1. Written Paper
Paper One

2. Plan for seminar Format Content ‘Skeletons’ Examiners’ comments
Different types exam questions – tips for each
Implications for revision
‘Skeletons’
Examiners’ comments

3. http://www.rcgp.org.uk Resource Number One past papers
examiners comments
regulations
syllabus

4. FORMAT

5. Written Paper Format
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

6. Written Paper Format Combined question and answer booklet
May use reverse side
Implications
Repetition
Candidate number
Answer all questions

7. Written Paper Format 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

8. CONTENT

9. Major Themes of Written Paper Are:
consultation-based problem-solving, informed decision-making and clinical management
consultation and communication skills
evidence-based practice in the treatment and prevention of disease

10. Major Themes of Written Paper cont’d:
critical appraisal
challenges and dilemmas in practice
values, sensitivity and empathy
responsibilities to partners, other health professionals, and society

11. Question Glossary (look them up)
comment
discuss
factor
implication
issue
manage
process
respond

12. Test of literature knowledge

13. Test 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

14. May 2003 (HRT)
It is worth pointing out to future candidates that when asking for evidence, examiners want to read of the knowledge gained from research evidence, rather than simply be given a reference to a trial.

15. May 2003 (HRT)
Where possible, identifying the precise source of evidence is worthwhile but of secondary value to actually knowing the evidence base of good current medical practice.

16. 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)

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

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

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

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

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

22. 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

23. Test of literature knowledge
REVISION
revise common clinical problems and themes rather than consecutive journals

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

25. Revision Study group to share the load PBL during the consultation
Areas of weakness
Everyday general practice
Flash cards?
MSN MRCGP newsgroup

26. Evaluation of written material
Each paper has had at least 3 of these type of questions

27. 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

28. 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

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

30. Commenting on study design

31. Commenting on Study Design
How to read a paper
Trisha Greenhalgh
Cheap version –

32. 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?

33. 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?

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

35. 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?

36. Study design - overview
Concurrence with other studies
Concurrence with own experience
Implications for me

37. Study design - Checklists
eBMJ
editor’s checklist
peer reviewer’s checklist
statistician’s checklist
qualitative research checklist
drug points checklist
economic evaluation

38. Study design - Checklists
(qualitative research)
(information for authors and readers)
(RCT/Consort)

39. Checklist - CONSORT statement
CONsolidated Standard for Reporting Trials
Chicago published 1996

42. Implications for practice

43. 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

44. Problem-solving questions
Around half of the paper – 6 questions

45. Problem solving questions
Complex situations or difficult patients - no right or wrong answers
Answers will be evaluated for grasp of CONSTRUCTS

46. 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

47. 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.

48. 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.

49. 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.

50. 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.

51. PAPER ONE -problem solving questions
Andrea Bachelor, 26, presents with a vaginal discharge.
How do you arrive at a diagnosis?

52. 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

53. 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.

54. Time spent vs marks gained

55. “Skeletons”

56. 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.

57. Consultation Behaviour
Presenting Problems
Continuing Problems
Help Seeking Behaviour
Opportunistic Health Promotion

58. Treatment Options DO NOTHING DO SOMETHING
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.

59. 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.

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

61. In A Conflict Situation
AGREE
DISAGREE
REFER
NEGOTIATE
COUNSEL
EDUCATE

62. 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

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

64. 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

65. THE INFINITE POTENTIAL OF THE CONSULTATION- cont’d
PRESCRIBE
ANTICIPATE FUTURE PROBLEMS
PREVENTION / HEALTH PROMOTION
FOLLOW UP
LIAISE WITH OTHER AGENCIES

66. SKELETONS THE INFINITE POTENTIAL OF THE CONSULTATION
NOW SOON FUTURE
HISTORY
EXAMINATION
DIFF.DIAG.
INVEST.
MAN.PLAN
HELP
REFER
PRESCRIBE
ANTICIPATE
PREVENT.
FOLLOW UP
LIAISE
AUDIT

67. Buzz Words Doctor-patient relationship Doctor Patient
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

68. ‘Universal Framework’
Build rapport
Empathy and listening approach
Patient issues
Further Hx Ex Ix
Relatives
Doctor issues
Practice issues and dynamics
Family dynamics
Social and Work issues
Ethical issues and patient autonomy
Medicolegal
Management options in community
Health promotion
PHCT
Follow up

69. New Format Questions peak flow chart family tree
letter from consultant
fill in the gaps
MCQ
Extended matching item

70. Examiners’ comments
Candidates who answered the question as asked did well
‘the question was definitely about feelings and those candidates who answered the wrong questions scored very low marks’
It is important to understand the concepts of relative and absolute risk
When looking at data it can be useful to identify the extremes and comment on trends

71. Examiners’ comments
Poor candidates emphasised general points such as ideas concerns expectations shared management and consultation models without applying these to the specific problem in the question

72. Examiners’ comments
Poorer candidates included irrelevant material such as ethical grids clearly learnt specifically for the exam but not really applicable to this situation

73. Examiners’ comments
A few candidates still appeared to have little or no understanding of the basic principles of qualitative research

74. Examiners’ comments
Some candidates were sidetracked into wanting protocols for sickness certificates, wanted to discuss the case with their partners and/or their defence society, were going to audit their sickness certificates, were worried their staff were going to be attacked and would hold a significant event audit. IT IS BEST TO ADDRESS THE QUESTION ASKED.
Think broadly and laterally but do stick to the question

75. Examiners’ comments
If a question is phrased ‘discuss your management’ – check glossary
SPECIFIED as
History
Exam
Treatment
Investigations
Referral
Consultation skills
If covered broadly, -> sure of passing or better mark!

76. Stinky question
"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?

77. The finish – LIKE THIS

78. OR LIKE THIS
GOOD LUCK 