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How to Prepare for the CSA

How to Prepare for the CSA

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How to Prepare for the CSA

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  1. How to Prepare for the CSA Dan Berkeley GP Maryport Health Services

  2. Overview • Practical aspects of the CSA • Costs and booking • Set up of the exam/what to expect on the day • My thoughts on the exam • How to prepare as a GPR

  3. What relevance does this picture have to preparing for the CSA exam?

  4. Practical Aspects of CSA • Final of the two exam parts of the MRCGP • Cannot be done until 3rd year • Used to only be 3 sittings/year, now 8. • GPR can have four attempts! (unless they run out of money first) • You do not need to have passed the AKT first, although practically most have

  5. Practical Aspects of CSA • Cost 1563 pounds (including 10% discount) • Book on the RCGP website, you don’t get any choice over day or time • Add to this 100 pounds for train, 150 for hotel, 50 for food etc and its a pretty expensive, and unpleasant, holiday • This is now tax deductable following Bannerjeevs HMRC 2008 ruling, but they still take it to the wire

  6. What to expect on the day • Will vary depending on time of day you are sitting • Morning sitting • Arrive 7.30am, sit around for 30 mins in locked room, avoid eye contact • Briefing for 15 minutes, more waiting • Led through to exam room, items in locker, clear bag for equipment (see list) • Own room, ipad with 13 cases, 15 mins to look at before exam starts

  7. What to expect on the day • Horn blows • Patient knocks and enters, examiner follows and sits in corner • 10 full minutes i.e. longer than ‘real’ consults • Goes very quickly • 7 cases – ‘break’ – avoid eye contact • 6 more cases • Fire alarms – avoid eye contact • Pm sessions allegedly even more waiting

  8. What to expect on the day • Finished! Massive relief • May have dissociated to the extent can’t remember the cases • Try to enjoy the rest of the day • Up to 6 weeks before you hear results • Hopefully a one off experience...

  9. Preparing for the Exam • What does the college suggest you do? • The exam is representative of UK general practice, so if you of the standard to be a GP in the UK you will pass the exam • They want us to train our GPRs to be a good GP and use Calgary Cambridge style communication skills (standard consultation model in the UK) • This is putting a lot of pressure on the exam to be perfect

  10. Preparing for the Exam • Priority 1 : train to be a good GP – of course! • Priority 2: prepare for the CSA • PLEASE DON’T FALL INTO THE TRAP OF THINKING PRIORITY 2 WILL SIMPLY FOLLOW PRIORITY 1 IF DONE WELL – this would only be the case if the exam was a perfect representation of UK general practice • The exam is not directly testing your ability to be a GP. • It is using an imperfect surrogate measure: • Can you consult an actor pretending to be a patient, whilst being observed in a room in London

  11. What did we do? • Got frightened because one of our friends failed and had to extend his training • Took the exam early (before we were back in GP for 3rd year) so we could have ‘a second shot’ if need be. (No longer relevant with 8 sittings) • Small group work ++ using cases in books and online • Critique of consultations and endless role play practice – simulating the exam • Mix of UK and foreign graduates – important

  12. Tips for Preparing • Firstly, ensure that you are becoming a good GP – Clearly most important priority! • Secondly, in the 6-12 months prior to the exam do specific CSA training as well • Try to simulate the CSA • Role play • Consider meeting in small groups, this is not something for your tutorials – you should be doing it outside work

  13. Tips for preparing • Consider taking the exams early and back to back to give yourself chance for resits • Less stress ‘I can always take it again’ • Only ‘revise’ once • If you are well prepared (more later) your main enemy on the day is stress, it will make you consult differently to how you normally do, or practised to do.

  14. How is the exam marked? • Scoring system • Three domains • Information gathering • Management skills • Communication skills • But they are not perhaps as equal as they initially look...

  15. Negative Descriptors • 1. Disorganised / unstructured consultation • 2. Does not recognise the issues or priorities in the consultation (for example, the patient’s problem, ethical dilemma etc) • 3. Shows poor time management • 4. Does not identify abnormal findings or results or fails to recognise their implications • 5. Does not undertake physical examination competently, or use instruments proficiently

  16. Negative Descriptors • 6.Does not make the correct working diagnosis or identify an appropriate range of differential possibilities • 7. Does not develop a management plan (including prescribing and referral) reflecting knowledge of current best practice • 8. Does not show appropriate use of resources, including aspects of budgetary governance • 9. Does not make adequate arrangements for follow-up and safety netting • 10. Does not demonstrate an awareness of management of risk or make the patient aware of relative risks of different options • 11. Does not attempt to promote good health at opportune times in the consultation

  17. Negative Descriptors • 12. Does not appear to develop rapport or show awareness of patient’s agenda, health beliefs and preferences • 13. Poor active listening skills and use of cues. Consulting may appear formulaic (slavishly following a model and/or unresponsive to the patient), and lacks fluency • 14. Does not identify or use appropriate psychological or social information to place the problem in context • 15. Does not develop a shared management plan, demonstrating an ability to work in partnership with the patient • 16. Does not use language and/or explanations that are relevant and understandable to the patient

  18. How is the exam marked? • Most of the descriptors in fact relate directly to communication skills • And all those that don’t, require good communication skills to obtain • So in reality the thing the exam is testing more than anything is communication skills • This is good as it’s representative of our role as GPs, also the AKT is designed to test knowledge specifically anyway • Concentrating on revising clinical knowledge for this exam is therefore a poor use of time • Despite it being the focus of almost every CSA book.....

  19. How are the results presented? • Unusual system • Grid of 16 negative descriptors, get Xs in ones you didn’t meet • But only get X’s in a neg descriptor category if you failed in that domain at least twice • Can make it hard to know how to improve if you need to resit • Look at the types of descriptor you failed, is there a common link to them?

  20. Communication skills and the CSA • You will already have excellent communication skills. • The CSA wants to see you apply focused ‘consultation skills’ • It wants to see a doctor led patient centred consultation • It requires you to play a sort of ‘game’: • Pretend the exam is 100% real – when its the most unreal experience of your life • And ?like a driving test – see that you do this every day with confidence

  21. Summary so far: • Ensure that you do separate CSA preparation as well as normal tutorials to help you become a good real world GP • Role play in your free time in small mixed groups, with family etc • Don’t try to ‘make yourself feel safer’ by revising lots of knowledge. The exam is not testing this as much as you might think • There are only 2 CSA books that I found helpful currently – they have cases in them and the cases are realistic CSA type cases – they are designed to be used for role play. Either use these or the internet for cases e.g. Pennine VTS website

  22. Consultation skills • You have to have a format for consulting – for instance the framework on the next slide • But you must not be formulaic • They want to see the consultation being like a conversation – everything you ask should ideally lead and reference what has been said before. Tailored to that specific patient.

  23. Consultation skills: • The key skill being tested in the CSA: • What does the patient want from the consultation? • What do you think is going on? • Can you use communication skills to bind these into a plan which the patient is happy with and you are happy is safe and doesn’t abuse resources.

  24. Framework option for CSA • Say hello, consider shaking hands • Get presenting complaint • Open questions including ICE, effect on life • Focused closed questions with signposting, red flags, drugs, allergies • Examination (if needed) • (6 minutes approximately are up) • Explanation and discussion of agendas to find a 'middle path' • Management (shared options) • Safety netting • Shake hand and say goodbye/run out of time

  25. Introduction • How do you start the consultation? • Non verbal communication • Rapport – mirroring etc

  26. Data Gathering • No irrelevant questions please! You only have six minutes here • Open questions, ICE • Consider signposting your ICE • Occupation, lifestyle etc (if relevant) • Closed questions – for red flags, to nail down diagnosis etc – signpost and interrogate! • Summarise

  27. Examination • Offer to examine only if relevant – don’t examine for no reason • You may be asked to actually do examination • You may be given findings by picture/text/verbal, but only at the moment you are about to examine – explain as normal • If you do examine – then focused – not MRCP style – focused! 1-2 mins max

  28. Management • You should know patients agenda • You should know what you think is going on • Explain what you think is going on – 1 min or so – can tie in their ICE into this if you can – use it to ‘set up’ your plan • Offer reasonable options, and explain pros and cons of each – don’t just list them • Discuss as needed • Don’t avoid areas of conflict – the CSA is probably testing any difficulties that are arising

  29. Finishing • Safety net – red flags, and be open and realistic about prognosis and time frames. Educate and it will be a better safety net • Shake hands etc and check patient happy. Can check understanding if need be, but don’t do this as matter of routine • If you are running out of time try to get onto management ASAP and tie safety netting into your explanation to get as many marks as possible

  30. Controversial slide? • Ongoing debate about fairness of exam • Now websites discussing how to ‘change’ for the exam • Examiners want you to consult naturally, how can you do this if you are trying to be someone else entirely? • If you trained abroad please do throw yourself into local activities to get more hands on experience of British culture, but please don’t change who you are for the exam.

  31. End of part 1 • Any questions? • In part 2 we split into groups and do some role play and I’ll do my best to give individual feedback to as many as possible

  32. Useful Resources

  33. Useful Resources Continued • My friends Jenny, Ellen, and Irina are currently in final phase of publishing an epic flipchart case book which will be amazing I suspect • I have written a very concise, completely CSA focused communication skills, consultation skills book too which is available on Amazon for under ten pounds – paperback and kindle editions

  34. Any Questions?