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HELPING IMGs WITH THE CSA

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:

  1. In Data Gathering, they are testing communication skills AS WELL AS clinical skills like clinical examination; around 3 stations will involve clinical examination.
  2. Clinical management includes synthesis, diagnosis, appreciation of co-morbidity, flexibility and sharing management options with the patient.
  3. 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)

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…

  1. The Inner Consultation by Roger Neighbour (a great starter esp for ST1s).
  2. Skills for Communicating with Patients by Silverman et al (one of the best foundation books around – a definite worthwhile read).  
  3. The Doctor’s Communication Handbook by Peter Tate (another foundation book).
  4. The Naked Consultation by Liz Moulton (covers a variety of tricky scenarios – another definite worthwhile read).

The IMG failure rate

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 important  little things which the patient yields during a consultation than an IMG.  Therefore, if you’re an IMG and you want to increase your chances of passing the CSA – you’ve got to start getting used to and understanding the British culture and the way people say things and the little odd ways they behave in Britain.  In this section, we will tell you how.

By the way, one thing I do want to say is BE POSITIVE about being an IMG.  Do not think for a second that you are going to fail.   Many IMGs pass first time, and you can be one of them too if you take heed of the advice offered on these pages.

Join a CSA group

  • You have to get out there and practise – it’s the best way of achieving the level communication, clinical and interpersonal skills required to pass the CSA.  
  • The number of IMG GP trainees I see that try to memorise stuff from CSA books is beyond belief – it’s crazy to rely heavily on books because what is being tested is not just what you know but what you say, how you say it and how you perform and interact with the patient.   
  • Good ‘performance’ can only be gained through regular practise, not through just reading a CSA book!   

For a simple analogy: imagine that you’re going to be a passenger in a car that is setting off from Leeds to Birmingham (about 90 miles).  Tell me which of these two drives would you like to take you?  Driver A believes he is a good driver because he has read the highway code and has memorised a book called ‘how to drive safely’; but he has never stepped inside a car.   Driver B has not only read the relevant books but has actually practised loads of times with a qualified driver.  

So, who will it be?   

  • Can you see why just reading a whole load of CSA books is not going to help you pass the exam?  
  • Driver B is the better and safer bet out the the two.
  • The CSA exam is a PRACTICAL exam and that means you need to PHYSICALLY PRACTISE.  

(By the way, the real answer in the real world is that you wouldn’t go with either driver because neither is qualified!)  🙂 

So, one of the best ways to practise is to form a CSA study group early on.   When you do join a CSA group…. please, please, please do NOT joing a group where nearly every person is also an IMG like you – even if they are from a different country.   Why?   Because I said earlier that you need to become familiar with the intricate words and behaviours us British people do and how to respond to them.   How can another IMG advise you on that when they’re not born here?    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!

Don’t get me wrong.  I am NOT saying only join a CSA group with no other IMGs.   What I am saying is that there should be a mixture.   You need to watch and learn from how British-born graduates do things.  And get feedback from them to help you improve.    So, in a CSA group of about 6 people, 3 IMGs and 3 British-born graduates is well-balanced.

Do lots of practice with your trainer

Practise in a variety of ways with your GP Trainer

  • Ask your trainer to do some role playing CSA sessions with you.
  • Also also them to look at your consultation videos not just through COT but ask them how you would have done in the CSA – ask them to grade according to the three domains – Data Gathering, Clinical Management, Interpersonal Skills.    
  • And of course, practise with your trainer through doing Sit and Swap surgeries (ask your trainer if you don’t know what these are). 

See lots of real patients and do lots of real surgeries

SEE REAL PATIENTS IN REAL SURGERIES 

  • The biggest training session you have in your daily working life is normal surgery consultations with real patients.   
  • But many GP trainees will book weeks off to ‘study’ for the CSA – when actually, it’s the practise that is important.  And what better way to practice your consultation and clinical skills than with real patients who present with a wide variety of things.   
  • If you get stuck with a patient – if it’s a clinical thing – look it up online.  Improve your knowledge.   In fact, I encourage you to look up things with most patients you see on places like Clinical Knowledge Summaries (CKS) or GP Notebook.   Even if you think you are well versed in something – quickly scan the information on one of these sites in case you’ve overlooked something.  You can look up things with patients or after surgery.  I prefer to do it with patients because I involve them and it makes it look like I am jointly engaging them in the management plan.  And the more I do it, the quicker and more skillful I am at doing it and reading the pages at a glance.
  • If you get stuck and it’s a consultation skills thing – talk to your trainer.   By reflecting on your behaviour, your approach, your clinical knowledge and the way you say things with real patients is the most effective and effortless way of learning and preparing for the CSA exam.  Much better than books!   What you see a lot of in GP surgeries is what you are expected to know in your head and are often the type of things that come up in the CSA exam.
  • Ask if you can sit in with your GP trainer and observe him/her – this will open your eyes to alternative approaches, wordings and skills.
  • Sit in with other health professionals, like the nurses, and observe how they do things like asthma reviews.

Watch the video clips on www.bradfordvts.co.uk

Go to the main CSA menu page on this website.   We have loads of videos you can watch – videos on explanations, videos on whole CSA cases and more.   Watch these.   There are DVD resources you can buy too.    Do a search on Amazon or something.

In fact – VIDEO YOURSELF

  •  Video your own surgeries (with consent of course).   And then watch them by yourself – you don’t always have to use a trainer or TPD.   You’re an adult learner and you should be able to educate yourself.  Compare them to the clips you have watched.  How do you compare?
  • Video the role plays in your CSA study group – suggest it to them.  You/They might not like it at first, but it is an incredibly powerful tool that can help you pass.  By the end, you will love video work (or something closer towards love!).   
  • Like I said before, video provides that vital third external diagnostic eye that you can turn towards and reflect on yourself.   It makes you aware of things you say and do which you would not be aware of otherwise.   Sometimes what we think we have said or behaved is far from what actually was said or done.   Video is the thing that will open your eyes.   So video your surgeries and video your role plays in the CSA study groups.  Watch some together with your trainer, TPD and trainees and watch some on your own.   

If you've previously failed the CSA

If you have failed the CSA, do NOT form a study group purely consisting of others 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).

Improving your English, and your understanding of British culture

Tips to help you become familiar with UK culture and everyday spoken English…

  • At home, try and speak to other family members in English
    Especially if they can talk English too and especially with your children who might be able to tell you when you are saying things wrong.   
  • If you share a house with others
    Talk to your housemates in English.  It is the most easiest and effortless way of improving your English – especially if they are born and bred in the UK. 
  • Join an ‘English Evening Class’ at your local college or university.
    There’s lots of classes like this available and many offer conversational classes too.  They’re not expensive.  And you make new friends in the process.    
  • 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; it’s a lengthy, steady but rewarding journey if you commit to it.

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