MRCGP - An examiner's guide to the CSA

MRCGP examiner Dr Rhona Knight shares helpful tips for passing the clinical skills assessment.

Use role play with other trainees to get used to performing in front of an audience (Photograph: Jason Heath Lancy)

The warning whistle sounds. Audience and actors are at the ready. The curtains open. The play, which consists of two acts and one 20-minute interval, begins.

In the 13 successive scenes there is just one main actor, the candidate. Up to 78 versions of this play can be enacted in one day. The play is the clinical skills assessment (CSA) and the theatre is the RCGP Assessment Centre.

The CSA, an established part of the MRCGP exam since 2007, is taken by all GP registrars towards the end of specialty training. It aims to be an assessment of a doctor's ability to integrate and apply clinical, professional, communication and practical skills appropriate for general practice.

The candidate faces 13 'consultations' with different 'patients'. These cases are written by examiners and cover the breadth of the GP curriculum learning outcomes.

Although content will vary, each 'surgery' should cover a similar spectrum of body systems in different contexts, and may include telephone calls, home visits and third party consultations.

From September 2010, all 13 'consultations' will be formally assessed and the pass mark will be decided upon using the borderline group method. This change in method of deciding the pass mark, which previously required candidates to pass a certain number of cases, has been made to account for the variation in difficulty of cases on different days. The first attempt pass rate was 81.4 per cent in 2008 and 83.9 per cent in 2009.

A performance
The exam is not the same as a general practice surgery, and is perhaps better seen as a performance, where both doctor and patient are actors playing roles in front of an audience, the examiner.

The candidate must pretend that each role player they see is a real patient and deal with the reversed power dynamics of the role play consultation.

Unlike real life, in the CSA the power lies mainly with the 'patient' who already knows the conscious and unconscious narrative they must present; the cues they will offer; the questions they will ask; their deep-seated ideas, concerns and expectations; how they will respond to different treatment options.

In this performance, it is essential that candidates know the generic script and practise performing beforehand. At the same time, they must ensure they do not develop a mechanistic tick-box approach, erroneously thinking this will help them pass the exam.

A more valuable preparation method is to spend time developing effective consultation skills for everyday practice and transferring these over to the CSA context.

Helpful tips
I have outlined eight helpful tips for preparing for and passing the CSA:

1. Learn to consult well.

Develop a solid foundation of consultation skills to use in the many situations encountered in general practice.

2. Organise your consultations effectively. Clarifying the presenting problem near the beginning of the consultation is usually time efficient and guides what further information you need to gather.

3. Record, watch and reflect on videos of your own consultations. This aids identifying strengths and areas that need further work.

4. Read at least two good books on consultation skills. Your trainer can guide you to those suited to your individual learning needs.

5. Read the RCGP website. It gives up-to-date information on the exams.

6. Get a good book on the CSA. There are many books on the market. Choose carefully.

7. Rehearse and practise. About four months before the exam, start preparing to perform with an audience.

a. Form a learning set with a diverse group of colleagues. Meet on a regular basis.

b. Write your own cases, aimed to last 10 minutes. Write CSA-type marking schemes covering the domains of data gathering, management and interpersonal skills. Base these on real cases, using a good template.

c. Practise role-playing cases in front of each other, giving feedback in a supportive and challenging way.

d. Identify and address learning needs arising out of each consultation.

e. Populate your ePortfolio with the skills you have learnt.

f. Consider attending a course, if there is one that specifically meets your needs.

8 Book your exam slot in good time. Make sure you know when and where it is and how to get there in time.

As doctors, we may not class ourselves as thespians, but we are performers.

On a daily basis, we perform in a variety of situations. By developing these performance skills and applying them to the consultation skills used in everyday practice, registrars can be prepared the meet their 'critics', resulting in 'positive reviews' and a pass in the exam.

  • Dr Knight is a CSA examiner and GP training programme director in Leicester and author of a book on CSA preparation


Visit the GP Curriculum Centre for hundreds of articles linked to key topics in the RCGP curriculum

CSA practice cases to be used in a group

CPD IMPACT: Earn more credits

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Consider the skills required to communicate effectively in a consultation. With the help of your trainer, look back at some recorded consultations and identify strengths and areas for improvement.
  • Read a book on consultation skills, consider the key points and share them with your peers at revision sessions.
  • At the end of each 'real life' consultation, take some time to reflect on your consultation skills. What went well and what needs improvement?

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