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Independents' Day

My experience of clinical skills assessment

The CSA may be new to the RCGP but has been used for a number of years in Canada and North America. MRCGP examiner, Dr Glen Sykes, who sat the exam in Canada a few years ago describes what to expect

The CSA may be new to the RCGP but has been used for a number of years in Canada and North America. MRCGP examiner, Dr Glen Sykes, who sat the exam in Canada a few years ago describes what to expect

The CSA (Clinical Skills Assessment) is one of three parts of the nMRCGP, the other two being the Applied Knowledge Test and the assessments that make up the Work Place Based Assessment.

The CSA is likely to represent the greatest challenge of the nMRCGP and much as the orals do in the current MRCGP exam, it is likely to generate considerable feelings of fear and trepidation in a number of candidates.

The concept of the CSA in the UK is a relatively new one and I think it is fair to say that the CSA( as part of the nMRCGP)is a developing process and is likely to involve a steep learning curve for both candidates and examiners.

The intention of the CSA is to reasonably represent real life situations presenting in day-to-day general practice, for example dealing with common clinical scenarios, breaking bad news, dealing with angry or drug seeking patients.

Using specially trained actors to take the part of patients, the examination will consist of a number of ‘stations', each lasting ten minutes. The candidates will be expected to stay in the same room while simulated patients (role players) accompany their CSA Assessor and rotate around the circuit.

The Canadian CSA

A few years ago I contemplated a move to family practice in rural Canada and as part of the process I was required to undertake a CSA in Canada. The assessment consisted of 14 stations, eight of which were ten minute patient encounters and six of which were five minute patient encounters, coupled with a five minute written exercise.

While the concept of the CSA is relatively new within the United Kingdom, it has been used for a number of years in North America and Canada. In the US and Canada standardised patients (SP's) are professional actors who are taught to mimic a number of signs and symptoms and role play the part of patients. These role players tend to become extremely experienced in the role and are very convincing. Indeed, so much so that the role player contributes to the evaluation of the candidate and has a bearing on the overall mark that the candidate receives! In the UK there are no such plans at this time to introduce similar input, however, this may change in future .

My ‘patients'

Examples of some of the stations I encountered during my CSA experience included;

• a 45 year old with asthma who had noticed a marked deterioration in his symptoms following the prescription of beta-blockers for newly diagnosed hypertension by a doctor whilst on holiday

• a 63 year old with diabetes requesting sildenafil

• an 84 year old lady who collapsed in my waiting room and became unconscious (the only clinical information provided was that her pulse was 44/minute-leading me into a discussion surrounding ECG interpretation and management of complete heart block- possibly an unlikely scenario for the nMRCGP!)

Essentially, after each case I was left with the overwhelming impression that I could have done better and inevitably there was a slightly artificial and surreal feeling to the whole experience . There is no doubt that the presence of another doctor within the consulting room, sitting with a clipboard, appearing to hang on your every word, ticking off things on a list, did alter the dynamics of the consultation. Nevertheless, I believe the concept of the CSA as an assessment tool is a useful one.

Tips for success

I believe a number of simple steps may well be beneficial in preparing for the CSA:

1. Read the instructions provided for each case carefully.

2. Be polite and patient centred, remember you may well earn marks simply for introducing yourself in a correct manner.

3. Practise a number of different common general practice scenarios, which are likely to come up, preferably in groups. In my own case lack of preparation was evident. I found in some cases I was finishing too early and sitting for periods with an uncomfortable silence and yet in other stations I was running out of time. I believe courses will inevitable pop up over the next 12 to 18 months, which will allow candidates to be better prepared for the CSA.

4. There are a lack of UK books to help with CSA preparation but a number of US books can be obtained from internet sources, such as Amazon. Whilst these are not ideal in the preparation for a British post-graduate general practice examination they are still useful in my opinion.

5. Remember the CSA is not only a test of what you know but also how you apply it. Listen carefully, don't lecture patients, don't hurt or embarrass anyone, try to get slick at performing focused physical examination within the confines of a ten minute assessment. This may seem like common sense but it is worthwhile practicing on a regular basis.

6. Expect to be nervous on the day. Regular practice sessions may help prior to the actual exam. Don't be too depressed if you leave the examination with the feeling you could have done better. My suspicions are that most candidates will feel this way and inevitably the post examination discussion with fellow examinees will no doubt uncover areas you either missed or did not fully identify at the time.

7. Finally, whilst the CSA forms an essential part of the nMRCGP it may be worthwhile bearing in mind that it is not impossible that all practising doctors in the country may at some point in the future find themselves being subjected to this type of assessment.

I anticipate that very much like the oral examination in the MRCGP examination, the CSA examination will become the most feared and potentially difficult component of the nMRCGP examination. Careful preparation and practice are likely to be the key to passing .

Dr Glen Sykes is a GP in Greenock, Scotland. He is an MRCGP examiner and sits on the RCGP's CSA case writing group.

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