Matt Smith

What are the odds?

The February to March 2015 CSA

Pass rate for first time applicants was 78%

3 main reasons for failure(1) Does not recognise the issues or priorities in

the consultation (e.g. 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 plan

The 3 areasData gatheringManagement plan (most important)Interpersonal skills

Data gathering• Does not assimilate the written material provided

e.g. misses the fact that tests are abnormal (or concentrates on the wrong one!

• The first intervention is a semiclosed question• The doctor interrupts and breaks the story telling• Cues are missed• Failure to gather psychosocial information i.e.

home life, workplace, caring responsibilities, community etc

• Failure to find out what the patient’s thoughts, fears and hopes are

Data gatheringTries to be comprehensive rather than

appropriately selective e.g. does systems review, orders batteries of tests

Misses red flagsFails to examine competentlyFailure to get to the diagnosis e.g.

Depression

Management planTime pressure – don’t even get this farBecome doctor centred and ‘deliver’ the planFailure to give options and negotiateFailure to take account of patient’s thoughts,

fears and hopes (particularly so when they have not been obtained....)

Best medical practice is not followed

Management planToo superficial Inability to manage risk safely, safety net

appropriately etcMuddles data gathering and management

e.g. starts asking for more data in the management part of the consultation

Does not come to a shared management plan

Interpersonal skillsPoor rapport buildingMissed cuesConsultations are formulaic and woodenDoctor centred, not patient centredUnable 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.......”

An example from a recent mock CSAPatient says - “I feel so depressed I’ve

thought about ending it all….”GP Registrar replies “Oh right. Had you

thought what might be wrong and what worries you?

How to fail the CSA!

The different types of failing registrar

Under prepared or badly preparedGo to pieces on the day

(1) Go underprepared – wing it!Plan to use a good consultation structure on

the dayForget all this stuff about basic knowledge &

evidence based practice Don’t worry if you can’t apply knowledge and

skillsStick with 15-20 minute appts at work – you

will be fine speeding up to 10mins on the dayGO on LOTS of courses – much better than

seeing patients

(2) Ensure you are poorly preparedDo the minimum number of COTsDo lots of COTS but no video skills or sit & swap

surgeries relating to CSA performanceKeep focussing on ICEing the patientsDon’t worry about using time effectively e.g. moving

the patient along, closing the consultationMake sure you have a small supply of stock formulas

and phrases to useRemember you may already KNOW the case (seen it

before on the course)Join a CSA group late, meet infrequently with no

strategy and ensure the group is homogenous e.g. all male

(3) Go to pieces on the dayMake sure you read the notes of the patient

who has just left, the one you just mucked up, not the one who is about to come in!!

Try to interact with the examiner (they are pretending to be invisible, so try really hard)

Go on the day, drive to Euston, misplace your ID at the hotel, take your old BNF with all your crib notes (which is then taken away at the start of the exam), don’t worry about checking your equipment, PARTY the night before!

Key messagesTreat every new patient or review patient

coming with a new problem as a CSA caseExperiment with consultation skillsEmbed your consultation modelWork on moving the consultation alongDevelop your options list for common medical

conditions and ‘spinning options’ to achieved shared management

Work your Trainer!Work your CSA group