Transcript The CSA guidance from trainees who’ve done it. What the RCGP has to say… ‘An assessment of a doctor’s ability to integrate.

The CSA
guidance 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 information
and apply learned understanding of disease processes and
person-centred care appropriately in a standardised context, make
evidence-based decisions, and communicate effectively with
patients and colleagues. Being able to integrate these skills
effectively 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:
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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
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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
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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:
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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 management
 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 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
 5 MIN
 5 MIN
 Open Questions
 Explanation (eg diagnosis)
 Rapport building, Active
listening, Summarising etc  Management Options
discussion
 ICE
 Psychosocial context
 Check understanding &
agreed plan
 (a little further Hx taking)  Safety Netting/ F/U
 Red Flags
 Examination
Nub of the Case
 Cues
 Flexibility
Nubs of Cases
TATT:
a) explanation of low T4 (ref to info sheet)
b) depression/ psychosocial element
HRT
a) explanation & sharing options
b) negotiation (eg herbal, HRT given hi risk factors)
c) psychosocial
First Fit
a) clinical Mx
b) psychosocial- HGV driver
+ negotiation/ breaking bad news
Headache/ Palpitations
a) explanation/ reassurance/ exploring ICE
b) 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 Plans
 Shared
 Managing Medical Complexity
 Fish out of Water
 Linguistic Capital
IMGs cont
 Communication
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Eye contact vs sensitivity/ cues
Formulaic
Interrogation
Eliciting not exploring
Picking up Pt language
Over-categorical
No sunny pairing
Unclear Explanations
Interactional smoothness
IMGs cont
 Communication
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Informal speech patterns
Avoid Medical Jargon
Idioms/ Colloquialisms
Jokes
 Dr-Pt partnership
 Topics
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Palliative Care
Death and Bereavement
Sex and Sexuality
Mental Health
IMGs- moving forward
 Start Early
 Resources
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Website
Books
TV
Trainer
GPSTs
 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 approach
 Don’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 started
 provides the
 ???Use curriculum
proverbial....
Some Suggestions
 Case 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
thinking
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what you’re
- 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:
 Harrogate
 Pennine
 Hull
 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 Take
 Photo ID!
 BNF
 Stethoscope
 Ophthalmoscope
 Auroscope
 Thermometer
 Tendon hammer
 Tape Measure
On The Day…
 Arrive on time!
 Briefing
Cases
 Acute and chronic
 Ethics
 Health Promotion
 Negotiation
 Telephone
 Home Visit
 Good luck!