2015 clinical teaching visit guide - rvts€¦ · clinical teaching (ct) visits are an essential...

2015 Clinical Teaching Visit Guide

Remote Vocational Training Scheme Ltd.

PO Box 37 Albury NSW 2640

RVTS Clinical Teaching Visit Guide 2015

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Phone: 02 6057 3400 Fax: 02 6041 5149

www.rvts.org.au

Copyright © RVTS 2015

http://www.rvts.org.au/


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Contents

Introduction ............................................................................................................................................ 3

Why do Clinical Teaching Visits ....................................................................................................... 3

CT visits – ‘hot learning’ ................................................................................................................... 3

Supportive critique .......................................................................................................................... 3

Aboriginal Community Controlled Health Services ......................................................................... 3

Skills needed .................................................................................................................................... 3

Formative MiniCEX forms and training ............................................................................................ 4

The Clinical Teaching visit ....................................................................................................................... 4

Clinical Advice and Medical Indemnity ................................................................................................... 4

Workers Compensation Insurance.......................................................................................................... 4

The CTV process : The CTV Co-ordinator ........................................................................................ 4

The day before the visit ................................................................................................................... 5

The Visit ........................................................................................................................................... 5

The Write Up ........................................................................................................................................... 6

Minimum requirements for a CTV report ........................................................................................ 6

Recommended Further Reading ............................................................................................................. 7

Appendix 1: Sample letter to practice............................................................................................. 8

Appendix 2: Sample Patient Consent .............................................................................................. 9

Patient Consent ...................................................................................................................................... 9

Appendix 3: Sample Report Template .......................................................................................... 10

Appendix 4: Sample Report ........................................................................................................... 11

Appendix 5: Hays Clinical Consultation Assessment Tool ............................................................. 14

Appendix 6 - ACRRM FORMATIVE MINICEX SCORING FORM (2014) ............................................ 15

Appendix 7: OTD Communication and Language Assessment ..................................................... 19

Appendix 8: Further CTV Tips - ...................................................................................................... 20

Appendix 9: Shortage of patients to see in remote communities. ............................................... 20

Appendix 10: Suggestions for activities if there are insufficient patients .................................... 21

Appendix 11: If hiring a car ........................................................................................................... 21

Appendix 12: Travel Tips for Visitors Travelling to Remote Communities .................................... 21

Appendix 13: Guidelines on giving constructive feedback PEARLS and Pendleton ...................... 22

Appendix 14: Recognising Consultation Styles ............................................................................. 23

Appendix 15: Tax Invoice Pro-forma ............................................................................................. 25

Appendix 16: Expense Reimbursement Claim Form ..................................................................... 27


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RVTS Guide to Conducting Clinical Teaching Visits

Thank you for agreeing to do a clinical teaching visit for a Remote Vocational Training Scheme (RVTS) registrar. We hope that you enjoy the experience.

Introduction

Why do Clinical Teaching Visits

Clinical teaching (CT) visits are an essential part of the Remote Vocational Training Scheme program and provide an opportunity to observe registrars working in their practices and seeing first hand the relationships between the registrar, staff, patients, other health professionals and the community in general. Most of clinical practice can be assessed at a distance using video, audio and file review, but the CT alone gives the visitor the chance to observe the registrar conduct physical examinations. Clinical Teaching visits are particularly important for RVTS registrars who work in solo or isolated practice and cannot get direct feedback from practice colleagues.

CT visits – ‘hot learning’

Clinical practice is varied and unpredictable – that’s what makes it so interesting but it also creates a risky learning environment. Clinical practice is described as a place of ‘hot’ learning: you cannot predict the workload or its urgency so a flexible approach to what to discuss is needed.

Supportive critique

A CT visitor needs to set a positive tone for the visit and strike a balance of supportive critique. It’s important to actively and specifically encourage the registrar in what is being done well. We all thrive on positive feedback and it’s particularly important for solo practitioners. To learn and develop as clinicians, registrars also need registrar centred, specific, clear feedback on what could be done differently. The CT visitor can also be a sounding board for the Registrar or a ‘mirror’ reflecting back observations to the registrar and leaving them to decide on whether change is needed.

Aboriginal Community Controlled Health Services

Since 2014 RVTS has been providing GP Vocational Training to doctors practising in Aboriginal Community Controlled Health Services (ACCHS) across the country. In addition to offering GP services, many ACCHSs offer a wide variety of support services to local Aboriginal and Torres Strait Islander communities. In some cases the local Aboriginal Health Workers may also be present during consultations. It would be useful to make yourself aware of some of the history and traditions of the community prior to your arrival.

Skills needed

A CT visitor needs to:

Observe accurately

Be curious not judgemental

Negotiate with the registrar and agree on priorities for teaching

Resist the temptation to interfere in consultations unless asked

Encourage self-reflection of the registrar


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Distinguish between differences in style and substance – base comments on patient outcome not ‘fashion’

Give clear, specific, feedback – (see Appendix 13 for information regarding PEARLS, Pendleton’s rules and Calgary– Cambridge guide)

Encourage registrars to experiment with different consultation skills and not get defensive

Formative MiniCEX forms and training

The miniCEX is an excellent form of assessment of the components of the registrar’s consultation skills. RVTS uses this assessment technique for all of its registrars. Some registrars will be training for FACRRM and will require formative miniCEX as part of their training.

Please complete a minimum of two miniCEX's per visit even if the registrar is planning to sit for the FRACGP exam and not FACRRM, as they may change their mind at a later date. Use the current year’s supplied form and a different miniCEX form for each consultation.

The summative miniCEX conducted by ACRRM examiners requires the performance of five physical examinations with at least three of the following: cardiovascular, respiratory, abdominal, neurological, endocrine, musculoskeletal or mini mental. Encourage the registrar to undertake detailed physical examinations in preparation for the summative miniCEX, especially if they are planning to obtain a FACRRM and as preparation for the OSCE component of the AMC or FRACGP examinations.

When filling in the ‘Assessment of Registrar’s Competence’ by marking Unsatisfactory/Borderline or Satisfactory, consider what you can suggest for improvements that will enable the registrar to achieve an Excellent mark and put this in the space provided for that consultation.

The Clinical Teaching visit

Clinical Advice and Medical Indemnity

RVTS does not have medical indemnity insurance. It is therefore extremely important that the CT visitor has their own medical indemnity cover. Any direct patient contact by the CT visitor is not encouraged and is done on a personal basis rather than on behalf of RVTS, and therefore such advice must be covered by the CT visitor’s own medical insurance.

All CT visitors must provide RVTS with evidence of current medical indemnity cover. This can be faxed to 02 6041 5149. RVTS staff will remind each CT visitor when a copy of their new medical indemnity cover is required.

Workers Compensation Insurance

Visitors who undertake a clinical teaching visit and invoice RVTS as a Company or Partnership must have Workers Compensation Insurance via their Company or Partnership. Doctors who undertake the visit as a sole trader are covered for workers compensation by RVTS.

The CTV process : The CTV Co-ordinator

Sends the CT visitor an appointment letter to be completed and returned with a copy of their current medical indemnity and workers compensation insurance.

Co-ordinates the CT visit dates and duration of visit (ie half or full day)


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Arranges travel, cab charges, accommodation and hire car (if applicable).

Sends a confirmation letter/email to the practice outlining the patient requirements, timing and a patient consent form with a copy to the CT visitor and registrar. (see appendix 1 & 2)

Provides the registrar’s practice phone number, mobile number and practice address to the CT visitor (if applicable)

Emails a reminder to the practice approximately two days before the visit and cc’s the registrar and the CT visitor.

Emails the registrar with a copy of ‘CTV Advice to GP Registrars’ and includes any feedback from previous CTV with a cc to the CT visitor.

Can email you some well written examples of CTV reports on request.

The day before the visit

We suggest that you phone the registrar/practice manager and confirm your time of arrival and departure.

Photocopy and pack:

o reporting pro-forma/Hays/miniCEX forms/OTD

o travel arrangements (if applicable)

o RVTS office phone number (02) 6057 3400

RVTS prefers to arrange a hire car for land travel. If a visitor chooses to drive their own car, they can invoice RVTS for an amount equivalent to the cost of a hire car for the journey. (See appendix 12) The RVTS office will advise the visitor of the amount. (Please note that RVTS cannot be held responsible for any damage that may occur to your own vehicle.)

The Visit

On arrival / before commencing

Introduce yourself to the practice manager. Where possible, talk to the receptionist and/or practice manager one on one & get their feedback on the registrar, (including their strengths & weaknesses).

Ideally, spend 15 mins talking to the registrar about

o their medical background

o how long they have been at the practice

o how things are going

o which exam they plan to sit (RACGP or ACRRM) and when they intend to sit exams

o whether they would like you to focus on anything in particular eg management phase of the consultation, body language etc

o be clear with the registrar that you will not talk during the consultation unless they ask for your opinion.

o advise the registrar to obtain patient consent before the patient enters the room. Occasionally patients will say no.

o discuss with the registrar how they would like you to introduce them, as a visitor can be seen as indicating that the doctor is being checked for poor performance, for example:


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“This is doctor x from y who is sitting in to observe me today because I’m studying for a higher degree in general practice”

o advise the registrar that if they conduct sensitive physical examinations. eg PR or vaginal examination/Pap smear, to draw the curtain around the patient as you will not be observing the examination. Registrars need to advise patients about this.

o discuss a strategy at the beginning of a CTV, for instances that may require you to intervene in some form for the benefit of patient welfare. Once you have alerted the registrar, options include

Can I offer you something from my experience?

Tell registrar ‘This is the way I like to do this’ (ie correct positioning or of an instrument)

(Rarely) Ask the registrar to come out of the consultation room with you to discuss issues regarding the patient. (eg: where the patient or the registrar may be embarrassed by the discussion or where a serious error of judgement is concerned)

o The registrar should feel free to ask questions if they, or the CT visitor thinks they are out of their depth.

o Ask the registrar to brief you on the patient. This encourages the registrar to read the notes and summarise before the patient comes in.

o Suggest to the registrar that you go through their notes and their list of patients from yesterday together and discuss how accurately the notes reflect what was going on.

o Looking at referral letters is a good way to see how the registrar has relayed the information to the person that’s receiving the referral letter.

o advise the registrar that you will be filling out at least two miniCEX forms during your visit. Show them the form (appendix 6) and ask them to sign it and write a comment on it if time permits. Wait until the registrar has seen one or two patients and is comfortable with you being present before suggesting that the next patient be used for a miniCEX.

The Write Up

Minimum requirements for a CTV report

Typed reports are preferred.

The report should be written in the first person as if the registrar is the reader. eg “You established rapport with all of your patients” rather than “John established rapport with all of his patients”.

The sample report and template provided (appendices 3 & 4 ) is individual patient based whilst the consultation feedback tool, as the one developed by Richard Hays, (see appendix 5) should be based on an overall review of all patients.

For each patient seen:

1. Summarise the case, (except for miniCEX see below) eg patient’s age and sex, their problem/diagnosis and management. Please do not use the patient’s real name or initials in the report.

2. Write a specific example(s) of what was done well (if applicable).


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3. Write a specific example(s) of what could be done differently.

4. Conclude the report by listing or writing about what the registrar does well overall (eg good rapport with patients, relaxed manner) and some general issues that need improving (eg don’t interrupt, avoid asking several questions one after the other without getting an answer)

5. If appropriate, suggest the registrar discuss a particular scenario and/or role play it with their supervisor.

6. End the letter with something positive eg. wishing them all the best for the future.

7. There is no need to duplicate information about the miniCEX patients in your written report. Just write eg. Patient 4 - see miniCEX report.

OTD Communication & Language Assessment For the overall visit

Many overseas graduates have encountered difficulty in communication, this form is aimed to assist the registrar with those difficulties. (see appendix 7)

Email ([email protected]), post (RVTS PO Box 37, Albury, NSW, 2640) or fax (02-60415149) the CTV report, tax invoice & claim forms for reimbursement (appendix 16) and costs such as petrol, with copies of tax invoice (appendix 15) within one week of visit.

Notify CTV Coordinator at RVTS if you have any concerns about the visit eg. registrar over/under-booked or if you have concerns about the registrar’s performance. This can be discussed confidentially with a RVTS Medical Educator.

NB. RVTS does not provide feedback on reports unless specifically requested or unless something needs to be done differently in the future.

Recommended Further Reading

Each of the readings listed are available electronically from the RVTS office upon request. Hays RB, Content validity of a rating scale for General Practice Consultations, Medical Education 1990; 2:100-116 as quoted in The Royal Australian College of General Practitioners, RACGP training program curriculum companion1999, South Melbourne, Vic Hays R, Sitting in Chapter 5 in Practice based teaching A Guide for General Practitioners (2006), Eruditions Publishing, Melbourne John Spencer ABC of learning and teaching in medicine Learning and teaching in the clinical environment BMJ 2003; 326: 591-594 Jill Gordon ABC of learning and teaching in medicine One to one teaching and feedback BMJ 2003; 326: 543-545

Fiona R Lake and Gerard Ryan Teaching on the run Teaching on the run tips 3: planning a teaching episode MJA 2004; 180 (12): 643-644 http://www.mja.com.au/public/issues/180_12_210604/lak10260_fm.html John Fraser Registrar clinical teaching visits, Evaluation of an assessment tool Australian Family Physician Vol. 36, No. 12, December 2007 pp 1070-1072 http://www.racgp.org.au/afpbackissues/2007/200712/200712fraser.pdf

mailto:[email protected]

http://www.mja.com.au/public/issues/180_12_210604/lak10260_fm.html

http://www.racgp.org.au/afpbackissues/2007/200712/200712fraser.pdf


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The Skills Cascade website is a collection of resources setup by East Anglia Communications skills cascade facilitators to promote and support the teaching of communication skills in health care. The website has handouts and presentations on aspects of teaching communication skills such as teaching time management and dealing with the angry patient. http://www.skillscascade.com/index.html

Appendix 1: Sample letter to practice

Letter/email sent by RVTS staff to RVTS practice about clinical teaching visit plans

Health Centre/Practice Manager

Registrar’s practice address

Date

Dear Practice Manager,

This letter is to confirm the arrangements for Dr xx to undertake a clinical teaching visit with Dr yy you on zz.

Insert travel arrangements

Arrival time at the clinic

Accommodation – if relevant

Dr xx will get the most out of these visits if you book no more than 3 patients per hour for the time that Dr yy is there; this gives plenty of time to discuss the patients and the issues that arise, thus maximizing the educational value of the session. Obviously urgent cases will be managed as needed. Please allow 15 minutes between the arrival of the clinical teaching visitor and the first patient so that there is time for the visitor to introduce themselves to the registrar.

It is also important that the patients are made aware of Dr yy’s presence in the consulting room when they arrive for their appointment, and are offered the opportunity to see Dr xx without the clinical teaching visitor if that is their preference. A sample patient consent form is included which you can make use of if appropriate.

If Dr xxx requires a permit to enter the community, we’d be grateful if you could arrange this on our behalf or let RVTS staff know whom we should contact.

Please confirm these arrangements by a brief email/letter.

Yours sincerely

RVTS admin

http://www.skillscascade.com/index.html


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Appendix 2: Sample Patient Consent

ACRRM FORMATIVE MINICEX 2014 PATIENT

CONSENT FORM

Consulting Doctor:

Observing Doctor:

Dear Patient

Today I will be participating in an educational assessment known as the Mini Clinical Evaluation Exercise (MiniCEX) assessment, which is conducted by the Australian College of Rural and Remote Medicine. The observing doctor in today’s consultation will provide information that will help me, your doctor move forward in attaining higher medical qualifications and is an important part of my ongoing education and training. Your participation as a patient will greatly assist in this process by providing an opportunity for me to demonstrate my medical skills.

The consultation will be unchanged except that a senior doctor will be sitting in with us in the same room and observing this consultation. The observing doctor will not contribute to the consultation. Although the observing doctor may make notes during the consultation, these notes will not include any identifying features so that you will remain an anonymous participant.

If you have any further questions about this process you are welcome to discuss them with me or if you wish with the Assessment Team of the Australian College of Rural and Remote Medicine (contact details at the bottom of this form).

If you decide to participate, you are welcome to withdraw your consent at any time and ask the observing doctor to leave the room. Any decision you make about whether to participate or not will have absolutely no bearing on your medical care by me or anyone else.

Thank you for considering participating in this important event.

Yours faithfully Dr

Patient Consent

I agree to participate and understand the issues that have been raised in this document. I understand that I can ask the observing doctor to leave at any time and any decision I make regarding this will have absolutely no bearing on my current or future health care.

Name (please print):.............................................................................................................................. Signature: ...................................................................... Date: .............................................................

Two copies are required. One copy is for the patient, the second copy is to be retained on file and faxed to RVTS on 02 6041 5149.


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Appendix 3: Sample Report Template

(Please print clearly or type!)

Registrar Name ....................................................................................................................

Visitor Name ........................................................................................................................

Date of Visit ................................................................................

Summary of Patients seen during the visit

Patient 1

................................................................................................................................................................

................................................................................................................................................................

Observations: ..........................................................................................................................................

................................................................................................................................................................

Learning Points: ......................................................................................................................................

Patient 2

................................................................................................................................................................

................................................................................................................................................................

Observations: ..........................................................................................................................................

................................................................................................................................................................

Learning Points: ......................................................................................................................................

Patient 3

................................................................................................................................................................

................................................................................................................................................................

Observations: ..........................................................................................................................................

................................................................................................................................................................

Learning Points: ......................................................................................................................................

Patient 4

................................................................................................................................................................

................................................................................................................................................................

Observations: ..........................................................................................................................................

................................................................................................................................................................

Learning Points........................................................................................................................................

Patient 5

................................................................................................................................................................

................................................................................................................................................................

Observations: ..........................................................................................................................................

................................................................................................................................................................

Learning Points: ......................................................................................................................................


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Patient 6

................................................................................................................................................................

................................................................................................................................................................

Observations: ..........................................................................................................................................

................................................................................................................................................................

Learning Points: ......................................................................................................................................

Registrar notes consulted prior to patient coming in: (please circle) YES NO

Standard of notes: (please circle) POOR GOOD EXCELLENT

Registrar strengths

................................................................................................................................................................

................................................................................................................................................................

................................................................................................................................................................

................................................................................................................................................................

Scope for Registrar improvement

................................................................................................................................................................

................................................................................................................................................................

................................................................................................................................................................

................................................................................................................................................................

Please insert copy of Hays Consultation Feedback Tool and ACRRM miniCEX forms

Resources:

Any other comments/additional information relevant to the Registrar’s circumstances or future plans.

................................................................................................................................................................

................................................................................................................................................................

................................................................................................................................................................

................................................................................................................................................................

Signature ................................................................................................. Date ...................................

OFFICE USE ONLY

CTV Report read by RVTS Medical Educator ………………………………………………………………..

Approved for release: Signed………………………………………………………………………………….

Returned to CTV Co-ordinator for processing. Date:…………………………………..


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Appendix 4: Sample Report

Registrar Name: Dr X

Visitor Name: Dr Y

Date of Visit: 1/1/2010

Summary of Patients seen during the visit

Patient 1

66 yo male. PHx – hypertension & COPD.

Came in for BP check and complained about painful left heel, injured on exercise bike 8 weeks ago.

Requested x-ray, which was ordered. Nurofen suggested.

- When an over the counter medicine is suggested, ask patient if they’d like the name written down.

- Avoid jargon eg “calcification”.

- Tell patient when you’d like to review them rather than having patient ask when to be seen again.

Patient 2

80 yo female with multiple medical problems including recent thymectomy and UTI on discharge from hospital presented with daughter. Patient had symptoms of depression, a painful area of her ear, a cold sore on her lip and pain on the side of her thymectomy scar, causing pain when she moved her arm.

- Avoid interrupting patient when she talks about how she is feeling.

- You commenced her on an antidepressant. When you asked the patient and her daughter how they felt about her starting antidepressants, you needed to give them more information before they could make an informed choice, including how long the antidepressants take to work, possible side effects and what to do if she has side effects.

- You comforted her appropriately using touch.

- Check recent guidelines re first line antidepressants. You prescribed Efexor.

-Discuss time management in relation to a patient with multiple problems with your supervisor (Do you deal with everything or prioritise and allocate some issues for next visit? Role playing this with your supervisor may be helpful.)

Patient 3

35 yo female. Punch biopsy carried out on left arm lesion.

Procedure done competently and appropriate follow up instructions given.

Patient 4

See miniCEX sheet for comments.

Patient 5

75 yo female. PHx – TB.

Presented for BP check – it had been low, so Micardis ceased 2 weeks ago.


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Patient asked if a urodynamics bladder study is needed for her bladder problem. You said it was, but you need to explain why and also to address her reluctance about having the test. (travel time etc).

You gave appropriate follow-up recommendations.

Patient 6

See miniCEX sheet for comments.

Registrar strengths

Very caring and compassionate

Good rapport with patients

Relaxed manner

Good role model for patients

You have a strong focus on prevention and public health issues and encourage patients to live a healthy lifestyle.

Scope for Registrar improvement

Avoid asking 3 questions one after the other (Ask one question at a time and wait for the answer).

Deal with patient’s presenting problem first, rather than checking BP or discussing results.

Improve time management. Discuss how to manage patients with multiple problems with your T.A. or GP Supervisor.

Avoid missing patient cues eg patient one came in and said it was a difficult time last week. You may not have heard him say this because you were focussed on the computer. You need to respond to this comment.

Any other comments/additional information relevant to the Registrar’s circumstances or future plans.

................................................................................................................................................................

................................................................................................................................................................

................................................................................................................................................................

................................................................................................................................................................

It was a pleasure to visit you, [name].

I wish you all the best for the future.

Signature ....................................................................... Date .............................................................


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Appendix 5: Hays Clinical Consultation Assessment Tool

To be completed as an overall review in conjunction with appendix 3.

Strongly disagree Strongly Agree

Introductory phase

The introduction to the patient was appropriate 1 2 3 4 5

The patient was placed at ease 1 2 3 4 5

History-taking phase

The patient was listened to attentively 1 2 3 4 5

Non-verbal cues were appropriately followed up 1 2 3 4 5

Appropriate question style was used 1 2 3 4 5

Medical jargon was avoided 1 2 3 4 5

Appropriate eye contact was made 1 2 3 4 5

Examination phase

The examination was appropriate to the history 1 2 3 4 5

Diagnostic phase 1 2 3 4 5

Appropriate hypotheses were formed and problems defined 1 2 3 4 5

Reasons for coming to the clinic were adequately defined 1 2 3 4 5

Other relevant problems were defined 1 2 3 4 5

Management phase

Appropriate action for each defined problem was taken 1 2 3 4 5

Correct use of time and resources was made 1 2 3 4 5

Explanation to the patient was adequate 1 2 3 4 5

The patient was appropriately involved in decision-making 1 2 3 4 5

Illness prevention/health promotion was provided 1 2 3 4 5

Closing phase

The timing of closure was appropriate 1 2 3 4 5

Appropriate follow-up arrangements were made 1 2 3 4 5

General comments

Empathy/understanding was exhibited 1 2 3 4 5

A good relationship was established 1 2 3 4 5

The doctor appeared confident and relaxed 1 2 3 4 5

Overall

Overall performance – 1 2 3 4 5

Reference: Hays RB. Assessment of general practice consultations: content validity of a rating scale. Medical Education 1990; 24: 110–6. Hays R, Sitting in Chapter 5 in Practice based teaching A Guide for General Practitioners (2006), Eruditions Publishing, Melbourne


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Appendix 6 - ACRRM FORMATIVE MINICEX SCORING FORM (2014)

Registrar’s Details

Name of Registrar: Date:

Location: Time:

Type of Practice:

Assessor’s Details

Name of Assessor:

Assessor’s Position:

FACRRM Rural Doctor/GP Specialist Educator

Other (Please Specify):

Level of Complexity

Low : This may include presentation where there is a single problem, requiring limited history, limited physical examination and straightforward management, e.g. uncomplicated respiratory infection, uncomplicated essential hypertension which is well controlled and requires only repeat medication, pre-anaesthetic check in a well person, uncomplicated subsequent antenatal visit.

Medium: This may include presentation where there are one or more problems, requiring a detailed history and examination of multiple systems, the diagnosis is not straightforward and patient review following a period of management will be required, e.g. review of a patient with multiple chronic diseases who is reasonably well, a new patient with a chronic disease requiring decisions about long term management, first antenatal visit.

High: This may include difficult problems where the diagnosis is elusive and highly complex,

requiring consideration of several possible differential diagnoses, and the making of decisions about the most appropriate investigations and the order in which they should be performed, e.g. acutely unwell patient requiring admission to hospital for diagnosis or management, initial diagnosis of severe disease requiring consideration of complex management plan within the rural/remote context (more than simply referral).


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Please note that there are mandatory requirements for history taking and physical examinations in a summative miniCEX examination. Please refer to the MiniCEX Rules and Regulations document for further information.

Provide a Brief Description of Case:

Clinical Problem Category (tick those that apply for this MiniCEX)

Curriculum Areas Covered Case Summary

1. Aboriginal & Torres Strait Islander Health Setting

2. Adult Internal Medicine Hospital inpatient

3. Aged Care Hospital outpatient

4. Anaesthetics Residential aged care

5. Business & Professional Management Medical centre / office based practice

6. Child and Adolescent Health Other (specify):

7. Dermatology Patient Age:

8. Information Management & IT Gender:

9. Mental Health Presentation

10. Musculoskeletal Medicine New patient to this practice

11. Obstetrics/Women’s Health New patient for this doctor but been at this practice before

12. Ophthalmology Returning patient with new problem

13. Oral Health Returning patient with chronic disease and a new problem

14. Palliative Medicine Review of an acute problem

15. Radiology Review of chronic disease

16. Rehabilitation Other (specify):

17. Research & Teaching Case Focus

18. Surgery Communication Skills

History Taking

Physical Examination

Clinical management in the rural/remote context


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Assessment of Registrar’s Competence

Overall Clinical Competence

Comments for improvement:

Unsatisfactory Borderline Satisfactory Excellent

Clinical management in the

rural/remote context


Not Observed Unsatisfactory Borderline Satisfactory Excellent

History Taking



Physical Examination



Communication Skills




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Assessor’s Comments

Registrar’s Comments

Assessor’s Signature: Date:

Registrar’s Signature: Date:


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Appendix 7: OTD Communication and Language Assessment

COMMUNICATION SKILLS

Skill area Problem area Yes/No

Building rapport Adequate introduction Patient was not given time to explain why they had attended Was the question and answer session haphazard? Were questions out of context in the consultation? Was examination needed but not done? Permission not obtained when examination was needed. Did the doctor terminate without asking if the patient had any further

questions?

Attending, listening & responding Was there overuse of direct questions? Were patient questions ignored? Managing patient / doctor “talk” Was too much jargon used? Was any patient jargon misunderstood? Jargon used but not clarified? Was there a lack of response to patient cues? Relationship related language behaviour and appropriate use of non-verbal communication

Was there overuse of affirmative response? Eg nodding, agreeing , saying yes.

Was there inappropriate laughter? Disinterest in patient communication e.g. yawning without apology? Audibility of speech Was the speech too quiet? Empathy Did the doctor respond to the patient? Did the doctor talk over the patient?

Were the patient’s words clarified?

LANGUAGE SKILLS

Accent related comprehensibility of speech

Does the doctor’s accent cause misunderstanding?

Appropriate rate of speech Was speech too fast? Was speech too slow? Use of appropriate words Failed to explain medical terminology. Used medical words instead of common English words Patient has more than one problem Were other problems ignored? Was the patient’s preference selected for attention? Work injury / insurance claim consultation

Adequate management of consultation?

Psychiatric consultation Adequate management of consultation? Culturally sensitive issues Termination of pregnancy, oral contraception Sexually transmitted disease, intimate examination

Appropriate management?

Adequate management?

Drug seeking behaviour Adequate management of consultation? Written Information provided Was supportive material offered? (e.g. handout) Referral Letter Adequate?


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Appendix 8: Further CTV Tips -

Observing rather than talking may feel alien at first and takes considerable discipline. Tell the registrar to ask you to leave the consultation if your presence is stopping the patient saying something crucial to the doctor or might prevent culturally appropriate health care. The latter is more common if the CT visitor and registrar are different genders.

Find a place to sit in the consultation room where you can see the registrar and the patient but be unobtrusive, ideally out of the line of sight of the patient. In small rooms this can be a challenge.

Make electronic or paper notes during the consultation on what you see. Some people keep chronological notes, others divide a page into aspects of the consultation that were effective and points for discussion. Make detailed notes during a CTV so you can quote the registrar during feedback sessions if appropriate.

After each consultation ask the registrar to reflect on the consultation. For registrars early in training, making use of Pendleton’s rules (appendix 12) is recommended, but advanced registrars may learn more by a more focussed approach discussing elements of the consultation that they recognise they want feedback on (see appendix 12, giving constructive feedback in clinical practice). Information about recognising different patterns of problems in the consultation is available in appendix 9.

At the end of the day thank the registrar for the privilege of sitting in and the clinic for their hospitality. Check if you can help by taking anything back to town such as pathology specimens.

Strategies to use if the cases are too simple:

After the patient has gone, think of how to make the case more complex. Ask the registrar what they would have done in that situation. Role play the scenario (if appropriate, with the registrar as the doctor.)

Ask the registrar what they would have done differently if they had been in an exam. Then ask them to reflect on why they didn't do it differently in real life.

If you have serious concerns about a registrar’s progress, safety or welfare, and feel they may be at risk from a professional or personal point of view, please contact RVTS’ CTV Medical Educator or the registrar’s Registrar Training Coordinator (RTC) as soon as possible after the visit. If you do not know who the RTC is, please contact the CTV coordinator at RVTS and they will provide you with the RTCs contact details.

Giving feedback to a registrar who lacks insight into their performance can be very challenging. The following questions may be helpful.

‘How do you think the patient felt?’

‘Do you think the patient would come back to you if they had a choice?’

If a registrar is an International Medical Graduate (IMG) & English is not their first language, encourage them to check their patient's understanding by asking the patient to repeat what they have been told.

Appendix 9: Shortage of patients to see in remote communities. This may be an issue in some remote and Aboriginal and Torres Strait Islander communities where the nonattendance rate is generally high, and/or due to sorry business. This possibility can be planned for in advance by discussing contingencies with the registrar prior to the visit. eg. ask if they would like a particular skill on topic(s) taught if things are quiet. Only agree to teach something if you feel comfortable doing so.


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Appendix 10: Suggestions for activities if there are insufficient patients

Role play cases from your own practice & give the registrar feedback

Discuss exam(s) & give tips if you are familiar with the process

Do a chart audit - discuss patient management &/or look at the quality of the record keeping

Discuss practice management topics e.g. IT, billing Medicare, recall and reminder systems, dealing with conflict, human resource management

Discuss current patients that they are concerned about and management strategies

Provide the opportunity to debrief on past concerns

Visit the local shop if in a remote community & discuss relevant public health issues with the registrar, including the cost of food, its quality and placement

Discuss possible ways of improving the public health of the community. Encourage the registrar to consider community relevant activities that could be initiated

Discuss the registrar’s career aspirations and their feeling about working in a remote community, if applicable

Discuss online resources and systems in clinics

Appendix 11: If hiring a car

Ask the hire car company where to return car and keys

Ask where the nearest petrol station is (it is preferred that you return the car full of petrol, as the car hire company charge a significant amount for doing this). Please ensure that you keep a copy of the tax invoice to claim for reimbursement.

Ask if the car hire company has a map of the location you are visiting if required.

A hire car is recommended for all car travel. Any damage that occurs to a personally owned car during a clinical teaching visit must be covered by your own car insurance.

Appendix 12: Travel Tips for Visitors Travelling to Remote Communities

Keep in mind that road travel to remote communities can take several hours & petrol stations may be few & far between. Rain can sometimes cause flooding of roads, making certain areas inaccessible by car. The wet season is generally between the months of October and March. When confirming your visit, check if there are any items or supplies they would like you to bring. (There is often no general store in remote communities).

Before leaving home, reconfirm your visit, check that roads are accessible.

If you have an overnight stay prior to the day of your visit, phone again to check access before leaving if it has been raining, as unexpected flooding and blackouts can occur.

It is advisable to take the following additional items to cater for the unlikely event of being delayed unexpectedly eg. due to weather conditions or car problems:

Snacks & lunch / 2 litres drinking water/ Sunscreen - the sun can be quite harsh, even when driving

Your mobile phone

GPS or a map from car hire companyplace. Ask them where the petrol stations are, & ensure you have sufficient fuel.


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If the registrar is called away to attend an emergency, eg motor vehicle accident, go with them (if the capacity allows for this) & observe them in the field!

Appendix 13: Guidelines on giving constructive feedback PEARLS and Pendleton

The ability to give constructive feedback is critical in medical education. It is the one teaching skill for which there is overwhelming evidence of its effectiveness. This guide is designed to help you give constructive feedback.

As teachers or mentors we are giving feedback all the time whether we are aware of it or not. RVTS registrars are competent and experienced doctors but feedback from peers or colleagues is rare. Seeming uninterested or an over concerned look from a clinical teaching visitor could have unintended ramifications for reducing registrar confidence. To avoid this mistake the opposite can occur of the clinical teacher being overly positive and avoiding addressing important clinical issues. Finding the balance is important.

PEARLS (1) is a useful acronym for setting the tone for feedback.

Partnership – joint problem solving Empathic understanding Acknowledge unavoidable barriers to the learner’s success – this is particularly relevant with the demands of solo

or remote practice Respect for the registrar Legitimise the registrars feeling & intentions Support for efforts at correction

With the relationship and basis for feedback set, listen carefully to the first few words that the registrar says after the consultation finishes. Give them space to breathe and reflect – you need to hear their emotional reaction to the consult and often they will come up with plenty of ideas on what they could do differently. These few seconds of self-reflection are vital for showing how much insight the registrar has into their consulting and its effectiveness. You can then pitch your teaching appropriately. Often your role is merely to agree with their self-diagnosis and help them work out how things can improve in the future.

But it does help to have a framework for what you are going to say.

Pendleton’s rules can feel odd to use at first but have the great advantage that they force the doctor to verbalise what they have done well.

Pendleton’s Rules

Briefly clarify matters of fact

The doctor first says what was done well, and how

The observer says what was done well, and how

The doctor then says what could be done differently, and how

The observer says what could be done differently, and how

Once you have done a few consultations using Pendleton’s rules it begins to feel rather cumbersome and the registrar begins to want more focussed feedback. You can then switch to using the Calgary-Cambridge SET-GO method.

SET-GO

Facilitator: What I Saw – descriptive, specific, non-judgemental -

Registrar: What Else did you see?

Facilitator: What do you Think? Registrar given opportunity to acknowledge and problem solve


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Facilitator: What Goal does registrar want to achieve?

Facilitator: Offer suggestions, alternatives to be rehearsed

Further details about the Calgary-Cambridge method of giving feedback is available on the skills cascade website www.skillscascade.com To reduce defensiveness in the registrar it’s recommended that your comments are: non-judgemental, specific, directed towards behaviour rather than personality, checked with the registrar, based on patient outcomes, addressed to the registrar’s agenda or self-identified learning needs, and aimed at problem-solving by suggestions rather than prescriptive comments.

References:

Milan FB, Parish SJ, Reichgott MJ. A model for educational feedback based on clinical communication skills strategies: beyond the "feedback sandwich". Teaching & Learning in Medicine. 2006; 18(1):42-7.

Pendleton D, Schofield T, Tate P, Havelock P. The Consultation: An Approach to Learning and Teaching. Oxford: Oxford University Press; 1984 Kurtz SM, Silverman JD, Draper J (1998) Teaching and Learning Communication Skills in Medicine. Radcliffe Medical Press (Oxford)

Appendix 14: Recognising Consultation Styles

A useful set of questions to ask yourself as you are watching any consultation are:

can you recognise any patterns here?

have you seen this problem before?

how might the learner who performed the consultation be feeling?

how might the “patient” be feeling?

what does the learner already know?

how could you “generalise away”? ie from the specific problem demonstrate a broader principle of medical practice

when would the best time be to do it? ie during or after the session

what area or what research and theory would be relevant to teach on?

Some of the common problem patterns which occur in consultations are as follows:

the learner does not discover all the issues or problems the patient wishes to discuss

the learner does not listen, often not asking open ended questions initially or interrupting with closed questions

the learner does not elicit the patient’s ideas, concerns, expectations and feelings; or establish a collaborative relationship, and instead takes a doctor-centred position throughout the interview

the learner develops little rapport or is not responsive to the patient

the learner misses important cues from the patient

the learner obtains an inaccurate or incomplete clinical history because of failure to get the balance right between open and closed questions, summarising, checking, or sharing his/her thinking process

the learner forgets to find out what the patient already knows before giving an explanation

http://www.skillscascade.com/


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the learner gives too much information at once and uses jargon

the learner does not negotiate with the patient and check that the patient is agreeable to the plan

the learner makes inadequate follow up arrangements or none at all

Adapted from http://www.skillscascade.com/handouts/pattern_recognition.htm accessed 22/2/08

The SkillsCascade website is a collection of resources setup by East Anglia, UK Communications skills cascade facilitators to promote and support the teaching of communication skills in health care.

http://www.skillscascade.com/handouts/pattern_recognition.htm


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Appendix 15: Tax Invoice Pro-forma

INVOICE TO:Remote Vocational Training Scheme Ltd PO Box 37, Albury NSW 2640

Organisation Name:

ABN: Are you registered for GST?

Address:

Email:

Registrar visited:

(Please note: Unless an ABN is quoted, tax will be withheld from payment at 49 %.)

Bank Account Details for EFT (Transfers cannot be made to bank account numbers with more than ten digits (not including BSB) or credit card

accounts)

Bank: Branch:

BSB: Account Number:

Account Name:

Tick box to request email advice when payment has been made:

A. SESSIONS

$150/hr up to a maximum of $1,200 per day

Date Details No of Hrs

$

$

$

A. TOTAL SESSIONAL AMOUNT $

(Note: These rates are based on ATO Tax Determination 2014/19 - What are reasonable travel and overtime meal allowance expense amounts for 2014/15

from the ATO legal database and will be reviewed annually in August to maintain parity with ATO rates).

B. MEALS ALLOWANCE

Meals you have had to provide for yourself

Number Rate Allowance

Breakfasts $32.55

Lunches $46.10

Dinners $64.60

B. TOTAL MEALS ALLOWANCE: $


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C. INCIDENTALS

Incidentals allowance covers expenses which would not otherwise have been occurred (eg. Newspapers, refreshments etc) and is payable @ $26.75 per 24 hour period and part thereof

C. TOTAL DAYS _____ X $26.75 = $

D. USE OF PRIVATE VEHICLE (prior authorisation is required)

Engine capacity Cents per kilometre

Ordinary car Rotary engine car

1600cc (1.6 litre) or less 800cc (0.8 litre) or less 63 cents

1601cc - 2600cc (1.601 litre - 2.6 litre) 801cc - 1300cc (0.801 litre - 1.3 litre) 74 cents

2601cc (2.601 litre) and over 1301cc (1.301 litre) and over 75 cents

Date Details No of Kms

$

$

$

D. TOTAL VEHICLE ALLOWANCE: $

TOTAL CLAIMED (A + B + C + D) $

GST (if registered for GST) $

INVOICE TOTAL $

Signature: Date:

Office Use Only:

Account No: 61105

Approved by:

Date Paid: EFT/Cheque Number:

Fax to 02 6041 5149 or mail to RVTS, PO Box 37 Albury NSW 2640


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Appendix 16: Expense Reimbursement Claim Form

Name:

Postal Address

Telephone (BH)

Email

Signature

Bank Account Details for EFT

Transfers cannot be made to bank account numbers with more than ten digits (not including BSB) or credit card accounts

Bank: Branch:

BSB: Account Number:

Account Name:

Tick box to request email advice when payment has been made:

Expenses Incurred

Please ensure a receipt is provided for all items claimed, and a Tax Invoice is provided for all items that include GST

Date Description Amount Tax Invoice Attached

Office Use only

Account

Total Expenses Claimed

Office Use only

Authorised for Payment

Authorised for Payment

Amt paid: $ Date Paid: EFT No:

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