Abstract
Failing the Clinical Skills Assessment (CSA) examination is a difficult experience, and every registrar will have their own version of events and come to their own conclusions as to why this has happened. Many candidates already know that things did not go well; and indeed, some will have booked a further attempt even before the results come out. For others, it is a complete shock and a huge worry, particularly when failure is by a narrow margin. This article on picking up the pieces cannot possibly cover all the issues registrars might raise but hopefully can provide a useful overview of some of the important ones.
The post-mortem
A normal reaction to examination failure is to do a ‘postmortem’ on the result, but, even after this, some candidates will be left perplexed as to how they performed poorly in particular cases. Clearly, the marking schedule for each case cannot be fed back to the candidate as this might compromise future use of the case, but feedback is now given in every case where the examiner has identified inadequate areas of performance and this is designed to help candidates understand where their fundamental weaknesses might lie.
Feedback statements are all ‘negative’ and candidates can expect to see three or four feedback statements on each problem case. It should be remembered that feedback statements are not ‘all or nothing’. It may be, therefore, that a candidate's performance in a particular area was ‘patchy’, in other words not quite good enough rather than failing to demonstrate the competency at all. If no feedback is given for a particular case, this does not necessarily mean that you have performed to the highest standard in each domain, but it does indicate that there were no major concerns in the opinion of the examiner who marked that case.
When looking at your feedback, do not get bogged down in individual cases. It is much more useful to look at patterns when planning your learning. For example, if you are consistently marked down on your clinical management plans, you may need to look in more detail at current National Institute for Health and Clinical Excellence (NICE) guidance for common chronic conditions. More difficult to resolve quickly are some of the interpersonal skills components, such as sharing management or picking up cues. In these cases, tutorials focusing on parts of the consultation such as negotiating a management plan with some role play of different scenarios can help.
Having looked at your feedback and reflected on your performance, hopefully you can identify your main areas of weakness and discuss these with your trainer or programme director. Apart from addressing any specific learning needs, what general steps can be useful when preparing to resit?
Getting ready for the resit
Joint surgeries
Joint surgeries are an excellent learning tool. The situation is similar to the exam itself, with your trainer observing the consultation, and ‘urgent’ cases are often best to demonstrate competencies in all the key areas. Remember, case authors often write from their own surgery experience, and it is worthwhile treating every surgery as a mock CSA.
Consultation Observation Tools
Consultation Observation Tools (COTs) are also useful, with your trainer feeding back on your video consultations. There are some potential problems using COTS to prepare for the CSA, in that, it can lead to candidates looking rather over-rehearsed or ‘formulaic’ in their consulting. You certainly need the foundations in consultation skills covered in COTs, but the CSA tests your ability to apply these skills in often challenging consultations within a tight time frame. Attempting to tick all the boxes that you need to produce the perfect COT is not always possible in the CSA. Indeed, doing so can sometimes break up the fluency of the consultation, without always adding anything. A good example of this is when a candidate goes to great lengths to check understanding, when there has been an excellent two way dialogue throughout. One tip is to use the CSA generic domain descriptors rather than the COT marking sheet for analysing some of your videos as this will focus feedback on the broader requirements of the CSA.
Time management
Time management is vitally important at the CSA. Before you consider sitting, you should be consulting at 10 minute intervals at your training practice, perhaps with an additional block to catch up in the middle of your surgery but not much more. One of the main problems tends to be getting caught up in history taking and you need to work on making this focused and relevant to the matter in hand. Do not get sidetracked by peripheral issues: as an example, candidates will sometimes identify a relevant piece of health promotion in a case, but by over-concentrating on this might neglect the main point of the case, leading to clinical management being rushed and marks lost.
Examination skills
Examination skills should not be overlooked when preparing for the CSA. Many candidates look hopefully at the examiner when any form of physical examination is required, looking for a card giving the relevant findings. In the future, it is likely that a higher proportion of cases will require some form of examination, and again, it is important that you are competent and look as if you have done it before. The Royal College of General Practitioners (RCGP) e-GP website has a physical examination series which is a helpful guide to choosing appropriate examinations in the GP setting.
Mock CSA circuits
Most training schemes run mock CSA circuits once or twice a year. These can be very helpful, particularly if they have a mix of cases testing clinical, communication skills and the ability to consider ethical dilemmas. Courses usually give formative feedback and tips based on some of the generic skills rather than giving specific ‘grades’ (which may in any case be misleading and unreliable).
Using role play in small groups can be less intimidating than when it is used in courses or mock exams and registrars can often give honest and constructive feedback to their colleagues. The presence of an experienced trainer to overview the session can be useful to highlight shared weaknesses that might be overlooked. Alternatively, tools such as the RCGP Wessex Deanery series of guides to the CSA in DVD format showing CSA cases marked by examiners can also be used in group exercises as a basis for discussion and rough calibration.
Keeping up to date
Keeping your clinical knowledge up to date is often overlooked when preparing for the CSA as candidates focus their attention on communication issues. It is worth remembering that inadequate clinical management remains a major source of failure in the CSA. Developing awareness of NICE or Scottish Intercollegiate Guidelines Network (SIGN) guidance around the investigation, management and referral criteria for chronic conditions can be invaluable.
What if I fail again?
If you have failed the CSA on two or more occasions, it is likely you will need extended training and additional support. Registrars who are a long way short of the pass mark may not benefit from resitting too quickly and should take advice from their Deanery about how their training needs should be addressed. In some cases, there are problems in interpersonal skills, which may benefit from specific consultation courses. The London Deanery has developed courses, looking at not only consultation skills but also cultural issues which may be important if English is not your first language. Work is also being done to provide Deaneries with details of local examiners who may be able to offer advice or have specific skills in different areas around the CSA or other parts of training.
It is possible to make great strides within a relatively short time if you reflect on your feedback, identify your problem areas (which may not be huge) and formulate an action plan to deal with them.