1. The CSA: How can my ST3 fail? Trainer’s workshop Nov 2012

2. Today The CSA exam: Standards Why failure happens How might we avoid this? A CSA case

3. CSA data ► ~ 3000 candidates pa ► Pass rate ~ 70% (75 first time) ► UK Grads ~ 80-90% ► Mean score ~ 80 (Max 117, range 40-110)

4. IMG

5. Gender

6. The CSA: aim “to assess a doctor’s ability to integrate and apply appropriate clinical, professional, communication and practical skills in general practice”

7. CSA ► 13 consultations ► 10 minutes each ► Hugely varied content “representing the range and diversity of cases seen in General Practice”

8. The three domains in each case ► Data gathering, technical and assessment skills ► Clinical management skills ► Interpersonal skills

9. The three domains Four possible grades for each domain Clear Pass 3 marks Pass 2 Fail1 Clear Fail0 ► Each domain counts equally!

10. The generic descriptors ► http://www.rcgp.org.uk/gp-training-and- exams/mrcgp-exam- overview/~/media/Files/GP-training-and- exams/Guide-to-how-the-CSA-is- marked.ashx

11. How good is good enough? ► http://www.rcgp.org.uk/gp-training-and- exams/mrcgp-exam- overview/~/media/Files/GP-training-and- exams/CSA%20page/CSA-Grade- descriptors.ashx

12. The four types of failing registrar? ► Not cut out for the job ► Underprepared ► Go to pieces on the day ► Badly prepared

13. Lessons from the shop floor ► How good registrars fail…

14. Rigid or Formulaic ► “I WILL show empathy and ICE everyone” ► “I am concerned re my breast lump”…”anything else you’d like to discuss?” ► Prevention: Emphasise flexibility, spiral consulting and patient centredness ► On the day: Stay with the patient

15. Over cautious ► “As long as you’re safe you’re OK” ► “I’ll refer you to dermatology for that slight itch…” ► “I’ll check with my senior colleagues and get back to you” ► “Let’s do a million blood tests, just to be sure” ► Prevention: Do good, appropriate general practice. ► On the day: Make a decision.

16. Patient led, not patient- centred “As long as you’re nice you’re OK” “The patient didn’t want me to call 999” “I didn’t do anything about his arthritis but I was terribly understanding” Prevention: Know and implement NICE Guidance Developing skills in negotiation/challenge On the day: Up to date management must be demonstrated

17. Case spotting ► “This must be the Gillick competence station” ► “I mustn’t give a sick note” ► “I mustn’t prescribe codeine” ► “I must get patient to accept LARC” ► Too many courses/books ► Prevention: Do lots of real General Practice ► On the day: Stay with the patient

18. Time Keeping ► “I didn’t get round to making a plan, taking a history took too long..” ► Prevention: Time keeping skills for CSA ► …and for life

19. Housekeeping ► “I messed up that chest pain station…it all went wrong after that” ► House keeping skills for CSA ► …and for life

20. How can we help? ► In fours ► Think about the reasons for failure ► How can we help? Practical steps to share

21. As trainers - how can we help? ► Be familiar with the exam and how it is marked ► Offer feedback on each domain, be a hawk! ► ‘Diagnose’ your registrar’s particular problems

22. Key messages ► As a trainer we are expert! ► BUT ► It is their assessment not ours….

23. What’s going on here? ► http://www.youtube.com/watch?v=Jb71- kSFsdw&feature=channel http://www.youtube.com/watch?v=Jb71- kSFsdw&feature=channel http://www.youtube.com/watch?v=Jb71- kSFsdw&feature=channel ► GP registrar patient centred consultation skills ► http://www.youtube.com/watch?v=Jb71- kSFsdw http://www.youtube.com/watch?v=Jb71- kSFsdw http://www.youtube.com/watch?v=Jb71- kSFsdw

24. Norman Price ► 55 year old man ► Financial advisor ► 2/52 ago saw another GP in practice: ► “Trouble passing urine, frequency. MSU NAD. For bloods” ► PSA: 3.1 ► Random gluc: 5.2 ► 3/12 ago: BP 132/73 ► 9 years ago: tension headache

25. NICE LUTS ► http://guidance.nice.org.uk/CG97/QuickRef Guide/pdf/English http://guidance.nice.org.uk/CG97/QuickRef Guide/pdf/English http://guidance.nice.org.uk/CG97/QuickRef Guide/pdf/English

26. Data gathering problems: Failure to… ► Gather psychosocial information ie homelife, workplace, caring responsibilities, community etc ► Pick up on cues ► Establish the patient’s thoughts, fears and hopes ► Resist interrupting ► Avoid early closed questions and assumptions ► Reach agreed shared understanding of the problem

27. Data gathering problems: Failure to… ► Assimilate/interpret the written material provided ► Be appropriately selective e.g. does systems review, orders batteries of tests ► Get to the diagnosis e.g. depression

28. Management plan problems: Failure to… ► Get this far due to time pressure ► Be patient centred and give options and negotiate ► Take account of patient’s thoughts, fears and hopes ► Follow best medical practice ► Manage risk safely, safety net appropriately etc

29. Interpersonal skills ► Poor rapport building ► Missed cues ► Consultations are formulaic and wooden ► Doctor centred, not patient centred ► Unable to summarise, empathise, state what they are seeing “You seem upset about that”

30. Comment from a GPST after completing a recent mock CSA ► “I don’t know what went wrong – after all I ICE’d all the patients.......”

31. Another example from a recent mock CSA ► Patient: “I feel so awful I’ve thought about ending it all….” ► ST3:“Oh right. And is there anything else you’d like to talk about today?”

32. Consultation Models ► Pros: give structure to the consultations and remind the registrar about key areas ► Cons: can be formulaic rather than natural, may use up too much time if not focussed

33. What are the most common feedback statements? (1) Does not recognise the issues or priorities in the consultation (eg the patient’s problem, ethical dilemmas etc) (2) Does not develop a management plan (including prescribing and referral) that reflects knowledge of current best practice (3) Does not develop a shared management plan

34. As trainers - how can we help? Observed consultations, videos, (COTs), joint surgeries Feed back on all three domains

35. As trainers – how can we help? ► Time management skills – early on ► Housekeeping skills ► Know when to draw the line!

36. Key messages ► Avoid formulaic communication skills ► Listen to the patient ► Ensure psychosocial aspects are considered ► Remember to make an appropriate, shared management plan ► Keep open mind, deal with what is brought by case on the day. Do not case spot! ► Do good general practice