Abstract
Before sitting the Clinical Skills Assessment (CSA), it was described to me as ‘the surgery from hell’. This made it seem like a very daunting task. Now that I have taken and passed the exam, I believe that there are some basic strategies to use that will really maximize your chances of success.
The key to this exam is adequate preparation and practice time. The Royal College of General Practitioners (RCGP) states that GP trainees are eligible to sit the CSA when they are within 12 months of the expected date of completing their training (i.e. during ST3). This is because consulting with patients in general practice is the best preparation and I feel that this, alongside practice with colleagues or your trainer, is enough to adequately prepare yourself.
Here are my top tips!
Start your preparation for the CSA once you begin working in a GP surgery. Regular consulting is a great way to prepare. Whenever you encounter a problem during a consultation that you are unsure how to manage, make a note of this and then look it up as a similar situation may well occur in the exam. Time management is essential. I would advise dividing your time in the consultation to cover the key components of the assessment domains.
Assessment Domain 1: Data gathering and technical and assessment skills. Key areas are clarifying the patient's presenting problem, gathering appropriate information, performing a relevant examination including competent use of medical equipment and interpreting investigation results if required Assessment Domain 2: Clinical management skills. Key areas are establishing a diagnosis, developing a structured but flexible management plan with options, safety netting and health promotion if relevant In all areas of the consultation, your interpersonal skills need to be demonstrated (see Point 5) Practise with friends or colleagues from your Vocational Training Scheme (VTS). Four to six weeks before the exam, get together regularly and practise consultations. Ideally, work in a group of three (patient/doctor/examiner). Use CSA books (there are plenty out there) or your own patient experiences as a guide, ensuring all areas of the curriculum are covered. From the start allocate 10 minutes per consultation. Videoing your consultations and then reviewing them with your trainer is also extremely useful as is the RCGP DVD ‘A Guide to the CSA’ (available from the RCGP bookshop). Approach CSA consultations in a logical manner that is patient centred. Your management plan needs to be backed up by sound medical knowledge ensuring that a sensible and safe plan is developed. It is important to know all the red flag symptoms, as failure to recognize these will indicate a GP who is unsafe and will result in failure for that consultation. I cannot emphasize enough how important it is to carry out all consultations in a patient-centred way. Start to incorporate this into your everyday practice so that it comes naturally during the exam. Active listening, particularly at the beginning of the consultation, is essential. This is best achieved by using open questions that allow the patient opportunity to speak freely. It is then important to ask closed questions to clarify certain points. Eliciting the patient's agenda includes exploring their ideas, concerns and expectations and identifying the effect of the problem on the patient's life. Do not ignore any clues patients might give in the quest to satisfy your own agenda. Do not worry if you are not carrying out 10 minute consultations at work. This is because in the exam there is no computer to look at, no data entry and generally most patients will present with one problem. At the start of the CSA exam you will be given information about each patient in a booklet. This information is very minimal and consists of name, age and basic past medical history. This may not be relevant to the presenting problem. There may be investigation results included for some patients. Make sure you turn over the page as this information may extend overleaf. You will have 2 minutes between each consultation to prepare. Be prepared for a telephone consultation or home visit. The telephone consultation could be a discussion with a colleague, patient or parent. For telephone consultations, you will be taken to a room that has a phone on the desk. At the start of the consultation the phone will ring. The examiner is listening to your conversation but is not in the room with you. Imagine the patient is sitting in front of you. It is important to cover the same ground as you would do in a face-to-face consultation. Make sure that you firstly introduce yourself and check the identity of the caller. Summarize everything that the caller has said to you and be clear and concise throughout. Ask the caller to repeat back to you the management plan to check understanding and always safety net. Practise your basic examination routines, including cardiovascular, abdominal, respiratory, joints, thyroid and Rinne and Weber tests. These examinations need to be focused and quick. The examination may be part of the consultation or its main emphasis. Do not worry about losing marks if there is not enough time to write a prescription. It is adequate to inform the patient about which drug you will prescribe and advise how to take it. You will not lose marks by not writing a prescription. Similar advice applies to organizing blood tests. The CSA exam covers the entire GP curriculum and requires a good breadth of knowledge. Do not underestimate areas of the curriculum that you may have less experience with, for example ethical or confidentiality issues. Good communications skills are vital but need to be backed up by a sound knowledge base.
And finally make sure you arrive in plenty of time with the required identification and medical equipment. The RCGP website gives information about this. On entering the consulting room have a look at items on the desk and familiarize yourself with these. Take suitable layered clothing, as some rooms can be very cold, and a bottle of water: you will be doing a lot of talking.
I would recommend going on a CSA course. This can be great for boosting your self-confidence, it enables you to see how other people at your level consult and will increase your familiarity with the exam process.
Although this is a hard exam, the majority of doctors do pass. Do not despair if you feel it did not go exactly to plan. In general, people do a lot better than they think.
Good luck!!!
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