The CSAguidance from trainees who’ve done it.

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 informationand apply learned understanding of disease processes andperson-centred care appropriately in a standardised context, makeevidence-based decisions, and communicate effectively withpatients and colleagues. Being able to integrate these skillseffectively is a key element of this assessment.

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!

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

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

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.

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

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

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

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

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

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

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

Feedback Statements

Clinical management6. 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.

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

CSA in 10min

Nub of the Case

Cues

Flexibility

Nubs of CasesTATT:

a) explanation of low T4 (ref to info sheet)b) depression/ psychosocial element

HRTa) explanation & sharing optionsb) negotiation (eg herbal, HRT given hi risk factors)c) psychosocial

First Fita) clinical Mxb) psychosocial- HGV driver

+ negotiation/ breaking bad newsHeadache/ Palpitations

a) explanation/ reassurance/ exploring ICEb) Clin Mx & explain re fastrack (or 24 ECG)c) depression/ psychosocial

IMGs

the ‘under performance’ of minority ethnic candidates UK graduates 91.6% Non-European 56.9%

Communication

Patient-centred

Clear Management PlansShared

Managing Medical Complexity

Fish out of Water Linguistic Capital

IMGs cont

CommunicationEye contact vs sensitivity/ cuesFormulaic InterrogationEliciting not exploringPicking up Pt languageOver-categoricalNo sunny pairingUnclear Explanations Interactional smoothness

IMGs cont

Communication Informal speech patternsAvoid Medical Jargon Idioms/ Colloquialisms Jokes

Dr-Pt partnership

TopicsPalliative CareDeath and BereavementSex and SexualityMental Health

IMGs- moving forward

Start Early

ResourcesWebsiteBooksTVTrainerGPSTs

Video Consultations

Joint Surgeries

CSA practice with range of GPSTs

Summary

Integrated assessment of Clinical Skills

Safe to Practise Independently

Mark-schemes

Expect to examine

Structured approachDon’t forget the Management Plan!

It is acheiveable!

CSA - PREPARATION

When to Start?

After all tomorrow is another day..............

Generally 2 - 3m

Where to Start?!!Overwhelming - need to know ‘everything’

Consultations to identify learning needs

Group practice - good impetus to getting startedprovides the proverbial....

???Use curriculum

Some SuggestionsCase practice - probably most useful

lots of books with scenarios ?write own cases

Study group

Identify consultations felt uncertain about

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!!

Dealing with Monotony.......

Practice small sections eg. explanation, management - common reasons for failure

Quick fire questions

Look at some PILS - patient.co.uk

Which Books?

Other Resources

NICE, patient.co.uk, CKS, GPnotebook

InnoVait, BMJ

GP Handbook

Courses

Loads available, BOOK EARLY

Yorks & Humber Deanery courses available in:HarrogatePennineHull

RCGP - Croydon

Bradford VTS website is fab

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

RCGP

2 days

Opportunity see centre

Run by senior examiners

Also talk by role-playing lead

Presentation based

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

VTS Session

Mock CSA

~6 -8 cases

Observed, then get feed-back

Well worth going

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

The “What To Do On The Day” Bit

Where It Is…The RCGP

Assessment Centre

12 – 16 Addiscombe Road

East Croydon

CR0 0XT

18th, 19th & 20th floors

Where To Stay

Croydon Park Hotel

Jury’s Inn

Travelodge

Victoria London

What To TakePhoto ID!

BNF

Stethoscope

Ophthalmoscope

Auroscope

Thermometer

Tendon hammer

Tape Measure

Peak Flow Meter

On The Day…Arrive on time!

Briefing

Cases

Acute and chronic

Ethics

Health Promotion

Negotiation

Telephone

Home Visit

Good luck!