What You can Learn from the CSA Simulated Patients

Who are the CSA actors?

All CSA role players are professional actors, but before they embark upon the CSA itself, they have to attend a training session introducing them to the exam. We emphasize the need for fairness and consistency, to ensure all candidates are given an equal opportunity to perform.

We discuss ‘cueing’—not the normal cueing for actors—in the CSA; this means what information to give you, the candidate, either verbally or non-verbally. Don't just listen to what the ‘patient’ is saying; watch the body language for cues as well.

Most importantly, they are instructed how to deal with you. If you use jargon or terminology which a lay person wouldn't understand, they will bat it back to you—‘I don't understand’—and the 26th candidate in the day will get the same response, even though the actor may have had to do this 25 times already! If you simply say ‘I'd like to examine you', you will get the response ‘What do you want to examine, what are you looking for’—so save a few seconds and say exactly what you want to do and why.

Perhaps, the most instructive part of the training is the session where they role play both parts—the patient and then the doctor. You'll be gratified to hear that, when asked how it feels to play the doctor, the actors always say how hard it is and express admiration for the work you do!

Calibration

The final part of the training for role players prepares them for the ‘Calibration Meeting’. The CSA takes place on three floors, so every case is performed simultaneously by three actors who are each paired with an examiner. Before the exam, the three examiners agree how the case will be marked, and the three role players practise the role, calibrating each other's performance to attain consistency.

This is the actors' dress rehearsal and each will have a run through at the meeting. They will have received their briefing notes (two or three A4 pages of background information about the patient) about a week before the day of the exam. The only scripted part of the case is the opening statement, and the wording of this, the tone in which it is delivered, and the accompanying body language will be practised by each actor at the start and end of the meeting. Beginning each candidate's exam in exactly the same way is one of the methods by which we ensure consistency from actor to actor, candidate to candidate.

Should the case entail actual physical examination, the examiners, who are all GPs, will examine each of the actors to ensure that they have no physical signs that could confuse you. The role players will also be taught how to react to the examination—both physically (where the pain is, etc.) and verbally (what information to give you).

What do the role players think about the CSA exam?

I have been involved with the Royal College of General Practitioners (RCGP) simulated surgery exams for 7 years and with colleagues have undertaken research with the actors who simulate ‘patients’. Among other things, we wanted to discover what they think of the CSA exam, and what makes a good candidate in their eyes. Actual comments from the research are shown in italics. The actors are all very aware just how important the CSA is and of their responsibilities in ensuring a fair and reliable exam for all, and, in general, they think that the CSA is a fair test and about as realistic as it could be. They are proud of their part—‘We have an enabling role’—allowing candidates to show their consulting capabilities.

However, they also know that once the opening statement is given, what happens next depends entirely on you, the candidate. ‘We know we've got to get from A to B … but if they don't give you the triggers, I can't go.’ The flow of the consultation depends on the questions you ask and your behaviour—‘my responses change because of the way the GP deals with me—my reactions and emotions change.’ Box 1 summarizes why candidates may fail on interpersonal skills.

Your body language, eye contact and the way you encourage dialogue are all crucial. A good consulter will ‘nod and agree, and encourage you, and be more positive with the body language, eye contact … suddenly there's this natural sense of interest, and my whole demeanour changes towards them.’ And that positive reaction starts to form within the first few seconds, based on both verbal and non-verbal aspects—the quality of the welcome (e.g. standing to greet the patient), introductions, eye contact, smiling, …

Remember that the role player has been primed to ‘cue’ you, so listen to what you are being told and watch for non-verbal cues. For the first minute or so of the consultation try to say as little as possible yourself, just using positive body language and open questions or phrases, such as ‘Tell me more’, to encourage the ‘patient’ to open up to you.

ICE questions, designed to elicit the patient's Ideas, Concerns and Expectations, are a valuable questioning tool, but they must only be used when relevant and appropriate—and certainly not by rote! ‘I've got to be caring here, I've got to ask this question here … It's as if they're thinking,—‘I'm going to ask this, irrespective of what you've just said, this is how I want to move it on’—and that's different from somebody who is genuinely interested.’

There are very few cases with hidden agendas, so the repetition of the question—‘Is there anything else?’ isn't usually necessary once the patient has said ‘No’. You should also only question about smoking, alcohol, etc. if it is actually relevant to the case.

Many actors hate being asked—‘Did you have any thoughts about what it might be?’—usually responding—‘No, you're the doctor, you tell me!’ They are, however, in my opinion wrong to dismiss the question and a follow-up such as—It's just that some people come with their theories … ‘—can often elicit further information. The best patient-centred doctors will see issues of health and illness from a patient's perspective and will understand the impact the symptom or problem is having on the patient's world—family, work, etc. They were responding to my cues and joining in and seeing my frustrations. They understood the impact it was having’.

A question of time

How do you do all this effectively in a 10 minute consultation? You will certainly need to be able to select from a range of consulting skills—learn to listen properly, be curious and encourage dialogue, sharing ideas, options and decisions. Box 2 lists some questions to ask yourself about each patient that you see.

You also need to understand the structure of the consultation, which means that after 5 minutes or so, you should be getting on to the development of your management plan—including appropriate follow-up and inclusion of the patient in the decision making. Many candidates fail because of an inadequate or inappropriate management plan.

So finally, when the buzzer goes at the CSA exam and that first patient walks through the door, remember that (s)he is there to enable you to perform at your best and has been carefully trained to ‘cue’ you. So, listen carefully and watch the body language.

Good luck!