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Ramesh MehayProgramme Director (Bradford VTS)
Originally written 2007, updated Jan 2009
Aims and objectives
Aims Increase our understanding of nMRCGP Help us feel more prepared for the assessments And therefore feel better!
Objectives Provide an overview of nMRCGP Share understanding Share concerns (and address them?) Practise COT
Session plan
Overview of the MRCGP and its components Share fears and concerns Practise some COTs in groups ?modelling (IS2 – practise some CBDs)
Background to nMRCGP
nMRCGP replaces both old MRCGP and SA Based on new GP curriculum
new curriculum developed by reviewing literature, very extensive consultation with doctors and patients, etc
All components of nMRCGP are mapped to the competencies in the curriculum
GP training now overseen by PMETB, like all other medical specialties (JCPTGP is dead)
A programme of assessment…
Components
AKT (Applied Knowledge Test) machine marked test, 3x/year, at various venues
CSA (Clinical Skills Assessment) OSCE-type exam, 3x/ year, Croydon
WPBA (Workplace Based Assessment)recorded in e-portfolio held by GP trainee throughout the 3 years
Clinical Skills Assessment ‘Integrative assessment’ with 3 domains
Data gathering, technical and assessment Clinical management Interpersonal skills
13 stations, 10 mins each, balanced selection of cases
clear pass, marginal pass, marginal fail, clear fail, ‘serious concerns’
significant failure rate take early enough to have time to retake
Work Place Based Assessment: WBPA
Workplace assessment: the assessment of actual working practices undertaken in the working
environment
Overview of WBA
What the trainee actually does Competencies demonstrated ‘when ready’ Assessment of developmental progression -
guides decisions about future learning Recorded in an electronic portfolio Process is learner led - trainee has to ensure their
e-portfolio covers the e-curriculum
WBA: compulsory components
Case Based Discussion (CBD) Consultation Observation Tool (COT) or Mini-
Clinical Evaluation Exercise (Mini CEX) Multi Source Feedback (MSF) Patient Satisfaction Questionnaire (PSQ) Direct Observation of Procedural Skills (DOPS)
WBA: local subunits
OOH work booklet Clinical Supervisor’s Report (CSR)
Naturally Occurring Evidence (NOE) Significant Event Review (SER) Referrals analysis Audit (Case Review, Personal Learning, Complaints)
Who makes judgements?
The Trainer/Clinical Supervisor as (s)he does the assessments
Educational Supervisor as he reviews the ‘whole’ thing with the trainee
ARCP panels who review the whole thing when a trainee is moving up an ST grade
Case based Discussion (CBD) Structured interview designed to explore
professional judgement in clinical cases Professional judgement = ability to make holistic,
balanced and justifiable decisions in situations of complexity and uncertainty
Attributes tested: Application of medical knowledge Application of ethical frameworks Ability to prioritise, consider implications, justify decisions Recognising complexity and uncertainty
CBD Competency areas
CBD looks at 10 of the 12 competencies
Practising holistically Data gathering and interpretation Making decisions/diagnoses Clinical management Managing medical complexity Primary Care Administration (IMT) Working with colleagues Community orientation Maintaining an ethical approach Fitness to practice
(not assessed by CBD: communication skills AND maintaining performance/learning/teaching)
CBD - the process
Trainee selects 3 cases, gives material to trainer 1w in advance
Need balance of cases and contexts Trainer selects 2, and plans structured questions
in advance 1h session = cover 2 cases 20mins case, 10mins feedback Trainer records evidence and judges level of
performance (insuff evid/needs devel/competent/excellent)
Need to do a MINIMUM of 6 per post All 6 before the ES meeting! (really, within 4m)
Key Points on CBD
It is a STRUCTURED oral interview On what the trainee actually did And why they did that And if they considered anything else at the time
So, don’t ask “what if” questions like you do in Random Case Analysis
Stick to the ‘here and now’ of the case Use the question maker framework on
www.bradfordvts.co.uk (click nMRCGP then click CBD)
CBD: What’s the Experience So Far? Trainees
Initially anxious but less stressful than current SA Valued feedback Found it realistic Some concern re relationship with trainer
Trainers Time consuming, need extra protected time Helpful structure May be more helpful for difficult trainees Concern re relationship with trainees
Consultation Observation Tool (COT)
Single consultation per session Trainee and Trainer view together Trainer assesses consultation on 4pt rating scale
(similar to old MRCGP/SA) No rule about consultation length Ideally at least one consultation is assessed by
someone other than trainer Ideally: wide range of contexts required, including
at least one child, older person, mental health problem
What was wrong with the old MRCGP or Summative Assessment?
Miller’s Pyramid or Prism of Clinical Competence
What is Authentic Performance?“Testing should be as close as possible to the
situation in which one attacks the problem.”
“Ill-structured problems are not found in simulated and/or standardized tests.”
“The variation inherent in professional practice will always elude capture by a set of rules.”
Wiggins, Assessing Student Performance: Exploring the Purpose and Limits of Testing, Jossey-Bass, Inc. 1993
Relationship between tools and competency areas
Good Assessment Instruments have: Reliability (R) Validity (V) Educational impact (E) Acceptability (A) Cost (C)
(Mnemonic: CARVE)Van der Vleuten, The assessment of professional competence:
developments, research and practical implications, Adv Health Sci Educ 1 (1996),
Why WPBA?
High validity = Authenticity High educational impact Reliability = depends on how many you do; also
some built in triangulation Reconnects assessment with learning and the
workplace Assessment over entire training envelope Cost Effective and now accepted!
And it gives continuous feedback
“a process of monitoring student’s progress through an area of learning so that decisions can be made about the best way to facilitate future learning”
The Problem With WPBA
Inter-observer variation Intra-observer variation Case specificity
Requirements of a high stakes performance assessment Specification Calibration Moderation Training Verification and audit
(Baker, O’Neil, Linn 1991)
Rough Guide to Rating Scale
Excellent – Smooth and efficient. Able to use knowledge, judgment and skills to adjust management appropriately to the specific patient and operative procedure.
Competent – Lacks smoothness and efficiency but is able to use knowledge, judgment and skills to adjust management appropriately to the specific patient and operative procedure.
NEEDS FURTHER DEVELOPMENT: Beginner – Lacks smoothness and efficiency. Able to
manage the case but exhibits limited use of personal judgment and responsiveness to the specifics of the patient and operative procedure. Requires some limited coaching or attending intervention.
Novice – Can only manage the case with extensive coaching and attending intervention.