Final Year General Practice Syllabusgp2.sgul.ac.uk/final-year-1/final-year-gp-practice-syllabus-r7.pdf · Final Year General Practice Syllabus 4 Clinical practice outcomes- involve,

Final Year General Practice Syllabus

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Final Year General

Practice Syllabus


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Contents

Page no

Index 2

Introduction 4

Clinical practice outcomes 5

Overview of the final year General Practice syllabus 6

Weekly timetable 7

Assessment 8

Assessment content summary 9

Final year general practice syllabus by outcome

1. Teaching and learning 10

2. History 11

3. Examination 12

4. Differential diagnosis 13

5. Investigation 15

6. Diagnosis and problem lists 15

7. Emergencies 16

8. Procedures 17

9. Patient-centred practice 18

10. Management 18

11. Prescribing 19

12. Multiprofessionalism 19

13. Legal, ethical and professional issues 20

14. Evidence for patients and populations 20

15. Patient safety and quality improvement 21

Appendices

Appendix 1 Priority list: core conditions for General Practice 22

Appendix 2 Confidence rating 26

Appendix 3 Sample of learning outcomes for General Practice 29

Appendix 4 The Cambridge-Calgary approach to the medical interview 44


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Appendix 5 The St George’s student formulary 48

Appendix 6 UK Notifiable diseases 51

Appendix 7 Brief guidance on clinical attachment certificate 52

Appendix 8 Guidance on workplace-based assessments 53

Appendix 9 Guidance on patient survey 55

Appendix 10 Tutor guidance on video assignment 60

Appendix 11 Suggested practical student guidance on video assignment 63

Appendix 12 Patient video consent form used at SGUL 64

Appendix 13 Exemplar reference system 65

Appendix 14 Suggested references for UK General Practice 66

Appendix 15 Guide to domain-based OSCEs 67


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Clinical practice outcomes- involve, guide, support

The St George’s MBBS is moving from learning objectives to an outcomes-based syllabus forthe clinical years. The new syllabus organises the teaching, learning and assessment in termsof the tasks and activities regularly performed in the workplace. This rewards students forgetting fully involved in the life of their clinical teams, and makes thinking at the “point ofcare” the starting point for their self-directed study.

The tasks and activities identified in the outcomes include our daily practice in history,examination, differential diagnosis, investigation, diagnosis and drawing up problem lists,emergency care, clinical procedures, management and prescribing. In addition, it identifiesthe daily clinical tasks that relate to broader aspects of practice that are well-developed inthe St George’s curriculum: patient-centredness, medical law and ethics, public health andprofessionalism.

The general practice attachment has always been orientated towards active learning andparticipation in the practice team so the day to day structure of the placement and studentactivities are not changing. However, we intend that the reworked syllabus will enhance theway you: involve the students in the natural opportunities that come up in general practicerelated to these broader practice outcomes; guide the students in reference to a definedsyllabus shared by other clinical placements; and continue to support the individual studentslearning needs as you always have.

The core statement for each clinical practice outcome is listed on page 2. Each final yearplacement has developed the core statement to be relevant to its particular context. Thissyllabus statement for general practice is on page 3: further notes are given in the body ofthe document for each outcome. Appendices 1-6 refer to curriculum resources referenced inthis document. The core conditions (priority list) for the placement are listed in Appendix 1.


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Core statements for clinical practice outcomes

1. Develop and demonstrate effective learning and teaching skills for the workplace

2. Elicit a clinical history and give information

3. Perform a clinical examination

4. Prioritise a differential diagnosis following a clinical encounter

5. Formulate a plan of investigation and interpret the results of investigations

6. Synthesise information from history, examination and investigation, define the likelydiagnosis and draw up a problem list

7. Recognise a patient requiring emergency care, and initiate evaluation and management

8. Observe, assist and perform clinical procedures appropriate to the stage of training

9. Demonstrate patient-centred consultation and management skills

10. Formulate a comprehensive plan for treatment and management of acute and long termconditions, taking account of the patient’s social context

11. Prescribe drugs and monitor patient outcomes

12. Communicate and collaborate in a multiprofessional environment

13. Integrate legal, ethical and professional guidance and standards into the care of patients

14. Form clinical questions and interpret evidence to inform the care of patients and Populations

15. Critically evaluate systems of care and contribute to a culture of patient safety and qualityimprovement


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The Final Year General Practice Syllabus

1. Evaluate the gap between foundation year standards and your own performance and takeaction to develop your practice

2. Use problem focussed history skills, collateral history and information from computerisednotes to gather a clinical history

3. Perform a problem focussed clinical examination, integrating regional examination asappropriate, and eliciting common clinical signs

4. Organise symptoms from a first presentation into either those to be normalised, temporisedor prioritised and build a differential diagnosis for common clinical presentations

5. Plan tests for the purpose of screening, diagnosis and monitoring disease

6. Draw up a holistic problem list for patients in primary care that takes account of social,psychological and care needs

7. Recognise red flags and early warning signs for common clinical conditions in general practice,alert clinical supervisors and be prepared to initiate basic life support

8. Take opportunities to practice common clinical procedures in general practice underappropriate supervision and with informed consent of the patient

9. Gather a narrative of the patient’s illness alongside the clinical history and prioritise theirneeds and wishes

10. Draw up a holistic management plan, and record the plan agreed with the patient and yourclinical supervisor in the clinical notes

11. Obtain an accurate medication history, identify potential interactions between medications,and discuss planning and initiating new medications with your clinical supervisor

12. Witness the communication and collaboration that occurs between the practice team,primary health and social care team and secondary care to assess and manage patients

13. Reflect on and discuss with your clinical supervisor the everyday legal and ethical dilemmasin general practice, such as capacity, confidentiality, best interests and end of life care

14. Participate in the health promotion, opportunistic and systematic screening and preventionactivities occurring in general practice

15. Appraise patient records, noting how problems, allergies and out of hours contacts arerecorded; discuss child and adult safeguarding processes and take part in significant eventanalysis.


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Weekly timetable

As a minimum, students are expected to:

Five clinical sessions (surgeries and home visits) of which a minimum of two should beself-conducted.

For self-conducted surgeries, students should get 20 minutes with the patient, plus somefeedback time with the GP tutor totalling 30 minutes. The student should be given a widerange of patients covering acute and chronic management. This will also include managingthe patient survey and completing work based assessments (see assessments).

One session allocated to a weekly tutorial with the Local organiser

Two sessions self-directed to include recording (filmed consultation with a patient) andanalysis of the video consultation, quality improvement activities in the practice such as audit,significant event meetings, personal reflection

One for community experience, e.g. District Nurse, Midwife, Social Services, primary care

team etc

Total: 9 sessions

You should be satisfied that by the end of the attachment the student has worked/attended at

least 35 sessions in order to pass the attachment.

Poor Attendance

The following may guide the GP tutor in circumstances where students are poorly attending. A session

is classed as a morning or afternoon slot of a minimum of 3 hours; please do let the course organiser

know as a matter of urgency if there are any issues with attendance:

35 or more sessions: Acceptable

< 35 sessions: Unacceptable

o GP tutor and Local Organiser usually specify any extenuating circumstances

Students who have attended fewer than 35 sessions will:

o be asked to see academic staff

o need to take further sessions; registry will be informed

o be unlikely to be signed off the attachment


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Assessment

Assessment

Every clinical attachment in T, P and F year is assessed in the same way under four elements:attendance, clinical practice, professional behaviour and practical procedures. There areadditional formative assessments in the general practice attachment.

The main assessments are:

Clinical attachment certificate which assesses attendance and professional behaviour (Appendix7)

Clinical practice and practical procedures are assessed using formative workplace basedassessments DOPs, CBD and Mini CEX (Appendix 8)

Formative patient survey (Appendix 9)

Video analysis assignment (Appendices 10-12)

Overleaf is a checklist for your records of all of the assessments you need to complete per student;

some of the assessments need contributions from both the GP tutor and local organiser (LO). Please

note that in order to balance the student’s workload, tutors should plan with the student when the

video assignment and patient survey should be done during the first week of the attachment.


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Table 1: General Practice attachment final year: Assessment content summary

LO = Local organiser GPT = GP tutor

Assessments that must be undertaken in general practice Further

information

Type When Who Compulsory Purpose Appendices

Formative Summative

MiniCex (1) Early GP Tutor √ √ 8

Case Based

Discussion (1)

Early GP Tutor √ √ 8

Patient Survey Early GP Tutor √ √ 9

Video Hand-in at

OSCE

**GP Tutor &

LO

√ √ 10-12

OSCE Final week GP Tutor & LO √ √ 15

Attendance End GP Tutor* √ √ √

Clinical Practice

and

professionalism

certificate

End GP Tutor* √ √ √ 7

Final year assessments that may be undertaken in general practice

Prescribing

WPBA

Throughout

year: All

firms

GP Tutor √ √ Dr as a Profhandbook

DOPS Throughout

year:

All firms

GP Tutor √ √ √*** 8

Notes:

* Local organiser to contact GP Tutor if there are any concerns about attendance, professional

behaviour and clinical practice. It is important that GP tutors contact the Marshall University St

George’s lead as soon as they have concerns, preferably within the first week of the attachment.

Attendance: <35 Unacceptable (whatever reason); 35 or more = Acceptable

Clinical Practice: If any compulsory assessment is missing the student should be awarded a U


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Criteria for grading on attachment form:

Professional Behaviour: If there are any (minor or major) concerns, please answer yes on attachment

form and fill in the long form and give specific concerns in written feedback. Minor concerns may be

part of a bigger picture for that student, students won’t be penalised for one or two minor issues,

but may be if this is part of a recurrent pattern over different firms. If tutors have concerns about

the completion of the professionalism form for the student, please contact the St George’s lead as a

matter of urgency.

** video assessment to be double marked by GP tutor and local organiser. Feedback to go to student

after end of attachment, within 2 weeks.

*** DOPS standard = safe, supervised with consent and completed successfully on a patient in F year.

SGUL clinical practice workplace outcome 1: Teaching and learning

1. Evaluate the gap between foundation year standards and your own performance and take

action to develop your practice

Students use self-assessment of learning needs, a 1:1 tutor support and feedback

relationship and formative assessment to reflect on learning needs and prioritise areas for

development. The emphasis is students taking responsibility for their learning, facilitated by

support and guidance from their GP tutor

Prior to the attachment, students complete the Confidence Rating Scales (Appendix 2) andemail them to their GP tutor. The aim of this is to help the GP tutor assess the students’learning needs and plan for their arrival. The Confidence Rating Scales list a number ofareas in both skills and symptom management. This is repeated and reviewed at the endof the placement

The emphasis is on learning from participation in practice. Most, if not all of this syllabuswill be covered in the natural course of the placement but self-study to support practiceexposure is encouraged. Examples of resources are given under each outcome and asample of general practice orientated learning outcomes to support students self-directed learning are given in Appendix 3 (this is list is not exhaustive).


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SGUL clinical practice workplace outcome 2: History

2. Use problem focussed history skills, collateral history and information from computerisednotes to gather a clinical history

By the end of T year, students can elicit a full clinical history using appropriate communication skills.

They are familiar with the Cambridge-Calgary approach (Appendix 4) and should communicate

clearly, sensitively and effectively with patients, relatives or other carers, by listening, sharing and

responding regardless of age, background or disability.

During P year, students become familiar with specialty histories including paediatric, obstetrics andgynaecology, neurology, psychiatry, palliative care, geriatrics and cardiology but have not yetintegrated these elements when required into a problem-focussed history. Information fromcollateral sources and from computerised notes should also be encouraged.

Problem-focussed history is a key outcome of this placement. GP tutors can support studentsto construct a problem-focussed history according to their differential diagnosis by reflectionon case histories.

P year psychiatry is hospital focussed. A primary care orientated history, including assessmentof suicidal intent is a key outcome for this placement.

Limited exposure to ophthalmology, ENT, dermatology and rheumatology occurs in P year, sothis placement provides useful exposure and development for these elements.


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SGUL clinical practice workplace outcome 3: Examination

3. Perform a problem-focussed clinical examination, integrating regional examination asappropriate, and eliciting common clinical signs

Students have learnt all the examinations below in P year in the hospital setting. By the end of thisattachment, they should be competent (foundation year standard) in the following examinations inthe primary care setting. We appreciate that, though invaluable for students, gaining practice for theintimate examinations* can be difficult. Selecting appropriate opportunities for this is left to thediscretion of patients and tutors and is not mandatory.

Table 2: Core examinations

Measuring BP Joint examination

Chest and praecordial examination Back examination

Abdominal examination Examination of the skin

Rectal examination* Otoscopy of children and adults’ 2

External eye examination Examining children

Fundoscopy 1 Vaginal examination*

Problem-focussed neurological examination Taking cervical smears*

Mental state examination Taking high vaginal swabs*

Breast examination

1. Detection of otitis media, otitis externa and tympanic perforation

2. Detection of marked changes of diabetes and hypertension


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SGUL clinical practice workplace outcome 4: Differential diagnosis

4. Organise symptoms from a first presentation into either those to be normalised,

temporised or prioritised and build a differential diagnosis for common clinical

presentations

General Practitioners see patients very early in their illness. Patients present with symptoms, rather

than diseases, that need to be evaluated in terms of the possible underlying causes.

Patients may bring symptoms that represent underlying disease processes (“clinical presentations”)

or that may be self-limiting or even normal. Before constructing a differential diagnosis, students

must learn to consult effectively and be able to sort these symptoms which may be brought “mixed

up” to together.

In T year students observed GPs normalising, temporising (“if it doesn’t get better in 2 weeks,

come back”) or prioritising symptoms during the consultation. Final year students should

discuss cases they see with their GP tutor using this approach.

For prioritised symptoms, students need to be able to construct a differential diagnosis, and

focus history and examination towards their hypotheses.

Particular approaches in general practice include recognising red flags in yellow flags. Using

red flags involves active consideration of serious conditions such as emergencies and cancer

in their differential diagnosis. Using yellow flags involves actively considering the psychosocial

impact of the illness the patient which the patient may not share when presenting symptoms.


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Table 3: Core clinical presentations for general practice

Cardiorespiratory/General Medicine Paediatrics

Acute chest pain Fever

Breathlessness The sick child

Cough Rash

Weight loss Wheeze/cough

Limb swelling and oedema Dysuria

Anaemia Constipation/diarrhoea

Fever Parental concern with development

Gastro/Abdominal surgery Squint

Abdominal pain including dyspepsia Renal

Bleeding PR Urinary symptoms

Dermatology Neurology

Pigmented lesion Headache

Red rash Geriatric Medicine (non-specific presentation)

ENT Acute confusion (delirium)

Throat symptoms Breakdown in Social Circumstances

Earache Chronic confusion (Dementia)

Hearing loss, tinnitus, vertigo Falls

Gynaecology Rheumatology

Menstrual disorders Swollen joint

Vaginal discharge Chronic pain

Bleeding in early pregnancy Back pain

Pelvic pain Non-specific

Breast lump Tiredness/fatigue

Mental health Dizziness

Depression Opthalmology

Tension/Anxiety The red eye

Grief Sudden visual loss


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SGUL clinical practice workplace outcome 5: Investigations

5. Plan tests for the purpose of screening, diagnosis and monitoring disease

Students are familiar with common investigations used in hospital practice. Key outcomes of this

placement are

Managing uncertainty and resources when planning tests in general practice; investigating

patients with a lower pre-test probability of having a disease process

Use of tests for monitoring long term conditions including medication monitoring

SGUL clinical practice workplace outcome 6: Diagnosis and problem list

6. Draw up a holistic problem list for patients in primary care that takes account of social,

psychological and care needs

Listed in Appendix 1 are the diagnoses that students are likely to see in general practice.

Students should be familiar with diagnostic criteria as defined by recommendations in

clinical guidelines from NICE https://www.nice.org.uk/guidance/published?type=cg and

https://www.brit-thoracic.org.uk for asthma and COPD

The problem list should be extended to include social, psychological and care needs. Related

outcomes include 9,10,12


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SGUL clinical practice workplace outcome 7: Emergencies

7. Recognise red flags and early warning signs for common clinical conditions in generalpractice, alert clinical supervisors and be prepared to initiate basic life support

In Appendix 1, emergencies that are more commonly seen in GP are listed with a red rating. Students

should familiarise themselves with the red flags/early warning signs for emergency presentations of

these conditions and their management. The role of the primary care team in these situations is

different from secondary care teams and involve 3 core activities:

Safety netting-educating patients what to do if symptoms progress or worsen, and having a

clearly recorded plan in the notes to alert other team members. This is particularly important

in the children and elderly, brittle control of chronic disease such as asthma and diabetes.

Red flags-recognising early warning signs of emergencies and taking action to treat or refer in

a timely way. Examples include ectopic pregnancy, suicidal risk.

Initiating emergency management of life threatening conditions. This is similar to secondary

care professionals but with a more limited range of investigations and management options.

In particular the management of acute severe asthma, anaphylaxis and initiation of basic life

support should be prioritised.

Practices should ensure students to be familiar with the location of emergency equipment and drugs,

and demonstrate any system for alerting the primary care health team to come to their aid

immediately in the rare event of a life threatening emergency in one of their consultations


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SGUL clinical practice workplace outcome 8: Procedures

8. Take opportunities to practice common clinical procedures in general practice underappropriate supervision and with informed consent of the patient

Students have been directly supervised performing procedures in T and P years. Procedures

supervised in T and P year relevant to general practice are listed in table 4 below. Any

opportunities for continued supervised practice are welcomed.

In addition, students are required to perform a number of procedures in F year at least once

successfully during the entirety of their final year. The final year procedures more relevant to

general practice that they may have an opportunity to undertake with you are given in table

5. Practice should be supervised using a DOPs form to record performance and feedback.

The standard required for final year is students successfully complete the final year list ofprocedures on at least one occasion. Students are aware of: the clinical indications andcomplications of procedures and can discuss the procedure as part of the patients’management; of their own limitations and need for supervision; and the need to work withinappropriate professional guidance including patient consent.

Table 4: Designated DOPS previously undertaken by students in T and P years relevant to generalpractice

Diagnostic Therapeutic

Venepuncture and managing

blood specimens

Vaginal examination Sub-cutaneous

injection

Administering

oxygen

Recording ECG Rectal examination Intramuscular

injection

Measuring Peak Flow vaginal examination with

Cusco's speculum plus

swabs and/or cervical

cytology'

Transcutaneous pulse

oximetry

Table 5: DOPs required for final year that students may have opportunity to perform in general

practice

- Wound care, basic wound dressing and skin suturing

- Use of local anaesthetics

- IM injections

- SC injections


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SGUL clinical practice workplace outcome 9: Patient-centred practice

9. Gather a narrative of the patient’s illness alongside the clinical history and prioritise theirneeds and wishes

This outcome requires students to have a systemic understanding of how the patient’s life interacts

with the system of care they are receiving and communicate and respond sensitively to their needs

and wishes. Home visiting is a useful way of emphasising this.

It includes integrating the following components (taken from Tomorrows Doctors 2015) into their

consulting and forms the basis of holistic problem evaluation and holistic management planning.

Respond to patients’ concerns and preferences, and respect the rights of patients to reach

decisions with their doctor about their treatment and care and to refuse or limit treatment.

Understanding psychological and social factors that contribute to illness, the course of thedisease and the success of treatment; understand psychological aspects of behaviouralchange and treatment compliance.

Appreciate the importance of individual, psychological, spiritual, religious, social and culturalfactors.

The video consultation assignment (Appendix 9-12) and the patient survey (Appendix 8) support thisoutcome. The video consultation is an in depth reflective summary of the phases of one consultationusing the Cambridge Calgary approach (Appendix 4) and the patient survey evaluates the impressionsof a sample of patients in regard to the everyday practice of the student.

SGUL clinical practice workplace outcome 10: Management

10. Draw up a holistic management plan, and record the plan agreed with the patient and yourclinical supervisor in the clinical notes

Foundation year hospital posts require junior doctors to be the principle coordinator of the

management and discharge plan. Final year preparation for this includes

Knowledge of the evidence-based management for common diagnoses (Appendix 1).

Discussion with patients, carers and the clinical team to tailor management plans to the

individual patient.

The agreed plan should addresses the problem list which may include clinical, psychological

and social care needs and be recorded in the clinical notes.


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SGUL clinical practice workplace outcome 11: Prescribing

11. Obtain an accurate medication history, identify potential interactions between

medications, and discuss planning and initiating new medications with your clinical

supervisor

Appendix 5 lists the drug classes and commonly used drugs that the students are required to learn

over the entire MBBS. Some are more relevant to general practice than others. Prescribing case based

discussions required over the whole of the final year are outlined in the Doctor as a Professional

Handbook.

Students should obtain an accurate medication history, identify potential interactions

between medications, and discuss planning and initiating new medications with your clinical

supervisor.

GP tutors may direct students to focus their self-study on prescribing in relation to

management of long term conditions.

Awareness of medicines management within the practice: practice protocols, liaison with

prescribing advisors, community pharmacists should also be discussed with students where

relevant.

SGUL clinical practice workplace outcome 12: Multiprofessionalism

12. Witness the communication and collaboration that occurs between the practice team,

primary health and social care team and secondary care to assess and manage patients

Holistic care planning requires effective handover between doctors, communication within the

primary care healthcare team and working with other professionals from health, social care and

secondary care. Any opportunities to witness collaborative care planning or communication should

be encouraged.

Students should attend whole team meetings with a clinical focus.

Cases with involvement of other health and social care professionals should be highlighted to

the students. This may be particularly relevant to housebound patients and home visiting with

their GP tutor is encouraged.

Students should be supervised writing hospital referral letters and reviewing hospital

discharge letters.


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SGUL clinical practice workplace outcome 13: Legal, ethical and professional issues

13. Reflect on and discuss with your clinical supervisor the everyday legal and ethical dilemmas

in general practice, such as capacity, confidentiality, best interests and end of life care

Students should be able analyse and discuss with GP tutors the ethical and legal dimensions of the

everyday clinical cases they see. Students should demonstrate good professional behaviour in

keeping with the standards expected by the UK General Medical Council. Priorities for this placement

are

Applying the principles of the Mental Capacity Act 2005 -a brief summary can be found at

http://www.gpnotebook.co.uk/simplepage.cfm?ID=x20090315201720749131 and cards

2,3,and 4 of https://www.bma.org.uk/mentalcapacity

Children and young people’s ethics (cards 1,2,3,4 and 5 of the toolkit), confidentiality and

end of life care. Resources can be found at

https://www.bma.org.uk/advice/employment/ethics/ethics-a-to-z

Students should be familiar with GMC guidance and safeguard themselves from breaches of

professionalism, such as seeking help if they are not confident about the performance of a

task. For guidance see http://www.gmc-uk.org/education/undergraduate/studentftp.asp

http://www.gmc-uk.org/education/undergraduate/professional_behaviour.asp

Everyday examples can be seen at http://www.gmc-uk.org/gmpinaction

SGUL clinical practice workplace outcome 14: Evidence for patients and populations

14. Participate in the health promotion, opportunistic and systematic screening and prevention

activities occurring in general practice

Students are encouraged to contribute to health service quality, health improvement and health

protection for the population they serve. The main focus of this outcome in this placement is the

opportunistic and systematic public health disease monitoring activities occurring in general practice

and service development to support these activities. Students should witness and become familiar

with practice organisation and delivery of care around.

Immunisation cervical screening, health checks for overall risk of heart disease and stroke,opportunistic screening for smoking, alcohol intake, obesity and blood pressure.UK current immunisation schedule can be found at

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/532787/PHE_Complete_Immunisation_Schedule_SUMMER2016.pdf

Notifiable diseases (Appendix 6).

Disease registers for review of long term conditions.


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SGUL clinical practice workplace outcome 15: Patient safety and quality improvement

15. Appraise patient records, noting how problems, allergies and out of hours contacts are

recorded; discuss child and adult safeguarding processes and take part in significant event

analysis

How to access information on problems, medication allergies and out of hours contacts

should be demonstrated to students and the importance of these aspects of care highlighted.

Students should become familiar with child safeguarding advice: cards 10, 11 of

https://www.bma.org.uk/advice/employment/ethics/children-and-young-people/children-

and-young-peoples-ethics-tool-kit and adult safeguarding advice and agencies see cards

3,4,14 of https://www.bma.org.uk/advice/employment/ethics/ethics-a-to-z of the

safeguarding vulnerable adults-a toolkit for GPs (2011).They should alert clinical supervisors

if they have concerns.

Encourage students to attend practice quality improvement activities such as significant event

analysis, practice development following patient feedback meetings, audit presentations.


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Appendix 1 - SGUL priority list

SGUL learning objective priority codes

*Emergency, life threatening or serious condition.Must recognise and be able to initiate treatment or refer appropriately

1= Should have a good knowledge of these conditions and be able to recognise and manage as anewly qualified doctor

2=should have some knowledge of these conditions, recognise them and seek appropriate help fortheir management as a newly qualified doctors

3= be aware of the existence of these conditions and know where to seek appropriate help fortheir diagnosis and management

Respiratory System

Asthma 1*

Chronic Obstructive Pulmonary Disease (COPD) 1*

Pneumonia 1

Cardiovascular System

Acute Coronary Syndrome / Myocardial Infarction (MI) 1*

Hypertension 1

Ischaemic heart disease/Angina 1

Arrhythmias and Conduction Defects (atrial fibrillation) 1

Cardiac Failure 1

Gastrointestinal System

Acute Abdomen 1*

Gastro-Oesophageal Reflux and Barrett’s Oesophagus 2

Peptic Ulcers 2

Functional Gastro-Intestinal Disorders –Irritable bowel syndrome 2

Anal lesions 3

Endocrine System

Type 1 and Type 2 Diabetes Mellitus 1*

Hyperlipidaemia 1

Thyroid Disease 2

Renal system

Infections of the Kidney and Urinary Tract (cystitis, acuteyelonephritis, urethral syndrome)

1

Chronic Renal Failure 1

Musculoskeletal System

Osteoarthritis 1


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Skin

Dermatological Malignancies 1*

Eczema 2

Psoriasis 2

Infectious Disease

Antibiotics and Resistance 1*

Haematology

Iron Deficiency Anaemia 1*

Oncology

Presentations and Principles of Malignant Disease 1

Geriatric Medicine

Atypical Disease Presentation and Multiple Pathology 1

Evidence Based Prescribing 1

Falls 1

Delirium (acute confusion) 1

Dementia 1

Breakdown in Social Circumstances 1

Principles of Rehabilitation and Multidisciplinary Team Working 1

Nervous System including Neurology, Neurosurgery and NeurorehabilitationPlease note there is an additional P year firm covering this

Headache (including migraine and tension type) 1

Cerebrovascular disease 1

Breast

Breast Cancer 1

Breast Infection 3

Ears, Nose and Throat

Hearing Loss 2

Acute Otitis Media 2

Chronic Otitis Media 2

Tinnitus 2

Vertigo 2

Earache (Otalgia) 3

NoseRhinitis, Nasal Polyps 2


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Obstetrics and Gynaecology

Early Pregnancy 1*

Menstruation and Menstrual Disorders 1

Fertility Control 1

Climacteric and Menopause 1

Antenatal Care 1

The Puerperium 1

Paediatrics

Basic Paediatric Skills

Respiratory

Asthma 1*

Croup (Laryngotracheobronchitis) 1*

Bronchiolitis 1

Pneumonia 1

Otitis Media 1

Tonsillitis 1

Neurology and development

Developmental Delay 1

Febrile Convulsions 1

Squint 1

Urinary Tract and Nephrology

Urinary Tract Infections 1

Gastro-Intestinal Disease

The acute abdomen in children 1

Immunology, Allergy and Dermatology

Eczema 1

Nappy rash 1

Infections

Septicaemia 1*

Throat

Laryngitis 2*

Pharyngitis and Tonsillitis 2

Ophthalmology

Ophthalmological Emergencies 2*

Uveitis 2*

Conjunctivitis 2

Cataract 2

Retinopathy – diabetic, hypertensive, other 2

Eyelids (entropion, ectropion, blepharitis, stye, chalazion) 3


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Chicken Pox 1

Gastroenteritis 1

Measles/Mumps/Rubella 2

Child Psychiatry and Aspects of Social Medicine

Child abuse 1

Psychiatry

Self Harm and Suicide 1*

Addictive behaviour (alcohol, smoking and drugs) 1

Mood Disorders 2

Anxiety Disorders 2

Medically Unexplained Symptoms (somatoform,hypochondriacal and dissociative disorders)

2

Psychological Aspects of Chronic Pain and Disability 2

Schizophrenia and Psychosis 2


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Appendix 2: Confidence Rating ScaleFinal Year GP Attachment Confidence Rating Scale:

Student name: Date:

GP tutor:

Skills/clinical areas Initial rating Second rating

1 Measuring BP

2 Chest and praecordial examination

3 Abdominal examination

4 Rectal examination*

5 External eye examination

6 Fundoscopy 1

7 Problem-focussed neurological examination

8 Mental state examination

9 Joint examination

10 Back examination

11 Examination of the skin

12 Otoscopy of children and adults’ 2

13 Examining children

14 Vaginal examination*

15 Taking cervical smears*

16 Taking high vaginal swabs*

17 Breast examination

18 Contraceptive methods

19 Measuring blood glucose

20 IM injections

21 SC injections

22 Urinalysis

23 Prescribing for the elderly

24 Prescribing for children

25 Prescribing in pregnancy

26 Using a peak flow meter, Asthma drug deliverysystems and nebuliser use

* Indicates areas in which we know experience is difficult to obtain


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Final Year GP Attachment Confidence Rating Scale:

Student name: Date:

GP tutor:

Symptoms/Disease Initial rating Second rating

27 Acute chest pain

28 Breathlessness

29 Cough

30 Weight loss

31 Limb swelling and oedema

32 Anaemia

33 Fever

34 Abdominal pain including dyspepsia

35 Bleeding PR

36 Pigmented lesion

37 Red rash

38 Throat symptoms

39 Earache

40 Hearing loss, tinnitus, vertigo

41 Menstrual disorders

42 Vaginal discharge

43 Bleeding in early pregnancy

44 Pelvic pain

45 Breast lump

46 Fever

47 The sick child

48 Rash

49 Wheeze/cough

50 Dysuria

51 Constipation/diarrhoea

52 Parental concern with development

53 Squint


28

Final Year GP Attachment Confidence Rating Scale:

Student name: Date:

GP tutor:

Symptoms/Disease Initial rating Second rating

54 Urinary symptoms

55 Headache

56 Acute confusion (delirium)

57 Breakdown in Social Circumstances

58 Chronic confusion (Dementia)

59 Falls

60 Swollen joint

61 Chronic pain

62 Back pain

63 Depression

64 Tension/Anxiety

65 Grief

66 Tiredness/fatigue

67 Dizziness

68 The red eye

69 Sudden visual loss

70 Disability/handicap

71 Vaccination

Professional Issues Initial rating Second rating

72 Dealing with medically unexplainedsymptoms73 Dealing with emotion in the consultation

74 Breaking bad news

75 Dealing with one's own emotions as a doctor

76 Hospital referral letters

77 Hospital discharge letters

78 Social determinants of health

79 Sickness certification


29

Appendix 3:

Learning Outcomes for Common Conditions in Primary Care Final Year

Please note these are not all-inclusive and are examples of those aspects which are most relevant orbest learnt in primary care.

Asthma

By the end of this attachment, you should be able to:

diagnose asthma in children and adults.

describe the key symptoms or signs.

outline the advantages and disadvantages of peak flow monitoring diaries.

differentiate between mild, moderate and severe asthma clinically.

describe the Red Flag symptoms for acute severe asthma. Describe how you manage this in

primary care.

discuss with a patient the distinction between reliever and preventer inhalers.

describe the mechanism of action of drugs used in asthma treatment.

describe to a patient how to use the available inhaler and check their technique.

outline the physiological and therapeutic rationale of the British Thoracic Society guidelines.

During your GP attachment, you should:

demonstrate to a patient how to use a peak flow meter.

demonstrate to a patient good inhaler technique.

observe or perform spirometry.

Chronic Obstructive Pulmonary DiseaseBy the end of this attachment, you should be able to:

discuss witha patient the factors inthe causationof COPD andthe importanceof smoking

cessation.

discuss the key investigations in making a diagnosis of COPD.

describe the Red Flag symptoms for severe COPD.

distinguish between mild, moderate and severe COPD and functional status.

diagnose an infective exacerbationof COPD, outline a therapeutic plan andwrite a prescription

for checking by your GP tutor.

describe to a patient the different modalities of treatment and the importance of preventative

Respiratory System


30

factors.

describe the indicators for long-term oxygen therapy.

During your GP attachment, you should be able to:

check a patient’s inhaler technique and give advice regarding improvement.

demonstrate peak flow monitoring and pulmonary function testing.

observe spirometry and assess its role in diagnosing COPD.

Cardiovascular disease: Primary and Secondary Coronary Heart Disease

By the end of this attachment, you should be able to discuss a management plan that suggestsappropriate targets and interventions in the context of:

Primary prevention of coronary heart disease (CHD) or other occlusive arterial disease.

Secondary prevention of CHD or other occlusive arterial disease.

Define the terms primary and secondary prevention in relation to coronary heart disease.

Describe the targets and interventions appropriate in a patient with diagnosed CHD or other

occlusive arterial disease.

List the risk factors you would identify for estimating an individual's 10 year risk of coronary

heart disease in the context of primary prevention.

Estimate the risk of CHD in an individual by using the Joint British Societies coronary risk

prediction charts.

Suggest appropriate interventions to modify this individual’s risk.

Suggest appropriate targets for these interventions.


Audit the notes of a patient with CHD or other occlusive arterial disease and review whether

appropriate targets and interventions for this patient have been reached.

Assess a patient without diagnosed CHD or other occlusive arterial disease for risk factors,

estimate their 10-year risk of CHD using a risk prediction method and suggest appropriate

interventions to your GP tutors.

Hypertension

By the end of this attachment, you should be able to include in your management plan for a patient

Cardiovascular System


31

with essential hypertension:

at diagnosis.

subsequent review appointments.

how to confirm a diagnosis of hypertension in the context of:

o primary prevention of cardiovascular disease,

o secondary prevention of cardiovascular disease, and

o Diabetes Mellitus.

bedside examination and tests that identify end organ effects of hypertension.

evidence that you have considered whether the patient has essential or secondary hypertension.

a strategy to investigate the presence of end organ effects of hypertension.

a strategy to define other cardiovascular risk factors in your patient.

a management strategy that may include:

o lifestyle changes,

o choice of appropriate first line anti-hypertensive therapy including awareness ofcautions and contra-indications to these drugs,

o a plan for monitoring of blood pressure control and drug side effects, and

o a strategy for combining anti-hypertensive drugs if control is not achieved.


observe the Practice Nurse giving lifestyle advice to a patient with hypertension.

practise taking blood pressure from patients with and without detected hypertension.

perform and interpret an urinalysis from a patient with hypertension.

observe your GP tutor perform a hypertension review.

take a history and examination from a patient with essential hypertension and write amanagement plan for them.

References

http://www.nice.org.uk/page.aspx?o=CG034fullguideline. Updated guideline between NICE and theBritish Hipertension Society. 2007

Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JP, Sever PS and Thom S McG; TheBHS Guidelines Working Party. British Hypertension Society Guidelines for HypertensionManagement, 2004 - BHS IV: Summary. BMJ 2004; 328: 634-640


32

Lipids

By the end of this attachment, you should be able to include in your management plan for a patientwith an abnormal lipid profile:

at diagnosis.


how to confirm a diagnosis of hyperlipidaemia in the context of:

o primary prevention of cardiovascular disease,

o secondary prevention of cardiovascular disease, and

o Diabetes Mellitus.

clinical examination and blood tests that identify hyperlipidaemia.

evidence that you have considered secondary causes of hyperlipidaemia.

a strategy to define other cardiovascular risk factors in your patient.

a management strategy that may include:

o lifestyle changes,

o choice of appropriate lipid lowering agent including awareness of cautions and contra-indications to these drugs, and

o a plan for monitoring lipid control and drug side effects.


observe the Practice Nurse giving lifestyle advice to a patient with abnormal lipids.

observe your GP tutor perform a review of a patient with hyperlipidaemia.

perform a cardiovascular risk assessment on a patient.

Diabetes

By the end of this attachment, you should be able to include in your management plan for a patientwith Type 2 Diabetes Mellitus:

at diagnosis.


tests to confirm the diagnosis of Diabetes Mellitus if appropriate.

evidence that you have distinguished Type 1 from Type 2 diabetes.

a management strategy (diet and choice of appropriate oral hypoglycaemic therapy includingawareness of cautions and contra-indications) for glycaemic control of Type 2 Diabetes.

a plan for monitoring of glycaemic control with urine and blood tests.

Endocrine System


33

evidence that you have considered criteria for outpatient hospital referral.

evidence that you have considered criteria for emergency admission and/or discussion with adiabetologist the same day.

a strategy for the detection of eye, renal and foot complications.

a strategy for defining and managing other cardiovascular risk factors.


observe the Practice Nurse giving dietary advice to a diabetic patient.

perform and interpret an urinalysis from a patient with Diabetes.

take a capillary blood glucose and estimate the blood glucose reading.

observe your GP tutor perform a diabetic check.

take a history and examination from a patient with Type 2 Diabetes and write a managementplan for them.

References

National Institute for Health and Clinical Excellence. Type 2 Diabetes: The Management of Type 2Diabetes. Quick Reference Guide. 2008


take a focussed history of minor illness from a patient.

examine the upper respiratory tract including the ears and throat in children over two years

and in an adult

describe the differential diagnosis of acute and chronic sinusitis from an URTI.

discuss with a patient ways to alleviate symptoms of the following minor illnesses:

o Headache

o “Flu”

o Otalgia

o Sore throat

o Upper respiratory tract infection

explaintoapatienthowtoavoidrhinitisandhowtouseOTC drugssafelytocontrol symptoms of

rhinitis.

Ears, Nose and Throat (ENT)


34

discuss with a patient the mechanisms of action of drugs commonly used in the management

of primary care ENT problems and how to use them, e.g. antihistamines, steroid nasal

preparations, anti-fungal and antibiotic aural preparations.

discuss with a patient the benefits and drawbacks of prescribing for minor ENT illnesses such

as sore throat and otitis media.

describe the indications for prescribing antibiotics for minor illnesses.

Hearing Loss, Tinnitus and Vertigo

After this attachment, you should be able to:

describe the role of the Primary Healthcare Team in detecting, aiding and supporting those

with loss of hearing at all ages.

describe the differential diagnosis of hearing loss at different ages of life.

describethebehaviouralandlearningproblemscausedbydeafnessinchildrenanddiscuss with

a parent ways of overcoming these.

demonstrate the ability to consult sensitively with patients of variable hearing abilities.

take a focussed history of hearing loss from parents of a child.

outline the detection and referral processes for children with hearing loss.

perform a distraction hearing test on an 8-month old child.

describe the problems caused by ear wax, and the indications, contra-indications, pros and

cons of its removal.

discuss witha patient the process of syringingthe ear to remove impacted wax andthe

alternatives.

list the commonest causes of “giddiness” in General Practice.

takea focussed history froma patient withdizziness, perform an appropriate examination and

suggest the initial investigations indicated.

give the Red Flags for diagnosis on Meniere’s disease and cerebella lesions.

Laryngitis and Epiglottitis


describe the diagnosis and management of croup in primary care.

describe the indications for URGENT referral of a child with croup.

describe the symptoms and signs that suggest acute epiglottitis.

explain why acute epiglottitis is an acute emergency.

describe how you would manage a) a child, and b) an adult with acute epiglottitis.


35

Otitis Externa


describe the symptoms and signs of otitis externa.

outline the management of otitis externa.

advise a patient on ways to avoid recurrence of otitis externa.

Otitis Media, Acute and Chronic


give a differential diagnosis for earache.

diagnose otitis media by history and examination.

explain why some children may be prone to recurrent acute otitis media.

list and describe the Red Flags suggestive of life-threatening complications of ear infection.

describe to a patient the pathological process of serious otitis.

describe to a patient thepharmacological and surgical treatments available for serious otitis.

identify the presence of grommets and, e.g. goodes tubes in the tympanic membrane.

By the end of this attachment and the time of sitting finals, you will need to be able to:

communicate sensitively and effectively with women and colleagues about general health andproblems related to their reproductive system.

perform a “booking consultation” and an “antenatal” review consultation within a set timeframe.

demonstrate sensitive examination of the pregnant woman including abdominal palpation.

performintimateexaminationswhereappropriate, includingvaginalandspeculum examinationson gynaecological patients (with chaperone).

have achieved competence at taking cervical smears, vaginal and cervical swabs (withchaperone).

test urine for sugar and protein.

Obstetric Care


counsel women with regard to pre-pregnancy health education and promotion including folicacid, diet and appropriate exercise.

take a history to diagnose pregnancy and calculate gestation.

perform an antenatal examination.

Obstetrics and Gynaecology


36

perform a urine dipstick pregnancy test.

describe the risk factors, clinical presentation including Red Flags, diagnosis and complications ofectopic pregnancy.

describe the patterns of antenatal care available in the community and the staff that providethem.

outline the indications for consultant led antenatal care.

counsel a woman who is requesting home delivery.

discuss with a woman the principles and practice of screening tests used in antenatal careincluding:

o routine booking investigations,

o serum screening,

o ultrasound screening including nuchal translucency, and

o amniocentesis and chorioniv villus sampling.

offer advice to a woman who is suffering from nausea and vomiting in earlypregnancy.

discuss with a woman the diagnosis of pregnancy induced hypertension and pre-eclampsia and appropriate management.

discuss with a patient the changes that may occur within family relationships during theantenatal period and into the puerperium.

discuss with a patient the options for analgesia available to her in labour.

describe how you would define, diagnose and manage obstetric emergencies in thecommunity including:

o ante-partum haemorrhage, and

o pre-eclampsia.

counsel a woman regarding the pros and cons of breast feeding.

outline the principles of prescribing during pregnancy and lactation.

recognise abnormalities of the puerperium and describe their causes andmanagement including:

o secondary PPH, and

o postnatal psychological disorders and screening techniques.

outline the role of women in society, particularly to changing attitudes towardschildbearing and working patterns and how these factors influence healthcare provisionfor women.

Contraception

By the end of this attachment, you should be able to include in your consultation for a patient requestingthe combined oral contraceptive pill:


37

at the first appointment

subsequent review appointments

o evidence that you have checked the acceptability of the COC with your patient,discussing failure rate, method of administration, side effects and positive effects.

o evidence that you have checked the safety of the COC in your patient by historyand examination.

o differentiate between second and third generation pills with respect to risk of venousthromboembolism.

o choose an appropriate COC and write a prescription to be checked by your GP tutor.

o evidence that you can teach the patient how to take the pill effectively.

o a plan for monitoring the patient while on the COC.

o a strategy to prevent pill failure in the situation of:

missed pills,

diarrhoea and vomiting, and

concurrent prescription of broad spectrum antibiotics.

o a strategy for changing pills in the case of:

breakthrough bleeding, and

unwanted side effects.


observe your GP tutor performing a review of a patient on the COC.

perform a review of a patient on the COC.

Learn about long acting forms of contraception

Cervical Smears

By the end of the GP attachment, you should be able to:

understand how the NHS cervical screening programme works and who is the target population.

understand the system of smear reporting used and relate this to pathological changes seen oncervical smears.

explain an abnormal smear result to a patient and describe the process of colposcopy.

discuss the risk factors for cervical cancer with a patient.


ensure you can pass a speculum

ensure you can clearly visualise a cervix

take a cervical smear.


38

Climateric and Menopause

By the end of the GP attachment, you should be able to:

outline the psychological changes that occur around the time of the menopause.

discuss the pharmacological and non-pharmacological treatments of the menopause.

list the risks and benefits of HRT with reference to epidemiological studies.

Child DevelopmentBy the end of the GP attachment, you should be able to:

understand the role of Health Visitors and School Nurses.

know the range of normal you would expect to find for a child aged six weeks, eight months,18 months and three years in the four developmental areas:

o fine motor,

o gross motor,

o speech and hearing, and

o social behaviour and play.

know the common presenting features of autism.

be aware of the first steps in management of common childhood problems such as bedwetting, eating problems, sleeping problems, temper tantrums and school refusal.


carry out a six-week baby check.

The Sick Child

By the end of this skills topic, you should be able to:

recognise signs of dehydration in a child, and understand how to advise parents or referappropriately.

describe the BTS guidelines for asthma, and be able to recognise a child who needs hospitaltreatment.

recognise bronchiolitis,andknow what symptoms or signs would warrant admissionto hospital.

recognise signs of septicaemia in children of different ages.

be aware of the common causes of abdominal pain in children and understand ways in whichyou can distinguish one from another.

recognise the signs of child abuse and understand the correct course of action to take if yoususpect abuse is taking place.

understand the acute management of a child with a febrile fit. Be able to carry out appropriateexamination after a fit and know how to advise and re-assure parents.

Paediatrics


39

Childhood Illnesses

By the end of the attachment, you should be able to have knowledge on how to manage a child with:

wheeze/cough

fever

rash

constipation/diarrhoea

failure to thrive

developmental delay

a squint

dysuria

Childhood Infectious Diseases


recognise the clinical features of each of the following childhood infectious diseases:

o Chickenpox

o Croup

o Epiglottis

o Hand, foot and mouth

o Measles

o Meningococcal meningitis/septicemia

o Mumps

o Rubella

o Scarlet fever

o Slapped cheek disease (Fifth disease)

o Whooping cough

understand infectivity and incubation periods.

be aware of potential complications.


explain the management and the likely course of the illness of at least one of these illnessesto parents.

Childhood Immunisations

By the end of this attachment, you should:

know the current childhood immunisation schedule.


40

understand contra-indications for immunisations and be able to take an appropriate historyfrom a parent before a vaccination can be given.

be able to discuss the rationale for the MMR vaccination programme.

know how to treat anaphylaxis.

describe the potential complications of measles, mumps and rubella and use theseappropriately in the discussion with a parent regarding MMR vaccine.


outline indications for referral of patients with psychiatric illness including in an emergency.

discuss how to maintain appropriate levels of confidentiality and information-sharing withinthe Practice.

Alcohol and Drug Abuse


distinguish between physical and psychological dependency.

demonstrate the ability to sensitively screen a patient for excessive alcohol or drug use inprimary care.

take an accurate alcohol history to elicit a) number of units drunk per week, b) features ofproblem drinking.

advise a patient regarding the “safe limits” for the consumption of alcohol and explain whythese are different for men and women.

discuss with a patient the help available to them to give help reduce/give up alcohol or druguse in the community.

outline the general practitioner’s responsibility with respect to alcohol and drug abuse in society.

describe the general practitioner’s role in the care of drug addicts.

Anxiety Disorders


demonstrate the specific skills required to obtain a clear and comprehensive history of anxiety.

give a differential diagnosis for anxiety disorders.

describe appropriate prescribing practices and non-pharmacological strategies for anxietymanagement.

Psychiatry


41

Mood Disorders


utilise screening devices such as the GHQ or Edinburgh Post Natal Depression Scale to detectmood disorder in primary care.

outline the varying presentations of depression in primary care.

describe how you would recognise depression in a patient presenting with symptoms and signsof physical illness and discuss the effect of depression on the presentation of, and recoveryfrom physical illness.

demonstrate the assessment of severity of mood disorder and suicide risk in a patient.

discuss with a patient the diagnosis of depression and anxiety outlining the causes, treatmentsand prognosis.

list physical illnesses that can present as depression.

describe the basic principles of support and psychotherapy and their importance in the treatmentof depression.

Cognitive Problems (Organic Psychiatric Disorder)


recognise the differing presentations that may be found with patients suffering from dementiain the community.

discuss with a patient or carer the diagnosis of dementia and the care and support that is availableto help.

list reversible and irreversible causes for chronic dementia and describe how you wouldinvestigate this in primary care.

describe the role of the multidisciplinary team in management of behavioural problems anddisability associated with dementia.

distinguish between acute confusional state (delirium) from a chronic confusional state(dementia).

Schizophrenia and Psychosis


discuss the interrelationship between biological, psychological, family, social and culturalfactors that may influence the nature of the presentation of psychotic disorders, and thedevelopment of relapses.

outline the levels and types of care available for patients who are dependent as a result ofpsychiatric illness or organic psychiatric disorder.

Smoking


quantitate cigarette consumption in pack years.


42

demonstrate the ability to counsel a patient regarding their smoking and offer appropriateadvice on how to give up.

explain the role of advice and counselling by health professionals and the Primary HealthcareTeam in initiating and supporting quit attempts.

advise a patient regarding the various treatments (including side effects) available, both overthe counter and on prescription, to assist them in quitting smoking.

Psychological Aspects of Chronic Pain and Disability


describe psychological morbidity associated with chronic pain.

outline the management of psychological morbidity secondary to chronic illness.

outlinethe management of chronic pain with referenceto treatment of underlying cause,

analgesia and physical measures to relieve pain.

discuss the problems associated with hypnotic (sleeping tablet) prescribing and outline

appropriate strategies for treating sleep problems and those patients who use hypnotics long-

term.

Emergency Care


take a focussed history of chest pain to elicit characteristics of ischaemia.

describe how you assess and manage an acutely ill patient in the community.

describe the acute management of ischaemic chest pain in primary care.

describe the features of a sick child which warrant emergency action.

describe the commonest situations in primary care likely to result in anaphylaxis.

describe the emergency treatment of anaphylactic shock.

discuss the emergency treatment of bronchospasm and severe asthma.

demonstrate the ability to nebulise a patient with an acute attack of asthma.

explain to a patient with uncontrolled hypertension why their surgery has been postponed.

describetheroleplayedby theparamedics inthe management of acutely ill patients inthe

community and what they can and cannot do.

Emergency care and pain management


43

Pain Management


describe the concept of the Analgesia Ladder and its role in acute and chronic pain control.

describe the major and minor analgesics available in primary care.

take a pain history from a patient.

develop an evidence based management plan for the following patients:

o 6 year-old child with earache,

o 25 year-old male with a fractured clavicle,

o 53 year-old woman with colles fracture and history of reflux, and

o 68 year-old man with prostatic secondaries in the lumbar spine.

list the major adverse events associated with NSAIDs.

discuss the use of combined analgesics in pain management.

discuss the importance of psychological support in chronic pain management.

discuss the use of alternative therapies in the management of acute and chronic pain.

give indications for referral to the Pain Clinic.


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Appendix 4: Cambridge Calgary Guide to the Medical InterviewAnalysing the Video Recorded Consultation

This method of analysis will provide a logical framework for students reviewing theirconsultation.

INITIATING THE SESSION: ESTABLISHING INITIAL RAPPORT

1. Greets patient and obtains patient’s name.

2. Introduces self, role and nature of interview; obtains consent.

3. Demonstrates interest, concern and respect, attends to patient’s physical comfort.

Identifying the reason(s) for the consultation

4. Identifies the patient’s problems or the issues that the patient wishes to address withappropriate opening question (e.g. “What problems brought you to the hospital?” or “Whatwould you like to discuss today?”).

5. Listens attentively to the patient’s opening statement, without interrupting or directingpatient’s response.

6. Checks and screens for further problems (e.g. “so that’s headaches and tiredness, what otherproblems have you noticed?” or “is there anything else you’d like to discuss today as well?”).

7. Negotiates agenda taking both patient’s and physician’s needs into account.

GATHERING INFORMATION

Exploration of patient’s problems

8. Encourages patient to tell the story of the problem(s) from when first started to the present inown words (clarifying reason for presenting now).

9. Uses open and closed questions , appropriately moving from open to closed.

10. Listens attentively, allowing patient to complete statements without interruption andleaving space for patient to think before answering or go on after pausing.

11. Facilitates patient's responses verbally and non–verbally, e.g. use of encouragement, silence,repetition, paraphrasing, interpretation.

12. Picks up verbal and non–verbal cues (body language, speech, facial expression, affects); checksout and acknowledges as appropriate.

13. Clarifies statements, which are vague or need amplification (e.g. “Could you explain what youmean by light headed").

14. Periodically summarises to verify own understanding of what the patient has said; invites patientto correct interpretation or provide further information.

15. Uses concise, easily understood language, avoids or adequately explains jargon.


45

Additional skills for understanding the patient’s perspective

16. Determines and acknowledges :

o Patient’s ideas (i.e. beliefs re cause) and concerns (i.e. worries) regarding each problem.

o Patient’s expectations: goals, what help the patient had expected for each problem.

o Effects: how each problem affects the patient’s life.

17. Encourages expression of the patient’s feelings and thoughts.

Providing structure to the consultation

18. Summarises at the end of a specific line of inquiry to confirm understanding beforemoving on to the next section.

19. Progresses from one section to another using signposting (signals change in focus ofinterview); includes rationale for next section.

20. Structures interview in logical sequence.

21. Attends to timing and keeping interview on task.

BUILDING RELATIONSHIPS

Non-verbal behaviour

22. Demonstrates appropriate non–verbal behaviour, e.g. eye contact, posture and position,movement, facial expression, use of voice.

23. If reads or writes notes or uses computer, does so in a manner that does not interfere withdialogue or rapport.

Developing rapport

24. Acknowledges patient's views and feelings; accepts legitimacy; is not judgmental.

25. Uses empathy to communicate understanding and appreciation of the patient’s feelings orpredicament.

26. Provides support: expresses concern, understanding, willingness to help; acknowledges copingefforts and appropriate self care; offers partnership.

27. Deals sensitively with embarrassing and disturbing topics and physical pain, including whenassociated with physical examination.

Involving the patient

28. Shares thinking with patient to encourage patient’s involvement (e.g. “What I’m thinkingnow is…….”).

29. Explains rationale for questions or parts of physical examination that could appear to benon-sequitors.

30. During physical examination, explains process, asks permission.


46

EXPLANATION AND PLANNING

Providing the correct amount and type of information

Aims: to give comprehensive and appropriate information, to assess each individual patient’sinformation needs, and to neither restrict nor overload.

31. Chunks and checks: gives information in assimilatable chunks, checks for understanding, usespatient’s response as a guide to how to proceed.

32. Assesses patient’s starting point: asks for patient’s prior knowledge early on when givinginformation, discovers extent of patient’s wish for information.

33. Asks patients what other information would be helpful e.g. aetiology, prognosis.

34. Gives explanation at appropriate times: avoids giving advice, information or reassuranceprematurely.

Aiding accurate recall and understanding

Aims: to make information easier for the patient to remember and understand.

35. Organises explanation: divides into discrete sections, develops a logical sequence.

36. Uses explicit categorisation or signposting (e.g. “There are three important things that I wouldlike to discuss. First…..”, “Now, shall we move on to…..”).

37. Uses repetition and summarising to reinforce information.

38. Uses concise, easily understood language, avoids or explains jargon.

39. Uses visual methods of conveying information: diagrams, models, written information andinstructions.

40. Checks patient’s understanding of information given (or plans made): e.g. by asking patientto restate in own words; clarifies as necessary.

Achieving a shared understanding: incorporating the patient’s perspective

Aims: to provide explanations and plans that relate to the patient’s perspective, to discover thepatient’s thoughts and feelings about information given, and to encourage an interaction ratherthan one-way transmission.

41. Relates explanations to patient’s illness framework: to previously elicited ideas, concerns andexpectations.

42. Provides opportunities and encourages patient to contribute: to ask questions, seekclarification or express doubts; responds appropriately.

43. Picks up verbal and non-verbal cues e.g. patient’s need to contribute information or askquestions, information overload, distress.

44. Elicits patient's beliefs, reactions and feelings re information given, terms used; acknowledgesand addresses where necessary.


47

Planning: shared decision making

Aims: to allow patients to understand the decision making process, to involve patients in decisionmaking to the level they wish, and to increase patients’ commitment to plans made.

45. Shares own thoughts: ideas, thought processes and dilemmas.

46. Involves patient by making suggestions rather than directives.

47. Encourages patient to contribute their thoughts: ideas, suggestions and preferences.

48. Negotiates a mutually acceptable plan.

49. Offers choices: encourages patient to make choices and decisions to the level that theywish.

50. Checks with patient if accepts plans, if concerns have been addressed.

CLOSING THE SESSION

51. Summarises session briefly and clarifies plan of care.

52. Contracts with patient re next steps for patient and physician.

53. Safety nets, explaining possible unexpected outcomes, what to do if plan is not working, whenand how to seek help.

54. Final check that patient agrees and is comfortable with plan and asks if any corrections,questions or other items to discuss.

www.skillscascade.com

Ref: Silverman JD, Kurtz SM, Draper J. Skills for Communicating with Patients. Oxford, RadcliffeMedical Press 1998


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Appendix 5: The St George’s student formulary (top 100 drugs/classes)

This list of the 100 drugs/classes (and 5 fluids) most commonly prescribed by newly qualified doctors wasdeveloped by audit of in-hospital and GP prescribing. As an F1 doctor you will prescribe most of these drugsregularly. It is important you know them very well so you are prepared.

Drug, class or BNF grouping Commonly prescribed example(s)

Emergency treatment of poisoning

1 Activated charcoal

2 Acetyl cysteine

3 Naloxone

Gastrointestinal system

4 Alginates and antacids Gaviscon®, Peptac®

5 Antimuscarinics, cardiovascular andgastrointestinal uses

atropine, hyoscine, butylbromide,glycopyrronium

6 H2-receptor antagonists ranitidine

7 Proton pump inhibitors lansoprazole, omeprazole, pantoprazole

8 Antimotility drugs loperamide, codeine phosphate

9 Aminosalicylates mesalazine, sulphasalazine

10 Laxatives, bulk forming ispaghula husk, methylcellulose, sterculia

11 Laxatives, stimulant senna, bisacodyl, glycerol suppositories, docusatesodium

12 Laxatives, osmotic lactulose, macrogol, phosphate enema

Cardiovascular system

13 Digoxin

14 Diuretics, thiazide and thiazide-like bendroflumethiazide, indapamide, chlortalidone

15 Diuretics, loop furosemide, bumetanide

16 Diuretics, potassium-sparing amiloride (as co-amilofruse, coamilozide)

17 Aldosterone antagonists spironolactone, epleronone

18 Adenosine

19 Amiodarone

20 Beta-blockers bisoprolol, atenolol, propranolol, metoprolol

21 Alpha blockers doxazosin

22 Angiotensin converting enzymeinhibitors

ramipril, lisinopril, perindopril

23 Angiotensin-II receptor antagonists losartan, candesartan, irbesartan

24 Nitrates isosorbide mononitrate, glyceryl trinitrate

25 Calcium channel blockers amlodipine, nifedipine, diltiazem, verapamil

26 Nicorandil

27 Adrenaline/ epinephrine

28 Heparins and fondaparinux enoxaparin, dalteparin, fondaparinux,unfractionated heparin

29 Warfarin

30 Aspirin


49

31 Clopidogrel

32 Dipyridimole

33 Fibrinolytic drugs altepase, streptokinase

34 Statins simvastatin, atorvastatin, pravastatin,rosuvastatin

Respiratory

35 Beta2-agonists salbutamol, salmeterol, formoterol, terbutaline

36 Antimuscarinics, bronchodilators ipratropium, tiotropium, glycopyrronium

37 Corticosteroids (glucocorticoids), inhaled beclometasone, budesonide, fluticasone

38 Compound (2-agonist-corticosteroid)inhalers

Seretide®, Symbicort®

39 Antihistamines (H1-receptor antagonists) cetirizine, loratidine, fexofenadine,chlorphenamine

40 Oxygen

Central nervous system

41 Benzodiazepines diazepam, temazepam, lorazepam,chlordiazepoxide, midazolam

42 Z-drugs zopiclone, zolpidem

43 Antipsychotics, first-generation (typical) haloperidol, chlorpromazine, prochlorperazine

44 Antipsychotics, second-generation(atypical)

quetiapine, olanzapine, risperidone, clozapine

45 Antidepressants, tricyclics and relateddrugs

amitriptyline, lofepramine

46 Antidepressants, selective serotoninreuptake inhibitors

citalopram, fluoxetine, sertraline, escitalopram

47 Antidepressants, venlafaxine andmirtazepine

venlafaxine, mirtazepine

48 Anti-emetics, histamine H1-receptorantagonists

cyclizine, cinnarizine, promethazine

49 Anti-emetics, phenothiazines Prochlorperazine, chlorpromazine

50 Anti-emetics, dopamine D2-receptorantagonists

metoclopramide, domperidone

51 Anti-emetics, serotonin 5-HT3 receptorantagonists

ondansetron, granisetron

52 Paracetamol

53 Opioids, compound preparations co-codamol, co-dydramol

54 Opioids, weak tramadol, codeine, dihydrocodeine

55 Opioids, strong morphine, oxycodone

56 Lidocaine

57 Carbamazepine

58 Phenytoin

59 Valproate sodium valproate, valproic acid

60 Gabapentin and pregabalin

61 Dopaminergic drugs for Parkinson’sdisease

levodopa (as co-careldopa, co-beneldopa),ropinirole, pramipexol


50

62 Nicotine replacement and related drugs nicotine, vareniciline, bupropion

Infections

63 Penicillins benzylpenicillin, phenoxymethylpenicillin

64 Penicillins, penicillinase-resistant flucloxacillin

65 Penicillins, broad spectrum amoxicillin, co-amoxiclav

66 Penicillins, antipseudomonal piperacillin with tazobactam (e.g. Tazosin®)

67 Cephalosporins and carbapenem cefalexin, cefotaxime, meropenem, ertapenem

68 Tetracylines doxycycline, lymecycline

69 Aminoglycosides gentamicin, amikacin

70 Macrolides clarithromycin, erythromycin, azithromycin

71 Vancomycin

72 Trimethoprim trimethoprim, co-trimoxazole

73 Metronidazole

74 Quinolones ciprofloxacin, moxifloxacin, levofloxacin

75 Nitrofurantoin

76 Anti-fungal drugs nystatin, clotrimazole, fluconazole

Endocrine system

77 Insulin insulin aspart, insulin glargine, biphasic insulin,soluble insulin

78 Sulphonylureas gliclazide

79 Metformin

80 Thiazolidinediones pioglitazone

81 Thyroid hormones levothyroxine, liothyronine

82 Corticosteroids (glucocorticoids),systemic

prednisolone, hydrocortisone, dexamethasone

83 Oestrogens and progestogens combined ethinylestradiol products, desogestrol

84 Bisphosphonates alendronic acid, disodium pamidronate,zolendronic acid

Obstetrics, gynaecology, and urinary-tract disorders

85 5-reductase inhibitors finasteride

86 Antimuscarinics, genitourinary uses oxybutynin, tolterodine, solifenacin

87 Phosphodiesterase (type 5) inhibitors sildenafil

Malignant disease

Nutrition and Blood

88 Iron ferrous fumarate, ferrous sulfate

89 Vitamins folic acid, thiamine, hydroxocobalamin,phytomenadione

90 Potassium, oral potassium chloride, potassium bicarbonate

91 Calcium and vitamin D calcium carbonate, calcium gluconate,colecalciferol, alfacalcidol

Musculoskeletal and Joint Diseases

92 Non-steroidal anti-inflammatory drugs naproxen, ibuprofen, etoricoxib


51

93 Gout and hyperuricaemia allopurinol

94 Quinine quinine sulfate

95 Methotrexate

Eye

96 Prostaglandin analogue eye drops latanoprost, bimatoprost

97 Ocular lubricants (artificial tears) hypromellose, carbomers, liquid and white softparaffin

Ear, nose and oropharynx. Skin

98 Corticosteroids (glucocorticoids), topical hydrocortisone, betamethasone

99 Emollients aqueous cream, liquid paraffin

Immunological products and vaccines

100 Vaccines and antisera childhood vaccines, influenza vaccine,pneumococcal vaccine

And 5 fluids:

Fluids

101 Colloids (plasma substitutes) gelatins, albumin

102 Compound sodium lactate (Hartmann’ssolution)

103 Glucose (dextrose) glucose 5%, glucose 10%, glucose 20%, glucose50%

104 Potassium, intravenous potassium chloride (as a constituent of IV fluidpreparations)

105 Sodium chloride sodium chloride 0.9%, sodium chloride 0.45%


52

Appendix 6: List of notifiable diseases

Diseases notifiable to local authority proper officers under the Health Protection (Notification)Regulations 2010:

Acute encephalitis

Acute infectious hepatitis

Acute meningitis

Acute poliomyelitis

Anthrax

Botulism

Brucellosis

Cholera

Diphtheria

Enteric fever (typhoid or paratyphoid fever)

Food poisoning

Haemolytic uraemic syndrome (HUS)

Infectious bloody diarrhoea

Invasive group A streptococcal disease

Legionnaires’ disease

Leprosy

Malaria

Measles

Meningococcal septicaemia

Mumps

Plague

Rabies

Rubella

Severe Acute Respiratory Syndrome (SARS)

Scarlet fever

Smallpox

Tetanus

Tuberculosis

Typhus

Viral haemorrhagic fever (VHF)

Whooping cough

Yellow fever


53

Appendix 7: Brief guidance on clinical attachment certificate

Students receive a separate grade for attendance and clinical practice.

The behavioural descriptors for each clinical practice grade are now clearly printed on the form. Thereare boxes to tick to indicate areas where a student’s performance is unsatisfactory.

Attendance requirements are <35 Unacceptable (whatever reason); 35+ Acceptable.

Please document that the student has completed their workplace based assessments but these areformative and not intended to determine your clinical practice grade.

Students are required to hand forms in to Marshall University within one week of completing theirattachment.

Forms available in Dr as Professional Handbook and on student tablets

A short form will ask you to assess different aspects of the student’s professionalism – moststudents will have no problems but we are keen to identify those who have them. Please informyour course administrator if you have any concerns with completing the professionalism form.


54

Appendix 8: Guidance on Workplace Based Assessments

Purpose: For final year students, Mini-Cex and Case Based Discussions are formative butcompulsory – the aim is observed practice and developmental feedback. For Direct ObservationProcedural Skills, the assessment is summative the designated procedure should be ‘safe,supervised, procedurally correct and successful’.

Numbers: Students will need to complete a minimum of one Mini-CEX and one CBD for GeneralPractice (see handbook). Over the whole of the Final Year, students need to successfully complete14 different DOPS in F year, and 6 prescribing workplace based assessments.

Planning: Students should know how many assessments are needed per attachment and havebeen told to start them early in the attachment. Mini-Cex and CBD are formative anddevelopmental. Students should not leave them until the last week. Similarly, some students waituntil late to record their video, only then realising that there is a technical issue. Please alsoremember that the video assignment is due on the final Monday (Week 5). The final block willhave adjusted deadlines which will be circulated nearer the time.

Assessor grade: Year 1 foundation doctor and above (or other professional routinely performingprocedure) for DOPS all years. Completed certificate general practice or equivalent and above forF year for Mini-Cex and CBD.

Feedback: Observation of histories, examinations, procedures and CBDs can be done in groups.But feedback should be individual and confidential.

Compulsory written comments: Assessors must write narrative comments in the feedbacksection. Forms will be rejected if this is incomplete. You can use the categories on the form tosuggest areas needing reward or development.

The key purpose of the different undergraduate workplace based assessments

All of these forms are available on student tablets

Mini-CEX

Students often present their findings from history and examination but are rarely observedtaking the history or performing the examination – to improve they need to improve theprocess of data gathering as well as presenting. The Mini-Cex comprises a short focusedobservation of a history (e.g. focused history for cough) or examination (e.g. CVS or knee). Itshould take no more than 15 minutes with five minutes for feedback. The assessmentstandard for Mini-Cex for the Final year is graduation: i.e. ready for entry to foundationtraining. Students in the final year greatly value the feedback which accompanies their MiniCex opportunities.

Case Based Discussions (CBD)

Generally, the CBD should be informed by computer records written by the student. The CBDfocuses on deeper discussion, synthesis and understanding of certain aspects of the case, theuse of applied knowledge and clinical reasoning. It aims to assess the integration of historyand examination with knowledge. Areas of focus may be ethics, investigative process,diagnostic reasoning, therapeutics, or any other aspect the case emphasises. The assessmentstandard for CBD for F year is graduation: i.e. ready for entry to foundation training.


55

Prescribing Mini-Cex and CBD

In F year there are six prescribing Mini-Cex and CBD which can be completed at any timeduring the year. Three of them are suitable for use in primary care and are included in theDoctor as a Professional handbook. These are aimed at giving the students key prescribingskills ready for foundation year, and also as practice for their prescribing test during the finalexaminations in April. The prescribing CBD requires a special form which is shown in therelevant section below.

Direct Observation of Procedural Skills (DOPS)

The designated practical procedures can be attempted at any time during the Final year.Assessors should only allow students to attempt procedures under supervision if the studentknows the procedural process and associated risks, prior to starting. The standard for DOPSin F year is procedurally correct, successfully completed, and safe. The assessor is not signingthe student to be competent at the procedure, merely how well they have performed theprocedure on this supervised occasion. DOPS documents not only that a procedure is donebut ensures next time the procedure is done better. For the purposes of medical schoolassessment, they need to demonstrate one successful attempt at all of a designated list ofprocedures by DOPS, during the F year. DOPS assessors can be foundation year doctors orabove, or any staff member who usually performs the procedure.

Many, but not all, designated DOPS are not suited for general practice. You may also want toask if your student has previously performed any vaginal examinations – only about 70% doso during the P year O and G attachment, and General Practice is a good place to learn.


56

Appendix 9: Patient Survey: GP Attachment

The purpose of this formative survey is to familiarise the students with patient surveys, to give thestudents some experience of feedback from patients, and for them to appreciate the value andlimitations of patient feedback.

It will be hard for students to achieve large enough samples during their attachment, in order to makerobust conclusions, so this should be seen as a ‘taster’ of more formal patient surveys they willexperience later in their career.

Assessment Status: Compulsory but Formative.

Source: GPAQ – communication skills direct feedback (amended)

Number: Minimum of 5 suggested – 10-15 would be more useful, but depends on how many patientsthe student sees initially alone at each practice.

Suggested process:

Time: Week 2 or 3 (to allow development during the attachment)

Receptionists disseminate patient surveys (adapted from GPAQ) to patients that have seenthe student.

Receptionists hand the completed surveys to the GP tutor.

GP tutor reads the surveys and gives to the student.

The student reads the feedback and summarises and reflects on the key points.

The student gives the tutor the summary and reflections, and in a brief meeting (≈ 30 mins) the tutor and student discuss the findings and mutually agree an action plan for the student regardingcommunication skills for the rest of the attachment. The discussion should ideally include thepossibility of respondent bias or selection bias, the sample sizes necessary for valid robustconclusions.


57

Student Name………………………………………………………………………………………………

Dear Patient,

Your feedback on the St George’s Medical Student you have just seen or are about to see would be

really helpful to them. Your feedback does not affect their grading or exams in any way. Instead, they

will use your comments to develop their communication skills with patients during the rest of their

medical course.

Thinking about your consultation with the student today, how do you rate the following?

Ver

yP

oo

r

Po

or

Fair

Go

od

V.G

oo

d

Exce

llen

t

No

t

Ap

plic

able

1. How thoroughly the student askedabout your symptoms and how youare feeling?

2. How well the Student listened towhat you had to say?

3. How well the student put you atease during your physicalexamination?

4. How well the student explainedyour problems or any treatment thatyou need?

5. The student’s patience with yourquestions or worries?

6. The student’s caring and concernfor you?


58

7. Any other comments?

Survey amended from GPAQV2 http://www.gpaq.info/GPAQ_SURGERY.pdf

Thank you for filling in the survey. Please hand back to the receptionist.


59

Medical student patient survey: Discussion template.

Student Name …………………………

Student summary of Patient Survey Results

No. of forms. _______

Question 1

Question 2

Question 3

Question 4

Question 5

Comments

Student Reflections on Survey Results

1.

2.


60

3.

4.

Assessor comments on survey results

Action Plan for Student Communication Skills Development

1.

2.

3.

Tutor Name Date / /


61

Appendix 10: Tutor guidance on the video assignment

All students will need to conduct and write up a video recorded consultation. The deadline forstudents to hand is the final Monday of the attachment. The marking deadline is two weeks afterthe end of the attachment.

A reflective summary of 500-1000 words, based on the Cambridge-Calgary Model of what studentshave learnt from the video analysis is required as below with the following headings:

Do you have any comments to make about your interviewing style (e.g. to what extent doyou think that you are patient-centred)?

What comments would you make about how you structured your interview?

Any observations about your relationship-building skills.

What was your overall impression of how your patient was feeling during the interview?

Did your own feelings change during the interview?

Was there anything that your patient said during the interview that you now interpretdifferently?

Do you think that there were any hidden agendas?

Were there any psychosocial/cultural issues on which you would like to comment?

Any comments about your own and/or your patient’s non-verbal behaviours.

How efficiently did you use your time in the interview?

How thorough were you in covering all the important history areas?

Was there anything important that you missed or that you would like to have explored further?

Did your patient say anything that you think you should have picked up on or investigatedfurther?

Peer review of video

In the last tutorial of the attachment the local organiser will work with the student group to facilitatepeer review of the video consultations. Students should hand in their video assignment work at thisstage if they want their chosen assignment video to be peer reviewed. Otherwise a different videoshould be chosen for the group to look at. The purpose of this tutorial is to help them withcommunication skills and allow them to get feedback at an appropriate time. Please note that whenstudents obtain consent from patients for this video assignment they indicate that the student groupon the local attachments may be seeing the video.

You may want to go through video consultations with students to give them an idea of how to analysetheir performance and the reflective summary above may aid discussion between you and the studentthrough this process:

Please see the GP website for ‘Guidelines for Giving Feedback’.


62

Patients and the video consultation

Students can use any of the consultations that they record in their weekly allocated sessions orthat they want to record at any other time, depending on what is practical in your Practice. Theymay ask for your help in identifying suitable patients for them to approach for consent tointerview. Use your own discretion as to suggestions you might make. You may prefer not to haveany input into the selection process. Either way, it is important that the students approach thepatients on their own, to go through the consent procedure. We encourage students to select aconsultation that is challenging.

Patient consent form

These forms have been written for this particular exercise and students are instructed to askpatients to sign two copies. One is to be submitted with the student’s assignment and the other isto be kept by the patient. A copy of the consent form is included in Appendix 12.

Recording of consultation

Local organisers will be provided with DVDs, memory cards, or USB sticks. Please let us know inadvance if you have any IT requirements or need equipment replacing. Please encourage studentsto start recording consultations after their first settling-in week, to avoid a logjam at the end of theattachment. For the purposes of quality assurance, it is important that the recordings are keptwhile the student is in training and a further one year thereafter. Students will hand in their videoassignment to the GP tutor on the final Monday of the attachment. A copy of the video should begiven to the local organiser at the OSCE that week. All recordings will therefore need to be returnedto the Division via the SGUL representative attending the OSCE. If no SGUL representative ispresent, then the administrator will arrange for a courier to pick these up.

Marking the Video Assignments

We are asking that the student’s GP tutor and local organiser mark the video assignmentindependent of each other. For students who have a local organiser as their GP tutor, wesuggest that the local organiser either nominate a local GP tutor to double mark or contact thecourse administrator to arrange for marking by the division. For the purposes of qualityassurance, it is important that all recordings, once second-marked, be sent back to thecourse administrator via the SGUL representative attending the OSCE.

All written work should be marked and the results are to be entered and submitted on-line withintwo weeks of the end of the attachment. Consider your marking under the following scales:

A (Excellent) B (Above Average) C (Average)

D (Borderline Fail) E(Fail) U (Unable to Assess)

You may want to consider marking the work under the terms of Content, Application andStyle.


63

Content: This should be appropriate, as well as accurate. All work should bereferenced appropriately and systematically (as per journal standard).Information on an exemplar referencing system is given in Appendix 13.

Application: At this level, students should be able to demonstrate reflection and makeconstructive comments on their observations, both of themselves andothers. They should be able to relate the work of others to their own workand use this to draw their own conclusions.

Style: The students have been given word limits and should be expected to producework to within 10% (excluding tables and references) of this figure.There should be a logical progression from introduction to conclusion.Minor errors of spelling or grammar can be excused, but anything moreshould be commented on. A good standard of written English is requiredfrom all students.


64

Appendix 11: Student guidance on the video consultation assignment

Suggested practical guidance for students is given below

Aim

The aim of this exercise is for you to carry out a self-critique of your communication skills in a GeneralPractice consultation.

You should submit the following:

A recording of the whole interview on DVD or Flash Drive to your GP tutor.

A copy of the patient’s consent form should also be attached (please submit patient’sconsent form with your assignment).

A written assessment: the shorter 500 to 1000 words version.

Practical arrangements for this assignment

You will need to take a week to settle in to your attachment but you can start recordinginterviews for this assessment at any time after then. You have a weekly session allocated torecording your consultations, so there is plenty of opportunity for carrying out this task. Trynot to leave it until the last moment or you may not be able to book a camcorder.Camcorders are available on loan from your local organiser. Please note that if there aretechnical issues with the camcorder, the practice staff should be encouraged to contact theUniversity administrative team at the earliest opportunity.

The assignment is to be handed in to your GP tutor and your local organiser on the last day ofyour attachment or at the OSCE.

Consent and confidentiality

Your GP tutor may be able to suggest suitable patients for you to approach. However, it isimportant that patients do not feel under any pressure to agree to your request so please gothrough the consent procedure with them on your own, making sure that they do not feelcoerced.

The information that patients need to have is included on the consent form (Appendix 12)Please ask the patient to sign two copies: the patient should keep one form and you shouldhand in the other with your assignment. It is essential that patients’ confidentiality is protected,so please take care when writing your report that your patient and family members areidentified only as Mr/Mrs/Miss/Ms X, and no details are given about addresses.

65


Appendix 12: Video consent form used at SGUL

Institute of Medical and Biomedical Education(IMBE)

Cranmer Terrace

London SW17 0RE

Dr Imran Rafi

Course Director

Course Administrator Tel No: 020 8725 5417

Consent to video recording

The Final Year medical student who has approached you today is attached to yourGeneral Practice and would like to make a video recording of the interview. This will notinclude any physical examination.

The recording is for assessment of the student’s communication and clinical skills, which arebeing learned as part of his/her medical training.

The recording will be used only for the education of these medical students during their trainingat SGUL, and not for any other purpose.

The recording will be seen only by other students attached to local practices, their GPtutors/Local Organisers and possibly tutors from SGUL. The recording will be kept in a secureoffice at SGUL for a period of one year after which time it will be erased.

You do not have to agree to this and if you would rather not be recorded, this will not affectyour medical care in any way.

If you do agree to this recording, but then decide during the interview that you wouldrather the camera was turned off, please just tell the student. If, at the end, you decidethat you do not want the recording to be kept, tell the student, who will erase it as soon aspossible.

If at any time after the interview, you decide that you would like to have the recording erased,please contact either your GP or the Course Administrator at SGUL.

Thank you very much for considering this proposal. If you consent to the interview being recorded,please would you sign below:

Patient’s name (in capitals): _______________________________________________________

Signature of patient: ___________________________________ Date______________________

Thank you for allowing the recording of your consultation. If you are happy for the student toanalyse the contents of the recording, then please sign and date below:

Patient’s name (in capitals): _______________________________________________________

Signature of patient: ___________________________________ Date______________________

Name of student (in capitals) _______________________________________________________


66

Appendix 13: Exemplar referencing system

The Vancouver referencing system

This is the system of referencing most commonly used internationally for medical journals andshould be used for your written assignment. Further information is available from:

International Committee of Medical Journal Editors. Uniform requirements for manuscriptssubmitted to biomedical journals. JAMA 1997; 927-34. New Engl J Med 1997; 309-15

or at http://www.ana-assn.org/public/journals/jama/jamahome.htm

References should be numbered in the text consecutively and listed in numerical order at the endof the text. Several word-processing packages e.g. Microsoft Word have referencing systems tohelp you do this automatically (e.g. the Endnote system in Word). Journal titles may beabbreviated according to the format used in Index Medicus. A complete list of abbreviations canbe found at the NLM website (http://www.nim.nih.gov/).

References are identified in the text by Arabic numerals in parentheses or brackets and thesereferences are then listed in numerical order at the end of the text.

The author is listed first, surname then initials, then the title in full followed by the journal nameabbreviated as above, year of publication; volume: page numbers in full.

Personal communications should not be cited unless absolutely necessary. If so the name and dateof communication should be given in the text in brackets.

Articles accepted for publication but not yet published may be referenced with the term “in press”.The full reference should be given including the predicted date and journal of publication.

Vancouver referencing system: Examples:Journal article: singleauthor

Connors MM. Risk perception, risk taking and risk management among intravenousdrug users: implications for AIDS prevention.

Soc Sci Med 1992;34(6):591-601

Journal article: multipleauthors

List all authors. If more than 6 list the first 6 followed by et al.

Davison CD, Frankel S, Smith GD. The limits of fatalism: re-assessing ‘fatalism’ in the popularculture of illness prevention. Soc Sci Med 1992; 34 (6):675-685

No author The chartless office; some practical considerations [letter; comment}. CanMed Assoc. J 1991;145(7):768

Personal Author/s Ridsdale L. Evidence-based General Practice a critical reader. London: WB Saunders CompanyLtd; 1995

Editor as Author Silagy C, Haines A, editors. Evidence based practice in primary care. London: BMJ Books; 1998

Chapter in a Book Guillebaud J. Contraception. In: McPherson A, Waller D, editors. Women’s Health. 4 th ed.Oxford General Practice Series 39. Oxford: Oxford University Press; 1997. p128-21 6.

Institution/Organisation asauthor

NHS Management Intelligence. Purchasing intelligence. London: NHS Management Executive;1991

Electronic Journal Thomas S. A comparative study of the properties of twelve hydrocolloid dressings. WorldWide Wounds [serial online] 1997 Jul [cited 1998 Jul 31. Available fromURL:http://www.stml.co.uk/World-Wide-Wounds/


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Appendix 14: Suggested references

The following books provide a background to UK general practice

Burton J and Jackson N (Eds). Work-based learning in Primary Care. Radcliffe Primary Care, 2003.

Carr A and Hamilton W. Orthopaedics in Primary Care. Elsiveier Limited, 2005.

Fraser Robin C. Clinical Method: A General Practice Approach. Oxford; ButterworthHeinemann, 1999. 3rd edition.

Hopcroft K and Forte V. Symptom Sorter. Radcliffe Publishing, 2007.

Kurtz S, Silverman J and Draper J. Teaching and Learning Communication Skills in Medicine.Oxford; Radcliffe Medical Press, 2005. 2nd edition.

Neighbour R. The Inner Consultation: how to develop an effective and intuitive curriculum style.Radcliffe Medical Press, 2004.

Neighbour Roger. The Inner Consultation. Dordrecht; Kluwer, 1984.

Orme-Smith A and Spicer J. Ethics in General Practice: A Practical Handbook for PersonalDevelopment. Oxford; Radcliffe Medical Press, 2001.

Pendleton DA, Schofield T, Tate P and Havelock P. The New Consultation: Developing Doctor-Patient Communication. Oxford; Oxford University Press, 2003.

Rile B, Hayes J and Field S. The Condensed Curriculum Guide. Royal College of GeneralPractitioners 2007.

Silverman J, Kurtz S and Draper J. Skills for Communicating with Patients. Radcliffe MedicalPress, 2005. 2nd edition.

Simon C and Everitt H. The Oxford Handbook of General Practice. Oxford University Press, 2006.

Stephenson Anne (Ed). A Textbook of General Practice. London; Arnold, 2004.

Simon C and Everitt H. The Oxford Handbook of General Practice. Oxford University Press, 2006


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Appendix 15: Guide to domain based OSCE scheme

Guide to the domain based OSCE scheme

The OSCEs are marked by the local organisers, GP tutors and visiting academic members of theDivision. The medical school has altered its assessment of OSCEs using a domain based markingscheme. The OSCE station is based on a construct (in the example below it would be ‘ ability togather relevant information from a patient with diabetes in order to establish her diabetic controland monitoring. The station also assesses whether candidates can offer advice about appropriatediet’). There are various listed domains under which the student is assessed (see below). The use ofthe newly introduced domain system of assessment should allow markers to be consistent for eachstudent. Simulated patient only provides information when the student has pressed for it (but withoutmaking the consultation unnaturally stilted). The visiting examiners from the school will beexperienced OSCE markers and will be happy to help with any concerns you may have.

St George’s, University of London

Exam Title

Station Number Examiner Marksheet

A=Outstanding B=Good, C=Adequate, D= Marginal, E = Inadequate

1. Initial approach to patient A B C D E

2. Clinical content: Information-gathering A B C D E

3. Communication: information-gathering A B C D E

4. Clinical content: giving information A B C D E

5. Communication: giving information A B C D E

6. Rapport and professionalism A B C D E


69

7. Sp mark A B C D E

GLOBAL

RATING

1

CLEAR FAIL

2

BORDERLINE

FAIL

3

BORDERLINE

PASS

4

CLEAR PASS

5

VERY GOOD

6

EXCELLENT

Examiner feedback


70


Exam Title Diabetic control – SAMPLE QUESTION

Station Number Information for examiner under domain headings

Construct: The station tests candidates’ ability to gather relevant information from a patient withdiabetes in order to establish her diabetic control and monitoring. The station also assesses whethercandidates can offer advice about appropriate diet.

1. Initial approach to patient

Students should make an appropriate introduction and orientation including consent. Goodstudents will identify early in the station that recent bloods show problem with blood glucosecontrol.

2. Clinical content: Information-gathering

Good students will gather some background information e.g. when patient was diagnosed,what type of diabetes, whether on medication

Assesses self-monitoring and BM Stix readings. Good students will do this in some detail.

Students should elicit key information about smoking, alcohol and medication. They will checkin reasonable detail diet, exercise, cholesterol, blood pressure control, frequency of eye andfeet checks. Good students should also ask about neuropathy and bladder infections,identifying deterioration of renal function

3. Communication: information-gathering

Students should use an appropriate mix of open and closed questions and they should avoidasking leading questions (assuming the answer) and multiple questions. Questions should beclear and jargon either avoided or explained.

Good students will demonstrate active listening, picking up cues, responding appropriately tothe patient’s replies, not repeating questions.

Good students will be organized and systematic in their approach, demonstrating skills suchas signposting and summarizing.

4. Clinical content: giving information

Establishes patient’s views about her diet

Makes an attempt at some broad messages about need for a healthy and balanced diet.

Good students will convey the message that diet should comprise complex carbohydrates(with examples) and explain why. Balance is also maintained by increasing fruit andvegetables (at least 5 a day) and decreasing food containing fats and sugar


71

5. Communication: giving information

Explanations are clear, well-paced and appropriate to patient’s level of understanding.Medical language will be avoided or explained.

Students should make an attempt to close the interview e.g. thanking the patient and tellingher about what will happen next

6. Rapport and professionalism

Students should show interest in and respect for the patient. Tone and level of voice and non-verbal communication will be appropriate. Good students will position themselves at anappropriate distance from their patient and maintain eye contact.

7. Sp mark

I thought the student was supportive and non-judgmental. I felt comfortable talking to him/her.


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Station - SAMPLE Candidate Instructions

This is a 10-minute station.

You are a senior medical student working in the diabetic clinic today.

Marianne Hilton is a 52-year-old restaurant manager who has diabetes. She is attending clinic for her

annual diabetic review.

Her most recent blood results show that her blood glucose is poorly controlled with an HbA1c of 10%

and that her renal function has deteriorated with a creatinine of 153mmol/l (98 – 109mmol/l)

Task

Please take a relevant history to establish Miss Hilton’s diabetic control

At 7 minutes, the examiner will then ask you to discuss diet with Miss Hilton to help her

control her blood sugar

Documents

Final Year General Practice Syllabusgp2.sgul.ac.uk/final-year-1/final-year-gp-practice-syllabus-r7.pdf · Final Year General Practice Syllabus 4 Clinical practice outcomes- involve,