nMRCGP: CSA practice case - Forgotten medication

To be used individually or in a study group with someone playing the doctor, patient and assessor. Dr Prashini Naidoo provides this CSA practice case

The clinical skills assessment (CSA) tests the candidate's ability to gather and assess medical information, make structured, evidence-based and flexible decisions and communicate with patients in a way that moves the consultation forward in an ethical and responsible manner.

The candidate passes if they ask the patient the right questions, at the right time, in the right way, perform the right examination correctly and communicate effectively, all within 10 minutes.

Performing mock cases with your tutor or fellow registrars is a way of gaining valuable feedback and to see how your skills are improving along the way.

In this series of mock CSA cases, patient and doctor roles are provided along with examiner feedback to see how you score across the three CSA marking domains.

Do not turn over the page until you are ready to read the marking guide and debrief. The marking guide and debrief also provide useful pointers towards the knowledge base needed for passing a CSA consultation such as this.

How to use this article
This article can help GP trainees prepare for CSA. It is written for use in a study group, ideally consisting of three trainees.

The marking grid in this article models an ordered, step-wise approach to data gathering, management and communication and the group debrief is essential to review the actual performance.

The feedback as a whole informs the doctor about their current knowledge and communication skills and advises them how to improve their performance for success in the CSA.

The 'patient'
The trainee playing the patient should read the 'brief to the patient' section to enable her to understand the expectations of the patient so she can then answer the doctor's questions.

If an examination is expected, the patient is briefed about the findings and may have to make up a card containing the relevant information prior to starting the consultation.

If the patient brief does not contain this information, for example a BP reading, and the doctor wishes to examine the patient, the patient should allow the examination to occur. Performing irrelevant or unjustified examinations eats into the consultation time. Intimate examinations are not permitted.

The 'doctor'
The trainee playing the doctor should read the 'patient medical record' section at the start of consultation because it contains a summary of the patient's relevant details.

A recent test result, such as a fasting glucose result, may be provided. Sometimes, a copy of the last patient consultation is given. The background information often provides a clue about the consultation or gives important data relevant to management decisions.

The 'examiner'
Ideally, the third trainee playing the examiner should enter the consulting room with the patient and sit unobtrusively where the doctor cannot see them.

The examiner should mark the case using the marking guide by ticking against the positive or negative indicators as the consultation unfolds.

At the end of the consultation, the examiner should also make a global judgment of whether the doctor, based on this consultation, is fit for independent practice. The examiner times the case sounding an alarm when the 10 minutes are up.

Patient: Brief to patient
  • Mariam Aziz, a 71-year-old Pakistani woman. Today you travelled from Glasgow to visit your son.
  • You present as an emergency because you forgot to pack your BP medication.
  • Your son called your Glasgow practice to find out the medication, which is bendroflumethiazide 2.5mg once daily, atenolol 50mg once daily, aspirin 75mg once daily, and diazepam 2mg at night.
  • Your son accompanies you into the consultation.
  • You speak good English. If asked, you don't mind your son coming in with you. However, if probed about your medical issues, you become uncomfortable discussing these in your son's presence.
  • You mention that a week ago, the hospital heart doctor recently added a tablet because the heart was 'getting weaker'. You are unable to remember the tablet's name. Your feet are not swollen and your pulse today is 64 bpm and regular.
  • If questioned about the diazepam in front of your son, you are reluctant to discuss the issue. If on your own, you discuss your grief at your husband's death two years ago, your subsequent depression and insomnia. You stopped the antidepressants but when you tried stopping the diazepam, you felt anxious and couldn't sleep. You want the diazepam prescribed and become upset if the doctor seems reluctant to prescribe it.
  • You are happy for the doctor to call your GP and issue a script later.
  • You are a quiet woman but when asked, you have opinions on what you want.
  • You are also slightly hard of hearing and if the doctor speaks too quietly you ask him or her to repeat the information.
Doctor: Patient medical record

Name: Mariam Aziz (71 years)

Past medical history: Not known - patient is a temporary resident.

Examiner: Marking guide
GENERIC INDICATORS FOR TARGETED ASSESSMENT DOMAINSDESCRIPTORS - POSITIVE AND NEGATIVE

A. Data gathering, technical and assessment skills:

  • Gathering of data for clinical judgment, choice of examination, investigations and their interpretations.
  • Demonstrating proficiency in performing physical examinations and using diagnostic and therapeutic instruments.













Positive indicators:

  • Establishes rapport with Mrs Aziz and is mindful of discussing her medical issues in front of her son.
  • Asks open questions to explore the medication request, followed by closed questions to clarify how the list was compiled and whether the repeat scrip includes the 'new' tablet.
  • Enquires about the medication, possible side-effects, dosing regime and compliance.
  • Excludes red flags, such as heart failure or arrhythmias.
Negative indicators:
  • Questioning is not sufficiently detailed. Most questions should address a medication review to enable safe prescribing.
  • The patient's use of diazepam is not explored.
  • If a physical examination is undertaken, examination skills are neither sufficiently selective nor fluent.
B. Clinical management skills
  • Recognition and management of common medical conditions in primary care. Demonstrates flexible and structured approach to decision making.
  • Demonstrating ability to deal with multiple complaints and comorbidity and to promote a shared approach to managing problems.
Positive indicators:
  • Discusses what they feel is the safest course of action and explains their reasoning.
  • Management options, including writing a scrip following a telephone call to the patient's GP, are openly discussed and offered to the patient.
  • Management is appropriate to the patient's level of risk. If new medication is to be prescribed, the need for follow-up is discussed.

Negative indicators:

  • Failure to prescribe safely or in line with current best practice.
  • Follow-up arrangements are inadequate.
C. Interpersonal skills
  • Use of recognised communication techniques that enhances understanding of a patient's illness and promote a shared approach to managing problems.
  • Practising ethically with respect for equality and diversity in line with accepted codes of professional conduct.
Positive indicators:
  • Displays rapport-building skills; the doctor communicates effectively with the patient, not her son, using appropriate language and volume.
  • Identifies the patient's embarrassment at discussing her medical details in front of her son and responds appropriately.
  • Develops a shared management plan, which incorporates the patient's specific concerns about diazepam withdrawal.

Negative indicators:

  • Assumes the patient cannot speak English and communicates with her son.
  • The language is not pitched at the right level for this patient.
  • Speaks too softly or too loudly.
  • Appears judgmental about the use of diazepam.

Debrief

  • Assess the doctor's verbal and non-verbal response to the patient and her son. Were assumptions made about the patient based on her ethnic or cultural background?
  • Was the patient's medical confidence preserved?
  • Did the doctor seem genuinely interested in helping the patient obtain her medication and in prescribing it safely?
  • Was the patient given the opportunity and time to answer questions?
  • Was there a shared management plan that incorporated the patient's concerns and expectations?
  • A common reason for failure in the CSA is the doctor 'does not identify the patient's agenda, health beliefs and preferences or does not make use of verbal and non-verbal cues'. Did the doctor detect and respond to the patient becoming uncomfortable with detailed questioning in her son's presence?
  • Another common reason for failure is 'does not recognise the challenge (for example, the patient's problem or ethical dilemma)'. Was the doctor mindful of the recent cardiology recommendation and check if this had been added to the patient's repeat medication? Evaluate whether the patient's medical confidence was protected throughout the consultation.

Resources
National Prescribing Centre. A guide to medication review 2008. www.npci.org.uk/medicines_management/review/medireview/resources/agtmr_web1.pdf

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