The MRCGP Clinical Skills Assessment (CSA) accounts for a third of the MRCGP exam, but to a large number of candidates it can be the most daunting part. It is therefore reassuring to note that the pass rate has been much higher than that of the AKT. In 2015, the overall pass rate of candidates sitting the CSA exam for the first time was about 85%. This figure was around 75% for those sitting the AKT for the first time.
The CSA is described by the RCGP as ‘An assessment of a doctor’s ability to gather information and apply learned understanding of disease processes and person-centered care appropriately in a standardised context, make evidence-based decisions, and communicate effectively with patients and colleagues.’
The format of the day
The format of the CSA exam is essentially that of an objective structured clinical examination (OSCE) It is a little different to the OSCEs that you may have faced at earlier stages in your medical training in as much as it very much a real-life simulation of actual GP consultations. Professional actors who work hard to deliver a standardised consultation throughout the day play the patients you will encounter.
Each candidate has 13 ten-minute consultations and is allocated a consulting room for the duration of the exam. There is a single 15-minute break that occurs at some point during the cases. One of the cases may be a simulated home visit, or a telephone call. The telephone cases may involve members of the wider medical team, such as a receptionist or a district nurse. With these cases it is always important to remember to safety net appropriately.
Since the end of 2013 child role players have been used for some of the paediatric cases. Although this may seem daunting, the children are often older than the age they are role-playing, as they too have to aim to deliver a standard consultation each time. Just give some thought to how you’d approach a paediatric case and in particular how you’d involved the parent in the consultation too (could you expand on this statement at all? Perhaps a little more information about how to cope with the paediatric cases and expand as a separate paragraph?)
When you enter your room, you will see an iPad on the desk, through which you can access your patient list and any case notes available. You will need to login using your GMC number. Before the start of the exam you will have a few minutes to quickly read over the case summaries for the session. Case notes and any examination findings/ hospital letters can be accessed by tapping the screens. At the end of each case the candidate clicks on ‘Mark case as complete’ button that is visible in the bottom left hand corner.
There is a timer in each room, and at the end of ten minutes a buzzer will sound. It is therefore important to practice the timings of your consultations. The occasional glance at the timer is fine, but looking at it too often will distract from the consultation.
General advice for the day
As with any exam it is always a good idea to leave plenty of time to get to the venue and arrive early – you definitely don’t want to add being late to your nerves! Look smart and professional, but make sure that you are also comfortable and able to move around easily. You must bring a photo ID (e.g. passport or driving license) and any personal electronic devices will be taken from you at the reception area.
Remember to bring your equipment with you. Items that you should remember include:
- BNF, BNF for children
- Tape measure
- Peak flow meter (and disposable mouthpieces)
- Patella hammer
(you don’t need to bring a sphygmomanometer)
The following items will be supplied in the room:
- Prescription pad
- Blood test request forms
- Imaging request forms
Don’t try and second-guess what may come up. Rather have a strategy that you can use for any situation. Consultations are dynamic and it is important to be confident in the ‘method’ that you have for approaching the cases. The RCGP is very strict about the confidentiality of the cases, and you should never attempt to case-share.
There are 3 parts to the marking scheme:
- Data Gathering
- Clinical Management Skills
- Interpersonal Skills
- Data Gathering:
It is important to take a thorough and focused history. Try to let the patient talk without interruption for about the first minute to ensure they have given their history in detail. You can then step in and start focusing the consultation.
Exclusion of red flags is an important area. The RCGP have commented that these have been missed in the past and, as patient safety would be at risk, you can fail the station if you do not rule these out. Make sure you also explore the patient’s ideas, concerns and expectations as they may not be the same as yours.
Offer to examine the patient where appropriate. The examiner may simply tell you the findings, or ask to you to conduct the examination. On average, you may be expected to examine in about 4 or 5 of the cases. Remember to keep the examination focused to the relevant case.
- Clinical Management Skills:
These include formulating sensible differential diagnoses and arranging for appropriate investigations. Clear explanations for the treatments offered and good safety netting and follow up are also excellent skills to bring to this section. You may need to explain the meaning of a patient’s test results, and implications for follow up or when to refer on to secondary care.
- Interpersonal Skills:
These can usually be translated across most of the cases the candidate will encounter. Simply establishing a good rapport will go a long way. Explaining things clearly and not using confusing medial jargon is another way to score well. It is important to be non-judgmental, particular in any ethical cases that come up. Being sympathetic and reassuring when appropriate, and responding to verbal and non-verbal cues are good skills to have in most consultations.
And finally remember!
If the previous case went badly, the examiners of the next case have no idea, and so it is really important to start each case afresh. Take a deep breath, count to 10 and try and relax as best you can. The examiners and the actors are people too – they will get tired and will also experience some of the emotion that the day brings. Being polite and kind will always be a good starting point. Keep practicing, as this will make your consultations go more smoothly and the day seem less daunting.
Best of luck with your preparation for the CSA and the actual day!
Thank you to the joint editorial team of MRCGP Exam Prep for this ‘Exam Tips’ blog post.