Preparing for the CSA: Overview

Dr Claire Powell

September 2017

Communication Skills training

Started September 2012

Three year modular communication skills training

Six VTS afternoons per Academic year

Autumn term – 3 meetings

Spring term- 2 meetings including a “mock CSA” afternoon in January

Summer term- 1 meeting

Why?

The CSA exam is the main reason ST3 registrars need extensions to training

The CSA exam is seen as “challenging” by ST3s

The CSA pass rate is very variable and appears to favour female UK graduates

Communication skills

• ST1

• Consultation models

• Verbal and non verbal communication

• Consultation styles

• Rapport

• Information gathering and giving

Communication skills

• ST2

• Information gathering and giving-2

• Psychosocial context

• Information giving-good practice

• Information giving-practical session

• Videos and feedback

Communication skills

• ST3

• Videos and role plays

• Videos and role plays

• Mock CSA

• Videos and role plays

• Session 6-hot topics/TBC

CSA Examination What is it all about?

• Passing!

• Skills for life as a GP

• What are the rules?

• How should you prepare?

• Are there any top tips?

CSA- what is it for?

• Examination designed to assess safety and competence as a jobbing GP.

• Are you safe to be practising as a GP outside of the training scheme

• It is an assessment of the doctor’s ability to carry out EFFECTIVE consultations

Conversation

• What is a conversation?

• CP/JA conversation

Consultation

• CP/JA consultation

Listening

So: its all about the consultation

• Beginning

• Middle

• Ending

Styles of consultation

• What do we mean?

Introductions

• Introduce yourself to your neighbour

• Neighbour-ask about what they had for breakfast today

What happens at the CSA

• 13 cases, all of them count.

• Three circuits each session

• Each case has an examiner,

• 10 minutes with each case, after which actor and examiner leave the room

• 2 minutes between cases

• Case notes are now on iPads

Timings in the CSA B

ell*

**

*

2 minutes preparation

Read the info for the next case B

ell

**

**

10 minutes for the case

Bell*

**

*

Prepare the next case

The Patients

• Are mostly adult actors.

• Some adults can play children of 12+

• From November 2012 there may be children as patients (not many)

• A “parent” may come without their “child”

The Cases

Every session- 3 circuits same 13 cases, 3 different actors play each case Are rehearsed by the examiners on the day All cases start in the same way and develop depending on you. Should respond with the correct info if you ask the correct question

The Examiners

• Are all working GPs

• Will mark the same case for the session

• Are involved in setting the pass mark for the session, based on the “Borderline Group Method”

• Don’t worry about this. It makes it fair each session

How are the cases assessed?

Domains

Data Gathering

Clinical management

Interpersonal skills

• History

• Examination

• Diagnosis

• Treatment

• Follow-up

•Rapport

•empathy

• ICE

•context

Data Gathering

• Read the history provided on iPad

• Proficient history, focussed, relevant

• Exclude red flags

• Choose correct examination/Ix

• Proficient, courteous, physical examination if indicated-NOT A MEDICAL SCHOOL EXAMINATION

• Proficient use relevant diagnostic tools

• Max 3 points

Clinical management skills

1. Explain the problem / diagnosis if possible

2. Offer effective and safe treatment with choices, explain options

3. Use investigation, prescription and referral appropriately.

4. Recognise an urgent situation and respond.

5. Manage risk, co-morbidity, HP where possible

Interpersonal skills

Attitude, empathy and good communication skills

1. Do you establish rapport.

2. Do you show sensitivity and empathy.

3. Do you explore the patient’s concerns.

4. Active listening and show understanding.

5. Use language suited to the patient.

6. Discuss options for treatment.

7. Respect patient autonomy.

Interpersonal Skills

• Do you elicit a “good story”-does it flow?

• Do you “get on board with the patient”

• Do you show skill in explaining, summarising

• Do you involve the patient in the management plan

Overall…..

• The examiner makes an overall judgement.

IS THE CONSULTATION EFFECTIVE?

Relevance?

• Consulting is the main task of a GP

• These are skills for your working life

• Sooner you start the easier the CSA will be when you get to it!

Tea break

Exercise

• Groups of 3

speaker

observer

listener

Observers

• Look for active listening

• Look for clarification

• Look for rapport

First speaker

Tell your listener in great detail about a TV programme or a film that you have seen recently……..

Second speaker

• Tell your listener about a recent holiday that you have had

Third speaker

• Tell your speaker about your favourite album/band

Feedback

THE SCORING In each domain of each case:

3 =clear pass=above average 2 =pass 1 =fail 0 =clear fail You have to perform well in every domain

to pass the case

Scoring in the CSA

Data Gathering

0-3

Clinical management 0-3

Interpersonal skills 0-3

Maximum for each case 9

Maximum for 13 cases 117

Appealing your result

• You can only appeal on the grounds that the Process was not properly followed.

• You can’t appeal if you disagree with the marking of a case

So what sort of cases will there be?

TYPES OF CASES • Mostly face to face consultations with the

“patient” • Can be proxy consultations with the

parents of a child • There can be telephone triage/advice

cases. • Professional conversations- DN, hospice at

home etc. Think about phone consults when you are DD

• Home visits-patient in a bed in a special room

Types of scenarios

• Clinical scenarios with targeted examination

• Complex cases

• Results

• Medical

• Patients with issues-emotional-angry

• Urgent cases

• Interrupted cases

• Almost anything can be adapted for CSA!

Don’t assume you have guessed the scenario

• The cases change all the time

• It is better to act as if you are seeing real patients

• You can easily go down the wrong track

Examination • Carry on and examine if you would

normally in your consultation. The examiner will interrupt you with a card if appropriate

• There may be prostheses eg breast lump • There may be photographs-rash, mastitis,

cellulitis etc • Think about conditions suitable to be

“acted” • There may be real breast examinations

included

Why do candidates fail?

Data Gathering

• Time management

• Prioritising/Agenda setting

• Not excluding red flags

Clinical management

• Time management

• No coherent management plan

• Poor explanations

• Insufficient consideration of the differential diagnosis

• Inadequate sharing of a realistic range of management options

Interpersonal skills

• Poor understanding of the values a patient brings to the consultation

• ICE through all domains

• Not checking that the patient

understands

• Formulaic consultations that don’t feel “natural”-stock phrases etc

• Poor housekeeping

How should you prepare? Start in ST1 thinking about

Consultation skills. Aim to get to 10 minute consultations

as early as possible in ST3 Courses Small group learning/Peer review-good if the group is good VIDEO for your benefit and for debriefing/peer review Ask your trainer to sit in with you, in a normal surgery ATK knowledge-don’t forget it!

ARE THERE ANY “TOP TIPS”

Think about the examiners first impression of you

• Be and look ENTHUSIASTIC

• The examiner is seeing you for the first time

HOUSEKEEPING

• The examiner knows nothing about your last case

• As soon as the case has walked out PUT IT TO BED

• Spend the 2 minutes preparing the next case not beating yourself up about the previous case

Ignore the Examiner

• 100% eye contact with the patient

• Don’t interact with the examiner AT ALL

• Don’t wait for an examination card-CARRY ON

• NEVER ask the examiner “shall I examine the patient”

Actors….

Can probably mimic

Tennis elbow

RSI

Back pain

But NOT-splenomegaly or AF

Data Gathering

• Don't use all the stock phrases in every consultation. The consultation needs to FLOW naturally.

• Agenda setting is important but USE YOUR COMMON SENSE……..

• Empathy is good…but think about what you say….

If you examine the patient….

• TALK THROUGH the examination to the PATIENT not the EXAMINER

• Explain what you are doing and what you have found

• Summarise at the end TO THE PATIENT

Manage the TIME

• Time management is vital- most of us could easily data gather for the whole 10 minutes.

• You are unlikely to pass if you never get to Management

• After 5 minutes move on to management/explanation etc

Explanations

• Management plan is for the PATIENT. Do not lecture the examiner on the diagnosis.

• If smoking is an incidental finding SIGNPOST the patient don’t embark on a Smoke-Stop lecture-it takes too much time ( and might irritate the examiner-would you do this in your surgery???)

Endings…

• If the consultation comes to a natural end before the buzzer goes LET IT

• Don’t assume you have missed something!!

• Be natural, let it flow!!

• The patient/examiner will wait outside until the buzzer goes-if you think of something you have missed call them back in.

Take home messages

• Even though the pass rate has fallen it is still high

• Everyone can pass on the day if they are all good enough

• The best preparation is completed TEN MINUTE CONSULTATIONS in your practices

• ST1s- START NOW!!

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Any questions