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So good afternoon everyone. It's just gone past 12. I apologize. My car was blocking a skip that came to, um, collect, they came to collect the skip. So my name is Doctor Rashid and I'm a G P and I'll be doing a series of family medicine lectures. Um, and before we get started, it's always a good idea because we are sitting in a virtual classroom. Is it possible I can have a conversation with you? I can sort of, um, introduced yourselves to me so that then we can, uh, you know, I, because I, I would want the lectures to be interactive. So my name is Doctor Rashid. I'm a working G P here in the U K. Um, and I see we have Sharon's Ipad. Hi, Shereen. Hi, Shirin. Can you see your face? So that's not allowed? Okay. Hi. Oh, hi there. Hi. Hi. Hi. So, tell me about yourself, Sharon. You're very consistently doing my six year in one of the Ukraine Universities. But I mean, UK at the moment. So. Okay. All right. That's wonderful. Thank you so much for joining us. Thank you. And then I believe I had Jake is that my Jake. Is that, is that the Jake the title? Oh, hi, Jake. How are you? Jake is one of my students from Bulgaria. Thank you, Jake. Thank you for being with us. Wonderful. And we've got Kaiho. Hello. Good day doctor. Good evening, my dear. And what year are you? Um, mom always say I'm Taiwo. I'm a medical student from Ukraine. What we're telling, what year are you? 68 60 82 50 year. Okay. Are you in the UK now? I'm in Germany. Where are you? I'm in Germany. Oh, okay. That's fine. No worries. And then we have Mohamed El. Heavy, heavy in. Hello? Okay. We'll move on to Mr Ali. Okay. Don't want to talk to me, Mr Assad. Yes, I'm a 60 students. Is that, how are you? What year are you? I'm a 60 year student in Google Bullets, Medical University and Key. Okay. And where are you, where are you protecting? Uh, right now I'm home. Mumbai India. Okay. Okay. Okay. So that's great. I'm so glad you've joined us. And then I see we have Doctor Sarah Aberdeen who I know very well. And I've got Irene. Is that my Irene Irene? Is that you Irene mckee? Yes, it is. Okay. And then we have Hodja. I don't know this Hajjar a but high Hajjar a good morning. Good afternoon. Okay. So what I'll do is I'll now start the screen share from um uh this is what we want to share. So today we're going to talk today is our introductory lecture on family medicine. Now, I've had a look at the UK MLA and there is quite a lot of overlap with, uh, family medicine. So it seems that it would be very relevant to you. Uh, sorry doctor. Um, your, your mind. Okay. So, can you see my screen? No, it's not showing. Okay. Let me just see why that's not showing. Ok. That ought to show. Uh Can you not see that? Know? Maybe if you accent, try again. Okay, let's try again. Uh Can you see, can you see that? Can you see that now? Yes. Yeah. Yeah. Okay. So, so what we, what I uh one of the, one of the things that I did before I started uh preparing for these lectures is I've had to look at the UK MLA Mapping. And what I've come to realize is that almost a third of all the topics that they're going to require you for the UK MLA exam has mapped across to family medicine. So, what I was thinking of doing is we'll start with some basic general um orientation around um uh family medicine. Um And then today I was hoping we'll do consultation skills. I think my second lecture is to do with gynecology. So um we'll just get started with that. Um So general practice is also known as family medicine and in the UK, almost 87% of uh 97% of our patient's are registered with the G P. And if we look at the scope of family medicine, we do quite a lot in family medicine. It's the first point of contact for access to healthcare. And um GPS are typically community physicians who specialize in general is um now that seems like a bit of a paradox. But actually, the reason I say they specialize in general is um is because I believe general is um itself is a specialty and GPS who work in the community, they usually office based and we do some bits, bits of outreach work for people who are not familiar with British General Practice and who are contemplating sitting the UK ML A. It's good to understand how healthcare works here in, in, in the UK. And if a patient needs to um access a uh any kind of healthcare, the first point of contact has to be with the G P. Um and some of the GPS will also become specialist. So we have specialist GPS in women's health contraception E N T GPS can specialize in neurology, ultrasound cardiology. Um And we mainly treat minor illness and a bulk of our work is long term condition management. So that includes asthma, COPD, heart failure, dementia and general practice is unique because we look after patient's from cradle to grave. So almost as soon as the baby is born, um they get registered with the G P practice and general practice offers in its unique in that it offers continuity of care. We also have access to the patient's entire record which sometimes even secondary care doesn't have. And a part of the work in primary care is health promotion and prevention. GPS were also recently involved in commissioning and rationing but that rule is now reduced. Um In the U K. Uh there is a change now in, in, in the way GPS are working and they are now grouped in large primary care networks. And these primary care networks have allied teams and they, there are new rules that are being added to general practice, social prescribers, physicians', associates care coordinators, and these are becoming larger and larger groups. Um And the reason for that is that the government wants the primary care network to take over a lot of the public health delivery, a lot of the health promotion and a lot of the preventative work is now going to be done through primary care networks and funding is now coming into general practice through primary care networks. So it's possible that the actual relevance of individual practice will diminish with time and that most of the healthcare will be delivered across 50 to 100,000 patient population through the primary care network. So this is this is a uh evolution in general practice uh to the extent that we haven't seen this before. So um it has its opportunities and it has its challenges. And through the primary care network, a lot of funding has come into general practice today. What I wanted to do is I wanted to focus on consultation skills because when you sit the UK ML A, there will be a part of the UK MLA which are the or ski, so which is traditionally plaid one and club to um and in order to uh maneuver that part of the exam, there are certain criteria that have to be fulfilled, which means that you have to be able to visibly perform in an exam setting um and be able to elicit and demonstrate all of these points because if you're not able to demonstrate it, and unfortunately, you're not going to be able to get that mark and to pass that Oskin module. Um And the uh if you look at the models of consultation over the years, going as back as the 19 fifties, there have been many different models of consultation and you can pick that up anywhere on the internet. Today. I'm going to talk about the practicalities of achieving this in the exam. And the fundamentals of all these models are that when you look at the older models compared to uh say phrase in 1992 they have become more patient centered in more patient centric. And what you need to be able to demonstrate in the exam scenario is you should be able to empathize and respond to the patient uh established relationship with the patient. Manage the presenting problem. You should be able to elicit any continuing problems. And as a part of your consultation, which we will go through a consultation observation tool. Um you can do uh you know, modify the patient's health seeking behavior, do opportunistic screening, summarize and safety netting. So I'll be taking all of these individually and actually demonstrate to you how we're going to actually demonstrate this in a traditional consultation uh setting. So the consultation observation tool is a feedback tool um and it's used in G P training and we use it for medical students. Um And what we do is we actually sit and listen or we watch students in consultation and we use the tool to give them some useful feedback as to how they can improve the consultation skills. For those of us who are on the Ukraine program and those of us who are listening from abroad who might contemplate uh doing the UK ML A. Um You, you won't be uh surprised to know that the UK MLA will be delivered in the future by the ECF MG. And whether you go to, can ID A, you go to America or you go to uh come to the U K. There will be some element in your exams of actually examining your rapper with the patient, your language skills and your consultation skills. And the key elements of that consultation are the examiners want to see if you are engaging with the patient, whether you can take a relevant history, you are encouraging patient contribution. Can you be shown to be responding to the cues? An important part of this uh consultation will be placing the complaint in a psychological context, exploring the patient's understanding and including or excluding significant conditions. And I believe the CRF are going to be doing uh um a workshop on the UK MLA. So this might be a part of it. So I thought I would take this now for any of the students that might be attending that day. So um as a part of that, you will be, you will have to demonstrate that you can select an appropriate physical or mental state examination, um make an appropriate working diagnosis and then feedback to the patient, explain the problem in an appropriate language, seek to confirm the patient's understanding and then develop a management plan, involve the patient in the management plan and make effective use of resources, specify intervals for follow up and then do the safety netting. Now, this looks like it's a lot but students who have worked with me, um Jake and Irene will be able to tell you people who have worked with me. Once you develop the skill of, of doing this, it becomes a a part of your second nature. So when I was a GP in training, I had made a list of this and I had put it on the wall and it feels a bit artificial when you first start out. But I had trained myself to be able to take a consultation through these steps and, and the reason for that is, uh, unfortunately, although it feels a bit artificial, unfortunately, in the exam, if you don't elicit it, you might think that I've done it. But if you don't actually specifically elicit it, the examiner cannot give you a grade and you could get a grade of insufficient evidence, which basically means that the numbers won't add up. Um And and skilled people can reach either competence or excellence levels. So if we look at a consultation observation criteria, um uh what, what, what you need to do before you start a consultation is my recommendation is that you open the record and you look at the booking information. So in the UK, we have electronic systems and those of uh the students who have done a clinical attachment with me, they know that when the patient does uh makes a request for an appointment, there is some information there on the record. So it's good practice to just spend about three minutes to open the record, to go through the entire record. And that helps you set out for yourself what you're actually going to get into because invariably a patient is coming with either a new problem or they're coming with something that they have, uh which is an ongoing problem so it might be chronic pain, it could be the asthma, it could be the COPD, they might be booked in for a medication review. And it's important to ensure that in a consultation you, you're not interrupted in COVID, obviously a lot changed in COVID and we've become more telemedicine based. So, whereas previously, all consultations were face to face, they are now more uh it depends on which practice you're working in. But some element of the consultation is invariably doing a triage talking to the patient and then bringing them in later on for an examination. But in the exam scenario, you will have to demonstrate all of this in one bundle. So we'll start going through that. Um So you, you have to be aware of what the patient has come for for. And as I explained before, you have to be able to demonstrate the requirements of the court's at the risk. Otherwise, is if you don't achieve it on the, the, the examiner cannot mark you for. Um something that you didn't specifically illicit because the examiners are given a, a sheet um as a G P tutors um and and G P trainers, we all have a sheet on which we can, we can mark. Um So the first performance criteria is the doctor is seen to encourage the patient contribution. So if I could ask um for some um interaction here, how do you think in a consultation, you could encourage the patient's contribution so you, you can have active listening skills. But what, what would be an open question? How would you, how would you demonstrate that? Okay. Uh just, just feet the patient, like with noting, you know what I mean? And uh just uh what brings uh her today, but see if I were to ask an open ended question, how would, what would that open ended question be? Well, it's not a yes or no answer. So, something like, how are you feeling like would bring like first agreed and you agreed and ask what brings him or her today? Uh You could feel like what has brought you to the surgery today or how can I help you today? Yeah. So because when you look at the classical history taking, um classical history taking is the presenting complaint is always in the, in the words of the patient's when you're recording it, what I sometimes record in speech marks is the patient says I'm feeling awful today, isn't it? So I put that. So we use open questions. So what's the advantage of using open questions? Patient express, express itself and spain or herself in their own words? Yeah. So they do express themselves. That's quite, quite, quite right. You're quite right that they are expressing themselves. But the advantage in that is you're not prejudging or assuming anything, you're pretty much allowing the patient to take control of the consultation. So you are validating, they're concern you are making them feel comfortable and you are showing you're demonstrating that it's okay to allow them to talk. So when they are giving the first, I would say the 1st 20 minutes at the 20% of the consultation, which is the first uh part of the consultation. If you don't interrupt them, pretty much, you will be able to work out their ideas, expectations and concerns because patient's um uh often in general practice, they would have been waiting weeks to see their GP and they've got a list of concerns and the moment you allow them that opportunity, it will all come out. You see. And then how do you sort of explore or clarify symptoms? How, what, what is your opening gambit? What do you do in consultations? Because I'm not sure how much patient contact you've had in the past, in, in, in the years that you've been there in Ukraine. How did you come, you start off with, with your consultation? Like first we start, what's the main problem like, uh what's the main problem has given like pain or is it a distress? And then we asked the timing of it, it, when did it all started? Like it started suddenly or it was five weeks or days? And now it's now we decided that first we start the main complaint that we, we ask the timing of completion. Uh okay. Okay. And then, um uh do you, do you allow the patient to see it in your, in their own words. Is that how you would do it? Uh Yes, let them describe the, how they feel first. And if they're not getting, getting to it, uh you provide to use words like to help them to reach to the point which they want it. Scuse first, let them express it then. Uh And what about nonverbal skills? What kind of nonverbal skills would you use if you were in an exam scenario? If this was your M L A, what would you, what would you use as a nonverbal skill? So it's something like so you, you, you can hum and whole and you can make eye contact and you can nod your head and you can demonstrate that you're actually listening to what they're saying because what that does is it encourages them to carry on telling them, telling you what they want you to hear. Yeah. Now the next one that they will examine you on is that they want to see you respond to signals or cues that leads to a deeper understanding of the problem. And how do you do that? What is the key to being able to respond to the signals accused? Because in an exam situation, it's usually quite tricky because you're under a lot of pressure. So there's a time pressure and within the 15 minutes or 20 minutes that you've what the language on director conflict just going to help expressing like facial expression like yes. Okay. Oh man, thank you. Not just adults. Hello doctor. Can you hear me? Hello? Can I can you hear me? Hello? Yes. Yes. Did you drop out for a little while? Yes, ma'am. So, so do you remember what slide we were on? Were you were we on slide too? Yes. Yes. Yes, everyone slide too. Okay. So, so um so in an exam scenario, there will be um there will be actors and invariably the scenario that they give you, there will be a little, there will be a hint to the verbal and nonverbal cues and you have to be conscious of that so that you can pick it up. So it might be uh something simple like the patient or the actor might say that I'm really worried this is a cancer. So you understand then that that is the ice of that patient. That is the idea concerns and expectations of that patient. Yeah. Sorry doctor. You're not sharing your slides anymore, right? OK. Can you see them now? Not yet. No. Okay. Let me just go back because it can you see that? Is that visible now? No. Why is that the case? Uh it says in my screen is being shared. Can you see it now? No, it's just a black screen. So you try again, maybe. Do you want me to log out and log in again? Um I'm not sure how necessary the slides. I mean, we've got 15 minutes left for this lecture. So I think I'm doing the next one to, aren't I? Yes. So, so we can just go straight on from this to that. Uh I ki it is a different, it's a different zoom link. So maybe different people will be joining. So we'd have to start the next meeting. So it'll be a different meeting. Okay. It doesn't matter. So, what we'll do. Okay. So, what we'll do is then I'll continue this. If we run over this, then what I'll do is I'll continue this team in our next lecture um in the next family medicine lecture. So I, I don't understand why I cannot seem to share because mm. Can that be seen? No. No, because we'll have the same problem in the next, you can't see any of this. No. Unfortunately, maybe if you exit the Power Point app for a bit and then go back into it. I've done that and it says I'm sharing my screen. So at my end, I it says I am sharing the screen. So I don't know. Okay. I'll tell I'll stop the shed and I'll start it again. Is that better? Yes. No, it's working okay. So, um we'll, we'll move on swiftly because as Hannah has said that we only have 15 minutes left. Um So if you go on to the next consultation criteria, it says, does the doctor use appropriate psychological and social information to place the complaint in uh in it's appropriate context. So what medical students often forget to do is they forget to ask a social and an occupational history. And it's really important in this criteria to be able to assess the impact on the activities of daily living. So if somebody has had back pain for a month, you need to be able to ask them, are you able to get to work? Are you able to do your shopping? Are you able to uh drive a car, change your clothes? Um So when you, especially if you're dealing with muscular skeletal problems, are I am in the habit of using standardized orthopedic scores and that is actually a very good score ing tool that enables you to assess the impact on on the patient's activities of daily living. The next criteria is you have to be able to demonstrate that you have explored the patient's understanding. So people with long term conditions, they usually quite clued into their uh medical condition because for example, we have the diabetes education program, we've got um other patient groups. So patient's can access quite a bit of information, but when it is a new condition, so say, for example, they've developed an abdominal complaints or they've had a change in bowel habits, they would have spent a bit of time talking to their family or their friends going on the internet. They've already made up their mind that there is something wrong with them. So it's really important that you can actually elicit in the consultation. You know, what do you think is going here? What is your worst fear and what has brought you to, to us today? Um And when you're taking the history and this has to be very slick because again, 15, 20 minutes is not a long time. This is the one part of the history where you can ask close questions. So the difference between an open question is you, you can in an open question, you pretty much leave it to the patient to be able to tell you what they want to tell you. But in a close question, you ask sort of all the relevant questions that you want to elicit the information from the patient from. And in that you have to visibly demonstrate the inclusions and the exclusions. For example, if somebody comes with abdominal pain, you need to be able to demonstrate in the history, you've asked something like, has there been any weight loss? Is there a change in bowel habit? Has there been any rectal bleeding? How's your appetite? Have you lost weight? Um Is there a family history of bowel cancer? Um And then of course, you ask them an open question that what do you think is wrong with you? The other thing to be mindful of is not to ask for something which is rare as hen's teeth because that would be regarded as not an efficient use of the consultation time. Now when it comes to examination and I'll make this very brief because time will run out in 10 minutes is you must not offer or uh choose an irrelevant examination. And the reason for that is in an exam scenario, of course, you're trying to gain the marks. But even in clinical practice, you could be accused of unnecessarily doing an examination that was not appropriate or that was not called called for and obviously any intimate examinations, they're not recorded on any video or any, any screen, but you must be able to ensure that you've taken consent for that examination. So even if it is as simple as listening to somebody's chest or examining somebody's abdomen, you must offer a chaperone and you must document that you have done that. Um And as you start to go through your algorithm, you have to start beginning to explain to the patient what you're thinking of why you're doing what you're doing. And as you go through the consultation and you're examining the patient to explain to the patient where you're thinking is going and then leave a little time for the patient to come back and ask you questions so that you can explore their comfort. You know, because there is a delicate balance between how much information to give to the patient before you actually make them so scared and worried that you have compounded the problem, not relieved or reassured them. And when you're explaining to the patient, and that's the skill you need to acquire is to be able to talk to the patient in lay language. So you're not going to say uterus, you will say something like womb, you're not going to say um you know, um humerus, you will say the shoulder joint. So try to develop a vocabulary of non medical language that would help you communicate with the patient's. And then it does help if you have spent some time in the country, if before you, you actually do the actual exam or doing some clinical consultation, skills courses. Um And at the end to, to confirm if the patient has understood um what you're doing. So as you go through the consultation, a simple question would be, is it okay? Do you understand so far? What I have said? Is there anything I can explain further? So you, you need to actively elicit this for, for, for your exam. And then as you formulate the management plan, you need to be aware that your management plan will be judged according to the guidelines. So any appropriate referral or investigation that is relevant should be evidence based and you have to seek the patient's consent when, when you're formulating the management plan. So it's not as if you will do it in isolations and and that is where shared decision making comes in. Do you have to be able to actively demonstrate that that there is shared decision making that you've explained to the patient the risks and the benefits. Now sometimes the very complex um situations, it can be too much information for the patient to take in in one go and you have to be able to just assess that, that how much can the patient absorb in this, this this particular opportunity? And you can sometimes schedule a follow up, especially if there are other interested parties. So if you have an elderly patient who comes in on their own, you can ask them to come back with a member of the family or somebody else, a friend, a neighbor and, and this is what in the eyes of the law, they we call interested party. So an interested party doesn't necessarily have to be somebody who's named on they're lasting part of attorney. It could also be a friend, enable a relative that's very much up to the patient who they want to bring in. And when you are doing your recording, you must uh verify the patient's capacity. So usually capacity is based on an assessment of the patient's ability to understand and retain to recall and to be able to understand the implications of what you're doing. So if somebody doesn't have capacity, then you cannot seek consent from them. It almost invalidates your consent. So you just have to be careful of that and make sure that you record all your encounters with the patient. Um uh appropriately and um in um you know, unambiguous language and contemplation. Ius Lee, another thing is, of course, the effective use of resources that they will see uh what you're doing. So if, if you're doing a consultation in primary care or you're a, uh you know, if your F I one or you're being assessed as an F I one, you would want to uh be able to demonstrate the initial investigations and usually investigations are either blood work or imaging. And you need to be able to explain to the patient. This has to come out that you have explained the relevance of the investigation, what you expect that it will show or not sure how it will assure you. And if you can, you can cancel the patient as to what the actual investigation will entail. For example, I would say to a patient, I think what we need to do is to arrange some bowel investigations. And what that will mean is that you will go into a day unit and, uh, the doctors would explain to you, it would be a camera test that would be done under light sedation. So you could be a bit drowsy afterwards. So in those kind of, uh, you know, in those kinds of terms and at the end of the consultation, couple of things are really important is you have to be able to specify the follow up. So what if you're treating somebody, you should be able to give them a trajectory of, um, improvement. So, if I was treating somebody for a sore throat and I put them on antibiotics, I'd usually say to them, I'd expect you would start feeling better within 48 hours if you haven't come back to me. So you need to document that. You've done that, you've specified the follow up and then you've done some safety netting. So, I think we are just on time. Is that Heather? Is that okay so far? Yes, we have another five minutes. Okay. So what I'll do is I'll go back to the main screen and I'll just leave it open for um colleagues here to ask questions. Anybody. Oh, MS Patel has joined us. That's very interesting. High Anjali, how are you, you know, like most of the way doctor? Okay. You have, you have good, good, good, good. Thank you. So um any questions anybody? Because what I was hoping to do in a subsequent clinic, not a subsequent clinic in a subsequent lecture. If there's an appetite, I wanted to do some communication workshops in which what I'll do is I'll give you a scenario and one of us can become the patient and then you can ask the questions and we can see how we perform because those of you who are finally as are going to be giving the MLA within the next year or so, isn't it pretty much? So, so the, the, the consultation observation tool is available on the internet. If you just put cotton tool, you'll get the whole criteria on the internet. Okay. Any other questions? No. Would you be interested in having a video clinic as a Mark clinic? Yes, you would silence. Remember everybody else? Okay. That's fine. We'll see how it goes because I think I'm meeting you all for the next lecture which is on amenorrhea. Is that correct? Yeah. Okay then. So what I'll do is I'll close this screen down and then we log in for the next link. I hope to see you all. They're all right. See you, doctor. Yes. Thank you. Bye bye. Thank you doctor. Um, the feedback link is in the chat. So please complete the feedback. And so is this a difficult for download for downloading? So, um, if you can download it, please go ahead and do that. Um, I'll leave this open for another minute and then we can move onto the next lecture. Thank you, everyone.