CSA How not to fail Dr. Louise Riley Trainer (Bradford VTS) Examiner (CSA component) Introduce / privilege / Code of conduct for examiners / I may say I’m unable to comment Fair and consistent exam, great lengths to ensure consistency of cases and marking

Help! When I say CSA what’s the very first thing that comes into your head? List on flip chart How we’ll address those issues

Agenda Introduction to CSA Personal experiences Case examples from college DVD Marking and discussion How to prepare Different people at different stages / personal experiences, bits that you cant get from books or rcgp website Types of cases, how they are selected / What are they looking for- Going to look at 2 cases from the college dvd, use the marking schedule discussion about marking and what’s really important about each case After coffee split into small groups and discuss ways to improve performance of the candidates seen

Knowledge Competence Performance What you can test... Knowledge Competence Performance Knowledge you test in an mcq Competence you test eg in a viva eg what would you do if... Performance is testing what you actually do Musical instrument

The Theory... ‘An assessment of a doctor’s ability to integrate and apply appropriate clinical, professional, communication and practical skills in general practice’ The point is that it tests performance- ie what you do , rather than what you know or say you do

Where... Croydon Park Hotel Jury’s Hotel Number 1, Croydon (opposite East Croydon station) Floors 18,19,20 Colour coded DO NOT BE LATE ! Stay at... Croydon Park Hotel Jury’s Hotel Huge tower cant miss it Stay in Croydon or at Victoria- 20 mins on train from there Don’t travel from Yorkshire for an a.m. exam!

What’s it like ? Simulated surgery 13 stations,12 “live” one pilot 10 minutes each 2 minutes between You stay put, role players and assessors move You are shown to a consulting room which will be your home for morning The assessors and role players rotate through each consulting room at 12minute intervals. When the 10 minute buzzer goes, everything stops. The rp and ass leave ,the assessor fills out a mark sheet and puts it in the door in which you are consulting. The floor marshal then collects these, the rps and asses move on to the next room and the process starts again

It’s not like this! A picture of everyone looking jolly In reality the assessor will be seated and as unobtrusive as possible! ASK PEOPLE TO SHARE THEIR EXPERIENCES

What do I need ? Passport or photo-card driving licence Doctor’s bag containing: BNF Stethoscope Ophthalmoscope Auroscope Thermometer Patella hammer Sphygmomanometer (aneroid or electronic) Tape measure Peak flow meter and disposable mouthpieces You need to bring all your own kit. If you don't have an ophthalmoscope you cannot demonstrate to the examiner that you know how to use one! On the table- prescription pads sick notes, case notes for each case- look at them carefully!

How are cases selected? Mostly written from GPs’ own experiences A spread of cases across the curriculum Each case mapped to a specific area of the curriculum There is a panel of case writers who are all experienced gps All cases are piloted before use and should have any problems ironed out Cases are typical of a normal gps working life, surgery, home visits, telephone consultations, maybe carers or parents Each case is mapped to an area of the curriculum- next slide

Case Selection Blueprint Clinical Skills Assessment Case Selection Blueprint Primary nature of case Primary system or area of disease  Acute Illness Chronic Illness Undifferentiated Illness Psychol and Social Preventive /lifestyle Other Cardiovascular Respiratory Neurological/ Psychiatric Musculo-skeletal Endocrine/ Oncological Eye/ ENT/ Skin Men/ Women/ Sexual Health Renal/ urological Gastro-intestinal Infectious diseases ETC A cross section of cases for each exam is selected using a specified choice from the matrix Also case selection criteria beyond the agreed rubric for the matrix: Gender mix Diversity eg culture, disability, religion and sexual orientation Age mix (child, older person).

What sort of cases are there? Cough with ACE inhibitor Young woman with headache Child with constipation Man with Dupuytren’s contracture Woman with diabetes and depression Man with anxiety and palpitations these are taken from the website or the CSA DVD Involve integrating communication skills, diagnostic skills, negotiation You could think of lots more, try writing down a few cases in your next surgery that might be suitable to give you a feel for the process

What are they looking for? 3 Domains: Data gathering Clinical Management Interpersonal skills There are 3 areas given grades for each case and then an overall grade is awarded Data gathering includes history and examination skills, investigations and their interpretation Clinical management- a structured and flexible approach, able to deal with managing complexity Interpersonal skills- comm skills to understand the patient’s illness experience and develop a shared approach to managing problems. Practising ethically with respect for equality and diversity

What are they looking for? In each domain we look for observed behaviours Establishing reason for attendance Examining chest Ability to negotiate Consider health promotion issues Practising ethically Management plan in line with best practice Word pictures

Marking You get a grade for each domain Then you get an overall grade Clear pass Marginal pass Marginal fail Clear fail Then you get an overall grade

Marking Scheme Case 1- Note for the Gym Domain Observed behaviours Grade (CP/MP/ MF/CF) Data gathering, examination and clinical assessment skills Establish reason for attendance ie need to get note for gym and what is required for this Explore any current health problems and past medical history, including raised cholesterol Show ability to check BP and chest Clinical management skills Formulate an appropriate plan to address possible raised cholesterol and BP Consider health promotion issues eg smoking, wt, alcohol and exercise Show ability to manage request for note appropriately, recognising implications Interpersonal skills Elicit any underlying concerns regarding raised cholesterol and heart problems Show ability to negotiate as necessary re the note and the management of any health problems, share management options Take an interest in the patient, avoid lecturing him about lifestyle Hers is a shortlist of observed behaviours. You may wish to include more when doing your own marking. Examiners might have 15 We havent had a calibration exercise

Do I get any feedback? Yes, but it’s feedback on the whole CSA performance, not an individual case The assessors pick from a list of feedback statements 16 feedback statements In exam, assessors mark 4-6 feedback statements if they have failed you on a case Only if 3 or more people have marked a statement will it be fed back to you I have given you a copy of the statements Split into pairs and discuss which ones you would give to the last candidate

Feedback statements Data Gathering 1. Disorganised and unsystematic in gathering information from history taking, examination and investigation 2. Does not identify abnormal findings or results or fails to recognise their implications 3. Data gathering does not appear to be guided by the probabilities of disease 4. Does not undertake physical examination competently, or use instruments proficiently Clinical management 5.  Does not make appropriate diagnosis 6. Does not develop a management plan (including prescribing and referral) that is appropriate and in line with current best practice. 7. Follow-up arrangements and safety netting are inadequate 8. Does not demonstrate an awareness of management of risk, and health promotion  Interpersonal skills  9. Does not identify patient’s agenda, health beliefs & preferences / does not make use of verbal & non-verbal cues 10. Does not develop a shared management plan or clarify the roles of doctor and patient 11. Does not use explanations that are relevant and understandable to the patient 12. Does not show sensitivity for the patient’s feelings in all aspects of the consultation including physical examination  Global  13. Disorganised / unstructured consultation 14. Does not recognise the challenge (e.g. the patient’s problem, ethical dilemma etc.) 15. Shows poor time management 16. Shows inappropriate doctor-centredness What f/back statements have people given? Discussion then coffee (?about 3.30) After coffe another case to mark and d/c use feedback statements

Marking Scheme 2: Pain in the Neck Domain Observed behaviours Grade (CP/MP/ MF/CF) Data gathering, examination and clinical assessment skills Take a history of the neck pain and what has been tried so far Examine neck/shoulders appropriately Explore psychosocial situation- effect on work and life Clinical management skills Give appropriate prescription for pain, or advise on over the counter remedies Advise on other appropriate treatments eg heat, stretching exercises, avoid collars Indicate how problem may resolve Interpersonal skills Explain pros and cons of various treatments Acknowledge patient’s ideas and expectations about treatment Negotiate with patient sensitively After coffee watch another case if time Discuss marks- show of hands pass/fail Anything she didnt do well?

Pick one feedback statement Feedback to group

How can Dr X Improve? Turn the feedback statement into constructive advice What practical steps might this doctor take to improve performance? Split into 3 groups and discuss ? of the feedback statements you have given for either case How could Dr X improve her performance? Spokesperson for each group to bring ideas to larger group

Feedback statements Data Gathering 1. Disorganised and unsystematic in gathering information from history taking, examination and investigation 2. Does not identify abnormal findings or results or fails to recognise their implications 3. Data gathering does not appear to be guided by the probabilities of disease 4. Does not undertake physical examination competently, or use instruments proficiently Clinical management 5.  Does not make appropriate diagnosis 6. Does not develop a management plan (including prescribing and referral) that is appropriate and in line with current best practice. 7. Follow-up arrangements and safety netting are inadequate 8. Does not demonstrate an awareness of management of risk, and health promotion  Interpersonal skills  9. Does not identify patient’s agenda, health beliefs & preferences / does not make use of verbal & non-verbal cues 10. Does not develop a shared management plan or clarify the roles of doctor and patient 11. Does not use explanations that are relevant and understandable to the patient 12. Does not show sensitivity for the patient’s feelings in all aspects of the consultation including physical examination  Global  13. Disorganised / unstructured consultation 14. Does not recognise the challenge (e.g. the patient’s problem, ethical dilemma etc.) 15. Shows poor time management 16. Shows inappropriate doctor-centredness What statements did you choose?-ask a spokesperson How did you turn this feedback into practical steps? Talk about rcgp suggestions- look on website

How can I prepare? Back in the large group, share ideas about preparation/ ways to improve performance How many of them are you doing already?

Ten Top Tips To Pass The CSA Arrive on time Bring your bag and identification Read carefully the information provided for each case Practice ten minute consultations Practice focussed examinations Don’t be phased by the cases, stick to the basic principles of patient centred consulting Don’t forget psychosocial and family history Remember treatment by other means as well as drugs Remember “Housekeeping skills” i.e. put the last case behind you and concentrate on the rest. You do not have to pass all thirteen cases Remember there is often not a right or wrong answer, examiners are looking for how you tackle the cases

Any Questions?

Good Luck!