MRCGP Feedback

Understanding the CSA exam feedback 
part 1

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1. Disorganised / unstructured consultation

The MRCGP CSA examiners felt that consultation was haphazard and lacked a sensible structure. The structure often looked for by the CSA examiners including starting off with an introduction, taking a brief history with ICE, examination, before progressing to the management plan with summarisation if appropriate. They may have felt your line of questioning was not focused enough on the presenting complaint or relevant to the case. A disorganised consultation for the patient can be confusing especially if discussing a diagnosis or a management plan prior to examining the patient. 

How to improve

Often subtle changes to your consultation are required to improve your structure. It can be quite difficult to do however as an excessive structured case can appear false, rigid and artificial. Whilst taking a history starting off with open questions before delving into more close and focused questions can help. If you have a working diagnosis, do not reveal it to the patient until closer to the end of the station at least after examining them. 

Like a driving test signposting is often useful for both the examiner and patient alike. Seek permission from the patient that you intend to ask more questions about their presenting complaint or in fact are going to examine them. You could say: ‘Is it alright if I ask you more questions about…?’ or ‘Is it OK if I go on to examine you now?’ 

At the end summarising back to the patient your findings is also a useful way of signposting to the patient that you intend to verify the information you have collected and are about to move on the discussing a management plan. 

2. Does not recognise the issues 
or priorities in the consultation

The MRCGP CSA examiners had felt that you had not fully acknowledged or addressed the issues or the patient’s agenda in the CSA station. Often this means that the case was not allowed to progress and was only superficially covered without delving in deeper. This may be that you had overlooked the patient’s own agenda which is often the reason. A patient may have attended diarrhoea and vomiting at work and the candidate failed to elicit the patient’s occupation, the impact his symptoms had on his work and whether the patient can in fact return to work especially if they worked around food i.e. a chef. 

How to improve

Patients rarely present forth right with their true agendas and often mask them behind numerous and at times complicated verbal and non-cues. Whilst it is important to tackling the presenting problem from a medical point of view, i.e. oral hydration etc, one must remain vigilant and actively observe for any non-verbal cues and listen to any subtle verbal cues. Often asking a simple question may unravel them, i.e. ‘you look confused when I asked about…’ or ‘can you tell me more about that…’ ’can you tell me what you meant by…’ 

A good technique to practice picking up cues and non-verbal communication is to have a practice consultation with a friend or patient and for a moment ignore their medical complaint and try listening and observing them and firing inquisitive questions on a human level rather than a medical one. If it is a real patient, do not forget to revisit their medical complaint and manage it appropriately of course! 

3. Shows poor time management 

Unfortunately the CSA examiners had identified that you had failed to complete the station within the assessed 10 minute consultation period. This is a common complaint made against registrars and can have a detrimental effect on other domains including management plan and your overall score. If you do not have sufficient time and are still stuck on examining the patient, the examiner will not be able to assess you or award you any marks on your management skills. 

How to improve

Often registrars elaborate too long on taking a thorough history and developing a strong rapport with the patient before running out of time. Alternatively they may perform an extensive examination or request for an endless number of blood tests or investigations. Making your history gathering focused by allowing the patient to lead the consultation can help. This helps prevent a battery of yes / no questions and make for a more natural consultation. 

Also it is useful to record and observe yourself on video to see if you have a habit of repeating a line of questioning. Often in real life patients forget and may answer differently to the same question. As a result doctors often repeat a question and phrase it subtly differently to get a different response. The CSA actors are effectively trained to give you accurate responses and will not intentionally mislead you down the wrong path. Similarly when explaining a diagnosis or management plan candidates should be succinct and to the point. Elaborating too much and repeating things can waste valuable time. 

Some candidates spend a significant time summarising every finding back to the patient at the end of the case. Whilst summarising is useful it should be condensed to the salient points only to save time making it relevant. Summarising back is a particularly useful tool if you are confused or stuck in the consultation but can result in the candidate running out of time if used incorrectly. 

4. Does not identify abnormal findings or results
or fails to recognise their implications 

This performance area suggests that the candidate did not interpret the medical information adequately. This may be in the form of a blood test, investigation, examination finding or from the history itself from the patient. Failure to interpret this information correctly can lead the consultation meandering away from the ideal outcome as it can lead to a misdiagnosis with potentially serious consequences with failure to offer appropriate advice and safety netting. 

How to improve

This is focused on your medical interpretation skills and knowledge base. If you have scored poorly in this area, consider revisiting the medical books to refresh your knowledge. Consider revisiting your AKT notes or the oxford handbook for General Practice. 

The CSA exam focuses on common conditions that are likely to present in general practice and exposure to more cases in real life with discussions with your GP trainer about these may help improve your performance in this area. 

Other helpful advice can be to review your practice QOF register and check on your colleagues and peers’ consultations. How did they manage those patients and what investigations were necessary for them? How were their results interpreted? 

Common pitfall areas include interpreting the peak flow difference needed to diagnose Asthma (PEFR) or interpreting spirometry results in a suspected COPD patient. Other difficult cases could include interpreting a patient’s CVD risk score and their cholesterol levels adequately. Often candidates may get muddled by the new indices for interpreting HbA1c levels and the cut off ranges to diagnose Diabetes or ‘pre-diabetes.’ Doctors can also struggle in knowing the cut off limits for interpreting PHQ9s or HADS scores in cases of depression or AMTS or MMSE correctly for a patient with suspected dementia. Knowing how to manage a patient with a drop in eGFR or diagnosing chronic kidney disease can be difficult especially with abnormal proteinuria or albuminuria. 

5. Does not undertake physical examination competently
or use instruments proficiently 

The CSA examiners felt that unfortunately you did not perform an adequate physical examination of the patient nor used the diagnostic instruments available to you proficiently. This can be that your examination was not focused enough on the presenting complaint and too broad in nature or that your examination was inadequate in detail and failed to elicit all the findings available from the patient. In adequate examination that failed to examine the relevant systems may lead to the MRCGP CSA examiner withholding vital information from you on the examination card. 

How to improve

The MRCGP CSA exam is looking for a focused examination on the presenting complaint. This can be quite tricky as it is a fine balance between performing a comprehensive examination that often is time consuming compared to a superficial one that is speedily performed but lacks detail. Also knowing when to examine is equally important. You may think a station is focused on communication skills when in fact a proportion of the marks was set aside for an assessment of your examining skills. 

Often screening examinations are useful that aims to pick up as many signs as possible with the addition of some focused special test such as Phalen’s test or Tinel’s test when examining for Carpal Tunnel’s syndrome for example. 

Consider performing more DOPS on your e-portfolio and have them observed by your trainer or by consultants or specialist SPRs in hospital. There are a range of useful e-learning video modules available on the internet and on the RCGP website showing how to perform the majority of these examinations proficiency and succinctly without wasting too much time. 

Consider what potential examinations can arise in your MRCGP CSA exam. The list is not unlimited and surprisingly short. Practice these examinations with your colleagues in your practice group so that they become second nature for you for the purpose of your exams as well as for the benefit of your daily consultations. 

6. Does not make the correct working diagnosis
or identify an appropriate range of differential possibilities 

The examiner has felt that you failed to make the correct diagnosis in your CSA station or offered suitable alternative differentials. Whilst it may be perceived as a fatal mistake missing the diagnosis, it is still possible to collect a significant number of points with good communication skills and safety netting appropriately. The key message is not to give up if you feel that you have missed the mark on the diagnosis but remain calm and collected and try your best to be as thorough as possible in other areas. 

How to improve

Admittedly there is some overlap with other areas of the feedback and this point is heavily linked to the previous heading of failing to interpret abnormal findings. Unfortunately if you fail to take a focused history and interpret the results correctly, it is more than likely that it will have an impact on reaching the correct diagnosis. 

Candidates can often fall in the trap of using vague language when they are trying to explain their diagnosis to the detriment of the patient and examiner. They may fall into autopilot mode and continue to explain the management plan of mechanical back pain without explaining the diagnosis or considering differentials with the patient. Patients are accepting if the doctor is not sure or unclear of what the diagnosis is at this moment and explaining this to them can be beneficial and appear honest. It may be worth explaining the differential diagnoses you are considering if this is the case. 

7. Does not develop a management plan (including prescribing and referral) reflecting knowledge of current best practice 

The examiners had felt they your medical management plan was lacking in depth and relevance to current up to date guidelines. It may have been that you had prescribed a medication or antibiotic that was not best practice for the presenting complaint or failed to refer them appropriately to the most appropriate service. In your MRCGP CSA exam, candidates are offered a pack of prescription paper and investigation forms that patients rarely may demand to take before they leave the room. Candidates are expected in this occasion to complete them correctly and legibly and they will be assessed upon it. Under the pressure of the CSA exam it is very easy to make a mistake or dosage error and be penalised as a result. 

How to improve

It is important to be familiar with the most up-to-date NICE guidelines and SIGN guidelines. There are other national guidelines that are available as well such as the RCOG that can be referred to in your management. MRCGP CSA cases are well researched and evidenced based by examiners and often if a candidate is reflecting recognised guidelines in their management the CSA examiners will reward you for it. 

Review your written entries with your GP trainer and confirm if you have best managed those patients against reported guidelines. Equallly discuss difficult cases in your VTS groups or practice groups for purposes of learning. Consider attending GP refresher courses at compact all the latest evidence based advice and guidelines into a day course. 

Try practicing in groups common presentations and forming bullet point management plans for each. If you intend to prescribe a drug to the patient have a habit of describing what the drug is, how it works and what dose and frequency they need to take it. This will naturally improve compliance with the medication. 

Consider bringing your referrals to the practice meetings and discuss them internally. Utilise the experience within the clinicians at your practice to consider if the referrals were appropriate and met national criteria. Memorise national two week wait criteria in case to encounter a patient with red flag symptoms. 

8. Does not show appropriate use of resources,
including aspects of budgetary governance 

The examiner has highlighted that the candidate has not utilised all the resources that is readily available to them and has not considered fully the financial verses cost benefit implications of their action. As GPs we are often seen as the entry point to the NHS or ‘gate-keepers’ and allow access to all secondary care services and beyond. However, equally we have a duty to ensure our activities, including referrals and prescribing, take into account best medical and cost effective practice. This is because the NHS has a finite resource that should attempt to benefit as many people as possible with. 

Examples where a doctor may have not have made best use of their resources would be complying with a patient who insists on having a specific branded more expensive medication rather than an equally effecting generic equivalent agent; or a patient who requests for prolonged inappropriate sick note from the GP despite resolution of their symptoms. Other examples include a GP referring a patient to cardiology outpatients for a simple ECG when they could easily organise simple investigations in the community or even within the practice; or a patient who has already been referred to see a specialist but insists on having second and even third opinions at other hospitals. 

How to improve

Many secondary care services are now moving into primary care and being aware of local pathways and protocols will give in an insight of what is readily available. Some musculoskeletal services are found in the community and there are numerous specialists such as Rheumatology, ENT, urology, dermatology and diabetes GP’s with specialist interests running local services. These clinics are often commissioned at a lower tariff compared to secondary care and can be cheaper to refer to for the health economy than the hospitals whilst offering similar quality. 

Engaging with a senior experienced GP at your practice will help you identify some of the local services available in the community. Also being aware of the resources at your own practice can be also useful. Some practices offered in house phlebotomy, ECG, ambulatory BP, smoking cessation clinics and sexual health clinics to name but a few. 

It is also important to engage yourself within the practice meetings and perform practice audits to familiarise yourself with budgetary responsibilities of GPs. Practices are responsible and accountable of their drug as well as referral budget and have a duty to minimise where possible in appropriate Accident & emergency visits by patients due to the cost impact on the health economy. Speak to your practice manager who would have also be a valuable resource of information. 

9. Does not make adequate arrangements for follow-up
and safety netting 

The examiners felt that the candidate did not put into place suitable arrangements to see them again in case their symptoms worsened. They did not make an adequate attempt to education the patient about worrying symptoms when they should seek medical advice. Examples include a patient with asthma with worsening shortness of breath. Whilst they visit you, you may make the decision that they are stable after assessing them and that they warrant treatment. However, it would be appropriate to follow the patient up to ensure that their shortness of breath improved and more importantly they be informed of red flag symptoms such as inability to complete sentences, haemoptysis, etc to seek advice more urgently. 

How to improve

As GPs we often encounter illness in its early phase making their presentations difficult to map to particular illness. We often have to work with uncertainty and may make early judgements on symptoms due to their prematurity in presentation. As the patient goes home, unknown to the doctor, their illness may later deteriorate into something more serious. GPs therefore use follow-up appointments and safety netting as a measure to minimise risk. 

When safety netting one should offer advice that includes what to expect of the illness in symptoms as it develops, its natural history in duration and worrying unexpected symptoms when to seek medical advice. 

You should also offer appropriate follow appointments depending on the problem and illness. A person with raised cholesterol levels may warrant a longer gap to ensure that they have implemented their diet change and for it to have any impact upon their levels compared with a patient with a nasty bout of shortness of breath and cough following a suspected viral infection. 

10. Does not demonstrate an awareness of management of risk or make the patient aware of relative risks of different options 

GPs encounter a degree of risk with every consultation. It may be that a patient presents with symptoms with borderline severity that you may feel can be managed in the community rather than secondary care. Other forms of risk may arise from your management options, such as counselling a patient for the pros and cons of surgery. Inaction equally can have risk and patients need to be informed of each. 

How to improve

Being able to risk manage first requires sound knowledge about the matter and then the communication and negotiating skills to convey the options to the patient. Try practicing with your peers or your GP trainer difficult scenarios where you are required to explain the risks of each option. Examples include considering starting a patient on Hormone Replacement Therapy (HRT) and advising them of the risk of breast cancer or recommending a patient to be started on a statin due to their CVD risk score being about 20%. Other cases include counselling a patient who has borderline UKMEC scores the option of taking a COC or POP. 

Other more subtle but equally challenging case includes assessing a depressed patient on their risk of self-harm. This would assess your ability to determine their risk through your history and observation skills and tactfully asking probing questions without upsetting them too much. 

11. Does not attempt to promote good health
at opportune times in the consultation 

The examiner had felt that you failed to offer adequate health promotion advice during the consultation. Patients are often unaware of what constitutes as healthy living – ie the amount and quality of exercise, food, levels of smoking and drinking that is acceptable. Many studies have shown the impact a few simple word of advice can do when given from the correct health professional. GPs are held in high esteem in society and we have a responsibility to recommend good healthy living for our patients. 

How to improve

Health promotion advice should be given opportunistically and in a timely fashion. It can be tempting when hearing a comment made by a patient regarding their smoking habits to bombard them instantly with smoking cessation advice. It would be especially inappropriate to do so if the consultation was about breaking bad news of breast cancer in the family. The doctor should make a habit of offering health promotion advice as a side note to their management plan rather than interrupt the flow of the consultation which would instead give the appearance that they are lecturing the patient. Also it has to be offered tactfully. Try enquiring gently if the patient has considered stopping and if they would be interested in knowing how to stop. 

Try familiarise yourself with common lifestyle advice such as techniques how to lose weight and do appropriate levels of exercise and what constitutes healthy living. It is equally useful in knowing health promotion advice in common conditions such as diabetes, hypertension, obesity and hyperlipidaemia. Read as many patient advice leaflets which often are rich in useful gems of knowledge and tips that can be given to patients. Peppering them in your CSA exam where relevant may make your consultation more natural. 

Avoid gifting only a leaflet to the patient and advising them to read it. Evidence suggests that they rarely do unless it is briefly explained to them of its content. Similarly you will likely be scored down in your exam if you do the same. 

Other tips include knowing the ages and limits for common immunisation and screening programme. It is always useful to remind patients that they are due the smear test or that their child requires their booster jabs. 

Reference: RCGP 

Making sense of the Feedback and Changing your Consultation

By Nazmul Akunjee & Muhammed Akunjee