Csa Book Mrcgp Csa Cases Mrcgp Course
Short Description
Practice CSA Cases & Communication Skills for the MRCGP CSA Exam...
Description
Practice CSA Cases & Communication Skills for the MRCGP Exam
MRCGP CSA CASES Practice CSA Cases & Communication Skills for the MRCGP CSA Exam
Muhammed Akunjee GP Principal
Nazmul Akunjee GP Principal Clinical Prep Publishing London
MRCGP CSA Cases Clinical Prep (Publishing), 2013 339/341 West Green Road London N15 3PB www.csaprep.co.uk First published in 2013 © 2013 Muhammed Akunjee, Nazmul Akunjee Muhammed Akunjee and Nazmul Akunjee have asserted their right under the Copyright, Designs and Patents Act 1998 to be identified as the authors of this work. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the copyright owner. Important Note from the Publisher The information contained within this book was obtained by Clinical Prep from sources believed to be reliable. Whilst every effort has been made to ensure the accuracy of the material contained herewith, no responsibility for loss, injury or failure whatsoever occasioned to any person acting or refraining from action as a result of information contained herein can be accepted by the authors or publishers. Although every effort has been made to ensure that all owners of copyright material have been acknowledged where relevant in this publication, we would naturally be pleased to acknowledge in subsequent reprints or editions any omissions brought to our attention. All readers should beware that medical sciences are constantly evolving and whilst the publishers and authors have checked all dosages and guidance are based upon current indications, there may be specific practices and procedures that differ between countries and nations. You should always follow the guidelines laid down by the manufacturers of specific products and the relevant authorities in the country in which you are residing and/or practicing. ISBN-‐13: 978-‐0-‐99276610-‐8 Typeset and designed by Clinical Prep, UK Printed and bound by Action Press, West Sussex, UK
Practice CSA Cases & Communication Skills for the MRCGP Exam
Preface Since the introduction of the Clinical Skills Assessment (CSA) as part of the requirements to qualify as a GP in 2007, some registrars have struggled to understand what is needed of them to pass these examinations. The CSA was set up to assess registrars using specifically trained actors recreating situations and scenarios that a competent GP would be expected to face or meet in the course of their clinical practice. A General Practitioner, as the name suggests, is a physician that has a wide knowledge base about a whole range of different conditions and problems. As in real life, almost any type of condition can present at the surgery and the same rings true for the CSA. This does not mean you must know every minute detail about all conditions, as we know that this will be impossible, but rather, means that one must be prepared to face a wide range of presenting complaints and know how to deal with them in a competent manner. Unfortunately, a cohort of registrars have been found to repeatedly fail the examinations irrespective of the length of their clinical experience nor their success in previous clinical examinations. Having worked with a large number of such registrars and helped many of them to pass the CSA examination, we felt the need to write a textbook of MRCGP CSA Cases that would help candidates appreciate the subtleties of the communication skills being assessed which has previously tripped up a number of these registrars.
MRCGP CSA Cases
This Book The MRCGP CSA Cases book has been divided into two sections; an introductory section that goes into detail about the key communication and interpersonal skills needed for the exams, as well as a section that contains challenging MRCGP CSA cases. We have written the cases to reflect the standard of the harder end of the examination spectrum and have tried to combine medical knowledge, with cues, and concerns that so often throw and confuse registrars. For each case we have a candidate brief, a comprehensive actors brief and a case walk-‐through, which we would consider to be the best-‐practice approach for that scenario. We have tried our best to make the cases as realistic as possible but to a level of complexity that can be completed in a 10 minute consultation. When using the book we advise you to practice with at least 2 fellow GP registrars, one acting as the examiner and the other as the actor. In this way, all registrars will be able to appreciate the different nuances of the cases from the perspectives of the examiner and the actor. We hope that this would give you some insight into what is required to pass the CSA exam. Muhammed & Nazmul Akunjee November 2013
Practice CSA Cases & Communication Skills for the MRCGP Exam
About the Authors Muhammed Akunjee MBBS MRCGP PgCert (Diabetes) PgCert (MedEd) Muhammed Akunjee has been a GP Principal in North London since 2007. He also works closely with the local PCT being both a board member as well as mental health lead. He qualified from Guy’s, Kings and St. Thomas’s Medical School in 2002 and completed his MRCGP gaining a distinction in 2006. During this time he was also awarded first prize for the Roche / RCGP Registrar award for a work on miscommunication between secondary and primary care. He is a GP Appraiser for the NCL cluster as well as a BMA Book Award Appraiser. He completed a Postgraduate Certificate in Medical Education at the University of Dundee and more recently, a Certificate in Diabetes at Warwick University. He has attended the London Deanery's, Introduction to Teaching in Primary care course and has taught and examined clinical skills at a London University. He is an avid medical book writer and has a number of articles published in peer review journals. Nazmul Akunjee MBBS MRCGP Nazmul Akunjee has recently completed his GP vocational training and is currently a GP Principal in a large North London practice. He qualified from GKT medical school in 2005 and is currently actively engaged in teaching medical students and preparing them for their exams. He has published a number of articles related to examination skills in peer-‐reviewed journals and more recently has been appointed as a GP Appraiser by NHS England (London).
MRCGP CSA Cases
Nazmul Akunjee passed and excelled at his CSA exam in February 2011 passing all 13 stations at the first attempt. Since that time he has been involved in 1-‐2-‐1 private CSA coaching as well as group tuition with GP registrars. He completed the London Deanery's, Introduction to Teaching in Primary care course in June 2011 and has taught and examined medical students at a London Medical School. Nazmul is currently a GP lead for the Primary Care Strategy of Haringey CCG and is the Medical Director for Tottenham Primary Care Services LTD. He is also the clinical lead for both the Haringey Primary Care Intelligence Group and CCG Access and Productivity Task Force looking to help improve quality in general practice across the borough. Nazmul Akunjee and Muhammed Akunjee are both authors of ‘The Easy Guide to OSCEs' series published by Radcliffe. In 2008 their book the 'Easy Guide to OSCEs for Final Year medical students' was Commended in the BMA book awards. Their second publication, ‘The Easy Guide to OSCEs for Specialties’ was Highly Commended in the BMA book awards the following year in 2009. Their most recent work 'Clinical Skills Explained' was Highly Commended at the BMA book awards, 2013. Radcliffe Publishing nominated the authors for the BMA Young Author of the Year in 2010.
Practice CSA Cases & Communication Skills for the MRCGP Exam
The CSAPrep Course The CSA Prep course was started in the winter of 2011 providing an intense one-‐ day coaching experience for GP registrars to help pass the RCGP CSA exit exams. It was the brainchild of Dr Nazmul Akunjee who sat and successfully passed the CSA examination at his first attempt. However, after he attended a number of courses, he felt that there was no course that actually reflected accurately the examination experience. Hence, he went about devising and creating a course that was, ‘as close to the exam as possible.’ The course is unique in that it solely utilizes MRCGP trained actors who have all acted out in the MRCGP CSA exams and appreciate the nuances of how to act out medical cases and when to drop cues. The full day course uses four different CSA actors who act out 18 different cases in total. The course employs 2 course facilitators, both of whom are GP partners, with each in charge of a group of 3 registrars so that each candidate gets at least 6 goes on the day and sees 12 further cases. The facilitators give honest and personalized feedback with a view to helping you through the CSA examination hurdle. The cases used on the day have been written to be equivalent to the harder end of the CSA exam spectrum and focus on difficult consultations such as dealing with angry patients, breaking bad news, underage consent and negotiating shared management plan, typically areas when GP registrars usually find challenging.
MRCGP CSA Cases
We pride ourselves in trying to give you an experience, ‘as close to the exam as possible’ and in this vein we have created our own MRCGP CSA Prep course app that allows you to practice with the Ipad during the course as you will have to do so in the real examination. For those who have completed the full-‐day CSA course and wanting further personalised feedback and more challenging cases covering other areas of the RCGP curriculum, is a half-‐day mini-‐CSA exam. This course uses 2 CSA actors, but has 10 further challenging cases and each candidate is allocated a single GP facilitator to coach them on their communication and consulting skills. The CSAPrep experience does not end there, but through the website, www.csaprep.co.uk you can gain access to free CSA cases as well as free communication skills material with quick reference tools on how to succeed in the examination. You can also download an exam-‐like free app that can be downloaded onto your iOS device and practice cases in a similar format to that of the examination. The website also contains numerous articles on top-‐tips on how to pass the CSA exam and how to understand the RCGP feedback following the examination.
Practice CSA Cases & Communication Skills for the MRCGP Exam
CIRCUIT 1 Case 10: Margaret Kennie Candidate’s brief Patient medical records Name: Past medical history: Drug history:
Margaret Kennie (31 years) Asthma (2000) Folic acid 400 mcg
Letter from Genetic clinic (1 week ago) Letter from Genetic Screening to GP: I am writing to summarise the results of the genetic screening tests. The couple had performed the initial tests but unfortunately they did not attend the follow-‐up appointment for the explanation of the results. Of note, the partner was tested previously and had been told he was a carrier. Cystic Fibrosis occurs when a child inherits a defective copy of the CF gene from both parents. A defect in the gene is not the same in all cases. However, in the couples’ case both partners have inherited the commonest type of defect called delta F508 gene and they are therefore both carriers. This means that there is a 1 in 4 risk of any child being born from the two partners being affected with CF. Dr Michael Shumer -‐ Consultant Geneticist Consultation (4 weeks ago) Dr Andrews: Patient reports she is pregnant. LMP 1 week late -‐ approximately 5 weeks gestation. Commenced on folic acid. Advice given in pregnancy regarding healthy eating, diet and alcohol -‐ Emma’s diary given. Non-‐smoker but drinks a glass of wine on occasions. Has agreed to stop for pregnancy. No cats in the house. Family history of CF. Organised referral to genetic clinic due to anxieties.
MRCGP CSA Cases
Actor’s brief Background: You are Margaret Kennie, a 31 year old, IT columnist for an online technology magazine. Approach: You are well dressed and are softly spoken. You are a confident middle-‐class lady. Opening statement: “Doctor, I guess you know I’m pregnant, but I am a little worried.” History Open history
●
You have been trying for a baby for a while with your partner and have just got pregnant. You are obviously very happy but also very anxious to make sure your baby is born healthy (verbal cue).
●
Verbal cue: You know you missed your appointment as you had been ‘overwhelmed with everything’.
Reveal history if asked DNA
●
You have been quite anxious about whether your child will be born health. After your partner and you had the blood test you were ‘overcome by nerves’ and could not face hearing the results. You already know that your partner is a carrier of the CF gene.
●
You missed the appointment but now having done some research on the web are more confused than ever. You managed to pluck the courage and book the appointment today with the doctor to know, ‘once and for all’.
Cystic Fibrosis
●
You have a nephew called, Daniel, who was diagnosed with cystic fibrosis. He is the son of your aunt (Martha) on your dad’s side.
Practice CSA Cases & Communication Skills for the MRCGP Exam
●
Your aunt and her partner, Tom, had a very difficult time bringing up Daniel. They were told that he would die before he passed his teenage years but instead he is still alive and is currently 22 years old.
●
When he was younger he had lots of chest infections and was quite unwell needing constant one-‐to-‐one lung physiotherapy. He was ‘always in and out of hospital’ and had a few close brushes with death due to pneumonia. However, he is more stable now and he is keen to be a physiotherapist and help others with the same condition.
●
After seeing how Daniel grew up, you know enough about CF and its treatment. However, now that you are pregnant -‐ ‘It’s hitting home, I need to know if my child has it or not!’
●
You do not want an explanation about the condition.
●
Ideas: You want to know the blood results: whether your child has cystic fibrosis or not.
● ●
Concerns: You are worried that your child has cystic fibrosis.
Expectations: You want the results of the genetic tests as you want to know with certainty whether your baby has Cystic Fibrosis or not.
Past medical history
●
You have suffered with Asthma for over 10 years but are well controlled with inhalers. For the last 1-‐year you have not needed to use your inhalers at all.
Past obstetric history
● ●
You have no previous pregnancies, children or terminations.
●
You are really excited with your pregnancy but you are finding it hard to celebrate with this hanging over you.
You have been previously reluctant to get pregnant with your knowledge that something was wrong with the genes in your family. However, you are overtly aware that ‘time is running out and nature does not wait for anyone’.
Family history
●
As above regarding CF.
MRCGP CSA Cases
●
You have no other medical problems in your family.
Drug history
●
You no longer need your inhalers. You take folic acid 400mcg as prescribed.
●
You have no drug allergies.
Social history
●
You do not smoke but drink the occasional glass of wine at least 3 times a week; usually at social events.
● ●
Your mood is stable and you sleep and eat well.
●
Occupation: You live in a 2 bedroom flat with a minimal mortgage. You have no financial worries and have a good job in the city as an IT journalist with a regular column for an online magazine.
●
Diet: You are conscious of what you eat after Dr Andrews informed you what diet is good for your baby. You have read all the books and avoid all the foods that you are meant to. You do not want either antenatal or booking advice today.
Relationship: You have been with your partner for 3 years and decided to try for a child this year as things between yourselves have never been better. You are happy with him and he is very supportive. He will support any decision you make about the baby.
Practice CSA Cases & Communication Skills for the MRCGP Exam
Nub of the case -‐ You are a middle class, softly spoken lady who is pregnant and worried about her baby having cystic fibrosis. -‐ You missed your genetic clinic appointment as you were too nervous of the results. Both you and your partner have already had your DNA/swab taken. -‐ You have a cousin who has CF and has struggled with his health from it (recurrent chest infections). -‐ You believe that the doctor is going to inform you whether your baby has CF or not. You are surprised it is only a probability score. -‐ You want to know how to test for sure whether your baby has CF or not.
How to respond
●
Results: If the doctor informs that you and your partners are carriers of CF gene act surprised and worried. Ask to clarify what that means for your baby: ‘Does that mean my baby has it?’
○ If the doctor informs you that there is a 1 in 4 chance that your baby has CF appear surprised and confused and suggest, ‘I thought I will be finding out today definitely whether my child had it or not. What does 1 in 4 mean?”
■ Accept an explanation of the chance of inheriting CF if explained accurately.
■ Remain puzzled if performed poorly. ○
If the doctor says that the test will not inform you 100% that your baby has CF or not act surprised that it is not conclusive. Request for a test that would give you a 100% answer as the stress is killing you.
●
Investigations: If the doctor suggests that there are tests that can be done in the womb, seek clarification what test and when it is done. Also ask how it is performed.
○ If the doctor suggests the test is performed with a needle, act alarmed (non-‐verbal cue).
■ Your concern, if asked, is whether the needle will hit your baby and cause bleeding to your child inside your
MRCGP CSA Cases
womb: ‘What if you insert the needle and hit my baby?’ Be reassured if they explain that it is ultrasound guided.
○ Enquire about the risks of the test i.e. miscarriage, harm to the fetus.
○ If the doctor suggests that you can wait until your child is born and then perform a sweat test reply that you must know now ‘to put your mind at ease’.
■ You believe that you will have an ‘awful 7 months’ of pregnancy if you did not know.
●
Implications: If the doctor asks you the question about what you would do if you learnt that your baby had CF then reply, ‘I really want this baby and I will do everything to keep it.’
○ Explain further that you want to be fully prepared for any eventuality and you learnt lessons from Daniel’s experience and believe that there are good treatments and support for children with CF.
○ Already you have seen Daniel live longer than expected with current treatments. You have been reading alot about viral gene technology and believe that by the time your baby is older, medical advancements will mean your baby will be almost cured of CF.
Examination findings
Examination Declines as has appointment in 3 days time with own midwife
Vitals BP Pulse BMI Temp
110 / 68 81 bpm 29 37.1oC
Practice CSA Cases & Communication Skills for the MRCGP Exam
CSA Case points This scenario is testing your ability to discuss genetics testing with a pregnant mother. The mother is already well informed about Cystic Fibrosis, and is keen to find out definitively as to whether her current pregnancy may be suffering with the condition. The case centers on taking a good history as well as the concurrent pyscho-‐social stressors surrounding the mother and ultimately exploring how exactly she wants to proceed if she were to learn the definitive results from further testing. CANDIDATE BRIEF The candidate’s brief offers a key insight into the possibility that this case will focus on a genetic topic. It is revealed that the mother is currently pregnant and that she has a family history of cystic fibrosis. As a result she has been referred to speak to the geneticist. However, as per the Consultant’s letter, she missed the follow-‐up appointment to discuss the results in detail. The geneticist has informed you that both partners were found to be carriers. Prior to the patient entering the room, you should plot out a genetic tree and calculate the risks of the baby being a carrier as well the risk of suffering the full-‐blown disease. Consider ways of how to communicate the different risks to the mother if she is attending today to discuss these. Given the mother’s anxiety about cystic fibrosis warranting a genetics referral, and the clear family history, it would be prudent to consider exploring these two issues further in the consultation. It is likely that she is attending today due to missing her appointment and perhaps, given that you are her GP, she is more likely to trust your explanation and be comfortable to ask questions. The patient is currently only on folic acid that was commenced a few weeks prior. However, there is a note that they have suffered from asthma. It may be useful during the consultation to establish how well controlled the patient’s asthma is and whether they are currently taking any treatment for this. It is a well-‐known fact that in about a third of pregnancies patients with asthma may develop worsening of symptoms. Given that she is pregnant, and there is little antenatal history, it may well be worth asking more history surrounding the mother’s obstetric background. Has
MRCGP CSA Cases
she been pregnant before? Had she had any terminations (if so, particularly was it due to a possible congenital deformity)? Does she have any children now? If so, are they healthy? INTERPERSONAL SKILLS Genetic cases are quite sensitive consultations since they broach subjects that may affect whether a pregnancy will be continued or not. The advice given during the consultation may alter the plans a mother, or the parents have for their child. Hence, one has to be quite conscious of the issues and broach the topic with the delicateness it deserves. As the patient begins, she starts with an opening statement that expresses her anxieties surrounding the pregnancy. It is important to use open questions to help allow the patient to offer her true feelings and the surrounding history as freely as possible without interruption. Ensure that you always act empathically if the patient reveals any anxieties or any concerns. Make sure that you do not over complicate any explanation or use excessive medical jargon particularly when speaking about genes and inheritance. This will only serve to confuse and confound the patient and is likely to make them feel even more anxious than they already are. Negative indicators:
●
Fails to listen to the patient and obtain a detailed understanding of the issues.
● ● ●
Fails to identify or respond to cues. Fails to use open questions and appears abruptive.
Uses excessive medical jargon when communicating the risk. DATA GATHERING Although the patient describes her anxieties about the pregnancy and the possibility of cystic fibrosis it is important to try and establish what she already knows. It may be an idea to quickly summarise the previous consultation back to her, to check she agrees with what was said and then to request whether she received a copy of the letter from the genetics clinic. It would be relevant as well to establish why she missed the follow-‐up appointment with the hospital.
Practice CSA Cases & Communication Skills for the MRCGP Exam
DNA
●
Try and find out why the patient missed the follow-‐up appointment? Did she do this willingly or was the appointment forgotten? If she missed it intentionally, what was the reason? What was she afraid of finding out? Does she want you to communicate the risk of CF today to her?
Cystic Fibrosis
●
Why is the patient so worried about the risk of Cystic Fibrosis? Has she or her partner been tested before? Does she know anyone with CF and what was their experience with it? What does she understand about CF?
●
Does she want you to explain the condition today? Or was she expecting something else from the consultation.
Psycho-‐social context
●
Establish the impact the symptoms have had on the patient’s cousin i.e. attendance to numerous hospital appointments, number of admissions and near-‐death experiences (ITU admissions).
●
Determine the patient’s current living arrangements and who they live with. What does their partner know about CF? What would the partner want to do if the child had CF?
●
Check if they smoke or drink and signpost to health promotion initiatives as appropriate.
Negative indicators:
●
Takes only a superficial history about the presenting complaint and fails to elicit subtle signs of anxiety about the pregnancy.
●
Makes superficial assumptions about the patient’s health and does not elicit relevant psycho-‐social context i.e. impact on life-‐expectancy.
CLINICAL MANAGEMENT SKILLS When a patient attends for their first appointment after finding out they are pregnant, it is important to ascertain their intentions with regards to keeping the baby or having a termination (TOP). This becomes more so when dealing with sensitive topics especially with genetic cases. If one were to assume that the patient intended to have a TOP, this may be taken as being judgmental and dramatically change the tone of the consultation. Often a good question to ask
MRCGP CSA Cases
early on would be: ‘If you found out that your baby had this condition, how would it change things? Would it change whether you wanted to keep this pregnancy or not?’’ Inheritance
●
Explain to the patient the mode of inheritance: ‘Genes come in pairs with one from each pair coming from both parents. A person suffering from CF inherits one copy of the sleeping defective gene from each parent who are the recessive carrier.’
●
Explain other possible outcomes: ‘If a person inherits a single defective gene than this means that they do not have the disease but are a carrier. This means they can pass on the gene to their children, but will not be affected with the disease themselves.’
●
Explain to the patient the risk to their child: ‘In your case, since both your partner and yourself are carriers there is a 1 in 4 (25%) chance that your baby will have Cystic Fibrosis. In other words if you were to have 4 children with your partner we would expect 1 child completely well without any defective gene, 2 children who are well and healthy but are carriers of the defective gene, and 1 child who will have CF.’
Definitive tests
●
Discuss with the patient options to conduct more accurate tests in-‐utero to determine whether the fetus has CF: ‘Chorionic villus sampling or amniocentesis are techniques that allow us to take a sample from the womb of the baby’s cells. We will pass a fine needle through the wall of your tummy. It is performed in early pregnancy (11-‐14wk -‐ CVS, 16wk -‐ amniocentesis) and we will use ultrasound to guide us to ensure the baby is safe.
●
Explain the risks associated with Chorionic villus sampling or amniocentesis: ‘However, the test is not 100 percent accurate and there is a slight risk of causing a miscarriage (1/100).’
Post delivery/diagnosis
●
Offer the patient alternative methods to diagnose Cystic Fibrosis including the heel prick test or sweat test. Emphasise that these tests can only be conducted once the baby has been delivered
Practice CSA Cases & Communication Skills for the MRCGP Exam
●
Referral: Support the mother in her decision to keep the baby. Suggest that you can organise an early obstetric and paediatric referral. Offer patient group details of charity information for patients with CF.
●
Follow up: Consider reviewing the patient in a few weeks after they have had time to discuss with their partner or the midwife. Consider seeing the patient with their partner to further explore the issues.
Negative indicators:
● ●
Uses inappropriate (e.g. technical) language.
●
Fails to incorporate patient’s ideas and expectations into the management plan i.e. patient wants to keep the child regardless of diagnosis and would like in-‐utero testing to be prepared.
Fails to offer suitable options for investigating CF i.e. CVS or amniocentesis.
View more...
Comments
