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Tips on how to pass the CSA

In the third of her series on getting through the nMRCGP exams, Dr Una Coales turns her attention back to the CSA module and gives some crucial advice on how to avoid being too egocentric!

In the third of her series on getting through the nMRCGP exams, Dr Una Coales turns her attention back to the CSA module and gives some crucial advice on how to avoid being too egocentric!

The next CSA exams run from May 7-20 of this month and word is that many will consist of re-sits from the Jan/Feb CSAs. The examiners will be on hand to assess whether these GP specialist trainees are fit to practice and receive their CCT license or not. There will also be the handful of trainees who have put off their CSA exam to this final May sitting in their ST3 year.

The number one reason for failing CSA is being too doctor-centred. What does this really mean? The analogy I often use to demonstrate this is the ‘waiter in a restaurant' scenario. Have you ever heard a waiter approach your table and declare, ‘I think you should start with the Caesar salad. Then you will have salmon and potatoes. And for pudding, we will order you the crème brulee. Is that okay?'

This usually gets peals of laughter from the audience and yet this is how hospital doctors speak. Patients would not dare challenge a surgeon regarding a recipe to take out an appendix. However being a GP is more about shared management or empowering the patient so that he can understand his illness and is competent to be involved in decision-making regarding the management of his condition.

So how do GPs become more patient-centred?

• Never use the word ‘I' or the royal ‘we' Have a go. Try to speak for 10 minutes without referring to yourself and your ego. When doctors use ‘I' repeatedly, it gives the impression of arrogance.

• Neutralise your speech. Use the gender-neutral pronoun ‘it.' ‘It may be an idea to…'

• Do not talk more than your patient. Running monologues are not permitted. If you talk and talk and talk, then YOU are the centre of your universe. Professor Steve Field, the chairman of the RCGP and former deputy video examiner advises that the ‘patient should be the centre of your universe.'

• Share in the dialogue. You speak for 1-2 sentences, and then the patient speaks for 1-2 sentences. This gives the impression of a shared 50:50 doctor-patient interaction.

• Customer service with a friendly smile. Yes, we must smile and not look stern at our patients. A stern look may be misconstrued as cold-heartedness. A genuine smile is warm, welcoming and endearing.

• Treat patients with respect and courtesy, as you would have them treat you.

• Educate the patient without jargon so that patients may better understand their conditions and be empowered to share in decision-making.

• Treat patients like adults and not children. Do not dictate to your patients. Offer your patients options/choices. ‘The options are 1, 2, 3. What would you prefer?' Good, you are now sounding like a waiter, patient-customer-centred.

• Do not lecture to your patients. After assessing motivation, If they are not ready to quit smoking, respect their choice and offer help when they are ready. Do not nag them to death!

• Avoid jargon and grandiosity. Not all patients have a university degree. Keep language simple and you may draw a basic diagram to illustrate better. Patient leaflets on give examples of how to explain various conditions in layman's terms.

• Do not argue with your patients! This warrants a clear fail. If it has reached this dysfunctional point, stop, and step back. Apologise and ask again ‘what were you hoping I could do for you?' And ultimately, give your patients what they want, unless it is unlicensed, addictive and dangerous!

Examples of doctor-centred speech and corrected patient-centred speech.

• ‘You will have a 12-lead ECG.' Rather ask ‘would you like me to arrange a heart tracing?'

• ‘Over there and get your kit off!' Rather ask ‘may I examine you please?'

• ‘I would like to start you on this anti-hypertensive drug.' ‘Rather ask ‘Would you be happy to start a tablet to lower your blood pressure?'

• ‘I will see you next week'. Rather ask ‘may I see you next week?' as they may be going on holiday next week. It is arrogant to presume they are free to see you at your will.

Tips on how to pass the CSA About Dr Una Coales

In 1993, as a US surgeon, I sat my first ruthless UK postgraduate exam, the PLAB exam with its 5-modules, fail one module, re-sit all policy. I made a promise to write a book on this exam if I ever passed!

As I progressed through most of the UK postgraduate exams (including the masochistic FRCS exams), I wrote exam books along the way to help colleagues. In 2002, as I sat the MRCGP exam at the Royal Horticultural Hall amidst 400 GPs, I wondered what exactly had I revised over 6 weeks as nothing seemed relevant to the actual MCQ paper in front of me.

There were no RCGP courses or books on the Simulated Surgery module and not surprisingly, the RCGP published pass rates between 56% and 60%. These GPs (who could not video-tape) needed help and so between 2004 and 2009, I have been teaching all 5 modules of the old MRCGP (MCQ, written, oral, video and simulated surgery) and now solely on the new MRCGP exam (AKT and CSA).

Visit for a full list of courses and books.

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