MRCGP

2. The Clinical Skills Assessment MRCGP

3. ‘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. Purpose of the CSA

4. Each case has marking schedule consisting of 3 domains Data Gathering, Technical and Clinical Assessment skills Clinical Management skills Interpersonal skills Each domain carries equal marks CSA: Marking Cases

5. CSA: The three domains

6. Four grades for each domain: Clear pass  Pass  Fail× Clear fail × Each domain carries equal marks Grade descriptorson RCGP website under ‘CSA cases’ Grades are converted to numerical scale to give an overall mark Examiners can flag up serious concerns which may be followed up by the RCGP CSA: Marking Cases

7. 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 Daily pass mark established to allow for differing case mix on different days Details on CSA webpage CSA: Standard setting

8. Borderline Group Method • The overall numerical case marks of the candidates in the borderline group are averaged. • These averaged scores are then aggregated across all the 13 cases to create the “cut score”, i.e. the approximation between a passing and a failing score. • The final, actual pass mark has an adjustment to the cut score to take account of the SEM (standard error of measurement).

9. A candidate who has failed will find the feedback helpful in preparing again for the CSA The CSA may be attempted a maximum of four times CSA: Failing Candidates

10. RCGP website CSA webpage ‘Information for Candidates’ Directions to the centre Timekeeping and conduct Format, timing, marking of the assessment Equipment to bring ‘Introduction to the cases’ document Feedback How to use the suggestions for improvement Preparation Courses at CSA Assessment Centre CSA: Further Resources

11. AB notes • 13 x 10minute cases, same room • 10 mins to settle in – look at the notes of first 7 patients on iPAD • 2 min reading time between cases • Can call role player back in within 10 min time slot • No penalty for “thinking time” if needed • 15 minute break after 7th case

12. AB notes • Increasing prescribing content – may need to write a prescription (pad provided) • Timer on wall – counts up to 10 mins • No marks awarded after buzzer • iPAD used by examiners and candidates (no internet though!) • Confidentiality agreement on iPAD • Patient records/letters/clinical findings on iPAD

13. AB notes • Examiners must have recent hands on experience training registrars • Same case all day – role players and examiners rehearse case • Mostly in hours surgery consultations but also tel triage, home visits, OOH • Casebank >700 cases • Re-sitting candidates should not get same case

14. AB notes • Emergency, acute or chronic conditions • Preventative medicine • Physical, psychological or social problems • Common conditions or serious • Consultations with health professionals • Ethical dilemmas • Complexity and co-morbidity • Most have paeds case (>8y or proxy) & elderly

15. AB notes • Different ethnicities • Different social classes • 4 nation compliant • Disabled – deaf, blind • Cases reflect real-life GP • Standard is of GPR towards end training • 4-5 cases will require clinical examination

16. AB notes - pitfalls • Jumping to Dx – think differential • Mechanistic consulting • Inadequate clinical examination skills • Looking for non-existent hidden agendas • Rigid Dr centred consulting • Time management • No QOF here – no irrelevant health promotion

17. AB notes • Monthly sittings Nov to May • Limited numbers for each session • Results published following week directly into ePortfolio • Feedback statements ticked but no free text feedback – not formative • 4 attempts – exceptional 5th sitting

18. AB notes – how trainers help • Exposure wide variety cases • Observed surgeries best prep – not selected • Move towards 10 mins as soon as possible but develop consultation skills first • Joint consultations – different styles • Role-plays for scenarios that trainee is not likely to see • Real training not courses

19. AB notes • Mainly single issue • If 2-3 problems the issue will be agenda setting and prioritising not full clinical Mx • Immediate emerg treatment eg ectopic preg or PE or MI • Emotionally challenging – breaking bad news or complaints • Can be review of patient seen by partner

20. AB notes • Proxy paeds case eg enuresis or stammer • Can teach role player to have tennis elbow or frozen shoulder but not AF! • May be given a model eg breast lump, pelvic model • May be given card with examination findings • At least 2 cases will have major prescribing safety elements eg calculate paeds dose

21. AB notes • If blind pt – ask them if can take their arm before you grab them! • If deaf patient may need to write everything down • In these cases the medical aspects will be straightforward as emphasis on inter-personal • Engage with patient and carer • No longer any interpreter cases

22. AB notes • Telephone cases – issue often confidentiality eg daughter phoning about elderly parent • Avoid unnecessary or unexplained touch

23. AB notes • Told to bring BNF/paeds BNF • Would be expected to look up dose methotrexate but know dose amoxicillin • No electronic BNF • Generic marking scheme but Intended Learning Outcomes for station

24. AB notes – at risk groups • IMG pass rate 31 – 53% • Males pass rate 63% (Females 87%) • Those who take it too early • The highly anxious • Those with lower exam/selection scores • The inappropriately confident

25. AB notes • Commonest reason to fail is not developing an adequate clinical management plan in line with current best practice or not making adequate arrangements for follow up and safety netting • True for both IMGs and UK graduates • Don’t recognise the challenge eg ethical • Don’t make appropriate diagnosis • Doesn’t develop shared management plan

26. AB notes • Understand impact – show interest in pt • Approx 5 mins data gathering and 5 mins management • Look for non verbal cues • Non genuine empathy is very clear • Candidates need to listen and react • Still need explanation even if give leaflets!

27. AB notes • Welcome important – stand up, make eye contact, introduce themselves • Positive body language • “Tell me more” will get the response “what do you want to know” • Target questions – “Tell me more about how this has changed over the last 2 months since it started”

28. AB notes • Open questions – psychosocial and ICE (sensible and sensitive and in context) • Closed Q – symptoms, red flags, excluding serious illness • Rarely hidden agenda • Listen properly, don’t interrupt • Share ideas and decisions • Examine unless told not to

29. AB notes • Why have they come today? • Are there other issues? • Do I need to examine physically or mentally? • What is my diagnosis and does pt agree? • What is Mx plan including follow up • Have I explained Mx plan and does patient agree?

30. AB notes – cultural issues • Dr/patient relationship different • Difficulties with empathy or admit uncertainty • Heirarchy of team relationships • Dr knows best – like clear solutions & rules • Hear feedback defensively • Used to being rewarded for spouting theory

31. AB notes – supporting IMGs • Early needs assessment • Use consultation models in teaching • Discuss pt and Dr expectations • Address managing uncertainty • Handling emotion and confrontation • Ethical issues and team heirarchy • Joint surgeries ++++++ • Allow them to flourish

32. AB notes • Start work at ST1 • Allow enough time to take more than once in ST3 – but not too early…. • Encourage them not to work only with others who are struggling • Don’t need to be perfect – not a checklist • Don’t have to pass every station

33. AB notes • Always 3 points for each of the 3 domains in every station • Can still get 3 points for a clear pass in a domain without doing everything calibrated by the examiners for that case • Not about gold standard – what is expected as a newly qualified independent GP

34. CSA 2015/16 all attempts • All HENE candidates: 69.8% pass rate (National 2014/15 75.8%) • UK Graduate HENE: 87.2% • Non UK Graduate HENE: 52.3% • 2014/15 nationally 76.2% candidates were UK graduates but 62.3% in our region

35. CSA 2015/16 first attempt • HENE all graduates: 71% pass rate • HENE UK graduates: 89.5% pass rate • HENE Non UK grads: 41.7% pass rate • 2014/15 national all: 83.4% • 2014/15 national UK: 90.9% • 2014/15 national non UK: 47.4%

36. Cumulative pass rate Nationally after 3 attempts UK grad pass rate 98% IMG pass rate 68% 1-5 trainees/yr will not complete training in our area at least partly due to exam failure so the vast majority pass even though we have a relatively high number in high risk groups