1. Dan Berkeley GP Partner Maryport

2.  Brainstorm 1 – worries and concerns  Practical aspects of the CSA ◦ Costs and booking ◦ Set up of the exam/what to expect on the day  Brainstorm 2 – how to consult for the CSA  My thoughts on the exam ◦ How to prepare as a GPR  Brainstorm 3 – working in small role play groups  Final question and answer session

3.  On one piece of paper in groups write down:  Anything you especially want to cover today ◦ In your group try to answer the questions if you can  Then come and present the answers and we can then make sure any unanswered questions get covered later

4.  Final of the two exam parts of the MRCGP  Cannot be done until 3 rd year  Used to only be 3 sittings/year, now many  GPR can have four attempts! (unless they run out of money first)  You do not need to have passed the AKT first, although practically most have

5.  Cost 1563 pounds (including 10% discount – probably more now!)  Book on the RCGP website, you don’t get any choice over day or time  Add to this 100 pounds for train, 150 for hotel, 50 for food etc and its a pretty expensive, and unpleasant, holiday  This is now tax deductable following Bannerjee vs HMRC 2008 ruling, but they still take it to the wire

7.  Will vary depending on time of day you are sitting  Morning sitting  Arrive 7.30am, sit around for 30 mins in locked room, avoid eye contact  Briefing for 15 minutes, more waiting  Led through to exam room, items in locker, clear bag for equipment (see list)  Own room, ipad with 13 cases, 15 mins to look at before exam starts

8.  Horn blows  Patient knocks and enters, examiner follows and sits in corner  10 full minutes i.e. longer than ‘real’ consults  Goes very quickly  7 cases – ‘break’ – avoid eye contact  6 more cases  Fire alarms – avoid eye contact  Pm sessions allegedly even more waiting

9.  Finished! Massive relief  May have dissociated to the extent can’t remember the cases  Try to enjoy the rest of the day  Up to 6 weeks before you hear results  Hopefully a one off experience...

10.  What does the college suggest you do? ◦ The exam is representative of UK general practice, so if you are of the standard to be a GP in the UK you will pass the exam – they say ◦ They want us to train to be a good GP and use Calgary Cambridge style communication skills (standard consultation model in the UK) ◦ This is putting a lot of pressure on the exam to be perfect

11.  Priority 1 : train to be a good GP – of course!  Priority 2: prepare for the CSA!!!!  PLEASE DON’T FALL INTO THE TRAP OF THINKING PRIORITY 2 WILL SIMPLY FOLLOW PRIORITY 1 IF DONE WELL – this would only be the case if the exam was a perfect representation of UK general practice  The exam is not directly testing your ability to be a GP.  It is using an imperfect surrogate measure: ◦ Can you consult an actor pretending to be a patient, whilst being observed in a room in London

12.  What do you think of this?  How might you prepare for the CSA whilst also preparing to actually be a GP

13.  Got frightened because one of our friends failed and had to extend his training  Took the exam early (before we were back in GP for 3 rd year) so we could have ‘a second shot’ if need be. (No longer relevant with 8 sittings)  Small group work ++ using cases in books and online  Critique of consultations and endless role play practice – simulating the exam  Mix of UK and foreign graduates – important

14.  Firstly, ensure that you are becoming a good GP – Clearly most important priority!  Secondly, in the 6-12 months prior to the exam do specific CSA training as well  Try to simulate the CSA ◦ Role play ◦ Consider meeting in small groups, this is not something for your tutorials – you should be doing it outside work

15.  Consider taking the exams early and back to back to give yourself chance for resits ◦ Less stress ‘I can always take it again’ ◦ Only ‘revise’ once  If you are well prepared (more later) your main enemy on the day is stress, it will make you consult differently to how you normally do, or practised to do.

16.  Scoring system ◦ Three domains  Information gathering  Management skills  Communication skills  But they are not perhaps as equal as they initially look...

17.  1. Disorganised / unstructured consultation  2. Does not recognise the issues or priorities in the consultation (for example, the patient’s problem, ethical dilemma etc)  3. Shows poor time management  4. Does not identify abnormal findings or results or fails to recognise their implications  5. Does not undertake physical examination competently, or use instruments proficiently

18.  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 show appropriate use of resources, including aspects of budgetary governance  9. Does not make adequate arrangements for follow-up and safety netting  10. Does not demonstrate an awareness of management of risk or make the patient aware of relative risks of different options  11. Does not attempt to promote good health at opportune times in the consultation

19.  12. Does not appear to develop rapport or show awareness of patient’s agenda, health beliefs and preferences  13. Poor active listening skills and use of cues. Consulting may appear formulaic (slavishly following a model and/or unresponsive to the patient), and lacks fluency  14. Does not identify or use appropriate psychological or social information to place the problem in context  15. 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

20.  Most of the descriptors in fact relate directly to communication skills  And all those that don’t, require good communication skills to obtain  So in reality the thing the exam is testing more than anything is communication skills ◦ This is good as it’s representative of our role as GPs, also the AKT is designed to test knowledge specifically anyway  Concentrating on revising clinical knowledge for this exam is therefore a poor use of time  Despite it being the focus of almost every CSA book.....

21.  Unusual system  Grid of 16 negative descriptors, get Xs in ones you didn’t meet  But only get X’s in a neg descriptor category if you failed in that domain at least twice  Can make it hard to know how to improve if you need to resit ◦ Look at the types of descriptor you failed, is there a common link to them?

22.  You will already have excellent communication skills.  The CSA wants to see you apply focused ‘consultation skills’  It wants to see a doctor led patient centred consultation  It requires you to play a sort of ‘game’: ◦ Pretend the exam is 100% real – when its the most unreal experience of your life ◦ And ?like a driving test – see that you do this every day with confidence

23.  Ensure that you do separate CSA preparation as well as normal tutorials to help you become a good real world GP  Role play in your free time in small mixed groups, with family etc  Don’t try to ‘make yourself feel safer’ by revising lots of knowledge. The exam is not testing this as much as you might think  There are only 3 CSA books that I found helpful currently – they have cases in them and the cases are realistic CSA type cases – they are designed to be used for role play. Either use these or the internet for cases e.g. Pennine VTS website

24.  In small groups try to build a very basic consultation model for the CSA which will hit as many of the marking descriptors as possible  How does this compare to standard Calgary Cambridge consulting?  What do you think the main challenges are in the CSA?

25.  You have to have a format for consulting – for instance the framework on the next slide  But you must not be formulaic  They want to see the consultation being like a conversation – everything you ask should ideally lead and reference what has been said before. Tailored to that specific patient.

26.  The key skill being tested in the CSA:  What does the patient want from the consultation?  What do you think is going on?  Can you use communication skills to bind these into a plan which the patient is happy with and you are happy is safe and doesn’t abuse resources.

27.  Say hello, consider shaking hands   Get presenting complaint   Open questions including ICE, effect on life   Focused closed questions with signposting, red flags, drugs, allergies   Examination (if needed)   (6 minutes approximately are up)   Explanation and discussion of agendas to find a 'middle path'   Management (shared options)   Safety netting   Shake hand and say goodbye/run out of time

28.  How do you start the consultation?  Non verbal communication  Rapport – mirroring etc

29.  No irrelevant questions please! You only have six minutes here  ‘OK can you tell me more about that?’  Open questions, ICE  Consider signposting your ICE  Occupation, lifestyle etc (if relevant)  Closed questions – for red flags, to nail down diagnosis etc – signpost and interrogate!  Summarise  Remember – Patient Centred – Doctor Led. You are a guide.

30.  Patients seemed to say less than ‘real’ patients. Open questions were harder  Wanted to stick to script. Was often quite easy to see if you were going ‘off piste’  Try to make questions flow, one from the other – hypotheticodeductive reasoning! Sounds good, and looks good too.  Like a well informed and knowing conversation  Make the actor like you - Get you inner ENFJ out!

31.  When to ask?  Early. Focuses consultation  Feel free to use the specific words  Make sure you soften it – makes it sound better and more likely to avoid a bad response  Worth asking about occupation and home life

32.  Signpost  ‘a few medical type questions…’  Bang  Etc  Red flags  Smoking  Alcohol etc

33.  Offer to examine only if relevant – don’t examine for no reason  You may be asked to actually do examination!  You may be given findings by picture/text/verbal, but only at the moment you are about to examine – explain as normal  If you do examine – then focused – not MRCP style – focused! 1-2 mins max

34.  You should know patients agenda  You should know what you think is going on  Now to join them together!  Explain what you think is going on – 1 min or so – can tie in their ICE into this if you can – use it to ‘set up’ your plan  Remember: Patient centred. Doctor Led. They have come to see you for help.

35.  e.g. 'OK, so you came with these headaches and you have been worried that they could be something serious, specifically some type of brain tumour. And you were hoping that we might refer you to see a neurologist at the hospital. Well the good news is that my examination of your eyes and nerves of the face was completely normal. This doesn't rule out cancer, but it does make it less likely. The really good news though is that the story you gave me about the symptoms doesn't really point towards cancer either, in fact it points to quite a common problem called 'tension headache'. Thankfully this is something we can help you with. How do you feel about that?'

36.  Offer reasonable options, and explain pros and cons of each – don’t just list them  Do what you would really do (within reason)  Discuss as needed  Don’t avoid areas of conflict – the CSA is probably testing any difficulties that are arising  If you think there will be conflict be gentle but address it early – you have probably discovered what the consultation is about

37.  Safety net – red flags, and be open and realistic about prognosis and time frames. Educate and it will be a better safety net  Shake hands etc and check patient happy. Can check understanding if need be, but don’t do this as matter of routine  If you are running out of time try to get onto management ASAP and tie safety netting into your explanation to get as many marks as possible

38.  Ongoing debate about fairness of exam  Now websites discussing how to ‘change’ for the exam  Examiners want you to consult naturally, how can you do this if you are trying to be someone else entirely?  If you trained abroad please do throw yourself into local activities to get more hands on experience of British culture, but please don’t change who you are for the exam.

39.  In small groups discuss what you have learnt and what you think you might need to do in order to be prepared for the CSA  Please share your ideas about how you might prepare for the CSA with your group

40.  Strongly think that roleplay is key to doing well. Very difficult to just rely on seeing lots of patients – CSA is a little different  Need to do both  Form small group at least six months before exam, meet 1-2 times monthly for a decent length of time  Practice at home too – non medical people  Role play explanations

41.  This is what the CSA is testing:  The key to passing the CSA is to have a structure that is neither so structured that it is formulaic, nor so loose that there is no structure and that it is therefore disordered.  The key skill being tested is the ability to discover what the patient wants from the consultation, ascertain what you want to do with the patient (having made some sort of diagnosis or a diagnosis of 'uncertainty'), and then use the glue of communication skills to bind these together into a reasonable plan, that the patient is happy with, and that you feel is safe.