Abstract
The CSA is a relatively new exam but this has not prevented a substantial mythology building up around it. To an extent this has been responsible for creating an industry for some of the organisers of preparation courses, who have a vested interest in maintaining the juicier misconceptions (and hence justify teaching you how to address them).
Misconception 1
‘Some CSA days are more difficult to pass than others’
The CSA involves 13 consultations with different role players. The role players and examiners travel around in pairs, meaning that a different examiner will assess you for each of your cases. Each case is scored and, at the end of the examination, these case scores are added to give you a total score. It's this total score that will determine whether you pass or fail. I've heard it suggested by some registrars that, because the case mix is different each day, you might suffer if you chance upon a ‘difficult’ day. I've also listened to others who suggest that you need to make sure that you don't sit the examination on the same day as clever people because your own performance may be judged poor by comparison with them.
Both of these ideas are ill informed and can be refuted by an understanding of:
How the cases are selected and marked How the total scores are used to decide on the pass mark each day
How cases are selected and marked
Before each case makes the floor of the CSA, it has already undergone extensive case assurance to ensure that it suitable for the examination. This process is ongoing, and cases are constantly revised in response to examiners impressions of how they work in reality. For each day of the examination, a case mix is decided upon that attempts to achieve a reasonable balance of case difficulty.
In order to ensure consistency for each case, marking is organised as follows:
On the day of the examination, the examiners marking the same case (there will be three if the examination is running on three simultaneous circuits) sit down with their role players for an hour and a half to ensure that they properly calibrate how their case is going to run and how it should be marked. They will have extensive case-specific notes to help them do this. The result of this is that candidates will be marked against previously agreed criteria and not against each other.
How the total scores are used
Since September 2010 the college has used the ‘borderline group method’ to determine the pass mark for each day of the exam. If you want to know how this operates in detail, there is an excellent explanation on the CSA page of the RCGP website. Suffice it to say that this is a psychometric exercise that corrects for the fact that, on a given day, both case mix and candidate mix might vary. This method is used extensively in other examinations and seems to be the best available for ensuring that it shouldn't matter when you sit the CSA or what company you have on the day.
Misconception 2
‘The role players are out to trip you up’
No, they're not. They're really, really not. Role players undergo extensive training, and know what is expected of them and how they should behave with candidates. They are not meant to be your friend but do understand the importance of helping your cause by being a convincing patient. They are remarkably good at this. If they exhibit challenging behaviour during the consultation, that is because the case has been written that way and not because they have decided to make life difficult for the fun of it.
I mentioned above the calibration exercise that role players and examiners undertake at the start of each examining day, and by the end of this the role player will have a very clear idea of how to be consistent and convincing for that particular case. Calibration cannot, of course, anticipate everything that a candidate might say or do but, in my experience, most role players are very agile at thinking on their feet and it is unusual for even the most determined candidate to throw them off course (although, to be fair, some candidates have a good go).
Role players play no part in assessing candidates and will not make any comments on their performance until after the examiner has completed marking that candidate. To be honest, most of their conversations with examiners concentrate on them ensuring their own performance is up to scratch. It pretty much always is.
A common mistake made by candidates is not to treat the role player as a patient but rather to try to second guess what's in their script. This is a very unwise strategy, as the interaction will look forced to the examiner and the role player will respond in much the same way as a real patient would to being asked incongruous questions. Similarly some candidates seem to feel that all they have to do is push the right button and the role player will spill everything into their laps. They wont, any more than your real patients will when they hear you incant the holy litany of ‘ideas, concerns and expectations’.
Consultation techniques that are effective in the real world will be similarly effective with role players – remember, they are very good at their job.
Exam Q&A: Should I acknowledge the examiners or ignore them?
Ignore them and give your full attention to the role player. The examiner will want to be as invisible as possible, so as not to get in the way of you doing this. Every bit of eye contact you try to make with the examiner is time taken away from fixing concentration on your ‘patient’. If the examiner needs to interact with you (for example, to give you examination findings), then they will.
Examiners are very chatty people and, under normal circumstances, are unable to sit quiet. The fact that they are prepared to do so during the CSA is a mark of their dedication!
Dr Roger Tisi
If you have a question that you would like to ask an examiner about, please e-mail your question to: