1. guidance from trainees who’ve done it.
The CSA
guidance from trainees who’ve done it.

2. What the RCGP has to say…
‘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.

3. A Few Key Points Only ST3 registrars can apply
The CSA may be attempted a maximum of four times
It costs £1445 to sit and if you fail you have to pay again!

4. The Cases
Each case is linked to learning outcomes from the MRCGP curriculum
Cases are meant to be representative of consultations seen in General Practice
There are 13 cases. ALL cases are counted towards final mark
There will be a mix of cases; some focusing on the clinical/medical aspects, others on ethics and communication skills e.g. difficult patients or negotiation
There may be a telephone consultation or a home visit

5. Marking Each case will be marked in 3 domains:
Data Gathering, Technical and Clinical Assessment skills
Clinical Management skills
Interpersonal skills
Each domain carries equal marks
There are positive and negative descriptors for each domain specific to each case which the examiners will refer to when marking

6. The 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.

7. Generic descriptors – Data Gathering
Positive Indicators
Clarifies the problem & nature of decision required
Uses an incremental approach, using time and accepting uncertainty
Gathers information from history taking, examination and investigation in a systematic and efficient manner.
Is appropriately selective in the choice of enquiries, examinations & investigations
Identifies abnormal findings or results & makes appropriate interpretations
Uses instruments appropriately & fluently
When using instruments or conducting physical examinations, performs actions in a rational sequence
Negative Indicators
Makes immediate assumptions about the problem
Intervenes rather than using appropriate expectant management
Is disorganised/unsystematic in gathering information
Data gathering does not appear to be guided by the probabilities of disease.
Fails to identify abnormal data or correctly interpret them
Appears unsure of how to operate/use instruments
Appears disorganised/unsystematic in the application of the instruments or the conduct of physical examinations

8. Descriptors
The full list of generic descriptors for each domain can be found at:
Exams_CSA_Generic_domain_indicators_v9.doc

9. Marks 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 mark
Each 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

10. Grades
Clear 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 patient
Pass: 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

11. More 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 website
Daily pass mark established to allow for differing case mix on different days

12. Results Results and feedback via ePortfolio
Candidates given their overall score, and passing score for that day
Areas 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

13. Feedback Statements Global Data Gathering
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.
Data Gathering
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

14. Feedback 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.

15. Feedback 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 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

16. CSA in 10min 5 MIN Open Questions Explanation (eg diagnosis)
Rapport building, Active listening, Summarising etc
Management Options discussion
ICE
Check understanding & agreed plan
Psychosocial context
(a little further Hx taking)
Safety Netting/ F/U
Red Flags
Examination

17. Nub of the Case Cues Flexibility Eg TATT:
a) explanation of low T4 (ref to info sheet)
b) depression/ psychosocial element
HRT
a) explanation & sharing options
b) negotiation (eg paeds, 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 Pt concerns
b) Clinical Mx & explain re fastrack (or 24 ECG etc)
c) depression/ psychosocial

18. Nubs of Cases
TATT: 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

19. IMGs Communication Patient-centred Clear Management Plans
the ‘under performance’ of minority ethnic candidates
UK graduates 91.6%
Non-European 56.9%
Communication
Patient-centred
Clear Management Plans
Shared
Managing Medical Complexity
Fish out of Water
Linguistic Capital
“can I have a look at your bottom?”
Resources:
Geet’s doc
Certain courses
Watching the English
Communication
Practice phrases
Revision Groups
Resources

20. IMGs cont Communication Eye contact vs sensitivity/ cues Formulaic
Interrogation
Eliciting not exploring
Picking up Pt language
Over-categorical
No sunny pairing
Unclear Explanations
Interactional smoothness

21. IMGs cont Communication Dr-Pt partnership Topics
Informal speech patterns
Avoid Medical Jargon
Idioms/ Colloquialisms
Jokes
Dr-Pt partnership
Topics
Palliative Care
Death and Bereavement
Sex and Sexuality
Mental Health
Not just avoid jargon but need to develop good ways to explain terms simply

22. IMGs- moving forward Start Early Resources Video Consultations
Website
Books TV
Trainer
GPSTs
Video Consultations
Joint Surgeries
CSA practice with range of GPSTs

23. Summary Integrated assessment of Clinical Skills
Safe to Practise Independently
Mark-schemes
Expect to examine
Structured approach
Don’t forget the Management Plan!
It is acheiveable!

24. CSA - PREPARATION

25. When to Start? After all tomorrow is another day..............
Generally 2 - 3m
Speed at which you work - slow and steady or last minute panic?

26. Where to Start?!! Overwhelming - need to know ‘everything’
Consultations to identify learning needs
Group practice - good impetus to getting started
provides the proverbial....
???Use curriculum

27. Some Suggestions Case practice - probably most useful Study group
lots of books with scenarios
?write own cases
Study group
Identify consultations felt uncertain about

28. Start identify what exam is testing
Often talk about the ‘nub’ of the case
Common problems/scenarios
About communication BUT need reasonable knowledge base - confidence
Need to show what you’re thinking verbalise!!
Nub of case
Common issues - complaints, angry patient, ethics, negotiation

29. Dealing with Monotony
Practice small sections eg. explanation, management - common reasons for failure
Quick fire questions
Look at some PILS - patient.co.uk

30. Which Books?

31. Other Resources NICE, patient.co.uk, CKS, GPnotebook InnoVait, BMJ
GP Handbook

32. Courses Loads available, BOOK EARLY
Yorks & Humber Deanery courses available in:
Harrogate
Pennine
Hull
RCGP - Croydon
Bradford VTS website is fab
Helpful - personal choice

33. Deanery Courses 1 day, BOOK IMMEDIATELY!!
Presentations - exam structure, what examiners looking for etc, marking scheme
4 cases, observed get feedback
Group observed cases - difficult scenarios

34. RCGP 2 days Opportunity see centre Run by senior examiners
Also talk by role-playing lead
Presentation based

35. In group total 12 cases, though may only get to role play once yourself
However do give good idea of what the exam is about
Lots of tips and tricks
Tips & tricks:
- stock phrases
- actors helping you
- read cases before start, write on sheets

36. VTS Session Mock CSA ~6 -8 cases Observed, then get feed-back
Well worth going

37. Booking 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

38. The “What To Do On The Day” Bit

39. Where It Is… The RCGP Assessment Centre 12 – 16 Addiscombe Road
East Croydon
CR0 0XT
18th, 19th & 20th floors

40. Where To Stay
Croydon Park Hotel
Jury’s Inn
Travelodge
Victoria London

41. What To Take Photo ID! BNF Stethoscope Ophthalmoscope Auroscope
Thermometer
Tendon hammer
Tape Measure
Peak Flow Meter

42. On The Day…
Arrive on time!
Briefing

43. Cases Acute and chronic Ethics Health Promotion Negotiation Telephone
Home Visit

44. Good luck!