MRCGP - CSA practice case - Emergency contraception

Play out the doctor, patient and assessor roles in a study group or plan on your own how you would approach this consultation. Dr Prashini Naidoo provides this CSA practice case.

No amount of reading can replace the clinical experience and time spent with patients necessary for a winning performance in the clinical skills assessment (CSA). But mock cases with your tutor or fellow registrars are a valuable source of feedback to see how your skills are improving.

This is the first in a series of mock CSA cases, with patient and doctor roles provided and examiner feedback to see how you scored across all three marking domains. Keep the next page folded over until you are ready to read the marking guide and the debrief.

How to use this article
This article is to help GP trainees prepare for CSA. It is written for use in a study group, ideally consisting of three trainees.

The CSA tests the 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 passes if he or she is able to ask the patient the right questions, at the right time, in the right way, perform the right examination correctly and communicate effectively, all within 10 minutes.

While the marking grid in this article models an ordered, step-wise approach to data gathering, management and communication for use by CSA study groups, it is also essential to review actual performance using the debrief prompts at the end of the article.

The feedback as a whole informs the doctor about his or her current knowledge and communication skills, and advises how this performance can be improved to achieve success in the CSA.

The 'patient'
The trainee playing the patient should read the 'brief to patient' section to enable her to understand the expectations of the patient so she can then 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 relevant 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 'doctor' should read the 'patient medical record' section at the start of consultation because it contains a summary of the patient's relevant details.

A recent test result, such as a fasting glucose, 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 him or her.

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 judgment of whether the doctor, based on this consultation, is fit for independent practice. The examiner times the case, sounding an alarm when the 10 minutes are up.

Patient: Brief to patient

  • Lizzie Rice, a 20-year-old unmarried woman.
  • Lizzie met a work colleague Tom, on Friday (the consultation is on Tuesday evening). A broken condom incident occurred at midnight. She is seeing Tom this weekend, but doesn't know his sexual history.
  • Lizzie is not taking oral contraception. She had Implanon removed four months ago because of irritating bleeding. She wanted the depot injection but the GP said she was too young. Lizzie also smokes and her grandmother had brittle bones. If future contraception is discussed, Lizzie wants the Pill or depot.
  • Lizzie thinks her chances of being pregnant are unlikely but definitely doesn't want to be.
  • Lizzie has come to see the GP because she wants emergency contraception. She couldn't get an appointment on Monday.
  • If questioned in detail, Lizzie reveals she had her first proper period since the Implanon removal two weeks ago. She only had one episode of unprotected sex. Lizzie has not had emergency contraception or treatment for STIs before.
  • Lizzie is adamant that she doesn't want the coil - she had enough problems with the Implanon. If asked why she rejected the coil, she repeatedly says 'I don't fancy it'.
  • Lizzie is concerned about pregnancy. If an offer of STI screening is made, she accepts.
Doctor: Patient medical record

Name: Elizabeth Rice (20 years)

Past medical history: Nil significant

Current medication: none

Consultation note by GP (four months ago): Implanon removed from left arm without difficulty. Current cigarette smoker - 10 per day. Given leaflets on combined Pill and Mirena. Advised to speak to practice nurse about contraception options if queries.

Assessor: Marking guide

GENERIC INDICATORS FOR TARGETED ASSESSMENT DOMAINS

A. Data gathering, technical and assessment skills:

  • Gathering of data for clinical judgment, choice of examination, investigations and their interpretations.
  • Demonstrates proficiency in performing physical examinations and using diagnostic and therapeutic instruments.

DESCRIPTORS - POSITIVE AND NEGATIVE
Positive indicators:

  • Obtains details of unprotected sexual intercourse (UPSI) - time of UPSI, last menstrual period (LMP), contraception, risk of STI.
  • Excludes red flags, such as previous episodes of UPSI since discontinuing contraception.
  • Elicits details about her partner/relationship. Discovers the patient's desire to have an STI screen.
  • Elicits and addresses her strong expectation for emergency oral contraception.

Negative indicators:

  • Fails to elicit above points.
  • Assumes this is an isolated case of UPSI.
  • Does not explore her rejection of the IUD.

 

 

B. Clinical management skills
  • Recognition and management of common medical conditions in primary care. Demonstrates flexible and structured approach to decision making.

  • Demonstrates ability to deal with multiple complaints and co-morbidity and to promote a shared approach to managing problems.

Positive indicators:

  • Calculates that it is now 72 hours after UPSI and appropriately advises that an IUD is more effective than emergency contraception.
  • Addresses concerns about IUD but acknowledges her desire for levonorgestrel. If prescribes levonorgestrel, discusses it is an out-of-license prescription. If levonorgestrel not prescribed, makes timely arrangements for further management. Flags up need for on-going contraception.
  • Arranges for STI screening and makes acceptable follow-up arrangements, in accordance with local guidance.

Negative indicators:

  • Fails to elicit above points.
  • Sufficient information for patient choice is not provided.
  • Is overly persistent about IUDs.
  • If prescribes levonorgestrel, fails to discuss its out-of-license use.
  • If chooses not to prescribe, fails to make acceptable and timely arrangements for further management.

C. Interpersonal skills

  • Use of recognised communication techniques that enhance understanding of a patient's illness and promote a shared approach to managing problems.
  • Practises ethically with respect for equality and diversity in line with accepted codes of professional conduct.

Positive indicators:

  • Is non-judgmental about the patient's refusal of a valid treatment option (IUD).
  • Offers the patient choice (levonorgestrel, IUD, telephoning family planning (FP) clinic, going to FP clinic tonight).
  • Involves the patient in decisions about IUD, levonorgestrel and STI screening.

Negative indicators:

  • Fails to demonstrate the above points.
  • Is inappropriately persistent and/or belittles the patient's decision.
  • Is inappropriately paternalistic and/or fails to move the consultation on.
  • Decides for the patient.

Debrief

  • Does the doctor ask a mix of open questions, such as 'tell me a bit more about why you may need emergency contraception' and closed questions to clarify details.
  • Does the doctor address Lizzie's agenda and ascertain what she knows about the comparative effectiveness of oral emergency contraception and copper IUDs? Is the information given in digestable chunks?

Lizzie should be informed that levonorgestrel is licensed for use within 72 hours of unprotected sex, with an efficacy rate at 72 hours of 58 per cent. The copper IUD is indicated for presentation with five days (120 hours) and is 99 per cent effective.

  • If the doctor prescribes levonorgestrel, is Lizzie told how to take the tablet and informed of its possible side-effects? Is Lizzie told that if she vomits within two hours of taking levonorgestrel, she should repeat the dose as soon as possible?

Is Lizzie warned that some women have light bleeding or spotting after taking levonorgestrel?

  • Does the doctor discuss contraceptive alternatives, arrange for STI screening as per local protocols and make adequate follow-up arrangements?
  • Is the doctor empathetic, non-judgmental and respectful of her treatment preferences?

Dr Naidoo is a GP trainer in Oxford. She has written two books on how to pass the CSA

This topic falls under sections 10.1 and 11 of the RCGP curriculum 'Women's Health and 'Sexual Health', www.healthcarerepublic.com/curriculum

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