Month: January 2018

Posted in CSA, MRCGP, Uncategorized

Getting stressed about your CSA?

Posted on by Emma

Don’t!

Yes that is much easier said than done. But try not to because it will hamper your preparation. And remember that everyone prepares in different ways and everyone is ready at different times. You might be sitting your CSA on the same day as one of your colleagues and be stressing about the fact that they’re so much better prepared than you are. However, does it really matter? As long as you are ready by the day of the CSA it doesn’t matter if you’ve been ready one month, one week or one day before it. Yes we may feel more confident if we have been ready for a month but the flip side to this argument is that you could just have a really bad exam day and struggle. You wont though because you’re going to consult like you do every day, and you’re going to be great! That is rule one – believe in yourself. If you are doing the day job well (I would hope your trainer has talked to you if you aren’t) then it should be just fine.

How can you prepare for the CSA other than do your day to day consultations? There are many ways:

Role play with your trainer, your fellow trainees and even your family.

Video your consultations and show then to your trainers. Watch them yourself too.

Joint surgeries.

Don’t forget your clinical knowledge – make sure you know your red flags, your guidelines, your management plans.

You can create opportunities every day to incorporate these forms of preparation. Set rules for feedback – you don’t want your confidence to be knocked by lots of negative feedback, but continually sharing only positive feedback, or saying ‘it was fine’ isn’t going to help you get better. My trainees’ might describe me a bit tough and honest where feedback is concerned. Here’s my thinking – I’m going to tell you if it was fine and you might manage a pass. But I’m going to be a bit fussy and excessive too. Why? Because my principle is that when you are preparing you should be aiming for that ‘perfect’ consultation. You know – the one where it all comes together and you send the patient away with an amazing plan! For what reason am I doing this, rather than just making sure you can pass each consultation? For two reasons – the first is that I want my trainee to be a great GP, and I want their patients to see just how good they are. The second is more CSA focussed. There are very few of us who do not suffer from some degree of nerves when we are faced with a pressurised situation. The CSA is just that – it’s the last big hurdle in our training, it’s really expensive so we don’t want to pay for it a second time, it’s a foreign environment (to most of us) and we know that people can fail it. What happens when we are nervous? We are potentially not on our top form. So lets aim for perfection when preparing so that when the nerves hit we perhaps drop a little but not below the pass/fail threshold. So whoever you’re preparing with – ask them to judge you to perfection.

If you’re role playing a patient for a colleague then make it a bit tricky every now and again. Put your peers under a bit of pressure. Again it makes facing the CSA that little easier. From experience I really didn’t find there was a patient there to trip me up, and no one was really terrible to me! But if your colleagues have been a bit tough on you here and there then you won’t be phased if you have a consultation that’s a bit trickier, and most of the consultations will feel like a breeze compared to the practice you’ve been doing.

It may seem a bit odd to suggest practicing with your non-medical family and friends. But it can be really helpful. I recall practicing telephone consultations with my sister who lives 100 miles away. I gave her a rough brief on a topic she might have some idea of what kind of symptoms to have – thyroid, an ill child, etc. Then we would undertake the consultation in ten minutes, and I’d see how she felt it went. Non-medics are also great for practicing your explanations and planning with. However good at role playing you are it is always hard to put your medical knowledge out of your mind. So the explanation might seem fine to a fellow medic, but not so clear to someone with no prior knowledge. So try explaining CKD3 to your partner, or the two week wait to your friend. Genetics is a really good topic to role play with someone non-medical, because you will soon see that you can’t drop into a full description of mendelian inheritance in a ten minute consultation – you have to keep it simple and concise.

Don’t let your theoretical knowledge slip away. This is a really good reason for getting tied up in knots in the exam. When observing, I can tell when someone is starting to question their plan because they can’t quite remember what the guidelines suggest, or they don’t recall the cut off values for this and that. The consultation then just slowly falls apart because the trainee isn’t confident in what they are doing, and they are running out of time to complete the consultation. So know your stuff. The consultation skills get you a long way, but to go the whole way you need to back it up with knowledge.

Be yourself. I remember watching some videos back when I was about 4 months away from the CSA and cringing. I realised that I was consulting completely differently to normal in a bid to undertake the perfect consultation structure. The consultations went terribly and didn’t reflect my usual practice. Once this was highlighted to me I took a step back and started trying to improve my consultation structure rather than start from scratch. You need to be yourself otherwise it will awkward for you, the patient and the examiner. The use of stock phrases just doesn’t work. If this phrase is new to you and doesn’t fit your style or personality then it wont work with the effect it is hoped to. But, by all means take feedback on board and try out new techniques or phrases. Just don’t do it all at the same time! I do advocate being conscious of any words or things you do that you might want to work hard to wipe out of your consultations. Apparently my phrase was ‘I think’. I’m pretty sure I have erased this from my consultations but I know that I use phrase too much in day to day life because my toddler went through a phrase of adding ‘I think’ to the end of most sentences! So just be cautious of repeated words and phrases you use, or those that might make an examiner or patient (who does not know you and will have one encounter with you) think that you are not confident in what you are saying or doing.

I really hope this post has given you some pointers as to how to approach CSA preparation. There really isn’t a one size fits all preparation guide because we all learn differently. If I can answer any questions then please get in touch.

Posted in Consultation skills, Diagnosis, Malignant disease, Uncategorized

Referring for suspected cancer

Posted on by Emma

This is written following some CSA preparation with a trainee. Let me start with a usual disclaimer – I am no expert in breaking bad news or discussing this topic! I have spent a number of years trialling different methods of approaching this with patients. I’m still not sure I have it right but I wanted to share some thoughts to help you build on your skills.

I don’t know if there are many people out there who do not know of cancer. I would say the vast majority, if not all, have heard of the word. It may be that they don’t fully understand what that means though. But how good are you at using the word in your consultations and saying it with ease? It’s an easy word to stumble over and turn in to the most awkward conversation you’ve had that day. Even with those patients who have a diagnosis of cancer. So practice saying it aloud regularly. Normalise the word.

Here’s where I think the problem lies. Most of us are all a bit too nervous to say the word aloud to someone who doesn’t already have a diagnosis. So when we sit there worried that their symptoms suggest cancer, and we want to refer them, we try to think of every other way of saying it without using the word. We talk about the need to exclude serious, sinister or worrying causes. But none of these words define cancer. They could define any illness that may be more than something minor, or something that someone may have to live with or need an operation for. Some people may not even be sure what sinister means. So here’s the issue – we tell someone we need to refer them to clinic to rule out something serious (or sinister; or worrying) but we don’t tell them we need to exclude cancer. We then send them via a clinic that is specifically to exclude this, where there’s a reasonable chance someone else is going to use this word. Imagine being the patient at this point in time. You’ve trundled along to the hospital, on your own having taken the bus, thinking you might have something wrong that that the GP can’t quite sort out. You’re then faced with someone telling you that you’re in this clinic to look for cancer. Yep, I’d feel pretty stressed too. What if I’ve got cancer? Am I going to have to get home by myself and hold it together? Especially, if they decide you need further investigations to rule it out.

So this is what we need to do – we need to find a clear, yet sensitive, way of breaking this news to the patient. I would like to hope that somewhere along the way in your medical training you’ve been given some guidance on breaking bad news, and had the opportunity to practice this. (I wish someone would have given some guidance in medical school on how to tell a relative their loved one is dying or has already passed away – it would have made my days a junior doctor a little less painful).

We need to model this explanation and planning upon the breaking bad news methods. Because that’s what we are kind of doing. We are introducing the possibility of cancer to a patient, who may not have even considered this as the cause for their symptoms.

Firstly – have you gathered the patient’s ICE (ideas, concerns and expectations)? If you have then you may have already garnered that they are a) worried they have cancer or b) have a completely different agenda. A good example is the consultation regarding a breast lump. On the whole a woman thinks a breast lump = cancer. They want you to tell them it’s not. So they are still a little surprised when you explain you’d like to refer them onwards, but they understand why from the get go. The opposite is bowel or urinary symptoms I find. They think there’s probably something wrong but they haven’t often considered it might be cancer. They just want you to stop them from opening their bowels several times per day for example. So ICE is your starting point for knowing what your opener needs to be.

Use the above knowledge to start the explanation. Here’s the important part – I really think you need to use the word cancer at some point during this stage of the consultation. How you do it is something to work out for yourself, via practice. If I am not truly convinced it’s cancer but they sit within the criteria for a two week referral I usually say something along these lines:

” From everything you’ve told me I think you fit within the criteria for us to refer you urgently to rule out cancer as a cause. I’m not entirely convinced this is the case, however I think it would be wrong not to consider this”

Or if you’re really nervous about telling them you could try:

“For each area of the body there are set symptoms and time frames that have been listed as a reason to refer someone to rule out cancer. From what you have told be you fit into one of these categories so I really think it would be a good idea to send you to the hospital clinic”

If you’ve examined them and you are really worried because you’ve found a mass for example then tell them:

“When I examined your tummy I could feel a lump there. There are many causes for feeling a lump in the tummy. However, when taking the symptoms you told me you have into consideration, I’m worried this could be a cancer. So I think we need to get this looked at urgently”

The same goes for discussing a result that is highly suggestive, or confirmatory for cancer. Speak the whole truth.

Whichever way you decide to drop the word cancer in. Follow it up with a ‘would that be ok?’ and a ‘do you understand?’ or a how do you feel about that?’ You know roughly the answers to these questions but asking them out loud rather than assuming allows you to open up the discussion about how they are feeling and to do some (metaphorical) hand holding. Acknowledge that you understand this may be worrying, stressful, etc.

Discuss the next steps. Confirm that two week wait means they will be seen within the next fortnight. If it’s such they may have investigations first then explain this. If they’re going to the breast clinic or neck lump clinic then tell them it might be a long day and they might want to take a book. Suggest they may wish to go along with someone for company.

When closing the consultation and planning suggest some follow up so they know they can come back to you. If they don’t have cancer then they will still have the symptoms that need to be managed, and if they do then they might want to talk to you about it. In addition, if appropriate, make sure you offer some management for the symptoms they have in the meantime.

You might have noticed that I have dropped the word cancer into this narrative many time – because it’s an actual word with a definition and we shouldn’t be afraid of it.

It’d be great if anyone else has any good tips to share on how they broach the subject of a two week wait referral.