Abstract
Each month Crammer’s Corner looks at one of the RCGP clinical examples that form part of the curriculum. We offer guidance on how entries into the ePortfolio can be used to show competence in this area as part of the Workplace-based Assessment (WPBA) part of the MRCGP.
Clinical example 3.19: Respiratory health
Respiratory symptoms are common in general practice. They can be a marker of acute or chronic disease and can have a significant impact on a patient’s level of function and quality of life. Learning outcomes defined in this clinical example are focused on enabling GP trainees to gain and show competence in the identification and management of respiratory disease, such as asthma, chronic obstructive pulmonary disease (COPD), pulmonary embolism (PE), bronchiectasis and lung cancer. Trainees must be able to recognise and treat potentially life-threatening presentations of acute respiratory distress and also show skills in long term condition management and health promotion. As well as displaying clinical skills in these area, trainees should show competence in the ability to encourage self management of asthma and COPD, promote compliance and good inhaler technique and discuss smoking cessation in smokers with diagnosed, and at risk of, underlying respiratory disease. Trainees should be able to use their communication skills to discuss the effects of smoking and obesity on respiratory function in a sensitive, evidence-based and non-judgmental manner.
Learning log
Trainees should write learning log entries on a regular basis when a learning experience evokes reflection and can be used to show competence in an area of the curriculum. They should ensure that they link them to the relevant curriculum headings and the educational supervisor (ES) will then link them to relevant competences (which now include the new competence of clinical examination and procedural skills). When validating the entry the ES may make a comment with regard to the content or quality of the entry, or suggest further learning. They may also ‘unlink’ inappropriate curriculum links. Trainees should keep an eye on their curriculum coverage and discuss any areas where they are struggling to show competence with their trainer. This might highlight areas of less clinical exposure and perhaps the need to gain experience of certain specialities outside of general practice, such as by observing a secondary care, specialist community-based or specialist primary care clinic.
Possible relevant entries to respiratory health:
Consulting with a 50-year-old non-smoker who presents with a 3-month history of cough Consulting with a 40-year-old smoker with a body mass index (BMI) of 38 kg/m2 who presents with shortness of breath on exertion Discussing and interpreting a spirometry result with the practice nurse Teaching a newly diagnosed asthmatic inhaler technique Referring an 80-year-old ex-smoker to secondary care who presents with weight loss and haemoptysis Reading the annual review report for a patient from a tertiary cystic fibrosis centre Consulting with an elderly patient with a background of asbestos exposure who presents with shortness of breath Liaising with the community respiratory nurse or matron regarding a patient with COPD who is poorly compliant with inhaler treatment Managing a brittle asthmatic patient who presents to the surgery suffering with a severe asthmatic attack Seeing a 6-month-old baby who presents with recurrent respiratory infections and failure to thrive Discussing a patient’s spirometry results with them who is found to have a forced expiratory volume in 1 second (FEV1) of 50% predicted and a FEV1/forced vital capacity (FVC) of 0.6 Referring a patient to the local service for consideration of home oxygen Attending the local smoking cessation clinic
Clinical examination and procedural skills
This new section of the ePortfolio evolved from the previous directly observed procedures (DOPs) section. It is also a new competence and can be linked to a learning log entry by the ES. At the start of their training, GP trainees should identify their learning needs with regard to their examination and procedural skills through discussion with their trainer and document these in their learning log and professional development plan (PDP). The type and number of examinations and procedures required to show competence with be individually tailored to each trainee, taking into account their clinical experience, level of competence and the ES’s professional judgement. However, all intimate examinations (breast, female and male genital, prostate and rectal examinations) are considered essential and trainees should ensure they complete these on an opportunistic basis.
Patient satisfaction questionnaire
Patients provide valuable feedback for a trainee on how they felt with regard to the trainee’s clinical, communication and consultations skills. The patient satisfaction questionnaire (PSQ) can highlight learning needs not previously highlighted by the trainee or trainer. Trainees must ensure they conduct one PSQ in a GP ST1 or ST2 post (if not already done so) and one in their ST3 post. They must collect 40 PSQ forms, in a non-biased manner. Most practice teams then help input the feedback before the ES reads and releases the results, highlighting strengths and weaknesses elicited and suggesting further development where appropriate.
Personal development plan
Trainees should ensure they have an active PDP and regularly upload entries when learning needs are identified. Learning outcomes should be specific, measurable, achievable, realistic and timely (SMART) and relevant to general practice training. Further entries are generated by the ES on completion of the educational supervisor’s report (ESR).
Suggestions for learning aims related to respiratory health:
Observing a consultant-led respiratory clinic Conducting an audit in the practice with regard to offering documented smoking cessation advice to smokers and ways in which this can be achieved Conducting a COPD review clinic with the local COPD specialist nurse with compilation of individual care plans Gaining awareness of availability, accessibility, location and referral pathways of local respiratory services, such as pulmonary rehabilitation, home oxygen service, community respiratory nurse clinics and respiratory charitable organisations
Consultation observation tool
The consultation observation tool (COT) is used to assess a trainee’s communication and management skills and clinical judgement. In relation to this clinical example, with regard to respiratory health, are the consultation and communication skills required to discuss management of a long term condition, patient empowerment with self-management, health promotion and managing acute alongside chronic symptoms. Trainees should be able to show competence in the appreciation of the impact of a patient’s symptoms on their day-to-day lives and on those of their families.