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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– editor’s checklist– peer reviewer’s checklist– statistician’s 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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Randomised trial Use of a structured format Prospective hypothesis Prospective clinical objectives Planned sub-group analysis Study population with inclusion/exclusion criteria Planned interventions with timing Outcome measures with minimum important differences Sample size calculations Rationale/methodology for statistical analysis Prospectively designed stopping rules Unit of randomisation Method for allocation schedule Method of allocation concealment Separation of generator from executor of assignment Blinding Trial profile Estimated effect using a point estimate & precision measure Summary data in sufficient detail to replicate analysis Protocol deviations with reasons Interpretation of study findings with sources of bias General interpretation in light of general evidence

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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:-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:-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:-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:-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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2 mins 4 mins 6 mins 8 mins 10 mins

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“Skeletons”

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CONSULTATION BEHAVIOUR

• EXPLORE patient’s knowledge, ideas, concerns, expectations.

• EXPLAIN symptoms and signs, diagnosis and prognosis.

• CONSIDER treatment options.• CONSIDER patient’s 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 patient’s 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, citizen’s 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 patient’s 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- cont’d

• 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

HISTORYEXAMINATIONDIFF.DIAG.INVEST.MAN.PLANHELPREFERPRESCRIBEANTICIPATEPREVENT.FOLLOW UPLIAISEAUDIT

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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

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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?