WPBA: Consultation Observation Tool (COT)

PC1: The doctor encourages the patient’s contribution at appropriate points in the consultation

Encourages the patient's contribution

• Clearly states their name, role and then initiates the consultation, with an open question. 
• Uses active listening skills, including verbal and non-verbal communication techniques and showing empathy to encourage the patient’s contribution.
• Chooses appropriate questioning techniques to elicit sufficient information about symptoms and details of history (part of defining the clinical problem). Asks open questions to explore the patient’s symptoms and clarify the agenda. 
• Avoids making unnecessary interruptions but, if does so, demonstrates clear advantages to this approach. Mirrors the wording the patient uses, to aid understanding, avoiding patronisation. Signposts and uses closed questions to steer the consultation, for example to rule out a red flag condition. Summarisation here can be a useful tool.
• In many consultations there is little need to encourage if the patient usually states their problem thoroughly. However, to demonstrate this criterion there should be evidence that the doctor encourages contributions when needed and not just providing the opportunity in their opening phrase. 
• There is evidence of compassion and kindness observed in the interactions between the patient and/or carer and doctor and that the patient and/or carer is treated fairly and with respect, acting without discrimination or prejudice. The interactions are professional throughout and the doctor acts with integrity. 

PC2: The doctor responds to signals (cues) that lead to a deeper understanding of the problem

Responds to cues

• Responds appropriately to important, significant (in terms of what emerges afterwards) cues that lead to, or could have led to, a deeper understanding of the problem. Both verbal and non-verbal cues are acknowledged as appropriate. Response to a cue may either be verbal (commenting that a patient seems upset, worried etc), non-verbal (use of silence) or active (a change in body posture, a touch, offering the patient a tissue). 
• An empathic response may be shown in a response to a cue. The “cue” may be explicit, but the emotional significance that is being responded to may be quite subtle. Not all cues need to be fully dealt with within the consultation but should be acknowledge and a plan made to address.
• Rapport-building is an integral part of the communication process; good rapport is needed to encourage the patient’s contribution. 

PC3: The doctor uses appropriate psychological and social information to place the complaint(s) in context

Places complaint in appropriate psychosocial contexts

• Relevant psychological, social (including occupational) aspects of the problem are considered. These may be known previously, offered spontaneously, or elicited. Demonstration of this criterion is through using the information available, and acquired through history taking, in exploring the context and impact of the problem e.g. “how does your backache affect your work  as a builder”? as well as consideration of how the patient’s lifestyle impacts on the problem e.g “does your work make your symptoms worse?”
• The psycho-social information gathered should enable the doctor to adjust their information sharing, risk assessments and decisions and actions including the management and follow-up plan.

PC4: The doctor explores the patient’s health understanding

Explores patient's health understanding/beliefs including identifying and addressing patient's ideas and concerns and expectations. 

• This criterion is about what the patient comes to the consultation thinking and knowing.
• The patient’s perspective of the problem (including health beliefs and ‘ideas, concerns and expectations’) is explored e.g. has the patient read something on the internet, consulted generative AI, or been told something by a friend, family member or colleague? 
• An effective exploration of the patient’s health understanding is observed, in the context of the problem discussed within the consultation with further questions asked in response to what the patient stated. 
• What the patient thinks or is concerned about is explored using a range and series of probing questions where appropriate.  Evidence of reflection in the consultation may be evident, which may enable the patient to talk more easily about their concerns, or repeating a patient's phrase and then leaving silence, to explore their thoughts more.

PC5: The doctor obtains sufficient information to include or exclude likely relevant significant conditions

Takes an appropriately thorough and focused history to allow a safe assessment (includes/excludes likely relevant significant conditions)

• Makes use of and integrates any pre-existing medical notes (past medical history, previous investigations and drug history). Takes focussed history of presenting problem and symptoms to make a safe an accurate assessment, and subsequent plan.
• Questions are asked to confirm or refute hypotheses (of both the doctor and patient). The history taking has an appropriate degree of detail to make a safe and accurate assessment of the patient’s problem in the context of general practice. Obtains sufficient information to understand the problem, as well as include or exclude likely relevant significant conditions. Closed questions may be the most efficient method of obtaining certain information, e.g. ‘red flag’ questions. ‘Red flags’ are asked to ensure more serious causes of the presenting symptom(s) have been considered.
• The history taking takes account of the prevalence and likelihood of conditions within local communities, remembering the context of GP and that common things occur commonly and rare things rarely.
• In cases where there is a lack of pre-existing notes for example in the OOH setting or a temporary patient where information about the patient may be sparse, the history is more thorough in certain areas to compensate for this e.g. clarifying past medical and drug history.
• A robust, organised and effective structure can be helpful to assess the clinical presentation.

PC6: The physical/mental examination chosen is likely to confirm or disprove hypotheses that could reasonably have been formed OR is designed to address a patient’s concern.

Performs appropriate physical or mental state examination

• The patient is put at ease with clear communication on what to expect for the examination. Consent is sought and a chaperone offered if appropriate. Consideration of cultural and ethical factors which may affect examination is given.
• The examination undertaken is appropriately detailed for the context of the consultation and structured in an organised manner. The findings are interpreted accurately.
• A recorded consultation may not be the best place for examination and/or procedural skills to be assessed. However, it may generate discussion. It should be possible to hear what examination is being undertaken and what explanations are being given.
• An assessment of mental state examination would be appropriate e.g. is the tone of voice and flow of conversation congruent to the history provided. Some examination may be undertaken ahead of the formal physical examination e.g. a patient becoming short of breath on walking to the consulting room.
• Where an examination is fully observed during a COT, consideration could be given to assessing the examination as a CEPS, in addition to the COT. It is important to remember that intimate examinations should not be recorded.

PC7: The doctor appears to make a clinically appropriate working diagnosis

Makes an appropriate working diagnosis

• Takes an organised approach to data gathering (pre-existing information, history and examination) and any investigation findings. Interprets these accurately and appropriately to provide a differential diagnosis or explains any furthers steps planned to reach one. On occasions, it may not be possible to make a diagnosis, but discussion with the patient/carer of what has been ruled out will be important.
• The best available, current, valid and relevant evidence is used to help make the working diagnosis.

PC8: The doctor explains the problem or diagnosis in appropriate language

Explains the problem in appropriate language

• There must be evidence of an adequate explanation of the patient’s problem or diagnosis, appropriate to the clinical context. A working diagnosis is shared with the patient and/or carer, based on the findings from the history and examination. A short explanation may be enough, but it must be relevant and understandable, using language appropriate to the patient (e.g. educational background or profession), being mindful to adjust the explanation for some patients, for example children, those with a learning disability or where there is a language barrier. Using diagrams or language aids may be appropriate. Explanations of risk should incorporate the patient’s perceptions of priorities and not be simply repetitions of statistics. The use of inappropriate abbreviations or medical jargon should be avoided.
• Some or all the patient’s health beliefs should be incorporated with reference to them during the explanation of the problem/diagnosis.
• Techniques such as summarising to clarify the problems can be used.

PC9: The management plan (including any prescription) is appropriate for the working diagnosis, reflecting a good understanding of current accepted medical practice.

The management plan (including any prescription) is appropriate for the working diagnosis

• The management plan should relate directly, and be appropriate to, the working diagnosis and must represent safe and current medical practice. Consideration should be given to managing acute and chronic conditions concurrently if appropriate.
• Investigations should be chosen bearing in mind how they will confirm or exclude a diagnosis and their impact on management. Supported self- care should be encouraged.
• Any prescribed medication should be safe, follow local/national guidelines, be cost effective and consider sustainable/environmental factors e.g. dry powder inhaler rather than CFC.  Patient requests are managed appropriately e.g. prescribing appropriate amounts of medication, for example tramadol. Reviewing medication and stopping medications which may be contributing to the presenting symptoms should be overtly considered.
• Any referral (within primary care teams, secondary care, voluntary, social prescribing etc.) should be appropriate and reflect the services locally. Where appropriate, there should be coordination to oversee the patient care across healthcare systems, recognising the benefits of a team-based approach.
• There is evidence of the doctor being able to accept and use strategies for managing uncertainty which ensure that patients’ worries are addressed.
• Prioritisation within the management plan is observed, attending to more urgent needs. The need for any follow up is conveyed and encourages continuity of care where appropriate.

PC10: The patient is given the opportunity to be involved in significant management decisions

The patient is given the opportunity to be involved in significant management decisions

• Shared decision making is evident between the patient/carer and doctor.
• There is evidence of the doctor consulting with the patient and/or carer, giving them the opportunity to be involved in and understand the management decisions, therefore creating a mutually acceptable treatment plan.  There is recognition that some patients do not wish to be involved, and others are not able to take decisions, and this should be respected. However, there should always be evidence that the patient has been enabled to define the extent to which they are involved in their treatment.
• There is evidence of the doctor’s ability to negotiate, if appropriate, with the patient and/or carer, if they have initially been opposed to the management decisions but then agree with the outcome. 
• Risk is communicated effectively to the patient, so they can be involved in the management decisions in an informed manner to an appropriate degree.

PC11: The doctor checks that there is a shared understanding of the diagnosis, management plan, treatment, safety-netting or follow-up arrangements.   

The doctor checks that there is shared understanding of the diagnosis, management plan, treatment, safety netting or follow up arrangements:

• This criterion is about what the patient leaves the consultation thinking and knowing.
• The patient’s understanding of the diagnosis and management plan, as appropriate to the individual patient, should be checked given that a surprisingly high proportion of patients do not understand or remember what their doctors tell them about diagnosis or treatment. It may be necessary to overtly check the patient’s understanding of red flags and safety-netting, or of the follow-up arrangements and attention to medication concordance. A cursory “Is that OK?” or the patient simply nodding is not enough. There must be an active seeking out of the patient’s understanding, agreement and an encouragement to accept appropriate responsibility. Rigid formulaic phrases should be avoided. Phrases used should be tailored and appropriate to the patient and consultation.

PC12: Makes effective use of resources

Makes effective use of available resources

• There is evidence of good time management, with the consultation an appropriate length for  the degree of complexity. The doctor uses different approaches depending on the patient and carer in front of them. They use resources to help patients who have specific communication needs including different languages, cultures, beliefs or educational backgrounds, to the doctor. Consideration is given to continuity of care and the benefits this can provide, especially for review of chronic conditions. There is evidence of being an effective member of a multi-professional and diverse team, working to reduce any health inequalities.
• The doctor takes into consideration local guidelines and resources available including near patient testing. Patients and/or carers are referred/signposted to appropriate resources/services including patient information leaflets, online resources, community nurse referral, routine GP review at a timely interval or voluntary care sector resources, e.g. the Samaritans.
• Referrals, investigations and follow-up appointments should be appropriate, being mindful of limited resources. The doctor ensures follow up is with the right health care professional at the right time interval enabling safe and effective patient care.
• Safeguarding policies are followed locally as needed to safeguard individuals, families and local populations.
• The cost of any medications prescribed should be considered both financially and in terms of sustainability, normally with the patient and recommendation of over-the-counter medication, rather than issuing a prescription, discussed when appropriate.

PC13: The doctor specifies the conditions and interval for follow-up or review.   

The doctor specifies the conditions and interval for follow-up

• Clear and precise safety-netting and follow-up instructions (including time frames for the level of care agreed) appropriate to the working diagnosis and outcome of the consultation are provided. The patient leaves with clear instruction on contacting the GP practice/OOH service again or other organisations if symptoms worsen, if the condition changes or the patient requires further information.
• The safety-net instructions given should include a full description of relevant symptoms which indicate a significant worsening of the patient’s condition that may require earlier intervention, tailored to the needs of the patient/carer and safety/risk of the consultation (e.g. the need to seek medical review if an unwell child has not had a wet nappy within a certain timescale). For some consultations, the follow-up could be broader (e.g. see the nurse or use home monitoring for a blood pressure review).
• Consideration is given when consulting with a patient with a long term (chronic or acute on chronic) condition to the continuity of care and there is discussion of how the team can most effectively balance this with the patient's accessibility or other needs. This may include proactively booking follow-up (if needed), avoiding inappropriate or unrealistic follow up, recognising the benefits continuity of care can provide, whilst balancing the demands of the busy system within general practice setting.