Preparing for CSA: guidance for candidates

Amar Rughani June 2007

Key points

  • CSA tests the patient-centred clinical method.
  • Candidates need to demonstrate a sound clinical approach and the ability to employ good interpersonal skills.
  • Candidates will see simulated patients in a series of encounters, in a test that mimics the surgery consultation.
  • Each encounter is limited to 10 mins, which means that candidates will need to be experienced enough to be fluent and proficient in this timescale. This time constraint will be a significant hurdle for many candidates.
  • The standard to pass is the standard expected of GPs who are new to independent practice but are competent to deal with patient’s problems without supervision.
  • In preparing for CSA, surgery consultations could be seen as "mock CSAs".
  • COT is an ideal opportunity to gauge readiness for CSA. With this in mind, candidates should not select low-challenge consultations for COT as these will not provide the insights that are needed.
  • Wherever possible in the CSA encounters, candidates should talk about what they are thinking.
  • Good explanations at all stages of the consultation will help the assessor to make an informed judgement of the candidate’s performance.
  • Most curriculum statements have a section on common and important conditions and cases are quite likely to be based on one of these.
  • To pass, performance should be:
  1. Consistent with current accepted medical practice, for example using management plans that are evidence-based and in line with nationally accepted guidelines. In preparing, candidates should discuss management with colleagues, asking them to comment particularly on risk management and safety-netting. Candidates are being assessed for general practice and should therefore consider common conditions in the differential diagnosis.
  2. Systematic and appropriately selective.
  3. Efficient, with good time management.
  4. Proficient with respect to performing examinations and using diagnostic and therapeutic instruments of the type commonly used by GPs.
  • The shared management plan may be improved by responding appropriately to the patient’s agenda and by attempting to involve patients in making decisions relating to their problem.

  1. Background

The nMRCGP is designed to test the GP curriculum. All aspects of the curriculum will be tested across the exam, but the focus of CSA is on testing your ability to demonstrate the patient-centred clinical method. Before looking at the practical ways in which you can prepare yourself for CSA, it is worth looking more closely at this method as it will help you to plan your preparation.

The curriculum has 6 core competencies and the diagram below shows how the first 3 of these, problem-solving skills, person-centred care and primary care management, encapsulate the patient-centred clinical method:

After Levenstein Stewart and Roter (1989) and Stewart et al (2003)

The first 3 curriculum competencies might be described as ‘basic’ not because of their simplicity but because they form the basis of good clinical practice in primary care. These 3 relate to each other as shown.

The dialogue begins with the patient presenting symptoms to the doctor. There then follows an attempt to understand the patient's experience of illness by exploring the patient’s agenda, health beliefs and preferences. Whilst doing so, the doctor gathers information, clarifies the problem and begins to consider what management options might be appropriate. As shown by the serpentine arrow, this process involves continual dialogue between doctor and patient. As a result of this process, doctor and patient are in a position to arrive at a mutually acceptable management plan that is based on a sound understanding of the nature of problems as they present in primary care. Because it is developed in partnership, such a plan is likely to have shared commitment from doctor and patient for implementation.

Mastering these curriculum competencies allows the doctor to competently employ the patient-centred clinical method. Being able to demonstrate this method in CSA is the key to success in the exam. We will refer back to this when we think about how best to prepare.

  1. Isn’t CSA like an ordinary surgery?

To demonstrate the patient-centred clinical method, candidates will be seeing simulated patients in a series of consultations, so isn't CSA much like an ordinary surgery? Well, yes and no. Although CSA may look to be like a simulation of what happens in surgery, there are important differences. As you might expect, you will be unable to ask a colleague for a second opinion! More subtly, you will not have access to the usual sources of information, particularly the full patient records, Internet sources of guidelines etc upon which most clinicians depend. You will not be able to see the patient again, which means that you will need to grasp the issue rather than defer, or defer if it seems the only appropriate thing to do in the circumstances. Finally, you only have 10 minutes for the case which means that you will need to be efficient, organised and fluent. These attributes only really come with experience, so it is not a good idea to take CSA until you feel you have reasonable time management.

In the exam, you will have a number of challenging cases to face one after the other. Unfortunately, unlike real life, you will not have the chance to "housekeep", for example by pausing for a few minutes and having a cup of coffee. Assessors understand that this adds stress to the whole experience and take this into account when designing the cases.

However, in those ways that are considered the most important, CSA is similar to the consultations you're used to and this is deliberate because it is this "authenticity" or similarity to real life that gives CSA its strength as a valid assessment of how GPs perform. Assessors are not looking for rare, esoteric or complicated skills that are seldom used in real life. Quite the opposite. The standard to pass is the standard expected of GPs who are new to independent practice but are competent to deal with patient’s problems without the need for supervision. Therefore, thinking about CSA as a surgery can be a very useful mindset in helping you to prepare and in helping you to perform well in the exam.

Therefore, think about your surgery consultations as "mock CSAs" in which you have to demonstrate that you have good clinical skills and that you can use these whilst maintaining a good interpersonal relationship with the patient. The exam will test your ability to do both things to an adequate standard and to do both things simultaneously. Why? Because in real life, we would not want doctors to be able to communicate well with a patient but not be able to deal competently with the clinical issues. Likewise, we would not want GPs to be medically knowledgeable, yet unable to communicate effectively or sensitively with the patient. One further point; if surgery consultations are like mock CSAs, then getting tested on these consultations through the Consultation Observation Tool (COT) is an ideal opportunity to see how fit you are for CSA. With this in mind, don’t select low-challenge consultations for COT, tempting though this may be, as these will not give you the insights you need for your preparation.

Having the skills is one thing but demonstrating them to an assessor is another. Interpersonal skills such as good communication, showing sensitivity and respect are fairly obvious to an observer. However, it is much less easy for the assessor to judge your clinical skills, particularly your clinical decision-making skills, without hearing your thoughts. Therefore, it becomes very important for you to talk about what you are thinking. For example, you may need to interpret the significance of test results, think about the differential diagnosis, decide what the priorities are and consider the management options. Fortunately, talking about what you are thinking is not only vital for CSA, but more importantly is good for patient care.

The mechanism by which doctors "speak their minds" in consultation is by describing and explaining their thoughts. Obviously, you may not wish to say everything that you are thinking perhaps because there would be little time for anything else or because you do not wish to alarm the patient. It is quite justified to be selective in what you say, but the key point for your exam preparation is to get into the habit of sharing your thoughts aloud with the patient and providing them with good explanations.

TIPS
Think of your surgery consultations as "mock CSAs”
Show that you can combine good clinical skills with good interpersonal skills.
Demonstrating your clinical skills is often a matter of sharing your thoughts and explaining well to the patient.
  1. How does CSA relate to the curriculum?

Firstly, a warning. Any part of the curriculum could be tested in any of the 3 components of the licensing examination. Therefore, you should not assume that you can prepare strategically and entirely ignore areas of the curriculum that do not seem to be prioritised within any particular component.

However, it is fair to point out that CSA has a focus, which has already been described. The GP curriculum appears on the RCGP web site as a number of "curriculum statements" The diagram below shows the domains contained in the Curriculum Statements, and the lines show the domains within which the CSA will be testing.

TIPS
Developing your understanding and skills in the curriculum areas that are shown, will help you to perform well in CSA.
Obtain the Curriculum Statements from the RCGP website and read through them thoroughly. Most curriculum statements have a section on common and important conditions and cases are quite likely to be based on one of these. They are likely to be regularly updated, so you should make sure you have the most recent versions.
  1. How do I develop my clinical skills for CSA?

Clinical skills are a continuum of:

Gathering data from selective history/examination/investigations

Interpreting the results of these data and deciding upon their significance

Creating a hypothesis (what might be the problem?)

Formulating/justifying a diagnosis and management plan

Monitoring/reviewing and learning from the outcomes

In CSA, you must demonstrate that your approach is:

  • Consistent with current accepted medical practice, for example by developing management plans that are evidence-based and in line with nationally accepted guidelines.
  • Systematic and appropriately selective
  • Efficient, with good time management.
  • Proficient with respect to your ability to perform the examinations and use diagnostic and therapeutic instruments of the type commonly used by GPs

Let us look at some of these areas in more detail:

Gathering data from selective history/examination/investigations

Gathering information requires you to be appropriately selective in the questions you ask, the tests you request and the examinations you choose to undertake. You may feel that it would be better to be “on the safe side” by ordering a battery of tests and whilst understandable, this is not good practice and will make you appear indiscriminate, disorganised and not a good use of resources. Likewise, history taking and examination is not expected to be all-inclusive and should be tailored to the circumstances.

Showing that you are appropriately selective means demonstrating that you understand what is likely, what is less likely and what is unlikely but important. First make sure that your knowledge-base is up to scratch and then improve your skills by explaining your approach to the patient. For example, explain what you are looking for, what you think the likely diagnosis will be and (where appropriate) what you feel is unlikely but needs to be ruled out.

TIPS
Practise these skills in consultation by having a mental approach of being selective and then explaining to the patient what you are doing and why. This is good for patient care and will also demonstrate to assessors that you have a clear and systematic approach.

Performing examinations and using instruments proficiently

Improving these skills is a matter of practice and it pays to spend time developing a systematic method that you can practice over and over again. Before doing so, take advice and make sure that your technique is correct; otherwise you will simply be reinforcing bad habits. Once correct techniques are practiced and become fluent, your approach will appear competent and confident to the assessor.

TIPS
Consider the types of clinical examination you could be asked to perform during the CSA, and practice focussed examinations. Ask someone else to watch you (perhaps your trainer) to give you feedback. There are some examinations you are very unlikely to be asked to demonstrate, for example, intimate examinations, but you could be asked to assess a leg, an arm, a chest, an abdomen etc.
Make sure you are conversant with any medical equipment you might need, and can handle it with confidence.

Interpreting the results of these data and deciding upon their significance

This is a clinical rather than interpersonal skill and requires you to make sure that you can correctly interpret the significance of test results or the findings of physical and mental state examinations. Deciding upon "significance" often means demonstrating that you can prioritise appropriately. In particular, you should be able to show that you can manage uncertainty and risk.

The abnormal findings will nearly always relate to common or important conditions. When you prepare for the exam, pay close attention to your ability to assess risk and to pick up on abnormal findings and deal with them safely.

TIPS
Think about the sort of letters you receive from secondary care and the types of test results you see (ECGs, spirometry, blood test results, urinalysis results, skin scrapings, swabs, smear results etc). Make sure you can interpret them correctly and explain them to a patient.
Discuss your management with colleagues, asking them to comment particularly on your risk management and safety-netting. Also, take an active part in significant event reviews, look back on SEAs relating to clinical errors and see what you can learn.

Formulating/justifying a diagnosis and management plan

Making a diagnosis means committing yourself on the basis of the information you have available to you. The case may not always require you to make a diagnosis, but where this seems appropriate, you should remember that you are being assessed for general practice and should therefore consider common conditions in the differential diagnosis.

TIPS
Make sure that your knowledge-base is adequate and then ensure that when you have made a diagnosis in consultation, you state this clearly and explain it to the patient using appropriate language. In the exam, if your summary is too vague, the assessor may not be sure that you have made a diagnosis at all.

The management plan needs to be in line with currently accepted practice and tailored to the patient's situation. The possible risks and benefits of different approaches including prescribing need to be clearly identified and discussed with the patient. However, you are not simply there to inform. Although patient autonomy is encouraged, you will be expected to assist the patient in making a decision by providing guidance drawn from your assessment.

Another and broader aspect of management is thinking about the prevention of future health-related problems. Health promotion requires doctors to demonstrate an awareness of health (rather than just illness) and to be proactive in maintaining the patient’s health.

TIPS
In consultation, get into the habit of thinking to yourself "How can I help my patient to remain well in the longer term and prevent ill-health from occurring prematurely?”
This mindset will automatically suggest to you which health promotion approaches might be appropriate. In addition, raising this issue with patients can help to empower them and take more control over their health.

Your management plans will include arrangements for follow-up. These should reflect the natural history of the condition, be appropriate to the level of risk and be coherent and feasible.

  1. How do I develop my interpersonal skills for CSA?

Interpersonal skills are a combination of communication skills and attitudinal approaches to the patient. An effective method of developing communication skills is through having your consultations observed either on video or by "sitting in" and then assessed informally or more formally through a consultation observation tool.

TIPS
Interpersonal skills lie at the heart of patient-centred consulting and a number of educational resources will help you to understand the concept.
You should prepare by allowing doctors who are skilled in this approach assess your performance and on the basis of this, learn to develop your ability to listen, to involve the patient and, making use of verbal & non-verbal cues establish the patient's agenda, health beliefs & preferences.

The main outcome of the patient centred clinical method that was described earlier is the shared management plan. Assessors will look closely at your ability to use interpersonal skills to develop this plan