MRCGP: CSA practice case - A concerned mother

To be used individually or in a study group with someone playing the doctor, patient and assessor. Dr Prashini Naidoo provides this CSA practice case.

A mother is frustrated by her daughter’s night-time cough, which is impacting on her sister’s sleep (Photograph: SPL)
A mother is frustrated by her daughter’s night-time cough, which is impacting on her sister’s sleep (Photograph: SPL)

The clinical skills assessment (CSA) aims to test a candidate's ability to gather and assess medical information, make structured, evidence-based and flexible decisions and communicate with patients in a way that moves the consultation forward in an ethical and responsible manner.

The candidate will pass if they ask the patient the right questions, at the right time, in the right way, perform the right examinations correctly and communicate effectively, all within a 10-minute consultation.

Performing mock cases with your tutor or other trainees can provide valuable feedback and indicate how your skills are improving.

In this series of mock CSA cases, patient and doctor roles are provided along with examiner feedback to see how you score across the CSA marking domains.

Do not turn over the page until you are ready to read the marking guide and debrief. They also provide useful pointers towards the knowledge base needed for passing a CSA consultation.

How to use this article
This article can help GP trainees prepare for the CSA. It is ideally used in a study group consisting of three trainees, each playing one of the roles described.

The marking grid in this article models an ordered, step-wise approach to data gathering, management and communication. The group debrief is essential to review actual performance. The feedback as a whole informs the doctor about their current knowledge and communication skills and advises them on how to improve their performance for success in the CSA.

The 'patient'
The trainee playing the patient should read the 'brief to the patient' section so that they understand the expectations of the patient and can answer the doctor's questions.

If an examination is expected, the patient is briefed about the findings and may have to make up a card containing the relevant information prior to starting the consultation. If the patient brief does not contain this information, for example a BP reading, and the doctor wishes to examine the patient, the patient should allow the examination to occur. Performing irrelevant or unjustified examinations eats into the consultation time. Intimate examinations are not permitted.

The 'doctor'
The trainee playing the doctor should read the 'patient medical record' section at the start of the consultation because it contains a summary of the patient's relevant details. A recent test result may be provided. Sometimes, a copy of the last patient consultation is given.

The background information often provides a clue about the consultation or gives important data relevant to management decisions.

The 'examiner'
Ideally, the third trainee playing the examiner should enter the consulting room with the patient and sit unobtrusively where the 'doctor' cannot see them.

The examiner should mark the case using the marking guide by ticking against the positive or negative indicators as the consultation unfolds.

At the end of the consultation, the examiner should also make a global judgement of whether the 'doctor', based on this consultation, is fit for independent practice.

The 'examiner' times the case and sounds an alarm when the 10 minutes are up.

Brief to patient
  • You are Mrs Perret, a 29-year-old mother. You present today without your children to obtain a prescription for two-year-old Anne, and for advice about five-year-old Olivia's night terrors.
  • When you consulted with Anne 10 days ago, the doctor agreed that Anne's persistent night-time cough and her occasional wheeze may be due to asthma. She advised you to try a blue salbutamol inhaler. Anne used the inhaler and facemask without difficulty. It has made some difference but she is not completely better.
  • Anne has used the inhaler two to three times a day; 30 minutes after using it, her cough recurs. You are not sure if the blue inhaler alone is adequate medication. You have had asthma since childhood and based on your experience, you feel Anne needs a brown steroid inhaler.
  • You are concerned about the night-time cough. It still disturbs Olivia, who has to wake up for school the next morning. You are also worried about Olivia's night terrors. Is the poor sleep making these worse? Is there anything you could do to help Olivia with her night terrors?
  • Olivia has had night terrors from the age of three. The health visitor advised a good night-time routine for her, but despite this Olivia tends to have at least one episode every week. If questioned, it usually happens two hours after she falls asleep. She sits bolts upright in bed, screams, looks ashen, cries inconsolably and never remembers it in the morning. It is difficult to rouse her from a terror.
  • You would like a prescription for a brown steroid inhaler for Anne and advice for Olivia. You did not think Anne needed to be re-examined today. She is usually fine during the day and, at the last consultation, the doctor did not detect anything untoward on examination. You do not think it is worth coming back with the children for medication to be issued. If you are asked to return before a prescription is issued, you want to know what the examination will add to the consultation.
Patient medical record

Name: Anne Perret (two years)

Consultation notes by GP (10 days ago):

  • Mum had asthma from age of five years. Anne occasionally has cough at night (after 9pm) and over past few nights, mum noticed wheeze. Kept sister (school age) awake.
  • Tried steam inhalation/propping up head of bed, but did not help. Frustrated as presented many times with cough and told it is a self-limiting viral illness.
  • On examination: chest sounds normal; no wheeze. Healthy looking.
  • Plan: try salbutamol inhaler and review if needed.
Accessor: Marking guide
Generic indicators for targeted assessment domains Descriptors - positive and negative
A. Data gathering, technical and assessment skills:
  • Gathering of data for clinical judgment, choice of examination, investigations and their interpretations.
  • Demonstrating proficiency in performing physical examinations and using diagnostic and therapeutic instruments.
Positive indicators:
  • Reads the previous consultation notes prior to the patient’s presentation.
  • Asks open questions to clarify the nature of the problem followed by closed questions to understand exactly what mum is requesting today.
  • The doctor systematically excludes red flags (intercurrent illness; severe asthma) that may signal the need for in-person review.
  • Comes to an understanding of how Anne’s night-time cough exacerbates Olivia’s night terrors and the impact on the family.
  • Elicits mum’s concerns about Anne’s ‘partially treated asthma’ and her expectations of a prescription.

Negative indicators:
  • The doctor fails to respond to mum’s cues about ‘disturbed sleep’. By not establishing the link between disturbed sleep and Olivia’s worsening night terrors, the doctor does not provide holistic family care. 
B. Clinical management skills
  • Recognition and management of common medical conditions in primary care.
  • Demonstrates flexible and structured approach to decision making.
  • Demonstrating ability to deal with multiple complaints and comorbidity and to promote a shared approach to managing problems.
Positive indicators:
  • Makes a clinically sound working diagnosis on the basis of probability. Either offers a test for asthma or initiates ‘step two asthma treatment’ on a trial basis.
  • The explanation about interrupted sleep aggravating night terrors is logical and incorporates the patient’s beliefs.
  • Advises about the treatment of night terrors.
  • Outlines when follow-up or review is needed (safety nettings). If referral to the asthma nurse is offered, mum is given sufficient information to make a decision.

Negative indicators:
  • Fails to prescribe safely, or in line with current best practice, or fails to justify why a prescription is given or withheld.
  • Fails to check patient’s understanding of the medication and/or her ability to use the medication appropriately.
  • Fails to formulate a management plan for night terrors or fails to advise why this needs to be addressed in a separate consultation.
C. Interpersonal skills
  • Use of recognised communication techniques that enhance understanding of a patient’s illness and promote a shared approach to managing problems.
  • Practising ethically with respect for equality and diversity in line with accepted codes of professional conduct.
Positive indicators:
  • Listens attentively and empathises with the adverse effect of Anne’s nocturnal cough on the family.
  • Is non-judgmental about mum’s ideas.
  • Encourages mum’s opinions and autonomy but maintains primary duty of care to the children.

Negative indicators:
  • The doctor interrupts unnecessarily and breaks the flow of conversation.
  • The doctor’s manner discourages questioning or the sharing of opinions.
  • The patient is not offered options regarding treatment or follow-up.

Debrief

  • Discuss how the doctor could improve his or her performance.
  • Assess whether the doctor showed poor time management.
  • How long did the doctor take to obtain the history? Was questioning appropriately selective or needlessly repetitive?
  • Was the second half of the consultation rushed?
  • Were the relevant psychosocial factors covered?
  • In the group, discuss whether the doctor developed an adequate management plan, and whether it was appropriate to the risk level.
  • Were the risks and benefits of different management approaches, including prescribing, clearly identified and discussed?
  • Dr Naidoo is a GP trainer in Oxford

For more CSA practice cases and tips on how to pass the CSA, visit our GP registrar resource centre.

Resources

  • van Dorp F. Consultations with children. InnovAiT 2008; 1(1): 54-61.
  • Driver HS, Shapiro CM. ABC of sleep disorders. Parasomnias. BMJ 1993; 306: 921-4.

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