Consultations with more than one patient in the room are not common in the CSA because of the resource implications, but they certainly exist.
How it is covered in the CSA exam
If one of the cases on an exam day includes a third person, you will usually find that the candidate briefing notes will indicate that the patient is attending with somebody else.
There are a variety of situations that could be covered, for example:
- A parent and teenager with behavioural problems.
- A woman and her mother who has early-stage dementia.
- A carer of an adult with learning disability.
- A patient with a domineering partner.
- A mother with her underage teenage daughter requesting the oral contraceptive pill.
- A child accompanied by a relative.
What to do in the exam
If it is not immediately obvious, ask yourself why the patient is being accompanied and determine which person is the patient. Carers often become stressed or have their own anxieties and agendas about the people they are caring for and these may be quite different from those of the patient.
You will be expected to interact with both of the people in the room, so allow each person time to talk. The interaction between the two of them is likely to be important, so watch for non-verbal cues.
When you have decided on your diagnosis and management plan, make sure you address the actual patient, and take time to explain to both of them.
There may be additional challenges, such as confidentiality, and it is worthwhile thinking about whether to obtain consent if you are going to interact with a carer, for example, if they will be ringing up for investigation results.
If it is a situation where the patient is mentally competent, you might need to think of strategies for bringing back the patient on their own.
For example, a teenage girl may wish to discuss conraception without her mother being present.
How to prepare
The best preparation is through practice, and having a trainer observe your consultations with more than one person. This could be through role-play, but the use of video is a good way of observing your skills in a real-life situation.
It is not easy to predict when more than one person is going to be present in your consulting room, so it is important to make frequent use of video to learn from your consultations.
Try to reflect on your own performance by using a consultation models checklist and making sure you have addressed the ideas, concerns and expectations of both people presenting.
It would also be useful to share the video material with your trainer, and ask for feedback on how you dealt with both the people in the room.
- Dr Denney is an MRCGP examiner, and a GP in Edinburgh