Promoting Excellence in Family Medicine West Midlands IMG Conference 2013 Jim Bartlett Training Lead for CSA Core Group

Who?? GP in Shropshire Trainer Former TPD for Shropshire VTS MRCGP Examiner Training & recruitment for CSA Previously managing the Case Writing Group

Assumptions? Me?You?

Zen and the art of CSA preparation To challenge assumptions To reduce the fear factor Address worries and concerns Build confidence

Outline A walk through tour of Euston square Update on CSA –current issues Pitfalls, myths and traps Features of passing candidates Hints & tips Questions

CSA update The Exam Centre- what happens Recent developments What’s on the horizon?

Exam Centre:30 Euston Square 3 purpose built ‘circuits’ State of the art Clocks iPads

30 Euston Square

Arrival Arrive on time at Euston Check in ID/phones Taken to briefing room Refreshments/toilets Brief by senior marshal Taken to floor

Purple Circuit

Consulting room

At the start All possessions put in locker Medical Equipment on the desk Your BNF will be checked You will be logged onto your iPAD & can start reading the cases

iPads

 Exams  MRCGP MRCGP exam overview May 2013 CSA: Delivery on iPads exams/mrcgp-exam-overview.aspx

Cases Cases represent everyday General Practice Cases could be – Acute medical problem – Chronic multiple pathology – Out of Hours situations – Telephone triage/home visit – Breaking Bad News – Palliative Care advice – Medical Certification – What happened today in your surgery?

Marking domains Each case is marked in 3 domains : Data gathering, examination and clinical assessment skills Clinical management skills Interpersonal skills Each Domain has the same number of marks.

TMahree domains for each case 3. INTERPERSONAL SKILLS: Demonstrating the use of recognised communication techniques to understand the patient’s illness experience and develop a shared approach to managing problems. Practising ethically with respect for equality and diversity, in line with the accepted codes of professional conduct. 1. DATA-GATHERING, TECHNICAL & ASSESSMENT SKILLS : Gathering & using data for clinical judgement, choice of examination, investigations & their interpretation. Demonstrating proficiency in performing physical examinations & using diagnostic and therapeutic instruments. 2. CLINICAL MANAGEMENT SKILLS : Recognition & management of common medical conditions in primary care. Demonstrating a structured & flexible approach to decision-making. Demonstrating the ability to deal with multiple complaints and co-morbidity. Demonstrating the ability to promote a positive approach to health.

Examiners

Ignore any observers / camera Ignore any observers / camera Behave normally –be yourself Behave normally –be yourself Don’t panic if things go wrong Don’t panic if things go wrong Be aware of your anxiety,but think yourself back home Be aware of your anxiety,but think yourself back home Housekeeping! Housekeeping! You won’t be the only one feeling stressed about a difficult case You won’t be the only one feeling stressed about a difficult case

New developments Feedback Dates of exams sittings ipads Child cases Children’s BNF

Child cases Child role players from the November 2013 exam onwards These new cases will include opportunities to test paediatric examination & prescribing skills Don’t forget your paediatric BNF!

What’s on the horizon? Exam date changes Feedback

Most used feedback statements 7 does not develop a management plan (including prescribing and referral) reflecting knowledge of current best practice. ( All 18%, RoW 24%) 13 Poor active listening skills and use of cues. Consulting may appear formulaic (slavishly following a model and/or unresponsive to the patient), and lacks fluency. (All 12 % RoW 21%) 2 Does not recognise the issues or priorities in the consultation (for example, the patient’s problem, ethical dilemma etc). (All 15% RoW 20%) 15 Does not develop a shared management plan, demonstrating an ability to work in partnership with the patient. (All 14 % RoW 20%)

How can we help? Challenge assumptions Seek feedback, and act on it Review performance Resources

You! Your trainer Your colleagues Your family Website

Resources MRCGP Clinical Skills Assessment (CSA)  More resources for CSA candidates  General comments about features/behaviours observed in passing and failing candidates in the CSA

Pitfalls: General features observed Passing Fluent, interactive and relevant Is able to take patient into medical world as a shared partner (use of we) Open about lack of knowledge or certainty and may use this constructively Active monitoring during consultation Failing Patronising (use of we) Uneasy with or unable to acknowledge own ignorance or uncertainty More scripted summary and checking understanding Poor use of time Does not appear to care about the patient Not curious Unaware of personal space

Myths There is NO RCGP model you need to follow Patient centred clinical method can appear doctor centred?? No one size fits all. Getting “ICE” is not as important as using it Ask yourself how much the patient’s ideas concerns and expectations influenced the outcome Were you curious and interested?

Traps Don’t second guess, many cases seem similar but just as patients vary in real life so do CSA cases. Don’t copy other peoples phrases and questions unless they feel natural to you. INSTEAD Do the consultation “for real” Make a diagnosis or address the dilemma Try to develop your own phrases and practice them

Key features in Data-gathering Passing Can take a focussed but full history Open, listening style then closed questions Embedding of questions in previous response Failing Formulaic questioning which can become interrogative Different types of info elicited in the same way Sequence of questions does not seem to make sense

Key features in Clinical Management Passing Appears knowledgeable and refers to recognised algorithms or modes of practice Able to suggest solutions to problems or a range of reasonable management options likely to be agreeable to patient Failing Insufficient knowledge base, or ability to think of realistic and effective alternatives Fails to integrate and apply knowledge Puts off making clinical decisions or a clear diagnosis Doesn’t appear to grasp the dilemma if there is one

Key features in Interpersonal skills Passing Connects instantly with patient Non-judgemental Interested in the patient Reformulates explanations using helpful metaphors Can meet patient half way – identifies patient’s agenda, Failing Pt concerns not addressed Unable to explain effectively – may be wrong or not tuned to patient Inappropriate use of terms Over patient-centred to the detriment of clinical outcome

Tips for during the exam Read supporting notes for the candidate. – may give a clue as to the direction expected in the consultation. Have “good housekeeping skills.” – Must move on from each case. – Each case is marked separately. Be confident at home visits and telephone consultations

You need to combine good clinical skills with good interpersonal skills. Demonstrating clinical skills is often a matter of sharing thoughts and explaining well to the patient. Build on the “raw material” offered to you "Focus on the patient, not what you imagine the examiner is looking for“

Tips Familiarise yourselves with the marking domains of the CSA. Regularly review your own consultations with your Trainer. Use COT – need to aim to be achieving “excellent” Use several trainers to review COT Must be able to consult in 10 mins in every day work

How trainers can help Identify and reinforce successful phrases and techniques Feedback on “clunky consulting”, over- modelling and “rote phrases” Encourage development of comfortable alternatives Encourage patient centeredness Encourage study groups

Lots of joint surgeries and CSA practise and seeing patients,see what the registrars are doing not what they say they are doing In joint surgeries-at critical points- don't be afraid to ask the trainee what they are thinking ie verbalise (eg diagnostic dilemmas treatment choices etc) Don't let your registrar practise with friends who might collude! Make sure your trainee is expanding their knowledge base at the same rate as their consulting skills.

Watch your trainees for clunky / embarrassed/formulaic phrases and work with them to try out more comfortable and natural ones. Encourage the use of open questions early on, & suggest a time plan so that clinical management gets a fair slice of the 10 minutes available. Identify the barriers to fluent consulting – any social/cultural barriers?.

Tips for trainees-preparation See patients- lots- do COTS and CBDs and don’t stay on half hour consulting for long Do joint surgeries with your trainer- partly to get used to being watched Work in a consortium of other candidates taking the CSA – but not just your friends :practise mock cases to get the timing right

Use a variety of settings- home visits, joint surgeries and don’t forget.. Telephone Triage Make the most of the OOH shifts Take every opportunity to seek and listen to feedback from experienced colleagues

Think of the consultation as a conversation - the patient says something then you say something that naturally follows, then the patient says something etc etc and so the story develops Think about who is doing all the talking - it shouldn't be the doctor. Throw away check lists and let it flow naturally.

Focus questions in a progressive manner indicating clear thought processes. Don't suddenly in the middle of taking a history interject with "how much alcohol do you take" or "Who is there at home?" when this is completely irrelevant. It may just suggest that you don’t know what to say next. Patients come in with symptoms, it is important to take the patient along the pathway between the symptom and their diagnosis ( and shared management) without gaps or odd jumps.

Be nosey- develop an inquisitive nature if you don’t have one. Passing candidates connect instantly with patient, remain responsive throughout, are fluent focused and use clear language Don't ask" Can I ask you some questions?" It wastes time and annoys everybody Don't use rote-learned questions - especially ICE questions when used at inappropriate times - listen to what the patient is saying and respond to that Explore the impact of the problem on the patient's life

For the exam: Imagine you are in your own surgery, & to do in Euston what you would want to do there! You've never met any of the CSA 'patients' before. Explore their psycho-social background with open questions before embarking on the medical questions There is no "right answer" to a case Do not think of the CSA as a game ('what do they want me to pick up', 'why have they put this case in'? etc) and think yourself into the real situation ('it's down to me to sort this patient out').

It is helpful to the patient to explain what you are doing when you examine them - practise examinations so that they are automatic and second nature. Don't ask the pt "What do you want to do" when the patient has not been given options with the pros and cons of each.

Suspend disbelief, and put yourself in your surgery, believing that these are YOUR patients. Ignore the examiner and don't try to double think what he/she wants to hear - it just causes confusion in your own brain and will be unhelpful to the ‘patient’. "if you think it say it": an assessor can only mark what they hear so if you have a bright thought you need to share it!

Time Management Keep an eye on the time Structure your consultations Use good general consulting skills- summarise, screen, safety-net Don’t cover only one domain area About halfway through the consultation, you need to move on from data gathering Avoid repetition

Summary Be yourself Get in ‘doctor’ role – not ‘candidate’ Confidence comes with practise And is polished with feedback