A Confucian approach to the interpersonal domain of the CSA

The second in our series from GP training programme director Dr Nigel Giam looks at behavioural indicators - and explains why empathy is not an act.

In this article I will look at some of the recent highlighted statements for failing around the interpersonal domain of the CSA.

Let us start with a quote: ‘Do not worry if others do not understand you. Worry if you do not understand them.'

Confucius was a Chinese philosopher of the Spring and Autumn Period. His philosophy emphasized personal morality, correctness of social relationships, justice and sincerity. Do these ‘behavioural indicators' sound familiar? Hopefully by the end of this article you will see the link and know exactly what is being looked for by examiners in the CSA, but more importantly by the patients you consult with every day.

The Interpersonal Domain – looking at statements 11-14

Reasons for failing:

11) Does not appear to develop rapport or show sensitivity for the patient's feelings

12) Does not identify patient's agenda, health beliefs & preferences

13) Does not make adequate use of verbal and non-verbal cues. Poor active listening skills.

14) Does not identify or use appropriate psychological or social information to place the problem in context

Behavioural Indicators – ‘One look is worth a thousand rumours'

Before detailing what it is that you are actually being assessed on, take a step back and think about a real-life consultation that went well and one that went badly. What can you recall about your ‘behaviour' in both of these consultations? Were you happy? Were you frustrated? And more importantly how do you think the patient perceived you to be?

It is very important to remember that your assessment in the CSA is based upon the examiner's perception of behavioural indicators. How you present yourself is of paramount importance. Two candidates can go into the CSA and say more or less the same thing, but one may do well and the other may not.

Why is this? Well, consider that it is not all about what you say, but how you say it. There is a famous Chinese proverb which goes ‘One look is worth a thousand rumours'. How often have you engaged or reassured a patient with a warm smile, as opposed to a limp handshake or superficial acknowledgment of the presenting complaint? Or perhaps recall a job interview where you felt you said all the right things but did not make the shortlist.

Presentation is key. The CSA and indeed consultations in real life do not generally fit into neat tick boxes. Doctors who can display self-awareness, sincerity and see the exam as being a real clinic, where you are talking to real patients, indeed see it at a very basic level as one human being conversing with another, are more likely to succeed than those who have pre-determined set responses to what they perceive to be artificial scenarios.

There are many ways in which we present ourselves and how we interact in everyday life. The challenge of the CSA is finding your way – a consultation style that is natural and individual to you as well as being focused on the challenge at hand. There is no one-size-fits-all approach!

Take the example of breaking bad news. This is something as doctors that we all have had to do in our working lives. It is of course a difficult consultation under normal, everyday circumstances, but with the anxiety of being scrutinized in the CSA, rigid behaviours can often surface.

Recently I had to tell a patient of mine that he had a recurrence of renal carcinoma and that it had spread to involve his liver. With the result of his scan in front of me, I did not immediately ask what he expected the result to show or if there was anything he was worried about, because this would have seemed unnatural and would have been asked out of context. However I frequently observe this undertaken by ST's on my CSA course.

The responsibility for breaking the bad news and the support that needs to be given immediately after relaying such news lies with me as the doctor. I did not ask these rigid questions because there is no ‘tick' in real life for doing so in such a scenario. Indeed, there is no tick in asking these questions out of context in the CSA (see statement 12).

Remember that to be assessed on breaking bad news, you do actually have to break bad news! No one else is going to do it for you. A warning shot is almost always necessary, but don't waste time fishing for ‘Ideas, Concerns, Expectations' out of context, because from a CSA point of view a patient is highly unlikely to respond by saying ‘Oh yes doctor, my concern is that the cancer has come back and my expectation is that this is going to be bad news!', thereby abdicating you of any responsibility.

Success in the CSA depends upon self awareness. I recall an anxious final-year medical student preparing for OSCE's and asking me how he could best fake an empathic response for a breaking bad news station. My response to the student was that empathy is not an act.

I asked him to put himself into the patient's shoes and consider how he would feel if about to be given a diagnosis of metastatic renal cancer. Rather than trying to hand over responsibility over to the patient, put yourself in the patient's position.

What would be the first thought that would enter his head? Now - what would yours be? Who would be the first person you think of? Your partner? Your children? Your family? Would you cry? Would you feel helpless? Consider your patient breaking down at the revelation that his cancer has returned, perhaps becoming a child in need of nurturing and support.

Now consider - how would you want your doctor to be with you? Would you want them to be supportive, empathic and caring? To spend as much time with you as needed? Or would you want them to immediately start talking at you, rather than with you, with regards to two-week waits and referrals.

What would Confucius advise? ‘What you do not wish for yourself, do not do to others.'

So what happened with my patient? He broke down into floods of tears. How did I respond? By letting him know that I was there for him, by being sincere and knowing what I would want if I were in his position. Although he was many years my senior it was clear that he became a child in need of nurturing, and I needed to take on a caring, supportive and parental role. We sat in silence for several minutes, but it was a comfortable silence and it was clear by the end that he knew that I would support him and help him find a light in that moment of utter darkness and despair. How you do that is up to you and ultimately it is the challenge you will be assessed on in the CSA.

Not all us are stage actors. In real life, empathy should come naturally. If it does not then consider if that is that a reflection of the patient, the situation we find ourselves to be in or perhaps something much closer or personal. Addressing the patient's agenda is key in passing the CSA. However eliciting the agenda takes skill and will not be attained by simply asking what a patient's 'Ideas, Concerns and Expectations' are out of context.

Dr Nigel Giam is the course director for Mentor MRCGP preparation courses – www.passmrcgp.com for more details.

He works as a GP and a lecturer in medical education. He is a Senior OSCE examiner and tutor of general practice at Kings College School of Medicine and Imperial College School of Medicine. He is a Programme Director for the St Mary's VTS, and has worked as RCGP course organizer.

This is the second instalment in Dr Nigel Giam's multi-part series to Passing the CSA. Please click here to read the full series.

Or you can access the first and third instalments directly.