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RCGP CSA: The Root of All Evil?

 

Just to clarify, the CSA in question is the Royal College of General Practitioners’ “Clinical Skills Assessment,” rather than any of the other recognised acronyms for the term.

For those who do not know what the CSA is; In a nutshell, it is an assessment which all GPs now need to complete in order to demonstrate their competence to be added to the GP Register. To most, this would seem like a good idea. In fact – to be absolutely frank – it sounds like a good idea to me. Any reasonable check which ensures GP competence, without being harmfully onerous, would seem sensible for the public interest. Dangerous doctors should not be in practice.

Unfortunately – like so many good ideas – this particular one falls flat on its face. A fool in politics might argue that the only way to give everyone an absolutely equal life opportunity would be to murder them all. Otherwise, there will always be the opportunity for inequality. This train of thought is so clearly correct, yet so ridiculously wrong. It is the consequence of looking deeply at a problem, without considering the full implications of the “solution.”

Clearly, the CSA is not quite this lethal, despite a disturbingly similar approach to problem solving. Yet just because one is able to imagine more damaging miscarriages of intelligent thought, should lesser stupidity should be ignored and accepted? I certainly hope not.

So, why do I consider the CSA to be so deeply flawed?

The first (and perhaps greatest) reason is the cost. When the exam fee is considered alongside related expenses, the cost is close to £2000. Two thousand pounds! In the middle of a recession. That is a year of food for someone. Or the cost of a holiday. Perhaps seven thousand miles worth of fuel in a Ferrari California (let’s not even think about the average person’s car). All for a half day exam. Imagine the guillotine of this expense quivering over your exposed throat as you attempt to demonstrate your natural, honest and relaxed compassion to a patient.

The next thing to think about is the fact that this patient is not even real. Their symptoms are not real. Their concerns are not real. Their examination findings are not real. The actors are exceptionally good, but they are simply NOT REAL! A skilled doctor, attempting to assess for subtle and unconscious nuances and examinational findings simply will not be able to find them. A mediocre doctor who is not able to detect such subtleties might excel here. A better doctor will simply see a fake and automatically wonder what the “real” issue might be.

Then there are the examiners. All experienced GPs. Trying to be inconspicuous in the background. Some of them manage. The majority just seem sinister as they stare silently over the top of their clipboards, further escalating the unnatural pressure. When I sat my exam, I found myself wondering if I should try throwing a pinch of salt over my shoulder at them, to see if they vanished in a puff of sulphurous smoke. Suspiciously, salt was not included in the list of items permitted into the exam.

Sadly, it is not just the exam cost and the exam process which show flaws. Imagine being isolated in a tiny room for two hours beforehand, with only a toilet and a supply of drinking water for entertainment (as anything else has already been confiscated). Some people might find silently stewing in a maelstrom of internal anxieties relaxing, but I remain unconvinced that this is the best approach to prepare for a clinical and communication exam. Two hours can seem a very long time.

If only the shortcomings of the exam began at its onset, but there is another vast oversight. The location. Euston Square in London seems like an ideal spot for a seat of political power, but not for an exam. For “Non-Londoners,” it is perhaps the most inaccessible place imaginable. For a profession which requires the use of a car, holding an exam in London is only marginally preferable to holding it in Shetland (in fact, as Shetland is such a nice place, perhaps even this is not true). Why not somewhere easily accessible to the majority and without the overinflated London prices? Instead, the exam requires a bus,  a train,  another train,  an underground train,  a walk and a stay in a hotel to reach. All this while attempting to carry smart clothing. Pure genius. The conceitedly smug weekly newsletter from The College, pointing out how “wonderful” their sparkly new building is simply adds to the sense of irritation.

No – I am not against standards. I am not against quality. I am not against trying to ensure that patients can be reassured that their care is up to standard. BUT, can I be confident that an exam which is simply not fit for purpose is the best way to assess a doctor’s fitness to practice? Might it not be reasonable to expect at least an iota of intelligence, understanding and compassion from the people who deem themselves fit to judge others on the same set of skills?

And finally, is it not just a little curious that the square root of six hundred and sixty six – the “root of all evil” – is 26 (to the nearest integer) – exactly the same as the number of actors and examiners in one circuit of the exam (again, to the nearest integer)?