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Matt SmithSeptember 2013
What are the odds?
The February to March 2013 CSA
Pass rate for first time applicants was 78%
3 main reasons for failure(1) Does not recognise the issues or priorities in
the consultation (e.g. the patient’s problem, ethical dilemmas etc)
(2) Does not develop a management plan (including prescribing and referral) that reflects knowledge of current best practice
(3) Does not develop a shared management plan
The 3 areasData gatheringManagement planInterpersonal skills
Data gathering• Does not assimilate the written material
provided e.g. misses the fact that tests are abnormal (or concentrates on the wrong one!
• The first intervention is a semiclosed question• The doctor interrupts and breaks the story
telling• Cues are missed• Failure to gather psychosocial information i.e.
home life, workplace, caring responsibilities, community etc
• Failure to find out what the patient’s thoughts, fears and hopes are
Data gatheringTries to be comprehensive rather than
appropriately selective e.g. does systems review, orders batteries of tests
Misses red flagsFails to examine competentlyFailure to get to the diagnosis e.g.
Depression• Failure to reach any agreed shared
understanding of the problem
Management planTime pressure – don’t even get this farBecome doctor centred and ‘deliver’ the planFailure to give options and negotiateFailure to take account of patient’s thoughts,
fears and hopes (particularly so when they have not been obtained....)
Best medical practice is not followed
Management planToo superficial Inability to manage risk safely, safety net
appropriately etcMuddles data gathering and management
e.g. starts asking for more data in the management part of the consultation
Interpersonal skillsPoor rapport buildingMissed cuesConsultations are formulaic and woodenDoctor centred, not patient centredUnable to summarise, empathise, state what
they are seeing “You seem upset about that”
Comment from a GPST after completing a recent mock CSA“I don’t know what went wrong – after all I
ICE’d all the patients.......”
An example from a recent mock CSAPatient says - “I feel so depressed I’ve
thought about ending it all….”GP Registrar replies “Oh right. Had you
thought what might be wrong and what worries you?
The different types of failing registrar
Under prepared or badly preparedGo to pieces on the day
How to fail the CSA!
(1) Go underprepared – wing it!Plan to use a good consultation structure on
the dayForget all this stuff about basic knowledge &
evidence based practice Don’t worry if you can’t apply knowledge and
skillsStick with 15-20 minute appts at work – you
will be fine speeding up to 10mins on the dayGO on LOTS of courses – much better than
seeing patients
(2) Ensure you are poorly preparedDo the minimum number of COTsDo lots of COTS but no video skills or sit & swap
surgeries relating to CSA performanceKeep focussing on ICEing the patientsDon’t worry about using time effectively e.g. moving
the patient along, closing the consultationMake sure you have a small supply of stock formulas
and phrases to useRemember you may already KNOW the case (seen it
before on the course)Join a CSA group late, meet infrequently with no
strategy and ensure the group is homogenous e.g. all male
(3) Go to pieces on the dayMake sure you read the notes of the patient
who has just left, the one you just mucked up, not the one who is about to come in!!
Try to interact with the examiner (they are pretending to be invisible, so try really hard)
Go on the day, drive to Euston, misplace your ID at the hotel, take your old BNF with all your crib notes (which is then taken away at the start of the exam), don’t worry about checking your equipment, PARTY the night before!
Key messages