2. MRCGP
The Clinical Skills Assessment

3. Purpose of the CSA
‘An assessment of a doctor’s ability to integrate and apply
appropriate clinical, professional, communication and practical
skills in general practice’
The aim of the CSA is to test a doctor’s ability to gather information
and apply learned understanding of disease processes and
person-centred care appropriately in a standardised context, make
evidence-based decisions, and communicate effectively with
patients and colleagues. Being able to integrate these skills
effectively is a key element of this assessment.

4. CSA: Marking Cases
Each case has marking schedule consisting of 3 domains
Data Gathering, Technical and Clinical Assessment skills
Clinical Management skills
Interpersonal skills
Each domain carries equal marks

5. CSA: The three domains DATA-GATHERING, TECHNICAL & ASSESSMENT SKILLS :
Gathering & using data for clinical judgement, choice of examination, investigations & their interpretation. Demonstrating proficiency in performing physical examinations & using diagnostic and therapeutic instruments. (Blueprint: Problem-solving skills, Technical Skills)
CLINICAL MANAGEMENT SKILLS :
Recognition & management of common medical conditions in primary care. Demonstrating a structured & 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. (Blueprint: Primary Care Management, Comprehensive approach)
INTERPERSONAL SKILLS:
Demonstrating the use of recognised communication techniques to understand the patient’s illness experience and develop a shared approach to managing problems. Practising ethically with respect for equality and diversity, in line with the accepted codes of professional conduct. (Blueprint: Person-centred approach, Attitudinal aspects).

6. CSA: Marking Cases Four grades for each domain:
Clear pass 
Pass 
Fail ×
Clear fail ×
Each domain carries equal marks
Grade descriptors on RCGP website under ‘CSA cases’
Grades are converted to numerical scale to give an overall mark
Examiners can flag up serious concerns which may be followed up by the RCGP

7. CSA: Standard setting 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
Daily pass mark established to allow for differing case mix on different days
Details on CSA webpage

8. Borderline Group Method
The overall numerical case marks of the candidates in the borderline group are averaged.
These averaged scores are then aggregated across all the 13 cases to create the “cut score”, i.e. the approximation between a passing and a failing score.
The final, actual pass mark has an adjustment to the cut score to take account of the SEM (standard error of measurement).

9. CSA: Failing Candidates
A candidate who has failed will find the feedback helpful in preparing again for the CSA
The CSA may be attempted a maximum of four times

10. CSA: Further Resources
RCGP website CSA webpage
‘Information for Candidates’
Directions to the centre
Timekeeping and conduct
Format, timing, marking of the assessment
Equipment to bring
‘Introduction to the cases’ document
Feedback
How to use the suggestions for improvement
Preparation Courses at CSA Assessment Centre

11. AB notes 13 x 10minute cases, same room
10 mins to settle in – look at the notes of first 7 patients on iPAD
2 min reading time between cases
Can call role player back in within 10 min time slot
No penalty for “thinking time” if needed
15 minute break after 7th case

12. AB notes
Increasing prescribing content – may need to write a prescription (pad provided)
Timer on wall – counts up to 10 mins
No marks awarded after buzzer
iPAD used by examiners and candidates (no internet though!)
Confidentiality agreement on iPAD
Patient records/letters/clinical findings on iPAD

13. AB notes
Examiners must have recent hands on experience training registrars
Same case all day – role players and examiners rehearse case
Mostly in hours surgery consultations but also tel triage, home visits, OOH
Casebank >700 cases
Re-sitting candidates should not get same case

14. AB notes Emergency, acute or chronic conditions Preventative medicine
Physical, psychological or social problems
Common conditions or serious
Consultations with health professionals
Ethical dilemmas
Complexity and co-morbidity
Most have paeds case (>8y or proxy) & elderly

15. AB notes Different ethnicities Different social classes
4 nation compliant
Disabled – deaf, blind
Cases reflect real-life GP
Standard is of GPR towards end training
4-5 cases will require clinical examination

16. AB notes - pitfalls Jumping to Dx – think differential
Mechanistic consulting
Inadequate clinical examination skills
Looking for non-existent hidden agendas
Rigid Dr centred consulting
Time management
No QOF here – no irrelevant health promotion

17. AB notes Monthly sittings Nov to May Limited numbers for each session
Results published following week directly into ePortfolio
Feedback statements ticked but no free text feedback – not formative
4 attempts – exceptional 5th sitting

18. AB notes – how trainers help
Exposure wide variety cases
Observed surgeries best prep – not selected
Move towards 10 mins as soon as possible but develop consultation skills first
Joint consultations – different styles
Role-plays for scenarios that trainee is not likely to see
Real training not courses

19. AB notes Mainly single issue
If 2-3 problems the issue will be agenda setting and prioritising not full clinical Mx
Immediate emerg treatment eg ectopic preg or PE or MI
Emotionally challenging – breaking bad news or complaints
Can be review of patient seen by partner

20. AB notes Proxy paeds case eg enuresis or stammer
Can teach role player to have tennis elbow or frozen shoulder but not AF!
May be given a model eg breast lump, pelvic model
May be given card with examination findings
At least 2 cases will have major prescribing safety elements eg calculate paeds dose

21. AB notes
If blind pt – ask them if can take their arm before you grab them!
If deaf patient may need to write everything down
In these cases the medical aspects will be straightforward as emphasis on inter-personal
Engage with patient and carer
No longer any interpreter cases

22. AB notes
Telephone cases – issue often confidentiality eg daughter phoning about elderly parent
Avoid unnecessary or unexplained touch

23. AB notes Told to bring BNF/paeds BNF
Would be expected to look up dose methotrexate but know dose amoxicillin
No electronic BNF
Generic marking scheme but Intended Learning Outcomes for station

24. AB notes – at risk groups
IMG pass rate 31 – 53%
Males pass rate 63% (Females 87%)
Those who take it too early
The highly anxious
Those with lower exam/selection scores
The inappropriately confident

25. AB notes
Commonest reason to fail is not developing an adequate clinical management plan in line with current best practice or not making adequate arrangements for follow up and safety netting
True for both IMGs and UK graduates
Don’t recognise the challenge eg ethical
Don’t make appropriate diagnosis
Doesn’t develop shared management plan

26. AB notes Understand impact – show interest in pt
Approx 5 mins data gathering and 5 mins management
Look for non verbal cues
Non genuine empathy is very clear
Candidates need to listen and react
Still need explanation even if give leaflets!

27. AB notes
Welcome important – stand up, make eye contact, introduce themselves
Positive body language
“Tell me more” will get the response “what do you want to know”
Target questions – “Tell me more about how this has changed over the last 2 months since it started”

28. AB notes
Open questions – psychosocial and ICE (sensible and sensitive and in context)
Closed Q – symptoms, red flags, excluding serious illness
Rarely hidden agenda
Listen properly, don’t interrupt
Share ideas and decisions
Examine unless told not to

29. AB notes Why have they come today? Are there other issues?
Do I need to examine physically or mentally?
What is my diagnosis and does pt agree?
What is Mx plan including follow up
Have I explained Mx plan and does patient agree?

30. AB notes – cultural issues
Dr/patient relationship different
Difficulties with empathy or admit uncertainty
Heirarchy of team relationships
Dr knows best – like clear solutions & rules
Hear feedback defensively
Used to being rewarded for spouting theory

31. AB notes – supporting IMGs
Early needs assessment
Use consultation models in teaching
Discuss pt and Dr expectations
Address managing uncertainty
Handling emotion and confrontation
Ethical issues and team heirarchy
Joint surgeries
Allow them to flourish

32. AB notes Start work at ST1
Allow enough time to take more than once in ST3 – but not too early….
Encourage them not to work only with others who are struggling
Don’t need to be perfect – not a checklist
Don’t have to pass every station

33. AB notes Always 3 points for each of the 3 domains in every station
Can still get 3 points for a clear pass in a domain without doing everything calibrated by the examiners for that case
Not about gold standard – what is expected as a newly qualified independent GP

34. CSA 2015/16 all attempts
All HENE candidates: 69.8% pass rate (National 2014/ %)
UK Graduate HENE: 87.2%
Non UK Graduate HENE: 52.3%
2014/15 nationally 76.2% candidates were UK graduates but 62.3% in our region

35. CSA 2015/16 first attempt HENE all graduates: 71% pass rate
HENE UK graduates: 89.5% pass rate
HENE Non UK grads: 41.7% pass rate
2014/15 national all: 83.4%
2014/15 national UK: 90.9%
2014/15 national non UK: 47.4%

36. Cumulative pass rate
Nationally after 3 attempts UK grad pass rate 98% IMG pass rate 68% 1-5 trainees/yr will not complete training in our area at least partly due to exam failure so the vast majority pass even though we have a relatively high number in high risk groups