The CSA - style 1
everything you ever wanted to know.
An intro to the CSA
First of all, if you don't properly understand how the CSA works or what it is testing, then it is unlikely you will succeed. Think about it for a moment - if you truly understand the marking schedule, then actually you have the 'answer' sheet which should guide you how to pass. So step one to passing is going back to basics and truly understanding what the CSA is about and what it is testing.
These are the 3 areas you will be tested on:
- In Data Gathering, they are testing communication skills AS WELL AS clinical skills like clinical examination; around 3 stations will involve clinical examination.
- Clinical management includes synthesis, diagnosis, appreciation of co-morbidity, flexibility and sharing management options with the patient.
- Interpersonal skills include, communication, respect for others, professionalism and other behavioural indicators.
And finally, always safety net (ask your trainer if you don’t know what this means).
More information is available on the RCGP CSA pages.
Develop your own framework (i.e. structure)
- CSARam’s ‘5+5’ CSA consultation method (helps with time-efficiency)
- CSA – managing the 1st five minutes (YouTube video clip by Matt Smith)
- CSA – managing the 2nd five minutes (YouTube video clip by Matt Smith)
- CSA consultation model to help with time-efficiency
- CSA consultation model by Dr Ross
- CSA consultation model by Flannagan
- CSA consultation model by Flanagan as a flow diagram
Reading a consultation book or two will definately help you get some of the cores communication skills to consult effectively with patients. Although some people are naturally good at patient-centred consultting and others less so, the good news is that these skills can be learnt. Yes! Even if you are not good at consulting in a person-centred way, with practise you can learn to be as good as those who are naturally good. Of course, the key word here is practise!
Some good consultation books are...
- The Inner Consultation by Roger Neighbour (a great starter esp for ST1s).
- Skills for Communicating with Patients by Silverman et al (one of the best foundation books around - a definite worthwhile read).
- The Doctor's Communication Handbook by Peter Tate (another foundation book).
- The Naked Consultation by Liz Moulton (covers a variety of tricky scenarios - another definite worthwhile read).
Practise Makes Perfect
I cannot emphasise how important practise is. Let me ask you a question. If you were advising a person on how to pass the practical aspect of a driving test what would you advise them? Would you advise them to read a book on understanding the gears and the different pedals? Or would you get them to get out there with an instructor and practise?
The same goes for the CSA - you have to get out there and practise. Yet the number of GP trainees I see that try to memorise stuff from CSA books is beyond belief and I hope you can see how crazy it is to rely heavily on books. This is a PRACTICAL exam.
So, one of the best ways to practise is to form a CSA study group early on. Around 6-8 members per group is about right. Try and get a diverse membership so that you get a breadth of diverse and differing opinions when dissecting a case.
If you're too scared of joining a big group, why not start off in pairs with someone. Don't just give direct feedback to each other after playing a scenario - use your practice's video camera to film your performance and watch it together. In that way, you get a more objective view. At some stage, you will need to join a bigger group.
All GP training schemes up and down the country run mock CSA sessions either at HDR or externally. Make sure you don't miss out on these invaluable practise opportunities.
There are now several CSA DVDs and YouTube CSA clips. Watch these. The RCGP have developed one called "A guide to the Clinical Skills Assessment (CSA)." And they've developed a CSA module.
On the right hand side are some CSA practise tools to help you practise CSA scenarios with your colleagues. Get a CSA book and practise and give feedback using the tools on the right.
And lastly - there is another way you can practise - and that is by doing normal surgery consultations with real patients. It surprises me how a lot of GP trainees will book time off to 'study' for the CSA - when actually, it's the practise that is important. And what better what to practice your consultation and clinical skills than with real patients who present with a wide variety of things. So, rather than booking time off near the exam, how about talking to your Practice Manager and see if you can (for that week or two before the exam) book patients in every 15 minutes (to help give you 5 mins after each patient to reflect).
CSA Practise Tools
- Consultation video analysis sheet (CSA style)
- CSA practise scoring sheet for observers
- CSA performance criteria (generic descriptors) & grading
- CSA template for writing your own
Scripts and Phrases for your Consultation
- Scripts for Ideas, Concerns and Expectations
- Scripts for Psycho-Social-Occupational Enquiry
- Scripts for Explanation (Diagnosis)
- Scripts for Formulating a Management Plan
- Scripts for Checking Understanding
Now - I've also provided some scripts and phrases that may help you with your communication skills. Generally , I don’t recommend memorising scripts and phrases because a conversation between two people naturally flows when each person respond to what each other has just said - and most of the time you cannot second guess what the other person will say. So - beware - scripts and phrases can make the consultation look artificial or contrived and the CSA examiners are very good at picking up things that sound artificial. However, on the other hand, scripts and phrases can provide you with a starting point by giving you some idea of what to say. If you can then modify them so that they fit with your personality and style then they may just help you. By the way, don't explore Ideas, Concerns and Expectations (ICE) just because others have told you it is a good thing to do. Do it because you are genuinely interested and only when the timing is right. The same goes for the psycho-social-occupational (PSO) exploration of the impact of an illness.
Some Top Tips & Examiners' Feedback statements
- Red Flags for the CSA
- Ram’s top tips for the CSA – part 1
- Ram’s top tips for the CSA – part 2
- Ram’s ‘on the day’ rules for the CSA
- What Yorkshire CSA Examiners Say…
- The RCGP’s ‘Case Cards’ resource
- Trainers – help your trainee pass CSA by tisi.doc
- CSA Preparation – by Tomson and Rughani
- CSA guidance – how to succeed
- CSA – how not to fail (powerpoint with slide notes)
- CSA – the way I did it 1 (an IMG trainee’s perspective – from 2010)
- CSA – the way I did it 2 (another trainee’s perspective – a high scoring trainee in 2013)
- CSA – guidance from trainees who have done it
- CSA myths and tips (YouTube video 11mins)
- ‘Arghhh, I’ve failed’ – how to make effective use of your feedback
Examiners’ Feedback Statements
There's a lot you can learn from Examiners' feedback statements on previous exams. They highlight common difficulties and failures - which you can learn from!
- CSA feedback statements from the RCGP (brief)
- Examiner’s feedback statements – why people fail (brief)
- Examiner’s feedback statements – why people fail (detailed)
- 2010 CSA Examiners’ Feedback
- 2011 CSA Examiners’ Feedback
- 2012 CSA Examiner feedback from Yorkshire
- 2015 Examiner’s feedback from RCGP course
- CSA summary reports (RCGP)
And if you are an International Medical Graduate...
It’s a well known fact that medical graduates who qualified outside of the UK have higher failure rates in the CSA than those born over here. This isn’t that surprising because in addition to clinical skills, the exam also tests communication and interpersonal skills. This means that when you are consulting with patients in the UK, you need to understand what they say in the context of UK culture. It also means having a good understanding of how everyday spoken English language works. If you are an international medical graduate (IMG), it’s very likely that you have a deep understanding of the societal habits, culture and nuances in language of the country you grew up in – more so than any graduate from the UK could possibly understand. Likewise, a UK graduate is more likely to understand British culture and the subtle differences in English language better than most IMGs. This means that a British graduate is more likely to pick up importance little things which the patient yields during a consultation than an IMG. Therefore, if you want to increase your chances of passing the CSA – get to know some British born trainees and practice cases with them.
Tips to help you become familiar with UK culture and everyday spoken English…
- Try and watch British based TV – especially soaps. In British soaps, actors will use colloquialisms, slang and other terminology and phrases which you will not have been taught at school. This is important because patients talk in everyday English and not textbook English.
- Try joining some sort of group in the UK. For instance, if you are a new mum, why not join your local new mums’ group (do a search on the net). Mix with people born in this country, chat to them and start becoming familiar with spoken everyday English. There are loads of different types of groups in the UK. If you are trying to lose a bit of weight, consider Slimming World or Weight Watchers – not only to help you lose that weight but to get you conversing with others. A good app for meeting up in groups is MeetUp: www.meetup.com which helps groups of people with shared interests plan meetings and form offline clubs in local communities around the world. Another great site is StreetBank: Streetbank puts you in touch with your community, bringing neighbourboods closer and making the world a bit nicer. www.streetbank.com.
- Start doing these sorts of things right from ST1 – don’t wait until ST3 because it will be too late by then! You cannot do a crash course in UK culture and English expressions; instead, it’s a lengthy but steady journey.
Tips with preparing for the CSA
- When your forming CSA study groups – join a study group with a mixture of trainees (i.e. some of whom are born in the UK and some abroad). Please do NOT form a study group purely with other IMGs – because you need to understand the cultural norms in the UK and the meaning of certain expression – another IMG’s interpretation of this might not necessarily reflect reality nor the truth!
- If you have failed the CSA, do NOT form a study group purely consisting of other’s who have failed the CSA. How will you pass if no one in your group can reliably offer you any advice for passing if they haven’t passed themselves. This is dangerous territory – stay away. The only way this will work is if you get an expert facilitator to help direct your group (i.e. someone who really understands the CSA – like a CSA examiner, a GP educator or a colleague who has passed with flying colours). If a group of you can’t get a good facilitator – make sure your group has a diverse range of people (i.e. has some British born trainees to guide you).
- Do not struggle with preparing for the CSA all by yourself. There are so many aspects to every clinical case – and you’ll become naturally aware of these if you start exploring CSA cases with a group of others. But if you do it all by yourself or with just one other colleague, it’s likely you’ll develop a one-track mind that is more likely to result in failure
COMMON CSA SCENARIOS
- Breaking bad news
- Motivational interviewing
- Proxy consultations
- Lesbian, Gay, Bisexual & Transgender issues
- Aggressive patients
- Manipulative patients
- Negotiation Patients who request a test
- Patients who want antibiotics
- Non-compliant patients
- Somatising patients
- Joint pains
- Non-specific abdo pain
- Tired all the time
- Relationship break up
- Anxiety/panic attacks
- Recurrent sore throat
- Non-specific chest pain
- Sexually Transmitted Infections