Introduction to the Cases in the Clinical Skills
Assessment
Selection of sample
cases with accompanying discussion
Introduction to the
cases
How the cases will be used in
the CSA
How to prepare for the CSA
Introduction to the cases
Cases are written by experienced General
Practitioner case writers, who are members of the MRCGP Panel or
Deanery representatives across the UK. All have undergone training
in case writing.
Cases are chosen to fit into a blueprint
derived from the MRCGP curriculum, and each case can be related to
a specific section of one or more of the Curriculum Statements
(which can all be found on the RCGP website). Cases are often
informed by real life situations the case writers have experienced
themselves and are therefore representative of current British
general practice.
Each case consists of several
sections: instructions to the role player playing the part of
the patient, instructions to the assessor and the case notes.
Candidates will only see the case notes, of course! These are
constructed to look as similar to medical case notes as possible,
although they are not electronically presented. Relevant details
are presented, including relevant past medical history, current
medication and social habits etc. The last consultation may also be
there, or a relevant letter from secondary care, test results, ECGs
etc. The case notes are kept to the essential minimum so that
candidates do not have to wade through unnecessary details to learn
about their ‘patients’.
The final and most important part of the case
is the marking schedule. This has been carefully tailored to the
assessment purpose of the case and some examples are given below.
The following broad areas, or “domains” are assessed in each of the
cases:
- Information gathering
- Clinical management
- Interpersonal skills
In the marking schedule, guidance is provided
to assessors as to what to look for in terms of appropriate or
inappropriate behaviour in the given situation. The generic
indicators used can be viewed by clicking
here. Assessors use this guidance and their observations to
mark each domain separately and then, based on this, produce an
‘overall’ grade for the case. There are four possible grades, which
are:
- Clear pass
- Marginal pass
- Marginal fail
- Clear fail
To view descriptors for these grades please
click here.
The candidate needs to pass a certain number of cases to pass the
assessment overall. The decision on what this number will be,
will depend on the outcome of the currently running national
standard setting exercise.
Candidates will be sent feedback on their
performance in the CSA after the assessment.
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How the cases will be used in
the CSA
The CSA will take place on three
purpose-designed floors of a modern tower block situated directly
opposite East Croydon station in south London. Candidates
will have to register on arrival, bringing proof of identity with
them. Two sessions will run each day, each comprising three
identical circuits (one on each floor).
Each circuit will consist of thirteen
10-minute stations. Candidates will be allocated a ‘consulting
room’, with very basic medical kit provided. They will be expected
to bring their own equipment with them – the equipment generally
found in a ‘Doctors’ bag’. Details of these contents will be sent
out with confirmation of candidates’ applications to take the
assessment.
Candidates remain in their room throughout the
assessment, only leaving for a short coffee break at a designated
time. At the start of the assessment a buzzer will sound, and the
first ‘patient’ will knock on the candidate’s door. These patients
are all role players who have been given a specific role to play,
based on the case instructions and marking schedule. Role players
will have been standardised across the three floors so that all
role players for a given case are playing their role in the same
way.
At the end of 10 minutes, another buzzer will
sound, and the role player will leave the room. After a short break
of 2 minutes, the next case begins with the sounding of the next
buzzer. This process is repeated until all 13 cases have been
seen.
The cases are marked by MRCGP assessors, who
are all trained assessors of postgraduate general practice. Each
assessor marks the same case all day, so that marking is calibrated
and reliable. Assessors follow the role player into the room and
mark the case as it unfolds, sitting out of the candidate’s line of
view. They do not interact with the candidate unless required to do
so. Examples when this might occur are if the candidate wishes to
examine the patient in a way that is unnecessary for the case
marking, or requests a piece of information that the role player
cannot provide or indicates that they would normally use a
particular piece of clinical equipment. Most of the time, they will
remain observant, but silent.
Case selection for each session is decided
according to a pre-determined formula. This will include a
selection of acute, chronic and undifferentiated presentations,
psychological/social cases and cases based on health promotion
issues. Within these parameters, cases will be selected to display
a range of ages, one or two cases will be based on some aspect of
diversity and there will be a selection of male and female
patients. Clinically, cases will span those clinical areas in the
MRCGP curriculum that can be tested in the CSA environment. A few
cases might require a clinical examination skill to be
demonstrated.
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Preparing for the CSA
The CSA cases are all written by GPs active in
British National Health Service and reflect real-life
presentations. Therefore, candidates should have no great
difficulty in taking the CSA, so long as they have had experience
in NHS general practice. For this reason candidates are recommended
to have firstly completed at least 6 months of British NHS GP
practice.
Although up to date knowledge of general
practice and of general medicine is necessary to pass this
assessment, it is not primarily a test of knowledge. It is a test
of the ability to integrate clinical and communication skills, to
produce a consultation that is meaningful to both patient and
doctor and which moves the patient forward towards a justifiable
management of their presenting problem.
Showing an ability to engage patients in the
consultation, using recognised interpersonal skills (such as
enquiring about the patient’s health beliefs and incorporating
these into the explanation given to the patient), is an important
part of the work of general practice and is assessed within the
‘interpersonal skills’ domain of the marking schedules. Valuing
patients’ contributions and respecting their autonomy and
decision-making is also assessed in some cases.
Efficient and targeted data-gathering,
together with correct diagnoses and management plans that are
congruent with current accepted British general practice is also
assessed. Some cases will require a physical clinical examination
and candidates will be expected to be knowledgeable in the
appropriate use of medical instruments and in examination
techniques. Fluency of these procedures will be rewarded.
The overall mark given to the case will depend
on the candidate’s ability to combine the two areas of clinical
consulting with interpersonal skills.
The following tips may help candidates prepare
for the CSA:
- Obtain the Curriculum Statements from the RCGP website and read
through them thoroughly. Each curriculum statement has a section on
common and important conditions and cases are quite likely to be
based on one of these.
- Video your own consultations and watch them with a colleague,
bearing in mind the points made above about the integration of
clinical approach and interpersonal skills. You might want to watch
your consultations several times, marking them for either of the
two skills, and then for the combination of both. This should give
you some idea of the gaps in your performance and where you could
be working to improve.
- Consider the types of clinical examination you could be asked
to perform during the CSA, and practise focussed examinations.
There are some examinations that you are unlikely to be asked to
demonstrate (for example, intimate examinations on a role player,
or examinations that might cause discomfort if repeated over and
over during an assessment day), but you could be asked to assess a
leg, an arm, a chest, an abdomen etc. Make sure you are conversant
with any medical equipment you might need and can handle it with
confidence.
- Think about the sort of letters you receive from secondary care
and the types of test results you see (ECGs, spirometry, blood test
results, urinalysis results, skin scrapings, swabs etc). Make sure
you can interpret them correctly and explain them to a
patient.
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Selection of
sample cases with accompanying
discussion
Document prepared by Kamila
Hawthorne
Sample cases prepared by Kamila Hawthorne,
Mark Coombe, Chris Elfes and Mei Ling Denney on behalf of the CSA
Operations Group
May 2007