Greg Irving is a Senior Lecturer in General Practice, Edge Hill University, Ormskirk
Martin Breach is a GP trainer, Haydock Medical Centre, St.Helens
Claire Clark is a GP trainer, Spinney Medical Centre, St.Helens
Steve Cox is a Visiting Professor, University of Chester, Chester
Simon Hargreaves is a GP trainer, Mill Street Medical Centre, St.Helens
Sue Hyde is a GP trainer, Eccleston Medical Centre, St.Helens
David Lawson is a GP trainer, Garswood Medical Centre, Wigan
Craig Morgan is a GP trainer, Rainford Medical Centre, St.Helens
Anna Newton is a GP trainer, Garswood Medical Centre, Wigan
Helen Parr is a GP trainer, Garswood Medical Centre, Wigan
Laura Pogue is a GP trainer, Patterdale Lodge Medical Centre, Newton-le-Willows
David Reade is a GP trainer, Hall Street Medical Centre, St.Helens
Ulrich Veltkamp is a GP trainer, Rainford Medical Centre, St.Helens
Why do we continue to examine GP trainees at 10 minutes when the RCGP itself has called for longer GP consultations?
The recently announced changes to the MRCGP in response to the COVID-19 pandemic has seen the replacement of the Clinical Skills Assessment (CSA) with the Recorded Consultation Assessment.1 Yet the guidance on the length of the face-to-face consultations to be submitted in the assessment remains at 10 minutes – even for complex cases. Arguments put forward in the past suggest that 10 minutes examination exists because 1) the exam only assesses the face-to-face element of the consultation and not those activities that take place either side of the consultation such as preparation and documentation 2) the exam must prepare the candidate to practice anywhere in the UK including those practices that offer 10 minutes and 3) the examination has been validated again the standard of a 10 minute consultation.
There is no agreed definition of what constitutes ‘the consultation’
The argument that the examination only assesses the face-to-face element of the GP consultation highlights a more fundamental problem in medical education, health service research and policy – that there is no agreed definition of what constitutes ‘the consultation’. Precision is important and without such definitions it remains unclear whether we are measuring and talking about the same intervention in policy and assessment. In two systematic reviews of GP consultation length of a wide range of approaches were used to define and measure consultation length.2,3 No trial or observational study fulfilled the TIDieR guidance how an intervention should be described. We would argue that definitions of the full range of GP consultation types are needed to be more precisely defined in accordance with the TIDieR framework.4
The argument that the exam prepares the candidate for practice anywhere in the UK including those practices that offer 10 minutes as standard is inconsistent with College reports even prior to COVID-19 that states that the 10 minute consultation is not safe and effective for current practice were multimorbidity and complexity is now the norm.5,6 Asking candidates to focus on one problem only creates and artificial scenario and contradicts evidence on best practice.7 It may also encourage gaming were patients may be coached prior to the consultation to only discuss one problem. The COVID-19 pandemic has also seen the widespread introduction of a digital first approach and total triage systems where most histories are taken by telephone or video and the face-to-face element reserved for physical examination only.8 Here the total consultation time for a single presentation may exceed 10 minutes. If an examination that is representative of current UK practice is the intention then it would be useful to align this with data from observational data for complex presentations e.g. from the RCGP Workload observatory, CPRD, QResearch or NHS digital.
Asking candidates to focus on one problem only creates and artificial scenario and contradicts evidence on best practice.
The final point that the examination has been validated against a 10 minute standard is not insurmountable. Validating the examination against 15 minutes or longer for those cases with multimorbidity and complexity would be a logical place to start. In the long term this could bring benefits to patients such as more accurate diagnosis of mental health problems and more opportunities for health promotion and reducing admissions for some ambulatory sensitive conditions such as diabetes. Crucially, it could also bring benefits to GPs including reduced burnout and improved job satisfaction.2,3 The COVID-19 pandemic has presented us with opportunities to decide which activities we should discard and what activities we wish to amplify. The new RCA change offers an opportunity to define what is we mean by consultation length, align policy and assessment, promote safe and effective practice and reflect real work UK practice.
- MRCGP: Recorded Consultation Assessment (RCA). [cited 30 Sep 2020]. Available from: https://www.rcgp.org.uk/training-exams/mrcgp-exam-overview/mrcgp-recorded-consultation-assessment.aspx
- Irving G, Neves AL, Dambha-Miller H, Oishi A, Tagashira H, Verho A, et al. (2017) International variations in primary care physician consultation time: A systematic review of 67 countries. Vol. 7, BMJ Open. p. e017902.
- Wilson AD, Childs S, Gonçalves-Bradley DC, Irving GJ (2016). Interventions to increase or decrease the length of primary care physicians’ consultation. Vol. 2016, Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.CD003540.pub3
- Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. (2014) Better reporting of interventions: Template for intervention description and replication (TIDieR) checklist and guide. BMJ. 7;34:8:g1687
- RCGP: Fit for the Future. [cited 30 Sep 2020]. Available from: https://www.rcgp.org.uk/policy/fit-for-the-future.aspx
- RCGP: Medical generalism. [cited 30 Sep 2020]. Available from: https://www.rcgp.org.uk/policy/rcgp-policy-areas/medical-generalism.aspx
- NICE Multimorbidity: clinical assessment and management. [cited 30 Sep 2020]. Available from: https://www.nice.org.uk/advice/ktt18
- RCGP RSC Workload Observatory | ClinInf.eu [Internet]. [cited 2020 Jun 3]. Available from: https://clininf.eu/index.php/rcgprscworkloadobservatory/