• About This Publication
• General Information
• Description Of The CSA
• Test Regulations
• Registration And Scheduling
• Common Questions
• Glossary And Common Abbreviations
• References

CSA Candidate Orientation Manual: PDF Format - for printing/downloading (1.0 MB)

ECFMG Home > Publications > CSA Candidate Orientation Manual > Description Of The CSA

Description Of The CSA

CSA Prototype

In your CSA administration you will have ten, eleven, or twelve patient encounters, ten of which will be scored. Non-scored patient encounters are added for research and other purposes, but those encounters are not counted in determining your score.

Before entering each examination room, you will have an opportunity to review information posted on the examination room door. This information gives you specific instructions and indicates the patient's name, age, gender, and reason for visiting the doctor. It also indicates his or her vital signs, including heart rate, blood pressure, temperature (Centigrade and Fahrenheit), and respiratory rate. You can accept these as accurate and do not need to repeat them unless you believe the case specifically requires it.

When you enter each room, you will encounter an 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 workup plan. You will also be expected to communicate in spoken English with the patients in a professional and empathetic manner. You should answer any questions they have, tell them what diagnoses you are considering, and advise them on what tests and studies you will order to clarify their diagnoses.

The kinds of medical problems that your patients will portray 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.

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, female breast, or corneal reflex examinations. If you believe one or more of these are indicated, you may include them in your proposed diagnostic workup.

You will have fifteen minutes for each patient encounter. The patient encounter begins with your review of the doorway information. 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 fewer than fifteen minutes. If so, you may leave the examination room early, but you are not permitted to re-enter. Be certain that you have obtained all of the necessary information before leaving the examination room.

Immediately following each encounter, you will have ten minutes to complete a patient note. If you leave the encounter early, you may use the additional time for the 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, female breast, or corneal reflex examination would have been indicated in the encounter, then list it as part of your diagnostic workup. Treatment, consultations, or referrals should not be included in your workup plan.

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.

You should 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 diagnoses. Be considerate of the patients, and always keep them comfortable and properly draped as you perform the physical examination. You should always wash your hands or put on gloves before beginning the physical examination.

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. The orientation given immediately before you take the CSA will include a brief demonstration of the instruments and equipment that you will use in the actual patient encounters.

Sample Opening Scenarios

To give you a better understanding of the typical mixture of cases presented in one CSA administration, ten sample opening scenarios are listed below. This is the basic information that is posted on the doorway of each examination room prior to your seeing the patient. The scenarios listed below are representative of, but are not the exact cases you will see in your assessment session.

Sample Case

Case Background Information

The following case excerpts were selected to familiarize you with the content and evaluative objectives that provide the basis for scoring. This information is used to train the SPs. When you take the CSA, you will not have access to the information below. The background information presented here is simply an example of the materials on which a typical case is based.

Most CSA cases incorporate patient history, physical examination, examinee communication skills (including spoken English proficiency), and a post-encounter patient note. You should become acquainted with the following examples of the doorway information, the checklists that the SPs use to document your actions during the encounter, the patient note format, and the evaluative tools used to derive doctor-patient communication ratings.

Chief Complaint

Jolene Brown is a 48 year-old female complaining of chest pain.

History of Present Illness

The patient is a 48 year-old female complaining of burning chest pain that began one and a half hours prior to presenting to the Emergency Department. The pain began 30 minutes after a heavy lunch. Nausea, slight sweating and dyspnea accompanied the pain. The pain passed spontaneously 20 minutes after its onset. She presently feels fine and wishes to be immediately discharged. She describes several similar episodes in the previous two to three months, especially after heavy meals or physical exertion, continuing for two to three minutes and passing spontaneously. Prior to this period Ms. Brown had no chest pain. She is not working harder nor experiencing any specific stress lately. She plays tennis once a week; no other physical activity. Lately, during matches, Ms. Brown complains of mild retrosternal burning sensation. Over the past two to three months, during the burning episodes, she used antacids, with partial relief of symptoms. For the past three to four years, the patient has had occasional heartburn after heavy meals and antacids gave partial relief. But now the pain is different. Her pain is not related to breathing or changes in body position. She has had no change in bowel movements, no melena. She has no symptoms of congestive heart failure or arrhythmias (no orthopnea, paroxysmal nocturnal dyspnea or palpitations).

Past Medical History

Hyperlipidemia: Ms. Brown had cholesterol checked on routine blood tests done two years ago. She was told that her cholesterol was high, but does not remember any specific values. A low cholesterol diet was suggested at the time, but she did not follow this advice. Otherwise, the patient is completely healthy. She has not seen a physician in two years.

Medication, Allergies, Diet, Immunization

Medications: The patient takes no prescribed medication. Occasional use of over the counter antacids.

Allergies: Penicillin caused her to break out in a rash.

Diet: Unremarkable.

Immunization: Unremarkable.

Family History

Older brother: Diagnosed with some sort of 'heart problem,' but never treated (patient does not know exact details).

Father: Peptic ulcer disease.

Mother: Non insulin-dependent diabetes mellitus (NIDDM) treated by diet alone.

Social History and Habits

Smoking: She stopped smoking three years ago, and until then she smoked two packs a day for 15 years.

Alcohol: Occasionally drinks socially, but takes in small amounts.

Occupation: Executive Vice President of a not-for-profit charitable organization.

Marital Status: Single heterosexual female.

Doorway Information

Before entering the examination rooms, you will be given some basic information. This doorway information is posted on each examination room door and is similar to a triage note that a nurse normally gives a physician. Reviewing the doorway information is part of the timed, fifteen-minute patient encounter.

Before seeing the patient, read the doorway information carefully, because it will tell you his or her name, gender, age, presenting complaint, and the tasks you are to complete. You should accept the doorway information as accurate, though in some cases reexamination of vital signs may be appropriate. Most CSA stations will have the same types of tasks listed, but some may include specific, unique tasks.

For your convenience, there will be a second copy of the doorway information in the examination room. Please do not remove the doorway information from the examination room.

Doorway Information (Sample)

1. Opening Scenario

Jolene Brown, a 48 year-old female, comes to the Emergency Department complaining of chest pain.

2. Vital Signs

3. Examinee Tasks

• Obtain a focused history.



• Perform a relevant physical examination
  (Do not perform rectal, pelvic, genitourinary, female breast, or corneal reflex examinations).



• Discuss your initial diagnostic impression and your workup plan with the patient.



• After leaving the room, complete your patient note on the form provided.

History Taking and Physical Examination Checklists

Standardized patients document your actions during the encounter, and they are trained to do so in a fair and consistent manner. Each patient fills out checklists that document the inquiries you make and maneuvers you perform during the encounter. The history taking checklist includes all of the key inquiries you are expected to make in the course of taking the patient's history for a particular case. Patients also use a physical examination checklist that includes all of the key maneuvers you should perform during the course of a physical examination for the particular case. Your technique in doing these maneuvers is also taken into account by the patient. He or she marks those items you asked or performed, for which you receive credit.

Since the cases are broad, your history taking should consider multiple possible diagnoses. Do not prematurely close your history taking on a single diagnosis, and do not attempt a complete history. During your physical examination of the patient, you should attempt to elicit important positive and negative signs. The fifteen minutes you have with the patient does not permit a complete history taking or physical examination, but only a gathering of relevant data. Make sure you discuss with the patient your initial diagnostic impression and workup plan. The patients are instructed to ask very specific questions concerning their complaints. These inquiries are intended to challenge you, so you should address each patient's concern as you would do normally in a clinical setting.

All physical examination maneuvers, including exposing and draping the patient, should be done as you would do them normally in regular practice. For abdominal examination, however, you should be able to obtain the information you need without extremely deep or forceful palpation. Additionally, certain parts of the physical examination must not be performed: rectal, pelvic, genitourinary, female breast, and corneal reflex examinations. Your score is based on what you look for in the encounter and the technique you employ while going about it.

The following sample checklist items are examples of examinee questions and physical examination maneuvers that might be expected in a particular case. However, the listed questions and maneuvers are not exact representations of complete history taking and physical examination checklists.

Standardized Patient History Taking Checklist (Sample Items)

Standardized Patient Physical Examination Checklist (Sample Items)

Sample Case

Patient Note

After leaving the encounter, you will have ten minutes to complete the patient note. In an actual practice setting, the patient note would be used to communicate with other health professionals. Keep in mind that once you leave the patient to complete your patient note, you cannot re-enter the examination room. Blank paper will be provided for note taking in the examination room. For security reasons, the sheets of blank paper are numbered and must be returned with your completed patient note for each encounter. These sheets are not scored.

A blank patient note is provided, followed by two examples of completed notes. There are several styles of writing patient notes that are acceptable. The two examples are presented to demonstrate some of the variations in style. They are not meant to represent ideal or perfect patient notes, nor should they be assumed to be complete or accurate with respect to content. Both formats and styles, however, would be considered acceptable, despite their differences.

History

Make note of significant positives and negatives from the history taking. The following history categories may yield important information, although not all will necessarily be pertinent to every case:

• Chief complaint (CC)
• History of present illness (HPI)
• Past medical history (PMH)
• Review of systems (ROS)
• Social history (SH)
• Family history (FH)

Physical Examination

List pertinent positive and negative findings from the physical examination.

Differential Diagnosis

Consider a range of possible diagnoses, and list up to five of them.

Diagnostic Workup

Write your immediate plans for further diagnostic workup. If you think rectal, pelvic, genitourinary, female breast, or corneal reflex examinations should be done as part of the evaluation for that specific patient, you may include them in your diagnostic workup plan on the patient note. Treatment (therapeutics) should not be included. Do not include hospitalization, consultations, or referrals.

You should order fundamental first line tests that will help point you in a diagnostic direction. These requested tests must also be specific. For example, if you suspect hypothyroidism, you might order "T4 and TSH," but not "Thyroid studies" or "Thyroid panel." Do not order "SMA-20," "Chemistry panel," or "Liver profile," but rather, the specific component tests you are interested in, e.g., "BUN, glucose, Na, K."

You may use abbreviations commonly used in the United States. If you are uncertain about the abbreviation, write out the full term. For the patient note to be scored, your handwriting must be legible. For your convenience in preparing for the CSA, the glossary lists some commonly recognized abbreviations and definitions, but it is not meant to be comprehensive.

There are some abbreviations not included in the glossary, but they are common enough to be recognizable by the practicing physicians rating the notes. The note is written in cursive script, but it is legible.

Patient Note Example Two

The following patient note is written in more of a telegraphic or "bullet" style. There are no complete sentences, although there are some phrases where appropriate. In some parts of the History in particular, there are one or two words that stand alone. The writer of this note has chosen to transcribe the patient's blood pressure from the doorway information. You may wish to include vital signs if they are particularly relevant to the case.

In this note only four items are listed in both the Differential Diagnosis and in the Diagnostic Workup sections; again this is acceptable. This sample also has some abbreviations or symbols not included in the glossary but, as in Example One, they are generally recognizable. This note is printed throughout, although a mixture of cursive script and printing would also be acceptable, provided both were legible.

Sample Case

Doctor-Patient Communication

Standardized patients undergo extensive and continuous training to rate your doctor-patient communication skills. This method of rating results in fair, valid, and reliable data. (See References.) During the encounters, the patients will evaluate your doctor-patient communication skills based on the following criteria:

• Skills in interviewing and collecting information
  
  
  • the clarity of your questions;
  • the effectiveness of your questioning techniques;
  • the use of language the patients can understand;
  • 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 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;
  • the level of empathy and support you show the patients.



• Personal Manner
  
  
  • your manner of introducing yourself to the patients;
  • the appropriateness of your demeanor;
  • your confidence level and attitude;
  • your manner while conducting physical examinations, including draping technique;
  • the appropriateness of how you expose and drape the patients.



• 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.

Doctor-Patient Communication Rating Scale

The following scale is used by the SPs to rate your doctor-patient communication performance. A rating scale is completed for each encounter.

Item 1. Skills in Interviewing and Collecting Information

(clarity of questions, open vs. closed questions, verification, summarization, transitions)

Item 2. Skills in Counseling and Delivering Information

(giving information, counseling, closure, language and speech, summarization and connection)

Item 3. Rapport (connection between doctor and patient)

(attentiveness, body language, attitude, empathy and support)

Item 4. Personal Manner

(introduction, demeanor, confidence, hygiene, physical examination, draping)

Item 5. Spoken English Proficiency

(ability to communicate understandably, pronunciation and grammar, amount of effort required by patients to understand you)

General Information on Scoring and Score Reporting

Overview

To pass the CSA, you must meet predefined performance standards set by medical experts in two separate components. The first component, called the Integrated Clinical Encounter (ICE), is a combination of the Data Gathering (DG) and Patient Note (PN) scores. The second component, Doctor-Patient Communication (COM), is derived from the SP evaluations of interpersonal skills and spoken English language proficiency. You will have ten, eleven, or twelve patient encounters. Ten of these encounters will be used to derive your scores.

Scoring Components

Integrated Clinical Encounter (ICE)

Data Gathering (DG)
Using the history taking and physical examination checklists, each SP documents your ability to gather data relevant to the clinical encounter. Your DG score for a particular encounter is the percentage of checklist items for which you were given credit in the history taking and physical examination. The SP does not evaluate your medical performance, but simply documents whether or not you successfully obtained relevant information or correctly performed the case-specific physical examination maneuvers. Your final DG score is the average of your DG scores for the ten scored encounters.

Patient Note (PN)
Following the encounter with the SP, you will be required to complete a patient note. Physicians are trained to rate these notes based on predefined criteria that include:

• Organization: Presentation of a clear portrayal of the patient's complaint; reasonable order of assessment and diagnostic workup.
• Quality of Information: Information is presented with appropriate detail including documentation of significant positive and negative elements of the history and physical examination.
• Interpretation of Data: Interpretation of data gathered is reflected in reasonable differential diagnoses.
• Egregious/dangerous actions: Avoids diagnostic workup plans that could result in harm; avoids expensive, non-indicated diagnostic tests.
• Legibility: Easily read with little effort required.

Your final PN score is the average of your PN scores for the ten scored encounters.

The DG and PN scores are combined to form an ICE score. Since your final DG and PN scores reflect your average performance for the ten scored encounters, you may compensate for poor performance in one encounter with excellent performance in another.

Doctor-Patient Communication (COM)

Following each encounter, the SP will also evaluate your doctor-patient communication skills along five dimensions:

• Interviewing;
• Counseling and delivering information;
• Rapport;
• Personal manner;
• Spoken English proficiency.

For each of these dimensions, the SP assigns a score. The SPs make these evaluations according to a scoring system that is fair, consistent and objective. Your COM score for the encounter is the sum of the five COM dimension scores. Your final score for the Doctor-Patient Communication component is the average of these COM scores for the ten scored encounters. Your score must meet or exceed a performance standard predefined by physician experts.

Score Reporting

An overall pass/fail designation will be reported to you six to eight weeks after your CSA administration. ECFMG reserves the right to delay the reporting of CSA results if additional data and/or analyses are required to assure the validity of the assessment scores. Candidates who meet the standards on both the ICE and COM components receive a "PASS" designation for the CSA. Substandard performance on either the ICE or COM component results in a "FAIL" designation. If you fail the CSA, your score report will indicate the areas in which you did not meet the standards.

You can check the status of your CSA score report by accessing OASIS on the ECFMG Home Page. To avoid misinterpretation and to protect your privacy, CSA results will not be provided by telephone, fax, or e-mail.

Score Rechecks

CSA results are based on the checklists and score sheets completed by SPs at the time of the assessment, as well as subsequent scoring of the written records by medically-qualified raters. Standardized procedures ensure that your scores are an accurate reflection of your performance. A change in your score based on a recheck is an extremely remote possibility. However, if you would like a recheck of your CSA result, submit a completed Examinee Request for Score Recheck Form (Form 751) and the fee for this service to ECFMG. Form 751 is available on the Publications Page of this website and from ECFMG, upon request. The recheck will consist of recalculating the component scores on which your CSA pass/fail designation is based.

Please send your request to:

ECFMG
Attention: CSA Score Inquiry
3624 Market Street
Philadelphia, PA 19104-2685 USA

Preparing for the CSA

History taking, physical examination, spoken and written English, and interpersonal behavior are all skills that can be improved by training, practice, and critique. You can refer to the multiple texts and other media sources that address these skills. Practice with colleagues, teachers, or mentors who portray patients could be useful, provided such role-plays are realistic and represent common complaints.

Perhaps the best preparation is to see actual patients in a real clinical setting, especially if this is done under the supervision and/or review of a competent clinical teacher. The CSA is designed to simulate an actual clinical experience, so the more clinical experience you have, the more comfortable you will feel during the examination.

You will find additional test-taking strategies in the videotape that is sent to registered applicants. The videotape gives more information on the CSA and shows excerpts from typical patient encounters.

Strategies for the Encounters

General Comments

• Greet the patient and state your name.
• Elicit or confirm the patient's name.
• Never attempt to communicate with the patient other than as a physician to a patient.
• Feel free to take notes during the encounter. (Blank paper will be provided.)
• Don't make assumptions about what you will see in each encounter.
• There may be more than one case testing related or similar clinical entities.
• Concentrate on the case on which you are working.
• Notify proctors of any problems.

History Taking

• Begin with broad questions, and then focus your inquiries.
• Don't rush the patient's answers.
• Don't cut the patient's answer off with another question.
• Repeat your questions in different terms, if necessary.
• Ask follow-up questions.

Physical Examination

• Do a focused examination based on the patient's complaint, symptoms, and history.
• Wash your hands between patients, preferably before touching the patient or beginning the physical examination.
• Tell the patient when you are going to begin the physical examination.
• Describe the maneuvers either before or as you do them.
• Always use patient gowns and drapes appropriately to maintain patient modesty and comfort, but never examine through the gown.
• Use the examination table extension when the patient reclines.
• If you ask a patient to get off the examination table, offer to assist him or her.
• Look for physical findings.
• Do not perform rectal, pelvic, genitourinary, female breast, or corneal reflex examinations.

Concluding the Encounter

• Note that there will be a time warning for five minutes remaining in the encounter.
• Tell the patient your initial impressions and your plan for the diagnostic workup.
• Ask for and answer any additional questions.
• Close the encounter when the "End of Encounter" signal is given.

Doctor-Patient Communication

• Make eye contact.
• Ask clear questions and speak understandably.
• If you use medical terms, explain yourself.
• Be direct and honest, but also be sensitive.
• If you don't know the answer to an SP's question, say so.
• Don't give false reassurance or a premature diagnosis.
• Acknowledge the patient's concerns or worries.

Patient Note

• Approach the note as if you are communicating with another health professional.
• Write legibly.
• Group similar data together.
• Write out information in a logical sequence.
• Be specific.
• Identify critical elements.
• Include pertinent positives and negatives.
• Make sure your plans for further diagnostic workup are reasonable.
• Do not include treatment in your plans for diagnostic workup.

Test of Spoken English

It is not required that you speak English that is comparable to that of a native speaker. However, if you are uncertain of your spoken English language proficiency, you are encouraged to take the Test of Spoken English^™ (TSE^®) as a screening test prior to applying for the CSA. The TSE exam is administered worldwide by the Educational Testing Service^® (ETS^®). Studies indicate that candidates who obtain a score of 35 or lower on the TSE exam are not likely to pass the CSA; however, a TSE score above 35 does not ensure that you will pass the CSA. A TSE score of 35 represents a speaker who generally does not communicate effectively and cannot compensate for weaknesses in language.

For information about TSE administration dates and locations, contact:

TOEFL^®/TSE Services
PO Box 6151
Princeton, NJ 08541-6151 USA

Telephone: (609) 771-7100

E-mail: toefl@ets.org

Internet: www.toefl.org

The Day of the Assessment

When you arrive at the CSA Center on the day of your assessment, please be prepared to present valid, government-issued photo identification and your admission permit. Arrive at the CSA Center no more than thirty minutes prior to your scheduled assessment. If you are traveling a long distance, consider arriving at least a day before your CSA session.

Please bring only necessary personal items with you to the center. Coat racks are available, and each candidate is assigned a small, open storage cubicle in which personal belongings must be stored during the assessment. However, these cubicles are not secure, and ECFMG assumes no responsibility for your personal items. Luggage cannot be stored in the center. There are no waiting facilities for spouses, family, or friends, so please plan to meet them elsewhere after the assessment. Wear comfortable, professional clothing and a white laboratory or clinic coat. The only piece of medical equipment you need to bring is your stethoscope. All other necessary medical equipment is provided in the examination rooms.

Throughout the assessment day, CSA staff, wearing identifying nametags, will direct you through the examination. Please follow their instructions at all times.

Each assessment session begins with an on-site orientation. This orientation is in addition to this manual and the videotape that ECFMG sends to registered candidates. The orientation will familiarize you with the equipment in each examination room and the nature of typical encounters. It is also intended to inform you about examination procedures and regulations.

Prior to the orientation, you will be asked to sign a confidentiality agreement. It stipulates that you, as a CSA examinee, will not reveal case information to anyone at any time. This agreement is a way to ensure that each examinee has the same opportunity as all others. If you disclose information to prospective candidates, there is no guarantee that the information you supply will aid them. In fact, it may confuse subsequent candidates because different sets of cases are used each day. In addition to the confidentiality agreement, you will be asked to complete demographic and feedback questionnaires after the assessment.

The CSA Center is a secured facility. Once you enter the secured area of the center for orientation, you may not leave that area until the CSA has been completed. The assessment lasts approximately eight hours, and two breaks are provided. The first break is thirty minutes long and takes place after the fourth encounter; the second break is fifteen minutes long and occurs after the eighth encounter. At break time, you are free to relax, use the rest rooms, and have refreshments. A light meal will be served, and there are vending machines available for drinks. You may also bring your own food provided that no refrigeration or preparation is required. Smoking is prohibited throughout the center. You may not use cellular telephones or beepers at any time during the CSA.

You cannot, during breaks or at any time, discuss the cases with your fellow candidates. Conversation among candidates in languages other than English about any subject is strictly prohibited at all times, including during breaks. Examination proctors will be with you to monitor activity. To maintain security and quality assurance, each examination room is equipped with video cameras and microphones to record every encounter. Please conduct yourself as you would during a normal day in a clinic.