Lets not forget its got to be done in 10 minutes!
There is cummalative pass mark (clear fail to clear pass - 0-3 marks) of 13 cases; with the threshold depednign on the days mix of cases. There are feedback statements which higlgiht areas for improvement for future exams. And the reason I am so interested in when I had been on the A&E locum circuit I met many people who had failed this exam and came out of GP land (you get 4 hances to sit the exam) and I dont want to be back there because in A&E you dont get to follow patients through and become the smae doctor a patient sees because the shift nature of the job. So it is important and ifficult to pass.
We recently had a practice session on doing a CSA style OSCE - I even volunteered for one of the cases - and it was the first taste of taking the examination to the next level. We watched 4 caes being attempted twice each - fatigue, depression and nitts as well as a staff complaint. In the CSA the cases are done stratified according to difficulty, age, type (telephone/visit/surgery) and type (psychological, preventative, acute/chronic/undifferentiated, examination) - so dont forget your doctors bag!
As a Gp trainee one can start on 30 minute consultations but the aim is to get down to 5-10 minutes mark (including checking and requesting investigation then initiating or modifying managment plans). The CSA however is focused on the history taking element and even if one does not know the complete in's and out's of the managment of a condition (tested in the applied knowledge test) one can still achieve some degree of success by demonstrating efficient and relevant data gathering [proficient exam/investigation choice and interpretation], good interpersonal skills [recognised communication technniques to understand patients illness exprience whilst ethiically developing a shared approach to management], and developing a safe managment plan (which may include looking up the condition, having a chat with a partner/senior, organising/instigating a critical event analysis, writing to or calling a patient back, or organising follow up with good safety netting e.g. if A happens do X or if B happens do Y) [structured and flexible approach to decision making; ability to deal with multiple complaints and comordbidites; ability to promote a positive approach to health].
When I saw other people do their consultations (I was one of the GP ST1's in a group dominated by the skiled ST3's with the CSA around the corner) I was impressed by their ability to appear very calm, and provide tangible managment plans. I also found, after doing my own consultation where I only got to the beginning of management before my 10 minutes were up, that they had time managed very well.
So what were the key lessons I drew from the day?
1. Time managment and consultation style influence the score more than the clinical knowledge for this exam so therefore I need to become aware of how to maximise these skills and demonstrate them. This is what the rest of the blog will devlop as a theme.
2. Some times nothing is wrong with the patient and they need to be reassured e.g. a patient with tiredness who had a new family and recently returned to work was tired - nothing was found to be clinically wrong on the tests so it was all about how you "sold" the management plan.
For example one trainer suggested that to inspire patients and reassure them he had metaphors to help the patient to visualise their situation in order to understand and relate to it. for example with the patient above he would say that she has differen pieces to her unique puzzle such as her children, her job and her inability currently to enjoy the hobbies which she previously used to keep fit with such as swimming at lunch time but that they way the pieces fitted together at the moment meant she was tired. He suggested she could go away and think how these pieces could better fit tgether e.g. part time work etc. and discuss this with her family. He would make her an appointment in 3 months to see how things are going but otherwise she could come back and seem him if anything else worried her.
I love this analogy and find it a really good tool.
3. A very insteresting point that an ST3 raised was that he had to constantly kick himself to ask the patient what they wanted to do - he was so used to hospital work where the patient is told what to do that he found it a struggle to just take that bit of extra time and negotiate. Funily enough one of the participants used the phrase at the end of his consultation (at least he got there unliek me!) "here's what we are going to do..."
A different trainer chared another excellent analgoy - the doctors job is only to offer the right menu to the patient a highlighting the benefits and risks of the different options but not to pick the dish :)
4. A fourth general point fomr the practice was that it was important to quickly "get to it" e.g. you sound depressed would you like help with this? Rather than talk around the topic. However the danger of this too early means you may come across as rushing the patient. Equally it may be too hasty to say too early on "is there anything else?" (often patients come with 2 or 3 agendas they want to deal with and the risk is that if you say this question at the end you may find a another problem you dont have time to help solve) as it may appear as if the condition they have presented is not worthy of your time or not big/impressive anugh to be seen with or again that you are uncaring as if you want to move off the topic.
The other important learning points from the day were drawn from the brilliant professional actors:
1. They suggested that some people were unclear as to what was being communicated. These difficulties in them recieving the message came from simple things such as doctors speaking to fast or not giving the patient enough time to process information and feel comfortable to ask questions and check they've understood, ranging to more difficult communication errors such as an unclear thought (one doctor asked a patient to comb the knits onto "the paper" as if he had already reffered to one but hadn't made clear that it could be any paper and the relevance of doing it was so no live knits could be seen) or a shaky unclear managment plan (one doctor suggested that the mother of child with knitts brought her in but then said she may not need to).
The trainer explained that the key here was to sign post clearly what was being done. So in the example above the doctor should have made clear exactly which was it - does he want to see the daughter or not; bearing in mind as long as he can explain the reaosning there is no wrong answer - and emphasise this in his closing summary of the plan.
2. They suggested that the doctors came across as cold and uncaring - too focused on gathering the clinical (biological) data and in too much of a rush to provide the cold information on the managment options. Interestingly - when in the above case of nits the doctor asked to see the daughter the mother had felt reasured the doctor cared and this was important to her. Being talked "at" - rather than "to" for example when being told about how depression can be treated where as it may have been better to ask what the patient felt like she would like or what options she knew about (however avoiding asking two or more questions or then quickly answering with ones own response before the patient has a chance to reply.
So bringing all of this together using the flanagans and Dr ross model from http://www.pennine-gp-training.co.uk/csa-case-scenarios-written-by-our-gpsts-for-their-csa-work-groups.htm combined I think the following is useful:
1. Welcome patient and introduce yourself
2. Start with big open question and fascilitate golden minute (cue handling)
3. Explore psychosocial (Social Hx:Work, family, driving, alcohol, smoking)
- mindful that in the second half of the consultation later you should relate the patients;
> ideas to your explanation of diagnosis and differentials
> concerns to the prognosis
> expectations to mangement (investigation, watchful wait, lifestyle change, medication, refferal)
4. Focussed questions & Red Flags Focused systemic enquiry, Red flags, PMH, DH, FH
7. Examination (focused /2 minutes)
8. Explanation & Rx option sharing +/- safety netting (no later than 8 mins into the consultation)
9. Shared decision making/management plan
10. Closure – checking understanding -/+safety net /follow up
And smile, be nice, be beliveable.
Indicators of good performance
Data Gathering
1. Organised and systematic in gathering information from history taking, examination and investigation
2. Identifies abnormal findings or results and/or recognises their implications
3. Data gathering does appears to be guided by the probabilities of disease
4. Undertakes physical examination competently, or use instruments proficiently
Clinical management
1. Makes appropriate diagnosis
2. Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice
3. Follow-up arrangements and safety netting are adequate
4. Demonstrates an awareness of management of risk and health promotion
Interpersonal skills
1. Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues.
2. Develops a shared management plan or clarify the roles of doctor and patient
3. Uses explanations that are relevant and understandable to the patient
4. Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination
So there you have it - a true beginners interpretation of the exam!
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