THE CSA EXAM: what it is and how to prepare
Dr. Aman Arora – Arora Medical Education
What is covered?:
- What is the CSA?
- When should I take it?
- How is it marked?
- How should I prepare?
- What happens on the day?
- My own experience
- Our courses and resources
- A final positive note
What is it?
The CSA (clinical skill test) is one of the three components of the MRCGP qualification – necessary to complete GP training in the UK. It aims to test various aspects of General Practice through the form of clinical stations. Areas tested include evidence-based practice, communication skills and patient-centered approach.
It is a 13-station clinical OSCE with each station lasting 10 minutes. The exam lasts approximately 3 hours and there is a break of 15 minutes after the first 7 cases.
The CSA can be taken from your ST3 year onwards and can be sat monthly from October to May. You can only take the exam at the RCGP building in London and you have a maximum of 4 allowed attempts.
Each candidate has their own room throughout the exam - set up to resemble a GP consulting room. Patients are played by trained role-players and enter at the beginning of each consultation with an examiner. The examiner follows the same role-player for the circuit meaning that 13 different examiners examine you throughout the exam.
The RCGP website outlines the following tested areas:
- Primary care management (common and important medical conditions).
- Problem solving skills (eg using data for enable effective decision-making).
- Comprehensive approach (eg taking into account co-morbidity and other factors).
- Patient-centered care (sharing management and involving the patient at all stages).
- Attitudinal aspects (eg ethics, professionalism).
- Clinical practical skills (eg common examination skills, instrument use).
These can be tested through different types of case:
- Face-to-face consultations (most cases will be in this format)
- Telephone consultations
- Home visit cases
- Colleague or 3rd party cases
The current exam fee is £1663 per attempt and exam booking occurs through the RCGP website. Each exam is usually bookable for a period of 3-5 days, usually about 5 weeks before the exam period itself. You could be given any date within the exam period that you choose though you can advise the college of any dates that you would struggle to attend.
How is it marked?
Each station is marked in two ways – numerically and subjectively. Numerically there are a maximum of 9 marks per case, meaning a maximum possible score of 117 (9 x 13 cases).
The pass mark varies from exam to exam - it usually ranges between low and high 70s (out of 117).
The 9 marks for each case are split into three domains, with a maximum of 3 marks for each domain per case. The three domains are:
- Data gathering.
- Clinical management.
- Interpersonal skills.
Data gathering assesses your ability to first gather, and then utilise data from various sources. These include relevant history taking and examination skills, as well as interpretation of results and clinical letters. Data gathering is not restricted to clinical issues – understanding the patient’s thoughts, as well as impact on their psychosocial life is also part of understanding key issues of the case. Being efficient, relevant and systematic is important as time can quickly add up – leaving enough time for management is key to using the data effectively.
Clinical management assesses your ability to use the data that you have elicited, both in terms of managing the clinical problem AS WELL AS managing the situation as a whole. Clinical decision-making, managing patient expectations, health promotion and effective use of resources may feature here.
Interpersonal skills run throughout the ten-minute consultation, assessing your ability to communicate effectively and with a patient-centered approach. It is not simply ‘being nice to the patient’ – adapting techniques for different situations is key – done so in a fluid, non-rehearsed way. It also focuses on areas such as ethics, equality and diversity, explanations and attitude.
In addition to a numerical score, each case is also assessed as a single global rating. This does not affect your final mark but is used to calculate the final pass mark for the session using the borderline group method.
I have found that some trainees worry too much about the mark scheme, sometimes leading to confusion when performing. Having a basic idea of the mark breakdown is good, but focusing on a clear, efficient consultation will usually mean all areas are adequately covered.
When should I take it?
I have seen a trend towards taking CSA earlier and earlier. Many now attempt it at the first opportunity in ST3, especially if just coming out of an ST2 GP rotation. I have also however seen many people struggle to get through when sitting too early which can have a big knock on confidence.
I don’t think there is no right or wrong time but I would say two things need to be in place:
- A core understanding of what is being assessed and what you need to demonstrate in those 3 hours.
- Enough practice under your belt, both at work AND in challenging scenarios within study groups.
From experience I would say 3-4 months of proper preparation seems to be average for those taking the CSA – once you decide and feel ready to sit, clear planning is required to maximise your chances of getting through.
How should I prepare?
For a full review of tips for CSA preparation see our article: ‘10 Power tips to Pass the CSA’.
From my own experience of trainees preparing for CSA there are two main chosen approaches – practice at work and practice with colleagues – and I am often asked which is best. My simple answer is that relying on one alone can leave you a little short.
No amount of practicing with friends can possibly allow you to build up many of the softer skills of consulting – things that you develop and integrate without even trying. Through seeing patients over time you work out distinct diagnostic patterns, ‘gut feelings’ about certain presentations and realise which responses or reactions work in which situation – definitely a large part of passing the CSA. Conversely there are many particular challenges that you may not see in real life patients before your exam – for example you may not come across a domestic violence scenario, a drug misuse patient or a case of recurrent hypoglycaemia. If these rarer situations present in the exam then you may find yourself working out the basics in a difficult, pressurised scenario. When practicing with colleagues you tend to work through some of the rarer presentations and consequently less is seen for the first time in the exam…. Ultimately if planned well, both work practice and group practice should be used hand-in-hand as both have clear advantages – don’t limit yourself to only one.
Another very common question is ‘which book or website should I use use?’ Firstly I have not had experience of all resources on the market and secondly I always say that a case/book is only as good as the acting of the role-player. You could have the ‘best book’ but if the acting is too easy, or there is no emotion in the case, it can become a robotic experience. The other problem that I often see with study group practice is the over-weighting of medicine. Remember in the CSA you are managing a whole situation, not just a clinical problem. ‘Which drug was correct?’ or ‘was that referral appropriate?’ often form the bulk of discussion in study groups, thereby missing other subtle, often more important parts of the case.
Self-reflection is critical for CSA practice. When with a group, the tendency is to move on quickly to the next case – everyone ultimately wants their own turn. At the end of the session however - perhaps on the way home - critically self-reflect on your own cases. Ask yourself things like ‘did I really find out their ICE?’, ‘did I put their medicine into context with psychosocial life?’ and ‘if I did these, did I come back to them in the second half or did the patient need to remind me?’ etc. Breaking your cases down by yourself helps highlight self-exposed gaps, allowing you to improve as you move forward.
On the day:
You will need to take a form of identification with a photograph (passport or driving licence photo card).
The RCGP also outlines a list of equipment that you need to take with you to the exam – make sure you look at the latest list beforehand.
On the day a member of the college (usually a senior examiner) will go through certain procedures and a briefing. You will probably be quite stressed at this point but usually some reassuring things are said!
Once taken to your room you will have an iPad which has cases stored in the order that you will see them. Information on each case can vary in detail and can be quite lengthy – make sure you have read to the bottom of each case before a case begins. There is a white board with an eraser which you can use to make notes. The desk will also have additional equipment which may be needed as well as prescription pads/blood test forms etc. in case you need them.
There will be a digital timer on the wall, which counts upwards from zero to ten minutes and automatically resets for each case. (It is important to practice in this style – many trainees practice with the time reducing from ten to zero and get very used to this. Once exam day comes it get confusing when suddenly everything is reversed!)
Patients enter one by one with their respective examiner for the first 7 cases up to the break as discussed earlier, before the final 6 cases take place.
Results are normally published around 10 days after the last exam date of the session and are released via your portfolio. You will be told your overall score as well as a breakdown of your scores for the three domains.
My own CSA experience.
Luckily I passed CSA first time and my memories of the whole process are still vivid. I remember walking into preparation very relaxed to begin with – that slowly changed as I realised the enormity of the exam! I decided to take the exam in November - three months into ST3. 4 or 5 of us formed a group and we started with weekly practice. This soon became bi-weekly, then tri-weekly and eventually for the last 2-3 weeks we were practicing at least 4-5 times a week. Weekends and evenings became a distant memory for a few months as we scrambled to find any time for those all-important role-plays. Study group practice was often too ‘nice’. Looking back at it we ought to have pushed each other a little more as exam-day certainly wasn’t as laid-back as what we had practiced for 2 months! And I forgot to mention – I got married a month before CSA…..and chose to do the whole thing abroad…..not the wisest decision ever made!
We used just about every book and website available in those 2-3 months. One thing that we did do well was maintain that ‘practice meant practice’. There were very few sessions where we didn’t achieve a good number of cases with good clear discussion afterwards – crucial I think in getting the right exam mindset.
Personally I found practicing at work a little challenging but I managed to focus on a few key areas each day, allowing me to feel that progress was being made. COTs with my trainer certainly helped in having the pressure of authority watching me perform!
I had a morning exam and so stayed overnight in London. Sleep was scarce and I woke up anxious. I don’t remember much between breakfast and the debrief before the exam! I deliberately didn’t read all my cases once I got into the room beforehand (I often get asked whether to do this or not and I don’t think there is a right or wrong answer) and suddenly the first bell went. My first case was a telephone consultation in which I know I made a few errors. The inevitable nerves settled by case three and then it became a lot more relaxed. By case 4 or 5 I can honestly say I had forgotten that I was in the CSA and things flowed much better. I tried to relax in the break but actually couldn’t wait for it to get started again. By case 11 I can remember counting down the cases – be careful here as standards can slip as you get excited about the end! I remember feeling a little anti-climaxed after the last case – I had thought that it would be a lot more relief – what probably happened was pure exhaustion!
After the exam I had the usual struggle – waiting for results is hard, especially when you have no idea if what you said in the exam was of any relevance! Normal ST3 day-work soon took over and was a good distractor. Eventually results day provided me with some good news and the next chapter of ST3 (out-of-hours) soon took over!
Our courses and resources:
1) Our flagship 1-day CSA course. Held in Birmingham, Manchester, London and Glasgow, we run a results-focused immersion CSA course. Experience the pressure of the CSA through 32 challenging cases in a day. There are only a maximum of 7 other trainees attending with you and everyone will experience a ‘mini’ mock in the afternoon. Each case is broken down with key learning points discussed afterwards. A variety of case types, both in terms of clinical content as well as challenging concepts will be covered, with the aim of you walking out much more confident in knowing what is expected of you and how to take preparation forward.
2) Our full mock CSA exam. For individuals only, this 4-hour session re-creates the ‘time-pressurised’ environment of a full 13-case mock exam – same timings, same layout, same intensity. Find out how you cope with 13 back-to-back cases, as well as a tiring mind towards the end. Timings include a 3-hour ‘exam’ followed by 1 hour of detailed feedback.
3) 1-to-1 sessions. For individuals or groups, book either a 3 or 4 hour session. We want you to get what you need – some prefer case-feedback-case approach, some prefer blocks of 3-4 cases back-to-back with feedback – it really is down to you.
4) Our 60-day CSA revision poster. A step-by-step guide to your CSA preparation. What to revise, key questions, breakdown of key case subjects and topics. Designed for complete coverage, in full colour, large A1 size for your wall.
5) Our free CSA/AKT Support group on Facebook. Daily revision snaps, bites, images and videos designed for quick and efficient retention. We hit those areas that people always struggle with.
6) Our CSA articles/blogs including:
- 10 Power tips to pass the CSA.
- 5 ways to maximise you study group practice.
- 10 key tips to beat exam fear.
On a final positive note:
Most people get through CSA…you will get through CSA! It does however take a little planning and concerted effort. If you start early, you’re efficient in your preparation and don’t rely on just one method of preparation, you have every chance of flying through this exam.