Written Paper Paper One. Plan for seminar Format Content Different types exam questions – tips for each Different types exam questions – tips for

Written PaperWritten Paper

Paper OnePaper One

Plan for seminarPlan for seminar

FormatFormat ContentContent

Different types exam questions – tips for eachDifferent types exam questions – tips for each Implications for revisionImplications for revision

‘‘Skeletons’Skeletons’ Examiners’ commentsExaminers’ comments

Resource Number OneResource Number One

http://www.rcgp.org.ukhttp://www.rcgp.org.uk past paperspast papers examiners commentsexaminers comments regulationsregulations syllabussyllabus

FORMATFORMAT

Written Paper FormatWritten Paper Format 3 hrs (+additional time for 3 hrs (+additional time for

source material- usually source material- usually around 30 mins)around 30 mins)

Examiner markedExaminer marked Answers legible, concise Answers legible, concise

and short notes encouragedand short notes encouraged 12 questions (or more)12 questions (or more) ~15 mins per question ~15 mins per question

including reading throughincluding reading through

Written Paper FormatWritten Paper Format

Combined question and answer bookletCombined question and answer booklet May use reverse sideMay use reverse side ImplicationsImplications

RepetitionRepetition Candidate numberCandidate number

Answer all questionsAnswer all questions

Written Paper FormatWritten Paper Format

Four question typesFour question types test of general practice literature knowledge test of general practice literature knowledge

(CRQ)(CRQ) test of evaluation of written material (CRQ)test of evaluation of written material (CRQ) test of ability to integrate and apply theoretical test of ability to integrate and apply theoretical

knowledge and professional values (MEQ)knowledge and professional values (MEQ) new formatsnew formats

CONTENTCONTENT

Major Themes of Major Themes of Written Paper Are:Written Paper Are:

consultation-based problem-solving, consultation-based problem-solving, informed decision-making and clinical informed decision-making and clinical managementmanagement

consultation and communication skillsconsultation and communication skills evidence-based practice in the treatment evidence-based practice in the treatment

and prevention of diseaseand prevention of disease

Major Themes of Written Paper Major Themes of Written Paper cont’d:cont’d:

critical appraisalcritical appraisal challenges and challenges and

dilemmas in practicedilemmas in practice values, sensitivity and values, sensitivity and

empathyempathy responsibilities to responsibilities to

partners, other health partners, other health professionals, and professionals, and societysociety

Question Glossary (look them Question Glossary (look them up)up)

commentcomment discussdiscuss factorfactor implicationimplication issueissue managemanage processprocess respondrespond

Test of literature Test of literature knowledgeknowledge

Test of literature knowledgeTest of literature knowledge

Majority of marks for demonstrating Majority of marks for demonstrating understanding of current views on a topic and understanding of current views on a topic and the the general evidence general evidence on which they are basedon which they are based

Higher marks for Higher marks for quoting sourcesquoting sources Higher marks still for including a Higher marks still for including a brief critical brief critical

appraisalappraisal references without understanding is not references without understanding is not

impressiveimpressive

May 2003 (HRT)May 2003 (HRT)

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

May 2003 (HRT)May 2003 (HRT)

Where possible, identifying the precise Where possible, identifying the precise source of evidence is worthwhile but of source of evidence is worthwhile but of secondary value to actually knowing the secondary value to actually knowing the evidence base of good current medical evidence base of good current medical practice.practice.

For example:- B.P.H.For example:- B.P.H.

Alpha blockers are better than placeboAlpha blockers are better than placebo 5-alpha reductase inhibitors are better 5-alpha reductase inhibitors are better

than placebothan placebo

(understanding of current views on a topic and the (understanding of current views on a topic and the general evidence general evidence on which they are based)on which they are based)

Two systematic reviews for alpha blockers Two systematic reviews for alpha blockers and one for 5-ARIand one for 5-ARI

Eur Urol 1999 and 2000Eur Urol 1999 and 2000

(Higher marks for (Higher marks for quoting sources)quoting sources)

High number of patients unaccounted forHigh number of patients unaccounted for

Considerable number of adverse effectsConsiderable number of adverse effects

(brief critical appraisal)(brief critical appraisal)

Tests of literature knowledge - Tests of literature knowledge - examplesexamples

Discuss the primary Discuss the primary prevention of prevention of osteoporosis in general osteoporosis in general practicepractice


Evaluate the evidence for Evaluate the evidence for the effectiveness of drugs the effectiveness of drugs after discharge from after discharge from hospital following an hospital following an uncomplicated MIuncomplicated MI


Summarise the available evidence for Summarise the available evidence for and against the use of antibiotics in and against the use of antibiotics in otitis mediaotitis media


Other recent questionsOther recent questions drugs in the management of chronic asthmadrugs in the management of chronic asthma recognition of depressionrecognition of depression methods to help people stop smokingmethods to help people stop smoking childbirth without consultant obstetricianschildbirth without consultant obstetricians current thinking on drugs for hypertensioncurrent thinking on drugs for hypertension

Test of literature knowledgeTest of literature knowledge

REVISIONREVISION revise common clinical problems and revise common clinical problems and

themes rather than consecutive journalsthemes rather than consecutive journals

RevisionRevision

sources includesources include BMJ / BJGPBMJ / BJGP Clinical EvidenceClinical Evidence Bandolier, EBM, DTB, Bandolier, EBM, DTB,

Effectiveness MattersEffectiveness Matters RCGP occasional papersRCGP occasional papers Guidelines of national statusGuidelines of national status books! & seminal papers of yrs books! & seminal papers of yrs

agoago

RevisionRevision

Study group to share the loadStudy group to share the load PBL during the consultationPBL during the consultation

Areas of weaknessAreas of weakness Everyday general practiceEveryday general practice

Flash cards?Flash cards? MSN MRCGP newsgroupMSN MRCGP newsgroup

http://groups.msn.com/MRCGPStudyGrouphttp://groups.msn.com/MRCGPStudyGroup

Evaluation of written Evaluation of written materialmaterial

Each paper has had at least 3 of Each paper has had at least 3 of these type of questionsthese type of questions

Evaluation of written materialEvaluation of written material

analyse auditanalyse audit

interpret the resultsinterpret the results - power of studies, p- - power of studies, p-values, confidence intervals, NNT, odds ratio, values, confidence intervals, NNT, odds ratio, sensitivity, specificity and predictive valuesensitivity, specificity and predictive value no calculations required but you must understand no calculations required but you must understand

what the terms meanwhat the terms mean


apply resultsapply results to a clinical scenario to a clinical scenario

apply EBM approachapply EBM approach to clinical scenario: to clinical scenario: question / search / appraisal / applicationquestion / search / appraisal / application

critically appraisecritically appraise presented material, a presented material, a clinical study, systematic review, guidelinesclinical study, systematic review, guidelines


Recognising the main issues raised.Recognising the main issues raised.

Commenting on Commenting on study designstudy design..

Discussing the implications and practical Discussing the implications and practical applicationapplication of the results to general of the results to general practice.practice.

Commenting on study Commenting on study designdesign

Commenting on Study DesignCommenting on Study Design

How to read a paperHow to read a paper Trisha GreenhalghTrisha Greenhalgh

Cheap version – Cheap version – www.bmj.comwww.bmj.com

Study designStudy design

Does the paper address a question Does the paper address a question relevant to your practice?relevant to your practice?

Where did the research take place and Where did the research take place and who are the authors?who are the authors?

Do they have a vested interest?Do they have a vested interest?

Study designStudy design

What type of study and is it appropriate?What type of study and is it appropriate? How were subjects / controls selected?How were subjects / controls selected? Were they randomised; if so, how?Were they randomised; if so, how? What were the outcome measures?What were the outcome measures? Are they clinically relevant?Are they clinically relevant? Do the sample numbers appear to be Do the sample numbers appear to be

appropriate?appropriate?

Study design - resultsStudy design - results

Are all the subjects accounted for?Are all the subjects accounted for? How are the results presented?How are the results presented? Is the statistical analysis present and Is the statistical analysis present and

appropriate?appropriate?

Study design- conclusionsStudy design- conclusions

Are the conclusions reasonable in the light Are the conclusions reasonable in the light of the results?of the results?

Do the authors address the limitations of Do the authors address the limitations of the study?the study?

Are the results believable?Are the results believable?

Study design - overviewStudy design - overview

Concurrence with other studiesConcurrence with other studies Concurrence with own experienceConcurrence with own experience Implications for meImplications for me

Study design - ChecklistsStudy design - Checklists

eBMJeBMJ editor’s checklisteditor’s checklist peer reviewer’s checklistpeer reviewer’s checklist statistician’s checkliststatistician’s checklist qualitative research checklistqualitative research checklist drug points checklistdrug points checklist economic evaluationeconomic evaluation

Study design - ChecklistsStudy design - Checklists

http://www.rcgp.org.uk/rcgp/journal/referee/method.asphttp://www.rcgp.org.uk/rcgp/journal/referee/method.asp

(qualitative research)(qualitative research)

http://www.rcgp.org.uk/journal/info/index.asp?menuid=71http://www.rcgp.org.uk/journal/info/index.asp?menuid=71

(information for authors and readers)(information for authors and readers)

http://jama.ama-assn.org/ifora_current.dtlhttp://jama.ama-assn.org/ifora_current.dtl

(RCT/Consort)(RCT/Consort)

Checklist - CONSORT Checklist - CONSORT statementstatement

CONCONsolidated solidated SStandard for tandard for RReporting eporting TTrialsrials

Chicago 1995 - published 1996Chicago 1995 - published 1996

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

Implications for practiceImplications for practice

Implications for practiceImplications for practice

Personal Patient ManagementPersonal Patient Management Practice PoliciesPractice Policies Practice OrganisationPractice Organisation Practice FinancesPractice Finances Work Of PHCT MembersWork Of PHCT Members Referral PatternsReferral Patterns PrescribingPrescribing Contracts / Purchasing / CommissioningContracts / Purchasing / Commissioning Consultants & Other Hospital StaffConsultants & Other Hospital Staff District Resources E.G.. PathologyDistrict Resources E.G.. Pathology Own Workload / Free TimeOwn Workload / Free Time Society As A WholeSociety As A Whole

Problem-solving Problem-solving questionsquestions

Around half of the paper – 6 Around half of the paper – 6 questionsquestions

Problem solving questionsProblem solving questions

Complex situations or Complex situations or difficult patients - no right or difficult patients - no right or wrong answerswrong answers

Answers will be evaluated Answers will be evaluated for grasp of CONSTRUCTSfor grasp of CONSTRUCTS

Problem solving questionsProblem solving questions

Read question carefully - answer what is askedRead question carefully - answer what is asked Think broadly but realisticallyThink broadly but realistically Avoid jargon and cliché - Avoid jargon and cliché - a good tip is to give a good tip is to give

examples (e.g. I.C.E. In M.S.)examples (e.g. I.C.E. In M.S.) More marks for management of problem than More marks for management of problem than

factual knowledgefactual knowledge

THE EXAMINERS LOOK FOR......THE EXAMINERS LOOK FOR......

A DIVERSITY OF APPROACH:-A DIVERSITY OF APPROACH:- Detailing a range of options and selecting the Detailing a range of options and selecting the

most appropriate, justifying selection with most appropriate, justifying selection with reference to the literature.reference to the literature.

Considering experiences and circumstances Considering experiences and circumstances other than those personally experienced.other than those personally experienced.

Showing consideration for patients’ health beliefs Showing consideration for patients’ health beliefs and feelings, relatives, co-workers and self.and feelings, relatives, co-workers and self.

Awareness of non-medical aspects of the Awareness of non-medical aspects of the problem.problem.


A DIVERSITY OF APPROACH:-A DIVERSITY OF APPROACH:- Detailing a range of options and selecting the most Detailing a range of options and selecting the most

appropriate, justifying selection with reference to the appropriate, justifying selection with reference to the literature.literature.

Considering experiences and circumstances other Considering experiences and circumstances other than those personally experienced.than those personally experienced.


Awareness of non-medical aspects of the problem.Awareness of non-medical aspects of the problem.













PAPER ONE -problem solving questionsPAPER ONE -problem solving questions

Andrea Bachelor, 26, presents with a Andrea Bachelor, 26, presents with a vaginal discharge.vaginal discharge.

How do you arrive at a diagnosis?How do you arrive at a diagnosis?

PAPER ONE -problem solving questionsPAPER ONE -problem solving questions

Norman Griffiths is an introspective 47 yr old Norman Griffiths is an introspective 47 yr old man who suffers from long-standing fatigue. He man who suffers from long-standing fatigue. He tells you he has seen a television documentary tells you he has seen a television documentary suggesting that the mercury in amalgam dental suggesting that the mercury in amalgam dental fillings is toxic. He is wondering whether to have fillings is toxic. He is wondering whether to have his fillings removed, and asks you for your his fillings removed, and asks you for your views.views.

Describe your thoughtsDescribe your thoughts

IMPLICATIONS OF MARKING SCHEMEIMPLICATIONS OF MARKING SCHEME

Broad impressions count.Broad impressions count. Layout and presentation important.Layout and presentation important. Relatively small differences in quality of Relatively small differences in quality of

content or presentation can make a real content or presentation can make a real difference.difference.

Relatively easy to get bulk of marks up to Relatively easy to get bulk of marks up to pass level.pass level.

Time spent vs marks gainedTime spent vs marks gained

0

1

2

3

4

5

6

7

2 mins 4 mins 6 mins 8 mins 10 mins

““Skeletons”Skeletons”

Consultation BehaviourConsultation Behaviour

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

EXPLAIN symptoms and signs, diagnosis and EXPLAIN symptoms and signs, diagnosis and prognosis.prognosis.

CONSIDER treatment options.CONSIDER treatment options. CONSIDER patient’s preference, involve patient in CONSIDER patient’s preference, involve patient in

management plan.management plan.

Consultation BehaviourConsultation Behaviour

Presenting ProblemsPresenting Problems Continuing ProblemsContinuing Problems Help Seeking BehaviourHelp Seeking Behaviour Opportunistic Health PromotionOpportunistic Health Promotion

Treatment OptionsTreatment Options

DO NOTHINGDO NOTHING Follow up at patient’s discretion or formally Follow up at patient’s discretion or formally

arranged.arranged.

DO SOMETHINGDO SOMETHING Discuss, negotiate, counsel, advise.Discuss, negotiate, counsel, advise. Discuss other management options, obtain Discuss other management options, obtain

implied or informed consent.implied or informed consent. Prescribe drug and / or appliance.Prescribe drug and / or appliance. Arrange or carry out procedure.Arrange or carry out procedure. Follow up.Follow up.

Referral OptionsReferral Options

WITHIN PHCTWITHIN PHCT SECONDARY CARESECONDARY CARE

In patient, out patient, domiciliary visit, pathology, In patient, out patient, domiciliary visit, pathology, radiology, physiotherapy, day hospital, radiology, physiotherapy, day hospital, occupational therapy.occupational therapy.

Consider NHS / private, local / regional / national, Consider NHS / private, local / regional / national, PCGs.PCGs.

SOCIAL SERVICESSOCIAL SERVICES Social worker, day centre, meals on wheels, home Social worker, day centre, meals on wheels, home

helps, part III accommodation, disabled parking helps, part III accommodation, disabled parking badge, welfare benefits, citizen’s advice.badge, welfare benefits, citizen’s advice.

Referral OptionsReferral Options

OTHER AGENCIESOTHER AGENCIES Self help groups, voluntary groups, Self help groups, voluntary groups,

local and national hospice movement, local and national hospice movement, Marie Curie Foundation, WRVS.Marie Curie Foundation, WRVS.

ALTERNATIVE THERAPIESALTERNATIVE THERAPIES

In A Conflict SituationIn A Conflict Situation

AGREEAGREE DISAGREEDISAGREE REFERREFER NEGOTIATENEGOTIATE COUNSELCOUNSEL EDUCATEEDUCATE

Giving Bad NewsGiving Bad News

ANXIETYANXIETY What are the the patient’s fears and worries?What are the the patient’s fears and worries?

KNOWLEDGEKNOWLEDGE How much does the patient know and understand How much does the patient know and understand

already?already? EXPLANATIONEXPLANATION

Diagnosis, prognosis, treatment and follow up (in terms Diagnosis, prognosis, treatment and follow up (in terms the patient understands).the patient understands).

SYMPATHYSYMPATHY SUPPORTSUPPORT FOLLOW UPFOLLOW UP

Dealing With AngerDealing With Anger AVOID CONFRONTATION.AVOID CONFRONTATION. FACILITATE DISCUSSION.FACILITATE DISCUSSION. VENTILATE FEELINGS.VENTILATE FEELINGS. EXPLORE REASONS FOR ANGER.EXPLORE REASONS FOR ANGER. CONSIDER REFERRING OR CONSIDER REFERRING OR

INVESTIGATING.INVESTIGATING. APOLOGISE (IF APPROPRIATE).APOLOGISE (IF APPROPRIATE).

THETHE INFINITE POTENTIAL OF THE INFINITE POTENTIAL OF THE CONSULTATION- ICONSULTATION- I

HISTORY- ideas, concerns, expectations; HISTORY- ideas, concerns, expectations; physical, psychological, socialphysical, psychological, social

EXAMINATIONEXAMINATION DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS INVESTIGATIONSINVESTIGATIONS FORMULATE MANAGEMENT PLAN WITH FORMULATE MANAGEMENT PLAN WITH

PATIENT +/- FAMILYPATIENT +/- FAMILY ARRANGE HELP - family, PHCT, social ARRANGE HELP - family, PHCT, social

services, voluntary organisationsservices, voluntary organisations REFERREFER

THETHE INFINITE POTENTIAL OF THE INFINITE POTENTIAL OF THE CONSULTATION- cont’dCONSULTATION- cont’d

PRESCRIBEPRESCRIBE ANTICIPATE FUTURE PROBLEMSANTICIPATE FUTURE PROBLEMS PREVENTION / HEALTH PROMOTIONPREVENTION / HEALTH PROMOTION FOLLOW UPFOLLOW UP LIAISE WITH OTHER AGENCIESLIAISE WITH OTHER AGENCIES

SKELETONSSKELETONSTHE INFINITE POTENTIAL OF THE CONSULTATIONTHE INFINITE POTENTIAL OF THE CONSULTATION

NOW SOON FUTURE

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

Buzz WordsBuzz Words

Doctor-patient relationshipDoctor-patient relationship Dependence, control, manipulation, collusion, Dependence, control, manipulation, collusion,

transference, heart-sinktransference, heart-sink DoctorDoctor

Eliciting, facilitating, empathising, counseling, Eliciting, facilitating, empathising, counseling, open / closed questions, reflected answers, open / closed questions, reflected answers, authoritarian, rejectingauthoritarian, rejecting

PatientPatient Autonomy, involvement, ventilation of feelings, Autonomy, involvement, ventilation of feelings,

guilt / blame, life events, compliance, somatic guilt / blame, life events, compliance, somatic fixation, self help groupsfixation, self help groups

‘‘Universal Framework’Universal Framework’ Build rapportBuild rapport Empathy and listening approachEmpathy and listening approach

Patient issuesPatient issues Further Hx Ex IxFurther Hx Ex Ix RelativesRelatives

Doctor issuesDoctor issues Practice issues and dynamicsPractice issues and dynamics

Family dynamicsFamily dynamics Social and Work issuesSocial and Work issues Ethical issues and patient autonomyEthical issues and patient autonomy MedicolegalMedicolegal

Management options in communityManagement options in community Health promotionHealth promotion PHCTPHCT Follow upFollow up

New Format QuestionsNew Format Questions

peak flow chartpeak flow chart family treefamily tree letter from consultantletter from consultant fill in the gapsfill in the gaps MCQMCQ Extended matching itemExtended matching item

Examiners’ commentsExaminers’ comments

Candidates who answered the question as Candidates who answered the question as asked did wellasked did well

‘‘the question was definitely about feelings and the question was definitely about feelings and those candidates who answered the wrong those candidates who answered the wrong questions scored very low marks’questions scored very low marks’

It is important to understand the concepts of It is important to understand the concepts of relative and absolute riskrelative and absolute risk

When looking at data it can be useful to identify When looking at data it can be useful to identify the extremes and comment on trendsthe extremes and comment on trends


Poor candidates emphasised general Poor candidates emphasised general points such as ideas concerns points such as ideas concerns expectations shared management and expectations shared management and consultation models without applying consultation models without applying these to the specific problem in the these to the specific problem in the questionquestion


Poorer candidates included irrelevant Poorer candidates included irrelevant material such as ethical grids clearly learnt material such as ethical grids clearly learnt specifically for the exam but not really specifically for the exam but not really applicable to this situationapplicable to this situation


A few candidates still appeared to have A few candidates still appeared to have little or no understanding of the basic little or no understanding of the basic principles of qualitative researchprinciples of qualitative research


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

Think broadly and laterally but do stick to the questionThink broadly and laterally but do stick to the question


If a question is phrased ‘discuss your If a question is phrased ‘discuss your management’ – check glossarymanagement’ – check glossary

SPECIFIED as SPECIFIED as HistoryHistory ExamExam TreatmentTreatment InvestigationsInvestigations ReferralReferral Consultation skillsConsultation skills

If covered broadly, -> sure of passing or better If covered broadly, -> sure of passing or better mark!mark!

Stinky questionStinky question

""There are people who strictly deprive There are people who strictly deprive themselves of each and every eatable, themselves of each and every eatable, drinkable and smokeable which has in any drinkable and smokeable which has in any way acquired a shady reputation. They way acquired a shady reputation. They pay this price for health. And health is all pay this price for health. And health is all they get out of it. How strange it is." they get out of it. How strange it is." Mark Mark TwainTwain

What dilemmas does this quotation What dilemmas does this quotation suggest for health promotion in modern suggest for health promotion in modern Primary Care?Primary Care?

The finish – LIKE THISThe finish – LIKE THIS

OR LIKE OR LIKE THISTHIS

GOOD LUCK

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Written Paper Paper One. Plan for seminar Format Content Different types exam questions – tips for each Different types exam questions – tips for