MRCGP: CSA practice case - Patient requests specific medication

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.

When preparing for the clinical skills assessment (CSA), mock cases with your tutor or fellow registrars are a valuable source of feedback to see how your skills are improving and to identify areas for 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 they ask the patient the right questions in an appropriate way, perform the right examination correctly and communicate effectively with the patient, all within 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. Do not read the marking guide and debrief until after you have undertaken the case.

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 models an ordered, step-wise approach to data gathering, management and communication. The group debrief is essential to review performance.

The feedback 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 the patient' section to enable him to understand the expectations of the patient so he 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 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 sit unobtrusively where the 'doctor' cannot see them.

The examiner should mark the case using the marking guide by ticking against positively or negatively as the consultation unfolds.

The examiner times the case, sounding an alarm when the 10 minutes are up, and at the end they should make a global judgment of whether the doctor, based on this consultation, is fit for independent practice.

Patient: Brief to patient

Download the brief to patient to print out.

  • You are Robert Williams, a 64-year-old engineer.
  • You present today, slightly embarrassed but determined, to ask for an erectile dysfunction drug.
  • Your wife died two years ago. You started dating a 54-year-old woman three months ago. You have a good relationship but are unable to maintain your erection.
  • If asked, you say that you still get erections at night. You have never suffered from premature ejaculation.
  • You find your partner attractive, your mood is good, your children like your new partner and you have no financial worries.
  • You think you have 'performance anxiety' and would like to take Viagra. You think that once the cycle is broken, you will not require medication.
  • If asked, you are in good health and you have not had previous medical issues or surgery. You are not on any medication, except for ibuprofen occasionally for back pain. You have no problems with urine flow or frequency. You do not know your family history, having been adopted.
  • You have put on 10kg in past two years, drink four beers three times per week and a bottle of red wine on weekends. You smoke the occasional cigar and do very little exercise.
  • If the doctor asks to examine your BP and weight, you hand him a card saying 'BP 134/86, weight 90kg; BMI 29'. If an examination of the genetalia is requested, give a card saying 'normal penis and testes'. Decline a prostate examination.
  • You would like a prescription, preferably an NHS script, but you are willing to pay for it. You are worried about the quality of the tablets sold on the internet. You want the scrip today because you have planned a romantic weekend away.

Doctor: Patient medical record

Download the patient medical record to print out

Name: Robert Williams (64 years).

Past medical history: Mechanical low back pain (2009) - sick note for one week. Fungal nail infection (2005).

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 medication request and sexual problem, and closed questions to clarify possible causes of erectile dysfunction (ED), such as cardiovascular problems, depression, endocrine, surgical, medication side-effect or psychological issues.

Enquires about lifestyle including smoking, alcohol, exercise, including number of hours cycling, and diet.

Undertakes a targeted examination: BP, weight, penis and testes. In the absence of lower urinary tract symptoms, a prostate examination is deferred.

Negative indicators:

Questioning is not sufficiently detailed to exclude organic or psychological causes of ED.

In particular, the opportunity to explore cardiovascular issues and question holistically (including job worries, children, grief) is missed.

The physical examination is not undertaken or insufficiently targeted.

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:

Discusses further investigation and justifies request for blood tests (fasting glucose, lipids, and 9-11am  serum testosterone).

Management options, including lifestyle changes and drug treatment are discussed.

Advises prescription following blood results, but if new medication, such as generic sildenafil, is prescribed, the patient is advised on safe dosing and cautioned about possible side-effects.

Adequate follow-up is arranged

Negative indicators:

The investigation of the problem is inadequate or poorly targeted.

Prescribing behaviour is not in line with NHS policy.

Generic sildenafil is prescribed on the NHS without explaining the dfference between short and long acting PDE-5 drugs.

Patient is inadequately advised about dose, timing, need for sexual stimulation or success rates

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:

Deals with this potentially embarrassing problem sensitively. Questions are asked in a professional manner.

The examination and management is conducted with confidence.

Information about further investigation is delivered concisely, in language that is easily understood.

The patient is provided with opportunities to seek clarification.

Negative indicators:

Assumes the patient wants an NHS scrip and the patient is not given options.

Does not encourage the patient to share his ideas.

Does not negotiate a mutually acceptable plan.

Debrief

  • Some CSA cases are written with the patient asking for something specific. In this case, the patient asks for sildenafil. In other cases, the patient may ask for a referral, a blood test or a procedure, such as a vasectomy. It is important in such cases to explore the patient's reasons for the request.
  • It is also imperative to assess if alternative options are more appropriate. In this case, marks are awarded if attention is paid to modifying the patient's lifestyle and assessing his cardiovascular risk as well as negotiating the sildenafil prescription.
  • A common reason for failure in the CSA is that the doctor 'does not recognise the challenge (for example, the patient's problem or ethical dilemma)'.
  • Evaluate whether the doctor adequately explored the patient's problem by asking sufficient questions about organic and psychosocial issues.
  • Did the doctor ascertain the patient's ideas and redress his expectations by discussing the limited success rate of the requested medication? Evaluate whether the ethical dilemma (most PDE-5 drugs are not funded) was negotiated in a supportive and sensitive manner.

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

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