1. CSA How not to fail Dr. Louise Riley Trainer (Bradford VTS)
Examiner (CSA component)
Introduce / privilege / Code of conduct for examiners / I may say I’m unable to comment
Fair and consistent exam, great lengths to ensure consistency of cases and marking

2. Help!
When I say CSA what’s the very first thing that comes into your head?
List on flip chart
How we’ll address those issues

3. Agenda Introduction to CSA Personal experiences
Case examples from college DVD
Marking and discussion
How to prepare
Different people at different stages / personal experiences, bits that you cant get from books or rcgp website
Types of cases, how they are selected / What are they looking for-
Going to look at 2 cases from the college dvd, use the marking schedule
discussion about marking and what’s really important about each case
After coffee split into small groups and discuss ways to improve performance of the candidates seen

4. Knowledge Competence Performance
What you can test...
Knowledge Competence Performance
Knowledge you test in an mcq
Competence you test eg in a viva eg what would you do if...
Performance is testing what you actually do
Musical instrument

5. The Theory...
‘An assessment of a doctor’s ability to integrate and apply appropriate clinical, professional, communication and practical skills in general practice’
The point is that it tests performance- ie what you do , rather than what you know or say you do

6. Where... Croydon Park Hotel Jury’s Hotel
Number 1, Croydon (opposite East Croydon station)
Floors 18,19,20
Colour coded
DO NOT BE LATE !
Stay at...
Croydon Park Hotel
Jury’s Hotel
Huge tower cant miss it
Stay in Croydon or at Victoria- 20 mins on train from there Don’t travel from Yorkshire for an a.m. exam!

7. What’s it like ? Simulated surgery 13 stations,12 “live” one pilot
10 minutes each
2 minutes between
You stay put, role players and assessors move
You are shown to a consulting room which will be your home for morning
The assessors and role players rotate through each consulting room at 12minute intervals.
When the 10 minute buzzer goes, everything stops. The rp and ass leave ,the assessor fills out a mark sheet and puts it in the door in which you are consulting. The floor marshal then collects these, the rps and asses move on to the next room and the process starts again

8. It’s not like this! A picture of everyone looking jolly
In reality the assessor will be seated and as unobtrusive as possible!
ASK PEOPLE TO SHARE THEIR EXPERIENCES

9. What do I need ? Passport or photo-card driving licence
Doctor’s bag containing:
BNF
Stethoscope
Ophthalmoscope
Auroscope
Thermometer
Patella hammer
Sphygmomanometer (aneroid or electronic)
Tape measure
Peak flow meter and disposable mouthpieces
You need to bring all your own kit. If you don't have an ophthalmoscope you cannot demonstrate to the examiner that you know how to use one!
On the table- prescription pads sick notes, case notes for each case- look at them carefully!

10. How are cases selected? Mostly written from GPs’ own experiences
A spread of cases across the curriculum
Each case mapped to a specific area of the curriculum
There is a panel of case writers who are all experienced gps All cases are piloted before use and should have any problems ironed out
Cases are typical of a normal gps working life, surgery, home visits, telephone consultations, maybe carers or parents
Each case is mapped to an area of the curriculum- next slide

11. Case Selection Blueprint
Clinical Skills Assessment Case Selection Blueprint
Primary nature of case
Primary system or area of disease 
Acute Illness
Chronic Illness
Undifferentiated Illness
Psychol and Social
Preventive
/lifestyle
Other
Cardiovascular
Respiratory
Neurological/ Psychiatric
Musculo-skeletal
Endocrine/ Oncological
Eye/ ENT/ Skin
Men/ Women/ Sexual Health
Renal/ urological
Gastro-intestinal
Infectious diseases
ETC
A cross section of cases for each exam is selected using a specified choice from the matrix
Also case selection criteria beyond the agreed rubric for the matrix:
Gender mix
Diversity eg culture, disability, religion and sexual orientation
Age mix (child, older person).

12. What sort of cases are there?
Cough with ACE inhibitor Young woman with headache Child with constipation Man with Dupuytren’s contracture Woman with diabetes and depression Man with anxiety and palpitations
these are taken from the website or the CSA DVD
Involve integrating communication skills, diagnostic skills, negotiation
You could think of lots more, try writing down a few cases in your next surgery that might be suitable to give you a feel for the process

13. What are they looking for?
3 Domains:
Data gathering
Clinical Management
Interpersonal skills
There are 3 areas given grades for each case and then an overall grade is awarded
Data gathering includes history and examination skills, investigations and their interpretation
Clinical management- a structured and flexible approach, able to deal with managing complexity
Interpersonal skills- comm skills to understand the patient’s illness experience and develop a shared approach to managing problems. Practising ethically with respect for equality and diversity

14. What are they looking for?
In each domain we look for observed behaviours
Establishing reason for attendance
Examining chest
Ability to negotiate
Consider health promotion issues
Practising ethically
Management plan in line with best practice
Word pictures

15. Marking You get a grade for each domain Then you get an overall grade
Clear pass
Marginal pass
Marginal fail
Clear fail
Then you get an overall grade

16. Marking Scheme Case 1- Note for the Gym
Domain
Observed behaviours
Grade
(CP/MP/
MF/CF)
Data gathering, examination and clinical assessment skills
Establish reason for attendance ie need to get note for gym and what is required for this
Explore any current health problems and past medical history, including raised cholesterol
Show ability to check BP and chest
Clinical management skills
Formulate an appropriate plan to address possible raised cholesterol and BP
Consider health promotion issues eg smoking, wt, alcohol and exercise
Show ability to manage request for note appropriately, recognising implications
Interpersonal skills
Elicit any underlying concerns regarding raised cholesterol and heart problems
Show ability to negotiate as necessary re the note and the management of any health problems, share management options
Take an interest in the patient, avoid lecturing him about lifestyle
Hers is a shortlist of observed behaviours.
You may wish to include more when doing your own marking. Examiners might have 15
We havent had a calibration exercise

17. Do I get any feedback?
Yes, but it’s feedback on the whole CSA performance, not an individual case The assessors pick from a list of feedback statements
16 feedback statements
In exam, assessors mark 4-6 feedback statements if they have failed you on a case
Only if 3 or more people have marked a statement will it be fed back to you
I have given you a copy of the statements
Split into pairs and discuss which ones you would give to the last candidate

18. Feedback statements Data Gathering
1. Disorganised and unsystematic in gathering information from history taking, examination and investigation
2. Does not identify abnormal findings or results or fails to recognise their implications
3. Data gathering does not appear to be guided by the probabilities of disease
4. Does not undertake physical examination competently, or use instruments proficiently
Clinical management
5.  Does not make appropriate diagnosis
6. Does not develop a management plan (including prescribing and referral) that is appropriate and in line with current best practice.
7. Follow-up arrangements and safety netting are inadequate
8. Does not demonstrate an awareness of management of risk, and health promotion
 Interpersonal skills 
9. Does not identify patient’s agenda, health beliefs & preferences / does not make use of verbal & non-verbal cues
10. Does not develop a shared management plan or clarify the roles of doctor and patient
11. Does not use explanations that are relevant and understandable to the patient
12. Does not show sensitivity for the patient’s feelings in all aspects of the consultation including physical examination 
Global 
13. Disorganised / unstructured consultation
14. Does not recognise the challenge (e.g. the patient’s problem, ethical dilemma etc.)
15. Shows poor time management
16. Shows inappropriate doctor-centredness
What f/back statements have people given?
Discussion then coffee (?about 3.30)
After coffe another case to mark and d/c use feedback statements

19. Marking Scheme 2: Pain in the Neck
Domain
Observed behaviours
Grade
(CP/MP/
MF/CF)
Data gathering, examination and clinical assessment skills
Take a history of the neck pain and what has been tried so far
Examine neck/shoulders appropriately
Explore psychosocial situation- effect on work and life
Clinical management skills
Give appropriate prescription for pain, or advise on over the counter remedies
Advise on other appropriate treatments eg heat, stretching exercises, avoid collars
Indicate how problem may resolve
Interpersonal skills
Explain pros and cons of various treatments
Acknowledge patient’s ideas and expectations about treatment
Negotiate with patient sensitively
After coffee watch another case if time
Discuss marks- show of hands pass/fail
Anything she didnt do well?

20. Pick one feedback statement
Feedback to group

21. How can Dr X Improve?
Turn the feedback statement into constructive advice
What practical steps might this doctor take to improve performance?
Split into 3 groups and discuss ? of the feedback statements you have given for either case
How could Dr X improve her performance?
Spokesperson for each group to bring ideas to larger group

22. Feedback statements Data Gathering
1. Disorganised and unsystematic in gathering information from history taking, examination and investigation
2. Does not identify abnormal findings or results or fails to recognise their implications
3. Data gathering does not appear to be guided by the probabilities of disease
4. Does not undertake physical examination competently, or use instruments proficiently
Clinical management
5.  Does not make appropriate diagnosis
6. Does not develop a management plan (including prescribing and referral) that is appropriate and in line with current best practice.
7. Follow-up arrangements and safety netting are inadequate
8. Does not demonstrate an awareness of management of risk, and health promotion
 Interpersonal skills 
9. Does not identify patient’s agenda, health beliefs & preferences / does not make use of verbal & non-verbal cues
10. Does not develop a shared management plan or clarify the roles of doctor and patient
11. Does not use explanations that are relevant and understandable to the patient
12. Does not show sensitivity for the patient’s feelings in all aspects of the consultation including physical examination 
Global 
13. Disorganised / unstructured consultation
14. Does not recognise the challenge (e.g. the patient’s problem, ethical dilemma etc.)
15. Shows poor time management
16. Shows inappropriate doctor-centredness
What statements did you choose?-ask a spokesperson
How did you turn this feedback into practical steps?
Talk about rcgp suggestions- look on website

23. How can I prepare?
Back in the large group, share ideas about preparation/ ways to improve performance
How many of them are you doing already?

24. Ten Top Tips To Pass The CSA
Arrive on time
Bring your bag and identification
Read carefully the information provided for each case
Practice ten minute consultations
Practice focussed examinations
Don’t be phased by the cases, stick to the basic principles of patient centred consulting
Don’t forget psychosocial and family history
Remember treatment by other means as well as drugs
Remember “Housekeeping skills” i.e. put the last case behind you and concentrate on the rest. You do not have to pass all thirteen cases
Remember there is often not a right or wrong answer, examiners are looking for how you tackle the cases

25. Any Questions?

26. Good Luck!