Written Paper
Paper One
Plan for seminar
 Format
 Content
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
Different types exam questions – tips for each
Implications for revision
 ‘Skeletons’
 Examiners’ comments
Resource Number One
http://www.rcgp.org.uk
 past
papers
 examiners comments
 regulations
 syllabus
FORMAT
Written Paper Format
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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
Written Paper Format
 Combined
question and answer booklet
 May use reverse side
 Implications
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Repetition
Candidate number
 Answer
all questions
Written Paper Format
 Four
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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
CONTENT
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
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
Question Glossary (look them
up)
 comment
 discuss
 factor
 implication
 issue
 manage
 process
 respond
Test of literature
knowledge
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
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.
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.
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)
 Two
systematic reviews for alpha blockers
and one for 5-ARI
 Eur
Urol 1999 and 2000
(Higher marks for quoting sources)
 High
number of patients unaccounted for
 Considerable
number of adverse effects
(brief critical appraisal)
Tests of literature knowledge examples
 Discuss
the primary
prevention of
osteoporosis in general
practice
Tests of literature knowledge examples
 Evaluate
the evidence for
the effectiveness of drugs
after discharge from
hospital following an
uncomplicated MI
Tests of literature knowledge examples
 Summarise
the available evidence for
and against the use of antibiotics in
otitis media
Tests of literature knowledge examples
Other recent questions
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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
Test of literature knowledge
REVISION
 revise common clinical problems and
themes rather than consecutive journals
Revision
 sources
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include
BMJ / BJGP
Clinical Evidence
Bandolier, EBM, DTB,
Effectiveness Matters
RCGP occasional papers
Guidelines of national status
books! & seminal papers of yrs
ago
Revision
 Study
group to share the load
 PBL during the consultation


Areas of weakness
Everyday general practice
 Flash
cards?
 MSN MRCGP newsgroup

http://groups.msn.com/MRCGPStudyGroup
Evaluation of written
material
Each paper has had at least 3 of
these type of questions
Evaluation of written material

analyse audit

interpret the results - power of studies, pvalues, confidence intervals, NNT, odds ratio,
sensitivity, specificity and predictive value

no calculations required but you must understand
what the terms mean
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
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.
Commenting on study
design
Commenting on Study Design
 How

to read a paper
Trisha Greenhalgh
 Cheap
version – www.bmj.com
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?
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?
Study design - results
 Are
all the subjects accounted for?
 How are the results presented?
 Is the statistical analysis present and
appropriate?
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?
Study design - overview
 Concurrence
with other studies
 Concurrence with own experience
 Implications for me
Study design - Checklists
 eBMJ

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editor’s checklist
peer reviewer’s checklist
statistician’s checklist
qualitative research checklist
drug points checklist
economic evaluation
Study design - Checklists
http://www.rcgp.org.uk/rcgp/journal/referee/method.asp
(qualitative research)
http://www.rcgp.org.uk/journal/info/index.asp?menuid=71
(information for authors and readers)
http://jama.ama-assn.org/ifora_current.dtl
(RCT/Consort)
Checklist - CONSORT
statement
 CONsolidated
Standard for Reporting
Trials
 Chicago 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 practice
Implications for practice
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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
Problem-solving
questions
Around half of the paper – 6
questions
Problem solving questions
Complex situations or
difficult patients - no right or
wrong answers

 Answers
will be evaluated
for grasp of CONSTRUCTS
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
THE EXAMINERS LOOK FOR......
A DIVERSITY OF APPROACH:
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
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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.
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.
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.
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.
PAPER ONE -problem solving questions

Andrea Bachelor, 26, presents with a
vaginal discharge.
 How do you arrive at a diagnosis?
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
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.
Time spent vs marks gained
7
6
5
4
3
2
1
0
2 mins
4 mins
6 mins
8 mins
10 mins
“Skeletons”
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.

Consultation Behaviour

Presenting Problems
 Continuing Problems
 Help Seeking Behaviour
 Opportunistic Health Promotion
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.
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.
Referral Options

OTHER AGENCIES


Self help groups, voluntary groups,
local and national hospice movement,
Marie Curie Foundation, WRVS.
ALTERNATIVE THERAPIES
In A Conflict Situation

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AGREE
DISAGREE
REFER
NEGOTIATE
COUNSEL
EDUCATE
Giving Bad News
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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
Dealing With Anger
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AVOID CONFRONTATION.
FACILITATE DISCUSSION.
VENTILATE FEELINGS.
EXPLORE REASONS FOR ANGER.
CONSIDER REFERRING OR
INVESTIGATING.
APOLOGISE (IF APPROPRIATE).
THE INFINITE POTENTIAL OF THE
CONSULTATION- I
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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
THE INFINITE POTENTIAL OF THE
CONSULTATION- cont’d





PRESCRIBE
ANTICIPATE FUTURE PROBLEMS
PREVENTION / HEALTH PROMOTION
FOLLOW UP
LIAISE WITH OTHER AGENCIES
SKELETONS
THE INFINITE POTENTIAL OF THE CONSULTATION
NOW
HISTORY
EXAMINATION
DIFF.DIAG.
INVEST.
MAN.PLAN
HELP
REFER
PRESCRIBE
ANTICIPATE
PREVENT.
FOLLOW UP
LIAISE
AUDIT
SOON
FUTURE
Buzz Words

Doctor-patient relationship

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Doctor


Dependence, control, manipulation, collusion,
transference, heart-sink
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
‘Universal Framework’

Build rapport
Empathy and listening approach

Patient issues
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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
New Format Questions
 peak
flow chart
 family tree
 letter from consultant
 fill in the gaps
 MCQ
 Extended matching item
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
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
Examiners’ comments
 Poorer
candidates included irrelevant
material such as ethical grids clearly learnt
specifically for the exam but not really
applicable to this situation
Examiners’ comments
 A few
candidates still appeared to have
little or no understanding of the basic
principles of qualitative research
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
Examiners’ comments
If a question is phrased ‘discuss your
management’ – check glossary
 SPECIFIED as


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



History
Exam
Treatment
Investigations
Referral
Consultation skills
If covered broadly, -> sure of passing or better
mark!
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?
The finish – LIKE THIS
OR LIKE THIS
GOOD LUCK 