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Faking it

In the ninth part of her series on how to pass the nMRCGP, Dr Una Coales outlines the different skills required for assessing actors rather than patients in the CSA exam.

In the ninth part of her series on how to pass the nMRCGP, Dr Una Coales outlines the different skills required for assessing actors rather than patients in the CSA exam.

Now that you have mastered how to minimise perception bias of appearance, cultural differences and speech, let us focus on the rest of the CSA exam - the actors, the examiners and the setting for a complete 360 ° assessment of the CSA exam itself.

• The actors are NOT real patients. The FRCS, MRCS, MRCOG, MRCP, MRPCH and DCH postgraduate medical exams all use real patients for their examinations. The nMRCGP is the only exam which employs actors. Does this make a difference? Absolutely! When an actor presents with red eyes, do not assume this is the case before you. It simply means the actor did not get much sleep the night before. He is not wearing customised red contact lens to mimic red eyes. Let's try again.

• When you perform a BP on an actor and the BP reading is high, this is NOT the case being tested. The actor cannot mimic high BP, and nor was he chosen for the role play because he happened to have an incidental finding of high blood pressure. So what do you do? You may hope that the actor says ‘That is not required for this station', or that the actor or examiner gives you a card with the correct BP reading for the station. Or else you may remain flummoxed as you feel the actor should be advised to see his own GP for further discussion of his BP and management.

• When a actor patient presents with a history of thyroid disease but has no goitre or exopthalmos when you glance at your healthy actor patient, remember she may still have ‘a goitre and bulging eyes.' So ask permission to examine her and hope you are handed a card which confirms or refutes any imaginary physical findings. Do not rely on your visual senses.

• When a actor patient presents with a history of PCOS and yet is not obese, hirsuite or sporting acne, remember to ask to examine the patient and hope that a card will reveal whether the patient is obese with facial hair and/or acne. The difficulty is that your senses, intuition, and experience tell you that the patient before you does not have PCOS, but you are supposed to ‘role-play' as though the actor does, even though the actor knows nothing about this condition, save what she was briefed that morning. This is where the most experienced clinicians face difficulty with CSA. They rely on years of experience of assessing a patient's appearance (unwell vs well), manner and demeanour, skin pallor, icteric sclerae, quality and strength of pulse, temperature of skin on touch, quality and rate of speech combined with respirations, use of accessory muscles of respiration, and so on and so forth ,and combine all these cues to help reach a working diagnosis. All these clinical tools are absent in the CSA when using healthy actors.

• When a actor patient discusses knee pain and yet you glance at his knee and it is perfectly shaped, remember to ask to examine the knee and hope to receive a photo or a note describing an abnormal knee. The difficulty may then be to examine the abnormal knee in the photo with an actor and his normal knee. You cannot elicit knee clicking, popping or crepitus. I suggest using the ‘willing suspension of disbelief'.

• When you book, select a morning over an afternooon session. The actors and examiners arrive early to be briefed and rehearse one role-play to be enacted for the entire day. That is 26 times role-playing the same case for one actor (13 times in the morning and 13 times in the afternoon), and it is 26 times for one examiner to observe and mark the same case over and over again. You got it! Acting and marking fatigue. Can we really rely on the actor remembering every sentence of his script on the 26th take of the role-play or the examiner to remain attentive the 26th time he observes the same case? Better not take any chances, click the am session.

• What about choice of day for your CSA? Well how would you feel at the end of a week of examining or acting, to then be told you had to come into work on a Saturday? Who likes to work on a Saturday? Better sign up for a Monday or Tuesday am CSA session.

• Perform a basic GP exam. Some stations are assessing your clinical examination skills. Then how is it that GPs with years of surgical or medical experience, MRCS or MRCP are failing their CSA? What was tip number one? The actors are NOT real patients. So when a GP with MRCS conducts a proper shoulder exam, with the Neer test, Apley scratch test, Hawkins test, empty can test, etc., the actor can only look baffled, as he has not been briefed how to respond other than to a basic range of movements of the shoulder that he learned that very morning. After your exceedingly thorough examination of his shoulder, you too are perplexed, as you are unable to distinguish between supraspinatus tendinopathy, rotator cuff tear, etc., as the physical finding responses given by the actor may appear nonsensical. So stick to a GP examination, and discard your specialist knowledge for 1 day.

• Read the free RCGP Curriculum online which lists all the cases that may be tested. Cases discussed above are from their respective curricula under learning outcomes for women's health, rheumatology/ musculoskeletal and metabolic problems.

Dr Una Coales: Assessing actors rather than real patients requires a different set of skills Dr Una Coales: Assessing actors rather than real patients requires a different set of skills

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