Why do registrars fail the CSA?

Liz MoultonOctober 2011

If you are an IMG…..

..or a man

What does the College say?

September 2011 exam – 3 main reasons for failure

(1) Does not recognise the issues or priorities in the consultation (eg the patient’s problem, ethical dilemmas etc)

(2) Does not develop a management plan (including prescribing and referral) that reflects knowledge of current best practice

(3) Does not develop a shared management plan

So what goes wrong…

The 3 areas

• Data gathering• Management plan• Interpersonal skills

Data gathering• Cues are missed• The doctor interrupts and breaks the story telling• The first intervention is a semiclosed question• Failure to gather psychosocial information ie

homelife, workplace, caring responsibilities, community etc

• Failure to find out what the patient’s thoughts, fears and hopes are

• failure to reach any agreed shared understanding of the problem

Data gathering

• Does not assimilate the written material provided

• Misses the fact that tests are abnormal (or concentrates on the wrong one e.g. slightly raised cholesterol when the real problem is the raised fasting blood sugar)

• Tries to be comprehensive rather than appropriately selective e.g. does systems review, orders batteries of tests

• Failure to get to the diagnosis e.g. depression

Management plan

• Time pressure – don’t even get this far• Become doctor centred and ‘deliver’ the plan• Failure to give options and negotiate• Failure to take account of patient’s thoughts,

fears and hopes (particularly so when they have not been obtained....)

• Best medical practice is not followed

Management plan

• Too superficial – eg patient with STI - arranges to treat this but misses contact tracing, current sexual partner etc

• Inability to manage risk safely, safety net appropriately etc

• Muddles data gathering and management eg starts asking for more data in the management part of the consultation

Interpersonal skills

• Poor rapport building• Missed cues• Consultations are formulaic and wooden• Doctor centred, not patient centred• Unable to summarise, empathise, state what

they are seeing “You seem upset about that”

Comment from a GPST after completing a recent mock CSA

• “I don’t know what went wrong – after all I ICE’d all the patients.......”

Another example form a recent mock CSA

• Patient says - “I feel so awful I’ve thought about ending it all….”

• GP Registrar replies “Oh right. And is there anything else you’d like to talk about today?”

Models

• can give structure to the consultations and remind the registrar about key areas

• BUT - can be formulaic rather than natural and the nonselective registrar can run out of time.

As trainers - how can we help?

(Thanks to Roger Tisi, an Essex GP and CSA examiner)

Lots of practice – observed consultations, videos, (COTs)•Help with colloquial English usage

– Soaps (East enders, Coronation Street)– Films – Brassed off, Billy Elliot

• Remember it is THEIR exam, not yours• Be familiar with the exam and how it is

marked• Be familiar with the 3 domains and how they

are assessed• ‘Diagnose’ your registrar’s particular problems• Know where to draw the line

The four types of failing registrar

• Underprepared • Badly prepared• Go to pieces on the day• Not cut out for the job

How to fail the CSA!

(1) Go underprepared – wing it!

• Do the CSA as early as you can in the ST3 year• Forget all this stuff about basic knowledge /

evidence based practice • Don’t worry if you can’t apply knowledge and

skills• Stick with 15-20 minute appts at work – you will

be fine speeding up to 10mins on the day• GO on LOTS of courses – much better than

seeing patients

(2) Ensure you are poorly prepared

• Do lots of COTS – the best preparation for CSA• Don’t worry about using time effectively eg

moving the patient along, closing the consultation

• Make sure you have a supply of stock formulas and phrases to use

• Remember you may already KNOW the case (seen it before on the course)

(3) Go to pieces on the day

• Make sure you read the notes of the patient who has just left, not the one who is about to come in!!

• Try to interact with the examiner (they are pretending to be invisible so try really hard)

• Go on the day, drive to Croydon, Don’t worry about checking your equipment, PARTY the night before!

(4) Cut out for General Practice?

Not all failing GPRs will come right with extended training / the right sort of training etcThere are now a maximum of 4 attemptsDiminishing returns….Some of those we take in will not make it.