Monthly Archives: September 2015

The CSA examination: learning to be a fox again

BJGP HeadshotKhalil Hassanally is a First5 GP and student of bioethics. Twitter: @asuitabledoctor

Coming from an immigrant community there has always been huge pressure on not losing one’s roots. Many apocryphal tales, anecdotes and fables are told in this regard, and one in particular that sticks in my mind is that of the fox who lost his walk. The story, as it goes, was of fox who used to be the envy of the other animals for his unique walk. One day, fox saw man who rather than walk on four legs walked on just two. Keen to maintain his reputation of being the best walker, fox attempted to walk on two legs, though try as he might fox could not replicate the walk of man.  Defeated, the fox tried to return to his own walk only to realise he had forgotten what it looked like and that is why fox today has the funniest walk of all the animals.

Many of us whose neighbourhoods are plagued with vulpes vulpes see nothing funny about how fleet of foot the fox is, or how deftly he empties poultry from the garden; nevertheless the story of the fox’s walk rang particularly resonant having finally completed the Clinical Skills Assessment (CSA). When we started off practising as trainees, we were individuals with our many voices and ways of consultation but by the end we were an indistinguishable homogeneous consultation machine.  The CSA was brought into sharp focus by last year’s judicial review with Justice Mitting stating that:

“I am also satisfied that the Clinical Skills Assessment is a proportionate means of achieving that legitimate aim…No better means of testing those skills has yet been devised than the Clinical Skills Assessment”.1

Whilst I don’t dispute the CSA has its uses (there’s nothing quite like an exam to focus one’s mind on the finer points of the menopause) I worry what it does to my consultation. Working in a particularly deprived and diverse area of London the CSA was the first session I have done where all my patients spoke English, where they only attended for one problem, and where general practice was reduced to a picturesque Dr Finlay-like entity. Eliciting patients’ ideas about their illness leads not to transcendent consultations but complaints to the trainer that this new doctor seems so lost as to what he is doing that he has to ask his patients what they think is wrong with them.  Whereas in many localities trainees may be urged to delay taking the CSA till they have enough experience, in mine we are gently nudged into taking it early lest we lose those textbook consultation skills that seem ill at home in modern day East London.

In preparing for the CSA most trainees will abandon their own natural consultation and give precedence to whatever consultation model that will secure them a pass. As the anti-colonial psychiatrist and philosopher Frantz Fanon writes:

“The oppressor, through the inclusive and frightening character of his authority, manages to impose on the native new ways of seeing, and in particular, a pejorative judgment with respect to his original forms of existing.”2

Whilst the CSA may feel cruel and unusual to those sitting it, it can hardly be compared to the evils of colonialism. Nevertheless it robs trainees of something important. I hope that unlike the fox I will once again be able to remember my walk.



1. R (on the application of Bapio Action Limited) v RCGP and GMC [2014] EWHC 1416

2. Frantz Fanon, Towards the African Revolution, Grove Press, 1969

Yonder: diabetes, orofacial pain, screening tests, and pharma

F1.largeAhmed Rashid is an academic clinical fellow in general practice at the University of Cambridge. He writes the regular monthly column “Yonder” in the BJGP: a diverse selection of primary care relevant research stories from beyond the mainstream biomedical literature. Twitter: @Dr_A_Rashid

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In recent years, improving care coordination and the interface between primary and secondary care have been particularly important targets for those designing diabetes services. A recent Australian study sought to investigate patients’ experiences of two GP-led integrated diabetes care services in Brisbane.1 They found that although patients listened to health professionals’ advice, the extent to which they were able to adopt it was determined unavoidably by their life circumstances. The various new relationships with different health professionals that resulted from the new service were another aspect that patients often found challenging to negotiate. The authors conclude that the flexible and personalised approach of a GP-led service can achieve good clinical outcomes and quality of life, although they emphasise the importance of preserving mutual trust between clinicians and patients in order to achieve this.

Orofacial pain
Pain in the face, mouth, and jaw is a common presentation to both medical and dental services and when it becomes persistent with no organic cause or trauma, it is labelled chronic orofacial pain (COFP). Although psychological treatments have been promising in clinical trials, they are not being widely used. In order to understand how a psychological approach may be better implemented in practice, a research team from Manchester interviewed patients with COFP as well as medical and dental practitioners.2 Although patients and clinicians recognised the importance of psychological factors as causes, they were largely focused on biomedical-management strategies. Dentists tended to view it as a non-dental problem, whereas GPs felt responsible to support patients using strategies adapted from other long-term conditions. The study suggests that improving the liaison between medical and dental services and increasing knowledge about the condition among GPs and dentists could help transform the care of this frustrating condition.

Screening tests
In recent years, there has been recognition from across the healthcare community that many clinical activities are ineffective and have the potential to cause physical and psychological harm. The Choosing Wisely campaign is an important part of the solution, highlighting ineffective tests and treatments that should be stopped or used less often. However, such strategies must include the views of patients and the public. A US team of researchers recently interviewed 50 individuals about what they thought of screening tests they’d been invited to take part in.3 Many participants could name no harms of screening and those that did, focused on harms of the screening test itself rather than those further along the management cascade. Benefits of screening, meanwhile, were easily identified and indeed, often overestimated. The study is a useful reminder that campaigns to save money or improve quality through disinvestment must focus on better communication with patients and the public.

Pharmaceutical industry interactions
The relationship between clinicians and the pharmaceutical industry has received considerable attention in the medical and lay press in recent years. Psychiatry has been a particularly high-profile discipline because of the nature of the drugs being prescribed. However, junior doctors in this specialty have yet to be investigated, prompting the European Federation of Psychiatric Trainees to survey trainee psychiatrists across 20 countries about their interactions with the pharmaceutical industry.4 The 62-item questionnaire was completed by over 1400 participants and demonstrated considerable variation across countries, with frequent interactions still taking place. The authors suggest creating alternative educational opportunities and specific training about the pharmaceutical industry to reduce the impact of industry marketing on psychiatric training. They also identify the importance of role models and encourage senior psychiatrists to reflect on the kind of examples they wish to set to their junior colleagues.

1. Burridge LH, Foster MM, Donald M, et al. (2015) Making sense of change: patients’ views of diabetes and GP-led integrated diabetes care. Health Expect doi:10.1111/hex.12331, [Epub ahead of print].
2. Peters S, Goldthorpe J, McElroy C, et al. (2015) Managing chronic orofacial pain: a qualitative study of patients’, doctors’, and dentists’ experiences. Br J Health Psychol doi:10.1111/bjhp.12141, [Epub ahead of print].
3. Sutkowi-Hemstreet A, Vu M, Harris R, et al. (Apr 14, 2015) Adult patients’ perspectives on the benefits and harms of overused screening tests: a qualitative study. J Gen Intern Med, [Epub ahead of print].
4. Riese F, Guloksuz S, Roventa C, et al. (2015) Pharmaceutical industry interactions of psychiatric trainees from 20 European countries. Eur Psychiatry 30(2):284–290.