MRCGP preparation course Written Paper 1

1. MRCGP preparation courseWritten Paper 1 Mark Williams GP Trainer - Selby

2. 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

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

4. 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

5. Test of literature knowledge

6. 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

7. 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)

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

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

10. Tests of literature knowledge - examples • Discuss the primary prevention of osteoporosis in general practice

11. Tests of literature knowledge - examples • Evaluate the evidence for the effectiveness of drugs after discharge from hospital following an uncomplicated MI

12. Tests of literature knowledge - examples • Summarise the available evidence for and against the use of antibiotics in otitis media

13. 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

14. TESTS OF LITERATURE KNOWLEDGE • REVISE COMMON CLINICAL PROBLEMS AND THEMES RATHER THAN CONSECUTIVE JOURNALS

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

16. Evaluation of written material Each paper has had 3 of these type of questions

17. 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

18. 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

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

20. COMMENTING ON STUDY DESIGN

21. 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?

22. 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?

23. Study design - results • Are all the subjects accounted for? • How are the results presented? • Is the statistical analysis present and appropriate?

24. 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?

25. Study design • Concurrence with other studies • Concurrence with own experience • Implications for me

26. Checklists • eBMJ • editor’s checklist • peer reviewer’s checklist • statistician’s checklist • qualitative research checklist • drug points checklist • economic evaluation

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

28. Checklist - CONSORT statement • CONsolidated Standard for Reporting Trials • Chicago 1995 - published 1996

30. 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

31. 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

32. Problem-solving questions

33. PAPER ONE -problem solving questions Complex situations or difficult patients - no right or wrong answers Answers will be evaluated for grasp of CONSTRUCTS

34. 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

35. 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.

36. 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.

37. 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.

38. 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.

39. Andrea Bachelor, 26, presents with a vaginal discharge. How do you arrive at a diagnosis? What makes a partners’ meeting a success? PAPER ONE -problem solving questions

40. 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

41. 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.

42. Time spent vs marks gained

43. “Skeletons”

44. 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.

45. CONSULTATION BEHAVIOUR • Presenting Problems • Continuing Problems • Help Seeking Behaviour • Opportunistic Health Promotion

46. 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.

47. 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.

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

49. IN A CONFLICT SITUATION • AGREE • DISAGREE • REFER • NEGOTIATE • COUNSEL • EDUCATE

50. 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