Matt Smith September 2013

What are the odds? The February to March 2013 CSA Pass rate for first time applicants was 78%

3 main reasons for failure (1) Does not recognise the issues or priorities in the consultation (e.g. 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 Does not assimilate the written material provided e.g. misses the fact that tests are abnormal (or concentrates on the wrong one! The first intervention is a semiclosed question The doctor interrupts and breaks the story telling Cues are missed Failure to gather psychosocial information i.e. home life, workplace, caring responsibilities, community etc Failure to find out what the patient’s thoughts, fears and hopes are

Data gathering Tries to be comprehensive rather than appropriately selective e.g. does systems review, orders batteries of tests Misses red flags Fails to examine competently Failure to get to the diagnosis e.g. Depression Failure to reach any agreed shared understanding of the problem

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 Inability to manage risk safely, safety net appropriately etc Muddles data gathering and management e.g. 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 ”

An example from a recent mock CSA Patient says - “I feel so depressed I’ve thought about ending it all….” GP Registrar replies “Oh right. Had you thought what might be wrong and what worries you?

The different types of failing registrar Under prepared or badly prepared Go to pieces on the day

How to fail the CSA!

(1) Go underprepared – wing it! Plan to use a good consultation structure on the day Forget all this stuff about basic knowledge & evidence based practice Don’t worry if you can’t apply knowledge and skills Stick with 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 the minimum number of COTs Do lots of COTS but no video skills or sit & swap surgeries relating to CSA performance Keep focussing on ICEing the patients Don’t worry about using time effectively e.g. moving the patient along, closing the consultation Make sure you have a small supply of stock formulas and phrases to use Remember you may already KNOW the case (seen it before on the course) Join a CSA group late, meet infrequently with no strategy and ensure the group is homogenous e.g. all male

(3) Go to pieces on the day Make sure you read the notes of the patient who has just left, the one you just mucked up, 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 Euston, misplace your ID at the hotel, take your old BNF with all your crib notes (which is then taken away at the start of the exam), don’t worry about checking your equipment, PARTY the night before!

Key messages