CSA Feedback Statements—What Do They Mean? Part One

Disorganized or unstructured consultation

Candidates usually come to the CSA with some form of memorized checklist or structure, such as the Consultation Observation Tool (COT) or a similar consultation model. However, things can go astray if the candidate fails to clarify either the problem or the patient's agenda before moving on to the examination and management. This inevitably leads to some backtracking later on in order to clarify the focus of the case, which can look untidy.

Consultations can also become disjointed when significant other medical or psychosocial issues cloud the ‘problem’. Taking these issues on board while moving the consultation forward and knowing which areas to ‘park’ is a key skill to practise.

Does not recognize the issues or priorities in the consultation

Registrars can be surprised to receive feedback in this category and do not realize that important aspects of the case with a bearing on management have been missed. The CSA requires doctors to adopt a broad holistic approach and the ability to think around challenges or dilemmas.

I recently watched a video consultation of an elderly patient presenting with insomnia and facing a hospital admission for a recently diagnosed cancer. You can easily be drawn into making assumptions in a case like this and become less alert to verbal cues as a result. The insomnia was partly due to worry around the long-term care of her partner who was suffering from dementia and this was completely overlooked. Listening to the patient carefully and picking up cues, both verbal and non-verbal, can really help in identifying those issues the patient finds important.

When preparing for the exam, practising cases highlighting interpersonal skills or ethical dilemmas can be more useful than textbook clinical cases.

Shows poor time management

This is usually the result of losing focus in the early stages of the consultation. You should practise at 10 minute intervals well before the exam itself. If you seem to be running out of time during your explanation, then outline your plans first so that the examiner can see where you are heading. Try to avoid too much checking or summarizing or looking up drug dosages. Failing to finish the case is not usually a problem if you have covered the main points and completing it very early may mean that certain elements have been overlooked.

Does not identify abnormal findings or results or fails to recognize their implications

Abnormal test results may be seen in the CSA and you will be expected to identify these (normal reference ranges are usually provided). It is well worth thinking about common haematological and biochemical findings and how you might approach them in practice. On some occasions, results may be bad news, which will need sensitive discussion.

Does not undertake physical examination competently or use instruments proficiently

The number of physical examination cases is increasing and it is important to appear confident and relaxed, keeping the patient informed and comfortable at all times. Some common scenarios are covered in the e-GP physical examination series. The clumsy use of instruments or lack of familiarity with them can be all too obvious in the CSA examination.

Does not make the correct working diagnosis or identify an appropriate range of differential possibilities

As doctors we do not like to be seen struggling to make a diagnosis and we can easily be tempted to skip over the diagnosis and move straight to management. This is not a good plan in the CSA and making other vague comments perhaps saying the complaint is ‘nothing serious’ is not much better. If you know the diagnosis, please state it clearly to give the patient and examiner confidence in your ability. Sharing your uncertainty and thinking aloud are fine as long as the examiner can see that you are moving safely towards one or two realistic possibilities.

Does not develop a management plan (including prescribing and referral) reflecting knowledge of current best practice

If there is up-to-date UK guidance, for example, from the National Institute for Health and Clinical Excellence (NICE), you would be foolish to ignore it during management. This does not mean you always have to stick rigidly to recommendations and you should always be prepared to negotiate with patients according to their preferences or circumstances. Remember that this is an examination for primary care and over-investigating or over-referral are common weaknesses.

Does not make adequate arrangements for follow-up and safety netting

It is important to make it clear whether you wish to follow a patient up. If you are not seeing the patient again, safety netting is about explaining what you think should happen and when to seek further help if things do not seem to be improving. Be specific about time. It is particularly helpful when you have a degree of uncertainty about the diagnosis or treatment. See point 3 (time management), these two often go together as it is the follow-up that is missed if you run out of time.

Does not demonstrate an awareness of the management of risk or make the patient aware of the relative risk of different options

When deciding on a management plan, we are balancing risks and benefits of different treatments all the time. Patients need to be aware of the risks in a way that they can understand and the examiner needs to know you have a safe level of awareness when making decisions. Think about your decision making when you issue any new drug particularly as a repeat prescription. Often, candidates discuss the risks of treatment but forget the effect on co-morbidities treating each new problem in isolation.

Does not attempt to promote good health at opportune times in the consultation

Health promotion and lifestyle advice can be very important and should be part of the management plan in many different conditions. The timing and delivery of this advice are vital to try to get the patient on board and take some ownership of the ideas. Lecturing or frightening the patient is best avoided. Random questions about smoking and drinking which disrupt the flow of the consultation about an unrelated complaint look over-rehearsed and scripted and may not get much of a response from the patient.