Transcript CSA Feedback Course

CSA Feedback – how not to
fail the CSA
Dr Chris Webb
Yorkshire and Humber Deanery
 Why
do candidates fail?
 What can you do to avoid failure?
Learning outcomes
How it is marked
 Data
gathering
 Clinical management
 Interpersonal skills
Feedback Statements
Feb/March 2011 Y&H Deanery


Disorganised / unstructured consultation
Does not recognise the issues or priorities in the
consultation (for example, the patient’s problem,
ethical dilemma, etc).
 Does not develop a management plan (including
prescribing and referral) reflecting knowledge of
current best practice
 Does not develop a shared management plan,
demonstrating an ability to work in partnership
with the patient
General Features

Passing

Failing

Fluent, interactive and
relevant
Is able to take patient into
medical world as a
shared partner
Open about lack of
knowledge or certainty
and may use this
constructively
Active monitoring during
consultation


Poor use of time
Uneasy with or unable to
acknowledge own
ignorance or uncertainty
More scripted summary
than checking
understanding
Unaware of personal
space





 Disorganised
/ unstructured consultation
 Does not recognise the challenge (eg the
patient’s problem, ethical dilemma)
 Shows poor time management
 Shows inappropriate doctor centredness
Data Gathering

Passing

Failing

Can take a focused
history that includes all
relevant information
Embedding of questions
in previous response

Formulaic questioning
which can become
interrogative
Repetitive questioning
Sequence of questions
does not make sense



Data gathering

Disorganised and unsystematic in gathering
information from history taking, examination and
investigation
 Does not identify abnormal findings or results or
fails to recognise their implications
 Data gathering does not appear to be guided by
the probabilities of disease
 Does not undertake physical examination
competently, or use instruments proficiently
Clinical Management

Passing

Failing

Appears knowledgeable
and refers to recognised
algorithms or modes of
practice
Able to suggest solutions
to problems or a range of
reasonable management
options likely to be
agreeable to patient

Insufficient knowledge
base, or ability to think of
realistic and effective
alternatives
Fails to integrate and
apply knowledge
Puts off making clinical
decisions or a clear
diagnosis
Doesn’t appear to grasp
the dilemma if there is
one




Clinical management
 Does
not make an appropriate diagnosis
 Does not develop a management plan
(including prescribing and referral) that is
appropriate and in line with current best
practice or makes adequate arrangements
for follow up and safety netting
 Does not demonstrate an awareness of
management of risk and health promotion
Interpersonal Skills


Passing
Connects instantly with
patient
 Non-judgmental
 Interested in the patient
 Reformulates
explanations using
helpful metaphors
 Can meet patient half
way – picks up patient’s
agenda, accent, or
cultural approach.


Failing
Doctor-centred/patient’s
concerns not addressed
 Patronising
 Unable to explain
effectively – may be
wrong or not tuned to
patient
 Inappropriate use of
terms
 Over patient-centred to
the detriment of clinical
outcome
Does not identify the patient’s agenda, health beliefs &
preferences / does not make use of verbal and nonverbal cues
 Does not identify or use appropriate psychosocial or
social information to place the problem in context
 Does not develop a shared management plan or clarify
the roles of the doctor and patient
 Does not use explanations that are relevant and
understandable to the patient
 Does not show sensitivity for the patient’s feelings in all
aspects of the consultation including physical
examination

How should we therefore aim
to consult?
What is your own consultation
model?
CC and the CSA
Data Gathering
Clinical Management
Global
Interpersonal Skills
Do Consultation Models help
or hinder Trainees taking the
CSA?
Dysfunctional learning?
The examiners are looking for pre-agreed competencies to
be displayed in the CSA
Certain behaviours of trainees are thought to demonstrate
these competencies
Trainers attempt to teach their trainees to exhibit these
behaviours
Some trainees are resistant to learning the behaviours
Others adopt the behaviours, but in a mechanistic way
which fails to satisfy the examiners
Tentative hypotheses
A focus on behaviours alone does not appear to
help trainees pass the CSA:
• We cannot say: “Do this and you will pass …”
A focus on behaviours may make things worse:
• ‘Artificial’ behaviour sequences may prevent people using the
natural rapport, listening and explaining skills they possess
A cognitive approach (knowing what to do) is not
sufficient:
• Skills are important
• Attitudes, beliefs and values are crucial
What is good about consultation
models?
Models help us to make sense of our world
They provide a framework or structure to
help us understand a large or complex
concept, and break it down into discrete,
manageable units
What’s wrong with consultation
models?
They focus on behaviours
They assume that cognitive insights will result in
better consulting
They don’t deal with intuition and the basic human
skills of interaction
They don’t address the beliefs and attitudes that
shape our interactions
Generic CSA Grade Descriptors
CP
The candidate demonstrates an above-average level of competence, with a
justifiable approach that is fluent, appropriately focussed and technically
proficient
The Candidate shows sensitivity, actively shares ideas and may empower the
patient
P
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
F
The candidate fails to demonstrate adequate competence, with a clinical
approach that is at times unsystematic or inconsistent with accepted practice.
Technical proficiency that may be of concern
The patient is treated with sensitivity but the doctor does not sufficiently
facilitate or respond to the patient’s contribution
CF
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
How to annoy the examiners
If you really want to annoy an examiner,
come out with a phrase that you have
learned from a consultation model that is
inappropriate for that consultation, or come
out with it at the wrong time (such as just
after the opening statement)
What are the alternatives to
models?
Knowing the patient
It is only through an attempt to know the patient that one can
engender the interpersonal respect necessary for the role of
healer. Thus, bedside methods are not brought to bear simply
in the search for a disease, but, rather, in order to know the
patient and answer the cardinal question:
“Why did this particular individual (with his or her unique
genetic, developmental, experiential and spiritual identities)
come to visit me, the doctor, at this particular time?”
Answering this question immediately accomplishes the 2 aims
previously seen as disparate: i.e. what is traditionally termed
making a diagnosis and being patient-centred.
These 2 goals are of a piece.
Boudreau, Cassel, Fuks (2007)
Why?
Why me?
Why now?
If you do use a model…
Neighbour: CSA Consultation model
Building
concordanc
e
Summaris
e
Recognising
&
responding
to cues
Dealing
with
emotion
Solve
the right
problem
The
assessed
consultatio
n
Patientcentred
eliciting
‘Sell’
your
solutio
n
Wrappingup &
closing
Rapport
© Roger Neighbour 2010
Safetynetting
Early stages
of the consultation
Later stages
of the consultation
patient’s contribution ≥ doctor’s
doctor’s contribution ≥ patient’s
Solve
the
right
proble
m
The
consultatio
n
‘Sell’
your
solutio
n
Summarise
Clinical evaluation
Decision-making
& action-planning
Play DVD 1
 Observe
summarising. Signposting,
sequencing
 Understanding the disease (illness) and
their perspective
 Non-verbal skills, rapport and involvement
Play DVD 2
Break
Clinical Management- Explaining
and Planning
 Providing
the correct amount and type of
information
 Aiding accurate recall and understanding
 Achieving a shared understanding:
incorporating the patient’s perspective
 Planning: shared decision making
Explanation

What does the patient already know?

What does the patient want to know?

What does the patient need to know?

Plus Structure
(signpost/summarise/language/visual)

The Explanation Game…in pairs
Explanation and Planning- Self
Rating









Have I put myself in a position to give information?
Do I understand the disease and the illness?
Do I know what information I want to give?
Does it relate to the patient’s framework?
Can I phrase and deliver it in a way the patient can
understand?
How can I make sure that I’m giving the information that the
patient needs and wants?
How do I check how the patient is reacting to what I am
saying?
How do I involve the patient in the process and encourage a
collaborative approach to decision-making
How can I check the patients’ understanding?
Final Point
Q. What is the commonest reason
candidates fail the CSA?
A.Of course, it’s a trick question – there are
many reasons, but “Clinical Management” is
the domain that gets lowest score so…
i.
ii.
You won’t pass the CSA on charm alone =
Know up to date management and the latest
guidelines
More Questions than
Answers?
The Thinker, sculpture by Auguste Rodin