The CSA

1. The CSA guidance from trainees who’ve done it.

2. What the RCGP has to say… ‘An assessment of a doctor’s ability to integrate and apply appropriate clinical, professional, communication and practical skills in general practice’ The aim of the CSA is to test a doctor’s ability to gather information and apply learned understanding of disease processes and person-centred care appropriately in a standardised context, make evidence-based decisions, and communicate effectively with patients and colleagues. Being able to integrate these skills effectively is a key element of this assessment.

3. A Few Key Points • Only ST3 registrars can apply • The CSA may be attempted a maximum of four times • It costs £1445 to sit and if you fail you have to pay again!

4. The Cases • Each case is linked to learning outcomes from the MRCGP curriculum • Cases are meant to be representative of consultations seen in General Practice • There are 13 cases. ALL cases are counted towards final mark • There will be a mix of cases; some focusing on the clinical/medical aspects, others on ethics and communication skills e.g. difficult patients or negotiation • There may be a telephone consultation or a home visit

5. Marking • Each case will be marked in 3 domains: • Data Gathering, Technical and Clinical Assessment skills • Clinical Management skills • Interpersonal skills • Each domain carries equal marks • There are positive and negative descriptors for each domain specific to each case which the examiners will refer to when marking

6. The 3 Domains Data Gathering, Technical and Assessment Skills: Gathering and using data for clinical judgement, choice of examination, investigations and their interpretation. Demonstrating proficiency in performing physical examinations and using diagnostic and therapeutic instruments. Clinical and Management Skills: Recognition and management of common medical conditions in primary care. Demonstrating a structures and flexible approach to decision making. Demonstrating the ability to deal with multiple complaints and co-morbidity. Demonstrating the ability to promote a positive approach to health. Interpersonal Skills: Demonstrating the use of recognised communication techniques to understand the patient’s illness experience and develop a shared approach to managing problems. Practicing ethically with respect for equality and diversity, in line with the accepted codes of professional conduct.

7. Generic descriptors – Data Gathering Positive Indicators • Clarifies the problem & nature of decision required • Uses an incremental approach, using time and accepting uncertainty • Gathers information from history taking, examination and investigation in a systematic and efficient manner. • Is appropriately selective in the choice of enquiries, examinations & investigations • Identifies abnormal findings or results & makes appropriate interpretations • Uses instruments appropriately & fluently • When using instruments or conducting physical examinations, performs actions in a rational sequence Negative Indicators • Makes immediate assumptions about the problem • Intervenes rather than using appropriate expectant management • Is disorganised/unsystematic in gathering information • Data gathering does not appear to be guided by the probabilities of disease. • Fails to identify abnormal data or correctly interpret them • Appears unsure of how to operate/use instruments • Appears disorganised/unsystematic in the application of the instruments or the conduct of physical examinations

8. Descriptors • The full list of generic descriptors for each domain can be found at: http://www.rcgp.org.uk/docs Exams_CSA_Generic_domain_indicators_v9.doc

9. Marks • Four grades for each domain: • Clear Pass (3) • Pass (2) • Fail (1) • Clear Fail (0) • Grades are converted to numerical scale to give an overall mark • Each domain is marked out of 3 giving an overall mark out of 9 for each case. • All 13 cases are marked and counted giving an overall maximum mark of 117

10. Grades • Clear Pass: The candidate demonstrates an above-average level of competence, with a justifiable clinical approach that is fluent, appropriately focussed and technically proficient. The candidate shows sensitivity, actively shares ideas and may empower the patient • Pass: The candidate demonstrates an adequate level of competence, displaying a clinical approach that may not be fluent but is justifiable and technically proficient. The candidate shows sensitivity and tries to involve the patient. • Fail: The candidate fails to demonstrate adequate competence, with a clinical approach that is at times unsystematic or inconsistent with accepted practice. Technical proficiency may be of concern. The patient is treated with sensitivity and respect but the doctor does not sufficiently facilitate or respond to the patient’s contribution. • Clear Fail:The candidate clearly fails to demonstrate competence, with clinical management that is incompatible with accepted practice or a problem-solving approach that is arbitrary or technically incompetent. The patient is not treated with adequate attention, sensitivity or respect for their contribution

11. More on the Marking • Cases change each day • Pass mark for each case created using the Borderline Group method. This is used to calculate the overall pass mark for each day – more details on RCGP website • Daily pass mark established to allow for differing case mix on different days

12. Results • Results and feedback via ePortfolio • Candidates given their overall score, and passing score for that day • Areas of improvement as identified by 2 or more examiners flagged (picking from 16 feedback statements) • Feb/March 2011: 75.2% pass rate (79.8% for first time candidates), scores ranged from 41-114

13. Feedback Statements Global • 1. Disorganised / unstructured consultation • 2. Does not recognise the issues or priorities in the consultation (for example, the patient’s problem, ethical dilemma etc). • 3. Shows poor time management. Data Gathering • 4. Does not identify abnormal findings or results or fails to recognise their implications • 5. Does not undertake physical examination competently, or use instruments proficiently

14. Feedback Statements Clinical management • 6. Does not make the correct working diagnosis or identify an appropriate range of differential possibilities. • 7. Does not develop a management plan (including prescribing and referral)reflecting knowledge of current best practice. • 8. Does not make adequate arrangements for follow-up and safety netting. • 9. Does not demonstrate an awareness of management of risk or make the patient aware of relative risks of different options. • 10. Does not attempt to promote good health at opportune times in the consultation.

15. Feedback Statements Interpersonal skills • 11. Does not appear to develop rapport or show sensitivity for the patient’s feelings. • 12. Does not identify or explore information about patient’s agenda, health beliefs & preferences. • 13. Does not make adequate use of verbal & non-verbal cues. Poor active listening skills. • 14. Does not identify or use appropriate psychological or social information to place the problem in context • 15. Does not develop a shared management plan, demonstrating an ability to work in partnership with the patient. • 16. Does not use language and/or explanations that are relevant and understandable to the patient

16. CSA in 10min • 5 MIN • Open Questions • Rapport building, Active listening, Summarising etc • ICE • Psychosocial context • (a little further Hx taking) • Red Flags • Examination • 5 MIN • Explanation (eg diagnosis) • Management Options discussion • Check understanding & agreed plan • Safety Netting/ F/U

17. Nub of the Case • Cues • Flexibility

18. Nubs of Cases TATT: a) explanation of low T4 (ref to info sheet) b) depression/ psychosocial element HRT a) explanation & sharing options b) negotiation (eg herbal, HRT given hi risk factors) c) psychosocial First Fit a) clinical Mx b) psychosocial- HGV driver + negotiation/ breaking bad news Headache/ Palpitations a) explanation/ reassurance/ exploring ICE b) Clin Mx & explain re fastrack (or 24 ECG) c) depression/ psychosocial

19. IMGs • the ‘under performance’ of minority ethnic candidates • UK graduates 91.6% • Non-European 56.9% • Communication • Patient-centred • Clear Management Plans • Shared • Managing Medical Complexity • Fish out of Water • Linguistic Capital

20. IMGs cont • Communication • Eye contact vs sensitivity/ cues • Formulaic • Interrogation • Eliciting not exploring • Picking up Pt language • Over-categorical • No sunny pairing • Unclear Explanations • Interactional smoothness

21. IMGs cont • Communication • Informal speech patterns • Avoid Medical Jargon • Idioms/ Colloquialisms • Jokes • Dr-Pt partnership • Topics • Palliative Care • Death and Bereavement • Sex and Sexuality • Mental Health

22. IMGs- moving forward • Start Early • Resources • Website • Books • TV • Trainer • GPSTs • Video Consultations • Joint Surgeries • CSA practice with range of GPSTs

23. Summary • Integrated assessment of Clinical Skills • Safe to Practise Independently • Mark-schemes • Expect to examine • Structured approach • Don’t forget the Management Plan! • It is acheiveable!

24. CSA - PREPARATION

25. When to Start? • After all tomorrow is another day.............. • Generally 2 - 3m

26. Where to Start?!! • Overwhelming - need to know ‘everything’ • Consultations to identify learning needs • Group practice - good impetus to getting started • provides the proverbial.... • ???Use curriculum

27. Some Suggestions • Case practice - probably most useful • lots of books with scenarios • ?write own cases • Study group • Identify consultations felt uncertain about

28. Start identify what exam is testing • Often talk about the ‘nub’ of the case • Common problems/scenarios • About communication BUT need reasonable knowledge base - confidence • Need to show what you’re thinking - - verbalise!!

29. Dealing with Monotony....... • Practice small sections eg. explanation, management - common reasons for failure • Quick fire questions • Look at some PILS - patient.co.uk

30. Which Books?

31. Other Resources • NICE, patient.co.uk, CKS, GPnotebook • InnoVait, BMJ • GP Handbook

32. Courses • Loads available, BOOK EARLY • Yorks & Humber Deanery courses available in: • Harrogate • Pennine • Hull • RCGP - Croydon • Bradford VTS website is fab

33. Deanery Courses • 1 day, BOOK IMMEDIATELY!! • Presentations - exam structure, what examiners looking for etc, marking scheme • 4 cases, observed get feedback • Group observed cases - difficult scenarios

34. RCGP • 2 days • Opportunity see centre • Run by senior examiners • Also talk by role-playing lead • Presentation based

35. In group total 12 cases, though may only get to role play once yourself • However do give good idea of what the exam is about • Lots of tips and tricks

36. VTS Session • Mock CSA • ~6 -8 cases • Observed, then get feed-back • Well worth going

37. Booking Exam • If you’ve got a preference book early - that morning • But don’t delay, have run out of places at busy times of year

38. The “What To Do On The Day” Bit

39. Where It Is… • The RCGP Assessment Centre 12 – 16 Addiscombe Road East Croydon CR0 0XT 18th, 19th & 20th floors

40. Where To Stay • Croydon Park Hotel • Jury’s Inn • Travelodge • Victoria London

41. What To Take • Photo ID! • BNF • Stethoscope • Ophthalmoscope • Auroscope • Thermometer • Tendon hammer • Tape Measure • Peak Flow Meter

42. On The Day… • Arrive on time! • Briefing

43. Cases • Acute and chronic • Ethics • Health Promotion • Negotiation • Telephone • Home Visit

44. Good luck!