Insufficient evidence (low challenge) cases in the RCA

In selecting consultations for the Recorded Consultation Assessment (RCA), it is important to choose cases which allow a candidate to demonstrate the appropriate professional capabilities. Some concerns have been raised over the submission of ‘low challenge’ cases in the initial diet of the RCA. Of 14,521 cases in the July diet of the RCA, 16.5% of cases were flagged by at least one examiner as low challenge.

The central idea is that the level of challenge in a case affects the opportunities for a candidate to display the professional capabilities which need to be demonstrated for licensing. The key issue is that where the level of challenge is low, there is likely to be insufficient evidence of these capabilities for an examiner to award a passing mark.

What sort of cases are likely to contain insufficient evidence?

An initial analysis of cases flagged by both examiners as low challenge (LCx2) in the July diet of the RCA shows some clear patterns.

In some cases, there was doubt about whether the patient needed to see a GP – the case being more appropriately handled by a nurse practitioner or pharmacist, for example. In many cases, the patient already had a diagnosis, or the explanation and management had already been done, either by the candidate on a previous occasion or by somebody else.

• Medication request / repeat prescription / adjust medication
• Pill check
• Follow up
• Recurrence
• Results
• Sick note request / fitness to work

Clearly, in these cases there was comparatively little for the candidate to do and therefore limited opportunity to display the capabilities necessary for licensing (especially in Data Gathering and Clinical Management). An initial psychometric analysis of the marking of cases flagged as low challenge in the July diet showed a difference of just over one mark in the mean overall case mark compared with other cases (5.15 compared with 6.19. Note that a pass in all three domains would give a mark of 6.). This seems likely to be related to the limited opportunity to display relevant capabilities. There may be confounding factors. For example, weaker candidates may be more likely to submit LC cases.

Certain clinical areas occur frequently:

• Skin / dry skin / skin lesion
• Eczema (especially recurrence or flare)
• Acne (especially recurrence)
• Molluscum
• Ear wax
• Earache
• Conjunctivitis / sticky eye
• Blepharitis
• Stye
• Hay fever
• Sore throat
• Tonsillitis
• Sinusitis
• Cough

Two areas, dermatology (18.1%) and ENT (14.8%), account for almost one third of LCx2 cases.

However, it would be dangerous to equate certain diagnoses with insufficient evidence (low challenge) in an overly simplistic way. The challenge could come from complicating factors such as patient expectations, beliefs, social situation, psychological issue, hidden agendas etc.  It is only when the simple diagnosis is completely straightforward that there is likely to be insufficient evidence. (There is a case of sinusitis in the CSA that is very discriminating.)

The four areas of challenge

Jonathan Cobb suggests that there are four main areas of challenge in a CSA case. These areas of challenge also seem relevant to the RCA.

The diagnosis

A new diagnosis of myasthenia gravis is important but rare. If such a case were submitted for the RCA, the level of clinical challenge would probably be high even if the presentation was typical. Tennis elbow, on the other hand, is relatively common but if there was an atypical presentation, the clinical challenge might still be moderately high.

The management

Even if the diagnosis is straightforward, the level of clinical challenge may be raised by factors which affect the management of the case. For example, the patient may have an established diagnosis of hypertension but have drug side effects or complications that require thought and debate.

The patient

An apparently straightforward case can be more challenging if the patient has unreasonable expectations or beliefs. For example, recent weight loss and haemoptysis may suggest an obvious diagnosis and management but if the patient initially refuses to consider referral then the doctor has to engage in a different type of debate.

The situation

Finally, a straightforward problem and a reasonable patient may be complicated by odd external circumstances. For example, consider the effects of an impending move abroad for work reasons when a woman presents with post-menopausal bleeding.

The first two areas – diagnosis and management – determine the level of clinical challenge; the second two – patient and situation – represent complicating factors.

The table below attempts to show how these can interact to create different opportunities to display capabilities overall. This may help conceptualise the challenge issue and be of use to trainees in selecting cases that are appropriate for the RCA. 

Complicating Factors (e.g. patient expectations, beliefs, psychological issues, social situation, hidden agendas)

It's important to note the limitations of the table. Not all insufficient evidence cases are defined by the diagnosis. If a candidate has an informed patient who delivers a "perfect"  history and outline of what management plan they would like, a candidate may only just agree. This hardly shows any relevant capabilities. For example, a case of a next of kin wanting a DNAR form for a patient who is having  " end of life" care. This could be a challenging consultation. But, if the relative was very well informed, had power of attorney, covered all the issues without prompting and all the candidate had to do was ask where the form should go, this would not demonstrate much in the way of capability. Just sitting and listening isn't enough.

This highlights one important difference between the CSA and RCA. As the cases are created for the CSA what the candidate elicits in data gathering and plans in management can demonstrate a capability. In the RCA examiners need to specifically look for that capability as not all consultations will show this.

Marking low challenge cases

The psychometric analysis of the marking of cases flagged as low challenge in the July diet showed a difference of just over one mark in the mean overall case mark compared with other cases (5.15 compared with 6.19).

Candidates begin a consultation with no marks and need to display appropriate professional behaviours and capabilities in order to earn marks. If there is very limited opportunity to display capabilities, then it is to be expected that the candidate will earn very few marks.

Key messages

• The difficulty of cases is influenced both by the level of clinical challenge and by the presence and severity of complicating factors.
• Although certain diagnoses occur frequently in low challenge cases, candidates and examiners should beware of equating these diagnoses with low challenge.
• Examiners need to see evidence of a competence to give appropriate credit for it when marking. Low challenge cases offer very limited opportunities to display relevant capabilities and marking will reflect that. This will inevitably penalise candidates submitting large numbers of low challenge cases.

Find out more

• MRCGP overview
• MRCGP: Recorded Consultation Assessment (RCA)

About the writer

Peter Cheung is a MRCGP Lay Adviser.

Acknowledgements

Thanks to 

• Richard Wakeford for the psychometric data on low challenge cases and to Gordon McLeay for his analysis of these cases.
• Mel Whitehorn for clarifying the role played by complicating factors in determining the overall challenge level.
• Nitin Gambhir and Gail Cobb for drawing my attention to Jonathan Cobb’s article.