CASC Communication skills

Dr Alin Mascas ST4 Psychiatry

Overview

• CASC structure• Theory – communication skills• Psychology• Do’s and Don’t’s• Practice – Introduction• Group practice

CASC structure

• 16 clinical scenarios (8 single stations and 8 linked stations)• Single stations - 7 min( 1 min preparation)

• Linked stations – 10 min(2 min preparation)

• Break between morning and afternoon sessions (don’t eat excessively).

Areas of concernPoor management of interview/discussion

• Lack of focus on the required task. • Lack of fluency to the task. • Interviewer interrupts the role player excessively. • Interviewer allows the role player to dictate the

theme of the consultation. • Poor management of the interview. • Fails to follow a line of enquiry/discussion to a

logical end point.

Areas of concernPoor communication skills

• Use of medical jargon without explanation. • Use of predominantly closed questions. • Use of multiple questions. • Uses inappropriately phrased questions. • Failure to listen/identify/respond to concerns or cues

from the interviewee. • Lack of flexibility of questioning style. • Lack of empathic response. • Lack of eye contact/non-verbal responses. • Poor body language.

Areas of concern• Significant deviations from the task

• Omissions related to poor prioritisation of the task. • Omissions related to lack of knowledge/ability. • Lack of recognition of importance of aspects of

the task. • Inappropriate avenues of enquiry or discussion. • Inaccurate or misleading information discussed. • Lack of analysis of problems and synthesis of

opinion.

Areas of concern

Lack of professionalism • Harmful interaction likely to cause either

psychological or physical distress. • Failure to respect the interviewee‟s rights. • Rudeness or arrogance. • Inappropriate or flippant manner. • Dismissive attitude to interviewee‟s concerns.

Areas of concernLimited depth and/or range to the task

• Aspects of history or mental state highlighted but not explored in depth or appropriate manner (not the same as an omission – eg. some aspects of orientation covered in a cognitive test such as time and place, but orientation in person not covered).

• Inadequate or superficial risk assessment. • Poor range of symptomatology explored. • Limited/incomplete explanation of concepts/problem. • Limited or incomplete management plan.

Approach

• Always READ the task and be 100 % clear of what is the task• Write down quickly patient’s name and the

most important “buzz words” from the vignette + the task• Prepare and visualize mentally your

introduction-first 1-2 sentences• Make sure you know the setting of the

vignette

Approach

• Greet the patient and introduce yourself• Explain the purpose of the meeting and check

their understand of the reasons for referral (negotiate the agenda).• Go with the flow• Don’t forget, this is an outpatient clinic and

treated as such.• If can’t remember the task say it and check the

vignette, be honest, don’t try to guess the task.

Approach

• Check with patient if they are happy with what you’ve told them, if not seek further concerns/expectations.

• 1 minute left-start wrapping up the interview-EQUALLY important as the beginning.

• Don’t ask open question in the last minute except if it is pass/fail question (i.e risk of suicide)

• Thank the patient and the examiner and put the whole station in a “locked box”.

History taking stations

• OPEN question moving gradually to CLOSED questions in a funnel fashion

• Listen carefully for 1 minute(golden minute)

• When patient stops to breath in you take the lead.

History taking stations-PC• Onset• Duration• Progress• Alleviating• Relieving• Coping/Effects• + ICE (always)• SUMARIZE

History taking stations• Be systematic in approach DO NOT

change your format of questioning

• ALWAYS start with an open mind

• Do not assume you know the diagnosis based on exam practice

• ALWAYS check RISK

• Actors are generally just doing their job (nobody’s out to get ya’).

Case discussion• Always check their understanding first

• Read RCPsych online leaflets

• Be prepared to encounter “what on Earth?” situations

• Be honest and say you don’t know if you don’t know.

• If not sure whether you’ve done well ask the patient and summarize at the end.

• Offer the option to read further information and only if happy offer leaflets, etc.

Difficult communication

• Most of the stations

Stations• Check Revisenow forum for past papers (Superego café forum) but….

• Have a clear understanding of what stations came previously(approx 150)

• DO ALWAYS prepare well for1. Psychotherapy2. Physical examination (including ECG)3. Cognitive examination4. MSE5. Risk assessment6. Management

Psychotherapy stations

• Make sure you know the basics of main types of psychotherapy

• STRUCTURE-(nr of sessions, with whom, when, timing, exclusion criteria)

• CONTENT(what is actually going on in the sesssion)

Physical examination stations

• Practice all physical exams and make sure you can do them smoothly

• ALCOHOL GEL BEFORE AND AFTER EXAMINATION• Look for what instruments are available -clues• Talk to the patient about what you intend to do, ask

permission before you proceed + consider chaperone• Be gentle• Privacy and dignity• Reassure them at the end and mention your findings if any.• No need to talk to examiner except in ECG stations.

Cognitive examination

• MMSE ALWAYS-can jot it down on the notepad before you enter the exam (high chance you’ll get it).

• Usually single station

• Aim for 5 min on MMSE and the rest on parietal/frontal lobes

MSE

• At least one station

• High expectations

• Make sure you cover the depth and range.• Don’t forget cognitive function

Risk stations

• ALWAYS in CASC

• ABC approach

• Check for past H/o incidents(sui, violence, etc)• Always ask about D&A

Management stations

• Present the findings as SBAR• Formulate the management plan and offer

options• Always bio-psycho-social but….prioritize• Be a safe doctor • Keep talking and look confident

PSYCHOLOGY OF CASC REVISION

• Revise theory in advance• Prepare mentally and physically• Eat healthy• Relax…you are already a psychiatrist• Dressing code• CONTROL, CONTROL, CONTROL-YOU ARE THE

CONSULTANT• Confident approach

“Do”s and “Don’t”s

Books• ICD 10• The NICE Guidelines• Sims/Fish psychopathology• Try to review all previous stations• Do your structures for each stations(keep it simple)

Practice….as much as possible

• Max 4 people

• Regularly

• Seek constructive feed back

• Don’t take it personally

• Combine revision with physical exercise/sleep/outdoor activities

• Cut down on sugar and caffeine….he says…

Crash course

• Useful but not a must (watch out for external attribution)

• Some better than other• They teach you how to pass• Don’t be desperate if you don’t get a pass in

the mock• Definitely do a Mock CASC few weeks prior to

exam