MRCGP: CSA practice case - Patient with insomnia

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.

The patient has difficulty falling asleep and then feels tired at work (Photograph: SPL)
The patient has difficulty falling asleep and then feels tired at work (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 look at the end until you are ready to read the marking guide and debrief. The marking guide and debrief also provide useful pointers towards the knowledge base needed for passing a CSA consultation.

How to use this article
This article is ideally used in a study group consisting of three trainees. The marking grid models an ordered, stepwise approach to data gathering, management and communication, and 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 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

  • You are Rodney Heron, a 33-year-old married telecommunications engineer. You present today because you had a terrible night's sleep earlier this week and want advice on insomnia.
  • On Sunday you went to bed at 11pm, your usual time. You finally dozed off at 3am. After three to four hours' sleep, you felt incredibly tired at work. This is becoming increasingly common. You worry about not being able to fall asleep, wake up unrefreshed and feel tired at work. You have not made any errors at work but double-check things now so jobs take longer.
  • If asked, the problem started insidiously, about two years ago. Nothing happened to trigger it. You have poor sleep on three to four nights per week. You have difficulty falling asleep, but once asleep you are fine. You wake up once to use the toilet, but fall asleep within minutes of returning to bed. You do not have any physical discomforts that wake you.
  • You reduced your caffeine intake, you exercise early each evening and you keep the bedroom cool and dark.
  • You think your mattress may be too hard but purchasing a new mattress would strain your budget. You are not keen on medication; colleagues have warned you how addictive sleeping tablets can be. You want some information so that you can decide if it is safe to try OTC medication.
  • If asked, you are not depressed; your mood is normal. Your wife has not told you that you have odd or loud breathing sounds or agitated movements during sleep.
  • Two years ago, after your dad had an MI, you lost two stone in weight, gave up smoking and restricted your alcohol intake to two bottles of wine over weekends. It is important to you to maintain a healthy lifestyle. You are not obese and your collar size is 15 inches.
  • You want to understand why your sleeping has been affected. If the doctor suggests medication, you want to know the risk of addiction. If asked, you are open to alternative treatments.

Doctor: Patient medical record

Name: Rodney Heron (33 years)

Past medical history:

  • Surgery for bilateral bunions 2008
  • Obesity due to excess calories 2006

Current medication: None

Assessor: 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:
  • Asks open questions about the sleep problem, daytime sleepiness/napping and factors interfering with sleep.  
  • Asks closed questions to clarify details and exclude secondary causes of insomnia: depression, alcohol, drugs, sleep apnoea and parasomnias.
  • Elicits how the problem affects the patient, his family and his work.
  • Discovers the patient’s health beliefs and expectations.

Negative indicators:
  • Questioning and examination are not sufficiently selective. Does not obtain sufficient information to support a diagnosis of primary insomnia.  
  • Failure to work through a diagnostic sieve and actively exclude secondary causes of insomnia.
  • Details of the patient’s agenda and health beliefs are not obtained or believed. The doctor persists in asking about hidden agendas, such as depression, despite the patient not reporting symptoms of a mood disorder.

B. Clinical management skills
  • Recognition and management of common medical conditions in primary care. Demonstrates a 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:
  • Doctor discusses what they feel the problem is (primary insomnia) and explains their reasoning, using the patient’s ideas and beliefs.
  • Management options, including ‘sleep hygiene’, restriction of time in bed, drugs and alternative remedies are openly discussed.
  • Management addresses the patient’s concerns and expectations.
  • Doctor advises appropriately on work, including the possible impact of a two-week sleep restriction programme on the patient’s ability to drive.

Negative indicators:
  • Doctor fails to explain the diagnosis or treatment options in jargon-free language.
  • The evidence base for various treatments is not provided in a simple format.
  • The patient is not given sufficient information to make informed decisions.
  • Follow-up arrangements are inadequate.

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:
  • Doctor listens attentively and summarises appropriately.
  • Communicates effectively using the patient’s ideas and beliefs.  
  • Involves the patient in decisions, offering choices and encouraging autonomy.

Negative indicators:
  • Doctor assumes the patient wants medication; the patient’s understanding of the available options is not explored.  
  • Doctor repeatedly questions the patient about depression/drugs, creating the impression that they strongly suspect a hidden agenda.
  • Doctor is unable to discuss the evidence base in a simple and meaningful way.

Debrief

  • Did the doctor ask sufficient questions in sufficient detail to make a diagnosis of primary insomnia? Did the history- taking feel like an interrogation or a conversation? Did the doctor use rote questions that interrupted the flow of the conversation?
  • Did the doctor provide management options? Did they discuss the benefits of 'sleep hygiene', restriction of time in bed, OTC medications (sedating antihistamines, melatonin, valerian), hypnotic drugs or sedating antidepressants or antipsychotics?
  • Some cases in the CSA seem simple. Have the confidence to explore hidden agendas. In this case, the doctor should establish that the patient is not depressed or requesting medication for illicit purposes. Have the courage to take the patient at face value, as you would in your consulting room.
  • This case tests whether the doctor can discuss management options meaningfully Is the doctor comfortable with discussing the evidence base? Is the doctor prepared to talk about complementary medicine? This case was not written to check for 'hidden agendas' so beware of second guessing the examiner.
  • Dr Naidoo is a GP trainer in Oxford

Resource
1. Falloon K, Arroll B, Elley CR et al. The assessment and management of insomnia in primary care. BMJ 2011; 342: d2899.

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