Box 2. Take home messages for candidates and trainers
Planning your learning
  • Use videorecordings of your own and others’ consultations to slow down the process so that you can analyse the successful and less successful performance features.

  • Also identify those communicative aspects of the CSA that require a different or heightened performance than that required in real consultations.

Managing the exam format
  • Be aware of the framework of the test in order to navigate the combination of time constraints and clinical performance requirements. Avoid late data gathering.

  • Tune into the likely ‘nub’ or ‘core’ of the consultation by listening carefully and making inferences from (often) subtle RP cues. If you think this case is turning out to have an ethical/legal or negotiating element, be prepared to be flexible with your timings and give more time to the explanation and discussion phases.

  • Be aware that RPs have a more powerful role than real patients and are likely to interrupt more and ask for more clarifications. RP interruptions could be a sign that your explanations are not clear enough.

  • Use ‘metacommunication’, or talking about talk, to show both the RP and examiner how you are structuring the consultation, creating natural speech bridges between sections of the consultation, your intentions in the action you take/talk you use and your attentiveness to interpersonal relations.

Talk and interaction
  • Be aware that the simulated consultation requires more talk from candidates than the average amount of doctor talk in real consultations.

  • Be alert to the amount of relationship work required in the CSA; focus on subtle ways in which alignment can be developed and maintained.

  • Identify misunderstandings and misalignments and reflect on how they could be prevented and repaired.

  • Be aware that much relationship work is done through typical exam phrases, widely perceived as formulaic. All candidates use ‘formulaic’ speech, but to get the most out of it, you need to use it appropriately: at the right point in the interaction and with time for RPs to express their feelings. Customise these phrases so that they sound part of your ‘natural’ conversation, convincing and sincere, rather than an unexpected phrase that has been rote-learned.

  • Focus on the explaining phase of the case, which can be particularly difficult because it requires an extended stretch of talk adapted to the RP’s level of involvement. Explanations require explicit practice, including practising the components outlined in Table 3, using everyday metaphors to take the ‘patient’ on a narrative journey they can understand and take action on.