Abstract
This is the second in a short series that looks in detail at the CSA exam. In the first article, we looked at how the exam is written and delivered. We will now look at the application process and how best to prepare for an exam, which aims to test integration of skills in a clinically competent patient-centred consultation, sampling across the GP curriculum. The next Crammer’s Corner article will be written by an AiT currently preparing for the next CSA.
Preparing to sit the Clinical Skills Assessment (CSA) examination
Planning ahead
You can only sit the CSA in your ST3 year, and there is no rush! Think of the CSA like a driving test. If you can drive competently, you should pass your driving test; if you can consult competently in 10 minutes, you should pass the CSA. Direct your efforts towards good consulting rather than to the exam itself. Use your trainer to advise on your readiness. Consider your own commitments and the exam dates: if you wait until May and then get ill, or need to resit, you cannot do so until October.
Needs assessment
The CSA is a test of integrated skills and knowledge. Most of you will already have studied for, and perhaps passed, the Applied Knowledge Test (AKT) before you sit the CSA. The knowledge base is similar, and a previous AKT article has dealt with assessment of need, so I will not repeat it (Elfes, 2016). CSA cases are based on real-life General Practice, and many common ‘minor’ issues do not crop up in textbooks. There is no substitute for clinical experience. E-learning modules, journal articles and online quizzes all have a place in identifying (and meeting) your educational needs, but you also need to see patients on a regular basis. In addition, use your trainer and your colleagues to identify any groups of patients that you are NOT seeing. Male trainees see less womens’ health. Do you see routine management of long-term conditions? Many feel less confident in dermatology and ear, nose and throat. How could you use to meet those needs?
Preparation
So much for your ongoing knowledge needs assessment. Now for consultation skills, where assessment and teaching are one. The earlier you start, the better. There is no one ‘RCGP model’, but your consulting is expected to become centred on the patient. That means considering the patient perspective: their understanding, their wants, their perceived needs. From there you can help an individual to modify their health understanding, and negotiate a management plan. It is easy to slip into telling the patient what we think they ought to know rather that what they are ready to take in. This ‘patient-centred’ approach has been shown to improve patient satisfaction, concordance and health outcomes: it is not just political dogma! It becomes easier with practice. Stay curious about your patients, try to see the world from their viewpoint, then share your thoughts and explain things in a way that fits with their understanding.
How can you practise? Take every opportunity to be observed and get feedback, including joint surgeries, videos and role-plays. Regularly review your own consultations with your trainer, and learn to assess your own performance on recorded consultations. Get more than one trainer to assess your clinical observation tools (COTs), perhaps within your training scheme. Use your out-of-hours (OOH) shifts and a variety of settings including telephone consultations and home visits. Involve other members of the practice team: watch the practice manager dealing with a complaint, join nurses in chronic disease management clinics. Do any use the care plan approach? Use study groups within your training scheme to address your gaps: breaking bad news? Defusing the angry patient? Consider setting aside 5–10 minutes at the end of every tutorial to practise physical examination of joints: start with the temporomandibular and work down to the toes.
Examiner top ten tips
You are now consulting in a patient-centred way, at 10–15 minute intervals. It is time to prepare for the exam. There is no substitute for clinical practice, but there are some ways to maximise your chances of success.
Book patients at 10-minute intervals. If you block catch-up slots for confidence, try not to use them. Scrutinise your time management within the consultation. Aim to finish your data gathering, including any examination, by 5 minutes, leaving plenty of time for a negotiated management plan. The three marking domains in the CSA are equally weighted. If you gather loads of information but take 8 minutes for that, you cannot score highly for clinical management: there is not enough time left. Reconsider your knowledge needs. Still weak on recognition of dermatology or ophthalmology? Organise to sit in on a 2 week wait clinic or eye casualty. Check your communication skills. Pair off in study groups and spend just 2 minutes each explaining medical conditions to each other, aloud. Use your own surgery lists for topics on which to quiz your study partner, and then swap. Can you explain heart failure without using jargon? Atrial fibrillation? Chronic obstructive pulmonary disease (COPD)? Before your 2 minutes start, ask what the ‘patient’ knows and wants to know. Continue to look with your trainer at your integration of clinical and communication skills. Use videos and joint surgeries. Ask your trainer to be brutally honest but supportive. Assess your trainer too: any new insights? Use the CSA e-learning module on the website. Look up the RCGP CSA website. Watch the walk-through video and the iPad document so that the surroundings and equipment will be familiar on the day. Look at the candidate briefing, so there can be no surprises about procedures and rules. Look at your desk: can you demonstrate confident use of the tuning fork? Peak flow meter? Snellen chart? Look up the list of equipment to bring with you. Renew batteries in any electronic instruments. Think about what you will be assessed on. The ‘Introduction to the cases in the CSA’ document on the website tells you that you are likely to see at least one case relating to a child and one to an older adult. How is your consultation different if a child is involved? Do you have any extra considerations when dealing with an elderly person? You will see at least one case with a significant element of diversity. This may be a patient with a disability, a different ‘protected characteristic’ or one whose presentation or management is significantly affected by their sociocultural status. What disabilities can you think of? Role-play the opening 2 minutes of a case – any case – with a person who has that disability. What type of patient may be disadvantaged by their sociocultural status, their difference? How might that affect your approach? You know that some cases involve an examination. What systems might you be asked to examine? Can you perform those examinations in a fluent and focused way within a 10-minute consultation? All of this ‘catch-up’ skill practising can be done in study groups. Like real patients, role players will start by saying something about their problem as they come in. Most candidates then follow-up with a ‘tell me more about that’ question. But this is an exam; the examiner needs to know what more you want to hear. So be prepared with a follow-up question and do not be floored if your ‘tell me more’ offer gets the reply ‘what more would you like to know?’ Look for a ‘formative’ CSA course to familiarise yourself with the process. Most Deaneries run them, and the RCGP accredits many more. Remember though, that no CSA case writer can write cases for these courses.
On the day
Arrive in plenty of time, having checked your equipment and packed your identification. Be confident that you have done your best to prepare and know that no-one is out to trick you. On the contrary, we want you to show us how well you can do. Focus on the patient, not what you imagine the examiner is looking for. Role players will not wilfully withhold information; show them that you are interested in them, and they will give you every opportunity to demonstrate your skills.
Do not try to take any information out. It will distract you from the exam when you need to be at your best. And it is just not worth the risk.
Application process
You can sit the CSA at any time in your ST3 year. Monthly sessions are held from Oct/Nov till May. Dates are based on previous candidate requests. If there is a sudden change in requested dates we try to be flexible, but cannot promise every candidate their session of choice. The dates and application process are all clearly outlined on the RCGP CSA exam website. If you have a disability requiring a reasonable adjustment, do look up the regulations in advance. Help us to help you.
The MRCGP is always evolving, so for the most up-to-date information please consult the RCGP website.
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