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 3.21: Care of people with skin problems
Consultations regarding identification and management of dermatological disease are very common in UK general practice. GP trainees often have limited exposure to the speciality throughout their undergraduate and postgraduate training, so the learning needs relating to skin problems can be marked at the start of training. Learning outcomes defined in this clinical example are focused on enabling trainees to gain and show competence in diagnosing and treating common benign skin lesions and rashes, identifying and appropriately referring lesions suspicious of malignancy, identifying skin manifestations of systemic underlying disease, and awareness and prompt management of dermatological emergencies such as erythroderma and anaphylaxis. Trainees must also proactively engage with health promotion and disease risk reduction through advice regarding sun protection and avoidance, application of topical treatments and self-management of chronic skin disorders. Recognition of the psycho-social impact of skin disorders and development of associated communication and consultation skills are paramount.
Learning log
Trainees should use a broad range of learning experiences (both clinical and non-clinical), which evoke reflection and can be used to show competence in a curriculum area, in order to formulate their learning log. Entries should be written and shared on a regular basis throughout the GP training programme and GPs should ensure that they link their entries to the appropriate curriculum statements. The educational supervisor (ES) will then link the entries to relevant competences and may comment on the quality or content of the entry or provide suggestions for further reflection or learning.
Possible relevant entries to the care of people with skin problems:
Consulting with a 40-year-old woman with a history of malignant melanoma who presents with a benign looking pigmented lesion Discussing prescription payment with a 20-year-old patient who requires multiple topical treatments for their eczema Consulting with a 14-year-old girl with mild facial acne vulgaris, whose mother is requesting referral to a dermatologist for roaccutane Managing a tearful patient who suffers with terrible nocturnal itching that is having a significant impact on their sleep and ability to work during the day Consulting with a 30-year-old patient who presents with signs of depression who suffers with severe widespread psoriasis Identifying and managing a presentation of herpetic eczema Examining a patient who has recently moved to the UK after several years living abroad, with increased sun exposure, who requests a ‘mole check’ and sun protection advice Identifying and prescribing treatment for a 70-year-old man with multiple scalp actinic keratoses Giving advice to the mother of a 3-month-old baby who has a single small capillary haemangioma on their torso
Patient satisfaction questionnaire
Patients provide valuable feedback for a trainee on how they felt with regards the trainee’s clinical, communication and consultations skills. This might be particularly relevant to those consultations in which the presenting complaint has an impact on the patient’s psychological well-being, such as with a skin disorder. This ‘softer’ evidence can be less easy to capture and the impact of this feedback should not be underestimated and may draw attention to some development needs not previously highlighted.
Personal development plan
Trainees should ensure they have an active personal development plan (PDP) and regularly upload entries when learning needs are identified. They should be mindful that the ES is asked to comment on the quality of their entries and the degree to which they have been achieved as part of the educational supervisor’s report (ESR).
Suggestions for learning aims related to skin problems:
Observing a consultant-led dermatology clinic Sitting in with a GP with a special interest in dermatology and gaining experience in visualising skin lesions with a dermatoscope Completing an audit in the surgery of those patients who have a diagnosis of eczema and the frequently by which they order their topical treatments Completing an audit of all 2-week wait referrals to dermatology and their outcome and presenting the results to the practice staff
Consultation observation tool
The consultation observation tool (COT) is a useful way in which a trainee’s communication, consultation and management skills can be assessed. This may be done by direct observation in a joint surgery, video of a consultation in surgery or a home visit. In particular, relevance to this clinical example with regards skin problems are the consultation skills required to discuss potentially sensitive and embarrassing symptoms with patients and the impact of these on their day-to-day lives, the communication skills required to discuss suspicion of malignancy and referral to secondary care, and the skills required to encourage patient empowerment and self-management of a chronic skin disorder.
Case-based discussion
Case-based discussions (CBDs) are a tool by which a GP trainer can assess a trainee’s clinical professional judgement. Trainees and trainers should agree on the case for discussion prior to the assessment date in order that both can prepare. Only the most relevant competences are discussed and marked. A log of the type of case and competences covered should be kept in order that trainees can ensure they cover a wide range of patients and all the competences by their training.
Possible CBDs relating to care of people with skin disorders with suggested associated competences are:
A mother who brings their 3-year-old child for topical steroid treatment for eczema, who does not use emollients
○ Data-gathering and interpretation ○ Clinical management Maintaining an ethical approach An elderly patient, who lives alone and declines hospital assessment, who presents with a facial lesion suspicious of an advanced squamous cell carcinoma
○ Practising holistically ○ Managing medical complexity ○ Working with colleagues and in teams A teenage patient with psoriasis who presents with low self-esteem and low mood
○ Practising holistically ○ Data-gathering and interpretation ○ Clinical management
It should be noted that the above are only suggestions and not an exhaustive list as to what to include in the ePortfolio. If you have any comments/ideas on how to improve Crammer’s Corner then please contact us.