CSA Examiner Feedback- Richard Adams, Bill Hall, Louise Riley as interpreted by Simon Hall

White Hart, Harrogate, 2nd May 2012

Do

Read all the information provided before the patient enters the room

LISTEN. Understand the reason why the patient is attending today. If you don't you won't recognise the
issues and priorities in the case. When reviewing consultations with your trainer try stopping the recording
when you feel certain you know why the patient has attended. Does your trainer agree?

Time management- use the 10 minutes you have wisely. Digital clocks are provided in the exam but great
interpersonal skills and data gathering will not be enough to pass if you don't get to the correct management
plan in place in time. Avoid repeating yourself when data gathering or developing the management plan.

Have an evidence based management plan. Make sure you review it with your trainer when reviewing cases
together in preparation.

Explain and negotiate in order to share the management plan. You need to reference their agenda in doing
so. A shared management plan is not simply a list of possible options. If different options are available then
some will be better than others. The doctor is there to help the patient to make an informed choice.

A short succinct summary then "is there anything else?" opened up a consultation by "encouraging the
patient's contribution" – but do this in the first half of the consultation NOT right at the end!

Get your management plan out in the 10 minutes perhaps with bullet points "from the way I'm thinking at the
moment there are 4 things we are going to need to do" may work whereas a long list may not. You should be
starting this around the 7 minute mark at the latest. "it also helps if the management plan is the correct one!"

Do acknowledge your uncertainty if unsure but do decide on a diagnosis and treatment at some point.
Avoiding making a decision becomes obvious to all.

Avoid a rigid structure to "go with the flow" so if the patient says something important follow them but still try
to keep the data gathering focused.

COTs are a useful framework for assessment but only help CSA preparation when used for teaching and
development purposes. "why and how something needs further development" should be considered. We
may need a shift of emphasis to make sure we consider the management plans.

Pick up on cues such as changes in facial expression, responding with "you look, sound" etc for non verbal
cues or perhaps echoing "special or strong" words and phrases. Also look out for things that don't quite fit.
"These patients aren't going to ramble on about grandma's illness unless grandma's illness is relevant, so be
nosey especially if something doesn't quite fit!"

Housekeeping. Nerves and anxiety will affect you but once a case is completed and if it hasn't gone well then
"it's past, it's history, move on"

Do what you normally do (so long as it's sensible!) in your own surgery. Don't do things differently. Don't try
to second guess what the examiner is looking for. For example "if you are not a natural summariser then
don't start summarising for the exam in May [the next exam diet]."

A systems review checklist uses up valuable time and often fails to provide any further useful information if a
proper history has been taken. It appears to be a pet hate of some examiners.

Any examination should be undertaken to the standard of a GP fit for independent practice. If an examiner
says nothing when you move to examine the patient then the examination should be undertaken in a focused
way. If they give you an examination card then there is no expectation of undertaking an actual examination
of the patient.

Listen to the feedback. People are trying to help you. Let them!
Don't

Go immediately/ very early to expectations "two sentences in going to what are you worried about?" and
"what do you want me to do about it?" there was no listening, no time spent, no rapport. A candidate may
appear "formulaic and over coached". The role players are briefed not to respond to such questions. Patients
won't either.

Avoid the use of formulaic phrases "what were you hoping we could do for you today?" after a patient tells
you their livelihood and marriage are threatened because of illness. The question "needs to sit in the right
place."

Use repeated summaries 3 or 4 times throughout the consultation- it is not being marked and though it may
be useful to the candidate to collect their thoughts if nervous or flustered it uses up 10, 20 seconds each
time.

A summary may close down the consultation if repeating in 2 minutes what had been gathered in the
preceding 5 minutes. Again time is wasted. So "this is what I heard" without any elaboration in an attempt to
demonstrate active listening brought a "what was the point?" reaction from the examiner. It simply "switched
the patient off and didn't open up anything."

The fact that the lack of a shared management plan is one of the commonest feedback statements doesn't
always mean that there isn't a correct course of action in an urgent situation such as Chest Pain or 2 week
wait.

The lack of a shared management plan feedback statement is commonly provided when a candidate "hasn't
uncovered the exact reason why the patient is there and understood them fully, where they are in their world
and what is bothering them, so you can't use that information to share a management plan."

Repeating a phrase which initially seemed sensitive and empathetic such as "you look worried, I'm here to
help" made it sound false and insincere. "sometimes you don't realise they are formulaic until you hear it
several times."

Not listening because of following a rigid structure. A really bad example was a candidate who elicited the
patient's concern regarding chest pain and that their father died of a heart attack at the same age. They said
okay but then asked what tablets they were taking because it was in their management plan to discuss
medication next in their checklist.

Showing off your knowledge of the possible causes of a presentation may only serve to frighten a patient
especially if it is a serious one.

Don't continually defer to a patient's wishes in regard to their management plan. They need to be directed,
through negotiation, to make an informed choice. You need to manage their blood pressure or treat their STI
and not ask them what they think needs doing. Don't be too patient centred.

Asking them what they think of a particular treatment for a particular condition, such as steroids for PMR,
comes across as the doctor not knowing what to do.

You must pass the lie detector test to avoid looking insincere. Look at some of your consultations. Do you
appear interested and concerned? Are you too doctor (or patient) centred? Do you appear empathetic and
sensitive? Does the examiner believe you?

Dr Simon Hall 2/5/12