Presentation on theme: "guidance from trainees who’ve done it."— Presentation transcript:
1guidance from trainees who’ve done it. The CSAguidance from trainees who’ve done it.
2What the RCGP has to say… ‘An assessment of a doctor’s ability to integrate and applyappropriate clinical, professional, communication and practicalskills in general practice’The aim of the CSA is to test a doctor’s ability to gather informationand apply learned understanding of disease processes andperson-centred care appropriately in a standardised context, makeevidence-based decisions, and communicate effectively withpatients and colleagues. Being able to integrate these skillseffectively is a key element of this assessment.
3A Few Key Points Only ST3 registrars can apply The CSA may be attempted a maximum of four timesIt costs £1445 to sit and if you fail you have to pay again!
4The CasesEach case is linked to learning outcomes from the MRCGP curriculumCases are meant to be representative of consultations seen in General PracticeThere are 13 cases. ALL cases are counted towards final markThere will be a mix of cases; some focusing on the clinical/medical aspects, others on ethics and communication skills e.g. difficult patients or negotiationThere may be a telephone consultation or a home visit
5Marking Each case will be marked in 3 domains: Data Gathering, Technical and Clinical Assessment skillsClinical Management skillsInterpersonal skillsEach domain carries equal marksThere are positive and negative descriptors for each domain specific to each case which the examiners will refer to when marking
6The 3 Domains Data Gathering, Technical and Assessment Skills: Gathering and using data for clinical judgement, choice of examination, investigations and their interpretation. Demonstrating proficiency in performing physical examinations and using diagnostic and therapeutic instruments.Clinical and Management Skills:Recognition and management of common medical conditions in primary care. Demonstrating a structures and flexible approach to decision making. Demonstrating the ability to deal with multiple complaints and co-morbidity. Demonstrating the ability to promote a positive approach to health.Interpersonal Skills:Demonstrating the use of recognised communication techniques to understand the patient’s illness experience and develop a shared approach to managing problems. Practicing ethically with respect for equality and diversity, in line with the accepted codes of professional conduct.
7Generic descriptors – Data Gathering Positive IndicatorsClarifies the problem & nature of decision requiredUses an incremental approach, using time and accepting uncertaintyGathers information from history taking, examination and investigation in a systematic and efficient manner.Is appropriately selective in the choice of enquiries, examinations & investigationsIdentifies abnormal findings or results & makes appropriate interpretationsUses instruments appropriately & fluentlyWhen using instruments or conducting physical examinations, performs actions in a rational sequenceNegative IndicatorsMakes immediate assumptions about the problemIntervenes rather than using appropriate expectant managementIs disorganised/unsystematic in gathering informationData gathering does not appear to be guided by the probabilities of disease.Fails to identify abnormal data or correctly interpret themAppears unsure of how to operate/use instrumentsAppears disorganised/unsystematic in the application of the instruments or the conduct of physical examinations
8DescriptorsThe full list of generic descriptors for each domain can be found at:Exams_CSA_Generic_domain_indicators_v9.doc
9Marks Four grades for each domain: Clear Pass (3)Pass (2)Fail (1)Clear Fail (0)Grades are converted to numerical scale to give an overall markEach domain is marked out of 3 giving an overall mark out of 9 for each case.All 13 cases are marked and counted giving an overall maximum mark of 117
10GradesClear Pass: The candidate demonstrates an above-average level of competence, with a justifiable clinical approach that is fluent, appropriately focussed and technically proficient. The candidate shows sensitivity, actively shares ideas and may empower the patientPass: 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. Fail: The candidate fails to demonstrate adequate competence, with a clinical approach that is at times unsystematic or inconsistent with accepted practice. Technical proficiency may be of concern The patient is treated with sensitivity and respect but the doctor does not sufficiently facilitate or respond to the patient’s contribution. Clear Fail: 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
11More on the Marking Cases change each day Pass mark for each case created using the Borderline Group method. This is used to calculate the overall pass mark for each day – more details on RCGP websiteDaily pass mark established to allow for differing case mix on different days
12Results Results and feedback via ePortfolio Candidates given their overall score, and passing score for that dayAreas of improvement as identified by 2 or more examiners flagged (picking from 16 feedback statements)Feb/March 2011: 75.2% pass rate (79.8% for first time candidates), scores ranged from
13Feedback Statements Global Data Gathering 1. Disorganised / unstructured consultation2. Does not recognise the issues or priorities in the consultation (for example, the patient’s problem, ethical dilemma etc).3. Shows poor time management.Data Gathering4. Does not identify abnormal findings or results or fails to recognise their implications5. Does not undertake physical examination competently, or use instruments proficiently
14Feedback Statements Clinical management 6. Does not make the correct working diagnosis or identify an appropriate range of differential possibilities.7. Does not develop a management plan (including prescribing and referral) reflecting knowledge of current best practice.8. Does not make adequate arrangements for follow-up and safety netting.9. Does not demonstrate an awareness of management of risk or make the patient aware of relative risks of different options.10. Does not attempt to promote good health at opportune times in the consultation.
15Feedback Statements Interpersonal skills 11. Does not appear to develop rapport or show sensitivity for the patient’s feelings.12. Does not identify or explore information about patient’s agenda, health beliefs & preferences.13. Does not make adequate use of verbal & non-verbal cues. Poor active listening skills.14. Does not identify or use appropriate psychological or social information to place the problem in context15. Does not develop a shared management plan, demonstrating an ability to work in partnership with the patient.16. Does not use language and/or explanations that are relevant and understandable to the patient
16CSA in 10min 5 MIN Open Questions Explanation (eg diagnosis) Rapport building, Active listening, Summarising etcManagement Options discussionICECheck understanding & agreed planPsychosocial context(a little further Hx taking)Safety Netting/ F/URed FlagsExamination
17Nub of the Case Cues Flexibility Eg TATT: a) explanation of low T4 (ref to info sheet)b) depression/ psychosocial elementHRTa) explanation & sharing optionsb) negotiation (eg paeds, HRt given hi risk factors)c) psychosocialFirst Fita) clinical Mxb) psychosocial- HGV driver+ negotiation/ breaking bad newsHeadache/ Palpitationsa) explanation/ reassurance/ exploring Pt concernsb) Clinical Mx & explain re fastrack (or 24 ECG etc)c) depression/ psychosocial
18Nubs of CasesTATT: a) explanation of low T4 (ref to info sheet) b) depression/ psychosocial element HRT a) explanation & sharing options b) negotiation (eg herbal, HRT given hi risk factors) c) psychosocial First Fit a) clinical Mx b) psychosocial- HGV driver + negotiation/ breaking bad news Headache/ Palpitations a) explanation/ reassurance/ exploring ICE b) Clin Mx & explain re fastrack (or 24 ECG) c) depression/ psychosocial
19IMGs Communication Patient-centred Clear Management Plans the ‘under performance’ of minority ethnic candidatesUK graduates 91.6%Non-European 56.9%CommunicationPatient-centredClear Management PlansSharedManaging Medical ComplexityFish out of WaterLinguistic Capital“can I have a look at your bottom?”Resources:Geet’s docCertain coursesWatching the EnglishCommunicationPractice phrasesRevision GroupsResources
20IMGs cont Communication Eye contact vs sensitivity/ cues Formulaic InterrogationEliciting not exploringPicking up Pt languageOver-categoricalNo sunny pairingUnclear ExplanationsInteractional smoothness
21IMGs cont Communication Dr-Pt partnership Topics Informal speech patternsAvoid Medical JargonIdioms/ ColloquialismsJokesDr-Pt partnershipTopicsPalliative CareDeath and BereavementSex and SexualityMental HealthNot just avoid jargon but need to develop good ways to explain terms simply
22IMGs- moving forward Start Early Resources Video Consultations WebsiteBooksTVTrainerGPSTsVideo ConsultationsJoint SurgeriesCSA practice with range of GPSTs
23Summary Integrated assessment of Clinical Skills Safe to Practise IndependentlyMark-schemesExpect to examineStructured approachDon’t forget the Management Plan!It is acheiveable!
25When to Start? After all tomorrow is another day.............. Generally 2 - 3mSpeed at which you work - slow and steady or last minute panic?
26Where to Start?!! Overwhelming - need to know ‘everything’ Consultations to identify learning needsGroup practice - good impetus to getting startedprovides the proverbial....???Use curriculum
27Some Suggestions Case practice - probably most useful Study group lots of books with scenarios?write own casesStudy groupIdentify consultations felt uncertain about
28Start identify what exam is testing Often talk about the ‘nub’ of the caseCommon problems/scenariosAbout communication BUT need reasonable knowledge base - confidenceNeed to show what you’re thinking verbalise!!Nub of caseCommon issues - complaints, angry patient, ethics, negotiation
29Dealing with MonotonyPractice small sections eg. explanation, management - common reasons for failureQuick fire questionsLook at some PILS - patient.co.uk
31Other Resources NICE, patient.co.uk, CKS, GPnotebook InnoVait, BMJ GP Handbook
32Courses Loads available, BOOK EARLY Yorks & Humber Deanery courses available in:HarrogatePennineHullRCGP - CroydonBradford VTS website is fabHelpful - personal choice
33Deanery Courses 1 day, BOOK IMMEDIATELY!! Presentations - exam structure, what examiners looking for etc, marking scheme4 cases, observed get feedbackGroup observed cases - difficult scenarios
34RCGP 2 days Opportunity see centre Run by senior examiners Also talk by role-playing leadPresentation based
35In group total 12 cases, though may only get to role play once yourself However do give good idea of what the exam is aboutLots of tips and tricksTips & tricks:- stock phrases- actors helping you- read cases before start, write on sheets
36VTS Session Mock CSA ~6 -8 cases Observed, then get feed-back Well worth going
37Booking Exam If you’ve got a preference book early - that morning But don’t delay, have run out of places at busy times of year