Presentation on theme: "MRCGP preparation course Written Paper 1"— Presentation transcript:
1MRCGP preparation course Written Paper 1 Mark WilliamsGP Trainer - Selby
2WRITTEN PAPER3 hrs (+additional time for source material- usually around 30 mins)Examiner markedAnswers legible, concise and short notes encouraged12 questions (or more)~15 mins per question including reading through
3WRITTEN PAPER Combined question and answer booklet May use reverse sideImplicationsRepetitionCandidate numberAnswer all questions
4WRITTEN 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
6TESTS OF LITERATURE KNOWLEDGE Majority of marks for demonstrating understanding of current views on a topic and the general evidence on which they are basedHigher marks for quoting sourcesHigher marks still for including a brief critical appraisalreferences without understanding is not impressive
7For 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)
8Two systematic reviews for alpha blockers and one for 5-ARI Eur Urol 1999 and 2000(Higher marks for quoting sources)
9High number of patients unaccounted for Considerable number of adverse effects(brief critical appraisal)
10Tests of literature knowledge - examples Discuss the primary prevention of osteoporosis in general practice
11Tests of literature knowledge - examples Evaluate the evidence for the effectiveness of drugs after discharge from hospital following an uncomplicated MI
12Tests of literature knowledge - examples Summarise the available evidence for and against the use of antibiotics in otitis media
13Tests of literature knowledge - examples Other recent questionsdrugs in the management of chronic asthmarecognition of depressionmethods to help people stop smokingchildbirth without consultant obstetricianscurrent thinking on drugs for hypertension
14TESTS OF LITERATURE KNOWLEDGE REVISE COMMON CLINICAL PROBLEMS AND THEMES RATHER THAN CONSECUTIVE JOURNALS
15sources include BMJ / BJGP Clinical Evidence Bandolier, EBM, DTB, Effectiveness MattersRCGP occasional papersGuidelines of national statusbooks! & seminal papers of yrs ago
16Evaluation of written material Each paper has had 3 of these type of questions
17EVALUATION OF WRITTEN MATERIAL analyse auditinterpret the results - power of studies, p values, confidence intervals, NNT, odds ratio, sensitivity, specificity and predictive valueno calculations required but you must understand what the terms mean
18EVALUATION OF WRITTEN MATERIAL apply results to a clinical scenarioapply EBM approach to clinical scenario: question / search / appraisal / applicationcritically appraise presented material, a clinical study, systematic review, guidelines
19CRITICAL APPRAISAL Recognising the main issues raised. Commenting on study design.Discussing the implications and practical application of the results to general practice.
21Study designDoes 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?
22Study 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?
23Study design - results Are all the subjects accounted for? How are the results presented?Is the statistical analysis present and appropriate?
24Study 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?
25Study design Concurrence with other studies Concurrence with own experienceImplications for me
30IMPLICATIONS FOR PRACTICE Personal Patient ManagementPractice PoliciesPractice OrganisationPractice FinancesWork Of PHCT MembersReferral PatternsPrescribingContracts / Purchasing / CommissioningConsultants & Other Hospital StaffDistrict Resources E.G.. PathologyOwn Workload / Free TimeSociety As A Whole
31Implications for practice - 4S study PPM- case finding/education/compliancePP- guidelines for doctors and nursesPO- impact on apts., lipid and LFT measurementPF- use of staff; special clinics; help from reps?R- inc.. awareness may inc.. referral for ETT & angioRx inform PCTCPC- inc.. angios; dec mortal; dec. MI; dec emerg.admiss.DR- path labWL- dec no of MI; (early a.m.) inc. workload in totalSOC- dec. cardiac morbidity and mortality
33PAPER ONE -problem solving questions Complex situations or difficult patients - no right or wrong answersAnswers will be evaluated for grasp of CONSTRUCTS
34Problem solving questions Read question carefully - answer what is askedThink broadly but realisticallyAvoid 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
35A DIVERSITY OF APPROACH:- 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.
36A 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.
37A 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.
38A 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.
39PAPER 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?
40PAPER 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
41IMPLICATIONS 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.
44CONSULTATION 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.
45CONSULTATION BEHAVIOUR Presenting ProblemsContinuing ProblemsHelp Seeking BehaviourOpportunistic Health Promotion
46TREATMENT OPTIONS DO NOTHING Follow up at patient’s discretion or formally arranged.DO SOMETHINGDiscuss, negotiate, counsel, advise.Discuss other management options, obtain implied or informed consent.Prescribe drug and / or appliance.Arrange or carry out procedure.Follow up.
47REFERRAL 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 SERVICESSocial worker, day centre, meals on wheels, home helps, part III accommodation, disabled parking badge, welfare benefits, citizen’s advice.
48REFERRAL OPTIONSOTHER AGENCIESSelf help groups, voluntary groups, local and national hospice movement, Marie Curie Foundation, WRVS.ALTERNATIVE THERAPIES
49IN A CONFLICT SITUATION AGREEDISAGREEREFERNEGOTIATECOUNSELEDUCATE
50GIVING BAD NEWS ANXIETY What are the the patient’s fears and worries? KNOWLEDGEHow much does the patient know and understand already?EXPLANATIONDiagnosis, prognosis, treatment and follow up (in terms the patient understands).SYMPATHYSUPPORTFOLLOW UP
51DEALING WITH ANGER AVOID CONFRONTATION. FACILITATE DISCUSSION. VENTILATE FEELINGS.EXPLORE REASONS FOR ANGER.CONSIDER REFERRING OR INVESTIGATING.APOLOGISE (IF APPROPRIATE).
52THE INFINITE POTENTIAL OF THE CONSULTATION- I HISTORY- ideas, concerns, expectations; physical, psychological, socialEXAMINATIONDIFFERENTIAL DIAGNOSISINVESTIGATIONSFORMULATE MANAGEMENT PLAN WITH PATIENT +/- FAMILYARRANGE HELP - family, PHCT, social services, voluntary organisationsREFER
53THE INFINITE POTENTIAL OF THE CONSULTATION- cont’d PRESCRIBEANTICIPATE FUTURE PROBLEMSPREVENTION / HEALTH PROMOTIONFOLLOW UPLIAISE WITH OTHER AGENCIES
54SKELETONS THE INFINITE POTENTIAL OF THE CONSULTATION NOW SOON FUTUREHISTORYEXAMINATIONDIFF.DIAG.INVEST.MAN.PLANHELPREFERPRESCRIBEANTICIPATEPREVENT.FOLLOW UPLIAISEAUDIT
55BUZZ WORDS DOCTOR-PATIENT RELATIONSHIP DOCTOR PATIENT DEPENDENCE, CONTROL, MANIPULATION, COLLUSION, TRANSFERENCE, HEART-SINKDOCTORELICITING, FACILITATING, EMPATHISING, COUNSELING, OPEN / CLOSED QUESTIONS, REFLECTED ANSWERS, AUTHORITARIAN, REJECTINGPATIENTAUTONOMY, INVOLVEMENT, VENTILATION OF FEELINGS, GUILT / BLAME, LIFE EVENTS, COMPLIANCE, SOMATIC FIXATION, SELF HELP GROUPS
56TRIADS PHYSICAL, PSYCHOLOGICAL, SOCIAL HISTORY EXAMINATION, INVESTIGATIONIMMEDIATE, SHORT TERM, LONG TERMPATIENT, FAMILY, COMMUNITYCULTURE, STATUS, IMAGEDOCTOR, PARTNERS, PHCTIDEAS, CONCERNS, EXPECTATIONS
57New Format peak flow chart family tree letter from consultant fill in the gapsMCQExtended matching item
58EXAMPLESMrs Dara Thakerar, a 35-year-old teacher consults you with headaches.How would you assess her problem?
59Quantitive systematic review of randomised controlled trials comparing antibiotic with placebo for acute cough in adultsMain 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.
60The 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
61We 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.
62Comment of the inclusion and exclusion criteria shown above.
63EXAMPLESIn conducting such a review where should authors search for data?
64EXAMPLESThe Boldison family of five has had twelve out-of-hours visits during the last month.What issues does this raise?
65EXAMPLESWhat are the challenges of implementing clinical governance within a Primary Care setting?
66EXAMPLESAlison Lippett, one of your practice nurses, asks whether the practice will support her in undertaking a nurse practitioner course.What issues does this raise?
67EXAMPLESHow does the evidence contribute to the management of sore throats in Primary Care
68"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 TwainWhat dilemmas does this quotation suggest for health promotion in modern Primary Care?