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‘IMG: A personal perspective’: Poole, 9 J an 2014 . Dilsher Singh First 5 GP Birmingham. Personal Journey. Common phrases. Spend a penny Water works Sample of water Feeling under the weather Suffering from pins and needles Problems with back passage

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Img a personal perspective poole 9 j an 2014

‘IMG: A personal perspective’: Poole, 9 Jan 2014

Dilsher Singh

First 5 GP


Common phrases
Common phrases

  • Spend a penny

  • Water works

  • Sample of water

  • Feeling under the weather

  • Suffering from pins and needles

  • Problems with back passage

  • X ray and blood test are ‘requested’ not ‘ordered’

Csa failure rates c ountry of graduation
CSA failure rates : Country of Graduation

Uk graduates fail rates
UK Graduates – Fail rates



British White: 4.6%

British Asian: 16.3%

  • British White : 5.2 %

  • British Asian: 17.7%

Communicative flexibility
Communicative Flexibility

  • All clinicians have to be Communicatively flexible

  • Local clinicians have to adapt their talk to a diverse patient population

  • IMG’s have to adapt their language skills and cultural understanding to a range of British consultations.

  • Mixed study groups maybe the way forward …

The way of talk
The way of Talk:

  • Conversalisation: eg metaphor : imagining and articulating the patient's thoughts back to them

  • Metacommunicating: sharing own thoughts with patients

  • Relativisation: relating/ connecting different parts of explanation

  • Thematisation: The way ideas are put forward and certain items selected for emphasis

  • Temporal logical sequencing

Why are the best clinical minds from abroad struggling
Why are the best clinical minds from abroad struggling

  • Is it:

    • Cultural ?

    • Language ?

    • Knowledge ?

    • Lack of Self- Esteem ?

    • Or

    • Something else?

Difference in approach
Difference in approach:

  • Different educational training: Doctors are taught to treat symptoms without emphasis on patient's social life

  • Difference in technique to approach the patient

  • Difference in patient expectations: patient allow doctors to lead management plans.

  • The above issues need to be tackled:

    • By the Trainee themselves

    • By the Trainers: who can help provide resources to bridge the GAP

The start of my csa journey
The start of my CSA Journey

  • Started with First IMG conference in Midlands

  • Gained insight into my consultation model

  • My consultation model: Long sentences – extended explanations

  • Identified common problem patterns in failing candidates

  • Learnt about strength of equal mix of study partners

  • Identified importance of work based assessments towards exam success

The preparation
The preparation

  • Identified common recommended books

  • Accumulated study material from colleagues

  • Started CSA practice from second week in GPST3

  • Developed regular Practice study schedule

  • Identified and attended CSA courses

  • Started Joint surgeries with trainer

  • Organised Video consultations

  • Practiced changing my consultations: one step at a time

Csa journey barriers
CSA Journey - Barriers

  • Cultural

  • Knowledge

  • Experience

  • Technique / Approach

  • Language

Csa exam
CSA Exam

  • First experience : Feb 2013


  • 13: Poor active listening skills, use of verbal/ nonverbal cues

  • 2: Does not recognise the priorities in the consultation

  • 4: Does not recognise abnormal findings and implications

  • 12:Does not explore patient's agenda , health beliefs

Reflections analysis
Reflections & Analysis

  • Had high number of ethnic patient consultations

  • Had very few video consultations

  • Had been practicing in only one group

  • Feedback from colleagues was very supportive

  • Concentrated more on my stronger areas of curriculum

  • Fear Factor: performance on the day suboptimal

  • Due to fear factor reverted back to my old consultation style


  • Increased the number of English speaking patients in clinics

  • For 6 weeks videoed every possible patient encounter

  • Reviewed my videos with trainer

  • Then reviewed with peers and myself

  • Watched each video 3 times

  • Learnt the use of succinct sentences to manage consultations

  • Aimed to explain the diagnosis in 2 lines only: using lay members of my family

  • Practiced with various other CSA groups

  • Developed a plan to manage uncertainty

Solutions continued
Solutions: Continued..

  • Feedback was constructive and brutal

  • Every new feedback was experimented immediately

  • Created style of statements that I could relate to

  • Developed sense of inquisitiveness about the patient: the impact of illness on their social life

  • Learnt to acknowledge cues

  • History: Red flags, ICE, Psychosocial(work/home/social/alcohol/ drugs), Why today

  • Learnt to critic the information presented: as has to have a reason

  • Use of play cards: to emphasise on one aspect of consultation at a time

Csa exam1
CSA Exam

  • Second attempt: May 2013


  • The International graduates need to understand their strengths

  • They need to identify their area of weaknesses

  • Active Listening skills need to be developed using echoeing and reflection

  • Trainees need Constructive & Honest feedback from trainers.

  • Trainees need to have mixed study Groups

  • Trainers/ colleagues could help international graduates to integrate into the local society


  • Trainers to identify and signpost resources to trainees to bridge the GAP

  • Trainees need to spend time on analysis of their Video consultations- at least 3 times per video

  • Trainees need to avoid rapid topic shifts rather than topic gliding

  • Trainees should aim to have joint surgeries with their trainers

  • Improve their consultations one step at a time- by use of cards method

  • Trainees/ Trainers need to actively analyse MSF feedback

  • Trainees need to avoid ‘Over-modeling’: Avoid phrases that don’t sound convincing.