Videoing Consultations

Videoing consultations is an excellent method of analysing and improving consultation and communication skills. It is now recognised internationally that training in communication skills is an essential part of medical education.^[1] Videoing has a high profile in many practices, and its application is likely to extend in the future. It has become an important part of medical training in the UK but is perhaps less well developed as an educational tool in other countries.^[2] Current applications include:

• Personal development: videoing consultations is a valuable tool for improving consultation skills.
• As part of the assessment to obtain a Certificate of Completion of Training (CCT) in general practice (see below).
• Consultation peer review: in the current climate regarding proposals for future revalidation of GPs, there is much support for the use of videotape consultations.

Guidelines on a code of practice for videotaping consultations

• A consent form should be completed by the patient prior to entering the consulting room.^[3]
• Post-consultation procedure: including the right of the patient to view the consultation in the proposed form of use, and the right to withdraw consent (with subsequent confirmation that the recording has been erased).
• Storage and erasure: stored as per other patient medical records with attached consents, and clear procedures to enable erasure no later than one year after recording.
• Areas of concern: when assessing a videoed consultation, it is no longer possible, under General Medical Council (GMC) guidance, to do nothing where the level of performance gives grounds for serious concern.

Guidelines for teaching

It is also important when using videotaping of consultations in teaching that feedback be given in a constructive way. Doctors are often wary of having consultations recorded, patients often less so. Subsequent analysis of consultations needs to be done in a way which allows learning and development of skills. The principles of constructive feedback form an important part of the training for GPs wishing to become trainers. The guidelines given by Pendleton are often referred to when giving feedback about consultations.^[4]

Discussion will often centre around an analysis of the consultation highlighting the tasks and strategies within the consultation. See separate article Consultation Analysis.

'New' Membership of the Royal College of General Practitioners

A single new assessment process for doctors wishing to obtain a CCT in general practice was introduced in August 2007. This new assessment will also be an essential requirement for entry to the GMC Generalist Register and Membership of the Royal College of General Practitioners (MRCGP). The 'new' Membership of the Royal College of General Practitioners (nMRCGP) is an integrated training and assessment programme that comprises three complementary components:

• Applied Knowledge Test (AKT)
• Clinical Skills Assessment (CSA)
• Workplace-based assessment (WPBA)

All three components must be completed successfully in order for a GP Registrar to be eligible for a CCT and for full membership of the RCGP.

Workplace-based assessment

The competences which form the framework for WPBA include (the following list only includes those competencies relevant to the consultation):

• Communication and consultation skills. This competence is about communication with patients, and the use of recognised consultation techniques.
• Practising holistically: the ability of the doctor to operate in physical, psychological, socioeconomic and cultural dimensions, taking into account feelings as well as thoughts.
• Data gathering and interpretation: the gathering and use of data for clinical judgement, the choice of physical examination and investigations, and their interpretation.
• Making a diagnosis and making decisions; demonstrating a structured approach to decision making.
• Clinical management: the recognition and management of common medical conditions in primary care.
• Managing medical complexity and promoting health: aspects of care beyond managing straightforward problems, including the management of comorbidity, uncertainty, risk and the approach to health rather than just illness.

The Consultation Observation Tool (COT) has been designed to be used by trainers as an evidence-collecting instrument to support the more holistic judgements made about GP Registrars at six-monthly and final reviews when the GP Registrar is in primary care. The starting point for this assessment is either a video-recorded consultation or a consultation directly observed by the trainer. The observation should generate discussion and feedback for the GP Registrar and yield evidence which should be recorded in the ePortfolio. The selected consultations are rated according to a set of criteria which have been developed from the experience with Summative Assessment and the MRCGP consultation skills' module. These criteria are built into the ePortfolio.

The GP Registrar records a number of consultations on video and selects one for assessment and discussion, or the GP Registrar and the trainer agree on a prospective patient encounter which will be the subject of direct observation. In either case the patient must give consent in accordance with the guidelines for consenting patients. Consultations should be selected across a range of patient contexts and over the entire period of training spent in general practice and should include at least one case from each of the following categories:

• Children (a child aged 10 or under).
• Older adults (an adult aged more than 75 years old).
• Mental health.

The requirement is for a minimum of 12 COTs (six before each six-monthly review) in Stage 3 of training (12 months in General Practice). The minimum requirement applies whether or not the GP Registrar is in full-time training. One consultation should be viewed at a time.

COT: Guide to the Performance Criteria^[5]

• PC1: the doctor is seen to encourage the patient's contribution at appropriate points in the consultation.
• PC2: the doctor is seen to respond to signals (cues) that lead to a deeper understanding of the problem
• PC3: the doctor uses appropriate psychological and social information to place the complaint(s) in context.
• PC4: the doctor explores the patient's health understanding.
• PC5: the doctor obtains sufficient information to include or exclude likely relevant significant conditions.
• PC7: the doctor appears to make a clinically appropriate working diagnosis
• PC8: The doctor explains the problem or diagnosis in appropriate language.
• PC9: the doctor specifically seeks to confirm the patient's understanding of the diagnosis
• PC10: the management plan (including any prescription) is appropriate for the working diagnosis, reflecting a good understanding of modern accepted medical practice.
• PC11: the patient is given the opportunity to be involved in significant management decisions.
• PC12: makes effective use of resources.
• PC13: the doctor specifies the conditions and interval for follow-up or review.

Assessment of a video consultation

The following is a summary of the aspects of a video consultation that have previously been assessed for the MRCGP examination and for Summative Assessment. The list is therefore useful for anyone wanting to use videotaping to improve consultation skills:

• Discover the reason for the patient's attendance:
  • Elicit an account of the symptoms:
    • The doctor is seen to encourage the patient's contribution at appropriate points in the consultation.
    • The doctor is seen to respond to signals (cues) that lead to a deeper understanding of the problem.
  • Obtain relevant items of social and occupational circumstances:
    • The doctor uses appropriate psychological and social information to place the complaint(s) in context.
  • Explore the patient's health understanding:
    • The doctor explores the patient's health understanding.
• Define the clinical problem:
  • Obtain additional information about the symptoms, and other details of medical history:
    • The doctor obtains sufficient information to include or exclude likely relevant significant conditions.
  • Assess the patient by appropriate physical and mental examination:
    • The physical/mental examination chosen is likely to confirm or disprove hypotheses that could reasonably have been formed, or is designed to address a patient's concern.
  • Make a working diagnosis:
    • The doctor appears to make a clinically appropriate working diagnosis.
• Explain the problem(s) to the patient:
  • Share the findings with the patient:
    • The doctor explains the problem or diagnosis in appropriate language.
    • The doctor's explanation incorporates some or all of the patient's health beliefs.
  • Ensure that the explanation is understood and accepted by the patient:
    • The doctor specifically seeks to confirm the patient's understanding of the diagnosis.
• Address the patient's problem(s):
  • Choose an appropriate form of management:
    • The management plan (including any prescription) is appropriate for the working diagnosis, reflecting a good understanding of modern accepted medical practice.
  • Involve the patient in the management plan:
    • The patient is given the opportunity to be involved in significant management decisions.
• Make effective use of the consultation:
  • Make effective use of resources:
    • In prescribing the doctor takes steps to enhance concordance, by exploring and responding to the patient's understanding of the treatment.
    • The doctor specifies the conditions and interval for follow-up or review.

Many alternative formats are used, but all should cover the following points:

• Communication: welcome, information gathering, explanation of management plan, exit strategy.
• Partnership: involvement of the patient.
• Health enablement (including health promotion): improving self-awareness.
• Management plan: options on best evidence, agreement, explanation, review.
• Insight and understanding: the doctor's post-consultation comments to reflect additional factors (social/family), past history, patient expectations, insight and understanding of consultation/performance.