1. CSA Feedback – how not to fail the CSA Dr Chris Webb Yorkshire and Humber Deanery

2.  Why do candidates fail?  What can you do to avoid failure?

3. Learning outcomes

4. How it is marked  Data gathering  Clinical management  Interpersonal skills

5. Feedback Statements Feb/March 2011 Y&H Deanery  Disorganised / unstructured consultation  Does not recognise the issues or priorities in the consultation (for example, the patient’s problem, ethical dilemma, etc).  Does not develop a management plan (including prescribing and referral) reflecting knowledge of current best practice  Does not develop a shared management plan, demonstrating an ability to work in partnership with the patient

6. General Features  Passing  Fluent, interactive and relevant  Is able to take patient into medical world as a shared partner  Open about lack of knowledge or certainty and may use this constructively  Active monitoring during consultation  Failing  Poor use of time  Uneasy with or unable to acknowledge own ignorance or uncertainty  More scripted summary than checking understanding  Unaware of personal space

7.  Disorganised / unstructured consultation  Does not recognise the challenge (eg the patient’s problem, ethical dilemma)  Shows poor time management  Shows inappropriate doctor centredness

8. Data Gathering  Passing  Can take a focused history that includes all relevant information  Embedding of questions in previous response  Failing  Formulaic questioning which can become interrogative  Repetitive questioning  Sequence of questions does not make sense

9. Data gathering  Disorganised and unsystematic in gathering information from history taking, examination and investigation  Does not identify abnormal findings or results or fails to recognise their implications  Data gathering does not appear to be guided by the probabilities of disease  Does not undertake physical examination competently, or use instruments proficiently

10. Clinical Management  Passing  Appears knowledgeable and refers to recognised algorithms or modes of practice  Able to suggest solutions to problems or a range of reasonable management options likely to be agreeable to patient  Failing  Insufficient knowledge base, or ability to think of realistic and effective alternatives  Fails to integrate and apply knowledge  Puts off making clinical decisions or a clear diagnosis  Doesn’t appear to grasp the dilemma if there is one

11. Clinical management  Does not make an appropriate diagnosis  Does not develop a management plan (including prescribing and referral) that is appropriate and in line with current best practice or makes adequate arrangements for follow up and safety netting  Does not demonstrate an awareness of management of risk and health promotion

12. Interpersonal Skills  Passing  Connects instantly with patient  Non-judgmental  Interested in the patient  Reformulates explanations using helpful metaphors  Can meet patient half way – picks up patient’s agenda, accent, or cultural approach.  Failing  Doctor-centred/patient’s concerns not addressed  Patronising  Unable to explain effectively – may be wrong or not tuned to patient  Inappropriate use of terms  Over patient-centred to the detriment of clinical outcome

13.  Does not identify the patient’s agenda, health beliefs & preferences / does not make use of verbal and non- verbal cues  Does not identify or use appropriate psychosocial or social information to place the problem in context  Does not develop a shared management plan or clarify the roles of the doctor and patient  Does not use explanations that are relevant and understandable to the patient  Does not show sensitivity for the patient’s feelings in all aspects of the consultation including physical examination

14. How should we therefore aim to consult?

15. What is your own consultation model?

16. Global Data Gathering Clinical Management Interpersonal Skills CC and the CSA

17. Do Consultation Models help or hinder Trainees taking the CSA?

18. Dysfunctional learning? The examiners are looking for pre-agreed competencies to be displayed in the CSA Certain behaviours of trainees are thought to demonstrate these competencies Trainers attempt to teach their trainees to exhibit these behaviours Some trainees are resistant to learning the behaviours Others adopt the behaviours, but in a mechanistic way which fails to satisfy the examiners

19. Tentative hypotheses A focus on behaviours alone does not appear to help trainees pass the CSA: We cannot say: “Do this and you will pass …” A focus on behaviours may make things worse: ‘Artificial’ behaviour sequences may prevent people using the natural rapport, listening and explaining skills they possess A cognitive approach (knowing what to do) is not sufficient: Skills are important Attitudes, beliefs and values are crucial

20. What is good about consultation models? Models help us to make sense of our world They provide a framework or structure to help us understand a large or complex concept, and break it down into discrete, manageable units

21. What’s wrong with consultation models? They focus on behaviours They assume that cognitive insights will result in better consulting They don’t deal with intuition and the basic human skills of interaction They don’t address the beliefs and attitudes that shape our interactions

22. Generic CSA Grade Descriptors CP The candidate demonstrates an above-average level of competence, with a justifiable approach that is fluent, appropriately focussed and technically proficient The Candidate shows sensitivity, actively shares ideas and may empower the patient P The candidate demonstrates an adequate level of competence, displaying a clinical approach that may not be fluent but is justifiable and technically proficient The Candidate shows sensitivity, and tries to involve the patient F The candidate fails to demonstrate adequate competence, with a clinical approach that is at times unsystematic or inconsistent with accepted practice. Technical proficiency that may be of concern The patient is treated with sensitivity but the doctor does not sufficiently facilitate or respond to the patient’s contribution CF The candidate clearly fails to demonstrate competence, with clinical management that is incompatible with accepted practice or a problem-solving approach that is arbitrary or technically incompetent The patient is not treated with adequate attention, sensitivity or respect for their contribution

23. How to annoy the examiners If you really want to annoy an examiner, come out with a phrase that you have learned from a consultation model that is inappropriate for that consultation, or come out with it at the wrong time (such as just after the opening statement)

24. What are the alternatives to models?

25. Knowing the patient It is only through an attempt to know the patient that one can engender the interpersonal respect necessary for the role of healer. Thus, bedside methods are not brought to bear simply in the search for a disease, but, rather, in order to know the patient and answer the cardinal question: “Why did this particular individual (with his or her unique genetic, developmental, experiential and spiritual identities) come to visit me, the doctor, at this particular time?” Answering this question immediately accomplishes the 2 aims previously seen as disparate: i.e. what is traditionally termed making a diagnosis and being patient-centred. These 2 goals are of a piece. Boudreau, Cassel, Fuks (2007)

26. Why?Why me?Why now?

27. If you do use a model …

28. Neighbour: CSA Consultation model © Roger Neighbour 2010 The assessed consultatio n Solve the right problem ‘Sell’ your solutio n Rapport Patient- centred eliciting Recognising & responding to cues Summaris e Safety- netting Dealing with emotion Building concordanc e Wrapping- up & closing

29. Solve the right proble m ‘Sell’ your solutio n Early stages of the consultation patient’s contribution ≥ doctor’s Later stages of the consultation doctor’s contribution ≥ patient’s Summarise Clinical evaluation Decision-making & action-planning The consultatio n

30. Play DVD 1  Observe summarising. Signposting, sequencing  Understanding the disease (illness) and their perspective  Non-verbal skills, rapport and involvement

31. Play DVD 2

32. Break

33. Clinical Management- Explaining and Planning  Providing the correct amount and type of information  Aiding accurate recall and understanding  Achieving a shared understanding: incorporating the patient’s perspective  Planning: shared decision making

34. Explanation  What does the patient already know?  What does the patient want to know?  What does the patient need to know?  Plus Structure (signpost/summarise/language/visual)  The Explanation Game…in pairs

35. Explanation and Planning- Self Rating  Have I put myself in a position to give information?  Do I understand the disease and the illness?  Do I know what information I want to give?  Does it relate to the patient’s framework?  Can I phrase and deliver it in a way the patient can understand?  How can I make sure that I’m giving the information that the patient needs and wants?  How do I check how the patient is reacting to what I am saying?  How do I involve the patient in the process and encourage a collaborative approach to decision-making  How can I check the patients’ understanding?

36. Final Point Q. What is the commonest reason candidates fail the CSA? A. Of course, it’s a trick question – there are many reasons, but “Clinical Management” is the domain that gets lowest score so… i. You won’t pass the CSA on charm alone = ii. Know up to date management and the latest guidelines

37. More Questions than Answers? The Thinker, sculpture by Auguste Rodin