1. MRCGP preparation course Written 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://jama.ama-assn.org/info/auinst_trial.html
(qualitative research)
(RCT/Consort)

28. Checklist - CONSORT statement
CONsolidated Standard for Reporting Trials
Chicago 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. A 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.

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. 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?

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

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

52. 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

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

54. 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

55. 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

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

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

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

59. 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.

60. 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

61. 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.

62. Comment of the inclusion and exclusion criteria shown above.

63. EXAMPLES
In conducting such a review where should authors search for data?

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

65. EXAMPLES
What are the challenges of implementing clinical governance within a Primary Care setting?

66. 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?

67. EXAMPLES
How 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 Twain
What dilemmas does this quotation suggest for health promotion in modern Primary Care?