Primary care

Patient centredness in the MRCGP video examination: analysis of large cohort

Peter Campion, professor of primary care medicine ^a, John Foulkes, consultant to MRCGP examination ^b, Roger Neighbour, former convenor of panel of examiners ^b, Peter Tate, convenor of panel of examiners ^b. 

^a Department of Public Health and Primary Care, Postgraduate School of Medicine, University of Hull, Willerby HU10 6NS, ^b Royal College of General Practitioners, London SW7 1PU

Correspondence to: P Campion p.d.campion{at}hull.ac.uk

The examination for membership of the Royal College of General Practitioners (MRCGP) consists of four modules. The consulting skills module, introduced in 1996, is normally taken by submitting a videotape of seven consultations, selected by the candidate to show "competency" in each of 15 "performance criteria." These criteria are explained in the examination literature and on the college's website.¹ The module is based on a competency model of assessment, which defines outcomes, in a hierarchical framework.² The performance criteria (see table) are grouped into five areas: discovering the reason for the patient's attendance, exploring the problem(s), tackling the problem(s), explaining the problem(s), and making effective use of the consultation.

	Participants, methods, and results

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Doctors may submit videotapes for examination in May or November. This report is based on submissions in May and November 1999 and May 2000, which together comprised 2094 candidates. Each candidate was assessed by seven examiners, each rating a different consultation on the tape. We have described the assessment method elsewhere.³ The examination is primarily a "competency hurdle"that is, candidates have to achieve competency across a range of criteria. Three criteria (numbered in the table as 4, 10, and 11) were found in pilot studies to be rarely achieved. However, as we considered these to be markers of "good practice" and, in particular, of patient centredness, we designated them "merit" criteriafor awarding the merit grade to candidates who had already passed on the other 12 criteria.

The table shows the extent to which each criterion was met in the first five consultations assessed because at that time pass-fail judgments were made initially on the first five consultations; the last two were considered only if the candidate had not clearly passed on the first five. (From 2002 all seven consultations are considered.) The column headed "mode" indicates the commonest frequency, whereas the "mean" column allows comparison between the criteria.

"Patient centredness" has been well defined and characterised,⁴ comprising five dimensions: a biopsychosocial perspective, the "patient-as-person," sharing power and responsibility, the therapeutic alliance, and the "doctor-as-person."⁵ We explicitly intended that our performance criteria should reflect this and have identified aspects of patient centredness in criteria 2, 3, 4, 10, 11, and 13. Competency in exploring the patient's own beliefs about the illness (criterion 4), using those beliefs in explaining the illness (10), and checking the patient's understanding after the explanation (11) were not seen in 14%, 31%, and 45% of doctors respectively. The related competency of involving patients in decision making (criterion 13) was not seen in 14% of doctors, and only 36% (762) managed to show it in three or more of the first five consultations (the stated target for a pass). These four criteria all had modes of 2 or less (table). In contrast, 69% (1442) candidates were able to meet the remaining performance criteria in at least three of the first five consultations (modes of 3, 4, or 5 in the table).

	Comment

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On the basis of their "best" five recorded consultations, doctors nearing completion of a three year postgraduate training in general practice showed only limited ability to achieve patient centred outcomes. The ability to elicit patients' ideas, concerns, and expectations is fundamental to good consulting, but our results suggest that few doctors regularly use this ability, even in a highly selected set of consultations. Likewise, the checking of understanding, and the involving of patients in decision makingboth likely to improve concordanceare rarely demonstrated. Patient centredness may not be appropriate for every consultation, but these abilities are held by the Royal College of General Practitioners to be necessary markers of good general practice.

	Acknowledgments

Contributors: PC, RN, and PT jointly conceived the paper; JF contributed to the design of the assessment and to the analysis. PC analysed the data and will act as guarantor. All authors contributed to the writing of the paper.

	Footnotes

Funding: None.

Competing interests: All authors hold honorary positions in the MRCGP examination of the Royal College of General Practitioners.

	References

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1.	www.rcgp.org.uk/rcgp/exam/modules/video/nov00/index.asp (accessed 5 August 2002)
2.	www.rcgp.org.uk/rcgp/exam/videoworkbook/intro.asp (accessed 5 August 2002)
3.	Tate P, Foulkes J, Neighbour R, Campion P, Field S. Assessing physicians' interpersonal skills via videotaped encounters: a new approach for the MRCGP. J Health Communication 1999; 4: 143-152.
4.	Stewart M. Studies of health outcomes and patient-centered communication. In: Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR, eds. Patient-centered medicine: transforming the clinical method. Thousand Oaks, CA: Sage, 1995:185-190.
5.	Mead N, Bower P. Patient-centredness: a conceptual framework and review of the empirical literature. Soc Sci Med 2000; 51: 1087-1110.

(Accepted 28 June 2002)