In Previous iterations of the final MRCGP Exam, this is the area where most people lost marks. To understand why this might be, and how you can avoid this, continue reading below…

Reasons Why: candidates score lower

There are many reasons why candidates may not do as well in this area. Highlighted below are some of those reasons, including ways to help you overcome them.

1: Time

One reason candidates don't do so well in this section is due to difficulties with time management. You're never going to score well in 'clinical management' if you run out of time. This is why it's very important that you structure your consultations in such a way as to leave you plenty of time (at least 3-4 minutes) to discuss management. Even the RGCP itself has acknowledged, that the main reason that people failed the clinical management section of both the previous exams (the CSA and RCA) was due to running out of time.

2: Lack of knowledge

Lack of knowledge on how to manage conditions is likely the largest contributor to poor performance in this heading. This is why it is of utmost importance that you stay up to date with current guidelines, and know how to manage common conditions within General Practice. It is not enough to simply know one or two management options, as often the cases will be designed to eliminate those options, to test how well you know the subject. For example: A case with a tennis elbow may be intolerant of opiate analgesia, has a past history of gastric ulcer (therefore can't have NSAIDS), and may have already tried a forearm band and had private physio. You therefore need to know what more can be done to manage this condition, otherwise, you're at risk of becoming unstuck in the exam.

Highlighted below are some useful resources for up to date management advice:

• NICE Clinical Knowledge Summaries: Excellent for up-to-date summaries on aetiology, diagnosis, and management, done from a primary care perspective

• NICE Clinical Guidance: Up-to-date NICE guidance

• SIGN Guidance: Up to date SIGN Guidance

• Guidelines In Practice: An excellent resource for keeping up to date with new published guidelines.

• Guidelines Summary: Diagnosis and Management guidelines are simplified, with a good search function, and easy-to-follow flow charts in most cases.

• Patient.co.uk: Needs no introduction, excellent for 'patient explanations' however, be careful, as management and diagnosis is not always up to date.

3: Poor Explanation / Option Sharing

Often candidates may know how to manage the condition, but to score top marks, you need to be able to present that information to the patient in a way that helps them make an informed decision. We will cover this in a bit more detail below

Option Sharing: sharing your expertise

1: Make sure you have options to share!

Before we even go into how we share options, it's important that you have options to share. It's known that during cases in the SCA, several options may be taken away from you (patient allergic, or already tried some of them without success...) so you need to know at least 4 management options for all conditions. One of the best ways to practice this is with your trainer during debrief sessions - where they can help you out if you're struggling to come up with enough options. If you're unable to come up with 4 options, brush up on your knowledge using the above links. It is also important that the options you present to the patients are tailored to their circumstances and needs.

2: There may not be more than one option

It is important to note that there may not be more than one option in SOME cases. For example a child with possible meningitis, a cancer referral, or someone who is acutely unwell and needs a 999 call. For these cases, don't waste time trying to think of lots of different options, just discuss with the patient why there is only one recommended course of action. Then help them explore any concerns / expectations surrounding the chosen course of action, for example - what might happen next, do they need to inform anyone, organise any temporary care for relatives/pets, and so forth....

3: Gift Wrapping

For most cases within the SCA, there will be more than one management option, it is therefore key to discuss these options with the patient, to help empower them to make an informed decision regarding their condition. This does NOT mean simply listing all possible options to the patient. Remember, that they are there to seek your advice and expertise, and not to simply be given a long list of possibilities without having any guidance as to which may be the best option for them.

This is where 'gift wrapping' comes into play. Gift wrapping is a term coined to explain a strategy where Doctors may make one option sound more appealing to patients, to help them decide on a particular course of action. An example may be that when explaining options to an individual who has tennis elbow, instead of simply listing all possible management options; "simple analgesia, home exercises, physiotherapy, elbow straps, and steroid injections or specialist referrals", we might say that "in your case, you've tried simple pain killers, and home exercises, so physiotherapy and a tennis elbow strap might be a good place to go to next as the former can help speed up healing and the latter can reduce symptoms. Steroid injections, whilst they may help with symptom relief, can prolong the condition, therefore it might be best to wait until we've tried other measures first." In this quick example, you can see that the options are still listed, but one or two of them are 'gift-wrapped' to make them seem more attractive. This technique can be very helpful in guiding patients through the plethora of management options present in some cases.

Safety netting: an art form in itself

Safety netting is an essential process to help manage uncertainty in the diagnosis and management of patients by providing information for patients and organising follow-up after contact with a health professional. This aims to empower patients and protect healthcare professionals. Safety netting may be performed at the time of the contact between health professional and patient or may happen after the contact through active monitoring and administrative systems to manage results and referrals.

It is really, really important that your safety netting is empowering, and NOT terrifying. To ensure that you structure your safety netting appropriately you can follow the proposed key components of good safety netting advice(1):

Communication of uncertainty

If the diagnosis is uncertain, that should be communicated to the patient so that they are empowered to re-consult if necessary. If you are not sure of the aetiology, explain this to the patient. This reduces the risk of false reassurance and most patients appreciate the honesty.

Advice on worrying symptoms and ‘red flags’

In order to know when to represent or seek further medical care, it is necessary for patients to know the ‘red flag’ or worrying symptoms they should look out for. If there is a recognised risk of deterioration or complications developing then the safety-net advice should include the specific clinical features (including red flags) that the patient (or parent/carer) should look out for.

The likely time course of the illness

Persistent or non-resolving symptoms may warrant further investigation or consultation and may be considered as a ‘red flag’. In order to know when a symptom is persistent or non-resolving, healthcare professionals need to communicate a likely time course to patients.

How and where to seek further medical care

Once patients understand the potential red flag or worrying symptoms and the likely time course of the symptoms, they need to know how and where to seek further medical care if symptoms persist or red-flag symptoms present. The key element of this component of safety netting ensures that patients know how, and where, to seek help if things do not go as planned or expected. The advice should include a description of the specific situations and how to go about seeking help in these situations.

Arrange planned follow-up

As well as advising patients on how to seek help should things not go as expected, arranging planned follow-ups may be a part of safety netting. Planned follow-up may be encouraged after having investigations, or in groups of patients who may be less likely to re-present without planned follow-up. Arranging appropriate follow-up for patients is an essential element of the consultation.

Primary care investigations and safety netting

Safety netting around investigations may include arranging patient follow-up as discussed above, but could also include an explanation of the purpose of tests, how they are undertaken, and how results can be obtained.

But I need to bring the patient down… next steps?

The RCGP has confirmed that there may be cases where you need to bring the patient down to see you in the practice, for further examination or investigations. However, all the cases have been carefully designed so that they can be completed (i.e., you can give a diagnosis, explanation, and management) without needing the results of any investigation or further examination. It is therefore of utmost importance, that you do not stop your consultation at the point at which you recommend they come down to see you. Make sure that you give a diagnosis, explain it, and come up with reasonable management (above and beyond bringing them down to see you)

Explanations: Coming soon…

1. Safety netting for primary care: evidence from a literature review. Daniel Jones, Laurie Dunn, Ian Watt and Una Macleod. British Journal of General Practice 2019; 69 (678): e70-e79. DOI: https://doi.org/10.3399/bjgp18X700193.