Physical Examination in the CSA

What is expected?

The standard of physical examination required in the CSA is that of a competent GP working in a general practice setting. Physical examination should be focused on the patient's presenting problem and be properly performed; by this, I mean that the examiner needs to be convinced that your technique is good enough to allow you to detect any physical signs that may be present. You should be efficient in your physical examination but not take inappropriate short cuts. Listening to a patient's chest through a woolly jumper is unlikely to go down well.

The e-learning for GP website (www.e-lfh.org.uk) has a series of videos on physical examination in general practice that is a useful reference resource.

What physical examination kit do I need?

Candidates are given clear instructions about what they are expected to bring with them on the day. Read these instructions carefully as the College does not have spares to hand out to those who forget them. If a particular piece of equipment is needed that is not part of the standard kit, then this will be provided on the day. So if you see a gleaming instrument waiting on your desk, you have just been given a strong non-verbal cue that you will need to use it at some point during the CSA. You will help your cause by using it on the right patient.

How do I know whether I should carry out a physical examination?

You should deal with cases in the CSA exactly as you would in your surgery. If you feel the patient's presenting complaint requires you to do a physical examination, then you should offer to do one. Not all the cases you encounter in the CSA will require physical examination and you should not attempt to shoehorn one in if it is not going to help your assessment.

In some CSA cases, physical examination might be appropriate but, because of how the case is written, the examiner does not need to see you perform it. In such cases, the examiner may intervene by telling you physical examination findings or handing you a card with the findings written on it. Examiners will, however, only give you this information if you have demonstrated to them that you intend to do the relevant physical examination. Examiners sometimes talk about candidates ‘earning the card’ and, for example, would not hand a card saying ‘Chest examination normal’ to a candidate who has just told the role player she wishes to examine his ear.

How should I treat the role player?

Just like a real patient. When you reach the point in the consultation where you would like to physically examine the patient, you should explain what you want to examine and why you wish to do so (the role players are often cued to ask you this if you do not volunteer the information spontaneously). You should maintain full focus on the ‘patient’ and not turn to the examiner to ask what he or she wants you to do as the examiner will only intervene if appropriately cued (for example, to give you a card with the examination findings). It is highly unlikely that you would be expected to perform an intimate physical examination in the CSA but, if the case demands it, you should proceed as if you are going to do it, right up until the point that the examiner intervenes.

When you conduct your physical examination, you should do so in a professional manner. This means using physical examination techniques that competent GP colleagues would recognize as proficient and treating your patient with courtesy and respect throughout. You should take care to explain what you are doing and demonstrate awareness of any potential embarrassment for the patient; this will include offering a chaperone if appropriate. Examiners take a dim view of candidates who cause distress to the role player by being clumsy or insensitive. Remember that, although playing a part, a role player is a real person too and will feel real pain if you choose to inflict it.

How should I interpret my examination findings?

You need to use a little bit of common sense here. Role players can be taught to mimic some physical signs but even the best role player in the world cannot act a pleural effusion or splenomegaly, so be careful about declaring such findings. Prior to the CSA, role players are examined to ensure that they do not have real physical signs that might mislead a candidate. In short, if your examination is normal, then assume that it is and do not fall into the trick of inventing findings to spice up the case a bit or make it fit with a hypothesis you might have formed earlier. You may feel this is obvious but, on more than one occasion, I have had to reassure anxious role players who have just been given a non-existent examination finding by a candidate.

Where do I go from here?

It makes sense to take a bit of time assimilating your examination findings. This can be particularly important if they are ‘given’ to you by the examiner as this cuts out some of your usual thinking time. Once you have gathered your thoughts, explain the findings to the patient, using terms he or she will understand and taking care to reference the findings to the patient's problem. Done well, this is a good opportunity to move the consultation from data gathering into clinical management and so it is important to carry the patient with you as you bravely venture into the next domain.