Why do registrars fail the CSA? - CityandHackneyTrainersWorkshop

The CSA:
How can my ST3 fail?
Trainer’s workshop
Nov 2012
The CSA exam: Standards
Why failure happens
How might we avoid this?
A CSA case
CSA data
3000 candidates pa
► Pass
► UK
rate ~ 70% (75 first time)
Grads ~ 80-90%
► Mean
score ~ 80 (Max 117, range 40-110)
The CSA: aim
“to assess a doctor’s ability to
integrate and apply
appropriate clinical,
professional, communication
and practical skills in general
► 13
► 10
minutes each
► Hugely
varied content “representing the
range and diversity of cases seen in General
The three domains in each case
► Data
gathering, technical and assessment
► Clinical
management skills
► Interpersonal
The three domains
Four possible
Clear Pass
Clear Fail
► Each
grades for each domain
3 marks
domain counts equally!
The generic descriptors
► http://www.rcgp.org.uk/gp-training-and-
How good is good enough?
► http://www.rcgp.org.uk/gp-training-and-
The four types of failing registrar?
► Not
cut out for the job
► Underprepared
► Go
to pieces on the day
► Badly
Lessons from the shop floor
► How
good registrars fail…
Rigid or Formulaic
► “I
WILL show empathy and ICE everyone”
► “I
am concerned re my breast lump”…”anything
else you’d like to discuss?”
► Prevention:
Emphasise flexibility, spiral consulting
and patient centredness
► On
the day: Stay with the patient
Over cautious
► “As
long as you’re safe you’re OK”
► “I’ll
refer you to dermatology for that slight itch…”
► “I’ll check with my senior colleagues and get back
to you”
► “Let’s do a million blood tests, just to be sure”
► Prevention:
Do good, appropriate general practice.
► On the day: Make a decision.
Patient led, not patient- centred
“As long as you’re nice you’re OK”
“The patient didn’t want me to call 999”
“I didn’t do anything about his arthritis but I was
terribly understanding”
Prevention: Know and implement NICE Guidance
Developing skills in negotiation/challenge
On the day: Up to date management must be
Case spotting
► “This
must be the Gillick competence station”
► “I mustn’t give a sick note”
► “I mustn’t prescribe codeine”
► “I must get patient to accept LARC”
► Too
many courses/books
► Prevention:
Do lots of real General Practice
► On the day: Stay with the patient
Time Keeping
► “I
didn’t get round to making a plan, taking
a history took too long..”
► Prevention:
► …and
Time keeping skills for CSA
for life
► “I
messed up that chest pain station…it all
went wrong after that”
► House
► …and
keeping skills for CSA
for life
How can we help?
► In
► Think
► How
about the reasons for failure
can we help? Practical steps to share
As trainers - how can we help?
► Be
familiar with the exam and how it is
► Offer
feedback on each domain, be a hawk!
► ‘Diagnose’
your registrar’s particular
Key messages
► As
a trainer we are expert!
► It
is their assessment not ours….
What’s going on here?
► http://www.youtube.com/watch?v=Jb71-
► GP
registrar patient centred consultation
► http://www.youtube.com/watch?v=Jb71-
Norman Price
55 year old man
Financial advisor
2/52 ago saw another GP in practice:
“Trouble passing urine, frequency. MSU NAD. For bloods”
PSA: 3.1
Random gluc: 5.2
3/12 ago: BP 132/73
9 years ago: tension headache
► http://guidance.nice.org.uk/CG97/QuickRef
Data gathering problems:
Failure to…
► Gather
psychosocial information ie homelife,
workplace, caring responsibilities, community
► Pick up on cues
► Establish the patient’s thoughts, fears and
► Resist interrupting
► Avoid early closed questions and assumptions
► Reach agreed shared understanding of the
Data gathering problems:
Failure to…
► Assimilate/interpret
the written material
► Be appropriately selective e.g. does systems
review, orders batteries of tests
► Get to the diagnosis e.g. depression
Management plan problems:
Failure to…
► Get
this far due to time pressure
► Be patient centred and give options and
► Take account of patient’s thoughts, fears
and hopes
► Follow best medical practice
► Manage risk safely, safety net appropriately
Interpersonal skills
► Poor
rapport building
► Missed cues
► Consultations are formulaic and wooden
► Doctor centred, not patient centred
► Unable to summarise, empathise, state
what they are seeing “You seem upset
about that”
Comment from a GPST after
completing a recent mock CSA
► “I
don’t know what went wrong – after all I
ICE’d all the patients.......”
Another example from a recent mock
► Patient:
“I feel so awful I’ve thought about
ending it all….”
► ST3:
“Oh right. And is there anything
else you’d like to talk about today?”
Consultation Models
► Pros:
give structure to the consultations and
remind the registrar about key areas
► Cons:
can be formulaic rather than natural,
may use up too much time if not focussed
What are the most common
feedback statements?
(1) Does
not recognise the issues or priorities
in the consultation (eg the patient’s
problem, ethical dilemmas etc)
(2) Does not develop a management plan
(including prescribing and referral) that
reflects knowledge of current best practice
(3) Does not develop a shared management
As trainers - how can we help?
Observed consultations, videos, (COTs), joint
Feed back on all three domains
As trainers – how can we help?
► Time
management skills – early on
► Housekeeping
► Know
when to draw the line!
Key messages
► Avoid
formulaic communication skills
► Listen to the patient
► Ensure psychosocial aspects are considered
► Remember to make an appropriate, shared
management plan
► Keep open mind, deal with what is brought
by case on the day. Do not case spot!
► Do good general practice