This is the 'heading' that most candidates do well in, according to RCGP data. I suspect the reason for this is that most candidates spend their time focussing and practising this part of the consultation. Outlined below are helpful hints and tips to aid you in your 'data gathering'.
Introduction : starting the consultation
In the CSA, the patients will enter your room once the bell has rung, it is advisable to get up to meet them, either with a handshake, or a smile. Don't just remain seated.
Everyone introduces themselves slightly differently, everyone will have their own style. It's usually advisable to introduce yourself as Dr (surname) or Dr (forename, surname) rather than just on a first name basis.
Make sure within this stage of the consultation you start with your open question, listening hard for any cues that are mentioned. We found in our exam that EVERY SINGLE case presented us with one cue within the opening sentence/paragraph.
Be sure to establish at this stage what they are presenting with, and if there are any other problems they wish to discuss today.
Consultation Models : putting theory into practice
No doubt you will remember revising for your AKT, learning about the different consultation models. Well now is your chance to apply them! There are a large number of consultation models out there, with the Calgary Cambridge method being a good starting point.
The Calgary Cambridge method. Derived from Pendleton's approach it is an evidence-based approach to integrating 'tasks' of the consultation for effective communication.
The consultation is divided into:
We found that adding in a few elements from Roger Neighbour's Inner Consultation method, helped to make a good basis for a consultation.
'The Inner Consultation' by Roger Neighbour
So if we combine the two we get:
Askdoctorclarke has a great document highlighting different consultation models, and how to apply them, click here to read it
History Taking : structured approach
It's important to have a structure for your history taking. We found this structure worked well:
Remembering that layout means you shouldn't forget to ask anything important.
Cue Handling : unlocking the consultation
Cues are probably the most important aspect to get right in the CSA. Whilst the above framework for history taking is a solid basis, it's not really possible to follow it rigidly in most cases.
One important point, there are no dead end cues: If a patient mentions a cue, it will be there for a reason. Remember that the cases you undertake in the CSA will have been practised and perfected that morning before you arrive. Any cue presented to you is a cue you must follow!
We found that within the presenting complaint, every case had a cue that you needed to deal with. So the next question, is how do you deal with these cues. There are two ways, the first is that you can park that cue:
"I noticed you've mentioned ..... I would like to come back to this later if this is ok?"
The second way is to deal with the cue there and then.
"I noticed you've mentioned ..... Tell me more about this.."
There is no right or wrong way to handle cues (with the obvious exception of ignoring them!). We found that following the cues when they first present was the easiest method for us, as this often exposed the patients ideas, concerns and expectations very quickly. Once you had then followed the cue as far as it went, then you go back to the above framework to fill in any details you haven't yet got. If you do decide to park the cue, then remember to come back to it later!
No : means no
This bit of advice is short and simple: No, means no! If you ask a patient something that is a dead end, or enquire further about something you feel is a cue but isn't, the patient will 'help' you by pointing out that there is nothing further to discuss in this area. This is usually done in a fairly unambiguous way.
Do not then continue to waste your time trying to go down the same route of enquiry, it will get you no where, and it will waste your precious time.
Examination : keeping it simple
Within the CSA exam you will be expected to perform clinical examinations of some patients. Most candidates will perform around 4 examinations during the 13 station examination.
It is impossible to know for certain before hand which stations will involve an examination, therefore it is advisable to reverse all of your clinical examination skills prior to sitting the CSA. However, certain stations do lend themselves more easily to examinations than others, such as ENT, Muskulo-skeletal cases, Cardiology, Respiratory, Gastroenterology etc..
As you do not know which stations require you to perform the examination, then if you feel clinically that an examination is warranted in any case, then go ahead and begin to undertake the examination as you would in clinical practice. Start by explaining what it is you want to examine, what the examination will involve, and why you are undertaking that particular examination. If a chaperone is required, then please state so now.
The above is very important, as the examiner may not reveal certain parts of the examination unless you state that you would have done such tests. I.e. they may not reveal fundoscopy findings, if you do not reveal that you wish to examine the back of the patients eyes.
If you re to continue to perform the examination, then the examiner will allow it, if not, then they will stop you, either revealing the examination findings on the iPad, or letting you know verbally what the examination revealed.
As you are well aware time is very limited during the CSA, therefore you must be able to perform the expected examination in under 2 minutes. This part of the revision process is so often overlooked, so make sure you spend some time perfecting your examination skills. Subsequently in certain cases (listed above) that are more likely to contain an examination, you will only have around 8 minutes left to do the rest of the consultation. So when timing yourself in such cases, make sure you can do them with the examination within 10 minutes, or in around 8 minutes without the examination.