Chapter 1
Maximizing your potential in the CSA

In planning this book, we aim to help you understand more about three main areas. Firstly, your own personal needs in order to pass the exam. Secondly, how to get the most from your 'patients' or role-players, and thirdly, how to understand more about the exam itself. This chapter addresses how you can develop to your full potential in the CSA exam and beyond. We cover how to assess your own needs in terms of knowledge, consultation skills and also, very importantly, the preparation needed for maximizing your performance on the day. The goal of passing the CSA may be the initial motivator to develop these areas. Our real hope, however, is that you come to see your journey to success in the CSA as an excellent preparation for your life as a GP. We expect you to go on, equipped with your skills, to be successful in General Practice.

The aim of this chapter is to suggest resources for you to assess your needs, identify any potential barriers to passing the CSA and generate strategies to overcome any such barriers. This will result in drawing up a 'CSA PDP' to use and put into practice in the weeks or months before the exam. Practice of both consulting strategies and psychological strategies for dealing with stress, so as to focus purely on the 'patient', will, therefore, be honed and your all-round potential maximized in time for the exam.

Take this moment to note down any areas where you feel less confident, and so to begin to draft your CSA PDP

Thoughts such as

'I hope undiagnosed vaginal bleeding, or Parkinson's disease, doesn't come up', are a good place to start making your planning list.

Think of your last difficult consultation, for example an angry or very anxious patient, and add that to your development list.

Think of the last patient who left your room less than satisfied, and add the possible reasons to your wish list to practise.

When doing an assessment of your educational needs, it is important to focus equally on the clinical aspects of general practice as well as on interpersonal skills. This is reflected in both the marking schedules and the college motto Cum Scientia Caritas, 'science with compassion'. The assistance of your trainer/educational supervisor in assessing your educational needs is paramount, as they will often have had the benefit of working with many other learners in order to form an opinion. Your Programme Directors may be valuable resources too, as, of course, are your peers on your VTS, in helping you build on your strengths and identify areas for improvement in terms of knowledge and competence.

Knowledge

Assessing your knowledge base is something you may have done at the start of your registrar year by self-rating, and also after a discussion with your trainer. This activity should lead to an educational plan. A month or 2 before the CSA is an ideal time to revisit this process, taking into account the current GP curriculum and any 'Hot Topics'. A number of tools exist - for example the RCGP 'Condensed Curriculum Guide self assessment scale'. This is available online, via the RCGP website, and can be purchased from the RCGP Bookshop.

It covers knowledge, skills and attitudes. A number of other possible rating scales exist - anything which accurately covers the curriculum will be fine, if the layout suits you. Patients themselves are an excellent resource. By identifying patient unmet needs (PUNs) in your consultations, you will identify your doctor's educational needs (DENs) - (Eve, 2003).

Time now to do a brief knowledge-base assessment to confirm areas of the curriculum needing attention

Ideally 1-2 months before the CSA exam:

• Use one of the GP curriculum confidence rating scales.
• Write the areas needing development in your CSA PDP form, at the end of this chapter.

Having decided any areas for development, these can be entered in your 'CSA PDP'. Following this, a strategy for improving these areas and potential resources for doing so can be listed.

LEARNING POINT 1: 'My CSA PDP' - resources for improvement

• RCGP e-modules EKU (Essential Knowledge Updates) are compiled by representatives of the examiners' panel.
• 'Innovait' - covers every section of the Curriculum on a 3 yearly cycle (ST1-3).
• Summaries of GP guidelines such as 'e-guidelines' which also produce a book with a compilation of current guidance in handy flow charts and tables.
• GP free magazines which include CPD or review articles, for example 'Prescriber' magazine.
• 'PUNs and DENs' after each surgery, with a quick reference to the current guidelines after seeing patients.

A tip we often give is to repeat an AKT test or two in the month or so before the exam - this may expose gaps in your learning and is likely to prompt you to polish areas that may be hotter topics.

Consultation skills

From the analysis of the feedback to candidates given by examiners during the marking process, we know which areas of the consultation are highlighted most commonly, and are, thus, the areas most likely to cause you difficulty in the CSA.

The first aim of this section, therefore, is to help you identify potential barriers to passing the CSA, and hence make plans to maximize your potential. Secondly, we will summarise the most successful ways you can develop awareness of your consultation style. Finally, but possibly most importantly, this section will raise awareness of behavioural theories, which help interpersonal interaction, and, therefore, have the potential to improve your patient consultations. Such skills can most certainly be learnt, but only with practice and feedback from your patients and educators.

LEARNING POINT 2: Examiners' feedback statements - areas commonly highlighted by examiners as needing improvement

• Consultation structure/time management.
• Management plans in keeping with current best practice.
• Identifying the patient's agenda, health beliefs and preferences.
• Use of verbal and non-verbal cues. Active listening.
• Sharing the management plan, clarifying the roles of doctor and patient (RCGP, 2014; Trafford, 2010).

Issues with structure can be addressed by watching your own videos, and analysing the sections of the consultation, using any of your favoured consultation models. Comparing your consultations against consultation models and also against the feedback statements may highlight for you which areas of the consultation are receiving least attention, and, therefore, need developing. Commonly, during the time-limited CSA consultations, candidates spend too long on data-gathering, leaving little time for the management plan, and even less for sharing ideas with the patient around the management plan. This is emphasised in the recent consultation model, 'The Consultation Hill' by McKelvey (2010), which refers to the preparation for the CSA in terms of managing 10-minute consultations and leaving sufficient time for these vital sections.

The feedback statement given to a candidate - 'Does not develop a management plan (including prescribing and referral) that is appropriate and in line with current best practice' - suggests that the knowledge base needs addressing. In a sense, it should be possible for all candidates to remedy this, using the methods mentioned in the 'Knowledge' section. Practice in applying the knowledge is required, as real patients are generally far more complicated than the guidelines suggest, often having multi-morbidity or important influencing factors in their social situations. Hence, discussion of cases with your trainer and practice/community team colleagues, and also checking that knowledge is truly sound, will improve these areas. Examples could include being aware of prescribing for the presenting condition safely, but in order to do this, you may have to take into account a patient's other medical conditions, or occupation, which would influence appropriate or safe choices (e.g. prescribing in safety critical jobs such as tube train drivers, or in pregnancy).

The feedback statements - 'Does not identify the patient's agenda, health beliefs and preferences', and also 'poor active listening and use of cues' - are at the heart of interpersonal skills during the data-gathering section of the consultation in particular. Here, GP consultation models as well as other simple behavioural models can be extremely effective in GP consultations, particularly with role-played CSA cases. Such behavioural or neurolinguistic models give us some very useful pointers to consulting effectively -

• Become interested and curious
• Create rapport
• Ask questions
• Listen and check your understanding of what they describe
• Pay particular attention to their non-verbal communication
• Leave enough time for management (adapted from Reg Connolly + Pegasus NLP, 2014 for the GP consultation by Dr R Roberts)

For example, if you ask a person presenting with headaches how things are at home, and there is an immediate break in eye contact, and a change in posture to become more closed, it would suggest that home may be...