Clinical Skills Assessment Overview of CSA Col Robin Simpson FRCGP CSA Core Group Lead Case Management Group Nov 14

The MRCGP  Three part assessment –Applied knowledge test (AKT) –Clinical skills assessment (CSA) –Work place assessment (WPBA)  Each test is independent and will test different skills  Together will cover whole GP curriculum

CSA WBAAKT MRCGP: an integrated assessment programme

CSA “An assessment of a doctor’s ability to integrate and apply clinical, professional, communication and practical skills appropriate for general practice” Assessment of consulting and examination skills Standard set as “safe for independent general practice” £1563 ( each attempt)

Why do we need the CSA?  Provides external validation / triangulation with the other testing methods used  Using simulated patients is a validated and reliable method for testing clinical skills, so long as quality assurance of case production, role player and assessor training is carried out.  Able to offer a standardised, pre-determined level of challenge to candidates and to vary this level of challenge as needed by the assessment requirements

New RCGP Euston 2012

IPAD

What happens at the CSA?  Arrive on time at Euston  Security - ID  Taken to briefing room  “Quarantined during changeover”  Toilets  Water / Drinks  Brief  Taken to floor

What happens at the CSA?  Room and locker  All possessions put in locker  Medical Equipment put into clear plastic brief case – checked  Taken to room  Notes IPAD in order you will see cases  Water  Hand wash

3 Circuits Three Circuits … (on three floors)

CSA 13 Station Simulated Surgery Each station 10 minutes Patient will enter room and present as a case that could be expected in GP Patient accompanied by an examiner Examiner sits “out of direct line of sight of candidate 2 minute gap between patients Buzzer at beginning and end of case Nothing said after buzzer will count Break in middle of surgery for a tea / coffee

What should you bring? On RCGP website  Please note that there is no need to bring a sphygmomanometer  Your responsibility to bring your medical examination equipment  Have all equipment in a bag – saves time unpacking  BNF + Children’s BNF  N.B. All BNFs must be free of hand-written notes: they may be checked before the start of the assessment and removed if they contain notes.  Clock in each room

What should you bring?  Any additional equipment will be provided. –prescriptions –certificates –laboratory forms –Possible props Peak flow reading Growth charts Pictures

How is the CSA constructed?  Cases represent everyday GP and could be: –Acute medical problem –Chronic multiple pathology –Adapted from real life –One of: Out of Hours situations Telephone Consultation –Discussion about a child –Breaking Bad News –Palliative Care advice –Medical Certification –What happened today in your surgery?

How is the CSA constructed?  The simulated patients (trained actors) could be. –male or female. –old or young (including child role players). –mother / father –different races, cultures, class or religions. –disabled.

Case Writing  Case writers. –document instructions to the role player playing the part of the patient, –instructions to the assessor. –case notes. –detailed marking schedule for assessors. –Case note for candidate. short notes detailing the PMH. available at the beginning of the “ surgery. ” brief but may include previous consultations, laboratory results or correspondence from secondary care.

Sample case notes Susan Davison Date of birth (Age) 28 Address 47 Florentine Way Croydon S ocial and Family History Single but lives with partner Past medical history Nil of note Current medication – Microgynon 30 Last consultation Saw Practice Nurse 3 weeks previously for a Pill and BP check. BP 110/70. Never smoked

Case Writing  The cases will be chosen to cover the areas of the GP curriculum that can be tested by CSA.

ENT Curriculum Statement

The Marking Schedule  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.

Three 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.

Four possible Grades  Clear Pass (CP)(3)  Pass (P)(2)  Fail (F)(1)  Clear Fail (CF)(0)

The Marking Schedule  Assessor uses word pictures –help decide grade for each “domain”  Examiners will also separately rate the candidate as a pass, a fail or a borderline, overall.  Feedback to candidates  Serious concerns box

CSA Pass Mark  The examiner marks each case on three domains or areas - Data Gathering, Clinical Management and Interpersonal Skills. This creates an overall numerical mark for the case. Each domain carries the same number of marks (3). The marks for each case (Max 9) are added to create a final mark (out of 117)

CSA Pass Mark  The pass mark is created using the borderline “group method” which establishes the pass mark for each different daily mix of cases.  As well as marking the domain scores, the examiners will also separately rate the candidate as a pass, a fail or a borderline, overall

CSA Pass Mark  For each case the overall numerical case marks of the candidates in the borderline group are averaged. These averaged scores are then aggregated across all the 13 cases to create the “cut score”, ie the approximation between a passing and a failing score.

Key features in Data Gathering  Focused but full history  Open listening style then closed questions  Embed questions in previous responses to move the consultation forward  Late data gathering is associated with lower marks

Key Features in Clinical Mx  Most common failing domain  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  Poor time keeping – Run out of time

Key features in IPS  Combine clear explanations with “alignment to patients”  Make talk more conversational  Customise phrases to avoid sounding formulaic  Communicate with fewer hesitations and false starts  Repair misunderstandings and misalignments more easily

Tips Cases originate in the GP Curriculum. Curriculum statements available on the RCGP website. Each has a section on common and important conditions. This may be a useful checklist of the sort of cases that may be used.  Identify your areas of weakness with your trainer – who are your least favorite patients?

Covering the Curriculum  Are there any groups of patient that you are not seeing? –patients with diabetes –female patients  Involve other members PHCT –practice manager dealing with a complaint –nurses in chronic disease management clinics Smoking cessation Ear syringing

Tips  You must be able to. –Undertake common clinical examinations. Proceed with examination as you would usually do May be asked “what you want to examine” Listen carefully if assessor s steps in and gives examination result May be passed a card with results Think of examinations covered in NICE Do you need a chaperone? –Use medical instruments likely to be part of the examination. –Explain hospital or laboratory reports to patients. –Break bad news.

Tips  Familiarise yourselves with the marking domains of the CSA.  Regularly review your own consultations with your Trainer.  Use COT – need to be achieving “excellent”  Get the video camera out and use it!  Use several trainers / TPD to review COT  Must be able to consult in 10 mins

Tips  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.  Make the most of your OOH shifts, which are ideal for CSA practice

Study Groups  Best results when in a study group  Use your own patients as examples for cases  Writing your own cases in groups  Practise explaining things to patients

Summary  Well prepared candidates Pass!  Trainers can make all the difference  Good Luck!

CSA Dates 2013 /2014

Further resources  RCGP website –CSA regulations –GP Curriculum –Wessex Faculty RCGP DVD on CSA –A Guide to the COT of Workplace Based Assessment –Consulting: Communication Skills for GPs in Training

Questions ?