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May 2007: Focus on the three domains for the clinical skills assessment exam

What will the CSA be like for candidates?

What is the most effective way to prepare?

How will the CSA be marked by assessors?

What will the CSA be like for candidates?

What is the most effective way to prepare?

How will the CSA be marked by assessors?

?The clinical skills assessment (CSA) component of the nMRCGP is the aspect of the membership exam that has undergone the most change. The RCGP states that the CSA is ‘an assessment of a doctor's ability to integrate and apply clinical, professional, communication and practical skills appropriate for general practice'.

The CSA is therefore more than just a test of communication skills in a clinical setting. It is a more complex assessment of a doctor's ability to sift relevant information, apply learned understanding of disease processes and make appropriate evidence-based decisions in a patient-centred manner. Clearly, candidates will need good communication skills to achieve all of this.

The Postgraduate Medical Education and Training Board (PMETB) has stipulated that all cases must be based on the PMETB-approved GP Curriculum.1

It is anticipated that cases will sample areas across this wide-ranging ‘definition' of general practice.

The CSA 'goes live' for the first time in October 2007 and is expected to run over several weeks, three times a year, at a temporary base in Croydon, pending the building of a dedicated assessment and training centre probably in around five years' time.

What is likely to happen on the day?

The temporary assessment centre will be located on the top floors of a large office block next to East Croydon station. It will have purpose-built consulting rooms and a pre-assessment waiting area. A senior assessor and members of the administrative team will ensure that candidates are sent to the correct rooms. Candidates will remain in one room for the whole assessment, effectively as if they were working in a busy, stressful, observed surgery at the training practice.

Each candidate will have 13 appointment slots, one of which will be a 10-minute rest station. Each of the 12 cases will be strictly time limited to 10 minutes, and a starting bell or whistle will sound to indicate that the role player, assessor and occasionally an observer are about to come in. The assessor and any observer will sit to one side, observing but not interacting with the candidate. They will not talk to each other, but will be marking and taking notes.

Once the timed 10 minutes is up, another bell or whistle will sound: at this point the role player will stop and leave.

Between each case there will be a standardised minimal break before the next bell sounds and the next role player knocks on the door.

Information in the form of relevant case notes will be on your desk for each case. Take good note of these and use the time between cases to read them rather than reflecting on the case you have just seen.

Each case is observed by a different assessor who will have no knowledge of your performance in the previous 10 minutes. Individual marking sheets will be collated and grouped together at the end of the assessment session.

You will not get your results on the day, but the results and feedback about your performance in writing will subsequently be sent to you by the College.

All the cases are played by professional actors who will have rehearsed their role in advance and run through extensive preparatory notes, as well as receiving lengthy guidance on the day from the assessor(s) they are working with.

What sort of cases can I expect?

You can expect a wide range of physical, psychological and social problems, all mapped from the extremely broad GP Curriculum.1 Common low impact medical conditions such as cough, urinary tract infection, earache and high blood pressure are likely to be encountered, as well as rarer but high impact conditions including presentation of cancers, serious acute illness and possibly end-of-life decisions. Ethical dilemmas will clearly feature – we all still struggle with competency issues and confidentiality, so expect the exam to test doctors in these areas.

What will the assessors be looking for?

Each case will be marked in three domains (see box 1,attached).

All three domains will have equal weighting on each case, and grades will be awarded for each case as:

•Clear pass

•Marginal pass

•Marginal fail

•Clear fail

•Serious concerns.

Breaking each domain down to basics, it can be seen that:

•Domain 1 (data gathering) is essentially about taking a structured, focused history, with good GP examination skills.

•Domain 2 (clinical management) is basically about flexible primary care management of the presented problem(s).

•Domain 3 (interpersonal) is clearly about good person-centred communication, based on the patient's own ideas, concerns and expectations.

How best to prepare for the CSA exam

There is no substitute for sound preparatory work based on the best material available, namely the real world of general practice in which you already work.

Your GP trainer will be invaluable, particularly if you can both look at videos of your consultations or perhaps ask your trainer to observe you consulting with the stated objective of looking at the three CSA domains. These three areas are central to the way GPs work and so should come naturally.

Revision books tailored to the CSA exam are not yet available. However, exam preparatory courses will quickly adapt to the nMRCGP. The RCGP is looking at the types of material that will be made available. This will probably include some specimen cases.

Course organisers and your colleagues in revision groups2 can also provide support. Role-playing of cases might not be popular with everyone, but is the best way to understand the processes involved in the CSA. Why not do this in your revision groups? One of you needs to think about and then act out the role of a patient you have recently seen, with a colleague taking the part of the candidate while other peers observe. Those of you observing need to check that all three domains have been adequately addressed.

The Wessex Faculty of the RCGP has produced a DVD specifically aimed at preparation for the CSA, in which doctors consult with role players (see useful information for details on how to obtain the DVD).

A workbook commenting on the performances in relation to the three CSA domains accompanies the DVD.

The bottom line is to think about what you need to demonstrate – three core areas are being marked and are the central tenets of the way we should conduct a consultation. The GP registrar year is the ideal opportunity for learning the skills necessary to achieve success in the CSA.


Dr Chris Elfes
GP, Swanage, Dorset, GP trainer, MRCGP examiner, nMRCGP assessor

Key points CSA Box 1 Box 1: The three domains for marking CSA cases Useful information CSA Useful information

nMRCGP – A guide to the Clinical Skills Assessment DVD
This DVD contains specific guidance, together with sample cases, for all doctors teaching or preparing for
the new CSA of the nMRCGP.
To order a copy, contact:
Carol White,
Wessex Faculty RCGP,
Andover War Memorial Hospital, Charlton Road,
SP10 3LB
Tel 01264 355013

CSA Box 2 Box 2: Specimen case nMRCGP proposed timetable

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