the examination to the next level. We watched 4 caes being attempted twice each - fatigue, depression and nitts as well as a staff complaint. In the CSA the cases are done stratified according to difficulty, age, type (telephone/visit/surgery) and type (psychological, preventative, acute/chronic/undifferentiated, examination) - so dont forget your doctors bag!
As a Gp trainee one can start on 30 minute consultations but the aim is to get down to 5-10 minutes mark (including checking and requesting investigation then initiating or modifying managment plans). The CSA however is focused on the history taking element and even if one does not know the complete in's and out's of the managment of a condition (tested in the applied knowledge test) one can still achieve some degree of success by demonstrating efficient and relevant data gathering [proficient exam/investigation choice and interpretation], good interpersonal skills [recognised communication technniques to understand patients illness exprience whilst ethiically developing a shared approach to management], and developing a safe managment plan (which may include looking up the condition, having a chat with a partner/senior, organising/instigating a critical event analysis, writing to or calling a patient back, or organising follow up with good safety netting e.g. if A happens do X or if B happens do Y) [structured and flexible approach to decision making; ability to deal with multiple complaints and comordbidites; ability to promote a positive approach to health].
When I saw other people do their consultations (I was one of the GP ST1's in a group dominated by the skiled ST3's with the CSA around the corner) I was impressed by their ability to appear very calm, and provide tangible managment plans. I also found, after doing my own consultation where I only got to the beginning of management before my 10 minutes were up, that they had time managed very well.
So what were the key lessons I drew from the day?
1. Time managment and consultation style influence the score more than the clinical knowledge for this exam so therefore I need to become aware of how to maximise these skills and demonstrate them. This is what the rest of the blog will devlop as a theme.
2. Some times nothing is wrong with the patient and they need to be reassured e.g. a patient with tiredness who had a new family and recently returned to work was tired - nothing was found to be clinically wrong on the tests so it was all about how you "sold" the management plan.
For example one trainer suggested that to inspire patients and reassure them he had metaphors to help the patient to visualise their situation in order to understand and relate to it. for example with the patient above he would say that she has differen pieces to her unique puzzle such as her children, her job and her inability currently to enjoy the hobbies which she previously used to keep fit with such as swimming at lunch time but that they way the pieces fitted together at the moment meant she was tired. He suggested she could go away and think how these pieces could better fit tgether e.g. part time work etc. and discuss this with her family. He would make her an appointment in 3 months to see how things are going but otherwise she could come back and seem him if anything else worried her.
I love this analogy and find it a really good tool.
3. A very insteresting point that an ST3 raised was that he had to constantly kick himself to ask the patient what they wanted to do - he was so used to hospital work where the patient is told what to do that he found it a struggle to just take that bit of extra time and negotiate. Funily enough one of the participants used the phrase at the end of his consultation (at least he got there unliek me!) "here's what we are going to do..."
A different trainer chared another excellent analgoy - the doctors job is only to offer the right menu to the patient a highlighting the benefits and risks of the different options but not to pick the dish :)
4. A fourth general point fomr the practice was that it was important to quickly "get to it" e.g. you sound depressed would you like help with this? Rather than talk around the topic. However the danger of this too early means you may come across as rushing the patient. Equally it may be too hasty to say too early on "is there anything else?" (often patients come with 2 or 3 agendas they want to deal with and the risk is that if you say this question at the end you may find a another problem you dont have time to help solve) as it may appear as if the condition they have presented is not worthy of your time or not big/impressive anugh to be seen with or again that you are uncaring as if you want to move off the topic.
The other important learning points from the day were drawn from the brilliant professional actors:
1. They suggested that some people were unclear as to what was being communicated. These difficulties in them recieving the message came from simple things such as doctors speaking to fast or not giving the patient enough time to process information and feel comfortable to ask questions and check they've understood, ranging to more difficult communication errors such as an unclear thought (one doctor asked a patient to comb the knits onto "the paper" as if he had already reffered to one but hadn't made clear that it could be any paper and the relevance of doing it was so no live knits could be seen) or a shaky unclear managment plan (one doctor suggested that the mother of child with knitts brought her in but then said she may not need to).
The trainer explained that the key here was to sign post clearly what was being done. So in the example above the doctor should have made clear exactly which was it - does he want to see the daughter or not; bearing in mind as long as he can explain the reaosning there is no wrong answer - and emphasise this in his closing summary of the plan.
2. They suggested that the doctors came across as cold and uncaring - too focused on gathering the clinical (biological) data and in too much of a rush to provide the cold information on the managment options. Interestingly - when in the above case of nits the doctor asked to see the daughter the mother had felt reasured the doctor cared and this was important to her. Being talked "at" - rather than "to" for example when being told about how depression can be treated where as it may have been better to ask what the patient felt like she would like or what options she knew about (however avoiding asking two or more questions or then quickly answering with ones own response before the patient has a chance to reply.
So bringing all of this together using the flanagans and Dr ross model from http://www.pennine-gp-training.co.uk/csa-case-scenarios-written-by-our-gpsts-for-their-csa-work-groups.htm combined I think the following is useful:
1. Welcome patient and introduce yourself
2. Start with big open question and fascilitate golden minute (cue handling)
3. Explore psychosocial (Social Hx:Work, family, driving, alcohol, smoking)
- mindful that in the second half of the consultation later you should relate the patients;
> ideas to your explanation of diagnosis and differentials
> concerns to the prognosis
> expectations to mangement (investigation, watchful wait, lifestyle change, medication, refferal)
4. Focussed questions & Red Flags Focused systemic enquiry, Red flags, PMH, DH, FH
7. Examination (focused /2 minutes)
8. Explanation & Rx option sharing +/- safety netting (no later than 8 mins into the consultation)
9. Shared decision making/management plan
10. Closure – checking understanding -/+safety net /follow up
And smile, be nice, be beliveable.
Indicators of good performance
Data Gathering
1. Organised and systematic in gathering information from history taking, examination and investigation
2. Identifies abnormal findings or results and/or recognises their implications
3. Data gathering does appears to be guided by the probabilities of disease
4. Undertakes physical examination competently, or use instruments proficiently
Clinical management
1. Makes appropriate diagnosis
2. Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice
3. Follow-up arrangements and safety netting are adequate
4. Demonstrates an awareness of management of risk and health promotion
Interpersonal skills
1. Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues.
2. Develops a shared management plan or clarify the roles of doctor and patient
3. Uses explanations that are relevant and understandable to the patient
4. Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination
So there you have it - a true beginners interpretation of the exam!
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