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 Guys, Kings and St. Thomass 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
Candidates 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 - Emmas 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

Actors 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 Im 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 dads 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 - Its 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 Daniels 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 candidates 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 Consultants 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 mothers 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 patients
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 mothers 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 patients cousin i.e.
attendance to numerous hospital appointments, number of admissions
and near-death experiences (ITU admissions).

Determine the patients 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 patients 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 babys 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 patients 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.