The aim of this article is to provide general practice trainers with a broad overview of clinical observation tools (COTs), a type of continuous and formative assessment within the workplace-based assessment.
The purpose of the COT is to assess and provide feedback on consultation skills across a case mix of patients (children, elderly, mental illness).
The RCGP website provides in-depth information on all assessments and is a good starting point. This article provides a trainer's perspective on using COTs to help trainees improve their consultation skills.
Video or joint surgery?
Broadly speaking, there are two ways of doing COTs: video or joint surgeries. There are advantages and disadvantages to each and they seem to be a matter of personal preference.
Most trainers prefer a mix of videos and joint surgeries. With the latter, the trainer directly observes the consultation as it unfolds in real time but does not participate in the consultation at all. Most of my trainees prefer joint surgeries for two reasons. First, in preparation for the clinical skills assessment, they want to get used to a silent hawk-like observer sitting in on their consultations. Second, they find it less time-consuming than arranging a video clinic.
Setting up the video equipment, liaising with receptionists to ask patients if they are happy to be videoed and formally consenting patients using the appropriate RCGP forms takes effort and organisation.
However, as a trainer, I like having the ability to stop a video to discuss a particular consultation technique or highlight a particular type of non-verbal response, made by the trainee or the patient, to develop the trainee's insight into their communication style. This is difficult to do in joint surgery.
Communication is king
When observing the trainees' consultation, I must satisfy myself that trainees gather data, appropriately manage patients and display good interpersonal skills.
For data gathering, I expect trainees to ask the right questions, at the right time, in the right way and perform the right examination correctly. For appropriate management, trainees should formulate a treatment plan in line with current accepted general practice.
However, as this assessment focuses on communication, the trainees' interpersonal skills are scrutinised. Did they communicate in a precise, understandable and sensitive manner?
I place less attention on the nuts and bolts of the management plan because the applied knowledge test focuses on this and the case-based discussion assesses clinical decision-making.
COT is primarily to assess and develop communication and interpersonal skills. I want to see trainees' ability to engage patients in the consultation, by enquiring about their health beliefs and incorporating these into the explanation given to patients.
I look for the trainee's ability to value patient contributions, and to respect their autonomy and decision making. I must be satisfied that trainees can communicate with the patient in a way that enhances the patient's understanding of an illness and promotes a shared approach to managing problems.
As the consultation unfolds, I note on the COT marking form the words the trainee uses and their non-verbal responses. At the end, I use this evidence to award one of four grades ranging from 'insufficient evidence' to 'excellent'.
'Insufficient evidence' is used where the specific criterion was not observed in the case, whereas 'needs further development' is used where the skill is present but not honed to the extent I would expect to see in a safe and independent GP.
1. The COT is primarily to assess and develop communication and interpersonal skills.
2. Consider if the trainee can communicate in a way that enhances the patient's understanding of their illness and promotes a shared approach to managing problems.
3. Suggest consultation models that might be suitable for the trainee if they need further development.
4. Ensure any learning needs are identified, logged in the ePortfolio and included in an action plan.
Often, when discussing ways to improve a particular communication or consultation skill, I draw on various consultation theories. For example, if a trainee 'needs further development', I might ask them about Roger Neighbour's safety netting. I would expect the trainee to know about this concept.
While the theory of consultation models is not directly tested, during feedback I discuss concepts that are most likely to improve the trainee's consultation style.
I may not directly tell the trainee how to become competent in a particular domain. However, in keeping with adult education theory, I am likely to signpost him or her to the relevant consultation theory.
The trainee and I usually agree an action, such as: 'I will read Neighbour's chapter on safety netting and reflect in a learning log various questions or statements I could make to achieve a safer conclusion to my consultation.'
COTs are very likely to identify learning needs that should feed into trainees' personal development plans. I occasionally check the ePortfolio later that week to see if the COT-generated learning needs have been developed into an action plan and if there are subsequent log entries as evidence of experiential learning.
- Dr Naidoo is a GP trainer in Oxford
- Detailed information on COTs www.rcgp-curriculum.org.uk/mrcgp/wpba/ consultation_observation_tool.aspx
- Information on consultation models and an excellent overview of 15 theories. www.skillscascade.com/models.htm