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This picture reminds me of my A& E posts at Leeds and Bradford where I learnt very valuable clinical points!
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What Will Our Examiners Say About The CSA Exam?
I thank Dr Simon Hall who has kindly send this article specially for You!
This information came from a Q&A system with the examinars on a Deanery CSA course.
CSA Examiner Feedback– Richard Adams, Bill Hall, Louise Riley as interpreted by Simon Hall. White Hart, Harrogate, 2nd May 2012.
DO
Read all the information provided before the patient enters the room
LISTEN
Understand the reason why the patient is attending today.
If you don’t you won’t recognise the issues and priorities in the case. When reviewing consultations with your trainer try stopping the recording when you feel certain you know why the patient has attended.
Does your trainer agree?
Use the 10 minutes you have wisely.
Digital clocks are provided in the exam but great interpersonal skills and data gathering will not be enough to pass if you don’t get to the correct management plan in place in time.
Avoid repeating yourself when data gathering or developing the management plan.
Have an Evidence Based Management Plan.
Make sure you review it with your trainer when reviewing cases together in preparation.
Explain and negotiate in order to share the management plan. You need to reference their agenda in doing so.
A shared management plan is not simply a list of possible options. If different options are available then some will be better than others. The doctor is there to help the patient to make an informed choice.
A short succinct summary then “is there anything else?” opened up a consultation by “encouraging the patient’s contribution” – but do this in the first half of the consultation NOT right at the end!
Get your management plan out in the 10 minutes perhaps with bullet points “from the way I’m thinking at the moment there are 4 things we are going to need to do” may work whereas a long list may not.
You should be starting this around the 7 minute mark at the latest. “it also helps if the management plan is the correct one!”
Do acknowledge your uncertainty if unsure but do decide on a diagnosis and treatment at some point.
Avoiding making a decision becomes obvious to all.
Avoid a rigid structure to “go with the flow” so if the patient says something important follow them but still try to keep the data gathering focused.
COTs are a useful framework for assessment but only help CSA preparation when used for teaching and development purposes. “why and how something needs further development” should be considered.
We may need a shift of emphasis to make sure we consider the management plans.
Pick up on cues such as changes in facial expression, responding with “you look, sound” etc for non verbal cues or perhaps echoing “special or strong” words and phrases.
Also look out for things that don’t quite fit. “These patients aren’t going to ramble on about grandma’s illness unless grandma’s illness is relevant, so be nosey especially if something doesn’t quite fit!”
HOUSEKEEPING
Nerves and anxiety will affect you but once a case is completed and if it hasn’t gone well then “it’s past, it’s history, move on”
Do what you normally do (so long as it’s sensible!) in your own surgery.
Don’t do things differently.
Don’t try to second guess what the examiner is looking for.
For example “if you are not a natural summariser then don’t start summarising for the exam in May [the next exam diet].”
A systems review checklist uses up valuable time and often fails to provide any further useful information if a proper history has been taken. It appears to be a pet hate of some examiners.
Any examination should be undertaken to the standard of a GP fit for independent practice. If an examiner says nothing when you move to examine the patient then the examination should be undertaken in a focused way.
If they give you an examination card then there is no expectation of undertaking an actual examination of the patient.
Listen to the feedback.
People are trying to help you.
Let them!
DON’T
Go immediately/ very early to expectations “two sentences in going to what are you worried about?” and “what do you want me to do about it?” there was no listening, no time spent, no rapport.
A candidate may appear “formulaic and over coached”.
The role players are briefed not to respond to such questions. Patients won’t either.
Avoid the use of formulaic phrases “what were you hoping we could do for you today?” after a patient tells you their livelihood and marriage are threatened because of illness.
The question “needs to sit in the right place.”
Use repeated summaries 3 or 4 times throughout the consultation- it is not being marked and though it may be useful to the candidate to collect their thoughts if nervous or flustered it uses up 10, 20 seconds each time.
A summary may close down the consultation if repeating in 2 minutes what had been gathered in the preceding 5 minutes. Again time is wasted. So “this is what I heard” without any elaboration in an attempt to demonstrate active listening brought a “what was the point?” reaction from the examiner.
It simply “switched the patient off and didn’t open up anything.”
The fact that the lack of a shared management plan is one of the commonest feedback statements doesn’t always mean that there isn’t a correct course of action in an urgent situation such as Chest Pain or 2 week wait.
The lack of a shared management plan feedback statement is commonly provided when a candidate “hasn’t uncovered the exact reason why the patient is there and understood them fully, where they are in their world and what is bothering them, so you can’t use that information to share a management plan.”
Repeating a phrase which initially seemed sensitive and empathetic such as “you look worried, I’m here to help” made it sound false and insincere.”sometimes you don’t realise they are formulaic until you hear it several times.”
Not listening because of following a rigid structure.A really bad example was a candidate who elicited the patient’s concern regarding chest pain and that their father died of a heart attack at the same age.They said okay but then asked what tablets they were taking because it was in their management plan to discuss medication next in their checklist.
Showing off your knowledge of the possible causes of a presentation may only serve to frighten a patient especially if it is a serious one.
Don’t continually defer to a patient’s wishes in regard to their management plan. They need to be directed, through negotiation, to make an informed choice.
You need to manage their blood pressure or treat their STI and not ask them what they think needs doing.
Don’t be too patient centred.
Asking them what they think of a particular treatment for a particular condition, such as steroids for PMR, comes across as the doctor not knowing what to do.
You must pass the lie detector test to avoid looking insincere.
Look at some of your consultations.
Do you appear interested and concerned?
Are you too doctor (or patient) centred?
Do you appear empathetic and sensitive?
Does the examiner believe you?
To add a brief anecdote.
I was told by one candidate who failed the exam several times. They received loads of different pieces of advice telling them to do this and not to do that and then on the day of the exam, time after time, they froze.
Eventually they were told to forget all the advice they had been given, to consult as they would do normally BUT at 6 and a half minutes in to the consultation to move onto the management plan.
So at the last attempt they consulted naturally, delivered the management plan and passed by 10 marks…
Dr Simon Hall
2/5/12
Hi Friend!
Me Again!
I thank Dr Simon Hall from the bottom of my heart for sending this article JUST FOR YOU & YOUR SUCCESS.
Thank You, Dr Hall.
What are you waiting for?
Start Practising from Now!
T o Your Success,
Hema xoxo.
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