Abstract
GP consultations involve application of clinical and consultation skills, as well as practical insight to provide high-quality patient care. The Recorded Consultation Assessment (RCA) is a summative assessment of a doctor’s ability to integrate and apply these skills in real patient scenarios. In this article, GP trainer, Dr Kunal Chawathey provides some insights to trainees about preparing for the RCA.
The RCA is one of the modalities of competency assessment for GP trainees, along with the applied knowledge test (AKT) and workplace-based assessments. In contrast to the clinical skills assessment (CSA), the RCA offers candidates the benefit of reviewing their own consultations prior to submission. This not only allows trainees a take-two (or more!) with their performance, but also the opportunity to analyse and polish their consulting skills to reach the standard expected from a GP.
Improving consultation skills
The RCA examines the candidate’s ability in the domains of data gathering, decision making & clinical management skills and interpersonal skills. Since trainees have the advantage of recording multiple consultations and reviewing them prior to submission, one might infer there would be a significant increase in the pass rate compared with the CSA. However, the interim report on performance of the MRCGP RCA (that considered all the AKT, CSA and RCA exams since 2014), showed that the first attempt CSA pass rate amongst UK graduates was 89.6%, whereas the RCA pass rate was 91.6%. The figures were 44.1% and 49.6%, respectively, for international medical graduates.
This highlights the importance of fine-tuning one’s consulting skills to be able to deliver high-quality consultations on a consistent basis. In the first 2–3 months of ST3 training, the focus of recordings, therefore, should be to analyse, reflect and improve upon your consulting skills, rather than recording with a view to submitting for the RCA. If you are a poor swimmer, selecting a new lane is unlikely to ensure a better performance.
Selecting cases
The RCGP website provides detailed information about case selection criteria (www.rcgp.org.uk/training-exams/mrcgp-exam/mrcgp-recorded-consultation-assessment/mandatory-case-selection-criteria-for-recorded-consultation-assessment.aspx). In a nutshell, these include at least one case involving:
A child aged 16 years or younger (can be by proxy) An older adult (age 65 years and older) An acute problem that needs urgent investigation or referral Maternal and reproductive health Mental health condition (within the DSM or ICD classifications), and A long-term condition, e.g. cancer, multi-morbidity or disability
The only exceptions allowed are for military trainees working solely in military training practices during ST-3, with limited or no opportunity to consult patients outside the age bracket of 17–64 years due to practice demographics these locations. For the remainder of cases, candidates must ensure the spread of cases is broad and include no more than two cases with a focus on the same clinical topic area.
Technology and governance for RCA
Make sure you are acquainted with the technology required for recording. These include being able to use key functions of your telephone, webcam and recording equipment. Ensure that you are aware of information governance issues surrounding recording and storing information, as well as being well versed with the consenting format on the submission platform you are using.
Finding and recording cases for submission
Once you are ready to take the exam, it is time to plan and to ensure you get the right mix of cases for recording. Highly complex cases are unlikely to be completed satisfactorily within 12 minutes whereas low-challenge cases will not allow adequate demonstration of consulting skills:
Have reception staff/care coordinator onboard and acquaint them with the list of presentations you are looking. This list may need to be ‘updated’ once you have covered some of the submission criteria. New presentations are likely to be more suitable as compared to follow-up reviews (e.g. new diagnosis of hypertension versus a hypertension review) Check with clinical staff for newly diagnosed problems that require a consultation (e.g. hypertension, diabetes, polycystic ovarian syndrome, etc.) Get permission from other clinicians to swap appropriate cases in your list Make sure that patients know that the call may come from a withheld number and that they need to provide consent before and after the consultation Do not submit consultations with a patient’s swimsuit area visible in the recording Use a ‘do not disturb’ sign on the door when you are recording Typing sounds can affect the quality of recording. An alternative is to make handwritten notes during the consultation and then add electronic entries afterwards Since the examiner is unaware of the past medical history, medication, etc., it is reasonable to verbalise relevant aspects of the clinical records to complete the picture – remember not to be mechanistic in this approach.
Reviewing your own consultations
As you start recording for the RCA you will realise that scoring your own consultations is helpful to finalise cases for submission onto the RCA portal Template grids are available online (e.g. via Fourteen Fish platform) or you could create your own ExCel spreadsheet for this task Figure 1 shows the marking scheme for the RCA. You can score a maximum of 117 marks per examiner, so the maximum attainable score is 234) The mark required to pass varies daily, but tends to be between 135 and 145 (a pass in all domains in all cases gets 156) Remember that examiners mark only what they see or hear RCA marking schema.
Good candidates will be able to demonstrate focused history taking skills while referring to relevant aspects of past medical history, medications and previous management plans from patients’ records. They also narrow down a differential diagnosis or identify a list of problems to manage and do this successfully, while incorporating the patient’s views.
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