The Membership of the Royal College of General Practitioners (MRCGP) is a qualification that confirms that a doctor has finished specialty training in general practice and possesses competencies consistent with independent practice in the UK. The Clinical Skills Assessment (CSA), a component of MRCGP examination, tests a doctor’s ability to integrate and apply clinical, professional, communication and practical competencies relevant to general practice.
It assesses how well a doctor can collect information, apply knowledge of diseases and person-centred care, make evidence-based decisions and communicate with patients and other professionals. The CSA is attempted in the ST3 year or later.
The CSA comprises thirteen realistic simulations of consultations; the cases are acted out by role players and assessed by GPs. At each sitting, before commencing, examiners calibrate the case with role players to ensure consistency. Each candidate is allocated a consulting room. On the desk is an iPad with a list of patients and notes for each case, a wipe-clean A4 board for note-taking purposes, mock FP10 prescriptions and Med3 forms and any other information or equipment – extra to what the candidate is required to bring – relevant to the case.
Each consultation has a duration of ten minutes with two-minute intervals for reading the case notes. A buzzer sound signals the start and end of the ten-minute period, corresponding to the role players’ and examiners’ entry and exit of the consulting room. The cases are typical presentations in UK general practices and candidates must pose relevant questions to obtain information from role players. Physical examinations may be conducted if candidates consider necessary.
Occasionally, if the candidate requests to examine, the role player or examiner may provide the results of the examination without it being performed. At the end of the ten minutes, the patient and examiner exit regardless of the stage of the consultation. Some cases may be based on a telephone consultation; telephones are available in all consulting rooms to facilitate this. Alternatively, for cases based on home visits, candidates are taken to another room. There is a short refreshment break after seven cases.
The cases are created by trained RCGP examiners. At each session, cases are selected to include a variety of diseases and case types, for example, acute and chronic illnesses and cases that comprise psychosociological, ethical or medico legal factors. At minimum, there are two cases that assess safe prescribing and one paediatric case that features child role players accompanied by parents or parents presenting on children’s behalf. Each case addresses a learning outcome from the RCGP curriculum. In the case notes, which are as brief as possible, candidates are provided the patient’s name, age and address. Examples of other information include past medical history, current medication, social history, test results and letters from specialists.
The CSA case bank comprises more than 600 cases; more are continually added. A different group of thirteen cases – that are selected to be balanced across the curriculum and comparable from day to day – are used on each day of the exam. Additionally, cases are often adapted so that, while the character of the role player is unchanged, there is an alternate objective for the consultation.
Consequently, it is improbable that candidates are given an exact case of which they have prior knowledge and are strongly advised not to allow colleagues who have undertaken the examination to discuss cases in detail with them. This may result in candidates formulating a diagnosis, after minimal data gathering, that is incorrect but correct for another similar case.
Additionally, candidates should not reveal the cases they have encountered to their colleagues as RCGP own the copyright and breach of this rule may result in referral to the GMC.
Venue, dates and application
Examination sessions are available during multiple months annually in the examination centre at the RCGP’s headquarters at 30 Euston Square, London, NW1 2FB. Applications are submitted online during booking periods a few months prior to the examination session. It is advisable to book early as places are limited and allocated on a first come basis. It is not possible to choose a specific date within the examination session, however, if candidates cannot attend at a date or time, this can be stated on the application. RCGP will try to accommodate requests where possible. The CSA fee is paid at the time of application. In 2019, this was £1,352.
Typically, the CSA has a duration of three hours. There are two sessions daily. For the morning session, candidates should arrive at the examination centre between 8.15am and 9.00am for a 10am start to the exam. The afternoon session commences at 2.00pm. Candidates should arrive at the examination centre between 11.45am and 12.30pm.
Equipment and dress code
Candidates are required to bring a doctor’s bag containing standard equipment (Box 2). No spares are available on the day.
RCGP dress code guidance indicates that, as the CSA features contact with simulated patients, candidates should maintain formality of dress that is conventional of professional practice as a doctor in the UK. As no invasive procedures are performed, the ‘bare below the elbows’ rule does not apply. It is recommended that face veils are not worn as they may impair the examiner’s ability to assess non-verbal communication skills. Candidates who choose to wear a face veil should notify the exam administration in advance.
All cases are marked by the examiner according to case-specific marking schemes that comprise three domains – data gathering, technical and assessment skills, clinical management skills and interpersonal skills. The first domain assesses candidates’ abilities to take clear, systematic and relevant histories that facilitate clinical judgement, choice of examinations and investigations, and their interpretation. Physical examination and equipment use are also part of this domain.
Clinical management skills assess structured and flexible decision-making when formulating diagnoses and managing common presentations. Candidates should be competent in managing multiple morbidities and promoting general health. Finally, interpersonal skills relate to candidates’ abilities to involve patients in decision-making, use communication techniques to comprehend patients’ experiences and practice with considerations of ethics, equality and codes of professional conduct.
Each domain corresponds to an equal mark, which are added to give an overall mark for each case. Adding the marks for all thirteen cases yields the final mark.
CSA results and feedback are published in candidates’ ePortfolios approximately one week after the examination. An overall grade – clear pass, pass, fail and clear fail – and mark out of 117 is provided. Grades awarded in each domain for each case are also published. Additionally, when an examiner sees skills requiring improvement, they choose one or more of sixteen generic feedback statements and these are provided beside the grades for each case.
In March 2020, the CSA overall pass rate was 84.27% and the mean score was 84 out of 117.