The CSA (Clinical Skills Assessment) is often seen as the ‘big one’ – I remember it seeming like the brick wall between me and being a GP, however much I was told otherwise. I remember not being able to plan beyond it and how the few months leading up to it felt solely about that day in London.
Having passed this exam myself, I remember areas that I struggled with, those that confused me, and those that simply scared me! There were many things however that I benefitted from – things that helped settle those nerves (even if only by 2-3%)!
Below are ten key, but often less discussed tips for this exam – both for preparation, as well as for the day itself.
1) It’s not only about practicing at work. We often hear how seeing patients at work is key to getting through this exam. Of course it is necessary to see patients – gaining experience of diagnostic patterns, figuring out the subtle intricacies of General Practice and gaining insight into how a patient’s mind works are all important – and realised through seeing patients again and again. However, practicing in the CSA format – getting your mind acclimatised to the specific challenges of this exam – is just as important. Set up a study group early; perhaps more importantly however, try to have two or three running at the same time. Practicing with the same people for 3 months non-stop becomes monotonous and mundane – bad habits set in once you ‘figure each other out’, sometimes you even end up saying the same things. Different people, different environments – keep it fresh.
2) Always show RELEVANCE. Data gathering is not done just for the sake of getting data. It is not only important what you ask (most trainees will end up asking similar core questions in the end) – it is important how you ask them. Two people can ask the same question – for example about smoking – but one will look forced and the other natural. The key difference is relevance. Linking questions to the symptom or condition can help show that everything you ask is for a reason. ‘Slightly odd question Mrs. X – sometimes indigestion can be made worse by habits such as smoking – can I check if you do this by any chance?’ is much better than ‘can I ask if you smoke Mrs. X?’, for example. Bring the symptom or condition back as many times as you can in data gathering to show continual relevance for everything that you’re doing.
3) Don’t forget the medicine. Ideas that seems to pop up frequently amongst the many CSA rumours, include that ‘it is a communication exam’ and that ‘its all about language and how nice you are’. Of course these things are important and can help give a better overall mark. Remember however, primarily this is a test of your clinical skills (its in the name!) Don’t focus so much on how you’re doing things that you forget to do the correct thing in the first place. After this exam you will be close to completing training as a GP – making sure your clinical judgement and abilities are sound has to be a priority for assessment – don’t neglect what you’ve been learning for 10+ years due for the sake of ‘trying to be nice’.
4) Start where you don’t want to go. Why do we always start with what we know or like? Whether reading about a condition, revising red flags, reviewing management options and sometimes even practicing cases, it can be tempting to start with ‘nice areas’ – things that you are already comfortable with. The areas that you find challenging are often left to the end – crammed in and covered in a last-minute panic. Start with these instead – the confidence gained from feeling comfortable in dealing with areas that you perceived weak or challenging, is immense. Commonly feared CSA areas? Genetics, palliative care, teenage health – start with those that scare you first.
5) Challenge each other. I remember our CSA study group sessions. Bunch of friends, relaxed environment, food and chat, mixed with a few cases. Even the cases were friendly – information given too easily, breaking into laughter when trying to play an angry patient, overly-positive feedback etc. Make sure you act well – put a little emotion into the case, add in a little challenge. Too often people come out of the exam thinking that it was a ‘step-up’ from what they were used to. Aim to make it feel like a ‘step-down’ instead – make the precious time spent practicing really worth it.
6) Get the first minute of management right. The first minute of management often signals the shift from patient-time to doctor-time. The first minute can eloquently set up the remainder of the case – make it work hard for you. As you sit down from examination, think clearly – what do I need to demonstrate in this next two, three or four remaining minutes. What are the key points that I need to cover? Find a way to demonstrate your understanding of the case early in management – show that you understand the issues going on in this SITUATION as opposed to the CONDITION. Management needs to highlight that everything that you did in data gathering was important and understood – getting the first minute of management right can go a long way to achieving this.
7) Don’t look at the clock 100 times. The clock can be a huge distractor. When practicing we often see this become the focal point of attention, often to the detriment of doctor-patient rapport. Try and resist looking at the clock every 30 seconds – time certainly doesn’t go any slower. Have a few check points that you use to gauge your position but try and keep them to a minimum. For example, the only time that I tried to look at the clock was after I sat down from examination. I wanted to know how long I had left for management, allowing me to understand how I could tailor what I needed to say accordingly. It was important for me to know whether I had two minutes left or five minutes – this clearly influenced how I progress. Time is key in this exam, but please don’t make it more important that the patient in front of you.
8) Use the board. They give you a board to use how you see fit. In real life we sometimes use paper or the screen in front of us to make notes – your board can be used in a similar way. Before a case, some people have a few bullet points written in big words – you will likely go blank at some stage and its nice to have something to flick down to and re-start – ‘Red flags’, ‘ICE’, ‘psychosocial’ are good examples. Some like to jot things down during the case as well, particularly if a lot is going on – again absolutely fine but consider informing the patient first: ‘Mrs. X I hope you don’t mind if a jot a few things down – there seems to be a lot going on here!’ Don’t feel frightened to use your board if you want to – but don’t feel that you must if it doesn’t help!
9) The role-player guides if you let them. Often role-players can be seen solely as the route to the examiner. We are ‘talking’ to the patient but what is being said seems clearly for the examiner’s benefit. Remember the role-player often knows all the key points of the case you’re doing themself – what the key issues are, which areas need discussing and which don’t, which cues are important etc. They can guide you down paths that need expanding or can try and divert you away from paths that are not being assessed. Often we can be so sure of what we think the right path is, the subtle hints and cues fall on deaf ears. The role-player will help you, but only if you listen and let them.
10) Know you’re going to pass. So often I hear people say ‘I’ll never pass the CSA’ or ‘I’ll never cover all of this’. Whilst wishing to pass won’t automatically make it happen, there is definitely something in favour of self-belief. Confidence is a key part of passing any exam – regularly telling yourself that you won’t pass, that you cant pass, but somehow hoping that you will, just makes your preparation that much harder. Regular pep-talks, reminding yourself that you actually know a huge amount and convincing yourself that you will easily pass, will push you that bit harder. Yes the CSA is a challenging exam, but it is one that you have been gearing up for a long time. All the time spent preparing will pay off – you just need to believe it for it to show on the day. Focus on the positive end-point and you’ll reach it much more easily.
CSA preparation is important. It is not just about doing 100 role-plays a week for months on end. Figuring out your strengths and weaknesses early, understanding what is being assessed and tackling your revision in an organised way are keys to success.
We cover these points in depth at our immersion 1-day CSA courses.
Our CSA video tips on YouTube also cover many of these points as well as others.
And if you’re sitting the CSA any time soon….GOOD LUCK!!