Dan Berkeley GP Maryport Health Services

 Practical aspects of the CSA ◦ Costs and booking ◦ Set up of the exam/what to expect on the day  My thoughts on the exam ◦ How to prepare as a GPR

 Final of the two exam parts of the MRCGP  Cannot be done until 3 rd year  Used to only be 3 sittings/year, now 8.  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

 Cost 1563 pounds (including 10% discount)  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

 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

 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

 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...

 What does the college suggest you do? ◦ The exam is representative of UK general practice, so if you of the standard to be a GP in the UK you will pass the exam ◦ They want us to train our GPRs 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

 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

 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

 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

 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.

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

 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

 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

 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

 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.....

 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?

 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

 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 2 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

 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.

 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.

 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

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

 No irrelevant questions please! You only have six minutes here  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

 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

 You should know patients agenda  You should know what you think is going on  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  Offer reasonable options, and explain pros and cons of each – don’t just list them  Discuss as needed  Don’t avoid areas of conflict – the CSA is probably testing any difficulties that are arising

 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

 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.

 Any questions?  In part 2 we split into groups and do some role play and I’ll do my best to give individual feedback to as many as possible

 My friends Jenny, Ellen, and Irina are currently in final phase of publishing an epic flipchart case book which will be amazing I suspect  I have written a very concise, completely CSA focused communication skills, consultation skills book too which is available on Amazon for under ten pounds – paperback and kindle editions