Transcript Slide 1

West Midlands IMG Conference 2013
Jim Bartlett
Training Lead for CSA Core Group
Promoting Excellence in Family Medicine
Who??
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GP in Shropshire
Trainer
Former TPD for Shropshire VTS
MRCGP Examiner
Training & recruitment for CSA
Previously managing the Case Writing Group
Assumptions?
Me?
You?
Zen and the art of CSA preparation
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To challenge assumptions
To reduce the fear factor
Address worries and concerns
Build confidence
Outline
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A walk through tour of Euston square
Update on CSA –current issues
Pitfalls, myths and traps
Features of passing candidates
Hints & tips
Questions
CSA update
• The Exam Centre- what happens
• Recent developments
• What’s on the horizon?
Exam Centre:30 Euston Square
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3 purpose built ‘circuits’
State of the art
Clocks
iPads
30 Euston Square
Arrival
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Arrive on time at Euston
Check in ID/phones
Taken to briefing room
Refreshments/toilets
Brief by senior marshal
Taken to floor
Purple Circuit
Consulting room
At the start
•All possessions put in locker
•Medical Equipment on the desk
•Your BNF will be checked
•You will be logged onto your iPAD & can start reading
the cases
iPads
iPads
• www.rcgp.org.uk  Exams  MRCGP
• MRCGP exam overview
• May 2013 CSA: Delivery on iPads
• http://www.rcgp.org.uk/gp-training-andexams/mrcgp-exam-overview.aspx
Cases
• Cases represent everyday General Practice
• Cases could be
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Acute medical problem
Chronic multiple pathology
Out of Hours situations
Telephone triage/home visit
Breaking Bad News
Palliative Care advice
Medical Certification
What happened today in your surgery?
Marking domains
• Each case is marked in 3 domains :
Data gathering, examination and clinical
assessment skills
Clinical management skills
Interpersonal skills
• Each Domain has the same number of marks.
1.
TMahree domains for each case
DATA-GATHERING, TECHNICAL & ASSESSMENT SKILLS
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Gathering & using data for clinical judgement, choice of examination,
investigations & their interpretation. Demonstrating proficiency in performing
physical examinations & using diagnostic and therapeutic instruments.
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CLINICAL MANAGEMENT SKILLS :
Recognition & management of common medical conditions in primary care.
Demonstrating a structured & 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.
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INTERPERSONAL SKILLS:
Demonstrating the use of recognised communication techniques to understand the
patient’s illness experience and develop a shared approach to managing problems.
Practising ethically with respect for equality and diversity, in line with the
accepted codes of professional conduct.
Examiners
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Ignore any observers / camera
Behave normally –be yourself
Don’t panic if things go wrong
Be aware of your anxiety ,but think yourself
back home
• Housekeeping!
• You won’t be the only one feeling stressed
about a difficult case
New developments
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Feedback
Dates of exams sittings
ipads
Child cases
Children’s BNF
Child cases
• Child role players from the November 2013
exam onwards
• These new cases will include opportunities to
test paediatric examination & prescribing skills
• Don’t forget your paediatric BNF!
What’s on the horizon?
• Exam date changes
• Feedback
Most used feedback statements
• 7 does not develop a management plan (including
prescribing and referral) reflecting knowledge of current best
practice. ( All 18%, RoW 24%)
• 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. (All 12 %
RoW 21%)
• 2 Does not recognise the issues or priorities in the
consultation (for example, the patient’s problem, ethical
dilemma etc). (All 15% RoW 20%)
• 15 Does not develop a shared management plan,
demonstrating an ability to work in partnership with the
patient . (All 14 % RoW 20%)
How can we help?
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Challenge assumptions
Seek feedback , and act on it
Review performance
Resources
Resources
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You!
Your trainer
Your colleagues
Your family
Website
Resources
• MRCGP Clinical Skills Assessment (CSA) 
• More resources for CSA candidates 
• General comments about
features/behaviours observed in passing and
failing candidates in the CSA
Pitfalls: General features observed
Passing
• Fluent, interactive and
relevant
• Is able to take patient into
medical world as a shared
partner (use of we)
• Open about lack of
knowledge or certainty and
may use this constructively
• Active monitoring during
consultation
Failing
• Patronising (use of we)
• Uneasy with or unable to
acknowledge own
ignorance or uncertainty
• More scripted summary
and checking understanding
• Poor use of time
• Does not appear to care
about the patient
• Not curious
• Unaware of personal space
Myths
• There is NO RCGP model you need to follow
• Patient centred clinical method can appear
doctor centred?? No one size fits all.
• Getting “ICE” is not as important as using it
• Ask yourself how much the patient’s ideas
concerns and expectations influenced the
outcome
• Were you curious and interested?
Traps
• Don’t second guess, many cases seem similar but
just as patients vary in real life so do CSA cases.
• Don’t copy other peoples phrases and questions
unless they feel natural to you.
INSTEAD
• Do the consultation “for real”
• Make a diagnosis or address the dilemma
• Try to develop your own phrases and practice
them
Tips for during the exam
• Read supporting notes for the candidate.
– may give a clue as to the direction expected in the
consultation.
• Have “good housekeeping skills.”
– Must move on from each case.
– Each case is marked separately.
• Be confident at home visits and telephone
consultations
• You need to combine good clinical skills with
good interpersonal skills.
• Demonstrating clinical skills is often a matter
of sharing thoughts and explaining well to the
patient.
• Build on the “raw material” offered to you
• "Focus on the patient, not what you imagine
the examiner is looking for“
Tips
• Familiarise yourselves with the marking domains of
the CSA.
• Regularly review your own consultations with your
Trainer.
• Use COT – need to aim to be achieving “excellent”
• Use several trainers to review COT
• Must be able to consult in 10 mins in every day work
How trainers can help
• Identify and reinforce successful phrases and
techniques
• Feedback on “clunky consulting”, overmodelling and “rote phrases”
• Encourage development of comfortable
alternatives
• Encourage patient centeredness
• Encourage study groups
• Lots of joint surgeries and CSA practise and
seeing patients ,see what the registrars are
doing not what they say they are doing
• In joint surgeries-at critical points- don't be
afraid to ask the trainee what they are
thinking ie verbalise (eg diagnostic dilemmas
treatment choices etc)
• Don't let your registrar practise with friends
who might collude!
• Make sure your trainee is expanding their
knowledge base at the same rate as their
consulting skills.
• Watch your trainees for clunky /
embarrassed/formulaic phrases and work
with them to try out more comfortable and
natural ones.
• Encourage the use of open questions early
on, & suggest a time plan so that clinical
management gets a fair slice of the 10
minutes available.
• Identify the barriers to fluent consulting –
any social/cultural barriers?.
Tips for trainees-preparation
• See patients- lots- do COTS and CBDs and
don’t stay on half hour consulting for
long
• Do joint surgeries with your trainerpartly to get used to being watched
• Work in a consortium of other candidates
taking the CSA – but not just your friends
:practise mock cases to get the timing
right
• Use a variety of settings- home visits,
joint surgeries and don’t forget ..
• Telephone Triage
• Make the most of the OOH shifts
• Take every opportunity to seek and listen
to feedback from experienced colleagues
• Think of the consultation as a conversation the patient says something then you say
something that naturally follows, then the
patient says something etc etc and so the
story develops
• Think about who is doing all the talking - it
shouldn't be the doctor.
• Throw away check lists and let it flow
naturally.
• Focus questions in a progressive manner
indicating clear thought processes. Don't
suddenly in the middle of taking a history
interject with "how much alcohol do you take" or
"Who is there at home?" when this is
completely irrelevant. It may just suggest that
you don’t know what to say next.
• Patients come in with symptoms, it is important
to take the patient along the pathway between
the symptom and their diagnosis ( and shared
management) without gaps or odd jumps.
• Be nosey- develop an inquisitive nature if you
don’t have one .
• Passing candidates connect instantly with patient,
remain responsive throughout, are fluent focused
and use clear language
• Don't ask" Can I ask you some questions?" It
wastes time and annoys everybody
• Don't use rote-learned questions - especially ICE
questions when used at inappropriate times listen to what the patient is saying and respond to
that
• Explore the impact of the problem on the patient's
life
For the exam:
• Imagine you are in your own surgery, & to do in
Euston what you would want to do there!
• You've never met any of the CSA 'patients' before.
Explore their psycho-social background with open
questions before embarking on the medical
questions
• There is no "right answer" to a case
• Do not think of the CSA as a game ('what do they
want me to pick up', 'why have they put this case
in'? etc) and think yourself into the real situation
('it's down to me to sort this patient out').
• It is helpful to the patient to explain what you
are doing when you examine them - practise
examinations so that they are automatic and
second nature.
• Don't ask the pt "What do you want to do"
when the patient has not been given options
with the pros and cons of each.
• Suspend disbelief, and put yourself in your
surgery, believing that these are YOUR
patients. Ignore the examiner and don't try to
double think what he/she wants to hear - it
just causes confusion in your own brain and
will be unhelpful to the ‘patient’.
• "if you think it say it": an assessor can only
mark what they hear so if you have a bright
thought you need to share it!
Time Management
• Keep an eye on the time
• Structure your consultations
• Use good general consulting skills- summarise,
screen, safety-net
• Don’t cover only one domain area
• About halfway through the consultation, you
need to move on from data gathering
• Avoid repetition
Summary
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Be yourself
Get in ‘doctor’ role – not ‘candidate’
Confidence comes with practise
And is polished with feedback