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 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' 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.
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
|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:
DESCRIPTORS - POSITIVE AND NEGATIVE
|B. Clinical management skills |
C. Interpersonal skills
- 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