HYMS

Year 2

Guidelines on Assessment of Clinical

Consultation Skills (ACCS) for Students
and Tutors

04/05/2011 1
Purpose of this document

This document is a supplement to the Code of Practice on

Assessment for Phase 1 of the MB BS course. It aims to provide
additional comments to help students and those involved in the
organisation of the clinical assessments.

Clinical assessment

Although we consider assessment largely in terms of the end result

for the Institution (granting a degree), almost as important is the
effect on student learning.

There is a surprising amount of research on assessment techniques

including those of clinical abilities and it is clear that much of
current practice is defective. There is however no perfect method;
just some methods better than others.

There are three main criteria by which assessment methods can be

judged; validity, reliability and practicability.

Validity asks whether a test really examines what we think it does.

Clinical examinations appear to score well in this regard, they do
after all seem to reproduce what doctors do. However competency
tends to be context specific; competency in one area does not
predict competency in another. This means testing has to be
extensive.

Reliability refers to reproducibility. If the examination is repeated on

different occasions with different examiners, will the results be the
same? With the variability in patients and in examiners it is no
surprise that reliability in clinical examinations can be low. More
extensive testing can help as this tends to even out the vagaries of
patients and examiners.

Practicability refers to the resources needed to mount an

examination in terms of patients, examiners, space and money. All
are finite.

It will be seen that there is an inherent problem in organising clinical

examinations; a large amount of testing is needed to improve
reliability but this quickly becomes impossible to resource. In Phase
1 Year 2 this dilemma is dealt with by use of a ‘mastery’ assessment
and in Phase 2 by sequential examinations

Summative assessment in Year 2

04/05/2011 2
Summative examinations in year 2 are similar to those in year 1 in
consisting of written papers in all three Theme Clusters and an
Objective Structured Clinical and Practical Examination (OSCPE).
However in addition there is provision for a clinical examination with
real patients called an Assessment of Clinical Consultation Skills
(ACCS). The purpose of this is two fold
• To drive the learning appropriately, particularly but not
exclusively in the clinical placements
• To ensure that students have acquired a basic facility with
real patients and are able to transfer their skills from
simulated to real patients and thereby to ensure that
they are fully equipped to enter Phase 2

Advised by Professor Newble of Sheffield University, the

examination will be taken as a ‘mastery’ examination. Students
have to demonstrate that they have reached a certain level of
proficiency, if they cannot they will have a period of further training
before a re-assessment. It this way it resembles postgraduate CPR
assessment or the driving test. This avoids some of the reliability
problems with small numbers of patients as indicated in the above
paragraphs

The skills that need to be demonstrated are given in the

Appendices. Each student will be observed taking a history from and
examining patients. The examination will take place both in
hospital and in general practice. This examination forms the first
part of an integrated progressive clinical examination system which
continues to the end of the course.

Organisation

The examination will be conducted at the end of the last Block of

the second year (Block 15 Gastrointestinal and Endocrine). It will be
conducted in clinical areas so that one of the two patients is seen in
a primary care setting in one Block and the other in a hospital
setting in the other Block. The examinations will be conducted by a
single clinical placement tutor other than that normally responsible
for the student. If examination of a third patient is necessary (see
below), the examination will be conducted in either general practice
or in hospital by a pair of examiners, at least one of whom will be a
senior clinical academic.

Conduct of the Examination

• the examiner will introduce the patient with a standard

introduction giving basic information to focus the discussion.
This introduction will be formulated in advance and given in
the same way to all examinees seeing that patient; e.g. "Mr S
is a 65 year-old retired electrician who has been getting

04/05/2011 3
 recurrent episodes of rectal bleeding associated with some
loose motions; find out more about this”.
• the student will be observed taking a history from the patient
for 10 minutes. This should be performed, as far as possible,
without interruption by the examiner; otherwise examiners
are likely to intervene to a different extent. An exception is if
the student is being seriously misled by the patient through
no fault of their own.
• the student will be asked what is the most appropriate
physical examination to perform based upon the history
obtained. The examiner will have agreed in advance what this
is, and will direct the student if their response is incorrect.
• the examiner then observe the student perform the specified
physical examination for 10 minutes.
• the examiner will then ask the student to describe their
findings and identify the possible underlying disease
processes, give the reason for their suggestions, and suggest
how the problem may be taken further. This should be more in
terms of the images needed to understand the problem than a
list of laboratory investigations (10 minutes)
• at the end of each stage the examiner should move the
student on at approximately 10 minute intervals so that the
examination is completed in 30 minutes

The examiner will grade performance according to defined

descriptors consistent with a modification of the ‘Calgary
Cambridge’ approach to consultation skills training. These
descriptors will be organised into Categories of Competence as
below.

Selection of Patients

Patients may be from GP surgery attenders, hospital in-patients and

out-patients and should be able to give a reasonably coherent
account of their illness. Common presentations reflecting disease in
the main body systems will be most suitable particularly if they also
illustrate some important principle of medical science. The patient
problems suggested in the clinical placement section of the Study
Guides are a good guide. Patients with psychological problems may
be used but it is important for examiners to remember that the
formal experience by students of patients with mental illness will be
over a year old and they have not yet had training in the formal
assessment of mental health. An abnormal sign is not necessary
and a patient with only ‘a good sign’ is not appropriate. The
experience of students will still be quite limited so the problems of
‘case specificity’ may be significant. Generic competencies should
be sought rather than specialised knowledge.

Examiners

04/05/2011 4
The examiners will be the clinical placement tutors. Examiners will
not examine students from their own tutor group

Categories of competence

Gathering information
Physical Examination
Problem Solving
Relationship with patients

Grades
Students will be separately graded on each category of competence
according to the following grade descriptors so that each patient
encounter generates 4 grades.

A Capable in every component to a high standard.

B Capable in all components to a satisfactory standard and a high
standard in many.
C+ Capable in all components to a satisfactory standard.
C- Capable in a majority of components to a satisfactory standard,
inadequacies in some components.
D Capable in a minority of components. No serious defects.
E Capable in a minority of components. One or more serious

defects.

It is important to recognise that this scale is applicable to a clinician

at any stage of their training. No allowance need be made for the
level of experience and no implicit reference should be made to
some theoretical average student at this stage of their training.
Most reasonable 2nd year students will be expected to get C- with a
modest number achieving C+. Finals students should generally be
at C+ and postgraduates at A or B. The main difference between
junior and senior students and later postgraduates is largely in the
range of competencies required and demonstrated.

Although these grades are expressed in a mathematical way (i.e.

majority) they should not be interpreted simply as an exercise in
counting. A broad judgement is required of the observed
performance.

Threshold
All students will be examined on two patients. Those obtaining
more than one D or E grade in any of the 4 categories of
competence in either of the two patients will be regarded as
unsatisfactory in the assessment and will need to see a third
patient. This calculation is therefore cumulative across the 4

04/05/2011 5
categories and the 2 patients. A further agreed D or E grade on the
third occasion will lead to the student being required to be re-
examined after a further period of clinical experience and
remediation. This re-examination will take place not less than 6
weeks following the time of the written and practical examinations
and will be in the same overall format as the original examination.

Appendix 1; Categories of Competence and Component

Competencies

Gathering information
Initiating the session
Greets patient and obtain patient’s name
Introduces self and clarify role
Identifying reasons for consultation
Uses an opening question to identify the issues
Listens to the opening response without interrupting or directing
Checks and confirm list of problems
Negotiates to set an agenda for the session
Exploring the patient’s problem
Encourages patient to tell own story
Uses open and closed questions, appropriately moving from open to closed
Listens attentively, leaving the patient space for thinking before answering, and continuing after
pausing
Facilitates responses by verbal and non-verbal techniques
Picks up and respond to verbal and non-verbal cues
Clarifies statements
Uses clear language avoiding jargon
Summarises to confirm understanding before moving on
Understanding patient’s perspective
Discovers patients’ ideas regarding each problem
Determines how each problem affects the patient’s life
Determines the patient’s goals - what help they expected for the problem
Encourages expression of feelings and thoughts
Explores context
Considers relevant physical, social and psychological contexts of the patient
Structures the consultation
Establishes dates, sequence of events
Summarises, thanks and closes

Physical examination
Performs focused physical examination in each major systems (see appendix 2
Performs an appropriate general and a full examination in each major systems correctly and
sensitively
Recognises major departures from normal physical findings (see appendix 3)

Problem solving
Discusses the likely underlying pathophysiology in the light of the patient’s presentation

Relationship with patients

Attends to patient’s physical comfort
Uses empathy to communicate understanding
Provides support
Deals sensitively with embarrassing topics
Explains rationale for questions; examination
Maintains friendly but professional relationship with patients

Appendix 2; Physical Examination Skills

In a normal subject students should be able to carry out the

following examination sequences. Year 2 competencies are in
italics

04/05/2011 6
General

Look for cyanosis, jaundice, anaemia, clubbing,

lymphadenopathy, thyroid enlargement, peripheral oedema

Respiratory system
Inspect the chest wall and respiration for equal movement,
depth and rate of breathing
Palpate to assess chest expansion, position of the trachea,
tactile vocal fremitus
Percuss; anterior and posterior, 3 zones each in sequence to
detect resonance over the lungs
Auscultate; anterior and posterior, 3 zones each in sequence
to detect vesicular breath sounds and added sounds, vocal
resonance
Examine the breast

Cardiovascular system
Take the blood pressure using an anaeroid sphynomanometer
and report on the result
Palpate the radial brachial, carotid, femoral, popliteal, dorsalis
pedis and posterior tibial arteries and report on the rate,
character and rhythm
Observe and report on the jugular venous pulse
Locate and report on the position of the apex beat in relation
to ribs and clavicle
Palpate the right ventricle
Auscultate the appropriate areas of the precordium for sounds
from each of the 4 valves and distinguish the 1st and 2nd heart
sounds timed by palpation

Abdomen
Inspect for swelling and scars
Palpate for enlargement of the
liver,
spleen
kidney
Percuss the liver
Percuss for ascites
Auscultate for bowel sounds
Examine a pelvic model

Musculoskeletal and central nervous system

Examine for abduction, adduction, flexion, extension, internal
and external rotation of the shoulder
Examine for flexion and extension of the wrist
Assess muscle power in the upper limbs (Year One shoulder
abduction and adduction, elbow flexion and extension) (Year

04/05/2011 7
 Two shoulder abduction and adduction, elbow flexion,
extension and supination, hand and wrist flexion and
extension)

Examine for flexion, extension, abduction, adduction, internal

and external rotation of the hip
Examine for flexion and extension of the knee
Assess muscle power in the lower limbs (Year One hip flexion,
knee flexion and extension) (Year Two hip flexion and
extension, knee flexion and extension)

Examine the thoracic and lumbar spine for deformity and

movement
Carry out sciatic and femoral nerve stretch tests
Measure true and apparent leg length

Look for muscle wasting

Test for muscle tone
Test for coordination using finger nose and heel shin tests
Assess sensation to touch and pain and position in the upper
and lower limbs
Elicit the reflexes: biceps, triceps, supinator, knee, ankle and
plantar
Examine the cranial nerves 1- XII in sequence

Other skills

Obtain consent from a patient to conduct a physical

examination
Demonstrate an efficient hand-washing technique
Carry out basic life support on an adult and child mannequin
Examine a normal child (it is in fact unlikely that students will
see a child in ACCS but may well be asked to talk with a parent
about a child in the OSCPE)

Appendix 3; Key abnormalities

While students can be expected to show competence in the

examination of normal subjects, it is difficult to describe the range
of abnormality with which they should be familiar. This is partly
because they all have had a different experience and partly because
a given sign may be readily detected in one patient but impossible
for all but the most experienced examiner in another.

However in order to give some guidance to students and examiners,

this is a list of the major abnormalities that students might be
expected to have seen and recognise by the end of the second year.
This is based on the Clinical Skills and Clinical Placement sections of
the Study Guides

04/05/2011 8
General Examination
Cyanosis
Jaundice
Anaemia
Clubbing
Lymphadenopathy
Thyroid enlargement
Peripheral oedema
Eczema
Psoriasis

Cardiovascular
Peripheral arterial insufficiency
Leg ulcers
Irregular pulse
Hypertension
Raised jugular venous pressure
Displaced apex beat
Systolic murmur

Respiratory
Reduced expansion on one side
Dullness to percussion
Diminished breath sounds
Wheeze
Crackles

Abdomen
Distension
Hepatomegaly

Central nervous system and musculoskeletal

Facial nerve palsy
Focal muscular weakness
Sensory impairment
Increased reflexes
Extensor plantar response
Joint swelling and/or deformity
Restricted joint movement

04/05/2011 9