MRCGP: CSA practice case - Discussing blood test results

By Dr Prashini Naidoo on the 9 December 2010

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

Find out what the patient knows about the tests and why they were done (Photograph: SPL)

The clinical skills assessment (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 examinations correctly and communicate effectively, all within a 10-minute consultation.

Performing mock cases with your tutor or other trainees is a way of gaining valuable feedback and to see how your skills are improving along the way.

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 turn over the page 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 can help GP trainees prepare for the CSA. It is ideally used in a study group 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 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 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

You are Evelyn Baker, a 35-year-old housewife.
You have come to discuss the results of a recent blood test. If questioned in detail, you had a glucose tolerance test because a fasting glucose test two months ago showed you had borderline diabetes. You also requested your cholesterol be checked because you are hoping to stop the cholesterol medication.
You deliberately, without telling the doctor, did not take your cholesterol tablets for the one month preceding the blood test hoping that if the level is low, your doctor will stop the cholesterol tablet. You give this information to the doctor only when your blood results are being discussed.
With your diet and exercise programme over the past year, you lost a stone and hope a healthy lifestyle will enable you to discontinue medication. You do not experience side-effects from the medication.
You think you may develop diabetes in future. Your mother's parents developed late-onset diabetes in their forties, your father had an MI in his fifties and your mother had one in her sixties. Three of your mother's uncles and her only sister have high cholesterol.
You expect the doctor to discuss your results and to stop the tablets if your cholesterol is low. You also expect your medication for heavy periods to be re-issued today. The gynaecologist you saw two weeks ago advised an operation to burn out the lining of the womb but, until then, you need medication to ease the bleeding. You and your husband are 80 per cent sure that you do not want children.
You are worried about being lectured about further weight loss. You think you have 'big bones' and a 'slow metabolism' and it took enormous effort to lose weight over the past year. You are tired of being warned about the risks of being overweight. You are a non-smoker. You and your husband share three bottles of white wine each week.
If the doctor examines you, you do not have corneal arcus, xanthelasma or xanthoma. If the doctor offers further blood tests or referral to a specialist, you want to know why.

Doctor: Patient medical record
Name: Evelyn Baker (35 years)

Past medical history
Iron deficiency anaemia 2008
Menorrhagia 2008
Latex allergy 2007
Current medication
Simvastatin 40mg at night
Mefenamic acid 500mg three times daily
Tranexamic acid 1g three times daily

Blood tests
Tests done two weeks ago.
Fasting glucose: 6.5 mmol per litre
Two-hour glucose: 10.8 mmol per litre
Serum cholesterol: 5.9 mmol per litre
(three years ago 7.9 mmol per litre)
HDL: 1.1 mmol per litre
Hb: 13.9g/dl
BP: 136/86mmHg
BMI: 34.7 kg/m2

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:

Finds out what the patient already knows about the blood tests and why they were done.
Discusses the patient's ideas about cholesterol and explores her beliefs regarding treatment.
Discovers the patient's expectation of discontinuing simvastatin and obtaining a repeat prescription for menorrhagia medication.
The patient is examined for clinical signs of hypercholesterolaemia.

Negative indicators:

Does not explore the patient's family history.
Time is wasted on examinations that contribute little to subsequent management plans.

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:

Negotiates and highlights the four main issues: her new diagnosis of impaired glucose tolerance, the possibility of familial hypercholesterolaemia, the risks and benefits of statin therapy, and a brief review of menorrhagia management prior to prescribing.
Addresses her concerns about unnecessary statin intake and manages in line with national policy.
The repeat prescription is issued with clear instructions, in line with national prescribing guidance.
Adequate follow-up is arranged and the doctor checks that the patient understands why future tests or referrals are needed.

Negative indicators:

Fails to interpret the results appropriately or the decision regarding statin therapy is not justified.
Prescribes inappropriately.
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:

Understands why she discontinued medication prior to the blood test.
Provides information about cardiovascular risk in language that is easily understood. Explanations are concise.
Provides opportunities for the patient to seek clarification.
Offers options and involves the patient in management decisions.

Negative indicators:

Adopts a 'parent-child' style of consulting.
Delivers standard health promotion advice without tailoring it to the patient's needs.

Debrief

The focus of some CSA cases is data interpretation. In this case, the patient's blood results are provided for interpretation. You need to interpret the results correctly. Sometimes candidates interpret the results correctly but then fail to act on them appropriately, so examiners conclude the candidate did not recognise their significance. It is imperative to deal with abnormal findings safely, in line with national or local guidance, to reduce risk.
When candidates fail to interpret data correctly, they invariably do not make the correct diagnosis. Making a diagnosis means committing yourself on the basis of the information you have available to you. You need a sound knowledge base.
State the diagnosis clearly and explain it to the patient using language that is understandable. The lack of a statement about the diagnosis and a vague summary leaves the examiner wondering whether you have made a diagnosis at all. In this case, evaluate how well the doctor explained impaired glucose tolerance and the possibility of familial hypercholesterolaemia to the patient.
To assess the doctor's interpersonal skills, consider whether the doctor worked in partnership with the patient, involved her in management decisions and demonstrated evidence of 'shared understanding' by asking the patient to summarise what she understood.

Dr Naidoo is a GP trainer in Oxford. She has written two books on how to the pass the CSA.

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Resources for revision

Choudhary F, Al-Hadithy H, Simon C. Hypercholesterolaemia. InnovAiT 2009; 2(12): 721-31.
Wylie G, Hungin APS, Neely J et al. Impaired glucose tolerance: qualitative and quantitative study of general practitioners' knowledge and perceptions BMJ 2002; 324: 1190.
DeMott K, Nherera L, Shaw EJ et al. Familial hypercholesterolaemia: the identification and management of adults and children with familial hypercholesterolaemia. 2008. London: National Collaborating Centre for Primary Care and Royal College of General Practitioners www.nice.org.uk/nicemedia/live/12048/41700/41700.pdf
Clinical Knowledge Summaries is a useful resource www.cks.nhs.uk/home