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nMRCGP Proctoscopy

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									       nMRCGP
(from August 2008 will drop the „n‟)




Dr David G Anderson
    August 2007
    The assessment system
What PMETB required from the College:
• not an exam, but an integrated set of
  assessments for the entire postgraduate
  training programme which supports the
  curriculum
• a curriculum based on competence, not
  content
          Competency-based
                    Outcome: knowledge application
Teaching and
                      Learner can be responsible for
Learning
                           content and process
                   Non-hierarchical ( teacher  student )
               Multiple measures - evaluation portfolio
               Authentic – mimic real tasks of profession
                 "In the trenches" - direct observation
Assessment
                          Criterion-referenced
                              Continuous
                        Emphasis on formative
Program
                                                Variable time
completion
               Adapted from: CARRACCIO, C., WOLFSTHAL, S. D., ENGLANDER, R., FERENTZ, K. & MARTIN, C. (2002)
                               Shifting paradigms: from Flexner to competencies. Acad Med, 77, 361-7.
              nMRCGP
• Started August 2007.
• Need to pass nMRCGP to be on GMC‟s
  Register of GPs and for Membership of
  the Royal College of General
  Practitioners.
• Information for this presentation taken
  from RCGP website.
       3 components of the
            nMRCGP
• Each independent and will test different
  skills.
• Together they will cover the curriculum for
  specialty training for general practice.
• Evidence for the workplace-based assessment
  will be collected in the e-Portfolio of each GP
  trainee.
• Doctors who are currently in GP training are
  subject to transition arrangements.
An integrated programme of
 assessment comprising of


             nMRCGP
     AKT

                WPBA

       CSA
            Miller’s Pyramid for
            Assessing Clinical
               Competence
        WPBA                 Action
                   Does
      CSA                       Performance
                 Shows How

  CSA                                 Competence
                 Knows How

                                         Knowledge
AKT
                  Knows
Applied Knowledge test
  Applied Knowledge Test 1

• Three hour test.

• 200 item multiple-choice test.

• Question formats will be the same as
  for the current MCP.
  Applied Knowledge Test 2

• Delivered using computer terminals at
  147 Pearson Vue professional testing
  centres around the UK.

• Sit on a computer work station, using a
  mouse and keyboard to select answers.
  Applied Knowledge Test 3
• Need to be able to apply knowledge at
  a level which is sufficiently high for
  independent practice.
• All questions will address important
  issues relating to UK general practice.
• Questions focus mainly on higher order
  problem solving rather than just the
  simple recall of basic facts.
  Applied Knowledge Test 4
• 80% of question items will be on clinical
  medicine.
• 10% on critical appraisal and evidence
  based clinical practice.
• 10% on health informatics and
  administrative issues.
  Applied Knowledge Test 5
• On three days each year candidates will be
  able to sit the AKT at one of the centres.
• The First AKT will be held on 31st Oct 2007.
• Candidates registered for nMRCGP call
  Pearson Vue to book a test and choose a
  centre.
• The earlier a candidate books, the greater the
  chances of getting their preferred centre.
• Pearson Vue will confirm booking by e-mail.
  Applied Knowledge Test 6

• Eligible to attempt the AKT at any point
  during their time in GP specialty
  training.

• Highest chance of success, will
  probably be whilst working as a GP
  trainee in ST3.
       AKT Application



http://www.rcgp.org.uk/the_gp_journe
  y/nmrcgp/akt.aspx
Clinical Skills Assessment
 Clinical Skills Assessment 1

• „An assessment of a doctor‟s ability to
  integrate and apply clinical,
  professional, communication and
  practical skills appropriate for general
  practice.‟
  Clinical Skills Assessment
• Available during a 3 or 4 week period in
  sessions in February, May and October each
  year.
• First time is 1st – 12th October 2007.
• It will take place in one location, initially in
  Croydon, and in later years in a purpose-built
  centre in London.
• Cannot be sat until last year of Training
  programme
 Clinical Skills Assessment 2
• Each candidate will be given a
  consulting room and will
  have appointments with 13 patients,
  each lasting around 10 minutes.
• The performance will be graded as
  either:
- Clear Pass
- Marginal Pass
- Marginal Fail
- Clear Fail.
Areas mainly tested by CSA 3
1.   Primary Care Management.
2.   Problem Solving Skills.
3.   Comprehensive Approach.
4.   Person-centred Care.
5.   Attitudinal Aspects.
6.   Technical Skills.
Areas mainly tested by CSA 4
1. Primary Care Management - recognition and
   management of common medical conditions
   in primary care.

2. Problem Solving Skills - gathering and
   using data for clinical judgement, choice of
   examination, investigations and their
   interpretation. Demonstration of a
   structured and flexible approach to decision
   making.
Areas mainly tested by CSA 5
3. Comprehensive Approach - demonstration
   of proficiency in the management of co-
   morbidity and risk.

4. Person-centred Care - communication with
   patient and the use of recognised
   consultation techniques to promote a shared
   approach to managing problems.
Areas mainly tested by CSA 6
5. Attitudinal Aspects - practising
  ethically with respect for equality and
  diversity, with accepted professional
  codes of conduct.
6. Technical Skills - demonstrating
  proficiency in performing physical
  examinations and using
  diagnostic/therapeutic instruments.
          CSA marking 7
Each case given grade for each of three
   Domains:
1. DATA-GATHERING, TECHNICAL &
    ASSESSMENT SKILLS.
2. CLINICAL MANAGEMENT SKILLS.
3. INTERPERSONAL SKILLS.
       DATA-GATHERING,
    TECHNICAL & ASSESSMENT
            SKILLS
•   Gathering & using data for clinical
    judgement, choice of examination,
    investigations & their interpretation.
•   Demonstrating proficiency in performing
    physical examinations & using diagnostic
    and therapeutic instruments.
•   (Blueprint: Problem-solving skills, Technical
    Skills)
    CLINICAL MANAGEMENT
            SKILLS
•   Recognition & management of common
    medical conditions in primary care.
•   Demonstrating a structured & flexible
    approach to decision-making.
•   Demonstrating the ability to deal with
    multiple complaints and co-morbidity.
•   Demonstrating the ability to promote a
    positive approach to health.
•   (Blueprint: Primary Care Management,
    Comprehensive approach)
    INTERPERSONAL SKILLS
•   Demonstrating the use of recognised
    communication techniques to understand
    the patient‟s illness experience and develop
    a shared approach to managing problems.
•   Practising ethically with respect for equality
    and diversity, in line with the accepted
    codes of professional conduct.
•   (Blueprint: Person-centred approach,
    Attitudinal aspects).
 Clinical Skills Assessment


• Examples of CSA cases on DVD.
Work Place Based Assessment
          (WPBA)
Workplace-based Assessment in
        the nMRCGP

• „The evaluation of a doctor‟s progress in
  their performance over time, in those areas
  of professional practice best tested in the
  workplace.‟
Why workplace-based assessment?
• Tests something important and different from
  other components
    • “Does do versus can do”
•   Reconnects assessment with learning
•   Has high educational impact
•   Valid and reliable
•   In keeping with PMETB guidance
The WPBA framework
     The components of the
          framework
Provide an integrated package comprising:

• A competency-based training record and…
• Two externally marked work-based tools
That applies over an entire training envelope
(3 years from August 2007)
            Key features
• Competency-based
       Competency-based
• 12 competency areas
• Best tested in the workplace setting
• Developmental progression for each
  competency area
• Competency demonstrated “when
  ready”
• Process is learner led
    The 12 competency areas
1. Communication and         7.  Primary care
   consulting skills             administration and IMT
2. Practising holistically   8. Working with colleagues
3. Data gathering and            and in teams
   interpretation            9. Community orientation
4. Making a diagnosis/       10. Maintaining
   making decisions              performance, learning
5. Clinical management           and teaching
6. Managing complexity       11. Maintaining an ethical
   and promoting health          approach to practice
                             12. Fitness to practice
                   How the doctor                             What the Doctor is
                Approaches their work                            able to do
                                                                    Communication &
               Practising Holistically                               Consulting Skills
            Managing Medical                                           Clinical Management
              Complexity
                                                                            Making a Diagnosis /
             Community                                                       Making decisions
             Orientation
                                            The doctor                            Data Gathering &
Maintaining an Ethical                                                             Interpretation
                                         as a professional
 Approach to Practice                                                                    Primary Care
                                                                                         Administration
                                                                                            & IMT
                                                Fitness to
                                                 Practise

                                         Working with Colleagues
                                               & in Teams

                                         Maintaining Performance,
                                          Learning & Teaching
            Key features
• Competency-based
• Developmental
   Developmental progression

“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”
            Key features
• Competency-based
• Developmental
• Evidential
              Evidential
• Notion of multiple sampling
• From multiple perspectives
• Tool-box of “approved” methods
  (locally assessed and national external
  tools)
• Sufficiency of evidence defined
              Key features
•   Competency-based
•   Developmental
•   Evidential
•   Locally assessed
            Locally assessed
• Assessed by clinical supervisor in hospital or
  general practice setting

• Regular reviews at 6 month intervals by
  educational supervisor
  • Review all the assessment information gathered
  • Judge progress against competency areas
  • Provide developmental feedback
              Key features
•   Competency-based
•   Developmental
•   Evidential
•   Locally assessed
•   Triangulated
                Triangulated
• Internally:
  • Different raters
  • Local tools (e.g. CBD, COT, mini CEX, DOPS)
  • Different settings (hospital and general
    practice)
• Externally:
  • Multiple raters
  • Externally marked tools (MSF and PSQ)
  • Different settings (hospital and general
    practice)
Gathering the evidence about
the learner’s developmental
          progress
          Evidence from
• Locally assessed tools
• External tools, and…
• Naturally occurring information
       Local tools

• CBD (case based discussion)
• COT (consultation observation
  tool)
• mini-CEX (clinical evaluation
  exercise)
• DOPS (direct observation of
  procedural skills)
     Case based discussion
• Structured oral interview
• Designed to assess professional
  judgement
• Across a range of competency areas
• Starting point is the written record of
  cases selected by the trainee
• Will be used in general practice and
  hospital settings
 Consultation Observation Tool

• Tool to assess consultation skills
• Based on MRCGP consulting skills
  criteria
• Can be assessed using video or direct
  observation during general practice
  settings
      Professional Competencies
                Grades

•   (I) Insufficient evidence.
•   (N) Needs further development.
•   (C) Competent.
•   (E) Excellent.

• All assessments are comparing the GPStRs
  level of competence with that of independent
  end point practice.
    Professional Competencies
              Grades
• (I) Insufficient evidence
  From the available evidence, the doctor‟s
  performance cannot be placed on a higher
  point of this developmental scale.
• (N) Needs further development
  Rigid adherence to taught rules or
  plans. Superficial grasp of unconnected
  facts. Unable to apply knowledge. Little
  situational perception or discretionary
  judgement.
     Professional Competencies
               Grades
• (C) Competent
  Accesses and applies coherent and appropriate
  chunks of knowledge. Able to see actions in
  terms of longer-term goals. Demonstrates
  conscious and deliberate planning with
  increased level of efficiency. Copes with
  crowdedness and able to prioritise.
• (E) Excellent
  Intuitive and holistic grasp of situations. No
  longer relies on rules or maxims. Identifies
  underlying principles and patterns to define
  and solve problems. Relates recalled
  information to the goals of the present situation
  and is aware of the conditions for application
  of that knowledge.
             Mini CEX
• Used instead of COT in hospital
  settings
Direct Observation of Procedural Skills

• There are 8 mandatory procedures to be covered:

• Breast examination                     Male genital examination
  Female genital examination             Rectal examination
  Prostate examination                   Cervical cytology
  Application of simple dressings       Testing for Blood Glucose

• Some of these procedures may be combined e.g. prostate and rectal
  examinations

• There are 11 optional procedures which should be recorded, if
  undertaken:

• Cryotherapy                             Curettage/shave excision
  Cauterisation                           Incision and drainage of abscess
  Aspiration of effusion                           Excision of skin lesions
  Joint and peri-articular injections     Hormone replacement implants
  Proctoscopy                                      all types/any types
  Suturing of Skin wound                  Taking skin surface samples for
                                                   mycology
           External tools
• MSF (multi-source feedback)
• PSQ (patient satisfaction survey)
                    MSF
• Assessment of clinical ability and
  professional behaviour
• Rated by 5 clinical and 5 non clinical
  colleagues on 2 occasions in ST1 and ST3
• Simple web based tool
• Is able to discriminate between doctors
                       BUT
• Needs skill of trainer in giving feedback
                  PSQ
• Measures consultation and relational
  empathy (CARE)
• 40 consecutive consultations
• Central optical scanning and generation
  of results
• Can differentiate between doctors
                    BUT
• Needs skill of trainer in giving feedback
Naturally occurring evidence
• From direct observation during training
• “tagged” against appropriate
  competency headings
• Other practice-based activities
                            Where to find the Evidence
Competency Area       MSF        PSQ     COT      CbD    CEX   CSR
Communication and                                          
consultation skills
Practising                                                  
holistically
Data gathering and                                         
interpretation
Making a                                                   
diagnosis/decisions
Clinical management                                        
Managing medical                                             
complexity
Primary care admin                                
and IMT
Working with                                                 
colleagues and in
teams
Community                                                     
orientation
Maintaining                                                  
performance,
learning and
teaching
Maintaining an                                               
ethical approach
Fitness to practise                                          
       Quantity of evidence
            required
• The following description given applies only to
  those Drs starting a three-year programme on 1
  Aug 2007.
• Trainees who have two years of training to
  complete from 1 Aug 2007, will begin WPBA
  from the heading Specialty Training Year 2
  onwards.
• Trainees who have one year of training to
  complete from 1 Aug 2007, will begin WPBA
  from the heading Specialty Training Year 3
  onwards.
• Doctors who have completed hospital and/or
  GPR posts prior to 1 Aug 2007, will be asked to
  produce the usual VTR/2 and/or VTR/1 forms
  for these posts.
                       Workplace-based assessment ST1
                                                                Deanery panel
                           6M                  6M
                                                                if unsatisfactory



                        Interim review        Interim review
                    Based on evidence:    Based on evidence:
                       *3 x mini-CEX          3 x mini-CEX
                              3 x CBD               3 x CBD
                              **DOPS                **DOPS
                            **Clinical            **Clinical
                     supervisors report    supervisors report

* COT if GP post
                                                       MSF
** if appropriate                                       PSQ
                      Workplace-based assessment ST2
                                                               Deanery panel
                          6M                  6M
                                                               if unsatisfactory



                      Interim review         Interim review
                Based on evidence:       Based on evidence:
                      *3 x mini-CEX         *3 x mini-CEX
                             3 x CBD               3 x CBD
                             **DOPS              **Clinical
                                          supervisors report
                           **Clinical
                    supervisors report             **DOPS
* or COT if GP post
** if appropriate
                       Workplace-based assessment ST3
                                                               Deanery sign
                              6M               6M              off or panel
                                                               review if
                                                               unsatisfactory


                        Interim review         Final review
                    Based on evidence:    Based on evidence:
                              *6 x COT              6 x COT
                               6 x CBD              6 x CBD
                               **DOPS                  MSF
                            **Clinical                 PSQ
                     supervisors report
                                                    **DOPS
* mini-CEX if hospital post
** if appropriate
            During training
• At the end of ST1 and ST2 a Deanery based
  panel will:
  • Review the ETR of any trainee who:
     • “Fails “ in any of the external tools during training
     • Where requested by the educational supervisor i.e.
       where there may be a problem with the trainee‟s
       progress in performance against the 12 competency
       areas
  • Ensure the trainee is making satisfactory
    progress
          Annual Review
• Educational supervisor meets with the
  GPStR
• Completes the Educational Supervisor‟s
  Structured Trainers Report
• One of 3 recommendations the Annual
  Review Competence Progression
  (ARCP) panel:
  • Satisfactory Progress
  • Unsatisfactory Progress
  • Panel review requested
       The Final Judgement
• The trainer makes a recommendation as
  to whether the registrar has achieved
  competence in all 12 ETR areas at the
  end of training
• This together with achievement in the
  external workplace assessments will be
  reviewed by a Deanery panel

								
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