I went to the autumn seminar at the end of September, and I saw a session on clinical management in the CSA. So I circled it and made sure to attend. Having sat the CSA myself I really couldn’t say with certainty exactly what they were looking for. I have also found this with trainees I have helped prepare since. I think the data gathering section is obvious (because you need to take a thorough yet relevant history), and interpersonal skills are also pretty straightforward. But with the clinical management it’s hard to be sure whether we are supposed to have a clear diagnosis, whether we need to show the examiner we know everything there is to know about a topic, give 10 options to the patient, or completely cure them in one consultation!
In addition, the commonest CSA feedback statements are related to clinical management, and this is where trainees are most likely to lose marks.
This session was, by far, the most useful I have attended to date. So I thought I would share some of my learning from it. It was led by Dr Roger Tisi, who is the Associate Postgraduate Dean for Health Education East of England. All credit is to him for making things clearer, and being a great presenter! In addition, this information is from his session so I must also credit him for the knowledge I pass on.
The first point that was made clear is that we should consider that we aren’t just getting 3 marks for the clinical management section. We should assume that half the marks for each station are related to clinical management since interpersonal skills run throughout, and are linked in with a good management plan.
The commonest pitfalls in the CSA are what we all know they are – running out of time, missing the point and managing a condition but not managing the patient who has the condition.
A lot of people in this session noted they would see a clear drop in energy levels as a trainee reaches the second half of the consultation. So you need to think about how you might keep that energy up, and provide a great management plan. Some suggestions included repositioning yourself and straightening your posture, taking a deep breath, etc. The clinical management section begins at the time that you put a possible diagnosis on the table. One possible way to ease in to the clinical management section is to repeat their ideas, concerns and expectations back to them. You might want to think about how you phrase this, but if you can achieve this then you know that you’ve got to the bottom of this consultations, and are on the right tracks. In addition, it means you are more likely to manage the patient and the psychosocial context rather than just the condition in general.
What I took away that is very important is that the CSA doesn’t require you to have a diagnosis in every case. You may be creating a differential diagnosis, or dealing with a dilemma, or providing something else such as advice or support. Remember this – how many times per session do you sit and listen to a history and make a definitive diagnosis at the first appointment? I know that I often come up with some differentials, and have to undertake some further investigations to create a diagnosis and an appropriate management plan. So if it’s ok in real life, it’s ok in the CSA!
You need to provide your explanations in such a way that both the patient and the examiner can understand. You may wish to refer back to any concerns the patient has raised here. Something I like to do, and that we discussed in this session, is thinking out loud (We’ll call it the Em Sheerham technique). Sometimes you have a lot of thought running through your head ‘it could be this or it could be that’, ‘to decided I think I need to do this or that’, ‘normally we’d do this but this patient is that’. If you sit in silence having those thoughts it looks awkward, and also no-one knows why you then come up with the plan you have made. In addition, if you’ve thought it all through in your head then there’s a good chance that when you verbalise it you do it in such a way that you don’t give the full information. Instead, say it out loud – confidently. If you do this then both the examiner and patient see where you’re coming from and understand your rationale. They are more likely to get on board if you make it clear what your thinking is.
Just to reiterate – you must put it into the context of the patient you have sat in front of you. E.g. the lady that’s had a funny turn (possible seizure) who drives for a living, the contraceptive advice for the 15 year old who’s boyfriend is 19. It might be when doing this that you realise you’ve missed a crucial piece of information. If you have then signpost that you hadn’t asked a question that may be of relevance and then ask it. The examiner might realise for the first time that you’ve missed something here so be careful!
Options, options, options! Guess what – sometimes it’s ok to give few or non-options. On the basis that you keep it patient centred, and explain your rationale. E.g. the patient who is worried he may have cancer, and you’re worried he has cancer. The only real option is 2WW referral – so that’s what you’re going to offer – just explain why! You need to inform the patient to allow them to be involved in the decision process, whether there are lots of options or none. Again, this is whether thinking aloud helps, and remembering that the consultation is a dialogue or a conversation – not a presentation!
But whatever you do – do something! A really good point that Dr Tisi made was that the examiner might ask himself at the end of the consultation ‘Is this patient better off for having seen this doctor today?’ They want to be able to say yes, and if you do nothing at all then the answer will be no. So make a plan that the patient is happy with and go with it. Do not run out of time before you’ve done this.
Make sure the patient knows what the plan is, agrees with it, knows how it is to be executed, and there is follow up to ensure patient safety. Be clear on it. E.g. if you say you’ll get in touch with them then tell them how e.g. telephone, writing to them or face to face.
Last crucial point – DO NOT AVOID THE ELEPHANT IN THE ROOM! It is in the CSA for a reason. However painful you might think it will be to address the 14 year old with the 20 year old boyfriend, the drug addict, the patient with back pain who probably has bone metastases, etc. You must address this, otherwise chances are you will fail!
Few little pointers:
- Video consultations – watch some of your own and check whether you are a serial word user. This can be annoying to an observer so just be careful! I remember I used to say ‘I think’ a lot, and my supervisor pointed out that I sound unconfident, even when I knew I was doing the right thing.
- Stock phrases such as ‘what were you hoping I could do for you today?’ need to be used carefully, and in the appropriate context. Otherwise they just sound wrong, patronising, ridiculous. If a phrase is completely out of your comfort zone then don’t bother with it.
- Patient preference doesn’t always take preference. It’s Ok if you don’t give the drug addict more fentanyl patches.
- Consultations don’t necessarily have to end on a positive note – e.g. as with the above scenario. But this shouldn’t be due to an inappropriate management plan or lack of consultation skills!
You just need to practice all of this, and with time it will just flow. Remember if you need to practice explaining diagnoses or treatments then the best person you can find is a non medical friend or relative. You can easily work on a jargon free explanation with said individual!
The GP trainee's survival guide 