In this blog, I’m going to give you a true insight into my RCA preparation. In this MRCGP RCA blog, I will focus on five mistakes I made during my submission and how you can avoid making them! This blog is purely my perspective on the MRCGP RCA. I have found that there isn’t a right or wrong way to prepare for the exam, but I hope this blog will stimulate some conversation with your educational supervisor.
MRCGP RCA mistakes and how to avoid them!
I’m really excited to bring you my first blog on the MRCGP Recorded Consultation Assessment (RCA). I’ve been toying with the idea of creating MRCGP RCA related content for several months.
Should I create an extensive guide on the MRCGP RCA?
Should I create a course similar to my MRCGP AKT courses?
However, in true WellMedic fashion, I’m going to give you a true insight into my RCA preparation. In this MRCGP RCA blog, I will focus on five mistakes I made during my submission and how you can avoid making them!
This blog is purely my perspective on the MRCGP RCA. I have found that there isn’t a right or wrong way to prepare for the exam, but I hope this blog will stimulate some conversation with your educational supervisor.
Have I left myself enough time?
Maintain control over your list.
Have I left myself enough time?
I sat the MRCGP RCA exam in February 2021, which was around six months after I started ST3. Given that you can submit consultations from up to three months before the exam, I really should have been prepared from November!
Unlike in previous academic years, I naturally think there is a more significant push for GP trainees to focus on recording their consultations from the beginning of ST3. I followed this advice and recorded an odd consultation every couple of days. This helped me become more comfortable with my voice, but it gave me something to review in our weekly tutorial.
When I initially started to record my consultations, my focus was to identify personal strengths. I wasn’t overly concerned with my timing, and when attempted to be done “correctly”, most of my consultations would take around 14 minutes or so.
Three months before submission, I would highlight a fundamental weakness per week and work on that for the next week’s recording. Simple things, like the use of verbal filler words. Um, ah, ok, tell me more…
Now, although this may seem like a pretty good approach, I only really felt that my consultations were ready for the RCA around four weeks before submission. All of the thirteen consultations submitted for the RCA had taken place in the final month of submission!
What can you take from this?
Do you work better under pressure? If so, leaving yourself a shorter time frame for submission may be the right way to approach the exam. It will give you a push in the right direction.
If you’re just starting your ST3 placement, I would highly recommend that you begin purposefully recording now, but do it in line with the RCA standards.
You can deploy several skills in a consultation, but use this time to practice with patients.
Here are a few pointers that I wish I’d practised before my submission;
Challenging a patients belief.
Summarising purposefully.
Feedback statements from the patient.
Exploring options in line with the patients’ ICE.
How often should I record?
This is a challenging question in line with the complexity of the RCA. It’s often not as simple as how often you should record, it can be further complicated by how often you come across suitable cases?
Here is a graph demonstrating the number of consultations that I reviewed leading up to my submission date. What it doesn’t show is how often I stopped recording during a telephone consultation!
The RCA is a challenging exam, and this is because there is a constant feeling that you need to find the right type of consultation. If I’m frank with you, I was utterly fed up with recording consultations, and the quality was impaired by week three. As I recorded less, the quality of my consultations improved, and I was more strategic about what I needed to record.
What should you do?
Try and find the right balance between recording and reviewing consultations.
When you feel a consultation isn’t suitable, stop recording. Do not try to revive every consultation when it’s going south.
Figure out which days are best to record on – Mondays may not be best for you, but they might be the best in terms of patient selection!
Where should you fit in your follow up patients? I would allocate my follow up patients to a Friday morning clinic.
Maintain control over your list.
The lack of control was arguably the biggest mistake that I made during my MRCGP RCA preparation. Interestingly, our practice had two ST3s, and my colleague implemented what I had learnt, and her lists were much better than mine!
To give you the best overview of this section, let’s discuss how you can maximise your list so that the patients are suitable for submission?
Who books the slot?
Initially, I decided to leave booking consultations in the hands of our reception team. I added some notes to my EMIS slots, asking them not to book coughs, sore throats and UTIs. Despite this, I would often have 2-3 straightforward complaints per session.
Had I not been so time-pressured for submission, simple problems to break up the session are helpful, especially when running behind!
GP receptionists are the unsung heroes of our workforce! In my opinion, asking them to screen my list was an unreasonable request.
Where did I fall short?
The lack of new presenting complaints.
I was often encountering patients who had already presented to a colleague with their complaints. Although this could work for the RCA, in an ideal scenario, if you find a patient at their first point of contact, they tend to make better submissions.
Even when you’re finding your long term condition criterion, don’t look for the asthma patient who had a flare last week!
Asking other GPs to book suitable patients.
I spoke with the other GPs within the practice and asked them to streamline cases they felt were suitable with clear guidance. This didn’t work particularly well as the workload is so high at the moment it’s not easy to send cases to a trainee, especially if they’ve already started the call.
How did I take control?
In my final three weeks, when the panic settled in, I took absolute control over what I did! I blocked off all of my slots for every session, and with consent, I began populating my list from the other sessions within the practice.
The most valuable patients came from the locum slot. If you have a locum doctor at your practice, look at their list. You will find several acute issues which are often great for the RCA!
Another tool that you have at your disposal is the e-consult tool. Despite their many limitations, e-consults can help set the scene and give you an insight into the type of patient you will speak with.
Involving the patient.
During my RCA sitting, the consultation time was set at ten minutes. I genuinely feel that the additional two minutes should help you involve the patient within the clinical management.
My experience working with some GP trainee colleagues has been that we are excellent at perfecting our data gathering. We can learn to listen actively, structure the consultation and have a reasonable midpoint to transition to handing over a working diagnosis.
However, there is just so much to get off your chest when it comes to clinical management!
Here are two things that you should be aware of when perfecting the second half of your consultation.
Does it remain a discussion?
Have you appropriately responded to the patient’s agenda?
If we take a second to just recap the marking domains, as a GP trainee, you will be assessed on your;
Data Gathering, Technical and Assessment Skills
Decision Making and Clinical Management Skills
Interpersonal Skills
The two points that I’ve mentioned fall under the interpersonal skills domain and they feed into the following feedback statement.
Interpersonal Skills 3 – “Does not develop a shared understanding, demonstrating an ability to work in partnership with the patient.”
Click here to read the complete feedback statements from the RCGP.
My favourite consultations are like a tennis game, you’re in the final set, it’s Nadal versus Federer, and the ball is flowing across the court.
Nadal… Federer… Nadal… Federer and on it goes!
Despite knowing my favourite two tennis players, there’s a purpose to this statement! The consultation should really flow, patient… doctor… patient… doctor and so on.
Listen back to your consultation and think about how often the patient contributes to keeping this flow up. If it’s you doing all the talking, it’s unlikely that you’ll meet the required threshold.
The RCGP makes some beneficial suggestions in terms of how you can improve on this feedback statement;
Have you responded appropriately to the patient’s agenda?
Simply acknowledging the ICE is not enough. Think about how you can bring their ICE into the management plan to make this patient-centred.
You’d be surprised at how much the patient can contribute to their management when prompted correctly.
“I’m going to prescribe a course of antibiotics for your cellulitis.” and pause…
This allows the patient to contribute, rather than rushing in with…
“It will be doxycycline because you’re allergic to penicillin, and you will need to take this once per day.”
Consider using a statement that the patient has already given you…
“You mentioned that the HRT might be causing the bleeding…” and pause.
The RCGP has kindly suggested that there should be a shared understanding before the patient leaves, and this can be confirmed by asking the patient to summarise what they have understood.
All too often, we don’t close the consultation properly. Check in with the patient and see what they’ve taken away from the management plan.
Chasing complex cases.
Understanding complexity for the recorded consultation assessment can be a minefield. Ironically, it’s the area that candidates routinely over-complicate.
Here is my attempt at simplifying complexity.
A low challenge case is a case that affects the opportunity for candidates to display the capabilities required for licensing. If you’re struggling to demonstrate the aforementioned marking domains, it isn’t complex enough!
The table below has been taken from the RCGP RCA guidance on low complexity cases. I feel that this is the best way to review the complexity of a situation.
Weigh up the clinical challenge from the case alongside the complicating factors. Complicating factors can make a low clinical case complex enough for the RCA.
Does the patient have an unrealistic belief or expectation?
Is there a hidden agenda?
The RCGP has recently removed breast lump presentations from the mandatory criterion for maternal and reproductive health, as part of their justification they have said the following, which I feel helps explain complexity well;
“We have found that breast lumps score poorly as the management is a straightforward (but appropriate) referral to a fast-track clinic of a breast surgeon with no other management skills that align with the original intention of the criterion. There have also been many submissions of male breast lumps.”
Try and find the right balance between clinical challenges and complicating factors to demonstrate skills under each of the three domains. Find your happy medium.
This is the first of our RCA blogs and there will be more coming your way very soon! If you’ve found this interesting please do share this amongst your GP trainee colleagues.
