Category: CSA

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, CSA, Diagnosis, MRCGP

CSA – What’s clinical management all about?

Posted on by Emma

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!