nMRCGP - An insider's guide to the CSA cases

By Dr Kamila Hawthorne, Dr Jim Bartlett and Dr Johnathan Cobb, the doctors who write the cases.

The cases of the clinical skills assessment (CSA) are considered realistic and representative of UK general practice.

Although registrars worry that they cannot be completed within 10 minutes, observers have agreed that this is feasible, as there are no interruptions and patients usually present with one problem.

Previous candidates have said that they become so engrossed in the cases that they are often unaware of the examiners.

Phtograph: Jason Lancy

Cases in the CSA are linked to one or more learning outcomes from a curriculum statement

Who writes the cases?
Cases for the CSA are written by a group of about 50 case writers across the UK, all from the CSA examiner panel.

Over the past two years, this group has remained relatively constant and has honed its skills, incorporating not only comprehensive briefs for all concerned in the case - candidate, assessor and role player - but also focused marking schedules.

These address how to incorporate a clinical physical examination if one is required, props needed for the case, how to write cases of appropriate challenge for a registrar completing GP training, and how to reference the clinical substance of the case to the current medical evidence base.

Tip: When preparing for the CSA, remember that case writers are also GPs, and will be writing from their clinical experience. Prepare yourself by seeing as many diverse patients as you can. Think about how you would tackle the case if it were seen in the CSA.

Some cases focus on the problems of chronic disease management, such as COPD or diabetes. These patients tend to gravitate to the well-established partners, so plan ahead to make sure you see a good range of patients in the practice.

Case development
The case writers use the CSA blueprint as a guide to which sections of the RCGP curriculum can feasibly be tested by the CSA.

Cases are written to reflect areas from all parts of the CSA blueprint in terms of clinical areas as well as age groups. In addition, issues of diversity and equality are sometimes incorporated.

Most cases are written from a seed core of a patient encounter, although during the development of the case the 'patient' may change considerably.

Case writers are given broad areas in which to develop new cases, and combine thinking about clinical cases with scrutiny of the relevant RCGP curriculum statements.

Each case is linked to one or more learning outcomes from a curriculum statement.

Sample cases can be found on the RCGP website.

Tip: Look through the curriculum statements and work out which areas you think could be tested by the CSA. Many of the clinical management statements have a box near the beginning, titled 'The knowledge base'. This will give you an idea of the clinical basis to the cases.

Cases pass through a rigorous piloting process, and are checked for consistency and accuracy several times.

One of the 13 cases during the CSA is a pilot case - hopefully, it will be polished enough for you not to be able tell which one it is. The marks for this case are not included in your overall mark for the CSA.

Tip: Treat every case as 'live'.

Case selection
All cases are linked to keywords, and are searchable on our database. Following a pre-designed algorithm, the case 'palette' for each day is electronically selected and checked manually by an experienced clinician.

This ensures that a selection of acute and chronic cases is made, with representation across age groups, diversity issues and a spread of clinical presentations.

Although cases are realistic and representative of UK general practice, the selection of cases is not intended to be a typical surgery. It is intended to test candidates across a range of domains in the CSA blueprint, and to check that they are able to work competently and independently.

Tip: Each case is designed to test something specific. Don't allow yourself to sit back during any one case or be put off by your performance in a previous case.

Read the case paperwork carefully - which is normally kept very short - and prepare for the next case in the interval.

Examining domains
What the examiners are looking for depends on the clinical context and specificity of the case.

In general, examiners are looking at the candidate's ability to gather focused information from patients and from any test results, or findings from a clinical examination, and then to make a competent differential diagnosis if this is indicated.

Next they want to see up-to-date clinical management, in line with current UK practice, and the whole consultation needs to be conducted in the context of good interpersonal skills. This is not a 'tick box' exercise, and there is no magic formula.

Examiners are looking for a fluent, integrated and time-efficient approach that is both patient-centred and medically competent.

  • Dr Hawthorne, Dr Bartlett and Dr Cobb are GPs and case writing leads for the CSA.

Learning points

1. Practise seeing patients, thinking about the domains the CSA marks - data gathering, clinical management and interpersonal skills. Try to accomplish this in 10 minutes.

2. Ask a colleague or your trainer to watch you consulting and give you feedback in these domains.

3. Video consultations are a good way to prepare. Assess your own consulting skills, using the CSA domains.

4. Finally, practise giving explanations about different types of conditions to a patient, using relevant and understandable language.

The Royal College of General Practitioners is a network of over 35,000 family doctors. It works to encourage and maintain the highest educational, training and clinical standards in order to improve care for our patients.

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