MRCGP preparation course Written Paper 1

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MRCGP preparation courseWritten Paper 1

• Mark Williams
• GP Trainer - Selby

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WRITTEN PAPER

• 3 hrs (additional time for source material-
  usually around 30 mins)
• Examiner marked
• Answers legible, concise and short notes
  encouraged
• 12 questions (or more)
• 15 mins per question including reading through

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WRITTEN PAPER

• Combined question and answer booklet
• May use reverse side
• Implications
• Repetition
• Candidate number
• Answer all questions

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WRITTEN PAPER

• Four question types
• test of general practice literature knowledge
  (CRQ)
• test of evaluation of written material (CRQ)
• test of ability to integrate and apply
  theoretical knowledge and professional values
  (MEQ)
• new formats

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Test of literature knowledge
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TESTS OF LITERATURE KNOWLEDGE

• Majority of marks for demonstrating understanding
  of current views on a topic and the general
  evidence on which they are based
• Higher marks for quoting sources
• Higher marks still for including a brief critical
  appraisal
• references without understanding is not impressive

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For example- B.P.H.

• Alpha blockers are better than placebo
• 5-alpha reductase inhibitors are better than
  placebo
• (understanding of current views on a topic and
  the general evidence on which they are based)

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• Two systematic reviews for alpha blockers and one
  for 5-ARI
• Eur Urol 1999 and 2000
• (Higher marks for quoting sources)

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• High number of patients unaccounted for
• Considerable number of adverse effects
• (brief critical appraisal)

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Tests of literature knowledge - examples

• Discuss the primary prevention of osteoporosis in
  general practice

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Tests of literature knowledge - examples

• Evaluate the evidence for the effectiveness of
  drugs after discharge from hospital following an
  uncomplicated MI

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Tests of literature knowledge - examples

• Summarise the available evidence for and against
  the use of antibiotics in otitis media

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Tests of literature knowledge - examples

• Other recent questions
• drugs in the management of chronic asthma
• recognition of depression
• methods to help people stop smoking
• childbirth without consultant obstetricians
• current thinking on drugs for hypertension

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TESTS OF LITERATURE KNOWLEDGE

• REVISE COMMON CLINICAL PROBLEMS AND THEMES RATHER
  THAN CONSECUTIVE JOURNALS

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• sources include
• BMJ / BJGP
• Clinical Evidence
• Bandolier, EBM, DTB, Effectiveness Matters
• RCGP occasional papers
• Guidelines of national status
• books! seminal papers of yrs ago

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Evaluation of written material

• Each paper has had 3 of these type of questions

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EVALUATION OF WRITTEN MATERIAL

• analyse audit
• interpret the results - power of studies, p
  values, confidence intervals, NNT, odds ratio,
  sensitivity, specificity and predictive value
• no calculations required but you must understand
  what the terms mean

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EVALUATION OF WRITTEN MATERIAL

• apply results to a clinical scenario
• apply EBM approach to clinical scenario question
  / search / appraisal / application
• critically appraise presented material, a
  clinical study, systematic review, guidelines

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CRITICAL APPRAISAL

• Recognising the main issues raised.
• Commenting on study design.
• Discussing the implications and practical
  application of the results to general practice.

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COMMENTING ON STUDY DESIGN
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Study design

• Does the paper address a question relevant to
  your practice?
• Where did the research take place and who are the
  authors?
• Do they have a vested interest?

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Study design

• What type of study and is it appropriate?
• How were subjects / controls selected?
• Were they randomised if so, how?
• What were the outcome measures?
• Are they clinically relevant?
• Do the sample numbers appear to be appropriate?

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Study design - results

• Are all the subjects accounted for?
• How are the results presented?
• Is the statistical analysis present and
  appropriate?

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Study design- conclusions

• Are the conclusions reasonable in the light of
  the results?
• Do the authors address the limitations of the
  study?
• Are the results believable?

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Study design

• Concurrence with other studies
• Concurrence with own experience
• Implications for me

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Checklists

• eBMJ
• editors checklist
• peer reviewers checklist
• statisticians checklist
• qualitative research checklist
• drug points checklist
• economic evaluation

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Checklists

• http//www.rcgp.org.uk/rcgp/journal/referee/method
  .asp
• (qualitative research)
• http//jama.ama-assn.org/info/auinst_trial.html
• (RCT/Consort)

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Checklist - CONSORT statement

• CONsolidated Standard for Reporting Trials
• Chicago 1995 - published 1996

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(No Transcript)
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IMPLICATIONS FOR PRACTICE

• Personal Patient Management
• Practice Policies
• Practice Organisation
• Practice Finances
• Work Of PHCT Members
• Referral Patterns
• Prescribing
• Contracts / Purchasing / Commissioning
• Consultants Other Hospital Staff
• District Resources E.G.. Pathology
• Own Workload / Free Time
• Society As A Whole

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Implications for practice - 4S study

• PPM- case finding/education/compliance
• PP- guidelines for doctors and nurses
• PO- impact on apts., lipid and LFT measurement
• PF- use of staff special clinics help from
  reps?
• R- inc.. awareness may inc.. referral for ETT
  angio
• Rx- inform PCT
• CPC- inc.. angios dec mortal dec. MI dec
  emerg.admiss.
• DR- path lab
• WL- dec no of MI (early a.m.) inc. workload in
  total
• SOC- dec. cardiac morbidity and mortality

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Problem-solving questions
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PAPER ONE -problem solving questions

• Complex situations or difficult patients - no
  right or wrong answers
• Answers will be evaluated for grasp of CONSTRUCTS

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Problem solving questions

• Read question carefully - answer what is asked
• Think broadly but realistically
• Avoid jargon and cliché - a good tip is to give
  examples (e.g. I.C.E. In M.S.)
• More marks for management of problem than factual
  knowledge

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THE EXAMINERS LOOK FOR......

• A DIVERSITY OF APPROACH-
• Detailing a range of options and selecting the
  most appropriate, justifying selection with
  reference to the literature.
• Considering experiences and circumstances other
  than those personally experienced.
• Showing consideration for patients health
  beliefs and feelings, relatives, co-workers and
  self.
• Awareness of non-medical aspects of the problem.

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• A DIVERSITY OF APPROACH-
• Detailing a range of options and selecting the
  most appropriate, justifying selection with
  reference to the literature.
• Considering experiences and circumstances other
  than those personally experienced.
• Showing consideration for patients health
  beliefs and feelings, relatives, co-workers and
  self.
• Awareness of non-medical aspects of the problem.

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• A DIVERSITY OF APPROACH-
• Detailing a range of options and selecting the
  most appropriate, justifying selection with
  reference to the literature.
• Considering experiences and circumstances other
  than those personally experienced.
• Showing consideration for patients health
  beliefs and feelings, relatives, co-workers and
  self.
• Awareness of non-medical aspects of the problem.

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• A DIVERSITY OF APPROACH-
• Detailing a range of options and selecting the
  most appropriate, justifying selection with
  reference to the literature.
• Considering experiences and circumstances other
  than those personally experienced.
• Showing consideration for patients health
  beliefs and feelings, relatives, co-workers and
  self.
• Awareness of non-medical aspects of the problem.

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PAPER ONE -problem solving questions

• Andrea Bachelor, 26, presents with a vaginal
  discharge.
• How do you arrive at a diagnosis?

• What makes a partners meeting a success?

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PAPER ONE -problem solving questions

• Norman Griffiths is an introspective 47 yr old
  man who suffers from long-standing fatigue. He
  tells you he has seen a television documentary
  suggesting that the mercury in amalgam dental
  fillings is toxic. He is wondering whether to
  have his fillings removed, and asks you for your
  views.
• Describe your thoughts

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IMPLICATIONS OF MARKING SCHEME

• Broad impressions count.
• Layout and presentation important.
• Relatively small differences in quality of
  content or presentation can make a real
  difference.
• Relatively easy to get bulk of marks up to pass
  level.

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Time spent vs marks gained
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Skeletons
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CONSULTATION BEHAVIOUR

• EXPLORE patients knowledge, ideas, concerns,
  expectations.
• EXPLAIN symptoms and signs, diagnosis and
  prognosis.
• CONSIDER treatment options.
• CONSIDER patients preference, involve patient in
  management plan.

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CONSULTATION BEHAVIOUR

• Presenting Problems
• Continuing Problems
• Help Seeking Behaviour
• Opportunistic Health Promotion

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TREATMENT OPTIONS

• DO NOTHING
• Follow up at patients discretion or formally
  arranged.
• DO SOMETHING
• Discuss, negotiate, counsel, advise.
• Discuss other management options, obtain implied
  or informed consent.
• Prescribe drug and / or appliance.
• Arrange or carry out procedure.
• Follow up.

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REFERRAL OPTIONS

• WITHIN PHCT
• SECONDARY CARE
• In patient, out patient, domiciliary visit,
  pathology, radiology, physiotherapy, day
  hospital, occupational therapy.
• Consider NHS / private, local / regional /
  national, PCGs.
• SOCIAL SERVICES
• Social worker, day centre, meals on wheels, home
  helps, part III accommodation, disabled parking
  badge, welfare benefits, citizens advice.

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REFERRAL OPTIONS

• OTHER AGENCIES
• Self help groups, voluntary groups, local and
  national hospice movement, Marie Curie
  Foundation, WRVS.
• ALTERNATIVE THERAPIES

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IN A CONFLICT SITUATION

• AGREE
• DISAGREE
• REFER
• NEGOTIATE
• COUNSEL
• EDUCATE

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GIVING BAD NEWS

• ANXIETY
• What are the the patients fears and worries?
• KNOWLEDGE
• How much does the patient know and understand
  already?
• EXPLANATION
• Diagnosis, prognosis, treatment and follow up (in
  terms the patient understands).
• SYMPATHY
• SUPPORT
• FOLLOW UP

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DEALING WITH ANGER

• AVOID CONFRONTATION.
• FACILITATE DISCUSSION.
• VENTILATE FEELINGS.
• EXPLORE REASONS FOR ANGER.
• CONSIDER REFERRING OR INVESTIGATING.
• APOLOGISE (IF APPROPRIATE).

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THE INFINITE POTENTIAL OF THE CONSULTATION- I

• HISTORY- ideas, concerns, expectations physical,
  psychological, social
• EXAMINATION
• DIFFERENTIAL DIAGNOSIS
• INVESTIGATIONS
• FORMULATE MANAGEMENT PLAN WITH PATIENT /- FAMILY
• ARRANGE HELP - family, PHCT, social services,
  voluntary organisations
• REFER

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THE INFINITE POTENTIAL OF THE CONSULTATION-
contd

• PRESCRIBE
• ANTICIPATE FUTURE PROBLEMS
• PREVENTION / HEALTH PROMOTION
• FOLLOW UP
• LIAISE WITH OTHER AGENCIES

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SKELETONSTHE INFINITE POTENTIAL OF THE
CONSULTATION
NOW SOON FUTURE
HISTORY EXAMINATION DIFF.DIAG. INVEST. MAN.PLAN HE
LP REFER PRESCRIBE ANTICIPATE PREVENT. FOLLOW
UP LIAISE AUDIT
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BUZZ WORDS

• DOCTOR-PATIENT RELATIONSHIP
• DEPENDENCE, CONTROL, MANIPULATION, COLLUSION,
  TRANSFERENCE, HEART-SINK
• DOCTOR
• ELICITING, FACILITATING, EMPATHISING, COUNSELING,
  OPEN / CLOSED QUESTIONS, REFLECTED ANSWERS,
  AUTHORITARIAN, REJECTING
• PATIENT
• AUTONOMY, INVOLVEMENT, VENTILATION OF FEELINGS,
  GUILT / BLAME, LIFE EVENTS, COMPLIANCE, SOMATIC
  FIXATION, SELF HELP GROUPS

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TRIADS

• PHYSICAL, PSYCHOLOGICAL, SOCIAL
• HISTORY EXAMINATION, INVESTIGATION
• IMMEDIATE, SHORT TERM, LONG TERM
• PATIENT, FAMILY, COMMUNITY
• CULTURE, STATUS, IMAGE
• DOCTOR, PARTNERS, PHCT
• IDEAS, CONCERNS, EXPECTATIONS

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New Format

• peak flow chart
• family tree
• letter from consultant
• fill in the gaps
• MCQ
• Extended matching item

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EXAMPLES

• Mrs Dara Thakerar, a 35-year-old teacher consults
  you with headaches.
• How would you assess her problem?

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• Quantitive systematic review of randomised
  controlled trials comparing antibiotic with
  placebo for acute cough in adults
• --------------------------------------------------
  -----------------
• Main outcome measures
• Proportion of subjects with productive cough at
  follow up (7 11 days after consultation with
  general practitioner)
• proportion of subjects who had not improved
  clinically at follow up
• proportion of subjects who reported side effects
  from taking antibiotic or placebo.

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• The above reading is the title and part of the
  summary of a recently published systematic
  review.
• Critically appraise the choice of outcome
  measures given above and evaluate possible
  alternatives

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• We included studies of patients aged greater than
  12 years who were attending a family practice
  clinic, community based outpatient department, or
  an outpatient department attached to a hospital.
  We included patients who complained of acute
  cough with or without purulent sputum that had
  not been treated in the preceding week with
  antibiotic. Patients with chronic obstructive
  airways disease were excluded. The included
  studies were prospective trials in which
  antibiotic was allocated by formal randomisation
  or quasi-randomisation, such as alternate
  allocation to treatment and placebo groups. Only
  placebo controlled trials were included
  comparative studies between different classes of
  antibiotics were excluded. Categorical and
  continuous outcomes were reported in the
  randomised controlled trials we concentrated on
  the three most commonly reported outcomes the
  proportion of subjects reporting productive
  cough, the proportion of subjects who had not
  improved clinically at re-examination, and the
  proportion of subjects who reported side effects
  from taking antibiotic or placebo.

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• Comment of the inclusion and exclusion criteria
  shown above.

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EXAMPLES

• In conducting such a review where should authors
  search for data?

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EXAMPLES

• The Boldison family of five has had twelve
  out-of-hours visits during the last month.
• What issues does this raise?

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EXAMPLES

• What are the challenges of implementing clinical
  governance within a Primary Care setting?

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EXAMPLES

• Alison Lippett, one of your practice nurses, asks
  whether the practice will support her in
  undertaking a nurse practitioner course.
• What issues does this raise?

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EXAMPLES

• How does the evidence contribute to the
  management of sore throats in Primary Care

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• "There are people who strictly deprive themselves
  of each and every eatable, drinkable and
  smokeable which has in any way acquired a shady
  reputation. They pay this price for health. And
  health is all they get out of it. How strange it
  is." Mark Twain
• What dilemmas does this quotation suggest for
  health promotion in modern Primary Care?