The universal GP Training website for everyone, not just Bradford.   Created in 2002 by Dr Ramesh Mehay

The CSA with Confidence


Why trainees run out of time

Trainees run out of time for a variety of reasons

  1. Not having a consultation framework to begin with
  2. Not paying attention to the first five minutes – particularly agenda setting and data gathering
  3. Not paying attention to the second five minutes  – particularly explanation 
  4. Not keeping an eye on time itself
Listen to this video clips for tips and advice on managing your time in the CSA.

1. Having a consultation framework

If you don’t have a consultation framework, then basically it’s a bit like a train on no tracks – it can go in all sorts of directions and end up anywhere.   The train can end up going around and around and around until it comes to a stop somewhere.  Likewise, doing a consultation by just jumping in without a framework is likely to result in 

  1. a higgledy piggledy unstructured chaotic consultation that
  2. eats up a lot of time and 
  3. which is unpredictable and therefore
  4. may or MAY NOT end up somewhere useful.

Do you really want to leave things to chance or do you want to be more in control and more certain that your outcomes are going to be helpful?   If you do, then use one of the consultation frameworks in the ‘DOWNLOADS’ section above.   Ram’s 5+5 CSA Consultation Framework is particularly helpful because it reminds you what should be roughly achieved by the first and second 5 minutes.  Alternatively, play with a few and formulate your own.

2. Paying attention to the first 5 minutes

There are two main things (other than developing rapport) that you need to achieve in the first 5 minutes of any consultation.

  1. Set the agenda
  2. Data gathering (= gathering information).

Setting the agenda is important if a patient comes in with a lot of problems.  You need to be able to work out which one to focus on first.    Sometimes the doctor will have to suggest what to look at first (particularly if there is something medically important that must be dealt with today eg chest pains).   But other times, it can be the patient that guides you.    Where trainees fall down is in spending too long the agenda setting   OR not truly doing any form of agenda setting.  The problem with not doing any form of agenda setting is that if the patient has two or more problems, you then end up mixing them up and your history taking will become messy as you start flitting between the two (or more problems).  In fact, this flitting between several agendas is dangerous because if you flit back and forth between multiple presenting complaints, YOU WILL overlook things and miss important questions to ask.   So, my advise to you is to set the agenda in a pretty slick and quick way.    Then move onto the data gathering.

The data gathering is another area trainees lose a lot of time.   Why?  Because they end up asking questions that aren’t important at the expense of the essential ones.   Look at these two dialogues to illustrate my point…

Doctor goes off at a tangent

  • Dr: So your headaches, tell me more about those.
  • Pt: Well they’ve been going for for 4 weeks now and they are really troublesome.
  • Dr: Whereabouts are they?
  • Pt: Over here doctor (patient points to frontal area)
  • Dr: And whats the pain like?
  • Pt: It’s excruciating doctor.   
  • Dr: So, it’s more sharp than dull, heavy or tight?
  • Pt: No, I’d probably say more tight.
  • Dr: And does the light hurt your eyes?
  • Pt: Yeah, a little bit.  yellow light particularly.
  • Dr: Why yellow light?   (NOT A HELPFUL QUESTION)
  • Pt: I don’t know.   I was dancing the other day at a friend’s party and the yellow light from the dancing strobe I think affected me more than the others I think.
  • Dr: How unsual.   
  • Pt: Yes I thought so too. 
  • Pt: Sometimes white or blue does too.
  • Dr: In the same way as the yellow light?     
  • Pt: Well, not as bad I suppose.  Just a twinge.
  • Dr: And did anyone else find those lights painful?  (UNHELPFUL QUESTION)
  • Pt: I don’t know really.  I didn’t ask anyone.
  • Dr: And were you wearing glasses at the time?  (UNHELPFUL QUESTION)
  • Pt: No, I don’t wear glasses.
  • Dr: How odd!   (WASTING TIME)
  • Pt: Yeah I thought so too.  That’s why I thought I’d mention it.  It’s not serious is it doctor?  Oh, I’m all worried now.

Doctor is methodical and structured

  • Dr: So your headaches, tell me more about those.
  • Pt: Well they’ve been going for for 4 weeks now and they are really troublesome.
  • Dr: Whereabouts are they?
  • Pt: Over here doctor (patient points to frontal area)
  • Dr: And whats the pain like?
  • Pt: It’s excruciating doctor.   
  • Dr: So, it’s more sharp than dull, heavy or tight?
  • Pt: No, I’d probably say more tight.
  • Dr: And does the light hurt your eyes?
  • Pt: Yeah, a little bit.  yellow light particularly.
  • Dr: So is it so bad you have to wear dark glasses or go shut your eyes and lie down?   (A MUCH MORE HELPFUL QUESTION)
  • Pt: Oh no, nothing like that doctor. 
  • Dr: Ok, that’s good.  So back to the questions, have you had any vomiting?
  • Pt: No
  • Pt: No
  • Dr: Fits, faints or funny turns?
  • Pt: Ermm…again, no
  • Dr: And what about your sleep, do you actually wake from your sleep because of the headache?
  • Pt: No
  • Dr: And from your records, I see there is no serious illnesses you’ve had like cancer or anything.  Is that right?
  • Pt: Yeah, I’m pretty well really.  
  • Dr: And finally, is it affected by your posture, like when you’re bending or anything?
  • Pt: Nope.

At the end of the day, you must know which questions are important to ask for common presenting complaints like back pain, headaches, tiredness all the time and so on.   In addition, you must know your red flags for each clinical system area. This will ensure you take a safe enough history.      It’s unforgivable to do an incomplete red flag enquiry.  You must ask the relevant ‘red flag data set’.

And don’t forget to signpost.  Say something like “Okay, I’d now like to spend a few moments asking you some important medical questions to help me work out what is going on.  Is that okay?”.   Signposting will help mark to both you and the patient that the next phase of the consultation is purely focused on asking those important medically questions and should (hopefully) stop either of you from veering off.  If the patient interrupts with something irrelevant or goes off at a tangent, please bring them back rather than follow them through.   Say something like “Okay, don’t worry, we’ll talk about your foot in a moment, but can we come back to these important medical questions that I need to ask you about your chest pains?”.

So, in summary, my advise would be…

  1. Know the important questions for common presenting complaints
  2. Know the ‘Red Flags for the CSA’ document like the back of your hand.  And get those questions out of the way…. document available in the QUICK LINKS section above.
  3. Signpost that you are going to ask some specific medical questions.  
  4. And ask the questions swiftly and quickly.

3. Paying attention to the last 5 minutes

Where trainees go wrong in the last 5 minutes of the consultation is spending way too long on an explanation.  Either that or they end up explaining things in such a complex convoluted way that it confuses the patient and the patient then asks more and more questions to clarify, when then eats up all the time.

So, in summary,

  1. Your explanation should be nice and simple.  Short and sweet.
  2. Avoid jargon.   Use everyday English.
  3. Relate it to the patient’s framework where possible,
  4. Use analogies if you can.
  5. Quickly move onto the management plan.

4. Paying attention to the Time...

In the CSA and in the practice sessions, please take a watch or timer of some sort with you.  Perhaps your phone timer?   A timer will help remind you…

  1. whether you are in the first five minutes or the second.  
  2. whether you are at the end of the first/second five minutes or not (and thus help you decide what needs rounding off).
But I have a word of warning for you.  Don’t keeping looking at your watch every 2 minutes.   It will disturb your flow if you do and you will miss things.  All of that will make the consultation look higgledy-piggledy and awful.    Instead, only look at the clock 2 or 3 times.    Just to see if (1) you should be moving over from the first five minutes to the second and (2) whether you should be closing off.  

I found this video clip which some people find useful to play on their phones.

  • Basically, it’s just a video displaying graphically where you should be in the consultation in real-time. 
  • I think it is very simple and very clever.
  • Try it and see.   There is intentionally no sound.   Play it as soon as you start your practise CSA case, and periodically look at it to see how you are doing.
  • I wouldn’t suggest using it all the time.  Just now and then to see how you are doing.   
  • Perhaps in the room where you are practising CSA, perhaps you can play it on a TV screen or a laptop or tablet device facing the role-playing doctor.

Please leave a comment below if you have any words of wisdom to help others or if you have any questions you wish to ask…

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