The CSA: The CSA: How can my ST3 fail?How can my ST3 fail?

Trainer’s workshopTrainer’s workshop

Nov 2012Nov 2012

TodayToday

The CSA exam: StandardsThe CSA exam: Standards

Why failure happensWhy failure happens

How might we avoid this?How might we avoid this?

A CSA caseA CSA case

CSA data CSA data

►~~ 3000 candidates pa 3000 candidates pa

►Pass rate Pass rate ~~ 70% (75 first time) 70% (75 first time)

►UK Grads UK Grads ~~ 80-90% 80-90%

►Mean score Mean score ~~ 80 (Max 117, range 40- 80 (Max 117, range 40-110)110)

IMGIMG

GenderGender

The CSA: aimThe CSA: aim

““to assess a doctor’s ability to assess a doctor’s ability to to integrateintegrate and apply and apply appropriateappropriate clinical, clinical, professional, communication professional, communication and practical skills in and practical skills in general practicegeneral practice””

CSACSA

►13 consultations13 consultations

►10 minutes each10 minutes each

►Hugely varied content “representing Hugely varied content “representing the range and diversity of cases seen the range and diversity of cases seen in General Practice”in General Practice”

The three domains in each The three domains in each casecase

►Data gathering, technical and Data gathering, technical and assessment skillsassessment skills

►Clinical management skillsClinical management skills

► Interpersonal skillsInterpersonal skills

The three domainsThe three domains

Four possible grades for each domainFour possible grades for each domain

Clear Pass Clear Pass 3 marks3 marks

Pass Pass 2 2

FailFail 1 1

Clear FailClear Fail 0 0

►Each domain counts equally! Each domain counts equally!

The generic descriptorsThe generic descriptors

►http://www.rcgp.org.uk/gp-training-http://www.rcgp.org.uk/gp-training-and-exams/mrcgp-exam-overview/~/and-exams/mrcgp-exam-overview/~/media/Files/GP-training-and-exams/media/Files/GP-training-and-exams/Guide-to-how-the-CSA-is-marked.ashxGuide-to-how-the-CSA-is-marked.ashx

How good is good enough?How good is good enough?

►http://www.rcgp.org.uk/gp-training-http://www.rcgp.org.uk/gp-training-and-exams/mrcgp-exam-overview/~/and-exams/mrcgp-exam-overview/~/media/Files/GP-training-and-exams/media/Files/GP-training-and-exams/CSA%20page/CSA-Grade-CSA%20page/CSA-Grade-descriptors.ashxdescriptors.ashx

The four types of failing The four types of failing registrar?registrar?

►Not cut out for the jobNot cut out for the job

►Underprepared Underprepared

►Go to pieces on the dayGo to pieces on the day

►Badly preparedBadly prepared

Lessons from the shop floorLessons from the shop floor

►How good registrars fail…How good registrars fail…

Rigid or Formulaic Rigid or Formulaic

► ““I WILL show empathy and ICE everyone”I WILL show empathy and ICE everyone”

► ““I am concerned re my breast I am concerned re my breast lump”…”anything else you’d like to discuss?”lump”…”anything else you’d like to discuss?”

► Prevention: Emphasise flexibility, spiral Prevention: Emphasise flexibility, spiral consulting and patient centredness consulting and patient centredness

► On the day: Stay with the patientOn the day: Stay with the patient

Over cautiousOver cautious

► ““As long as you’re safe you’re OK”As long as you’re safe you’re OK”

► ““I’ll refer you to dermatology for that slight I’ll refer you to dermatology for that slight itch…”itch…”

► ““I’ll check with my senior colleagues and get I’ll check with my senior colleagues and get back to you”back to you”

► ““Let’s do a million blood tests, just to be sure”Let’s do a million blood tests, just to be sure”

► Prevention: Do good, appropriate general Prevention: Do good, appropriate general practice.practice.

►On the day: Make a decision. On the day: Make a decision.

Patient led, not patient- Patient led, not patient- centredcentred

““As long as you’re nice you’re OK”As long as you’re nice you’re OK”

““The patient didn’t want me to call 999”The patient didn’t want me to call 999”““I didn’t do anything about his arthritis but I was I didn’t do anything about his arthritis but I was

terribly understanding”terribly understanding”

Prevention: Know and implement NICE Guidance Prevention: Know and implement NICE Guidance Developing skills in negotiation/challengeDeveloping skills in negotiation/challenge

On the day: Up to date On the day: Up to date management management must be must be demonstrateddemonstrated

Case spottingCase spotting

► ““This must be the Gillick competence This must be the Gillick competence station” station”

► ““I mustn’t give a sick note”I mustn’t give a sick note”► ““I mustn’t prescribe codeine”I mustn’t prescribe codeine”► ““I must get patient to accept LARC”I must get patient to accept LARC”

► Too many courses/booksToo many courses/books

► Prevention: Do lots of real General PracticePrevention: Do lots of real General Practice►On the day: Stay with the patientOn the day: Stay with the patient

Time KeepingTime Keeping

►““I didn’t get round to making a plan, I didn’t get round to making a plan, taking a history took too long..”taking a history took too long..”

►Prevention: Time keeping skills for CSAPrevention: Time keeping skills for CSA

►……and for lifeand for life

HousekeepingHousekeeping

►““I messed up that chest pain station…I messed up that chest pain station…it all went wrong after that”it all went wrong after that”

►House keeping skills for CSAHouse keeping skills for CSA

►……and for lifeand for life

How can we help?How can we help?

► In foursIn fours

►Think about the reasons for failureThink about the reasons for failure

►How can we help? Practical steps to How can we help? Practical steps to shareshare

As trainers - how can we help?As trainers - how can we help?

►Be familiar with the exam and how it is Be familiar with the exam and how it is markedmarked

►Offer feedback on each domain, be a Offer feedback on each domain, be a hawk!hawk!

► ‘‘Diagnose’ your registrar’s particular Diagnose’ your registrar’s particular problemsproblems

Key messagesKey messages

►As a trainer we are expert!As a trainer we are expert!

►BUTBUT

► It is their assessment not ours….It is their assessment not ours….

What’s going on here?What’s going on here?

►http://www.youtube.com/watch?v=Jb7http://www.youtube.com/watch?v=Jb71-kSFsdw&feature=channel1-kSFsdw&feature=channel

►GP registrar patient centred GP registrar patient centred consultation skillsconsultation skills

►http://www.youtube.com/watch?v=Jb7http://www.youtube.com/watch?v=Jb71-kSFsdw1-kSFsdw

Norman PriceNorman Price

► 55 year old man55 year old man► Financial advisorFinancial advisor

► 2/52 ago saw another GP in practice:2/52 ago saw another GP in practice:► ““Trouble passing urine, frequency. MSU NAD. For Trouble passing urine, frequency. MSU NAD. For

bloods” bloods” ► PSA: 3.1PSA: 3.1► Random gluc: 5.2Random gluc: 5.2

► 3/12 ago: BP 132/733/12 ago: BP 132/73► 9 years ago: tension headache9 years ago: tension headache

NICE LUTSNICE LUTS

►http://guidance.nice.org.uk/CG97/Quichttp://guidance.nice.org.uk/CG97/QuickRefGuide/pdf/EnglishkRefGuide/pdf/English

Data gathering problems: Data gathering problems: Failure to…Failure to…

►Gather psychosocial information ie Gather psychosocial information ie homelife, workplace, caring homelife, workplace, caring responsibilities, community etcresponsibilities, community etc

►Pick up on cues Pick up on cues ►Establish the patient’s thoughts, fears Establish the patient’s thoughts, fears

and hopesand hopes►Resist interruptingResist interrupting►Avoid early closed questions and Avoid early closed questions and

assumptionsassumptions►Reach agreed shared understanding of Reach agreed shared understanding of

the problemthe problem

Data gathering problems: Data gathering problems: Failure to…Failure to…

►Assimilate/interpret the written Assimilate/interpret the written material providedmaterial provided

►Be appropriately selective e.g. does Be appropriately selective e.g. does systems review, orders batteries of systems review, orders batteries of teststests

►Get to the diagnosis e.g. depressionGet to the diagnosis e.g. depression

Management plan problems: Management plan problems: Failure to…Failure to…

►Get this far due to time pressure Get this far due to time pressure ►Be patient centred and give options Be patient centred and give options

and negotiateand negotiate►Take account of patient’s thoughts, Take account of patient’s thoughts,

fears and hopes fears and hopes ►Follow best medical practiceFollow best medical practice►Manage risk safely, safety net Manage risk safely, safety net

appropriately etcappropriately etc

Interpersonal skillsInterpersonal skills

►Poor rapport buildingPoor rapport building►Missed cuesMissed cues►Consultations are formulaic and Consultations are formulaic and

woodenwooden►Doctor centred, not patient centredDoctor centred, not patient centred►Unable to summarise, empathise, Unable to summarise, empathise,

state what they are seeing “You seem state what they are seeing “You seem upset about that”upset about that”

Comment from a GPST after Comment from a GPST after completing a recent mock CSAcompleting a recent mock CSA

►““I don’t know what went wrong – after I don’t know what went wrong – after all I ICE’d all the patients.......”all I ICE’d all the patients.......”

Another example from a recent Another example from a recent mock CSAmock CSA

►Patient: “I feel so awful I’ve thought Patient: “I feel so awful I’ve thought about ending it all….”about ending it all….”

►ST3:ST3:“Oh right. And is there anything “Oh right. And is there anything else you’d like to talk about today?”else you’d like to talk about today?”

Consultation ModelsConsultation Models

►Pros: give structure to the Pros: give structure to the consultations and remind the registrar consultations and remind the registrar about key areasabout key areas

►Cons: can be formulaic rather than Cons: can be formulaic rather than natural, may use up too much time if natural, may use up too much time if not focussednot focussed

What are the most common What are the most common feedback statements?feedback statements?

(1)(1) Does not recognise the issues or Does not recognise the issues or priorities in the consultation (eg the priorities in the consultation (eg the patient’s problem, ethical dilemmas etc)patient’s problem, ethical dilemmas etc)

(2)(2) Does not develop a Does not develop a managementmanagement plan plan (including prescribing and referral) that (including prescribing and referral) that reflects knowledge of current best reflects knowledge of current best practicepractice

(3)(3) Does not develop a shared Does not develop a shared management management planplan

As trainers - how can we As trainers - how can we help?help?

Observed consultations, videos, (COTs), Observed consultations, videos, (COTs), joint surgeriesjoint surgeries

Feed back on Feed back on all threeall three domains domains

As trainers – how can we As trainers – how can we help?help?

►Time management skills – early onTime management skills – early on

►Housekeeping skillsHousekeeping skills

►Know when to draw the line! Know when to draw the line!

Key messagesKey messages

►Avoid formulaic communication skillsAvoid formulaic communication skills►Listen to the patientListen to the patient►Ensure psychosocial aspects are Ensure psychosocial aspects are

consideredconsidered►Remember to make an appropriate, shared Remember to make an appropriate, shared

management planmanagement plan►Keep open mind, deal with what is brought Keep open mind, deal with what is brought

by case on the day. Do not case spot!by case on the day. Do not case spot!►Do good general practiceDo good general practice