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Navigating the CSA - a Costly Stressful Anti-climax?

Our 'GP to be' registrar blogger Dr Syed Arfeen explains how he made it through the dreaded CSA exam.

Our 'GP to be' registrar blogger Dr Syed Arfeen explains how he made it through the dreaded CSA exam.


With an upcoming round of the tri-annual MRCGP CSA examination, approximately half of my GP registrar colleagues will be looking up and feeling a dark heavy cloud descending over them for the next few weeks.

Having suffered from the same and successfully navigated my way through to clearer post-exam skies, I thought a few words consisting of a combination of my subjective experience mixed with an attempt at an objective analysis may be timely. Some will already have read the highly recommended articles on Pulse by Dr Nigel Giam, which contain a more assured dissection and analysis of exam than my small account here, and which should be used as a compass to guide revision through the storm.

For those to whom the exam is imminent, the format will be only too familiar - for those in whom it is a little more distant it may not yet be. In essence, it now consists of 13 simulated patient consultations not dissimilar from a normal GP session. The cases of course are screened to be of a little more relevance, depth and complexity than perhaps may occupy a normal morning, but only to draw out the skills from the candidate - it is useful keep this in mind, especially when faced with the third type of case alluded to below.

So how did I find it? The exam itself was much same as every other medical clinical exam I have done. So the cases were a usual mix of ‘Ah, I was expecting that, nailed it!', ‘Hmmm, I'm pretty sure that was what I was supposed to do' and ‘What the %&$! was that about?'

Similarly, the sitting itself began with an initial wild sympathetic nervous system response that almost rendered organised thinking impossible, countered by an over-careful checking of time and patient briefs that gave way by station three to a homeostatic response that got me ‘in the zone' prescribing here, reassuring there, negotiating always.

However, by station eight a second self-doubting head of ‘I can't believe I seem to know what to ask, examine and prescribe; can I really be doing it right?; What does that actor's smile mean - sympathy, friendliness, a clinical sign?' appeared which distractingly hung over me untill station 11, when it melted away at the excitement of seeing the finishing line, which helped make a last big push through the hunger and fatigue to the end.

However, there is a one thing (ok, three things) that make this exam very different from all the other medical exams – and they are in each station:

1. The need to acknowledge the patient's underlying agenda/reason for attendance/ICE/health belief/motivation

2. The need to acknowledge the uncertainty of the situation with regards to the illness per se

3. Then to negotiate a plan that accepts and satisfies, both safely and yet meaningfully.

All of which is easy to say, but hard to do. But given that this is the essence of the exam and the art of general practice there is no way around it and also no way around the only way to develop them - by practice, both in real consultations and artificial role-plays.

Good luck!

Dr Syed Arfeen is a GP registrar at the Emperor's Gate Surgery in Kensington, London.

Click here to read more from the GPs to be Dr Syed Arfeen Passing the CSA

For further reading and advice on how to tackle the exam, check out Dr Nigel Giam's exclusive series for Pulse: 'Passing the CSA'.

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