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

2. warning Arrangements are all subject to change
See for latest info

3. 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

4. Transition arrangements
MRCGP modules
Summer 2007
Winter 2007
Summer 2008
Winter 2008
Multiple Choice paper
May 2007
October 2007 – nMRCGP AKT
May nMRCGP AKT
October 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 nMRCGP CSA
Consulting skills (Simulated surgery) Leicester
March & July 2007
October /November nMRCGP CSA or video
May 2008 –nMRCGP CSA or video

5. 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

6. 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’

7. 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.

8. 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

9. 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.

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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