CSA – that’s ‘constant stress and anxiety’. Okay, it’s ‘clinical skills assessment’. Just like the PSA, it’s an acronym with two interpretations and the potential to have you wetting yourself – though, in the CSA’s case, through fear rather than an unnecessary prostatectomy. For the uninitiated, the CSA is a major part of the MRCGP. It’s an ‘objective structured clinical examination’ involving actors playing patients and registrars playing by the book, or, at least, the GP curriculum. It’s supposed to mimic a ‘normal’ surgery – it does, in that the pretend punters are seen at
10-minute intervals with primary care-type problems, and doesn’t in that if you take the occasional pragmatic line of ignoring cues, dishing out unnecessary antibiotics or telling certain patients to sod off, you’ll fail.
The nation’s registrars are so preoccupied with jumping through this hoop that they’ve developed a new subtype of obsessive-compulsive disorder: OC(SA)D. Why? Perhaps it’s the cost. We all realise registrars want to pass exams first time because they’re vocationally driven and aching to save the world from UTIs and ear wax – but the £1,481 price tag probably focuses the mind, too. Or maybe it’s because the CSA has previous – headlines about poorly communicated changes to the format, low pass rates and a UK graduate bias. Or perhaps it’s just the high stakes and high intensity – the MRCGP induced in me nothing more than stress-induced hives, but back in the day it was just a voluntary stroll, not a mandatory marathon.
Whatever. How far, do you suppose, are candidates prepared to go in their CSA preparation? Practising cases with their trainer? Fine. Dummy runs with colleagues via Skype? No problem. CSA practice evenings among friends? It’s a social life, Jim, but not as we know it. All within normal limits though. But paying actors to play patients for private CSA rehearsals? Yes, really. True, it’s terrible seeing the next John Hurt waiting tables at TGI Friday, but it’s not our job to sort out his Equity card. Next stop: employing actors to co-habit so the candidate can live in a permanent CSA World where every second is exam practice.
Now, I know this will disturb those who view Dr Copperfield as the GP anti-Christ, but I am involved in education, meeting trainers and registrars from all over the place. So I’m in a position to confirm that OC(SA)D is having a number of unfortunate effects. It’s making registrars tattoo ‘ideas, concerns and expectations’ to the inside of their eyelids, so they’re reminded of this mantra every time they blink. And it’s making them brilliant at generating ‘options’, but incapable of making decisions.
Worst of all, obsessional CSA practice is distracting them to the point that they’re spending less time seeing real patients, which is precisely what the CSA is supposed to test their competence in. So do something, RCGP, before our registrars die of irony overload. Offer CBT with the CSA as a buy one acronym, get another free offer. Or better still, lower its cost, the stakes, the perceived unfairness and the intensity. Until then, registrars are preparing for the real world by living in a parallel one.
Dr Tony Copperfield is a GP in Essex