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COTs

COTs, or consultation observation tools, are utilised by the RCGP to assess your consultations. They form an essential part of your workplace based assessments required for the MRCGP exam. Your assessor can monitor your performance by either direct observation of your consultation by sitting in with you or via a video recording.

COTs should ideally vary in complexity and subject matter to reflect the full breath of primary care i.e. children, elderly patients, mental health reviews or chronic disease management. More complex cases are likely to provide your assessor with more supportive evidence which you can later reflect upon in your e-portfolio. Aim to keep COTs less than 15 minutes as time management is a criteria to assess your performance upon. 



Consent
It is essential that you obtain prior consent from your patients before completing a COT. This is especially important if you are conducting a recorded consultation



GP VTS ST1
ST1s require a minimum of 6 COTs per year with 3 COTs needed prior to your 6 monthly review


GP VTS ST2
ST2s require a minimum of 6 COTs per year with 3 COTs needed prior to your 6 monthly review


GP VTS ST3
In the absence of mini-CEXs, ST3s require a minimum of 12 COTs per year with 6 COTs needed prior to your 6 monthly review


Assessment
The COTs assess a range of consultations skills that can be used within a consultation. The criteria used to assess your performance is similar to that used in the MRCGP exam. Each domain is scored from insufficient evidence, needs further development, competent and excellent.  Under each domain the assessor has the opportunity to leave comments including supportive evidence from your consultation to justify their score. There are also marks for your overall assessment including documenting your feedback and recommended further developments.

  • Encourages the patient’s contribution
This focuses on your ability to use open questions, active listening skills and non-verbal skills. One should explore the presenting complaint and facilitate the patient to talk where possible. 


  • Responds to cues
Explore any cues that the patient may exhibit in order to obtain a deeper appreciation of their problem. This can be in the form of a non-verbal (reflecting body language - you look a a bit down) or verbal cue. Being empathic towards the patient such as offering a tissue may also fulfil this criteria if appropriate during the consultation.


  • Places complaint in appropriate psychosocial contexts
It use very useful to explore the patients psychologic, social as well as occupational history and establish how their symptoms have had impact upon these areas. 


  • Explores patient’s health understanding
This is assessing your ability to enquire about the patient's health beliefs and thoughts as to what was going on. It is looking at the patient's ideas, concerns and expectations and your ability to obtain this information naturally without appearing robotic in nature


  • Includes or excludes likely relevant significant condition
This looks at your ability to perform a focused history regarding the presenting complaint. Where relevant it should also include a few red flag symptoms to exclude more serious pathology. One should take into account the patient's demographs when creating a list of differentials and ask pertinent questions to include or exclude the most likely cause. A wide system review will unfortunately will not display a focused history. 


  • Appropriate physical or mental state examination
This assesses your ability to perform a focused examination relevant the presenting complaint and they should not be prolonged consuming a large proportion of the consultation. One may have to examine elements of more than one system in order to exclude potential differentials. Do not forget that intimate examinations should not be recorded.


  • Makes an appropriate working diagnosis
Whilst it may verbalised within your summary or explanation given to the patient, it should be clear from the line of questioning and your examination what your working diagnosis is.


  • Explains the problem in appropriate language
The doctor should make effort to explain their working diagnosis to the patient using vocabulary that is appropriate to the level of the patient. Where possible the trainee should attempt to weave some of the words used by the patient into their explanation and include or address the patient's own health beliefs about their problem. 


  • Seeks to confirm patient’s understanding
Often forgotten by registrars is to enquire about their patient's own understanding of the diagnosis. It may simply be an inquisitory probe such as, 'Is that alright?', 'Have I confused you?', 'What do you understand by diabetes?'


  • Appropriate management plan
You should offer an appropriate management plan for the patient including next step investigations or referrals. Try and use evidence based guidelines where possible. The RCGP appreciate that there may be a wide discrepancy between management protocols between hospitals, trusts and GP practices based upon local resources and pathways. Essentially they are looking as to whether your next steps are proportionate and safe even if they do not adhere perfectly to NICE guidelines


  • Patient given opportunity to be involved in significant management decisions
The trainee exhibits evidence of trying to engage with the patient in the decision making process. This involves seeking their own preference after being informed all the facts, i.e. informed of all the side effects of medications available to treat indigestion and asking what type of treatment or form (capsule, liquid) they would like for their dyspepsia. This does not mean that the doctor cannot offer their recommendation as the doctor is after all the clinician but they should not impose it rather reach a shared decision 


  • Makes effective use of resources
The RCGP is assessing your ability to utilise local resources available in the community. There are a range of services that have been commissioned by the CCG that are local and community orientated that may be more appropriate for the patient than referring to an out-patient service. The RCGP are acutely aware of the GPs role as the gate-keeper to the NHS service and our role to recommend the most appropriate and cost effective service for the patient. Examples include local GPSI services such as MSK, diabetic or dermatology clinics or even practice -in-house GUM or smoking cessation clinics. 


  • Conditions and interval for follow up are specified
This is an area often missed by trainees. GP trainees should offer a safety net or follow up interval if things do not improve and ideally link this to the expected prognosis of the condition. One should also inform the patient of red flags symptoms such that if they develop them to attend for review earlier. 


  • Overall assessment
This is an area for the assessor to provide their overall impression of your consultation