The CSA Exam ebook

Table of Contents

Cover

Title Page

Copyright

About the companion website

About the authors

Rachel Roberts

David Russell

Simon Ormerod

Anjum Iqbal

Acknowledgements

Foreword

Part One

Introduction

How to use this book to maximize success in your CSA exam

Chapter 1: Maximizing your potential in the CSA

Knowledge

Consultation skills

Exam-performance management

Conclusion

References

Chapter 2: What you can learn from the ‘patients’

Who are these simulated ‘patients’?

Calibration

What do the role-players think about the CSA exam?

So, what makes a good consulter – according to the actors?

Asking the right questions

Time management

‘Patient’ diversity

And, finally, remember …

References

Chapter 3: What to expect in the CSA

‘Being a general practitioner’

Preparing for the exam

A definition of the CSA

How the exam is structured

Timing

Setting the scene

Who are the examiners?

So how does it all run on the day?

Read the notes!

So now what happens?

Ignore the examiners

What kind of cases will I see?

So what is expected of me now?

Create a global Impression

Data-gathering (DG)

Clinical management (CM)

Interpersonal skills (IPS)

Ending the consultation

Marking

Feedback

If at first you don't succeed … You can!

Chapter 4: Dealing with challenging situations

General principles

Areas of application

Practical systematic approach to ethical dilemmas (PSA 2 EDs)

Case scenarios which you could face in general practice

Abbreviations

Appendix 1

Appendix 2

References

Chapter 5: Creating and role-playing your own CSA-type case

Choose a scenario

Notes for the candidate

Briefing the role-player

Marking schedule

The role-play

Conclusion

Chapter 6: Maximizing your potential with feedback from examiners

(Not) The CSA candidate feedback statements

Chapter 7: Strategies for candidate concerns with the CSA

Anticipating difficulty

Developing effective self-reflection to utilise learning plans

What kind of issues may I have if I have not passed the CSA?

Learning needs

More complex issues

Conclusion

References

Chapter 8: Learning points

Part Two: A ‘palette’ of 16 CSA-type cases and 6 ethical cases

Introduction to the sample cases

Case 1

Background

Opening statement

Information to give if specifically asked

Past medical history

Expect the candidate to ask to examine you

Questions for the role-player to ask the doctor, if appropriate

Behaviour/demeanour/body language

Issues for preparation of the case

Materials for the doctor [displayed on the iPad in the CSA]

Learning resources

Case 2

Background

Opening statement

Information to give

Questions to ask the doctor, if appropriate

Behaviour/demeanour/body language

Materials for the doctor [displayed on the iPad in the CSA]

Learning resources

Case 3

Background

Opening statement

Information to give

Information to give, if asked specifically by the doctor

Questions to ask the doctor, if appropriate

Behaviour/demeanour/body language

Physical examination

Issues for preparation of the case

Materials for the doctor [displayed on the iPad in the CSA]

Learning resources

Case 4

Background

Opening statement

Information to give

If specifically asked what you do/or about work/how it has been affecting you

Past medical history

Questions to ask the doctor, if appropriate

Behaviour/demeanour/body language

Issues for preparation of the case

Materials for the doctor [displayed on the iPad in the CSA]

Learning resources

Case 5

Background

Opening statement

Information to give, if asked specifically by the doctor

Questions to ask the doctor, if appropriate

Behaviour/demeanour/body language

Issues for Preparation of the case

Materials for the doctor [displayed on the iPad in the CSA]

Learning resources

Case 6

Background

Opening statement

Information to give

Information to give, if asked specifically by the doctor

Past medical history

Medication

Family history

Expect the doctor to ask to examine you

Questions to ask the doctor, if appropriate

Behaviour/demeanour/body language

Issues for Preparation of the case

Materials for the doctor [displayed on the iPad in the CSA]

Learning resources

Case 7

Background

Opening statement

Information to give

Information to give, if asked specifically by the doctor

Questions to ask the doctor, if appropriate

Behaviour/demeanour/body language

Issues for preparation of the case

Materials for the doctor [displayed on the iPad in the CSA]

Learning resources

Case 8

Background

Opening statement

Information to give

Questions to ask the doctor, if appropriate

Behaviour/demeanour/body language

Expect the doctor to ask to examine you

Materials for the doctor [displayed on the iPad in the CSA]

Learning resources

Case 9

Background

Opening statement

Information to give

Information to give, if asked specifically by the candidate

Questions for the role-player to ask the doctor, if appropriate

Behaviour/demeanour/body language

Instructions to examiner

Materials for the doctor [displayed on the iPad in the CSA]

Learning resources

Case 10

Background

Opening statement

Information to give

Information to give, if asked specifically by the doctor

Questions to ask the doctor, if appropriate

Behaviour/demeanour/body language

Issues for preparation of the case

Photos to show the doctor

Materials for the doctor [displayed on the iPad in the CSA]

Learning resources

Case 11

Background

Opening statement

Information to give

Information to give, if asked specifically by the candidate

Past medical history

Expect the candidate to ask to examine you

Questions for the role-player to ask the doctor, if appropriate

Behaviour/demeanour/body language

Issues for preparation of the case

Materials for the doctor [displayed on the iPad in the CSA]

Learning resources

Case 12

Background

Opening statement

Information to give

Information to give, if asked specifically by the doctor

Past medical history

Medication

Questions to ask the doctor, if appropriate

Behaviour/demeanour/body language

Materials for the doctor [displayed on the iPad in the CSA]

Learning resources

Case 13

Background

Opening statement

Information to give

Information to give, if asked specifically by the doctor

Questions to ask the doctor, if appropriate

Past medical history

Ashia's medication

Family history

Behaviour/demeanour/body language

Materials for the doctor [displayed on the iPad in the CSA]

Learning resources

Case 14

Background

Opening statement (given by mother)

Past medical history

Information to give freely if asked

His medication for asthma

If specifically asked

Expect the candidate to ask to examine Olu

Questions for the role-player to ask the doctor if appropriate

Behaviour/demeanour/body language

Issues for preparation of the case

Materials for the doctor [displayed on the iPad in the CSA]

Learning resources

Case 15

Background

Opening statement

Information to give

Information to give, if asked specifically by the candidate

Examination

Questions for the role-players to ask the doctor, if appropriate

Behaviour/demeanour/body language

Issues for preparation of the case

Materials for the doctor [displayed on the iPad in the CSA]

Learning needs/resources

Case 16

Background

Opening statement

Information to give

Information to give if asked about accompanying symptoms or things which affect the headaches

Information to give, if asked specifically by the doctor

Questions to ask the doctor, if appropriate

Behaviour/demeanour/body language

Issues for preparation of the case

Materials for the doctor [displayed on the iPad in the CSA]

Learning resources

Index

End User License Agreement

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Guide

Cover

Table of Contents

Foreword

Begin Reading

The CSA Exam

Maximizing your success

This edition first published 2016 © by Wiley-Blackwell

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Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by health science practitioners for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.

Library of Congress Cataloging-in-Publication Data applied for.

ISBN: 9781119079194

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Cover image: © KrulUA/Gettyimages

About the companion website

The companion website contains a number of resources, including 18 clips – 12 cases + 6 ethical dilemmas, general suggestions on making the best use of the clips and the video- and case-specific educational support material.

www.wiley.com\go\Roberts\CSAExam

About the authors

Rachel Roberts

Rachel is a GP, trainer, CSA examiner, and is a Patch Associate Director for General Practice, London. She is also the Associate Director for trainees in difficulty for North East and Central London. Her main interests are in helping learners to achieve their full potential and to enjoy working in a typical, busy general practice.

David Russell

As a retired teacher, David has a strong educational and examining background. Appointed Lay Adviser to the RCGP, he worked on the Simulated Surgery Exams and, subsequently, on the development of the CSA exam. He has been the CSA Role-Player Lead, responsible for the training and quality assurance of the simulated patients, and has published several papers about his work with the simulated ‘patients’ in the CSA.

Simon Ormerod

Simon is a GP with a special interest in General Practice. He has been a trainer since 1996, and a member of the MRCGP examiners panel since 2010. He is currently Honorary Secretary of the North East London Faculty RCGP.

Anjum Iqbal

Anjum qualified from the Royal Free Hospital and worked as a GP for 5 years in Stepney, East London. In 1996, he moved GP practice to Enfield, North London. He remains committed to Education and Training as a Trainer and Programme Director in Enfield. He has also been a CSA examiner since 2008. It remains a privilege for him to serve patients and enjoy consulting.

Acknowledgements

The authors would like to acknowledge the North East London faculty of the RCGP, and Anwar Khan, who brought the team together in organizing the RCGP course. Working together on this course, being GP educators and being examiners for the RCGP were the breeding ground for the ideas in this book.

We would also like to thank those who contributed to early versions of course material from all London faculties and the RCGP. They are Anwar Khan, Mei-Ling Denney and Marilyn Graham. We would like to thank Dr Anwar Khan for the ideas that developed into the six ethical case clips.

Foreword

The Clinical Skills Assessment (CSA) is less than a decade old. But during that time, it has continued to evolve to keep abreast of the latest in best practice in assessment. It has also been at the centre of a storm of controversy relating to differential pass rates for those who trained abroad and UK graduates from BME backgrounds. While the recent judicial review found no evidence of discrimination, it remains the case that the CSA is a challenge for many aspiring to be General Practitioners in the United Kingdom.

For those looking for a magic formula through the CSA, take note, you will be disappointed. Equally, this book does not offer a recipe for passing the examination. However, if you want to understand the essence of being a sophisticated consulter in a modern-day general practice, this book opens a world of opportunities. This book offers you three opportunities – the first is for you to learn about yourselves (what are your needs, how might you learn, where can you look to learn about the CSA and who can support you in your learning journey); the second is to make the most of the learning opportunities that general practice training has to offer; and the final is to demystify the CSA itself.

The chapters are written in an easy-to-read manner with a strong emphasis on simplifying the language around the CSA, a focus on bringing out the practical tips to maximize your learning and opportunities for improving your consulting. It reconnects the CSA with the best in educational practice, and in doing so, re-frames the CSA – not as an examination to be feared but to be seen as the culmination of a year-long (and career-long) expression of mingling the science of modern medical practice with compassionate consulting.

Three of the authors of this book are practising GPs – they apply the art of compassionate consulting and modern medicine in their day-to-day practice. They are all educators – they understand the challenges of preparing doctors for a life of general practice (not just preparing for the examination but for a career of consulting). The doctors are all CSA examiners – they know how examiners think and what they expect. In addition, Dave Russell has been the role-player lead for the CSA, who has a wealth of understanding around the simulated patient.

This book is the accumulation of their collective experience, their desire to show you that there is an alternative to learning focused on ‘getting through the exam’, and by doing so they are trying to achieve something greater – make effective consulting part of your daily practice and, by doing so, reduce the tension and anxiety associated with the CSA.

But don't just believe what I say! Dip into the book, read a couple of chapters and even try out some of the suggestions the authors make. It has the potential to transform how you do things in the consulting room!

Dr Sanjiv Ahluwalia MBBS FRCGP MSc Head of Primary Care Education and Development Health Education North Central and East London

Part One

Introduction

How to use this book to maximize success in your CSA exam

In planning this book, we aim to help you understand more about the three main components of the CSA exam, and to give insights into how you can maximize your potential for success.

Firstly, we will consider your own personal needs, as the Candidate, in order to pass the exam. Secondly, we will discuss getting the most from your Simulated patients (the role-players). Then we will give you an overview of the Assessment itself – what to expect and what is expected of you.

Each of these first three chapters contains boxes of essential ‘Learning Points’, and after each one we have listed as bullet points relevant ‘Tips and Hints’ under the headings of ‘Getting Started’, ‘The Consultation’ and ‘On the Day’. We hope you will find all these useful in your studies as a guide and aide-memoire.

Example:

We go on to give advice about dealing with dilemmas and applying an ethical approach in your consultations. We suggest an exercise to put all this into practice, and then go on to supplement this with a focus on CSA examiner feedback. Chapter 7 reviews possible areas of concern and how to avoid and/or deal with them. Part 1 concludes with a collation of the essential Learning Points from the earlier chapters.

In Part 2, we have collaborated to produce 16 cases to help you practise your exam technique, and perhaps to use as a template to apply to the exercise suggested in Chapter 5 creating your own cases, focusing on identified hot topics. In addition we have 6 ethical cases with supporting material in chapter 4.

Finally, in addition to the written materials in this book, we have filmed 18 clips – 12 cases + 6 ethical dilemmas to offer an additional learning resource. This gives a different perspective on the six cases illustrating ethical dilemmas in Chapter 4 of Part 1 and on 12 of the cases in Part 2. Purchasers of the book will have the opportunity to access these video clips on our website, and details of how we recommend they could be used are outlined in the Introduction to Part 2.

We hope you find this approach useful, and that our advice helps you to maximize your potential in the CSA. The RCGP demographic is changing since the MRCGP has become mandatory and the functions of the College are changing too. At its core remains the function of ensuring high-quality, professional GP care for all patients, and the MRCGP exam is essential to this. Patients need value-driven, patient-centred, quality- and safety-focused, energetic, knowledgeable, vocational doctors LIKE YOU!

Good luck!

Rachel RobertsDavid RussellSimon OrmerodAnjum Iqbal

Chapter 1Maximizing your potential in the CSA

In planning this book, we aim to help you understand more about three main areas. Firstly, your own personal needs in order to pass the exam. Secondly, how to get the most from your ‘patients’ or role-players, and thirdly, how to understand more about the exam itself. This chapter addresses how you can develop to your full potential in the CSA exam and beyond. We cover how to assess your own needs in terms of knowledge, consultation skills and also, very importantly, the preparation needed for maximizing your performance on the day. The goal of passing the CSA may be the initial motivator to develop these areas. Our real hope, however, is that you come to see your journey to success in the CSA as an excellent preparation for your life as a GP. We expect you to go on, equipped with your skills, to be successful in General Practice.

The aim of this chapter is to suggest resources for you to assess your needs, identify any potential barriers to passing the CSA and generate strategies to overcome any such barriers. This will result in drawing up a ‘CSA PDP’ to use and put into practice in the weeks or months before the exam. Practice of both consulting strategies and psychological strategies for dealing with stress, so as to focus purely on the ‘patient’, will, therefore, be honed and your all-round potential maximized in time for the exam.

When doing an assessment of your educational needs, it is important to focus equally on the clinical aspects of general practice as well as on interpersonal skills. This is reflected in both the marking schedules and the college motto Cum Scientia Caritas, ‘science with compassion’. The assistance of your trainer/educational supervisor in assessing your educational needs is paramount, as they will often have had the benefit of working with many other learners in order to form an opinion. Your Programme Directors may be valuable resources too, as, of course, are your peers on your VTS, in helping you build on your strengths and identify areas for improvement in terms of knowledge and competence.

Knowledge

Assessing your knowledge base is something you may have done at the start of your registrar year by self-rating, and also after a discussion with your trainer. This activity should lead to an educational plan. A month or 2 before the CSA is an ideal time to revisit this process, taking into account the current GP curriculum and any ‘Hot Topics’. A number of tools exist – for example the RCGP ‘Condensed Curriculum Guide self assessment scale’. This is available online, via the RCGP website, and can be purchased from the RCGP Bookshop.

It covers knowledge, skills and attitudes. A number of other possible rating scales exist – anything which accurately covers the curriculum will be fine, if the layout suits you. Patients themselves are an excellent resource. By identifying patient unmet needs (PUNs) in your consultations, you will identify your doctor's educational needs (DENs) – (Eve, 2003).

Having decided any areas for development, these can be entered in your ‘CSA PDP’. Following this, a strategy for improving these areas and potential resources for doing so can be listed.

A tip we often give is to repeat an AKT test or two in the month or so before the exam – this may expose gaps in your learning and is likely to prompt you to polish areas that may be hotter topics.

Consultation skills

From the analysis of the feedback to candidates given by examiners during the marking process, we know which areas of the consultation are highlighted most commonly, and are, thus, the areas most likely to cause you difficulty in the CSA.

The first aim of this section, therefore, is to help you identify potential barriers to passing the CSA, and hence make plans to maximize your potential. Secondly, we will summarise the most successful ways you can develop awareness of your consultation style. Finally, but possibly most importantly, this section will raise awareness of behavioural theories, which help interpersonal interaction, and, therefore, have the potential to improve your patient consultations. Such skills can most certainly be learnt, but only with practice and feedback from your patients and educators.

Issues with structure can be addressed by watching your own videos, and analysing the sections of the consultation, using any of your favoured consultation models. Comparing your consultations against consultation models and also against the feedback statements may highlight for you which areas of the consultation are receiving least attention, and, therefore, need developing. Commonly, during the time-limited CSA consultations, candidates spend too long on data-gathering, leaving little time for the management plan, and even less for sharing ideas with the patient around the management plan. This is emphasised in the recent consultation model, ‘The Consultation Hill’ by McKelvey (2010), which refers to the preparation for the CSA in terms of managing 10-minute consultations and leaving sufficient time for these vital sections.

The feedback statement given to a candidate – ‘Does not develop a management plan (including prescribing and referral) that is appropriate and in line with current best practice’ – suggests that the knowledge base needs addressing. In a sense, it should be possible for all candidates to remedy this, using the methods mentioned in the ‘Knowledge’ section. Practice in applying the knowledge is required, as real patients are generally far more complicated than the guidelines suggest, often having multi-morbidity or important influencing factors in their social situations. Hence, discussion of cases with your trainer and practice/community team colleagues, and also checking that knowledge is truly sound, will improve these areas. Examples could include being aware of prescribing for the presenting condition safely, but in order to do this, you may have to take into account a patient's other medical conditions, or occupation, which would influence appropriate or safe choices (e.g. prescribing in safety critical jobs such as tube train drivers, or in pregnancy).

The feedback statements – ‘Does not identify the patient's agenda, health beliefs and preferences', and also ‘poor active listening and use of cues’ – are at the heart of interpersonal skills during the data-gathering section of the consultation in particular. Here, GP consultation models as well as other simple behavioural models can be extremely effective in GP consultations, particularly with role-played CSA cases. Such behavioural or neurolinguistic models give us some very useful pointers to consulting effectively –

Become interested and curious

Create rapport

Ask questions

Listen

and check your understanding of what they describe

Pay particular attention to their non-verbal communication

Leave enough time for management

(adapted from Reg Connolly + Pegasus NLP, 2014 for the GP consultation by Dr R Roberts)

For example, if you ask a person presenting with headaches how things are at home, and there is an immediate break in eye contact, and a change in posture to become more closed, it would suggest that home may be an area of pain or discomfort for the patient.

‘Does not develop a SHARED management plan, or clarify the roles of doctor and patient’ applies the above principles to the discussion with the patient regarding the suggested management plan. For example, “be curious” about what they think of the plan or the options you have given them. You are then in a position to adapt and negotiate. Again, work in behavioural techniques suggests the following:

‘In any interaction, the person with the greatest behavioural flexibility has the most influence on outcome’.

‘Discover the person’s perceptions before you seek to influence them' (Connolly/Pegasus, 2014).

Our interpretation of this, in relation to our consultations, and particularly the CSA exam, is that patients will respond to empathic attitudes. Secondly, if the way you are approaching a consultation is not working, be prepared to change your approach – that is be truly patient-centred. Management plans not only need to take account of the current best practice, but, very importantly, also need to take into account individual patient factors – such as their fears, beliefs, or responsibilities (e.g. as carers). Finally, a reminder that time management is very important in allowing you to give enough attention to this section of the consultation, as it is most usually towards the end.

There is much more detail on how best to use Examiners' feedback statements in Chapter 6.

Exam-performance management

It has become apparent, in working with a range of GP registrars, and also with trainees in difficulty, that, for some people, exam-performance anxiety can be one of their main personal barriers to passing the CSA. Just as consultation skills can be learned, and practised, exam-performance management skills can also be learned and practised in your surgeries. There are also specific resources available to those who may need outside or specialist help. For example, barriers to success can be negative thinking, or self doubt, clouding the consultation and preventing you from truly hearing the patient.

Adapting neurolinguistic programming (NLP) resources to the GP consultation suggests tools such as identifying, challenging and replacing unhelpful thinking. For example, replace the fear, ‘I will fail’, with the fact that ‘there is evidence my consultations are good’ – as identified by trainer and patient satisfaction questionnaire feedback (Connolly/Pegasus, 2014).