• Write entries having decided which competence(s) you are intending to cover and looked at the relevant word pictures so that you can enable your ES or CS to validate the entries easily and provide evidence for you.
• Need to review in detail consultations, on your own, and / or with a peer to identify missed cues, (and what to do about these) missed opportunities to explore background and context (and suggest ways / words to discuss these) and episodes when consultation is circling, and ways to address / prevent this practice common disease explanations to non-medical friends primed to challenge the wording/ tone etc. These can be written up as professional conversations or clinical encounters depending whether you do these with others or alone.
• You need to demonstrate you are consistently able to communicate verbally and in writing in patient computer records and your e-portfolio so that other people are very clear what you are thinking and planning. Take two patient records that you have made and reflect on how you have kept these useable for others and how they reflect your verbal communication skills.
• Develop skills to really determine the impact of illness on the patient and their carers and finding out about the patient’s health beliefs. You need to consider how you can do all this in ten minutes. Strive to achieve excellent in this competence. Reflect on achievement of this against the excellent word picture on two occasions.
• Consider how you have adjusted your communication skills to make patients, especially teenagers, feel more at ease when you are taking a sexual history and consider steps you could take to improve this further  (on at least 1 LLE).
• Before the next ES meeting there should be three examples of learning log entries where communication with the patient of carers and 1-2 LLE with the team or other professionals) was highlighted. (Think  how you did this and what worked well as well as what you might change to improve this further)
• You need to consider trying to speak more slowly. This will be important for the CSA exam. When you are practising for CSA ask the group members/facilitators specifically about the rate of your speech. Collect their feedback and include it as a LLE with your reflection on it. You are likely to benefit from doing this several times.
• You need to ensure you are talking in English as much as possible throughout the day. Try to speak English at home, watch English television programmes, and speak to your children in English. Consider writing things in Word so that you can spell check and correct grammatical errors. The evidence for this will be in the quality of your written English on all your entries.
• You need to look at time management within the consultation and aim to complete consultations in ten minutes. Look at video consultations with your trainer and on your own reflect on the learning from these (as well as the times it took for you to do the consultations. Identify what parts of the consultation you especially need to work on.
• Join a CSA preparation group to help with communication and consultation skills.  You will then be able to write 2-3 LLE relating to the learning from these sessions in relation to consultation skills.
• Consider role play during tutorials, joint surgeries, de-briefs to gain and own phrases you can use with patients to ensure you are understood. Reflect on this process in LLEs.
• If you do not already have then get the RCGP Case Cards and practice explaining common diseases, conditions, investigations and procedures. You could try this with your CSA preparation group and in tutorials and with your Clinical Supervisor. Or with non-medical friends. Write some LLEs on their feedback about this.
• Repeat PSQ in ST3 – 2 review period. Repeat MSF in ST2 – 3 review period.
• You will be able to put consultations skills into practice with GP consultations again soon so you need to continue to reflect on this and the process of establishing concerns as part of helping people to clarify their needs. Will need further work on GP consultation timescales (though working on 15 at this stage is good)
• Consider how to develop this skill in hospital posts and apply them to the particular patient populations in each post. Even though not part of the hospital routine it will help your patients if you understand their ICE ( and help you if you reflect on this in you LLEs)
• Develop GP relevant consultation skills including exploration of ICE. Shared decision making and. Providing structure will be important. You will be able to demonstrate this through COT, but also in LLEs
• Paediatrics next and you need to develop a strategy for communicating effectively with children. Please use the learning log to document how this goes initially and your plans to develop your skills.
• You need to get Mini CEX done spaced over the post but otherwise continue this good progress. Don’t forget to keep your GP hat on whilst you are in hospital posts and keep thinking and documenting in your log how you will apply your skills in GP in the future.

• You need to remember to use joint surgeries for CSA practice as well as COTs as COTS are quite proscriptive in their scoring and you need to develop ‘soft’ skills. You should document at least 3 joint surgeries through COT or as LLEs
• Need to develop skills in identifying cues and sharing information and management plans, these are vital to develop into a rounded GP. You can reflect on this in  your clinical encounters as well as having this demonstrated in COTs
• As in your PDP, you now need to focus on explanations, don’t spend too long on the patients agenda as though this is important, it is important to get to the end of the case and be able to show of the explanation and negotiation skills! Practice your explanations in front of a mirror or with non-medical friends. Document your learning from this as a LLE.
• Be inquisitive, imagine a friend is telling you something – ask spontaneous questions to find out more, don’t just move on to the next question on your “medical” list – asking questions shows empathy and builds rapport especially if you use information you have heard earlier on.
• Move things forward towards 10 minute consultations and their limitations and with a view to CSA – learn to mix ICE with more Doctor centred approach in this area for CSA;  a difficult balance.
• Move to now look at more advanced techniques such as dealing with different sorts of patients and changing consultation  styles as appropriate, reflect on this at  least once in your e-P. We can discuss different ones and sources at your review
• PSQ needs to be done in the next post please and reflect on patients’ feedback.
• Need to further develop skills to be able to clearly explain to the patient the diagnosis/ likely nature of the problem and be clear when explaining the management (evidence this with LLE or COT or professional conversations.
• Last review we looked at shared decision making and different forms of communication in GP e.g. triage – as moving to paediatrics think about how you communicate with children – body language as well as phrases- do an entry around this and think about 3 way conversations plan to the patient. Reflect ion these in your e-P
• Add log entries that describe and discuss specific consultation skills used in real life consultations (as well as practice CSA cases).

• Use experience of the elderly and terminal care to detail in log entries the significant interaction between patient’s context and their experience of health.
• Video work as for consultation consider writing down on a card after each consultation whether you know the occupation , (interests,) effect on life of the problem of each patient, or their family ask your trainer to debrief on this each surgery for all patients as well as the ones you medically need to discuss
• The challenge is going to be – How do you gather a detailed psycho-social history and practice holistically and keep to time? I suggest trying to have a focused and structured consultation should allow you to do this in the constraints of a ten minute consultation. Choose 3 occasions when you significantly over ran and reflect on what happened in your e-P
• Continue being curious and understanding the different impact similar illnesses can have on different people. Remember, you need to be able to get a psychosocial history within the time constraints of a 10 minute consultation. Use your e-p to demonstrate times this has worked or you have struggled… think what was the difference.
• Be curious. British patients expect their doctor to ask them questions and appreciate it when the doctor really understands how their problem is impacting on their and their family and carer’s lives. They would not consider this rude or nosey. Consider how you might become more familiar with British culture – trainees in the past have found listening to the radio – Radio Sheffield for instance, watching the soap operas – Eastenders, Coronation Street, Emmerdale and watching British films can help them to understand British humour and family and community norms and culture. It is great if you reflect on learning from outside medicine in your e-P; please do this!
• Continue to be curious and inquisitive in order to ensure you offer the most appropriate management plan for each patient. Get feedback from those who observe you on this, and/ or reflect on this in e-P.
• Continue to provide evidence from COTs, CbDs and learning log entries to demonstrate this competence. Learning log entries should demonstrate you are able to manage patients with complex psychosocial problems and adjust your management plans accordingly.
• Consider how to develop these skills in the context of your next posts specifically in Paediatrics and A&E. Consider impact of problems and interaction with other services, e.g. social care/safeguarding and document this learning in your e-P.
• Read the word pictures and develop understanding of this competence and demonstrate this more fully in GP. Some trainees find it helpful to start their e-P entries with the competencies they think they are reflecting on. Try this!
• Paediatrics will give you a great opportunity to document how disease and medicine impacts on families and children. Reflect on this in you LLEs.
• As you move into GP this domain becomes easier to look at. Please collect evidence of your progression not just in COT and CbD but also by writing LLEs which you have planned to allow demonstration of this competence.
• Think about psychosocial impact of disease as you start GP next month.

• You need to continue to reflect on holism in GP context. It will be important to think more possibly about the socio-economic context of patients and how this affects their ability to cope with GP care. And share this learning on e-P.

• You are planning to start in a permanent GP position soon. I would encourage you to look at actively following up some patients, building enduring relationships with them and their families/carers. This can be one of the most rewarding aspects of being a GP.

• Look for difficult consultations or histories which may hide something at home, work or background that are causing problems – this may also be helpful later in the consultation in the shared planning stage.
• You need to choose cases to show this in CBDs as not enough so far. COTs can be joint surgeries but also videos which if appropriate can be discussed to show this.
• Use your natural empathy to gain this information but be aware of not acting as a sponge – more reflection to the patient leads to shared understanding.
• This is a critical part of understanding the patient’s agenda and understanding so keep making sure you explore this and demonstrate how you are doing this on e-P.
• You should consider doing three log entries where circumstance/social/work etc impacts on patients presentations.
• Going into Paediatrics you need to take a child with a long term condition and have a go at the narrative approach to the family and impact on them of sibling’s illness. Discuss as a CBD as well.
• Document cases with strong holistic care issues, and when an understanding of socio-economic background or culture has helped.

• When providing evidence for competences link this to entries in the learning log or other WPBA rather than writing descriptions of other cases in your evidence. It is better to provide the evidence in the log.
• Return to identifying which competencies you are reflecting on before writing the log entries so that you provide good and clear evidence for competencies in your logs ensure you choose CbD cases which allow assessment of your competence in working with colleagues.

• There has been a lot of evidence here which is good, and the feedback is positive, though the reminder to talk to all team members before making some decisions was good advice. It will be important to put this into action and the MSF will give you more feedback. It is important to look at how you manage the very different power and hierarchy issues in most GP practices. Please share your understanding on this as a LLE.
• Write an entry which looks at about what qualities you can bring to a team and what kind of team you want to be part of, and how will you achieve that. If you move to an unfamiliar locality to work, what resources and information will you need to be an effective part of the team?

• As per MSFs consider when your generally “chatty” approach might be misinterpreted or when it might be less appropriate… share thoughts on this on e-P as well as your plans.
• To consider when and how to appropriately delegate However, well intentioned you may be doing things yourself that should be appropriately delegated will not be in the longer term interests of you or the teams you work in! choose examples of when you have done things yourself or delegated and include in e-P to demonstrate your learning here.

• MSF next post please as you do your first GP job.
• Continue to work effectively, you have always had generally positive feedback, do an MSF in the next post and reflect on what you learn from this as a Professional conversation entry.

• I have given you feedback when I released your MSF scores so you are aware of some recommendations for action. Consider on your e-P how to utilise the skills of the practice team in order to delegate effectively, safely and efficiently. Consider how you might appear more approachable to reception staff.
• Complete an MSF. Add learning log entries demonstrating that you are now able to take on a leadership role with the MDT and act as co-ordinator of all the teams or people involved in the management of complex patients.
• Try and reflect on cases where others have used you as part of a team and how that worked/felt (do two cases).
• Make sure you are able to balance delegation with not dumping on people a fine balance as you noticed in the entry I have tagged ( do 2 entries relating to this).
• Remember the broader ‘team’ not just nurses and reception staff but the whole gamut of support colleagues we have access to and remember it works both ways – how do you respond to requests form others and how do we make ourselves available? Reflect on this in e-P.
• Different teams will require different approaches. Reflect on what happens when you pay the wages of most of the team members- log entry on this please.
• Get to know the community long term condition nurses – valuable source of information and expertise – see if you can have a day with some of them and reflect on this in your e-P.
• Continue to gain experience in working with the primary care team and look into practice management issues, leadership, integrated working, etc.
• You are moving to GP next. Make sure that you use your induction period effectively. This is a great opportunity to reflect on how you work with several different types of colleague I’m expecting several separate entries looking at this competency from your induction time.

• Choosing examination and investigation appropriately is a key descriptor for this competence. (DG)  Write 2-3 entries reflecting on the ways in which you did this when providing acute management of a patient
• Work on the cues and on widening differentials if not shared in the consultation write down possible differentials for all new diagnosis consultations and share in debrief; reflecting on e-p on the discussions. You  could also look in particular at tests you order … or review your work on management of results and again reflect on this in e-P
• You need to demonstrate with COTs and learning log entries that you can take a focused history and perform a focused examination.
• The challenge now is to ensure that the history and examination are focused and succinct to ensure you allow enough time for sharing the diagnosis and management of patients within the constraints of a GP consultation. Record the time you spend on this part of the consultation on 10 successive new diagnosis consultations and reflect on these in e-P.
• Continue to provide evidence in your learning log and WPBA that you have a structured and focused approach to gathering information and interpreting clinical signs and investigations appropriately. Think about the word pictures to help you cover this aspect on several e-P entries.
• Continue to demonstrate evidence. Look at interpretation to enable your differentials, etc. Choosing not to do things will become more part of GP work as you push yourself to do shorter consultations; doing good enough, not everything but the things that are needed thinking all time about what to do and why? Cover each of these areas in a separate LLE that comes from a real consultation.
• Use skills developed to consider appropriate level of investigation in GP.  Develop GP specific skills in your next post and get evidence of these on your e-p (CbD, COT, CSR, etc.).
• To develop clinical knowledge in weaker areas Consider how to apply this learning to guide data gathering in the consultation and in interpretation of investigations.
• Paediatrics often involves data gathering from a third party. Reflect on how these skills differ and the challenges this brings on at least 2 consultations.
• Don’t lose sight of the GP orientated focus with data gathering. Some of the log entries are around weird and wonderful things. You need to look at how you use prevalence as well as risk in judging what you do. It will help to reflect specifically on this in your e-P.

• Continue to integrate data gathering with a fluid patient centered consultation style.

• Need to be able to know when to take short cuts and when not to, be aware of subtle cues and red flags. Don’t ask routine questions on each topic or you will run out of time Reflect on when this went well – or badly!
• Always ask yourself what benefit is a test and what are the risks? (Radiation, etc.) Perhaps have a look at this and discuss CBD. Also consider sensitivity and specificity of at least 3 common tests (e.g. Haematinics) as a log entry).
• Write up cases that show your skills in data collection, such as dealing with abnormal results or in deciding which investigations to use for a specific problem.

• You should consider a retrospective review of a series of clinical encounters to look at whether your initial diagnosis was correct (based on any subsequent contact regarding the same problem) and to reflect on the outcome/value of any investigations undertaken. This can be a useful activity and would be an example of ‘quality improvement activity’ for revalidation.

• Reflect in 1-2 log entries on the prevalence and incidence of conditions and how this helped you to recognise their pattern.
• You need to demonstrate this (making diagnosis) effectively through your choice of CbD cases and you need to choose better log entries for this area to provide clear evidence.
• Differential diagnosis is important so practice after each new presentation both medical school style and thinking about likelihood for this patient. You can do this with friends. A patient comes to you with xx, yy, and z what are your differentials. They are now 80 not 30 how does the differential change  does the differential change if their sex is different – or class?
• You need to provide evidence of you coping with undifferentiated conditions and how you cope with uncertainty. (think CbD choices , choice of LLE and how you write these up).
• It would be really helpful to see clinical encounter entries where you have seen a patient presenting early in an illness/disease process and how over time you made decisions and come to a diagnosis.
• Continue to provide evidence from COTs and CbDs and learning log entries that you can consider appropriate differential diagnoses in the wide range of patients you will see as a GP. Separately you may also want to consider when you used time to make the diagnosis.
• You should be demonstrating that you can make decisions that are appropriate for the individual patient. Evidence needs to demonstrate you can think laterally and broadly and appropriately (in relation to risk, etc.) when considering differential diagnoses and making decisions.
• Need to concentrate on reflecting on this competency when doing log diary entries consultants seem happy with your competence on this  but it is easier to demonstrate in GP – Looking at the word statements helps clarity. Integration of previous info… how did you use this…. then choose  examples of  when you used time, etc.
• At the moment it is unclear to me whether your  difficulties in this area are primarily due to your knowledge base or whether you have specific additional development needs related to decision making per se. As a priority you needs to develop your knowledge base particularly in General Medicine, and demonstrate this on e-P and thorough CbD and mini CEX.
• Ask yourself what is most likely, but also  what is the one not to miss? Reflect on using these questions in your e-P.
• More of the CBDs you choose from now on should try and include positive proof of this as what you are doing when observed in joint surgeries and videos is clearly fine.
• Try to gain confidence in diagnosing and managing conditions you have explored, but as you say, coping with uncertainty and making appropriate decisions are the mainstay of good independent practice, so reflect on when you do this well in entries (as well as when it has been difficult!).
• Need to try and link some log entries and not just rely on WPBA, look at the word pictures for competent and excellent and reflect on some patient encounters using these.
• When reflecting, try and show you’re ‘working’ how and why did you make decisions the way you did and reflect on how you could have done it better.
• Pick a patient who comes in acutely and you  have seen over time as their diagnosis becomes apparent- write up showing how your differentials changed.
• Document cases that have been a challenge to diagnose, ideally also covering curriculum statements that need more evidence.

• Choose some (2-3) logs in which you focus especially on competences like providing continuity of care for the patient rather than the problem (should be possible in Pall Care) and review of drug interactions and side effects.
• You need to look at the word statements here ( Clinical management) and demonstrate them on routine cases to demonstrate the subsets of this competency.

• Improve your knowledge of the management of minor illnesses in GP. demonstrate this in entries looking at natural history and how you used this too.

• Consider how you can demonstrate using time as a diagnostic tool. Write up some cases when you have done this.

• On e-P write about how you might demonstrate being competent in dealing with the uncertainty you can have in General Practice and the challenges this can bring with sharing management options with the patient.

• As stated in your CSR – attend more out-patient clinics to give you exposure to the type of patient you are likely to see in the community and demonstrate you have developed skills to make decisions independently.

• You need to demonstrate you can independently manage all types of patients and conditions you are able to see in GP though a good choice of Clinical Encounters and through your choice of CbD and COTS.

• Continue to expand your knowledge as this will help with management decisions. Use NICE pathways as quick reference. Provide learning log entries (Clinical encounters and SEAs) that demonstrate logical thought processes when determining appropriate management plans for patients. Learning Log entries need to demonstrate you can manage patients independently without seeking senior advice (but of course still ask if patient safety needs this).

• When you ask for advice always make sure that you have written down your thoughts and plans before you get advice. Write LLE comparing the plan you had and that the senior person had.

• More log diary linkable entries which will be easier to do where the simple expectant approach is easier in the GP setting, as will be variation of options when slightly less constrained by hospital protocols. So time to rehearse options and possibilities and being appropriately flexible within the bounds of good care.
• Take up learning opportunities in your next post to learn GP relevant management Document the learning of this in your log.
• Consider in your e-P the difference in management in the GP setting. More use of time and clinical management of chronic conditions over multiple consultations.
• Lots of Paediatrics management is slightly different to adult medicine. Reflect on how this happens and how this might impact upon your career in GP.
• You will need to consider how GP management differs from the hospital posts that you have been used to.

• It would be good to see more evidence of follow up and provision of continuity of care when in a more permanent GP role. You should prepare evidence of your follow up for your first GP principal appraisal.

• get some different conditions that you feel are important to know about in Paediatrics e.g. asthma, DKA etc. and write up some management plans describing also how you would adjust these to changing circumstances.
• Document cases where continuity of care and follow up has been needed. Aim to reflect not only on your own clinical management decisions but on implications for the services offered by the practice and on future resource development for example.

Need some action points on Promoting Health

• Write a log entry ideally on the simultaneous management of chronic and acute issues.
• Write a log entry ideally on discussing risk with a patient or family and the challenge of managing uncertainty either for you or the patient / family.
• You need to plan for how to achieve evidence on this competency (medical complexity), choosing appropriate CbD cases will help, and ensuring that there are appropriately chosen log entries or SEA easily linkable to this competence.
• Remember to take every opportunity to promote health and prevent disease. This is not always evident from learning log entries, so write two specifically looking at how you did this.
• It would be great to see a learning log entry on your management of a patient with, for instance, chronic pain and how you manage with promoting a return to normal function. There are other situations where management can be very complex and involve strategies and the use of members of the extended team to help support the patient. End-of-Life care is often a good case to use to demonstrate this competence.
• When you see a complex patient it often takes several consultations before you can really address all the issues you find. Add a clinical encounter once you have seen the patient several times to give a picture of how you addressed all the issues and how you prioritised what you did initially and in what order things are addressed. These types of patients are also great for CbDs.
• Provide more evidence in the form of learning log entries of your ability to treat multiple conditions in a patient. CbDs are good for this as are end-of-life care patients, or complex arteriopaths.
• You need to ensure you provide more evidence for this domain by selecting clinical encounters and SEAs that demonstrate you are able to deal with multiple chronic and acute problems at the same time. Choose CbDs carefully so you will cover this competence, but remember that you’ll need several log entries too to demonstrate practice well.
• It is common to have difficulty demonstrating this competence in hospital practice, as hospitals do not consistently look at the complexity angle but itemise problems. You will need to look at this, and how to manage in GP many more log diary entries, etc. It will be important to concentrate on these word pictures when writing entries.
• Consider the relationship between acute and chronic problems in children presenting to A&E as well as issues of uncertainty and risk.

• I think it would be helpful to reflect on the wording in the ‘excellent’ section of the word picture below, particularly: ‘Accepts responsibility for coordinating the management of the patient’s acute and chronic problems over time’ – how will you put this into practice in the future?

• As this area is hard to score in CSR or COTs without specific comments you can’t rely on CBDs here – more log entries mentioning the complexity to alert the CS to this competence will be essential before the next panel.
• You need cases to discuss at CBD which also overlap as log entries as well as cover your lack of many curriculum statement areas.
• Coping with complexity and hence uncertainty is the bedrock of a good GP. You must look out for more cases to demonstrate this in CBD in the next 6m as well as making sure to discuss at debriefs and record these as an example of learning on e-P.
• Home visits are often a source of complexity so try and write these up whenever possible reflecting thinking about the competent and excellent word pictures of medical complexity.
• Use a narrative approach to family and describe the complexity of their condition and why you feel they are complex and how their condition affects them.
• Continue to reflect on managing uncertainty. Gain experience in managing multiple problems simultaneously and reflect on this on e-P and in your choice of CbDs.

More action points needed here for Leadership 

• Use the last two months in practice to consider how you will go about familiarising yourself with admin and IT systems in your next practice. Where are the risks? What can you do to minimise them? Thinking about clinical governance and data handling. You’ll be able to discuss this at your first GP appraisal but will need to write down some learning points as evidence.

• Please try to collect some evidence of competence you can do this in hospital practice. Examples might include discharge letters, referral letters, audit, etc.
• Please think about how GP notes differ and how experienced GPs manage to make notes and sort things out in 10 minute blocks reflect on your current practice and how to change this on e-P.

• You must focus on some entries whilst in hospital jobs as well which focus on the effect of quality of your note keeping and use of IT on the care of patients.
• You need a variety of log entries demonstrating effective use of data, or the practice IT system, or issues about data entry and its effect on the consultation.

• You must ensure your patient records are clear, concise and comprehensible. You need to demonstrate great attention to detail when undertaking prescribing. Look at the level of detail in your note, where could you be briefer, what bits need more details.

• Consider how you might demonstrate this competence as learning log entries. An Audit is one way; adapting or adding new templates specific for the practice can be another way. Do you know how to make patient information on the computer only accessible to clinicians? Maybe something to learn and then add an entry in your e-portfolio about.

• Consider how else you can demonstrate the use of IMT whilst doing hospital posts. (Hint – look at the third paragraph on the competent word pictures!).

• You really need to concentrate on improving your written communication so that colleagues can understand what you think the problem is, what your management is and what you plan to do for follow-up to ensure patient safety. You have had advice about how to improve learning log entries – write up as word document, spell check and then copy and paste into your learning log. However, this is harder to do for patient records and you must continue to practise writing clinical records that are concise, accurate and understandable.

• Learn how to use the GP clinical computer system (do an entry about this at the end of induction and again later) and undertake an audit or “QoF reflection” during ST1 GP post. This will give you several different log entries.
• Mostly these are examples of good practice it is a positive achievement to have written so many linkable IMT entries in hospital but it will be important to plan the GP audit- early, KISSing it (Keep It short and Simple!).
• Making good entries is only part of this skill – using them proactively in consultations and outside is another important area to demonstrate perhaps in CBDs or learning log entries.
• You need more log entries not just to show quality but also to link and to show understanding of how to use IT for more than recording information.
• Look to writing several entries showing other areas of IMT, QOF, Audit and perhaps use of past notes in current management.
• Look at using online resources and PILs in consultations as well as for learning, diagrams as well as reflecting on innovative ways of communicating, phones, email, webcams, and the uses of computers in the surgery, text reminders recalls and scanning are but some ideas for you to demonstrate in COT or reflect on as log entries.
• Not just keeping good records but using them proactively and trying to keep notes succinct but safe and useable to speed up consultations. When to abbreviate and cut corners in note keeping is another skill to learn, and demonstrate on e-P.
• Look at the systems within GP for consultations, messaging and scanning of correspondence onto the record. Then reflect on these in log entries and discuss at C.B.D.
• Would be good to look at some of the expanding areas, i.e. commissioning/risk tools/DES, etc. Perhaps see what’s going on and get involved.

• Look at the ‘excellent’ word pictures for this competency. Looking forwards, there will inevitably be an increasing need for GPs to engage in health and social care planning, service design and resource management. How will you engage in this? What are your interests? Where can you be most effective? What are the leadership skills you will need?

• You need to reflect and record specialist clinics which are available in the community as well as charity or other organisations relevant to your next two jobs in log entries your final post reflection is a good place to do this – especially as this is now expected of all trainees.
• You need to look at the impact of rationing (which in effect is part of CO) on the work of the units you are part of and reflect on this in e-P.
• You need to think about CO in relation to time in consultations. Use of GP resources, and awareness of what resources there are available, and the most cost effective use of resources all of these are aspects of CO. Thinking more widely will enable you to choose appropriate Log entries, and choose or suggest appropriate aspects of CbD discussions on cases.
• Continue to widen your knowledge of local resources available to the patient.
• Continue to develop knowledge of resources available in the community. Don’t forget there are voluntary and private sector resources for patients as well as in the public sector.
• You need to consider how you are going to provide learning log entries that will demonstrate competence in this area. Don’t forget local initiatives and the voluntary sector and the different availability to different groups in our society.
• Remember to balance the CO about knowing what is out there / resources you can use / teams that work in particular situations etc and the CO which is about controlling cost and getting best value for money.
• Learn more about the population aspects of this competence by involving yourself in these issues when in GP. Learn more about appropriate referrals and pathways in GP post.
• Take opportunities to extend learning in this area in secondary care posts – should be possible in psychiatric post. There are a lot of MH resources you should come across in the community. How do these work, and which ones have your patients used?
• Make sure you cover the other areas such as referrals, audit, and social, ethnic and disease demographics as well as prescribing in your log entries for the rest of the post.
• Rationing and CCG rules are also relevant here such as traffic light prescribing systems
• Find out about stronger families in Barnsley!
• Document evidence of cost effective practice. Reflect on issues regarding local service provision, resource allocation

• Think about how to maintain this approach when you are no longer in a training environment. What learning activities work best for you? What kind of working week do you aim for and where will you fit in time for CPD? Familiarise yourself early on with the requirements for Appraisal and revalidation.

• Continue to use the ES workbook as this provides you with awareness of where you need most evidence, as well as detailing your attendance at day release course, etc. Linked to this is ensuring you have reflected on your own teaching role, and reflected on your posts in relation to the relevant competencies and evidence.

• You need more entries, (especially clinical exposure derived ones) and need to complete the audit having worked on the criteria and results presentation.

• It is essential you maintain life-long learning and regularly review guidelines, attend up-dates such as PLIs, courses, etc. You may find it useful to continue in a study group. Write up how you have done this for your first GP appraisal.

• Consider now you have passed CSA giving tutorials to the ST1 and F2 trainees and de-briefing the F2 trainee. Don’t forget to ask them for feedback and include this on your e-P. This would demonstrate your skills as a teacher.

• There is a very positive comment in your MSF about your teaching skills and they would like you to do more teaching. Perhaps, now you have gained confidence you could take on more of a leadership role for the junior members of the team, and write some entries on how this goes for you, and them!

• Continue this momentum for learning and ensure you regularly review your curriculum coverage and competence coverage to ensure you cover all areas of both.

• You need to ensure you maintain a steady momentum for learning to ensure your knowledge base increases and you succeed at AKT. Consider reading NICE Guidelines but also looking at the NICE pathways as these can be easier to follow and remember. You should always be thinking when writing up learning log entries – how did this affect me, how did it effect the patient and their carers, how did I feel, how did the patient feel, what would I do differently, what do I need to learn? I think you would benefit from joining an AKT and CSA preparation group. Don’t forget to review your PDP, ensure completed learning objectives are signed off. You complete all boxes for each learning objective especially how you will know you have achieved your learning objective.

• Audit (or other quality improvement activities) will be an important as a source of evidence in GP. We will also have evidence from the MSF here; it  would be appropriate to have some entries looking at critical evaluation of evidence… to help you make decisions continue to do GP SEAs to learn from key experiences.

• Become more consistent in demonstrating learning in the log and as per CSR consider how to improve strategic learning to cover the curriculum and pass AKT.

• Keep up to date with learning log, develop effective habits to ensure you do not fall behind again. Undertake an audit or QoF reflection in GP ST1 post

• To continue to use the learning log effectively To identify clearly focussed learning needs for the next post and for other topics where you need to increase knowledge

• PLEASE put 2-3 entries on a week. Don’t leave things till the last minute.

•  Do more than the minimum number of WPBA. Please keep up with the EP as a live tool. Do 2-3 entries a week and share them!

• Use the feedback you get on your e-P entries and either do a new entry or respond with more information on the original entry.

• Space your WBPA out to show progression. Don’t be afraid to ask seniors to do them!

• You need more numbers and more focused log entries and improved PDP and timely entries on e-P. I do not doubt your intentions or goodwill here but you need to be more organised for lifelong learning!

• Proactive linking of entries to PDP and then further learning bodes well for appraisal and revalidation.

• Decide on just one periodical to follow in the next 6 months and see if you can keep up with it – If not come up with a plan for your learning.

• Continue to gain experience in teaching juniors. Get some formal feedback on your teaching / presentations. Document use of literature searches or evidence reviews and application of findings to individual patient management.

• From the ‘excellent’ word pictures: ‘Actively promotes equality of opportunity for patients to access health care and for individuals to achieve their potential’. Consider – how do we achieve this in relation to 2 different patients?

• Think of clear ethical frameworks (doing more harm than good ; or greatest good to the largest number of people ) etc. when discussing your involvement in some complex cases to ensure you have discussed this fully
• You need to demonstrate ethical reflection by choosing suitable cases for CbD … and reflecting on several cases in log entries. Remember there is an ethical dimension to prescription of pen V ( amount of information you give about side effects… amount of alternatives you discuss etc!.)

• Continue to be aware of the ethical conflicts you come across and reflect on these. Always consider the ethical framework when deciding the best management for a patient.

• Consider which ethical dilemmas cause you the most problems in making decisions – how might you gain confidence in this area?

• When writing up learning log entries involving ethical issues consider the ethical frameworks and demonstrate you are aware of what ethical issues are involved.

• You need to ensure learning log entries demonstrate you are aware of ethical frameworks. When discussing clinical encounters and SEAs consider what ethical framework you are working with – beneficence, justice, autonomy, etc. I still have not seen an entry regarding you reading and reflecting on Ran Gillon’s ethical principles which you said you’d do.

• Identify ethical issues as they arise Particularly in you next post consider issues of age and capacity and consent and ethical issues in relation to safeguarding.
• It will be important to look a bit more at the ethics of your actions and focus your discussions in log entries more on addressing this competency. You have demonstrated you can do this in the excellent entry here… and 1 2 1 in the CbDs but some more written log entry reflection would be helpful to demonstrate continuing understanding and engagement with this .

• Rather than just look for ethical cases in surgery or HDRC it sometimes can be good to do tutorial on them with the trainer presenting differing sorts to discuss – very similar to the old MRCGP viva, ask for this!
• Immunisation- how do you feel about parents who don’t immunise their kids? What are the pros and cons – what can you do as a doc ………is this a safe guarding issue, what are the ethical questions here?
• Routinely identify and address ethical conflicts in clinical practice. Use ethical models to work through these.

• It will be important to identify sources of support in your GP career. Consider engaging with the RCGP First 5 programme, or other peer support groups locally. You can provide evidence of involvement as part of your first GP appraisal.

• Please complete the advised reflection on post as a way to look back at how you have balanced work and the rest of life as this would be a good way to provide further evidence of this competence – as well as 9 and 10).
• You need to ensure that there are suitable entries, and CbD discussions, look at health , your own stress and your own feelings on cases in particular

• You need to ensure you address with the attention to detail expected of a professional especially when prescribing and completing tasks in a timely fashion. Reflect on how you do with this – in relation to three situations.

• Add more learning log entries to demonstrate this competence. Consider possibly a problem with a staff member, or when you might have to breach confidentiality.

• Now you have completed the hard work of preparing for CSA, try and ensure you become an integral part of the GP team, taking on the same responsibilities as a salaried GP. This will ensure you are fully aware of the work-load to expect post-CCT and allow you to consider how many sessions a week you wish to do once you become an independent GP to ensure you have a healthy work-life balance.

• It can be hard to balance work, family life and preparing for high stake exams. Ensure you maintain a healthy work-life balance to ensure success. But also write an entry reflecting on how you achieve this.

• Continue to maintain your positive attitude, commitment to learning and development. Consider how you might demonstrate your support for a colleague who is experiencing difficulties – this might be in relation to personal problems, a complaint, an error, etc.

• Consider, after CSA, taking on a leadership role in a specific clinical area.
• Consider how you might spend some informal time with the receptionists, nurses and other doctors in your busy day. Try not to isolate yourself in your room. Reflect on this as it is a balance between professional obligations and preserving your health.
• There is a slight contrast between your self-proclaimed concern about your confidence and the positive feedback here. From our meeting I am aware that you are looking after yourself but also that doing this is hard in hospital posts with changing rotas. The summary comments on the Paediatrics CSR about presenting the world with yourself as a confident and competent Dr are important to work on. This links I think strongly to achieving a balance which preserves health etc. I look forward to seeing some entries reflecting on this.
• Confidence is important without becoming arrogant. Try and find some log entries that show this in a non-clinical situation as well as clinical ones: leadership with humility is a rewarding style.
• Remember that this competence isn’t just about professionalism it also covers work life balance and coping with stress and supporting colleagues as well as patients; write entries using the full meaning of the competence area.
• Document any cases where Good Medical Practice guidance has helped. Continue to write up SEAs and reflect on outcome. Reflect on MSF comments re stress management.

• Concentrate on demonstrating you can competently and efficiently perform musculoskeletal examinations in your next A and E post.

• Gain more experience and ensure you are observed competently performing the GMC required PR, prostate, male genital examination, female genital examination and breast . Don’t forget other CEPS especially those involving the musculoskeletal and neurological systems.

• You must ensure you gain the skills and techniques to perform focused, GP appropriate examinations. Use every opportunity to ensure you get CEPs completed.

• Remember that CEPS is like any other competency and is linked to your log diary , COTS, Mini CEX , CSR and the specific CEPS evidence Make sure that you produce evidence when writing your reflective log diary entries.

• Continue to regularly perform intimate examinations to maintain skills. Consider completing CEPs that demonstrate competence in MSK and Neuro examinations.

• Ensure you complete at least 2 CEPs highlighting competence in examining babies, toddlers and children over the next 6 months.

• When you refer a patient based on your clinical examination ( e.g. abnormal PR or PV exam) and then get a letter back confirming the findings include this as part of your evidence for competence in this competency. Include at least one of these in the next 6 months.

• Look at the full word descriptors for CEPS, and include at least one reflection in the next 6 months on e.g. how you have adapted your examination to fit the circumstances and / or the preferences of the patient.

• Include at least one reflection looking at your adaptation of process to fit with the capacity of the patient relating to your examination.