How to Prepare for the CSA

Dan BerkeleyGP Partner Maryport

Brainstorm 1 – worries and concerns Practical aspects of the CSA

◦Costs and booking◦Set up of the exam/what to expect on the

day Brainstorm 2 – how to consult for the CSA My thoughts on the exam

◦How to prepare as a GPR Brainstorm 3 – working in small role play groups Final question and answer session

Overview

On one piece of paper in groups write down:

Anything you especially want to cover today◦ In your group try to answer the questions if you

can

Then come and present the answers and we can then make sure any unanswered questions get covered later

Brainstorm 1

Final of the two exam parts of the MRCGP Cannot be done until 3rd year Used to only be 3 sittings/year, now many GPR can have four attempts! (unless they

run out of money first) You do not need to have passed the AKT

first, although practically most have

Practical Aspects of CSA

Cost 1563 pounds (including 10% discount – probably more now!)

Book on the RCGP website, you don’t get any choice over day or time

Add to this 100 pounds for train, 150 for hotel, 50 for food etc and its a pretty expensive, and unpleasant, holiday

This is now tax deductable following Bannerjee vs HMRC 2008 ruling, but they still take it to the wire

Practical Aspects of CSA

Will vary depending on time of day you are sitting

Morning sitting Arrive 7.30am, sit around for 30 mins in

locked room, avoid eye contact Briefing for 15 minutes, more waiting Led through to exam room, items in locker,

clear bag for equipment (see list) Own room, ipad with 13 cases, 15 mins to

look at before exam starts

What to expect on the day

Horn blows Patient knocks and enters, examiner follows

and sits in corner 10 full minutes i.e. longer than ‘real’

consults Goes very quickly 7 cases – ‘break’ – avoid eye contact 6 more cases Fire alarms – avoid eye contact Pm sessions allegedly even more waiting

What to expect on the day

Finished! Massive relief May have dissociated to the extent can’t

remember the cases Try to enjoy the rest of the day Up to 6 weeks before you hear results Hopefully a one off experience...

What to expect on the day

What does the college suggest you do?◦ The exam is representative of UK general

practice, so if you are of the standard to be a GP in the UK you will pass the exam – they say

◦ They want us to train to be a good GP and use Calgary Cambridge style communication skills (standard consultation model in the UK)

◦ This is putting a lot of pressure on the exam to be perfect

Preparing for the Exam

Priority 1 : train to be a good GP – of course! Priority 2: prepare for the CSA!!!! PLEASE DON’T FALL INTO THE TRAP OF THINKING

PRIORITY 2 WILL SIMPLY FOLLOW PRIORITY 1 IF DONE WELL – this would only be the case if the exam was a perfect representation of UK general practice

The exam is not directly testing your ability to be a GP.

It is using an imperfect surrogate measure:◦ Can you consult an actor pretending to be a patient,

whilst being observed in a room in London

Preparing for the Exam

What do you think of this? How might you prepare for the CSA whilst

also preparing to actually be a GP

Discuss

Got frightened because one of our friends failed and had to extend his training

Took the exam early (before we were back in GP for 3rd year) so we could have ‘a second shot’ if need be. (No longer relevant with 8 sittings)

Small group work ++ using cases in books and online

Critique of consultations and endless role play practice – simulating the exam

Mix of UK and foreign graduates – important

What did we do?

Firstly, ensure that you are becoming a good GP – Clearly most important priority!

Secondly, in the 6-12 months prior to the exam do specific CSA training as well

Try to simulate the CSA◦ Role play◦ Consider meeting in small groups, this is not

something for your tutorials – you should be doing it outside work

Tips for Preparing

Consider taking the exams early and back to back to give yourself chance for resits◦ Less stress ‘I can always take it again’◦ Only ‘revise’ once

If you are well prepared (more later) your main enemy on the day is stress, it will make you consult differently to how you normally do, or practised to do.

Tips for preparing

Scoring system◦ Three domains

Information gathering Management skills Communication skills

But they are not perhaps as equal as they initially look...

How is the exam marked?

  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

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

Negative Descriptors

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 show appropriate use of resources, including aspects of budgetary governance

9. Does not make adequate arrangements for follow-up and safety netting

10. Does not demonstrate an awareness of management of risk or make the patient aware of relative risks of different options

11. Does not attempt to promote good health at opportune times in the consultation

Negative Descriptors

12. Does not appear to develop rapport or show awareness of patient’s agenda, health beliefs and preferences

13. Poor active listening skills and use of cues. Consulting may appear formulaic (slavishly following a model and/or unresponsive to the patient), and lacks fluency

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

Negative Descriptors

Most of the descriptors in fact relate directly to communication skills

And all those that don’t, require good communication skills to obtain

So in reality the thing the exam is testing more than anything is communication skills◦ This is good as it’s representative of our role as GPs,

also the AKT is designed to test knowledge specifically anyway

Concentrating on revising clinical knowledge for this exam is therefore a poor use of time

Despite it being the focus of almost every CSA book.....

How is the exam marked?

Unusual system Grid of 16 negative descriptors, get Xs in

ones you didn’t meet But only get X’s in a neg descriptor

category if you failed in that domain at least twice

Can make it hard to know how to improve if you need to resit◦ Look at the types of descriptor you failed, is there

a common link to them?

How are the results presented?

You will already have excellent communication skills.

The CSA wants to see you apply focused ‘consultation skills’

It wants to see a doctor led patient centred consultation

It requires you to play a sort of ‘game’:◦ Pretend the exam is 100% real – when its the

most unreal experience of your life◦ And ?like a driving test – see that you do this

every day with confidence

Communication skills and the CSA

Ensure that you do separate CSA preparation as well as normal tutorials to help you become a good real world GP

Role play in your free time in small mixed groups, with family etc

Don’t try to ‘make yourself feel safer’ by revising lots of knowledge. The exam is not testing this as much as you might think

There are only 3 CSA books that I found helpful currently – they have cases in them and the cases are realistic CSA type cases – they are designed to be used for role play. Either use these or the internet for cases e.g. Pennine VTS website

Summary so far:

In small groups try to build a very basic consultation model for the CSA which will hit as many of the marking descriptors as possible

How does this compare to standard Calgary Cambridge consulting?

What do you think the main challenges are in the CSA?

Brainstorm 2

You have to have a format for consulting – for instance the framework on the next slide

But you must not be formulaic They want to see the consultation being like

a conversation – everything you ask should ideally lead and reference what has been said before. Tailored to that specific patient.

Consultation skills

The key skill being tested in the CSA:

What does the patient want from the consultation?

What do you think is going on? Can you use communication skills to bind

these into a plan which the patient is happy with and you are happy is safe and doesn’t abuse resources.

Consultation skills:

Say hello, consider shaking hands   Get presenting complaint   Open questions including ICE, effect on life   Focused closed questions with signposting, red flags, drugs, allergies   Examination (if needed)   (6 minutes approximately are up)   Explanation and discussion of agendas to find a 'middle path'   Management (shared options)   Safety netting   Shake hand and say goodbye/run out of time

Framework option for CSA

How do you start the consultation?

Non verbal communication

Rapport – mirroring etc

Introduction

No irrelevant questions please! You only have six minutes here

‘OK can you tell me more about that?’ Open questions, ICE Consider signposting your ICE Occupation, lifestyle etc (if relevant) Closed questions – for red flags, to nail down

diagnosis etc – signpost and interrogate! Summarise Remember – Patient Centred – Doctor Led. You

are a guide.

Data Gathering

Patients seemed to say less than ‘real’ patients. Open questions were harder

Wanted to stick to script. Was often quite easy to see if you were going ‘off piste’

Try to make questions flow, one from the other – hypotheticodeductive reasoning! Sounds good, and looks good too.

Like a well informed and knowing conversation

Make the actor like you - Get you inner ENFJ out!

Data Gathering

When to ask? Early. Focuses consultation Feel free to use the specific words Make sure you soften it – makes it sound

better and more likely to avoid a bad response

Worth asking about occupation and home life

ICE

Signpost ‘a few medical type questions…’ Bang Bang Bang Etc Red flags Smoking Alcohol etc

Closed questions

Offer to examine only if relevant – don’t examine for no reason

You may be asked to actually do examination!

You may be given findings by picture/text/verbal, but only at the moment you are about to examine – explain as normal

If you do examine – then focused – not MRCP style – focused! 1-2 mins max

Examination

You should know patients agenda You should know what you think is going on Now to join them together! Explain what you think is going on – 1 min

or so – can tie in their ICE into this if you can – use it to ‘set up’ your plan

Remember: Patient centred. Doctor Led. They have come to see you for help.

Management

e.g. 'OK, so you came with these headaches and you have been worried that they could be something serious, specifically some type of brain tumour. And you were hoping that we might refer you to see a neurologist at the hospital. Well the good news is that my examination of your eyes and nerves of the face was completely normal. This doesn't rule out cancer, but it does make it less likely. The really good news though is that the story you gave me about the symptoms doesn't really point towards cancer either, in fact it points to quite a common problem called 'tension headache'. Thankfully this is something we can help you with. How do you feel about that?'

Joining the ICEs using ICE

Offer reasonable options, and explain pros and cons of each – don’t just list them

Do what you would really do (within reason) Discuss as needed Don’t avoid areas of conflict – the CSA is

probably testing any difficulties that are arising

If you think there will be conflict be gentle but address it early – you have probably discovered what the consultation is about

Options and plan

Safety net – red flags, and be open and realistic about prognosis and time frames. Educate and it will be a better safety net

Shake hands etc and check patient happy. Can check understanding if need be, but don’t do this as matter of routine

If you are running out of time try to get onto management ASAP and tie safety netting into your explanation to get as many marks as possible

Finishing

Ongoing debate about fairness of exam Now websites discussing how to ‘change’ for

the exam Examiners want you to consult naturally, how

can you do this if you are trying to be someone else entirely?

If you trained abroad please do throw yourself into local activities to get more hands on experience of British culture, but please don’t change who you are for the exam.

Controversial slide?

In small groups discuss what you have learnt and what you think you might need to do in order to be prepared for the CSA

Please share your ideas about how you might prepare for the CSA with your group

Brainstorm 3

Strongly think that roleplay is key to doing well. Very difficult to just rely on seeing lots of patients – CSA is a little different

Need to do both Form small group at least six months before

exam, meet 1-2 times monthly for a decent length of time

Practice at home too – non medical people Role play explanations

Small group work

This is what the CSA is testing: The key to passing the CSA is to have a structure

that is neither so structured that it is formulaic, nor so loose that there is no structure and that it is therefore disordered.

The key skill being tested is the ability to discover what the patient wants from the consultation, ascertain what you want to do with the patient (having made some sort of diagnosis or a diagnosis of 'uncertainty'), and then use the glue of communication skills to bind these together into a reasonable plan, that the patient is happy with, and that you feel is safe.

Final Thought

Good Luck!

Useful Resources

Useful Resources Continued

Any Questions?