I think we should watch and practise how we should present ourselves on the day of our CSA Exam.

Let us see what our RCGP says about it.

General comments about features/behaviours observed in passing and failing candidates in the CSA.

The following comments are based on qualitative analysis of factors contributing to good and poor consulting behaviour in the CSA in 2009. This analysis was carried out by two senior examiners for the CSA (Drs Sue Rendel and Kamila Hawthorne) working in partnership with an expert in linguistics and discourse analysis (Professor Celia Roberts from Kings College London).

General Features

The most noteworthy aspect of good consulting behaviour is seen in consultations that are fluent, interactive with the patient, and relevant to the issues being presented. The doctor can bring the patient into the consultation as a shared partner and can constructively discuss the problem presented, including topics where there is either little knowledge or certainty (either the doctor’s own lack of knowledge or areas of general uncertainty). Poor performance generally shows a candidate who uses time poorly and in a disorganised fashion, follows a pre-scripted approach that feels ‘clunky’ or insincere, and is uneasy with or unable to acknowledge areas of lack of knowledge or uncertainty.

Key features by domain

• Data Gathering

Good performers can take a focused but full history, embedding their enquiry in previous responses, so that a fluent and logical progression is clear. Poor data gathering is seen in candidates who ask for the same information repeatedly and do not appear to have listened to the earlier responses. They use formulaic phrases in their questions that are not normal for everyday consulting (e.g. ‘What are your worries?’). Sometimes this becomes an interrogation as the open questions rapidly turn to closed biomedical history-taking. In these consultations, the sequence of questioning does not make sense, as the doctor seeks to ensure that no information has been left out and works through a routine medical history. Sensitive information is asked for in the same manner as routine medical symptoms without sign-posting to the patient that one is entering potentially difficult territory.

• Clinical Management

Clinical management should be grounded in UK medical practice, linked to recognised algorithms or modes of practice as suggested by NICE, SIGN, or other national guidelines.  Candidates should be able to demonstrate problem-solving skills, with a range of reasonable management options to problems presented that are likely to be tailored to and acceptable to the patient. Poor candidates may have an insufficient knowledge base to be able to think of a range of such management options, or may not be able to integrate and apply their knowledge to the situation in hand. Sometimes they do not appear to have a full understanding of the dilemma/problem presented, or its implications for the patient. A frequent sign of poor consulting skills is the candidate who puts off making a diagnosis or making clinical decisions, thus running out of time in the consultation for going through the management options properly.

• Interpersonal Skills

Good interpersonal skills should run throughout the consultation. The candidate should show an interest, even a curiosity about the patient that is non-judgmental and caring in nature. He/she should be able to achieve a working relationship quickly and pick up the patient’s agenda early (‘connecting’ with the patient). If the patient does not appear to understand, the candidate should pick this up and reformulate explanations. Candidates who perform poorly in this domain tend to be doctor-centred, and while they may elicit patient concerns, they do not address or explore them properly. Explanations are poorly adjusted to the patient’s level of understanding, and there may be inappropriate use of jargon. Occasionally, candidates are too patient-centred, agreeing to everything the patient requests, to the detriment of the clinical outcome.

 

These observations are summarised in the table below. Trainers may find the table useful in systematically observing their trainees consult, particularly for those registrars who are re-sitting the CSA or on extended training.

 

	Passing 🙂	Failing 🙁
General Features	Fluent, interactive and relevant Is able to take patient into medical world as a shared partner Open about lack of knowledge or certainty and may use this constructively Active monitoring during consultation	Poor use of time Uneasy with or unable to acknowledge own ignorance or uncertainty More scripted summary than checking understanding Unaware of personal space
Data Gathering	Can take a focused history that includes all relevant information Embedding of questions in previous response	Formulaic questioning which can become interrogative Repetitive questioning Sequence of questions does not make sense
Clinical Management	Appears knowledgeable and refers to recognised algorithms or modes of practice Able to suggest solutions to problems or a range of reasonable management options likely to be agreeable to patient	Insufficient knowledge base, or ability to think of realistic and effective alternatives Fails to integrate and apply knowledge Puts off making clinical decisions or a clear diagnosis Doesn’t appear to grasp the dilemma if there is one
Interpersonal Skills	Connects instantly with patient Non-judgmental Interested in the patient Reformulates explanations using helpful metaphors Can meet patient half way – picks up patient’s agenda, accent, or cultural approach.	Doctor-centred/patient’s concerns not addressed Patronising Unable to explain effectively – may be wrong or not tuned to patient Inappropriate use of terms Over patient-centred to the detriment of clinical outcome

 

What are you waiting for?

Go and PRACTISE!

Consistent Practice make Perfect Action!

To Your Success,

Hema xoxo.

 

 

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