Popular Misconceptions about the CSA: Part Two

Misconception 3

There is a ‘right’ way of handling each case

No, there isn't. Although, to be fair, there are plenty of wrong ones. I wrote briefly in my last article about the process of case writing and assurance, one of the outcomes of which is that sufficient time is taken to work out the range of responses that different candidates might reasonably make to a given scenario. After all, general practice is often about making judgements between competing potential solutions.

In the CSA, providing the candidate's clinical management is coherent, well explained and properly involves the patient, they are likely to score well, even if the examiner might have handled things differently herself. Well performing candidates will often discuss the range of options available and help their patient decide on what is going to work well for them. Remember that role players, just like real patients, have no medical training and are likely to be trusting of your advice; so make sure that the advice you give conforms to presently accepted practice. There's little worse than a persuasive communicator sending a patient confidently out of the consulting room on a path to disaster.

Candidates sometimes worry about doing something that upsets an examiner to such an extent that they will ‘fail’ the exam. We are denied any such power. Remember that a different examiner marks you for each case, and so, even if you feel that you have performed badly in the case before, the next examiner to see you will have no idea of this and will judge this next case free from any preconceptions.

Your mark at the end of the exam will be the sum of 13 separate judgements and so no single examiner can make sure that you fail. Remember as well that each case is scored equally in the three domains of:

Data gathering

A single mistake that you might make in a case is unlikely to mean that you will score badly in all three domains. It's worth pointing out, however, that a simple mistake may not be quite as simple as it appears and may be the result of failures across the domains (and examiners doing their job properly will have worked this out). An example would be a missed diagnosis resulting from poor data gathering and inadequate interpersonal skills.

If you are seen to do something really off the scale, to the extent that it raises a question about your basic fitness to practice, then the Royal College of General Practitioners (RCGP), like any other professional body, has a responsibility to share its concern with the GMC. In reality, this is an exceptionally rare event and there are much more straightforward ways of bringing yourself to their attention!

Misconception 4

You should learn the ‘right’ answers before the exam

Dangerous. Remember, there are no ‘right’ answers. Of course, it's sensible to prepare for the CSA but, on several occasions, I've seen candidates who, believing they have spotted a case they have heard about before, attempt to shoehorn in a pre-prepared management plan. This very rarely works well. A better strategy is to keep an open enquiring mind and deal with the actual problem presented to you rather than one you prepared earlier. Strangely enough, this is just like real life.

The number of courses that are now available for prospective CSA candidates is impressive. Some of them are excellent, but I worry about those that promise to teach you how to handle specific problems, inferring that you can be ahead of the game for any case that might come your way. I worry more when I hear about a black market in sharing information about ‘actual’ CSA cases, not just because this compromises the CSA case bank but also because, for the reason I've given above, such (often spurious) information is likely to mislead candidates and divert them from dealing with the case in front of them.

What is valuable is to work on developing a flexible consultation structure, that you can apply during your CSA cases, which ensures that you don't neglect important aspects of the patient's presentation, e.g. their social history. You need to work on this before you reach the CSA, so that it becomes second nature, as you will otherwise appear forced and formulaic. Trust me when I tell you that there are no magic phrases that automatically gladden the hearts of examiners (and, indeed, some of them are more likely to produce a sinking feeling in our guts).

Misconception 5

Elephants are small creatures and so can be safely ignored

I often hear concerns voiced by candidates about having to uncover ‘hidden’ agendas in CSA cases. Actually, role player agendas in the CSA are usually not difficult to uncover, providing that you apply sound consultation techniques. In spite of this, it sometimes surprises me that great big slap-you-in-face agendas are either not seen or simply ignored.

I've often wondered why this should be. I've little doubt that some candidates just miss the point at times, but I've witnessed other occasions where candidates appear to see what the issue is but then work overtime at trying to avoid it. This may be because they feel it exposes an area of clinical uncertainty or perhaps they feel uncomfortable with handling the ethics of the case. Either way, they are hardly going to do themselves a service by hoping it all goes away. Some candidates try the strategy (mentioned above) of attempting to move the consultation onto ground where they feel safer but the role player will very quickly return the case to where it's meant to be.

All candidates will feel out of their comfort zone at times during the CSA. This is deliberate, as we are not working in a comfortable speciality. CSA cases that take you into difficult territory often require little more of the candidate than that they acknowledge such difficulty with the patient and come up with a sensible plan that is going to help them move forward. We certainly don't expect you to completely fix complex problems within the space of a 10 minute consultation.

I've also heard candidates express concerns about encountering ‘demanding’ patients in the CSA. I'd argue that dealing with them is often pretty easy, as their demands can usually be managed in a straightforward way. What we are looking for here is a safe negotiated outcome: being patient-centred doesn't mean giving patients everything they want but does require you to show awareness of their preferences. If a demand is unreasonable or unsafe, then say so and explain why. Don't agree to anything in the CSA that you know you would not agree to in your consulting room.

CSA examiners are, mostly, intuitive people but few of us possess the capacity to read minds. If you don't make it clear that you have recognized an important issue for your patient, then we are unlikely to be confident that you have seen it. So, in summary, if an elephant comes walking into your room at the CSA centre, shake it firmly by the hand and call it Jumbo.

Misconception 6

CSA examiners are out to fail you

All CSA examiners are jobbing GPs and many of them are trainers, programme directors and other such worthy stuff. They rank high on the CI scale (Cuddliness Index). Put them in an exam room, however, and they transform into critical analytical beings. The reason for this is that they have been trained to do so.

Examining is a difficult job and those who do it are acutely aware of the responsibility of making the right decisions. Our default position is to be supportive of candidates, but we recognize that, at times, this includes making judgements that a candidate's performance is not up to the mark. Failure to do so would be a disservice to that candidate (and, ultimately, to their future patients).

I've written before about the care that goes into writing cases and making sure that they are properly calibrated at each sitting of the exam, allowing examiners to have a clear idea of what they are marking. In addition to this, all examiners have regular training and appraisal of their performance. All of this should mean that the examiners watching your cases are not going to mark you down for the fun of it.

Candidates attending the CSA are usually impressed with how well they are treated on the day and appreciate the care taken by the examiner marshals in ensuring the smooth running of the process. This is as it ought to be; after all, we are examining you for membership of a college that we value and want you to be a part of. I don't pretend to be unbiased, but I think this is a fair exam and this impression is backed up by feedback from candidates, most of who feel that they have been put through a fair assessment.

The CSA is a challenging exam and those who pass it will feel a justifiable degree of pride at reaching standards agreed upon by their peers. Good luck with yours, and I hope that these articles, and those that are to follow over the next few months, will help you in your preparation.