Nmrcgp csa The Clinical Skills Assessment new membership of the royal college of general practitioners

warning Arrangements are all subject to change See http://www.rcgp.org.uk/ for latest info

Background MRCGP What does it test? nMRCGP Apply during final year of GP training Apply when accepted onto scheme (FY2) Voluntary Required for Certificate of Completion of Training (CCT) Multiple Choice Paper Facts Applied Knowledge Test (AKT) Written Paper Problem solving Oral exam Attitudes Video Consultation skills Clinical Skills Assessment (CSA) Workplace Based Assessment (WPBA) Professionalism & loads more WPBA leading to enhanced trainers report

Transition arrangements MRCGP modules Summer 2007 Winter 2007 Summer 2008 Winter 2008 Multiple Choice paper May 2007 October 2007 – nMRCGP AKT May 2008 - nMRCGP AKT October 2008 - nMRCGP AKT Written paper  October 2007  May 2008 October 2008 Oral examination June/July 2007 November / December 2007 June/July 2008 November /December 2008 Consulting skills (video)  November 2007 May 2008 October 2008 - nMRCGP CSA Consulting skills (Simulated surgery) Leicester March & July 2007 October /November 2007 - nMRCGP CSA or video May 2008 –nMRCGP CSA or video

Who does what? Current GPRs Future GPRs Finish training up to Feb 2008 Finish training from Aug 2008 Start vocational training Aug 2007 MRCGP &/or Summative Assessment nMRCGP &/or Summative Assessment nMRCGP Deadline for applying for old MRCGP extended to 29th August 2007 for these registrars Need a year in practice to fulfil WPBA

CSA – what is it? The Clinical Skills Assessment (CSA) is ‘an assessment of a doctor’s ability to integrate and apply clinical, professional, communication and practical skills appropriate for general practice’ http://www.rcgp.org.uk/nmrcgp_/nmrcgp/csa.aspx

CSA – where & when? Croydon, initially Purpose built centre, eventually First sitting October 2007 Subsequently February, May, October of each year Registrars who start their final year in August will probably aim to sit the CSA in February, after 6+ months in their GP attachment. That way, if they need to resit they can do so in May before they finish their training with a view to getting their CCT on time. http://www.rcgp.org.uk/nmrcgp_/nmrcgp/csa.aspx

CSA – how will it work? Each candidate will be given a consulting room and will have appointments with 13 patients, each lasting around 10 minutes The performance will be graded as Clear Pass, Marginal Pass, Marginal Fail or Clear Fail http://www.rcgp.org.uk/nmrcgp_/nmrcgp/csa.aspx

CSA – what is being tested? The CSA will test mainly from the following areas of the curriculum;- Primary Care Management Problem Solving Skills Comprehensive Approach Person-centred Care Attitudinal Aspects Clinical Practical Skills Primary Care Management - recognition and management of common medical conditions in primary care. Problem Solving Skills - gathering and using data for clinical judgement, choice of examination, investigations and their interpretation. Demonstration of a structured and flexible approach to decision making. Comprehensive Approach - demonstration of proficiency in the management of co-morbidity and risk. Person-centred Care - communication with patient and the use of recognised consultation techniques to promote a shared approach to managing problems. Attitudinal Aspects - practising ethically with respect for equality and diversity, with accepted professional codes of conduct. The CSA will also test: Clinical Practical Skills - demonstrating proficiency in performing physical examinations and using diagnostic/therapeutic instruments. http://www.rcgp.org.uk/nmrcgp_/nmrcgp/csa.aspx

CSA – other stuff Patient simulators (actors) will be used CSA assessor will observe and mark When time is up the ‘patient’ and assessor will get up and leave The next ‘patient’ and assessor will then enter for the next assessment Advantages to one assessor staying with a simulator for one session include comparability of candidates/validity. Bad idea to have same assessor for same candidate for whole surgery; first impressions may bias process etc. Assessors should be ignored by candidates as if they weren’t in the room. They will not be giving feedback or help. It could be quite off putting to a candidate when patient & assessor leave. stuff that’s not on the website, that may change

CSA – other stuff There is a bank of CSA scenarios; currently >250 Word is bound to get out – that doesn’t matter If candidates can learn all the cases and what’s being assessed, and show it in the CSA, then they deserve to pass. stuff that’s not on the website, that may change

CSA – other stuff If consultations require examination of the patient, candidates should tell the ‘patients’ they would like to examine them They then either examine the patient (because this is being tested) or will be given a printout of the examination findings by the ‘patient’ Similarly, if they need to “look up” the test results/x-ray or whatever, the patient will furnish the appropriate information when the candidate seeks it. stuff that’s not on the website, that may change

CSA – more on marking Clear Pass CP The candidate demonstrates sound performance in the domain both in principle and in detail, operating clearly above the level for safe independent clinical practice Performance is fluent, though not necessarily sophisticated. Positive behavioural indicators of performance are consistently and proficiently met and on balance any negative behaviours are not thought to be of concern. stuff that’s not on the website, that may change

CSA – more on marking Marginal Pass MP The candidate has a sound grasp of the principal of the domain, more so than the detail, operating at, or just above, the level for safe independant clinical practice Positive behavioural indicators are consistently met, although performance may not be fluent. On balance any negative behaviours are not thought to be of concern. stuff that’s not on the website, that may change

CSA – more on marking Marginal Fail MF The candidate’s performance shows ability but overall is below the level for safe independent clinical practice The positive behavioural indicators are not demonstrated to a consistently adequate standard and negative behaviours may be of concern stuff that’s not on the website, that may change

CSA – more on marking Clear Fail CF The candidate performs well below the level for safe independent clinical practice The range and depth of the positive indicators are poorly demonstrated and performances may be inconsistent. Negative behaviours may be of concern. stuff that’s not on the website, that may change

CSA – more on marking Other descriptors for exceptional use only Excellent Performance is not necessarily perfect but is consistently proficient, integrated, fluent and time efficient. The candidate’s performance is as good as could be achieved under exam conditions. Serious Concerns The candidate’s performance demonstrates serious deficiencies in thinking and behaviour that may place patients at risk of harm from actions that the doctor takes, or fails to take. stuff that’s not on the website, that may change

CSA – more other stuff Candidates do not have to pass every scenario Cases will present different levels of challenge Even a clear fail at one of the stations does not mean a candidate will necessarily fail the CSA Easy cases will be passed, or clearly passed by most candidates. The harder cases may well be failed or clearly failed by many candidates. A clear fail is not the same as a major error, which would (in all probability) lead to failing the CSA. Anyone can have a bad slot, just as any GP can have a bad consultation. stuff that’s not on the website, that may change

CSA – indicators for targeted assessment domains Problem Solving Skills Technical Skills Defined as Gathering and using data for clinical judgement, choice of examination, investigations and their interpretation. Demonstration of a structured and flexible approach to decision making. GP curriculum

CSA – indicators for targeted assessment domains Problem solving & technical skills Positive indicators Clarifies the problem and nature of the decision required Uses an incremental approach, using time and accepting uncertainty Negative indicators Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management GP curriculum

CSA – indicators for targeted assessment domains Problem solving & technical skills Positive indicators Gathers information from history taking, examination and investigation in a systematic and efficient manner Is appropriately selective in the choice of enquiries, examinations and investigations Negative indicators Is disorganised or unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease GP curriculum

CSA – indicators for targeted assessment domains Problem solving & technical skills Positive indicators Uses instruments appropriately and fluidly When using instruments or conducting physical examinations, performs actions in a rational sequence Negative indicators Appears unsure of how to operate/use instruments Appears disorganised or unsystematic in the application of the instruments or the conduct of physical examinations GP curriculum

CSA – indicators for targeted assessment domains Primary Care Management Comprehensive Approach Defined as Recognition and management of common medical conditions in primary care. Demonstration of proficiency in the management of co-morbidity and risk. Demonstrating the ability to promote a positive approach to health. GP curriculum

CSA – indicators for targeted assessment domains Management and comprehensive approach Positive indicators Recognises presentations of common physical, psychological and social problems Makes plans that reflect the natural history of common problems Offers appropriate and feasible management options Negative indicators Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve GP curriculum

CSA – indicators for targeted assessment domains Management and comprehensive approach Positive indicators Management approaches reflect an appropriate assessment of risk Makes appropriate prescribing decisions Negative indicators Fails to make patient aware of relative risks of different options Decisions on whether or what to prescribe are inappropriate or idiosyncratic GP curriculum

CSA – indicators for targeted assessment domains Management and comprehensive approach Positive indicators Refers appropriately & co-ordinates care with other healthcare professionals Manages risk effectively, safety-netting appropriately Simultaneously manages multiple health problems, both acute and chronic Negative indicators Decisions on whether & where to refer are inappropriate Follow up arrangements are absent or inappropriate Fails to take account of related issues or co-morbidity GP curriculum

CSA – indicators for targeted assessment domains Management and comprehensive approach Positive indicators Encourages improvement, rehabilitation &, where appropriate, recovery Encourages the patient to participate in appropriate health promotion and disease prevention strategies Negative indicators Unable to construct a problem list and prioritise Unable to enhance patient's health perceptions and coping strategies GP curriculum

CSA – indicators for targeted assessment domains Person Centred Approach Attitudinal Aspects = Interpersonal Skills Defined as Communication with the patient and the use of recognised consultation techniques to promote a shared approach to managing problems. Practising ethically with respect for equality and diversity, with accepted professional codes of conduct. GP curriculum

CSA – indicators for targeted assessment domains Interpersonal Skills Positive indicators Explores patient’s agenda, health beliefs and preferences Appears alert to verbal or non-verbal cues Negative indicators Does not enquire sufficiently about the patient’s perspective or health understanding Pays insufficient attention to the patient’s verbal and non-verbal communication GP curriculum

CSA – indicators for targeted assessment domains Interpersonal Skills Positive indicators Explores the impact of the illness on the patient’s life Elicits psychological and social information to place the patient’s problem in context Negative indicators Fails to explore how the patient’s life is affected by the problem Does not appreciate the impact of the patient’s psychosocial context GP curriculum

CSA – indicators for targeted assessment domains Interpersonal Skills Positive indicators Works in partnership, finding common ground to share a management plan Communicates risk effectively Shows responsiveness to the patient’s preferences, feelings and expectations Negative indicators Instructs the patient, rather than finding common ground Uses a rigid approach to consulting that fails to be sufficiently responsive to the patient’s contribution GP curriculum

CSA – indicators for targeted assessment domains Interpersonal Skills Positive indicators Enhances patient autonomy Provides explanations that are relevant and understandable to the patient Responds to needs and concerns with interest and understanding Negative indicators Fails to empower the patient or encourage self-sufficiency Uses inappropriate (eg technical) language Shows little visible interest or understanding. Lacks warmth. GP curriculum

CSA – indicators for targeted assessment domains Interpersonal Skills Positive indicators Has a positive attitude when dealing with problems. Admits mistakes & shows commitment to improvement. Backs own judgment appropriately Demonstrates respect for others Negative indicators Avoids taking responsibility for errors Does not show sufficient respect for others GP curriculum

CSA – indicators for targeted assessment domains Interpersonal Skills Positive indicators Does not allow own views/values to inappropriately influence dialogue Shows commitment to equality of care for all Acts in an open non-judgmental manner Negative indicators Inappropriately influences patient interaction through own views/values Displays inappropriate favour or prejudice Is quick to judge GP curriculum

CSA – indicators for targeted assessment domains Interpersonal Skills Positive indicators Is cooperative & inclusive in approach Conducts examinations with sensitivity for the patient’s feelings, seeking consent where appropriate Negative indicators Appears patronising or inappropriately paternalistic When conducting examinations, appears unprofessional and at risk of hurting or embarrassing the patient GP curriculum

CSA – more on scenarios Briefing Both simulator and assessor will have been thoroughly briefed on the scenario The patient will have a name The case will have a title (known to the simulator and assessor) Simulator and assessor will have a context for the case – i.e. what domain(s) is this case assessing Candidates should remember good manners; introduce themselves, call the patient by their name stuff that’s not on the website, that may change

CSA – more on scenarios Briefing (continued) There will be a marking schedule which specifically lists what positive and negative descriptors the case is designed to highlight If the candidate misses (for example) an important cue which is crucial to the case, the simulator will try again stuff that’s not on the website, that may change

CSA – more on scenarios Briefing (continued) Most scenarios will allow assessors to mark each of the following domains as CP, MP, MF or CF;- Data gathering, technical and assessment skills Clinical management skills Interpersonal skills Assessors will make notes whilst observing, to aid them in coming to a judgement The candidate is then given an overall mark (CP, MP, MF or CF) for that scenario, and this is the one which counts This has similarities to the deanery competency based selection process for entry onto VTSs stuff that’s not on the website, that may change