Transcript CSA Exam: Registrar Perspective

Dan Berkeley
GP Maryport Health Services
Practical aspects of the CSA
◦ Costs and booking
◦ Set up of the exam/what to expect
on the day
 My thoughts on the exam
◦ How to prepare as a GPR






Final of the two exam parts of the MRCGP
Cannot be done until 3rd year
Used to only be 3 sittings/year, now 8.
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




Cost 1563 pounds (including 10% discount)
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






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








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





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 does the college suggest you do?
◦ The exam is representative of UK general practice,
so if you of the standard to be a GP in the UK you
will pass the exam
◦ They want us to train our GPRs 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



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





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



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

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.

Scoring system
◦ Three domains
 Information gathering
 Management skills
 Communication skills

But they are not perhaps as equal as they
initially look...


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

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





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



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.....




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?




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




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 2 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



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.




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.



















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

How do you start the consultation?

Non verbal communication

Rapport – mirroring etc






No irrelevant questions please! You only have
six minutes here
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




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






You should know patients agenda
You should know what you think is going on
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
Offer reasonable options, and explain pros
and cons of each – don’t just list them
Discuss as needed
Don’t avoid areas of conflict – the CSA is
probably testing any difficulties that are
arising



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




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.


Any questions?
In part 2 we split into groups and do some
role play and I’ll do my best to give individual
feedback to as many as possible


My friends Jenny, Ellen, and
Irina are currently in final
phase of publishing an epic
flipchart case book which
will be amazing I suspect
I have written a very
concise, completely CSA
focused communication
skills, consultation skills
book too which is available
on Amazon for under ten
pounds – paperback and
kindle editions