Finding your way through the CSA

A new multi-part series offering practical advice on how to prepare for the CSA exam from GP training programme director Dr Nigel Giam

The MRCGP is changing. From the September 2010 sittings onwards there will be subtle differences in the assessment of the AKT and CSA components of the exam. It is important that candidates are fully aware of the changes and how to best prepare. In this series of articles I will look to provide practical advice as to how to structure your preparation, starting with the CSA.

What's different? The practicalities

Previously ST3s undertaking the CSA were assessed on 12 out of 13 simulated consultations. The one consultation which was not assessed was a pilot case. A pass in the CSA was defined as eight passes and a detailed breakdown of clear passes (CP), marginal passes (MP), marginal fails (MF) and clear fails (CF) for each case was sent to the ST e-portfolio.

From September 2010, all 13 cases will now be marked and each case will contribute equally to the overall score. As with previous CSA sittings the examiner marks each case on the three domains of Data Gathering, Clinical Management and Interpersonal Skills.

Each domain carries the same number of marks. Four grades are awardable for each domain - either CP, MP, MF or CF. Grades are then converted to numerical scale to give an overall mark for the case.

The pass mark for the circuit is created using the borderline group method. As well as marking the domain scores, the examiners will also separately rate the candidate overall as a pass, a fail or a borderline. For each case the overall numerical case marks of the candidates in the borderline group are averaged. These averaged scores are then aggregated across all the 13 cases to create the 'cut score', that is to say the approximation between a passing and a failing score.

The borderline group method establishes the pass mark for each different daily mix of cases and will therefore vary for each sitting. An ST3 undertaking the exam will receive electronic notification of their results, via the ePortfolio as before. The main difference will be that they will receive an overall score compared with the passing score for that day as opposed to the individual marks for each case.

In the unfortunate case of a fail, the ST3 will receive feedback statements on areas of improvement as identified by two or more examiners. The 16 feedback statements, which in essence make up the marking schedule for each case, have also been reviewed, taking into account comments from AiT representatives and CSA examiners. They have been clarified and the explanations that relate to them revised, with more information and advice on how to improve performance.

Candidates will receive more feedback information than previously, with any areas of performance identified as deficient linked to the Curriculum Statements of the cases in question. The candidates' experience of the CSA sitting will be the same as before and should not affect the way in which they prepare for the examination. However the challenge is of course preparing in the right way!

Changes in the feedback statements

It is important to study these in detail. Further details can be downloaded from the RCGP website or by clicking here.

I have summarized the headings from both the old and new feedback statements under the 3 domains as follows:

Old formative CSA feedback statements

DATA GATHERING

Reasons for failing:

1) Disorganised and unsystematic in gathering information from history taking, examination and investigation

2) Data gathering does not appear to be guided by the probabilities of disease

3) Does not undertake physical examination competently, or use instruments proficiently

ASSESSMENT/INTERPRETATION SKILLS

Reasons for failing:

4) Does not identify abnormal findings or results or fails to recognise their implications

CLINICAL MANAGEMENT SKILLS

Reasons for failing:

5) Does not make appropriate diagnosis

6) Does not develop a management plan (prescribing +/- referral) that is appropriate and in line with current best practice

7) Follow-up arrangements and safety netting are inadequate

8) Does not demonstrate an awareness of management of risk and health promotion

INTERPERSONAL SKILLS

Reasons for failing:

9) Does not identify patient's agenda, health beliefs & preferences/does not make use of verbal and non-verbal cues

10) Does not develop a shared management plan or clarify the roles of doctor and patient

11) Does not use explanations that are relevant and understandable to the patient

12) Does not show sensitivity for the patient's feelings in all aspects of the consultation including physical examination

GLOBAL OVERALL

Reasons for failing:

13) Disorganised/unstructured consultation

14) Does not recognise the challenge (eg the patient's problem, ethical dilemma)

15) Shows poor time management

16) Shows inappropriate doctor-centeredness

New formative CSA feedback statements – from September 2010

GLOBAL

Reasons for failing:

1) Disorganised and unstructured consultation

2) Does not recognise the issues or priorities in the consultation eg the patient's problem, the ethical dilemma

3) Shows poor time management

DATA GATHERING

Reasons for failing:

4) Does not identify abnormal findings or results or fails to recognise their implications

5) Does not undertake physical examination competently, or use instruments proficiently

CLINICAL MANAGEMENT SKILLS

Reasons for failing:

6) Does not make appropriate working diagnosis or identify range of differential possibilities

7) Does not develop a management plan (prescribing +/- referral) that is appropriate and in line with current best practice

8) Follow-up arrangements and safety netting are inadequate

9) Does not demonstrate an awareness of management of risk or make the patient aware of relative risks of different options

10) Does not attempt to promote good health at opportune times in the consultation

INTERPERSONAL SKILLS

Reasons for failing:

11) Does not appear to develop rapport or show sensitivity for the patient's feelings

12) Does not identify patient's agenda, health beliefs and preferences

13) Does not make adequate use of verbal and non-verbal cues. Poor active listening skills

14) Does not identify or use appropriate psychological or social information to place the problem in context

15) Does not develop a shared management plan, demonstrating an ability to work in partnership with the patient

16) Does not use language and/or explanations that are relevant and understandable to the patient

At face value there may not appear to be much difference in the feedback statements, but in fact on closer inspection it is apparent that there is now a much greater emphasis on the clinical management and interpersonal aspects of the consultation. Both of the latter depend of course on taking a structured and focused history, which is reflected in the global overall scores.

In my next article I will look at how to reflect on how you consult and how to use this to best prepare for the CSA, specifically for the interpersonal domain of the consultation - and using a Confucian approach.

Dr Nigel Giam is the course director for Mentor MRCGP preparation courses – www.passmrcgp.com for more details.

He works as a GP and a lecturer in medical education. He is a Senior OSCE examiner and tutor of general practice at Kings College School of Medicine and Imperial College School of Medicine. He is a Programme Director for the St Mary's VTS, and has worked as RCGP course organizer.

This is the first instalment in Dr Nigel Giam's multi-part series to Passing the CSA. Please click here to read the full series.

Or you can access the second
and third instalments directly.