Why do we continue to examine GP trainees at 10 minutes when the RCGP itself has called for longer GP consultations?
The recently announced changes to the MRCGP in response to the COVID-19 pandemic has seen the replacement of the Clinical Skills Assessment (CSA) with the Recorded Consultation Assessment (RCA).1 Yet the guidance on the length of the face-to-face consultations to be submitted in the assessment remains at 10 minutes — even for complex cases.
Arguments put forward in the past suggest that the 10 minutes examination exists because:
The exam only assesses the face-to-face element of the consultation and not those activities that take place either side of the consultation such as preparation and documentation
The exam must prepare the candidate to practice anywhere in the UK including those practices that offer 10 minutes, and;
The examination has been validated against the standard of a 10 minute consultation.
The argument that the examination only assesses the face-to-face element of the GP consultation highlights a more fundamental problem in medical education, health service research and policy — that there is no agreed definition of what constitutes ‘the consultation’. Precision is important and without such definitions it remains unclear whether we are measuring and talking about the same intervention in policy and assessment. In two systematic reviews of GP consultation length, a wide range of approaches were used to define and measure consultation length.2,3
No trial or observational study fulfilled the TIDieR guidance how an intervention should be described.
We would argue that definitions of the full range of GP consultation types are needed to be more precisely defined in accordance with the TIDieR framework.4
The argument that the exam prepares the candidate for practice anywhere in the UK including those practices that offer 10 minutes as standard is inconsistent with College reports even prior to COVID-19 that states that the 10 minute consultation is not safe and effective for current practice where multimorbidity and complexity is now the norm.5,6 Asking candidates to focus on one problem only creates an artificial scenario and contradicts evidence on best practice.7 It may also encourage gaming where patients may be coached prior to the consultation to only discuss one problem.
The COVID-19 pandemic has also seen the widespread introduction of a digital first approach and total triage systems where most histories are taken by telephone or video and the face-to-face element reserved for physical examination only.8 Here the total consultation time for a single presentation may exceed 10 minutes.
If an examination that is representative of current UK practice is the intention then it would be useful to align this with data from observational data for complex presentations, for example, from the RCGP Workload observatory, CPRD, QResearch or NHS digital.
MUTUALLY BENEFICIAL
The final point that the examination has been validated against a 10 minute standard is not insurmountable. Validating the examination against 15 minutes or longer for those cases with multimorbidity and complexity would be a logical place to start.
In the long-term this could bring benefits to patients such as more accurate diagnosis of mental health problems and more opportunities for health promotion and reducing admissions for some ambulatory sensitive conditions such as diabetes. Crucially, it could also bring benefits to GPs including reduced burnout and improved job satisfaction.2,3 The COVID-19 pandemic has presented us with opportunities to decide which activities we should discard and what activities we wish to amplify.
The new RCA change offers an opportunity to define what is we mean by consultation length, align policy and assessment, promote safe and effective practice and reflect current UK practice.
- © British Journal of General Practice 2021
