The audio clinical observation tool (COT) in GP training

Dr Prashini Naidoo explains why the audio COT forms part of a GP trainee's workplace based assessment and how it is conducted and assessed.

Around 12% of GP consultations are now carried out over the phone, a four-fold increase compared with 20 years ago.

Doctors in GP surgeries and out-of-hours settings use telephone consultations to help manage workload. In addition, many patients prefer a telephone consultation in some instance as it may save time and be more convenient. 

GP trainees therefore need to develop the skills required to safely assess patients over the telephone. The CSA may contain a telephone consultation case, but prior to the introduction of audio COTs there was no formative assessment of telephone consultation skills in the workplace.

How is an audio COT conducted? 

The GP trainer either directly observes a telephone consultation using a dual headset or listens to an audio-recording.

The telephone consultation should typically last between five to 10 minutes. The trainee can select a telephone triage call or a ‘routine’ telephone consultation, based either at the surgery or in the out-of-hours setting.

The COT is marked by a supervisor or an out-of-hours GP clinical supervisor who has received training in completing workplace-based assessments. Trainees are encouraged complete at least one telephone consultation in the out-of-hours/triage setting and one ‘routine’ telephone consultation.

How many audio-COTs should I do?

Telephone consultations can be complex, therefore the RCGP recommends that completion of audio COTs takes place in the ST3 year.

Full-time ST3 trainees are required to complete 12 COTs (six before each six monthly review). ST1 and ST2 trainees have the option of completing one audio-COT throughout the year (however this is not mandatory).

Trainees with severe or profound hearing impairment who are unable to conduct telephone consultations with reasonable adjustments will not be assessed on audio-COTs.

What consent is needed?

The patient must verbally consent to the audio COT, either the recording of the conversation or having a second doctor listening into the consultation. Usually the receptionist informs the patient of the audio-COT clinic.

The GP trainee should obtain consent from the patient at the beginning and confirm consent at the end of the consultation this is because the patient may disclose information during the course of the consultation resulting in them withdrawing consent at the end.

If a consultation is recorded, the patient should be informed about the length of time for which the recording it is kept; who has access to it (as these may include other healthcare professionals if the recording is used for training); and the purposes for which it can be used.

The GP trainee should reassure the patient that the contents of the recording would be treated in the same way as the patient's medical record. GMC guidance on making and using visual and audio recordings of patients can provide further information (see resources below) for further information:

How is the COT assessed?

The RCGP has produced an audio-COT assessment form (see resources below).

Marks are awarded to trainees introducing themselves, establishing the identity of caller, ensuring confidentiality, taking consent and establishing rapport.

The trainees’ ability to gather information is assessed. Trainees should be able to identify the reason for the call, encourage the patient’s contribution, place the complaint in an appropriate psycho-social context and explore the patient’s agenda (health understanding, ideas, concerns, expectations).

After taking an appropriately thorough and focused history, the trainee is expected to make a working diagnosis, the basis for formulating an appropriate, effective and acceptable treatment plan.

As with any consultation, it is important to confirm the patient’s understanding and safety-net. The trainee’s write-up of the consultation in the medical record is also assessed.

How is the COT graded?

The audio-COT is graded as ‘not observed’, ‘needs further development’, ‘competent’ or ‘excellent’. Competent refers to the standard that would be expected of a GP trainee on completion of their training.

GP supervisors are encouraged to mark ‘not observed’ for those descriptors that are not assessed. Supervisors should provide structured feedback, with recommendations for further development.

Formative assessment and feedback on telephone consultations help GP trainees to develop the skills required to safely assess patients over the telephone. Given the large proportion of telephone consultations in general practice, this is an important skill to practice and develop.

  • Dr Naidoo is a GP trainer in Oxford. She has written three books on how to pass the CSA. The latest book CSA Practice Cases for the MRCGP Paperback was published in Jan 2016.

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