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CSA course cases Top tips for the MRCGP CSA exam - CSA prep 2013



CSA Prep Top Tips for the MRCGP CSA Exam Part 2
Dr Muhammed & Nazmul Akunjee






CSA preparation How to best prepare for your MRCGP CSA exam

Give yourself plenty of time to prepare for your exams. People often leave 1 month to prepare for
the exam which is insufficient. At least 4 months is needed to prepare for the CSA exam
Practice in groups as practice makes perfect
Consider practicing in different groups (ideally 2 or a maximum of 3)
If practicing in groups, when you are neither the candidate nor the actor, simulate being the
examiner. When observing consider how you would have approached the same case
Avoid practicing with the same 1-2 friends. Often you can learn a lot from your peers but by
practicing with the same group that will limit what you can learn from each other and can result
sometimes in bad habits being shared
Consider practicing with people who have struggled in the exams before. Such relationships are
mutually beneficial. They may benefit from a fresh pair of eyes on their consultation skills whilst
you may benefits from tips about the structure of the CSA exam and from their own personal
experiences
If you cannot find anyone to practice with contact neighbouring VTS course directors for people
who are in a similar position or practice over the phone or via skype
Consider practicing with a recently qualified doctor who had just past the MRCGP CSA exams
Consider asking your trainer to practice challenging cases with you. Often experienced GPs have
numerous patients they had seen that had been difficult to manage
If you encounter a colleague whose trainer is experienced in the CSA and offers extra training
ask permission from both your trainer and theirs if you are allowed to join their study group
Speak to the Practice Manager about other areas of general practice such as complaints
procedures, data protection requests
Practice with a framework to data gather information in 5 minutes, perform an examination in 2
minutes and formulate a management plan in 3 minutes. This will offer you more time for
management if an examination is not required
Consider attending CSA courses that use medically trained actors. Often practicing with friends
who are medically trained will prevent them from highlighting medical jargon that you may use
especially if you practice with them often. This will not be able to create the exam pressure of
simulated patient and would be rather artificial
Consider practicing with friends who are not medically trained along with CSA case books
Do review your video consultations to see if you have any troubling nuances that can
unnecessarily prolong the consultation or appear unnatural such as saying: OK, or hmm
repeatedly. Also some people have a habit of repeating their explanation several times to
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CSA course cases Top tips for the MRCGP CSA exam - CSA prep 2013

improve patient understanding. This is unnecessary in the exam situation and can waste valuable
time
In daily practice at work, try having your consultations at 12 minutes so that you can simulate 10
minutes exam consultations with 2 minutes to document them on to the computer. Do not feel
pressured into moving to 10 minutes if you do not feel ready
Make sure you get into a habit of asking the patients ideas, concerns, expectations, psychosocial
history in a natural manner and not in a formulaic one
Get feedback from your patients at the end of your consultations whether you had explained
things well or had in fact confused them
Often registrars get lumbered with the duty doctor role and see only acute presentations such as
cough and colds. Ask your trainer if you can hold QoF clinics or share patients from their list
(with their permission). Often patients with chronic conditions are more complicated and tend to
migrate towards the long term regular doctors
Use your out of hours (OOH) sessions as an opportunity to practice telephone consultations.
Have your sessions monitored by a trainer who gives you constructive feedback.



General MRCGP CSA Exam consultation tips

Do not follow a rigid formulaic approach for asking ICE or the patients psychosocial history. Be
flexible in your approach and structure and make the consultation more of a conversation. Ask
these questions when it feels natural to do so
Do not approach CSA cases as if each one has a hidden agenda. React only to what is
presented to you. Often hidden agendas are not very hidden and are easily revealed if you
challenge the patients verbal and non-verbal cues
Do not make premature judgements about what the case is about in your first few minutes.
Candidates often make the mistake of believing they have grasped the nub of the CSA case
dismissing any further information given by the patient and then forcefully pursuing their own
agenda. The actor will not bring you back if you do this
If appropriate, enquire about red flag symptoms so that you exclude serious conditions and
demonstrate safety in your consultations
If you choose to summarise back to the patient, only summarise the salient points briefly as it can
be quite time consuming. Consider summarising back when you are stuck or not sure what the
case is about to buy time and as a prompt to the patient that you do not fully understand their
complaint. This also may allow the patient the chance to correct your history taking or add
something you may have missed
Check understanding only if it is appropriate, especially if you think the patient appears confused
once you have attempted to explain things. Inappropriate checking of understanding can be
laborious and time consuming
If you do check understanding reverse the phrase to put onus on yourself for the poor
understanding. Is there anything that I have said that I could have said more clearly? or I am
sorry, if I confused you. Do you want me to go through it again?
Ensure that you negotiate a management plan with the patient rather than list all options. Going
through all options will waste valuable time particularly if the patient is only interested in one
treatment option
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CSA course cases Top tips for the MRCGP CSA exam - CSA prep 2013

After sharing the management plan with the patient do not be afraid to offer your opinion or
recommendation. Patients consult doctors for advice and direction not to pick their own
treatment. You could say: After what you have told me about your symptoms, I would
recommend...
If you offer leaflets to the patient ensure that you explain its content as this will improve
compliance with the advice. Do not pick up plain white A4 sheets and offer these as improviso
leaflets. Tell the patient to wait in reception and to pick the leaflets up from there when you have
printed them out
Offer health questionnaires as an adjunct to the making a diagnosis rather than the sole means to
making a diagnosis i.e. phq9
Ensure that you safety-net your consultations where appropriate to show safety in your
consultations and offer the patient an open or time fixed appointment to come back for
assessment or discussion with you if things do not improve or worsen.