The Clinical Skills
Assessment (CSA) test was recently introduced to evaluate an international
medical graduate’s (IMG) ability to conduct a physical examination, communicate
with patients in English, and write up medical records including differential
diagnosis and recommended diagnostic workup.
The CSA is administered
by the ECFMG and is required for getting certification. Only IMGs need to take
the exam and they become eligible after both USMLE Step 1 and 2 have been
cleared. The exam is conducted throughout the year, but only in Philadelphia,
Pennsylvania in the US.
The exam comprises of 11 encounters with
standardized patients (SPs), i.e., essentially lay people who have been trained
to act as patients, of which ten are scored. In each encounter the candidate
has 15 minutes to interact with the patient and then 10 minutes after that in
which he is to take the patient history, conduct the appropriate physical
examinations, and then write up the medical record for each patient. The conditions
portrayed in the SPs are commonly encountered diseases or conditions in
physician offices in the US and represent a balanced mix of the basic medical
disciplines - internal medicine, surgery,
OB/GYN, pediatrics,
psychiatry, and
family medicine. There is also a balance of
genders, ages
and ethnicities among the SPs on any assessment.
A candidate’s performance on the CSA is
evaluated based on a combination of different metrics that are then translated
into an overall pass / fail score. An IMG must pass the CSA in order to get
certified.
To learn more about the CSA, choose the
appropriate section:
When and how to apply
When and How to Apply for CSA
International Medical Graduates
(IMG) become eligible for take the CSA after they have cleared both the Step 1
and TOEFL. Since the CSA is offered throughout the year, it is generally
advised that students apply for it soon after receiving their second USMLE score
– Step 1 or 2 depending on the order in which they are taken. It is important
to clear the CSA quickly so as to receive the ECFMG certification, which is a pre-requisite
both for the residency applications as well as for taking the Step 3 exam.
Getting the Application
Form
The CSA application is included in the ECFMG Information Booklet and can be obtained by writing to ECFMG or by downloading it off their web site. Their contact information is,
Education Commission for Foreign Medical Graduates (ECFMG)
3624 Market street,
Philadelphia, PA 19104-2686
(215) 375 1913.
For mail requests it typically takes 4 weeks to receive the application materials. Downloading from the web is the recommended and fastest way of getting the forms. Also, to ensure that one gets their preferred examination date, the application should be filled in and sent preferably 4-6 before the desired test date. However, the testing schedule is usually not very booked and a convenient testing date is usually available.
Eligibility Requirements
The technical requirement
for a candidate to be eligible to take the CSA is,
Either to be a medical student
officially enrolled in a foreign medical school listed in the current edition
of the World Directory of Medical Schools published by the World Health
Organization and be within 12 months of completion of the full didactic
curriculum, or
Be a graduate of a medical school
which was listed in the World Directory of Medical Schools at the time
of graduation, Have passed USMLE Step 1 or its equivalent and the English
language proficiency test (TOEFL)
For most IMGs this just implies
that they have to have cleared the TOEFL and USMLE Step 1 examination before
applying for the CSA.
Filling out the Form
The form for the CSA is
fairly straight forward and has instructions included with it.
It is also important to
point out that the CSA is an expensive exam with just the exam fees being
$1,200. The fact that its conducted only in Philadelphia makes it all the more
expensive, because the candidate then has to fly to the US in order to take the
exam.
After the application and fees have been sent, you will
receive an acknowledgement of receipt and sometime later a Notification of
Registration, which will also include information on scheduling the CSA.
Scheduling the Date
CSA can be scheduled
online. Instructions are provided in the CSA package you will receive.
Once the CSA has been scheduled, an admission permit confirming
the date, time and location of the assessment is mailed to the applicant and
usually takes 2-3 weeks. This admission permit must be carried to the CSA
Center in Philadelphia to gain admission to the test.
What to Study for CSA
The Clinical Skills Assessment tests two basic areas – the ability to perform a quick physical examination and writing the appropriate medical record. While a strong understanding of the basic medical and clinical principles is a must, those are areas that are more exhaustively covered as part of the USMLE Step 1 and 2 exams. Since all candidates taking the CSA have to clear both those tests, this section will focus more on resources for refreshing techniques in physician examination and medical record taking. The texts that students have found valuable and are recommended include,
1. Textbook of Physical Diagnosis, Schwartz
2. Guide to Physical Examination and History Taking, Bates
3. Mosby’s guide to Physical examination - Mosby
4. Essentials of Family Practice, Rakel
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Taking the CSA
The CSA exam is very different from all the
other test required for certification or getting a residency. Since it is not a
written exam, many students often do not know what to expect. To help you get a
better idea of how to go about taking the CSA exam we have tried to walk you
through the different steps with certain suggestions and tips along the way.
The testing area of the
CSA Center consists of a series of examination rooms equipped with standard
examination tables, commonly-used diagnostic instruments (blood pressure cuffs,
otoscopes, and ophthalmoscopes), latex gloves, sinks, and paper towels. There
will be an orientation given immediately before you take the CSA that will
include a brief demonstration of the instruments and equipment that you will be
using in the actual patient encounters.
When the exam first starts you will be given
a set of examination rooms where the patients you will be meeting are located.
Before you enter
each examination room, you will have a few moments to review information that
will be posted on the examination room door. This information gives you
specific instructions, and tells you the patient’s name, age, gender, and
reason for visiting the doctor. It will also indicate his or her vital signs,
including pulse rate, blood pressure, temperature (Centigrade and Fahrenheit),
and respiratory rate. You can accept these as accurate and do not need to
repeat unless you believe the case specifically requires it. Read these
carefully as they often play an important role in determining the correct
diagnosis.
Upon entering each room,
you will encounter a standardized patient (SP). By asking this patient the
relevant questions and performing a focused physical examination, you will be
able to gather enough information to develop preliminary differential diagnoses
and a diagnostic work-up plan. You will be expected to communicate in spoken
English with the patients and in a professional and empathetic manner. You are
to answer any questions they have, tell them what diagnoses you are
considering, and advise them on what tests and studies you will be ordering to
clarify their diagnoses.
The kinds of medical
problems that your patients will be portraying are those you would commonly
encounter in a clinic, doctor’s office, or emergency department. There are no
children presenting as SPs. However, there may be cases dealing with pediatric
issues in which you may encounter a sick child’s parent or caretaker. In such
cases, physical examination is obviously not possible and will not be expected.
The elements of medical
history you need to obtain in each case will be determined by the nature of the
patient’s problems. Not every part of the history needs to be taken for every
patient. Some patients may have acute problems, while others may have more
chronic ones. You probably will not have time to do a complete physical
examination on every patient, nor will it be necessary to do so. Pursue the
relevant parts of the examination, based on the patient’s problems and other
information you obtain during the history taking.
Perform physical
examination maneuvers correctly and expect that there will be positive physical
findings in some instances. Some may be simulated, but you should accept them
as real and factor them into your evolving differential diagnosis. However, be
considerate of the patients and always keep them comfortable and properly
draped as you perform the physical examination.
The key to interacting
with the SPs is to relate to them exactly as you would to any patients that you
may see with similar problems. The only exception is that certain parts of the
physical examination must not be done: rectal, pelvic, genitourinary, or female
breast examinations. If you believe these are indicated, you may include them
in your proposed diagnostic work-up.
You will have fifteen
minutes to spend with each patient. An announcement will tell you when to begin
the encounter, when there are five minutes remaining, and when the encounter is
over. In some cases you may complete the encounter in less than fifteen
minutes. If so, you may leave the examination room early, but you are not
permitted to re-enter. Immediately following each encounter you will have ten
minutes to complete a patient note. You will be asked to write a patient note
similar to the medical record you would compose after seeing a patient in a
clinic, office or emergency department. You should record pertinent medical
history and physical examination findings, as well as your initial differential
diagnoses. Finally, you will list the diagnostic studies you would order next
on that particular patient. If you think a rectal, pelvic, genitourinary, or
female breast examination would have been indicated in the encounter, then list
it as part of your diagnostic work-up.
Most cases are designed
to present more than one diagnostic possibility. Based on the patient’s
presenting complaint and the additional information you obtain as you begin
taking the history, you should consider all possible diagnoses and explore the
relevant ones as time permits.
Criteria for Evaluation
The CSA exam comprises of eleven patient encounters. Of
these only ten are scored and count towards your performance evaluation. The non-scoreable patient-encounter stations
are added to the CSA rotation for research and other purposes. For the
encounters that are scored, your performance in judged along a set of
criteria that include,
Ability to elicit an appropriate
history
Ability to perform an appropriate,
focused physical exam
Demonstration of interpersonal skills
appropriate to a physician-patient interaction
Generation of a legible, organized,
complete, and accurate written record of the encounter
Proficiency in spoken English
The demonstration of these skills across the patient interactions and write-up is needed to get a passing grade in the exam. The ability to take an appropriate history, write a good medical record, and understating of medical knowledge needed to get at the correct differential diagnosis and diagnostic work-up recommendations are inferred from the medical record that is written. On the other hand, the standardized patients (SP) evaluate your communication and interpersonal skills as well as the ability to perform a physical examination. Each SP fills out checklists that document the inquiries you make and maneuvers you perform during the encounter, and they are trained to do so in a fair and consistent manner for all the examinees that they interact with. The specific criteria used by them include,
Skills in interviewing and collecting
information
the clarity of your questions;
the effectiveness of your questioning
techniques;
appropriate use of medical language;
your verification and summarization of
information with the patients;
the effectiveness of your transitions
between different parts of the interview.
Skills in counseling and delivering
information
the clarity of the information you
give;
the effectiveness and sincerity of
your counseling;
the thoroughness of the encounter
closure;
the clarity and appropriateness of
your speech;
the effectiveness of your
summarization of information and how you link various information together.
Rapport (connection between doctor and
patient)
your attentiveness to the patients;
the appropriateness of your body
language;
your confidence level and attitude;
the level of empathy and support you
show the patients.
Personal Manner
your manner of introducing yourself to
the patients;
the appropriateness of how you expose
and drape the patients;
your manner while conducting physical
examinations;
the appropriateness of your demeanor.
Spoken English Proficiency
your ability to communicate
understandably;
your pronunciation and grammar;
your ability to correct or clarify
your language when needed;
the amount of effort required by
patients to understand you.
You evaluations from all the scored encounters are then weighed to get a pass or fail designation. This performance report is then mailed to you by the ECFMG approximately six to eight weeks after your assessment date.