How to avoid common pitfalls in the CSA

By Dr Bruno Rushforth and Professor Val Wass on the 3 September 2009

The RCGP has highlighted where candidates are falling down. Dr Bruno Rushforth and Professor Val Wass explain.

Ask about patients' ideas, concerns and expectations

Several thousand GP registrars have now made the trip to Croydon to the RCGP's clinical skills assessment (CSA) centre, overlooking the sprawling south London suburbs.

With the £1,323 price-tag, and the knowledge that passing the CSA is now a prerequisite for becoming a fully fledged GP, most candidates are keen to ensure that they pass first time.

The RCGP has provided information on the areas that candidates have found particularly tricky.

The CSA takes the form of 13 10-minute simulated consultations with role-playing actors. Examiners follow their allocated role player around the circuit of consulting rooms and give one of the following grades for each candidate per station:

clear pass
marginal pass
marginal fail
clear fail.

If the examiner gives a 'fail' grade - i.e. marginal fail or clear fail - for a station, then they have the opportunity to flag areas for improvement by highlighting any of the 16 feedback statements (see box). If two or more examiners flag the same feedback statement, this is reported to candidates when they get their results on the ePortfolio.

Candidates who have failed the CSA - and those who have passed but wish to further improve their performance - can use the highlighted feedback statements to identify areas that they need to focus on with their trainer.

Feedback statements

Frequency with which the 16 feedback statements were indicated
	Times statement ticked (%)
Data gathering
Disorganised and unsystematic in gathering information from history taking, examination and investigation	6.8
Does not identify abnormal findings or results or fails to recognise their implications	5.8
Data gathering does not appear to be guided by the probabilities of disease	5.7
Does not undertake physical examination competently, or use instruments proficiently	2.2
Clinical management
Does not make appropriate diagnosis	6.8
Does not develop a management plan (including prescribing and referral that is appropriate and in line with current best practice)	13.3
Follow-up arrangements and safety netting are inadequate	4.7
Does not demonstrate an awareness of management of risk and health promotion	4.1
Interpersonal skills
Does not identify patient's agenda, health beliefs and preferences/does not make use of verbal and nonverbal cues	8.7
Does not develop a shared management plan or clarify the roles of doctor and patient	8.7
Does not use explanations that are relevant and understandable to the patient	5.7
Does not show sensitivity for the patient's feelings in all aspects of the consultation including physical examination	3.9
Global
Disorganised/unstructured consultation	4.8
Does not recognise the challenge	9.3
Shows poor time management	3.9
Shows inappropriate doctor centredness	5.7
Reproduced with permission from RCGP Clinical Skills Assessment: Analysis of feedback statements given by examiners in the CSA (October 2007 - May 2008).

Management plan
As can be seen from the feedback statements, the most commonly flagged area for improvement, at 13.3 per cent, is 'Does not develop a management plan'.

This is not surprising given the time pressure in the CSA. When the bell rings at 10 minutes, the role player and examiner will simply get up and leave. If a candidate has spent too long taking a history, it can be easy to run out of time before a management plan has been established.

Trainees should wait to take the CSA when they have become proficient and feel comfortable handling single agenda consultations in their own surgeries within 10 minutes.

When practising mock scenarios with peers, one member should keep a close eye on the time. It may be useful to try to complete practice stations within nine minutes so that candidates will have some leeway to 'overrun' before the bell goes at 10 minutes.

Recognise the challenge
The second most commonly ticked statement, at 9.3 per cent, is 'Does not recognise the challenge'.

The case may be designed to see if candidates are competent in addressing lifestyle issues and preventive measures, or other aspects of the curriculum such as equality and dealing with ethically challenging situations.¹

The simulated patients for these stations may well present with a common complaint, but candidates need to be alive to the possibility that the station is testing more than their ability to manage mechanical back pain.

One suggestion is to ask about the patient's ideas, concerns and expectations (ICE) early in the consultation. It is important to practise asking about ICE in everyday surgeries.

Interpersonal skills
Equal third in terms of number of times the feedback statements were indicated, at 8.7 per cent, include two of the four interpersonal skills statements, namely:

- Does not identify patient's agenda, health beliefs/does not make use of verbal and nonverbal cues

- Does not develop a shared management plan or clarify the roles of doctor and patient.

Both of these tie in with the previous points, in that if candidates are not alert to cues from the simulated patient, then it is all too easy to miss key elements of the case. If time pressures mean it is necessary to rush through to finish the station, then candidates can fail to develop a shared management plan.

In summary, to ensure that candidates avoid the common pitfalls outlined, GP registrars are advised to practise both in surgery and with peers. Focus on eliciting the patient's agenda along with time management.

- Dr Rushforth is an academic teaching fellow in general practice in Leeds and Professor Wass is professor of community-based medical education, Manchester.

RESOURCES

Reference
1. RCGP The Clinical Skills Assessment: PowerPoint presentation. www.rcgp-curriculum.org.uk/docs/CSA% 20presentation 2008-2009.ppt