Abstract
Welcome to a new Recorded Consultation Assessment (RCA) revision section developed to provide a focus for GP trainees preparing for the RCA. This section includes a ‘Doctor’s sheet’ and a ‘Patient’s sheet’ to facilitate practising consultations with your trainer and colleagues. An ‘Examiner’s sheet’ describes the areas trainees need to display in each of the marking domains and finishes with key points and tips for the trainee. It is important that trainees are familiar with the RCA pages on the RCGP website as this provides further highly relevant information and guidance.
Doctor’s sheet
Patient: Lee Price Age: 33 years
This patient is on your routine call back list. The last consultation was 1 year ago for musculoskeletal back pain.
Patient’s sheet
Name: Lee Price Age: 33 years
Background
A young man who has had back pain for 3 weeks.
Opening line
I’ve had constant back pain for 3 weeks and I need something done now.
Behaviour
The patient is very insistent on having a scan and tramadol.
Ideas: Tramadol will help with the pain and a magnetic resonance imaging (MRI) scan will help with the diagnosis Concerns: The pain will continue to worsen, and he won’t be able to carry his children Expectations: A prescription for tramadol and a referral for an MRI scan
Information given freely
He sprained his back 3 weeks ago after lifting something heavy at work. The pain is no better with paracetamol or ibuprofen or co-codamol. The pain is particularly worse when trying to pick up his 5-year-old child.
Information to be given if prompted
He does not complain of any sciatica. There are no urinary or bowel symptoms or perianal paraesthesia. He has no weight loss. He works in a warehouse lifting heavy objects and is worried about losing his job. He therefore feels finding the cause via an MRI scan will help.
Past medical history: Nil Current medication: Nil Social history: Lives with his wife and 5-year-old child; works in a warehouse lifting heavy objects and enjoys playing football Examination: There is a full range of motion of his back; there is some pain at the extremes of movement; no spinal tenderness elicited; power and sensation of both lower limbs is intact
Examiner’s sheet
Data gathering
It is important to allow the patient time to explain why they have consulted. They should cover red flag symptoms and ask if and how the problem is affecting Lee at home and at work.
Reasonable examination offered and done.
Shows empathy with his situation at home and at work (after exploring them within the history).
Covers ideas, concerns and expectations and deals with them well.
Red flags
Ask about symptoms like sciatica, urinary and bowel symptoms and perianal paraesthesia to rule out cauda equina. Also ask about weight loss to rule out myeloma (although very unlikely with his age).
Clinical management
Explain that this is likely to be musculoskeletal pain. Suggest naproxen (if no contraindications) for the pain as tramadol is not ideal for back pain and can be addictive. Reassure that there are no red flags, and the pain should improve with time. Offer a physiotherapy referral if the patient is keen. Currently no evidence for a scan but can certainly continue to monitor actively with review in a couple of weeks’ time. Could offer blood tests – specifically a vitamin D level if indicated. This patient will need good explanations as he is very keen on certain medication and referral for a scan. Safety netting is important.
Interpersonal skills
Build a good rapport. Empathise and acknowledge that symptoms are affecting the patient’s home and work life. Offer a good explanation of the likely diagnosis, why a scan isn’t warranted and why you’re choosing a different medication. Check understanding with the patient and ask if they have any questions.
Key points
The trainee needs to be very inquisitive and try to understand why the patient is consulting (concern over symptoms affecting daily living). They must cover the red flag symptoms. Having a supportive nature and building a good rapport is important here to make sure the patient is happy with the endpoint. Focused examination and explanation of the likely cause should be jargon free. Blood tests should be stated (if offered), and medication should be explained. Reasonable follow-up should be specified.
Discussion with trainee
Adopting a patient-centred approach to a consultation and using a shared decision-making management plan.
Empathise with a patient whose symptoms are impacting their daily living.
Building a good rapport with a patient will increase the chances of them complying with a sensible treatment plan.
Top tips
The best way to prepare for the RCA is to consult with patients in general practice Trainees should build on feedback from previous Workplace-based Assessments like Consultation Observation Tools (COTs) and case-based discussions (CbDs), as well as constructive comments during observed clinics or hot reviews and by watching consultation videos Trainees should review their own consultation skills and develop their own style with input and feedback from senior colleagues and trainers Be aware of the marking domains and ensure appropriate areas within each domain are covered during the consultation
