1. Written Paper Paper One

2. Plan for seminar • Format • Content • Different types exam questions – tips for each • Implications for revision • ‘Skeletons’ • Examiners’ comments

3. Resource Number One http://www.rcgp.org.uk • past papers • examiners comments • regulations • syllabus

4. FORMAT

5. Written Paper Format • 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

6. Written Paper Format • Combined question and answer booklet • May use reverse side • Implications • Repetition • Candidate number • Answer all questions

7. Written Paper Format • 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

8. CONTENT

9. 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

10. 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

11. Question Glossary (look them up) • comment • discuss • factor • implication • issue • manage • process • respond

12. Test of literature knowledge

13. 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

14. 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.

15. 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.

16. 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)

17. Two systematic reviews for alpha blockers and one for 5-ARI • Eur Urol 1999 and 2000 (Higher marks for quoting sources)

18. High number of patients unaccounted for • Considerable number of adverse effects (brief critical appraisal)

19. Tests of literature knowledge - examples • Discuss the primary prevention of osteoporosis in general practice

20. Tests of literature knowledge - examples • Evaluate the evidence for the effectiveness of drugs after discharge from hospital following an uncomplicated MI

21. Tests of literature knowledge - examples • Summarise the available evidence for and against the use of antibiotics in otitis media

22. 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

23. Test of literature knowledge REVISION • revise common clinical problems and themes rather than consecutive journals

24. Revision • sources include • BMJ / BJGP • Clinical Evidence • Bandolier, EBM, DTB, Effectiveness Matters • RCGP occasional papers • Guidelines of national status • books! & seminal papers of yrs ago

25. 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

26. Evaluation of written material Each paper has had at least 3 of these type of questions

27. 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

28. 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

29. 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.

30. Commenting on study design

31. Commenting on Study Design • How to read a paper • Trisha Greenhalgh • Cheap version – www.bmj.com

32. 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?

33. 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?

34. Study design - results • Are all the subjects accounted for? • How are the results presented? • Is the statistical analysis present and appropriate?

35. 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?

36. Study design - overview • Concurrence with other studies • Concurrence with own experience • Implications for me

37. Study design - Checklists • eBMJ • editor’s checklist • peer reviewer’s checklist • statistician’s checklist • qualitative research checklist • drug points checklist • economic evaluation

38. 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)

39. Checklist - CONSORT statement • CONsolidated Standard for Reporting Trials • Chicago 1995 - published 1996

42. Implications for practice

43. 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

44. Problem-solving questions Around half of the paper – 6 questions

45. Problem solving questions Complex situations or difficult patients - no right or wrong answers Answers will be evaluated for grasp of CONSTRUCTS

46. 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

47. 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.

48. 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.

49. 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.

50. 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.