When I initially sat the CSA exam in February this year I failed by two marks. I was of course devastated, but I re-sat it in April and passed with flying colours.
I realised during the time preparing for the re-sit that there were a number of reasons why I failed on my first attempt - below I share those reasons to help you avoid making the same mistakes.
Patient- and doctor-centred consulting
I have always consulted in a doctor-centred way, and in real life not had any issues with this. I knew early on in my preparation for the CSA that I needed to find a happy medium between been doctor- and patient-centred consulting, but found this very difficult to actually put into practice.
One of the major influences of being doctor or patient centred is where you work. In socially deprived areas, especially with the time constraints of ten minutes, you may have to take a more prescriptive approach. Being patient centred means working with the patient to formulate a shared management plan; listening to their views, opinions and beliefs so that together you can do what is best for the patient.
Although the CSA, like any exam, is very artificial I do think that this is one of the key things you can take away from exam preparation and apply to every day practice. Take my advice and adapt your consulting style to be more patient centred if you currently take a doctor-centred approach.
The CSA is not about the diagnosis (but nor is real life)
This is something I really struggled with, but the earlier you get to grips with this concept the higher your chances are of passing first time round. I kept asking myself, how can it not be diagnostic when you have to state a working diagnosis or differentials and formulate a management plan?
When I look at my scores across my two attempts at the CSA, one of the big differences is due to my approach. Not only was I very doctor centred in my first attempt (despite my many efforts not to be), which meant I lost many marks in interpersonal skills, I was also very diagnostic. What does this mean? This means that I focused solely on the diagnosis instead of the patient and did not consider it in a psychosocial context.
This was not intentional, because I practised asking about the impact of the problem on the patient’s life and their ideas, concerns and expectations (ICE) many times in my study groups. However, I was not doing this enough day to day and this meant that with nerves and essentially panic I reverted to what I knew best in the exam - being diagnostic.
So, ensure you understand early what this means and apply it day to day in your training and practice - not only in study groups.
Study groups and the use of actors
The use of actors in preparation is debatable and I am sure many people pass the CSA without using them at all. However, I think using actors as much as possible can really help with exam success.
Doctors are not actors and therefore trying to act as the patient in study groups has many drawbacks. One of the difficulties I had with many of my peers was the use of cues; my peers would think that they were challenging me by giving me a cue and not elaborating on it when I asked, therefore affecting how well I could perform on a case.
In the actual CSA the cue is given to you and it should not take a lot of effort once it is recognised to ‘open it up’ and work out what the patient’s agenda is. So, when practising in your groups do not be too harsh on each other; give cues and give enough information to ensure your peer can work through the case effectively.
I would definitely recommend using actors as much as possible; your deanery may offer sessions with an actor and examiner, who may be a GP or communication expert. If you are in London there is more information on this here.
It is also really important when practising to assess each other consistently every time, using the mark scheme used in the exam based on the sixteen competencies. Practising with new people and making yourself uncomfortable is also an essential way to prepare for the CSA.
Don’t be afraid of the CSA
Before I even began to think about the CSA seriously I heard a lot of stories about it - how biased it was, how people failed by one or two marks. Although I wasn’t fazed by this initially, as I started to prepare for the exam those stories made me more frightened about sitting it.
I did also hear that the CSA was ‘challenging but fair’ and ‘you’re more likely to pass the CSA than the AKT’. Despite this, the former negative comments became etched in my mind. This undoubtedly contributed to my exam failure.
So, although I do think the CSA is a very subjective exam, I do believe that it is an exam that can be passed quite comfortably with the right guidance and support.
Do not let the pressure get to you
I put an immense amount of pressure on myself when I took the CSA. During ST3 you have a lot to do - you have to complete an audit, schedule in and cope with 72 hours of out-of-hours work, complete video consultations and sit your CSA (plus or minus your AKT).
This is pressure in itself but I set the goal of sitting the exam before an important life event, my birthday. I did not feel ready to sit the exam but I sat it anyway, listening to everyone who said ‘you will be fine’. In reality I probably was ready for the exam, I just did not have the self belief at that time to realise it.
The point here is - sit the exam when you ARE ready and when you BELIEVE you are ready. Do not put even more pressure on yourself than everyone else already does. For me, March or April would have been a much better time to sit the CSA.
At your surgery
What I found really helpful in the lead-up to the CSA was a timer on my desk, which helped put me under time pressure but also enabled me to keep a general track of time day to day.
I would also advise seeing patients in fifteen-minute appointments - or even 10-minute appointments - before sitting the exam. Undertaking joint clinics with various doctors, other than your trainer, is also a good idea. I found this made me uncomfortable because someone new who I wasn't used to was assessing me during consultations, but this allowed me to build the confidence I needed before sitting the exam.
I truly believe that if you follow the advice above you will be absolutely fine. Whilst the CSA does have some pitfalls it is an exam that can be passed quite comfortably. If you do fail, like I did, do not be too disheartened; use the feedback on your portfolio to change your technique. The feedback is generic, but it definitely helped me see how I was perceived and where my technique could be adjusted.
- Dr Baptiste is an ST3 GP trainee in Essex