MRCGP preparation course
Written Paper 1
Mark Williams
GP Trainer - Selby
1
WRITTEN PAPER
• 3 hrs (+additional time for source materialusually around 30 mins)
• Examiner marked
• Answers legible, concise and short notes
encouraged
• 12 questions (or more)
• ~15 mins per question including reading
through
2
WRITTEN PAPER
• Combined question and answer booklet
• May use reverse side
• Implications
– Repetition
– Candidate number
• Answer all questions
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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
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Test of literature knowledge
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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
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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)
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• Two systematic reviews for alpha
blockers and one for 5-ARI
• Eur Urol 1999 and 2000
(Higher marks for quoting sources)
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• High number of patients unaccounted
for
• Considerable number of adverse effects
(brief critical appraisal)
9
Tests of literature knowledge - examples
• Discuss the primary prevention of
osteoporosis in general practice
10
Tests of literature knowledge - examples
• Evaluate the evidence for the
effectiveness of drugs after discharge
from hospital following an
uncomplicated MI
11
Tests of literature knowledge - examples
• Summarise the available evidence for
and against the use of antibiotics in
otitis media
12
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
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TESTS OF LITERATURE
KNOWLEDGE
• REVISE COMMON CLINICAL
PROBLEMS AND THEMES RATHER
THAN CONSECUTIVE JOURNALS
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• sources include
– BMJ / BJGP
– Clinical Evidence
– Bandolier, EBM, DTB, Effectiveness
Matters
– RCGP occasional papers
– Guidelines of national status
– books! & seminal papers of yrs ago
15
Evaluation of written material
Each paper has had 3 of these
type of questions
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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
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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
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CRITICAL APPRAISAL
• Recognising the main issues raised.
• Commenting on study design.
• Discussing the implications and
practical application of the results to
general practice.
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COMMENTING ON STUDY
DESIGN
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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?
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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?
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Study design - results
• Are all the subjects accounted for?
• How are the results presented?
• Is the statistical analysis present and
appropriate?
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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?
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Study design
• Concurrence with other studies
• Concurrence with own experience
• Implications for me
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Checklists
• eBMJ
– editor’s checklist
– peer reviewer’s checklist
– statistician’s checklist
– qualitative research checklist
– drug points checklist
– economic evaluation
26
Checklists
http://www.rcgp.org.uk/rcgp/journal/referee/method.asp
(qualitative research)
http://jama.ama-assn.org/info/auinst_trial.html
(RCT/Consort)
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Checklist - CONSORT statement
• CONsolidated Standard for Reporting
Trials
• Chicago 1995 - published 1996
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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
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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
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Implications for practice
- 4S study
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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
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• SOC- dec. cardiac morbidity and mortality
Problem-solving questions
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PAPER ONE -problem solving questions
Complex situations or difficult patients - no
right or wrong answers

 Answers
will be evaluated for grasp of
CONSTRUCTS
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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
34
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.
35
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.
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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?
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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
40
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.
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Time spent vs marks gained
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6
5
4
3
2
1
0
2 mins
4 mins
6 mins
8 mins
10 mins
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“Skeletons”
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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.
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CONSULTATION BEHAVIOUR
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Presenting Problems
Continuing Problems
Help Seeking Behaviour
Opportunistic Health Promotion
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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.
46
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.
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REFERRAL OPTIONS
• OTHER AGENCIES
– Self help groups, voluntary groups,
local and national hospice movement,
Marie Curie Foundation, WRVS.
• ALTERNATIVE THERAPIES
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IN A CONFLICT SITUATION
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AGREE
DISAGREE
REFER
NEGOTIATE
COUNSEL
EDUCATE
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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
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• 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).
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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
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THE INFINITE POTENTIAL OF THE
CONSULTATION- cont’d
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PRESCRIBE
ANTICIPATE FUTURE PROBLEMS
PREVENTION / HEALTH PROMOTION
FOLLOW UP
LIAISE WITH OTHER AGENCIES
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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
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BUZZ WORDS
• DOCTOR-PATIENT RELATIONSHIP
– 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
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TRIADS
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PHYSICAL, PSYCHOLOGICAL, SOCIAL
HISTORY EXAMINATION, INVESTIGATION
IMMEDIATE, SHORT TERM, LONG TERM
PATIENT, FAMILY, COMMUNITY
CULTURE, STATUS, IMAGE
DOCTOR, PARTNERS, PHCT
IDEAS, CONCERNS, EXPECTATIONS
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New Format
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peak flow chart
family tree
letter from consultant
fill in the gaps
MCQ
Extended matching item
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EXAMPLES
• Mrs Dara Thakerar, a 35-year-old
teacher consults you with headaches.
• How would you assess her problem?
58
• 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.
59
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
60
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 quasirandomisation, 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 reexamination, and the proportion of subjects who reported side effects
from taking antibiotic or placebo.
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Comment of the inclusion and exclusion
criteria shown above.
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EXAMPLES
In conducting such a review where should
authors search for data?
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EXAMPLES
The Boldison family of five has had twelve
out-of-hours visits during the last month.
What issues does this raise?
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EXAMPLES
What are the challenges of implementing
clinical governance within a Primary Care
setting?
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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?
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EXAMPLES
How does the evidence contribute to the
management of sore throats in Primary
Care
67
• "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?
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