Category: MRCGP

Posted in ARCP, eportfolio, ESR, MRCGP

Learning logs, capabilities and self-rating

Posted on by Emma

Lets talk learning logs. The fourteen fish platform allows you to enter learning logs of varying types and keeps a tally of the number entered and how it compared to the expected number of entries. But how shall we use the learning log in the most effective way?

Lets think about what the learning log is aiming to achieve. What is it’s use. It’s clear aim is to allow you a place to store evidence of your development. It is there to allow you to evidence your capabilities and how you are covering the curriculum. When it comes to an Educational Supervisors report (ESR), you will use these entries to support your self-rating and your educational supervisor (ES) will use them to evidence their rating. Or, in the case of an interim ESR, to support your own self-rating. So in this respect the entries need to clearly demonstrate your level of competency.

The entries allow for reflection. Lets be honest – not everything you add to the learning log is going to create deep reflection. Attending mandatory BLS training is unlikely to leave you with a profound reflection. But the case reviews certainly should give you something to reflect on. But what this reflection is might vary.

I’m not going to discuss reflection any further in this post. You can see my earlier post on reflection here. What I’d like to do is think about the smart ways of using the portfolio to demonstrate evidence, and allow you to plan what you might need to add into the learning log.

So with each entry you are able to allocate both curriculum statements and capability statements. With respect to the curriculum statements you are aiming to show a well rounded coverage of these. Though the curriculum we cover will likely be influenced by the jobs we are in at that time. So to some extent you can plan which jobs will allow you work on which curriculum statements. Within general practice we will find that all areas can be covered. But medicine for the elderly and paediatrics will show some limitation, unless we are adding entries regarding weekly teaching sessions, revision for exams or other learning you undertake outside of the position you currently hold. By the end of ST3 though, we want to see a broad coverage of all the areas in fairly equal amounts.

Again, with each entry you are able to link it to up to 3 of the 13 capabilities. The trainee and their supervisor are then able to provide justification for demonstrating this capability. This is where I think the word descriptors should come into play. Below, after the example log entry, are some of the word descriptors for clinical management.

So when you’re recording this entry jump forwards to undertaking your self-rating and thinking about how to rate yourself. Make it easy on yourself. Look at the word descriptors as you record the entry. Copy and paste the descriptor that applies to what you are demonstrating and justify it. By doing this you are making it clear as to why you feel you achieve this self-rating and you are putting it on a plate for your ES to see and support your rating.

Lets take an example. I have a case where a patient came to me about their knee and was keen to get a referral for a knee replacement. I decided to examine them and as I was doing Lets take a made up example. A patient came to me to discuss their knee pain. They wanted a referral for a knee replacement. I asked if I could examine his knee. Whilst I was doing this I noticed he had a lesion on his shin. I asked a couple of questions about it and found out it had only been present for a couple of months but had grown quite a bit. The patient hadn’t been too worried about it and was more bothered about their knee pain. I was worried it could be an SCC. An SCC would warrant a 2ww referral. I therefore decided to acknowledge the knee issue but explained I was actually more worried right now about the lesion on their leg. I negotiated with the patient that I would organize a follow up call to talk further about their knee such that I could fully explain and discuss my worries about the lesion on the leg and what a 2ww referral entails. The patient was frustrated that I hadn’t sorted the knee out today but understood the importance of their referral.

So what capability is being demonstrated here? I looked over the word descriptors and think I have demonstrated and circled the ones I feel this case shows. So you can see that I have clearly covered NFD and competent word descriptors.

Perhaps if I had given the patient some more autonomy over when the follow up for the knee would be this would have also added a further competent area. I could also follow up with another entry from when I spoke the man again regarding his knee. Though he is showing signs of wear and tear he hasn’t gone down the physiotherapy route yet so he doesn’t meet local criteria for referral for knee replacement. It was a hard conversation to have and he asked me about how much I thought it would cost to have this done privately. After a further conversation we agreed that he would seek private physiotherapy to speed up the process and once this was completed I would refer him for consideration of a knee replacement. This then allows me to circle some of the word descriptors that come under excellent. I felt happy to consider myself ‘competent’ in my self-rating.

Regularly reviewing your capability areas and the evidence you have available in your portfolio will allow you to look for gaps and work out what you need to add to your log so that your entries are smart and relevant.

Also be aware that a case you log doesn’t have to always be something highly interesting/different/unusual. It just needs to provide evidence of what you are demonstrating in both capability and curriculum learning.

I addition I also urge you to think beyond this particular case/episode when reflecting. How does this case apply to your wider practice? Another example is:

You work in the endocrine department. You see a 23 year old who is suffering with DKA. You, alongside your seniors, initiate the correct management and her DKA resolves. You decide to enter a learning log and the reflection is that you now know how to manage DKA. So you link it to the clinical management and making a diagnosis capabilities. But in General Practice do we manage DKA? No. We need to recognize it but we will admit them to hospital. But what will we do as a GP? We will look after the long term management of this patient and her diabetes. We can provide education to prevent this from recurring, we can work with her to gain optimal control of her diabetes, monitor for complications and manage her emotional wellbeing. Was this something that was impacting upon her at the time of her DKA or subsequently. We could in fact draw upon the capability of practicing holistically because we are reflecting about how health beliefs can impact upon management of conditions, facilitating long term support, utilizing the community diabetes team or dieticians for support, for example. See where this is going? Think about the reflection more widely than “I was nervous because I didn’t know how to manage DKA but I do now and so in future I will not be nervous as I will know how to initiate treatment for DKA”

I hope this helps to think about how to use the learning log is a smart way that leaves you feeling like it has a purpose other than just extra work to complete!

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!

 

Posted in ARCP, eportfolio, ESR, MRCGP

Reflective learning

Posted on by Emma

This entry has come about through a chat with one of our trainee’s. He felt that it was difficult to get to grips with reflection. He told me that he got to know about Gibbs (1988) reflective cycle, and that this had improved his ability to reflect. I also recalled this was the model my sister was encouraged to use during her midwifery degree.

So I went back to my theory from my Postgraduate Certificate of Medical Education, did a bit more reading, and thought I’d share the salient features. Having looked through numerous theories of learning and reflection I do agree that Gibbs’ method fits the GP e-portfolio learning log well.

It’s important to note that reflection is a very personal experience. It can give an insight to your personality, and can reveal how you are feeling at a point in time. It’s useful to be open when writing a reflection, and feeling comfortable that whoever reads your entries will treat this information as confidential, and be supportive and developmental in their feedback. Though, it is sometimes easy to fall into doing a lot of description, and sharing of feelings, but less about how this has impacted upon your learning, and any changes you might make. Hence, why having some models to frame your reflection upon can help.

One of the earliest theorists to consider reflective learning was Dewey. His thoughts were that reflection was potentially very useful when making sense of situations that we may have found difficult. To learn from it required a description of the event and questioning ourselves to analyse why it occurred in that way, and considering ways to change the outcome of the event. (Dewey, 1933)

One of the most common theorists to come up in discussion of reflection is Kolb. His learning cycle (1984):Kolb learning cycle

It’s a very simple model. But what I don’t like about it is that one of the stages is to ‘reflect’ and I find that it doesn’t help with structuring the reflection. Instead, I would use this model in association with another model, that discusses the reflection in greater depth.

So we come to Gibbs Reflective cycle (1988).

Gibbs reflective cycle

Gibbs’ model of learning is what we call iterative – learning through repetition. The aims of his model are to:

  • Challenge assumptions
  • Explore different ways of doing things
  • Promote self-improvement
  • Link practice with theory
  • Thinking about the positive as well as the negative

I’m going to give an example of a reflection using this structure

Description – I saw a man in his 30’s who presented with haematospermia. It had happened on 2 occasions. As soon as he told me what the problem was I realised I knew nothing about the topic.

Feelings – I felt myself getting stressed because I didn’t know what I was going to do. I really had no idea whether this was something to be concerned about or not. I think, looking back, I must have looked disinterested because my mind was wandering trying to think what I was going to do, whilst he was still telling me about the problem.

Evaluation – Actually, I don’t know if he noticed just how stressed I was, as I managed to keep calm on the outside which was good. I explained a need to check some guidelines so I could quickly look on GP notebook to work out what to do! He seemed satisfied with the consultation, though I was quite worried that I’d missed something else during the time I wasn’t fully listening.

Analysis – I think my worry that I knew absolutely nothing about the topic hindered my ability to listen to the patient, and thus my consultation skills were not up to scratch. If I had been able to keep calm, and think ‘I can look this up’ earlier on, it would have facilitated a better consultation.

Conclusion – I could have been completely open with the man and said I wasn’t sure and needed to have a look/ask a colleague. I could have done this during the consultation or afterwards and followed this up with a call. I also think that I need to separate my concern about a lack of knowledge from the consultation structure. It hampered the consultation, and added extra stress.

Action plan – I will read up on haematospermia more thoroughly, and this might lead on to other men’s health topics I have less knowledge about. I will also try and role play some consultations where I really don’t know the answer, and try to focus on what I can do. I can also try out different ways to signpost that I need to look up some information.

References:

  • Dewey, J. (1933) How We Think. A restatement of the relation of reflective thinking to the educative process (Revised edn.), Boston: D. C. Heath.
  • Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development (Vol. 1). Englewood Cliffs, NJ: Prentice-Hall.
  • Gibbs G (1988) Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford.
Posted in Administration, ARCP, eportfolio, ESR, MRCGP, PDP, Uncategorized

A smart PDP

Posted on by Emma

I attended a joint trainer and trainee meeting, and the focus of the afternoon was how to develop and keep an active PDP during your training and beyond.

I thought I’d share some learning from this because I know that this is not the best part of my appraisal process, and an area that I have spent very little time thinking about previously.

This session really helped change my thinking and knowledge of the process.

What is a PDP?

It’s a personal development plan. It’s a way of showing your supervisor that you are considering your learning needs and how you plan to meet these needs. This is by setting an action plan that details what you will do to address this learning need, how you will evidence that this has been completed, and a timeframe for this learning.

Why is it important I hear you ask……

……because we are learning all the time. A good PDP will focus your learning, and allow you to prioritise your time and learning needs. There is large amount to cover during GP training, and it’s going to seem daunting at times. So setting some aims and making plans might just make it a little easier.

Also, being MRCGP focussed, apparently some ARCPs have flagged up a poor PDP, or with nothing ‘active’ within it. This has held up some trainees’ progress to certification. In addition, the PDP you have at the end of GP training will form your PDP for your on-going appraisal process. Having an active PDP is mandatory for appraisals, and completed appraisals, are mandatory for revalidation.

How do I get started?

Firstly, how many entries should we have on our PDP? The golden number is three, however you may more or less! You need enough to show you’re addressing your learning needs, but not so many that you cannot keep up with the learning. Some might be more straightforward than others, and some more complex. Some may have a relatively short time frame, and some longer.

What shall I include?

This is where it gets difficult. It’s a ‘personal’ development plan. So you are the only person that can answer this. You need to look at your learning needs (lets talk about learning needs assessment/analysis another time). Perhaps they will relate to the current job you’re undertaking. They may relate to where in your training you are. For example, if you are preparing for AKT they may be related to knowledge development, or preparing for the CSA they’ll perhaps be more specific to consultation skills. They might be related to developing an interest you have, or managing your work life balance. If you can justify the reason for including it at this time, then go for it.

Creating the perfect PDP item

It needs to be ‘SMART’

S – specific

M – measurable

A – attainable

R – realistic and relevant

T – timescale

I’m going to use an example from my current appraisal, which I have now refined to reflect the above learning! I think if I use an example to talk through it, it will make more sense.

Specific – ‘To become accredited as a full trainer’. This is a specific aim, as opposed to something along the lines of ‘develop my training skills further’. The latter could include anything, and doesn’t necessarily have an end point, whereas the former has a defined end point.

Measurable – I can evidence that this has been completed via being approved as a full trainer. I can link to areas in my learning log that show the things I have done to support and facilitate my application.

Attainable – Can I get this done? Well I know there is a trainer panel in February time. I have been attending the right meetings, and undertaking the appropriate work in anticipation of this, so it is definitely possible!

Realistic and relevant – The work I need to complete to achieve this is already part of my workload, so I am not adding more work to my plate. I do need to factor in some time to complete the paperwork though. It is relevant, because we have an ST3 currently, and without being a full trainer I cannot be a named supervisor for an ST3, which I would really like in order to further my position within the practice where training is concerned.

Timescale – Well I shall aim for the end of March, as this gives me time to complete the application, attend the panel and hopefully receive confirmation that this has been achieved!

By laying out the objective like this I have focussed my learning, I know what I need to do, and I am telling whoever’s reading it what I’m going to do and how.

I have added a link to a good RCGP document on completing a PDP, with some good examples of real PDP entries, and what makes them work well or not so well. Follow this link and then click on the PDP pdf.

Why don’t you sit and write a PDP entry now and see if it’s a bit easier. Feel free to share some ideas or ask questions in the comment sections below!

Posted in Administration, MRCGP, Uncategorized

Welcome

Posted on by Emma

This is a blog I have set up to share information about GP training with trainees. It might be or interest to trainers and fellow GP colleagues also.

I have been a trainee. Sometimes you just don’t find the answer you’re looking for about how to get things done. Sometimes you just need a snippet of information rather than a whole essay. Sometimes you’re just thinking ‘how do I explain this to a patient’.

I’m going to try and help! This is new for me, and I’m going to figure out what to add in as I go along. That’s where I need my readers’ help and interaction – If you give me ideas, based on what will help you I will shape this to meet your needs!

I’m an associate trainer, and I do weekly tutorials with my trainees’. I will take some inspiration from what they suggest as topics, and share some of these with you too.

I also hope it’s a place for support – if you work with me and use the comments section to share ideas, tips and thoughts, it develops a network of trainees beyond your local area potentially.

The only thing I wont be doing, and I really don’t want you to do, is put anything that is patient specific on here. Any ‘cases’ I use for learning will be ones that are made up. They will be those patients that make the ‘perfect’ CSA case, or ones that allow us to consider and practice our communication skills. They are often the brainchild of active imagination that I bring to role-plays – I do have an A* in GCSE drama don’t you know!!