MRCGP: CSA practice case - Patient presents with a list of problems

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

Ask the open questions to identify the main reason for the patient consulting
Ask the open questions to identify the main reason for the patient consulting

When preparing for the clinical skills assessment (CSA), working through mock cases with your tutor or fellow registrars provides a valuable source of feedback to see how your skills are improving and to identify areas for further improvement.

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 in an appropriate way, perform the right examination correctly and communicate effectively with the patient within the allotted 10 minutes.

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

How to use this article

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

The marking grid in this article models an ordered, step-wise approach to data gathering, management and communication and the group debrief is essential to review the actual performance.

The feedback as a whole informs the doctor about their current knowledge and communication skills and advises them how to improve their performance for 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 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 consultation because it contains a summary of the patient's relevant details.

A recent test result, such as a fasting glucose 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 sounding an alarm when the 10 minutes are up.

Patient: Brief to patient

Download the patient brief to print out.

  • Lorraine has come to see the doctor because she has been troubled by headaches, a cold that won't go away, morning sickness, sluggish bowels and thinning hair. She has written a list of her symptoms and her opening statement is 'I'm so forgetful these days. I brought a list of problems with me'.
  • If asked which symptom is most troublesome, she says all the symptoms are troublesome but the headaches are the worst because they have been present for two weeks, since the onset of her cold. The dull pain behind her right eye affects work.
  • Her right teeth ache. When questioned in detail, she admits to having hot and cold spells at night, an offensive post-nasal drip and her forehead pain worsens when she bends forward.
  • She wants to know if it is worth buying £12 acupressure bracelets for the nausea.
  • Her bowel pattern has altered from once daily to every two to three days.
  • She has always had fine hair but when her cousin was recently diagnosed with a thyroid problem, she checked the internet for advice.
  • She thinks she has a recurrence of migraine (which she had as a teenager). She is concerned about coping with tax season at work with these headaches.
  • Medication for the headache and a blood test for thyroid disease is a priority. If asked, she is not allergic to any antibiotics.
  • If examined, she does not have a temperature and she is tender over the right eye.

Doctor: Patient medical record

Download the patient medical record to print out

Name: Lorraine Brooker (28 years).

Past medical history: Currently pregnant, irritable bowel syndrome.

Current medication: Mebeverine.

Examiner: Marking guide

Generic indicators for targeted assessment domainsDescriptors – 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 (to explore the list’s contents) followed by closed questions to clarify detail, particularly of the headache.

Enquires about the past history of migraine. Understands how pressures at work (and her cousin’s recent diagnosis) affect her presentation.

The targeted examination is focused, practised and integrated into the consultation.

Negative indicators:
Fails to identify the patient’s agenda and preferences.

Makes assumptions (about migraine/minor pregnancy symptoms) and fails to recognise the challenge.

Is disorganised in gathering information.

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 comorbidity and to promote a shared approach to managing problems.

Positive indicators:
Explained clearly what they want to examine and why.

The risks and benefits of management options, including prescribing, are adequately discussed.

Responses to the patient’s concerns and expectations are smoothly woven into the consultation.

Negative indicators:
Fails to make an adequate diagnosis, with a vague explanation to patient.

Management plans, including prescribing, are not appropriate or in line with current best practice.

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:
Displays good listening skills; interested in getting to the heart of the problem.

Develops a shared management plan, incorporating the patient’s agenda and specific concerns.

Checks understanding and agreement with the patient.

Negative indicators:
Interrupts inappropriately, appears judgmental or lacks sympathy.

Uses formulaic questions; the consultation lacks natural flow.

Is doctor-centred; fails to adequately pick up or address verbal or non-verbal cues.

Debrief

  • Assess the doctor's verbal and non-verbal response to the patient presenting with a list of problems. Did the doctor seem genuinely interested in ascertaining the main reason for the patient consulting or did he/she show their dismay or negative feelings?
  • Was there a good mix of open and closed questions to adequately prioritise the focus of the consultation?
  • Did the doctor notice and respond to cues at the time they are offered by the patient? Did the doctor repeat back so the patient knew they understood? Did the doctor legitimise the patient's feelings, for example: 'This is clearly worrying you a great deal'.
  • Was there a shared management plan? Did the doctor draw up a list (migraine; impact of headache on work; blood test for thyroid disease) and negotiate which to deal with first, perhaps by first paraphrasing with 'We need to make the best plan we can to sort out these problems. I think we should take each one seriously, giving due time and attention rather than hastily construct a plan.'
  • One of the most common feedback statements to CSA failures is 'does not identify the patient's agenda, health beliefs and preferences or does not make use of verbal and non-verbal cues'. In this case, evaluate how well the doctor communicated with a patient presenting with a list of problems. Was the doctor able to provide specific information that moved the consultation forward, having assessed what the patient already knew, what they wanted to know and what they needed to know?

Dr Naidoo is a GP trainer in Oxford. She has written three books on how to pass the CSA. Dr Naidoo's latest book CSA Practice Cases for the MRCGP was published in January 2016.

Resources for revision

  • Suchman AL, Markakis K, Beckman HB et al. A model of empathic communication in the medical interview. JAMA 1997; 277(8): 678-82.

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