AKT

Which of the following is a good example of a patient specific direction (PSD)? Select ONE option only. Select one: A. Meningitis B childhood immunisation B. Amoxicillin for a lower respiratory tract infection C. Lactulose for constipation D. Hydroxocobalamin injections for vitamin B12 deficiency E. Trimethoprim for a simple urinary tract infection

'The correct answer is: Hydroxocobalamin injections for vitamin B12 deficiency Answer justification and feedback: A patient specific direction is an instruction to supply or' administer medication to a named patient. This must be signed for by a prescriber after assessment and allows health care assistants to administer prescription-only medications. As an example, a healthcare assistant with appropriate training can administer vitamin B12 injections but the dose and frequency must be written by a prescriber.

How many questions in the AKT test?

200

How long is the AKT test?

3 hours

what are the main domains of the AKT?

80% on clinical knowledge 10% STATS on evidence-based practice (including evidence interpretation and the critical appraisal skills needed to interpret research data) 10% ADMIN on primary care organisation and management issues (including administrative, ethical, regulatory and statutory frameworks

You see a teenage boy with severe acne. He has not responded to treatment with topical lotions or oral antibiotics. You discuss with him a referral to a dermatologist to consider oral isotretinoin. From what age is it presumed that a young person is able to consent to their own treatment? Select ONE option only. Select one: A. 18 years B. 13 years C. 17 years D. 12 years E. 16 years

Answer feedback and justification: People aged 16 or over are entitled to consent to their own treatment. Children under the age of 16 can consent to their own treatment if they're believed to have enough intelligence, competence and understanding to fully appreciate what's involved in their treatment under Gillick competency rules. The correct answer is: 16 years

You see a teenage boy with severe acne. He has not responded to treatment with topical lotions or oral antibiotics. You discuss with him a referral to a dermatologist to consider oral isotretinoin. From what age is it presumed that a young person is able to consent to their own treatment? Select ONE option only. Select one: A. 18 years B. 17 years C. 13 years D. 16 years E. 12 years

Answer feedback and justification: People aged 16 or over are entitled to consent to their own treatment. Children under the age of 16 can consent to their own treatment if they're believed to have enough intelligence, competence and understanding to fully appreciate what's involved in their treatment under Gillick competency rules. The correct answer is: 16 years

A study reveals that the use of aspirin reduces the number of strokes in a population from 15% to 11%. According to this study what is the number needed to treat (NNT) to prevent one stroke? Select ONE option only. Select one: A. 26 B. 15 C. 25 D. 4 E. 11

Answer feedback and justification: The absolute risk reduction (ARR) is 4% (or 4/100). The number needed to treat (NNT) is calculated as 1/ARR or 100/4. Therefore the NNT to prevent one stroke is 25. The correct answer is: 25

A 31-year-old hairdresser has a refractory dermatitis of her hands which, on patch testing is found to be related to dyes which she finds difficult to avoid at work. Which ONE of the options below represents the SINGLE MOST appropriate consultation technique? Select ONE option only. Select one: A. Catalytic intervention B. Cathartic intervention C. Housekeeping D. Safety netting E. Shared management plan

Answer feedback and justification: This patients' career is at stake and there are likely to be significant overtones. The first two options are psychological techniques described by John Heron whilst housekeeping and safety netting were described by Roger Neighbour. Sharing a management plan with this patient is essential not only for her, but for you as her doctor too since this condition can be very chronic. Resources: RCGP. Curriculum Topic Guides: consulting in general practice. 2019. The correct answer is: Shared management plan

According to the World Health Organisation's (WHO) Global Health Estimates, which ONE of the options below represents the greatest burden of disease, with the highest percentage of years lost due to disability (YLD)? Select ONE answer only. Select one: A. Respiratory disease B. Ischaemic heart disease C. Cancer D. Dementia E. Stroke

Answer justification and feedback: According to the WHO's Global Health Estimates, neonatal conditions, ischaemic heart disease, stroke and lower respiratory infections account for the top four causes of disability-adjusted life years in 2019. Resource: WHO. Global Health Estimates: Life expectancy and leading causes of death and disability. 2019 The correct answer is: Ischaemic heart disease

Michael Balint was a psychologist whose work is still appreciated within general practice today. What is an underlying principle in his work? Select ONE option only. Select one: A. Consultation is a 'game' of social interchange B. Illness has a social meaning and is derived from a patient's perspective C. Doctors are like drugs without side effects D. A doctor's behaviour and personality can impact on the doctor-patient relationship E. Communication is initiated by the sender and interpreted by the receiver

Answer justification and feedback: Balint introduced a pioneering approach to consulting in general practice. His work with other doctors highlighted the idea of the doctor as a 'drug' and suggested that doctors' feelings have a function and can guide the direction of the consultation. Resource: Neighbour R. Challenging consultations. InnovAiT 2018; 12(1): 24-29. The correct answer is: A doctor's behaviour and personality can impact on the doctor-patient relationship

A 38-year-old man has had low back pain for five years and investigations have been normal. He and his family have been attending joint consultations with a member of the mental health care team in order to find solutions to his problems. Which of the following BEST describes this therapeutic approach? Select ONE option only. Select one: A. Cognitive behavioural therapy B. Collaborative care C. Psychodynamic therapy D. Reattribution E. Brief intervention therapy

Answer justification and feedback: Collaborative care usually includes working with the patient and their family to define solutions to problems. Collaborative care studies have shown improvement both in symptoms and in health care utilisation costs for patients with medically unexplained symptoms (MUS). Brief intervention therapy is designed to motivate individuals with unhealthy behaviours such as smoking, alcohol and substance misuse to alter their behaviour. It often involves using validated tools ( e.g the Alcohol Use Disorders Identification Test (AUDIT)) to screen and identify those at risk. Cognitive behavioural therapy (CBT) is a form of psychological treatment that has been demonstrated to be effective for a range of problems including depression and anxiety. Reattribution is a technique which tests the thoughts and assumptions by considering alternative causes of events. This particularly helps to challenge beliefs held by people who perceive themselves as the cause of problem events. Psychodynamic therapy draws on theories and practices of analytical psychology and psychoanalysis. It is a therapeutic process which helps patients understand and resolve their problems, helping individuals to unravel, experience and understand their true, deep-rooted feelings in order to resolve them. The correct answer is: Collaborative care

Which ONE of the following describes the term 'collusion'? Select ONE option only. Select one: A. An unquestioning acquiescence to the explanation offered by the patient B. An agreement about treatment between doctors and patients, reached after negotiation C. A strengthening of the doctor-patient relationship with doctor and patient working together to resolve the problem D. An implication that the problem is imaginary or related to a psychological problem, which is perceived as stigmatising E. An explanation that the problem is within the normal range of experience and is likely to resolve spontaneously

Answer justification and feedback: Collusion is a recurring theme in a proportion of doctor-patient consultations, especially with patients with chronic or intractable health problems. Resources: Chew-Graham C, Maya C, Roland M. The harmful consequences of elevating the doctor-patient relationship to be a primary goal of the general practice consultation. Family Practice 2004; 21(3): 229-231. The correct answer is: An unquestioning acquiescence to the explanation offered by the patient- note to self: collusion is An unquestioning acquiescence to the explanation offered by the patient. acquiescence mean: the reluctant acceptance of something without protest.

=very important = A 26-year-old trans woman is taking oestrogen therapy before undergoing gender reassignment surgery. Which is the SINGLE MOST significant adverse event of this treatment? Select ONE option only. Select one: A. Type 2 diabetes B. Hirsutism C. Venous thrombosis D. Acne E. Hepatic cyst formation

Answer justification and feedback: Feminizing hormone therapy may increase the risk of venous thromboembolic disease, hypertriglyceridaemia, cardiovascular disease, hypertension, hyperprolactinaemia and prolactinoma. Male‑to‑female transgender clients on hormone therapy should be monitored for feminizing and adverse effects every three months for the first year, and then every 6-12 months. The correct answer is: Venous thrombosis

For a trans woman who requires anti-androgen therapy in addition to oestrogen therapy, which is the SINGLE MOST appropriate treatment? Select ONE option only. Select one: A. Anastrozole B. Diethylstilbestrol C. Goserelin D. Medroxyprogesterone acetate E. Tamoxifen

Answer justification and feedback: Gonadotrophin-releasing hormone (GnRH) agonists are mainly used in the UK, spironolactone in the US and cyproterone in Europe. If orchidectomy is undergone, the anti-androgen can be stopped. Resources: WPATH. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 2012. NHS. NHS England Service Specification for Gender Identity Development Service for Children and Adolescents. 2015. The correct answer is: Goserelin

Which ONE of the following patients would be entitled to claim Industrial Injuries Disablement Benefit for occupational deafness? Select ONE option only. Select one: A. A 34-year-old woman who works as a police firearms training officer and has a conductive hearing loss of 50 dB in the left ear and 30 dB in the right ear B. A 59-year-old woman who works with a wool spinning machine and has a sensorineural hearing loss of 55 dB in the left ear and 50 dB in the right ear C. A 27-year-old man who works with a circular saw and has a conductive hearing loss of 60 dB in the left ear D. A 44-year-old man who works with a metal cutting disc and has a sensorineural hearing loss of 40 dB in the left ear, and a conductive hearing loss of 35 dB in the right ear E. A 70-yea

Answer justification and feedback: Industrial Injuries Disablement Benefit may be claimed for occupational deafness when the hearing loss is: Sensorineural hearing loss amounting to at least 50 dB in each ear The average of losses at 1, 2 and 3 kHz frequencies (main speech frequencies) Owing in the case of at least one ear to occupational noise Resource: Department for Work and Pensions (DWP) / GOV.UK. Industrial injuries disablement benefit. The correct answer is: A 59-year-old woman who works with a wool spinning machine and has a sensorineural hearing loss of 55 dB in the left ear and 50 dB in the right ear

You receive a letter from a solicitor requesting a copy of the medical record of a patient who has recently been involved in a road traffic accident. The patient's written consent is enclosed. Following receipt of this written request, within how many days are you required to supply a copy of the patient's health record? Select ONE option only. Select one: A. 14 days B. seven days C. 40 days D. 60 days E. 28 days

Answer justification and feedback: Patients have a right to request access to their own medical records and can also provide consent for disclosure to third parties. A request by a patient, or a request by a third party who has been authorised by the patient, for access under the General Data Protection Regulations (and Data Protection Act 2018) is called a subject access request (SAR). Once the request has been received and verified, the information should be provided within 28 days of receipt. Resource: BMA. Access to health records. The correct answer is: 28 days

A male employee of the practice tells you that his wife is expecting twins and he would like to take some leave. He meets all the requirements for Shared Parental Leave. What is the MAXIMUM amount of time both parents are entitled to? Select ONE option only. Select one: A. Two weeks B. Four weeks C. Twelve weeks D. Fifty weeks E. Sixty weeks

Answer justification and feedback: Shared Parental Leave (SPL) gives more choice in how 2 parents can care for their child. Parents can share up to 50 weeks of leave and up to 37 weeks of pay and choose to take the leave and pay in a more flexible way (each parent can take up to 3 blocks of leave, more if their employer allows, interspersed with periods of work). Resource: Department for Work and Pensions (DWP) / GOV.UK. Shared Parental Leave and PayThe correct answer is: Fifty weeks-

A patient's wife comes to see you about possible benefits for her husband. He is 86 years of age and has terminal metastatic prostate cancer. The district nurses have told her that, as he has a life expectancy of just a few months, he may be eligible for some financial benefits. In addition to advising this patient's wife to apply for Attendance Allowance, which form is the SINGLE MOST appropriate to complete for this patient? Select ONE option only. Select one: A. DLA370 B. ESA113 C. DS1500 D. HSA1 E. FW8

Answer justification and feedback: Terminally ill patients or their relatives can apply for disability benefits; Personal Independence Payment (PIP) if over 16 years of age but under 65, and Attendance Allowance (AA) if over 65 years. A DS1500 form can be completed by any healthcare professional caring for the patient if life expectancy is less than six months. This expedites the claim for PIP or AA. Of note, this can be applied for without the patient's permission (e.g. by a relative) and the correspondence that follows will not mention that the claim has been expedited by the DS1500 'special rules'. Resources: Department for Work and Pensions. Carers and disability benefits. The correct answer is: DS1500- memo cue: DS 1500 it is pronounced EL death el dsss alef we khomsomeyaaa

Whilst practicing for the clinical skills assessment (CSA) it can be helpful to look at different consultation models. Which of the following models adopts an evidence-based approach with a structure that includes information gathering, building the relationship and explanation/ planning? Select ONE option only. Select one: A. Stott and Davies's 1979 model B. Roger Neighbour's 1987 model C. Pendleton's 1984 model D. Murtagh's 1998 model E. Cambridge-Calgary model

Answer justification and feedback: The Calgary-Cambridge system can be used to understand the structure of the consultation and also includes initiating the consultation, building the relationship and closing the consultation. Murtagh's model introduces the concept of uncertainty about the diagnosis and what conditions might be missed. Pendleton's model combines structure with a psychodynamic element introducing enquiry about ideas, concerns and expectations. Roger Neighbour's model includes the concepts of summarising, safety-netting and housekeeping. Stott and Davies introduced four key consultation tasks including modification of health seeking behavior, management of continuing problems and opportunistic health promotion. The correct answer is: Cambridge-Calgary model

A 19-year-old patient with recurrent sore throat requests antibiotics unnecessarily. The consultation becomes very difficult. You consider using a consultation model to help deal with the consultation. Which option is the SINGLE MOST appropriate? Select ONE option only. Select one: A. Helman-Folk Model B. Cambridge-Calgary model C. DR SAMOSA D. The FRAYED model E. Transactional analysis

Answer justification and feedback: The FRAYED consultation model is for situations when doctors deal with what might be considered unreasonable demands from difficult patients. One aim of this model is to preserve the GP's emotional health for the rest of the day's work. It is represented by the mnemonic FRAYED. F- Fact-Finding R- Refuse Request A- Acceptable Alternative Y- Yield or don't Yield E- End the Encounter D- Document Diligently Resource: Mirza D. The need for new GP consultation models. InnovAiT 2018; 12(1): 33-37. The correct answer is: The FRAYED model-memo cue: FRAY el mareed el sa3b

The Maternity Certificate (MAT B1) is specifically designed for the sole purpose of enabling a pregnant woman to claim Statutory Maternity Pay (SMP) from her employer or Maternity Allowance (MA) from Jobcentre Plus. At what stage of pregnancy can a doctor or registered midwife issue a maternity certificate? Select ONE option only. Select one: A. Not more than 12 weeks before the expected week of confinement B. Not more than 20 weeks before the expected week of confinement C. After confirmation of a positive pregnancy test D. After the dating ultrasound scan E. After an ultrasound scan confirming an intrauterine pregnancy

Answer justification and feedback: The MAT B1 enables a pregnant woman to claim: Statutory Maternity Pay (SMP) from her employer Maternity Allowance (MA) from Jobcentre Plus It cannot be issued not more than 20 weeks before the expected week of confinement. Resource: DWP. Maternity certificate (form MAT B1) - guidance on completion. The correct answer is: Not more than 20 weeks before the expected week of confinement- Note to self: A woman's confinement is the period of time just before and during which she gives birth to a child. [old-fashioned]

=VERY IMPORTANT =Learning to enquire into patients' ideas, concerns and expectations is a fundamental aspect of which consultation model? Which is the SINGLE MOST appropriate option? Select ONE option only. Select one: A. Calgary-Cambridge B. Transactional analysis C. Neighbour D. Health belief model E. Pendleton

Answer justification and feedback: The Pendleton model can be used to enquire into patients' ideas, concerns and expectations. The Calgary-Cambridge model can be used to provide a structure to the consultation, using tools such information gathering, providing structure to the consultation, building a relationship, giving information by explanation and planning and closing the session. The health belief model is a theoretical model that can be used to guide health promotion and disease prevention programs. Roger Neighbour's model, the inner consultation, focuses on summarising, safety-netting and housekeeping and transactional analysis. It can be used to understand the power balances in dysfunctional consultations. The correct answer is: Pendleton- memo cue: combine the motion of the pendulum with saying Ideas, Concerns, expectations.. same as they say in the movie..somow, 3lew, ertefa3

Which of the following forms is completed to allow a pregnant woman to claim statutory maternity pay? Select ONE option only. Select one: A. SC3 form B. MATB1 form C. E111 form D. MED5 form E. MED3 form

Answer justification and feedback: The correct answer is the MATB1 form. Form MED5 was replaced by the Fit Note (revised MED3) in 2010. An SC3 form is completed for those applying for statutory paternity pay. Resource: GOV.UK. Statutory Maternity Pay and Leave: employer guide. The correct answer is: MATB1 form

=v.v.v.impo= what is the difference between the mean, the mode and the median?

Answer justification and feedback: There are three main measures of central tendency: the mode, the median and the mean. The mean is the arithmetic average. In this example, the mean value is 149 mmHg. (((el magmou3 beta3 el BPs maksooman 3la el 3adad i.e 14))) The mode is the value that occurs most often. In this example, the mode value is 144 mmHg. (((memo cue: when you say my mode today is not good i.e the most often mood today is x happy , sad..etc))) The median is the value which falls in the middle of all the values if they are arranged in sequential order. In this example of 14 blood pressure readings, when arranged sequentially the two middle values are '146' and '148'. The median therefore lies midway between these two values at 147 mmHg. The correct answer is: 149 mmHg

Which of the following consultation models introduced and described the concept of 'housekeeping'? Select ONE option only. Select one: A. Helmann Folk B. Pendleton C. Tait D. Calgary-Cambridge E. Neighbour

Answer justification and feedback: There have been several consultation models developed and described for general practice over the years. Roger Neighbour described a five-point checklist for the consultation that described connecting, summarising, handing over, safety netting and housekeeping. Resource: Harmon M, Ellender M, Draper R. Innovative new ways of consulting. InnovAiT 2018; 11(9): 483-488. The correct answer is: Neighbour- memo cue: The neighbour is in the house! lol

A 54-year-old trans woman has been taking oestrogen therapy for 15 years. She is also taking risperidone 5 mg daily for schizoaffective disorder. She is a smoker with a body mass index (BMI) of 38 kg/m2. Which SINGLE disease is she MOST at risk of developing? Select ONE option only. Select one: A. Osteoporosis B. Prostate cancer C. Breast cancer D. Hepatoma E. Type 2 diabetes

Answer justification and feedback: This patient is at risk of type 2 diabetes from smoking, obesity and the risperidone. Each patient should be assessed on an individual basis and other health issues should be dealt with irrespective of the transgender treatment. Both testosterone and oestrogen increase bone density and although trans women can get both prostate and breast cancer, the incidence is thought to be low. The correct answer is: Type 2 diabetes

Breaking bad news unfortunately is common in general practice and the manner in which it is done can influence a patient's reaction. Which of the following frameworks can be used by clinicians to structure breaking bad news? Select ONE option only. Select one: A. Bathe model B. Calgary-Cambridge C. FRAMES D. SPIKES E. ICE

Answer justification and feedback: Using the SPIKES framework allows clinicians to convey the main goals of breaking bad news. It stands for: S - setting up P - perception I - invitation K - knowledge E - emotions S - strategy and summary Resource: Liddicoat P. Breaking bad news. InnovAiT 2018; 11(12): 671-675. The correct answer is: SPIKES

=very important = Which of the following statements is TRUE regarding the definition of young carers? Select ONE option only. Select one: A. Young carers are defined as any persons below the age of 25 years B. Young carers are defined as any persons below the age of 18 years C. Young carers are defined as any persons below the age of 20 years D. Young carers are defined as any persons below the age of 16 years E. Young carers are defined as any persons below the age of 21 years

Answer justification and feedback: Young carers are children and young people up to the age of 18 years, whose lives are affected by looking after someone with a disability or a long-term illness. Resource: Simon C, Slatcher C. Young carers. InnovAiT 2011; 4(8): 458-463. The correct answer is: Young carers are defined as any persons below the age of 18 years

The following results were gained from a case-control study exploring the relationship between occupational exposure to human immunodeficiency virus (HIV) and subsequent seroconversion with and without antiretroviral prophylaxis: Prophylaxis given? Three columns First coloumn Prophylaxis given? Yes No Second column to the right Number of cases who seroconverted 8 20 Third column to the far right Number of cases who did not seroconvert 160 200 From these results, which of the following statements is CORRECT? Select ONE option only. Select one: A. It is impossible to calculate the odds ratio in this scenario B. The odds ratio for the effectiveness of antiretroviral prophylaxis is 0.5 C. Relative risk is a better measure of association between outcome and exposure in case-control studies D. Prophylaxis increases the chance of HIV seroconversion E. The odds ratio for the effectiveness of antiretroviral prophylaxis is 2

First column Exposure Yes No Second two columns are outcomes second first half Yes A C second second half No B C Where: a = number of exposed cases b = number of exposed non-cases c = number of non-exposed cases d = number of non-exposed non-cases The odds of the outcome occurring given an exposure is a/b. The odds of that same outcome occurring without that exposure is c/d. The odds ratio is a/b divided by c/d. If OR = 1, exposure does not affect the odds of outcome If OR > 1, exposure is associated with higher odds of outcome If OR < 1, exposure is associated with lower odds of outcome In this study, the exposure is whether or not antiretroviral prophylaxis was given. The outcome is HIV seroconversion. So, the odds of seroconverting when given prophylaxis (exposure group) is 8/160 and the odds of seroconverting without prophylaxis (control group) is 20/200. The odds ratio is (8/160) ÷ (20/200) This is also expressed as (8 x 200) ÷ (20 x 160) = 0.5, meaning that prophylaxis reduces the risk of HIV seroconversion. Resources: Bland J, Altman D. The odds ratio. BMJ 2000; 320: 1468. Sedgwick P. Odds and odds ratios. BMJ 2013; 347: f5067. Sedgwick P. What are the odds? BMJ 2015; 350: h2327. The correct answer is: The odds ratio for the effectiveness of antiretroviral prophylaxis is 0.5

You are reviewing the literature to look for an answer to each of the following questions arising from your practice. Choose from the dropdown list the ONE type of research method that is the SINGLE MOST likely to provide the answer that you require. Each option may be used once, more than once or not at all. You have found a marked drop in the uptake of primary immunisation in your practice population over the past year, and wonder what are the most likely explanations, and how best to address this problem. Qualitative study Double-blind, randomised control trial Case-control study cohort study

Qualitative study Different types of research methods are more or less likely to provide answers to different types of questions. The first scenario is best suited to a qualitative study. Qualitative research is more suited to answering questions about people's behaviour.

1. A study of patients attending the emergency department over a five year period with non-traumatic headache and who are neurologically intact. The aim is to see which clinical characteristics would reliably inform clinical decision making regarding subarachnoid haemorrhage ?

Scenario 1 correct answer: Cohort study A cohort study would be the most appropriate study design for the first question. Cohort studies are observational and are useful for determining the incidence and natural history of a condition. In a cohort study, people separated into groups (cohorts) and followed up over a period of time to see whether they develop the outcome of interest.(((here the headache patients are followed and see who develops subdural haemorrhage. )))

Scenario 1: Identification of personal learning style is useful as it allows one to be better placed to select learning experiences that suit that style. At a teaching session with the GP registrars, your aim is to determine the learning styles in the group by identifying them as activists, reflectors, theorists and/or pragmatists Calgary-Cambridge Observation Guide Consultation Observation Tool~Honey and Mumford Questionnaire Johari Window Myers Briggs Questionnaires The Belbin Inventory Visual auditory kinaesthetic (VAK) questionnaire

Scenario 1 correct answer: Honey and Mumford Questionnaire The answer to the first scenario is the Honey and Mumford Questionnaire. Honey and Mumford use a questionnaire to define the preferred learning style that can help with the selection of educational experiences that suit that style. There are four learning styles identified, Activists, Reflectors, Theorists and Pragmatists. memory tip: Everyone is attracted to his honey,. (( aka: the honey and mumford questionnaire to find out what is your honey i.e preferred way of studying.

You are reviewing the literature to look for an answer to each of the following questions arising from your practice. Choose from the dropdown list the ONE type of research method that is the SINGLE MOST likely to provide the answer that you require. Each option may be used once, more than once or not at all. Your pharmacist advisor is advocating the use of a particular proton pump inhibitor (PPI) drug because of potential cost savings, but you have concerns about its clinical efficacy compared with your current first-line PPI. Qualitative study Double-blind, randomised control trial Case-control study cohort study

Scenario 2 correct answer: Double-blind, randomised control trial A randomised controlled trial is the most suitable study design for the second scenario. Comparison of drug performance requires randomised trials in order to prove efficacy.

For each scenario select the SINGLE MOST appropriate advice. Each option may be used once, more than once or not at all. A 61-year-old man develops an episode of right-sided arm weakness for three hours whilst abroad on holiday. He smokes 20 cigarettes per day and has a history of hypertension. Driving must cease for at least one week Driving must cease for at least one month Driving must cease for at least three months Driving must cease for at least six months Driving must cease for at least one year Driving must cease for at least three years Driving must cease for at least 10 years Driving must cease indefinitely Need not notify the driver and vehicle licensing agency (DVLA) Permitted to drive on recovery

Scenario 2 correct answer: Driving must cease for at least one month In the second scenario, the DVLA advises that all Group 1 licence holders (motor cars and motor cycles) must not drive for 1 month following a transient ischaemic attack (TIA) or stroke. Group 2 licence holders (taxis, large lorries and buses) will have their licence revoked for one year following a TIA or stroke. TIA ---> A month

2. A study aiming to explore the personal barriers to patients with angina being referred for possible revascularisation

Scenario 2 correct answer: Qualitative study The most appropriate design for the second question is a qualitative study. A qualitative study is primarily exploratory research which involves non-numerical data. It is used to gain an understanding of underlying reasons, opinions and motivations. It provides insights into the problem or helps to develop ideas or used to generate hypotheses for further quantitative stud

Scenario 2: You decide to organise an away day for your practice team. The aim of the away day is to find out more about the individual personality types within your team with a view to how this may affect 'team roles' and the working dynamics of the team. Nine types of personality type are found using this tool. Calgary-Cambridge Observation Guide Consultation Observation Tool~Honey and Mumford Questionnaire Johari Window Myers Briggs Questionnaires The Belbin Inventory Visual auditory kinaesthetic (VAK) questionnaire

Scenario 2 correct answer: The Belbin Inventory The correct answer to the second scenario is The Belbin Inventory. Dr Meredith Belbin studied team work for many years and observed that individuals in a team assumed different 'team roles, in relation to behaviour, contribution and interrelation with others'. He produced a questionnaire to identify the nine types of personalities that seemed important in teams. Memo cue: nine belbine i.e 9 types and all of them inside the bin lol memo cue 9 type -> Belbine Belnine ( aka 9 types), note that Mayers breggs 16 personalities

Scenario 3: You prepare a video of your patient consultations with the purpose of reviewing these with one of your colleagues. Your aim is to improve your communication skills in the consultation. The tool describes and expands on five tasks within the consultation from 'initiating the session' to 'closing the session'. Calgary-Cambridge Observation Guide Consultation Observation Tool~Honey and Mumford Questionnaire Johari Window Myers Briggs Questionnaires The Belbin Inventory Visual auditory kinaesthetic (VAK) questionnaire

Scenario 3 correct answer: Calgary-Cambridge Observation Guide The third scenario relates to the Calgary-Cambridge Observation Guide. The (enhanced) Calgary-Cambridge guide to the medical interview is a useful guide that can be used when analysing Dr/patient consultations. It considers how we provide structure within the consultation and allows in depth analysis of the following areas within the consultation, expanding on these to enable more effective communication. It describes the five tasks of the consultation as initiating the session, gathering information, building the relationship, giving information - (explaining and planning) and closing the session. The Consultation Observation Tool (COT) is used by general practice trainers and registrars to review videos of the registrar/patient consultation as part of their workplace based assessment. The Johari Window is a tool that can be used to assess and improve self awareness, and mutual understanding between individuals within a group and improve a groups' relationship with other groups. It was developed by American psychologists Joseph Luft and Harry Ingham in the 1950s, while researching group dynamics. The Myers Briggs Type Indicator Questionnaire (patented) which is usually completed under the guidance of a suitably qualified administrator can identify 16 personality types. It is one of the most widely used questionnaires in the world and can be useful when considering interactions within a team. VAK describes visual, auditory and kinaesthetic learning styles. Most people use a combination of learning styles. There is often one particular style that suits an individual best and the VAK questionnaire can help to identify this e.g. visual learners prefer learning resources that can be seen e.g. diagrams, video notes etc, auditory learners may find it useful to use audiotapes and kinaesthetic learners use learning resources that are hands on, speaking, singing, writing notes etc. memo cue johari -> self awareness like JOHARI the football coach. he is self aware that he is successful Calgary : is the purpose and the task (ID tasks of the consultation)

Choose from the dropdown list the ONE type of research method that is the SINGLE MOST likely to provide the answer that you require. Each option may be used once, more than once or not at all. You have found a marked drop in the uptake of primary immunisation in your practice population over the past year, and wonder what are the most likely explanations, and how best to address this problem. A patient with ulcerative colitis asks you if the condition could have been caused by exposure to excessive amounts of smoked fish in childhood.

Scenario 3 correct answer: Case-control study With the third scenario, questions of causation usually have to be addressed by observational, i.e. non-interventional, retrospective case-control studies.

What is the minimum number of years that must have elapsed for a traveller to be eligible for a tetanus booster (where appropriate), even if they have received five doses of a tetanus-containing vaccine previously? Select ONE option only. Select one: A. Five years B. 15 years C. 25 years D. 20 years E. 10 years

The correct answer is: 10 years Answer justification and feedback: Five doses of diphtheria, tetanus and polio vaccines ensure long-term protection through adulthood. However, those who are travelling to areas where medical attention may not be accessible, or if a tetanus prone injury is likely to occur, and whose last dose of a tetanus-containing vaccine was more than 10 years ago, should receive a booster dose. This is even if the individual has received five doses of vaccine previously and recommended as a precautionary measure in case tetanus immunoglobulin is not available. Resources: Public Health England. Tetanus: the green book, chapter 30.

According to recent evidence, injecting drug users (IDU) have an standardised mortality ratio (SMR) ten times that of the general population. What is the SMR for the IDU group? Select ONE option only. Select one: A. 90 B. 100 C. 190 D. 900 E. 1000

The correct answer is: 1000 Answer justification and feedback: The SMR is the ratio of observed deaths to expected deaths, multiplied by 100. An SMR of 100 means that the number of deaths is the same as would be expected for the general population. A number higher than 100 implies an excess mortality rate and an SMR of 1000 is ten times that of the general population. RCGP. Curriculum Topic Guides: evidence based practice, research and sharing knowledge. 2019. Note to self: The SMR is 100*observed death to expected death ((which is here ten times, in the question))

Risk assessment tools can be a very good way of assessing a person's risk of a particular condition and help in managing that risk in primary care. Which SINGLE condition does the FAMCAT clinical case-finding algorithm identify? Select ONE option only. A. Breast cancer B. Depression C. Myocardial infarction D. Familial hypercholesterolaemia E. Pulmonary embolism

The correct answer is: Familial hypercholesterolaemia Answer justification and feedback: There are ongoing research innovations within the UK to find disease-specific risk assessment tools. The The Familial Hypercholesterolaemia Case Identification Tool (FAMCAT) clinical case-finding algorithm identifies those with familial hypercholesterolaemia. Resource: Evans P H, Rafi I, Hayward J. Primary care genomic research: one eye on the future. InnovAiT 2021; 14(2): 131-136.

The use of genomic testing to 'prescribe the drug that is most likely to have a positive therapeutic effect, at the optimum dose and in the right combination with other medications to patients at the start of treatment' is known as? Which SINGLE option is MOST appropriate? Select ONE option only. A. Population health management B. Stratified medicine C. Targeted therapy D. Pharmacotherapeutics E. Pharmacokinetics

The correct answer is: Stratified medicine Answer justification and feedback: The UK Pharmacogenetics and Stratified Medicine Network defines stratified medicine as the use of genomic testing to 'prescribe the drug that is most likely to have a positive therapeutic effect, at the optimum dose and in the right combination with other medications to patients at the start of treatment'. The majority of prescribing is currently based on the signs or symptoms of the patient's disease. However, according to the network, 'prescribing patients their treatment based on their genetic profile, molecular basis of their disease, risk of the disease and response to a particular drug therapy improves healthcare outcomes'.

The power of a statistical study is determined by which ONE of the following calculations? Select ONE option only. Select one: A. 1 - (standard deviation) B. Variance C. √ (standard deviation) D. 1 - (type 1 error) E. 1 - (type 2 error)

The correct answer is: 1 - (type 2 error) Answer justification and feedback: A type 1 error is rejecting (the rejection itself is the error)the null hypothesis when it is in fact true, and a type 2 error is failing to reject (here is failing to reject) the null hypothesis when it is false. The statistical power of a study is how likely the study is to distinguish an actual effect from one of chance. It's the likelihood that the test is correctly rejecting the null hypothesis (i.e. "proving" your hypothesis). It is calculated as (1- type 2 error). ========================== addendum added by me: Scientifically speaking, a type 1 error is referred to as the rejection of a true null hypothesis, as a null hypothesis is defined as the hypothesis that there is no significant difference between specified populations, any observed difference being due to sampling or experimental error. note to self: to false positive (to say there is a relation but there is non ==== A type II error is defined as the probability of incorrectly failing to reject the null hypothesis, when in fact it is not applicable to the entire population. A type II error is essentially a false negative. note to self: The acceptance of a false null hypothesis

A research project looking at the management of moderate hypertension divides its subjects into two groups. Group A, with 1776 subjects, receives anti-hypertensive medication. Group B, with 1800 subjects, receives a placebo. After five years the risk of a stroke in Group A is 12%, while in Group B it is 20%. What is the number needed to treat (NNT) to prevent one extra stroke? Select ONE option only. Select one: A. 2 B. 1 C. 8 D. 13 E. 58

The correct answer is: 13 Answer justification and feedback: NNT is the reciprocal of the absolute risk reduction. For patients with moderate hypertension, receiving placebo treatments, about 20% would be expected to have a stroke over the next five years. This risk is reduced to 12% with anti-hypertensive drugs. This results in an absolute risk reduction of 0.20-0.12 = 0.08. The reciprocal of this number is 12.5 - implying that a doctor would need to treat about 13 moderately hypertensive patients for five years before he or she could expect to prevent one extra stroke. Resources: Cook R, Sackett D. The number needed to treat: a clinically useful measure of treatment effect. BMJ 1995; 310: 452. Bandolier. Getting NNTs.

A 56-year-old man attends the surgery with a print-out of readings from his home blood pressure (BP) monitor over the past seven days. Date Time BP (mmHg) Date Time BP (mmHg) 28.3.18 06.32 144/76 1.4.18 14.43 153/75 28.3.18 12.48 157/85 2.4.18 08.30 144/80 29.3.18 10.27 146/80 2.4.18 22.11 152/74 29.3.18 21.09 159/79 3.4.18 11.16 140/81 30.3.18 15.10 160/92 3.4.18 20.20 163/78 30.3.18 23.08 148/77 4.4.18 09.33 138/78 1.4.18 09.50 138/70 4.4.18 21.55 144/80 Which ONE of the following values is the MODE systolic blood pressure reading for this patient? Select ONE option only. Select one: A. 149 mmHg B. 144 mmHg C. 138 mmHg D. 162 mmHg E. 147 mmHg

The correct answer is: 144 mmHg Answer justification and feedback: The median is the value which falls in the middle of all the values if they are arranged in sequential order. In this example of 14 blood pressure readings, when arranged sequentially the two middle values are '146' and '148'. The median therefore lies midway between these two values at 147 mmHg. The mode is the value that occurs most often. In this example, the mode value is 144 mmHg. The mean is the arithmetic average. In this example, the mean value is 149 mmHg.

A pharmaceutical representative presents you with some study data for a new drug said to reduce cardiovascular death in patients at risk. The data shows that for the period of study the control group had a cardiovascular mortality of 10% and this was reduced to 5% in the treated group. The representative points out the impressive relative risk reduction of 50% in the treated group. How many at-risk people in the trial had to be treated in order to prevent one death? In other words, what was the 'number needed to treat' (NNT)? Select ONE option only. Select one: A. 2 B. 5 C. 10 D. 20 E. 50

The correct answer is: 20 Answer justification and feedback: This data indicates a relative risk reduction of 50% in the treated group (10% halved to 5%). But, in fact, this translates to an absolute risk reduction of 5% (10% minus 5%) and may be more meaningfully expressed by NNT - as this means that 20 patients have to be treated to save one event. The NNT of 20 is calculated by 100 divided by the absolute risk reduction expressed in percentage terms (1/0.05 = 20). In studies such as this where the incidence of the adverse events in question are low relative risk reduction and NNT are more likely to be meaningful. (((1/ARR)))

A female employee at your practice is currently pregnant and has requested statutory maternity pay (SMP) for the maximum allowance of 39 weeks. What is the minimum length of continuous service required with the same employer in order to receive this entitlement? Select ONE option only. Select one: A. 22 weeks B. 26 weeks C. 24 weeks D. 18 weeks E. 20 weeks

The correct answer is: 26 weeks-Answer justification and feedback: Statutory Maternity Pay (SMP) is payable for up to 39 weeks and employees are required to have been employed by the same employer continuously for at least 26 weeks in to the 15th week before the baby is due in order to be eligible. Resource: GOV.UK. Statutory maternity pay and leave: employer guide.

You speak on the telephone to the son of an 81-year-old woman with osteoarthritis. He has just found an old prescription for tramadol 50 mg capsules in his mother's handbag. The prescription is dated 1 September 2017. He asks you whether the prescription is still valid. Until what date is this patient's prescription valid? Select ONE option only. Select one: A. 31 August 2018 B. 28 February 2018 C. Indefinitely D. 28 September 2017 E. 7 September 2017

The correct answer is: 28 September 2017 Answer justification and feedback: Tramadol became a Schedule 3 Controlled Drug (CD) on 10 June 2014. Prescriptions for Controlled Drugs are valid for 28 days from the date of issue. Prescriptions for all other items are valid for 6 months (or 12 months for repeatable prescriptions). The following CD Schedule 3 requirements also apply: The prescription must clearly state the form (e.g. tablets, capsules), strength and dose The dose must be as specific as possible; 'Take One as directed' is acceptable, however, 'Take as directed' is not The quantity prescribed must be written in words and figures The total quantity supplied should not exceed 30 days, unless in exceptional circumstances as with all other controlled drugs

What PERCENTAGE of adult patients referred through the urgent two-week wait suspected cancer referral pathway might be expected to have cancer? Select ONE option only. Select one: A. 3 B. 27 C. 9 D. 40 E. 15

The correct answer is: 3 Answer justification and feedback: The National Institute for Health and Care Excellence (NICE) recommends that in order to improve the diagnosis of cancer, a 3% positive predictive value should be used as the recommendation for suspected cancer pathway referrals or arranging direct access investigations. This excludes recommendations for children and young people where the threshold is lower, or for initiating tests routinely available in primary care such as blood tests. Resource: NICE. Suspected Cancer: recognition and referral. NG12. 2015 (updated 2021).

You are attending an educational clinical meeting. A new drug 'Co-hypostat' is presented, which is licensed for hypertension and is claimed to reduce the risk of dementia. The following results have been made available from a recent randomised controlled trial of the new drug: Absolute risk of dementia in the control group 4 in 100 Absolute risk of dementia in the treatment group 2 in 100 Which SINGLE value represents the NUMBER NEEDED TO TREAT (NNT) to prevent one case of dementia in this study? Select ONE option only. Select one: A. 25 B. 50 C. 98 D. 2 E. 200

The correct answer is: 50 Answer justification and feedback: • ART (Absolute Risk of events in the treatment group) • ARC (Absolute Risk of events in the control group) • ARR (Absolute Risk Reduction) • NNT (Number Needed to Treat) ARR is the absolute difference in risk between the experimental and control groups in a trial. ARR = ARC - ART NNT is the number of patients who must (on average) be treated with a specific therapy for one of them to benefit. NNT = 1/ARR In this example ARR = (0.04-0.02) = 0.02 NNT = (1/0.02) = 50 The correct answer is: 50

Which ONE of the following patients would be entitled to claim attendance allowance? Select ONE option only. Select one: A. A 12-year-old girl with spina bifida B. A 45-year-old woman with multiple sclerosis C. A 58-year-old man with carcinoma of the prostate D. A 71-year-old man with chronic obstructive pulmonary disease E. A 26-year-old man with Down's syndrome

The correct answer is: A 71-year-old man with chronic obstructive pulmonary disease Answer justification and feedback: Attendance allowance (AA) is a tax-free benefit for people who have reached State Pension age who need help with personal care because because of physical or mental disability. Patients may be eligible to claim AA if: • They are over State Pension age • They have a physical or mental disability, or both • Their disability is severe enough for them to need help caring for themselves Patients who are terminally ill and are reasonably expected to die within six months do not have to have had care needs for six months prior and can claim straightaway.

As a general practitioner, you receive a letter from a lawyer on behalf of the daughter of one of your recently deceased patients. The daughter has an interest in the estate of her deceased father and she wishes you to release medical information that may be pertinent to this case. With regard to legislation, what ACT applies to such a request? Select ONE option only. Select one: A. Access to Medical Reports Act 1988 B. Health and Social Care Act 2001 C. Data Protection Act 1998 D. Freedom of Information Act 2000 E. Access to Health Records Act 1990

The correct answer is: Access to Health Records Act 1990-Answer justification and feedback: Access to Health Records Act 1990 (Northern Ireland 1993) - provides qualified right of access to a deceased individuals health records where the person seeking access has an interest in the estate of the deceased. The ethical obligation to respect a patient's confidentiality extends beyond death. Unless the individual requested confidentiality while alive, a patient's personal representative and any other person who may have a claim arising out of the patient's death has a right of access to information in the deceased person's records directly relevant to a claim. It is the BMA's opinion that under section 5(4) of the Access to Health Records Act, no information which is not directly relevant to a claim should be disclosed to either the personal representative or any other person who may have a claim arising out of the patient's death. The Access to Medical Reports Act 1988 - allows patients to see medical reports about them, for employment or insurance purposes, written by the doctor with whom they normally have a patient/doctor relationship. They may see the report before it is supplied or for up to six months afterwards. Access to the report may be denied in certain circumstances - if the reporting doctor feels that it contains information which may cause serious mental or physical harm to the patient, or if it contains information from a third party who has not given consent to disclosure. If they disagree with any part of the report they may withdraw consent for it to be supplied, ask for agreed inaccuracies to be altered, or require that a note be added outlining the differences between their view and that of the reporting doctor. The Data Protection Act 1998 - The act applies to all of the UK and governs access to the health records of living people. Individuals have a right to apply for access to health records irrespective of when they were compiled (subject to conditions outlined in BMA guidance). It applies to health records held by NHS bodies and to the private health sector. It also applies to employers who hold information relating to the physical or mental health of their employees if the record has been made by, or on behalf of, a health professional in connection with the care of the employee. The Freedom of Information Act 2000 - gives a general right of public access to all types of recorded information held by public authorities (including GP practices), sets out exemptions from that general right and places a number of obligations on public authorities. A response to a request for information must be made within 20 working days. From a GP's perspective, this Act is intended to cover general information held by the practice, not personal health information which is covered by other legislation (e.g. the Data Protection Act). It is important to get this correct. If in doubt one is advised to discuss the matter with a medical defence organisation. The BMA reference outlines the main differences between Scotland and the rest of the UK. The Health and Social Care Act 2001 (and subsequent amendments in 2006 and 2008) - conveys powers to the Secretary of State for Health (in England and Wales) to make regulations to enable, or require the release of, patient information where disclosures would otherwise be restricted by the common law. This is a wide-ranging act but, concerning information, it mainly relates to processing patient information for the diagnosis and treatment of cancer, the recognition, control and prevention of communicable diseases or other risks to public health. Resources: BMA. Fees when providing insurance reports and certificates. Data Protection Act 1998

You receive feedback from your prescribing advisor that your practice prescribes well above the average number of prescriptions for proton pump inhibitors (PPIs), and you wish to improve the quality of prescribing of these drugs. Which of the following would make the SINGLE MOST appropriate criterion statement for an audit? Select ONE option only. Select one: A. All patients on repeat prescriptions for PPIs continuously for six months or more should be totalled B. All patients on repeat prescriptions for PPIs should be totalled on a monthly basis C. All doctors in the practice should attend a refresher course on PPI prescribing D. All patients on repeat prescriptions for PPIs should include in their records an indication for commencing the PPI E. All doctors in the practice should prescribe no more than four repeat prescriptions for PPIs per month

The correct answer is: All patients on repeat prescriptions for PPIs should include in their records an indication for commencing the PPI- Answer justification and feedback: A criterion is an item of care or some aspect of care that can be used to assess quality. The criterion is written as a statement, such as 'All records of patients on repeat prescriptions for PPIs should include an indication for commencing PPI', which would be an appropriate criterion related to clinical PROCESS in this situation. The number of repeat prescriptions for PPIs cannot be directly related to quality of care without further information, and so simply counting them is not an appropriate exercise in clinical audit. Attendance at a refresher course is a less direct measure of quality of prescribing, and imposition of an arbitrary upper limit to the number of prescriptions is clinically inappropriate.

Photosensitivity is a common side-effect of which ONE of the following drugs? Select ONE option only. Select one: A. Amiodarone B. Varenicline C. Methotrexate D. Codeine phosphate E. Sildenafil

The correct answer is: Amiodarone Answer justification and feedback: Patients treated with amiodarone should be advised to shield their skin from the sun, during treatment and for several months afterwards due to the long half-life of amiodarone. Resource: BNF. Amiodarone hydrochloride.

A 69-year-old woman, who has just joined your list, attends. She has moved to the UK from Italy to be closer to her daughter. She has her arm in plaster, having tripped at the airport and sustained a Colles' fracture. She is diabetic. You review her list of regular medications. Which drug is the SINGLE MOST likely to be associated with her fracture? Select ONE option only. Select one: A. Ranitidine B. Gliclazide C. Metformin D. Aspirin E. Anastrozole

The correct answer is: Anastrozole Answer justification and feedback: Anastrozole is an aromatase inhibitor used in the management of post-menopausal breast cancer. Because aromatase inhibitors reduce circulating oestrogen levels, a decrease in bone mineral density can be anticipated. Therefore, a warning has been included in the summaries of product characteristics of all three aromatase inhibitors that women with osteoporosis or at risk of osteoporosis should have their bone mineral density formally assessed by bone densitometry at the beginning of treatment and, for anastrozole, at regular intervals thereafter. Treatment or prophylaxis for osteoporosis should be initiated as appropriate and patients treated with an aromatase inhibitor should be carefully monitored. In terms of diabetic agents, glitazones are also associated with an increased risk of bone fractures; but of all the options above anastrole has the highest risk. Metformin nor sulphonylureas are not associated with increased risk of fractures.

Which ONE of the following investigations is MOST LIKELY to generate a FALSE POSITIVE result for the given condition? Select ONE option only. Select one: A. Echocardiography in the diagnosis of heart failure B. Ultrasonography in the diagnosis of gallstones C. Urinary beta-human chorionic gonadotropin (B-hCG) in the diagnosis of pregnancy D. Cancer antigen 19-9 (CA 19-9) in the diagnosis of pancreatic cancer E. Antinuclear antibodies in the diagnosis of rheumatoid arthritis

The correct answer is: Antinuclear antibodies in the diagnosis of rheumatoid arthritis Answer justification and feedback: A test with a high specificity has a low false positive (or type 1 error) rate. Of the choices listed, antinuclear antibodies (ANAs) have a lowest specificity, 56% in rheumatoid arthritis, and hence has a high false positive rate. ANAs are found in patients with other connective tissue diseases and some autoimmune diseases (e.g. hepatitis C).

You are called to visit a 35-year-old man who has a chronic alcohol dependency. He is acutely unwell, drowsy, has ascites and a palpable liver edge. You suspect he has fulminant alcoholic hepatitis and recommend admission. He does not appear to understand nor retain your explanation of the likely diagnosis and seriousness of his condition. According to General Medical Council (GMC) advice, in this setting, which would be the SINGLE MOST appropriate management? Select ONE option only. Select one: A. Contact the duty psychiatrist to make an urgent mental health assessment B. Ask the patient if there is anything that would help him remember information or make it easier to make a decision C. Discuss treatment options in a place and at a time when the patient is best able to understand and retain the information D. Arrange emergency admission without his consent, in his best interests E. Encourage his relatives to persuade him to accept admission

The correct answer is: Arrange emergency admission without his consent, in his best interests-Answer justification and feedback: General Medical Council guidance on consent states that doctors must be satisfied that they have consent before: Carrying out any examination or investigation Providing treatment or Involving patients in teaching or research. Although there will be times when it is obvious that someone lacks capacity - they may be unconscious - in the majority of cases people retain the capacity to make some decisions. Efforts should therefore be made to support people in making decisions. The guidance states in emergency situations when it is not possible to find out a patient's wishes, you can treat them without their consent, provided the treatment is immediately necessary to save their life or to prevent a serious deterioration of their condition. The treatment provided must be the least restrictive of the patient's future choices. Resource: GMC. Consent: patients and doctors making decisions together. 2008.

You attend a local diabetes update course where a recent randomised controlled trial is presented. Which ONE of the following figures would BEST illustrate the flow of patients through the trial and the reasons for attrition and dropout? Select ONE option only. Select one: A. Population pyramid B. CONSORT diagram C. Funnel plot D. Histogram E. Run chart

The correct answer is: CONSORT diagram Answer justification and feedback: CONSORT (Consolidated Standards of Reporting Trials) group was developed to alleviate the problems arising from inadequate reporting of randomised controlled trials (RCTs). The CONSORT statement is an evidence-based, minimum set of recommendations for reporting RCTs. The statement comprises a 25-item checklist and a flow diagram. The checklist items focus on reporting how the trial was designed, analysed and interpreted, and the flow diagram displays the progress of all participants through the trial. Resource: The CONSORT group.

You receive a letter from a consultant at the local hospital describing a new study that she is organising in her fertility clinic. '...we are investigating the relationship between mobile phone use and male infertility. A group of men referred to my clinic with oligospermia will be questioned about their mobile phone habits. A group of age-matched patients referred to the eye casualty at this hospital will also be questioned about their mobile phone habits, using an identical objective structured questionnaire...' What is the SINGLE BEST description of this study type? Select ONE option only. Select one: A. Randomised controlled trial B. Quasi experimental study C. Case-control study D. Crossover study E. Cohort study

The correct answer is: Case-control study Answer justification and feedback: This is an example of a case-control study. A case-control study is a retrospective comparison between representative samples of people who get a disease and people who do not. It can show associations, but cannot establish causality. One particular problem with case control studies is recall bias - in that the cases with the disease are more motivated to recall apparently trivial episodes in the past, compared to the controls (who are disease free).

A study is designed to look at whether people that work at night have an increased risk of cardiovascular disease. Patients aged 40-50 years old will be followed over a 10 year period and cardiovascular outcomes measured. What is the correct description of this study design? Select ONE option only. Select one: A. Meta-analysis B. Randomised control trial C. Systematic review D. Crossover trial E. Cohort study

The correct answer is: Cohort study Answer justification and feedback: A cohort study follows a group of people over time, looking at a specific outcome (e.g. death) and whether exposure to a given risk factor (e.g. smoking) contributes to that outcome.

The department of general practice at the local university is proposing a study to investigate whether the use of proton pump inhibitors increases the risk of osteoporosis. Which is the SINGLE MOST appropriate study design to use in this case? Select ONE option only Select one: A. Cross-sectional study B. Crossover study C. Meta-analysis D. Cohort study E. Case-control study

The correct answer is: Cohort study Answer justification and feedback: Cohort studies are prospective and observational. The objective is to test aetiological hypotheses and would be the most appropriate study design in this case. With cohort studies groups of people are studied over a period of time with respect to a given disease. The comparison between groups is with respect to disease e.g. following groups of smokers and non-smokers in time to see whether one group is more prone to cancer. This is a good method for determining the incidence and natural history of a condition, and avoids the ethical issues that plague randomised control trials. Cohort studies also allow the calculation of the effect of each variable on the probability of developing the outcome of interest (relative risk). Case-control studies are retrospective and observational. Characteristics of subjects with a disease are compared with a selected group of control subjects without the disease. The comparison between groups is with respect to exposure, e.g. looking at groups of individuals with and without cancer to see if features in their past might explain a causal route for the cancer. Case-control studies can show associations, but cannot establish causality therefore would not be the most appropriate study design. In a crossover study each subject receives treatment and placebo in a random order. Each subject thus acts as his own control. Crossover studies are only suitable for evaluating palliative treatments of chronic stable conditions, e.g. assessing a new mucolytic therapy in cystic fibrosis patients and comparing this to current best treatment. Cross-sectional studies describe characteristics of a population. Data is collected at one point in time and the relationships between characteristics are considered. An example would be to see how many of a particular group of people drink alcohol, and how many of that group have liver cirrhosis. Meta-analyses review published literature from previously well-conducted trials. The results are then pooled and the data is re-analysed.

Jumping to conclusions and then looking for facts to corroborate them'. Which of the following types of bias does the above statement represent? Select ONE option only. Select one: A. Outcome bias B. Congruence bias C. Publication bias D. Courtesy bias E. Confirmation bias

The correct answer is: Confirmation bias Answer justification and feedback: Confirmation bias relates to a tendency to interpret information that confirms someone's preconceptions. A clinical example might be a patient who, despite our best explanations, continues to hold on to their preformed conclusions about a diagnosis. This of course is the opposite of testing hypotheses by traditional diagnostic processes. Note for self: as if you are looking for a confirmation to the point of view you have ALREADY on your mind.

Evidence based medicine involves critical appraisal of available evidence for its validity and usefulness in making decisions about the care of individual patients. Evidence is graded depending on the source from which it is obtained. Which ONE of the following correctly defines Level III evidence? Select ONE option only. Select one: A. Evidence from a case control study B. Evidence from a single descriptive or qualitative study C. Evidence from systematic reviews or meta-analysis of randomised controlled trials D. Evidence from at least one controlled study without randomisation E. Evidence from expert opinion

The correct answer is: Evidence from at least one controlled study without randomisation Answer justification and feedback: Hierarchy of strength of evidence used: Level I Evidence from a systematic review or meta-analysis of all relevant RCTs (randomised controlled trial) or evidence-based clinical practice guidelines based on systematic reviews of RCTs or 3 or more RCTs of good quality that have similar results. Level II Evidence obtained from at least one well designed RCT (eg large multi-site RCT). Level III Evidence obtained from well-designed controlled trials without randomisation (ie quasi-experimental). Level IV Evidence from well-designed case-control or cohort studies. Level V Evidence from systematic reviews of descriptive and qualitative studies (meta-synthesis). Level VI Evidence from a single descriptive or qualitative study. Level VII Evidence from the opinion of authorities and/or reports of expert committees.

Middle-ground research is needed to inform realistic medicine and service transformation and policy within general practice in a timely manner. What is the fundamental principle of 'middle-ground' research? Select ONE option only. Select one: A. Collation of quantitative data conducted by specialist clinicians B. Basing patient care on service evaluations conducted by local healthcare professionals C. Using randomised controlled trials to inform best practice D. Focusing healthcare on the needs and goals of patients E. For theoretical and academic research only

The correct answer is: Focusing healthcare on the needs and goals of patients Answer justification and feedback: Middle-ground research has been conceived to meet the rapidly changing needs of the population. The idea is to inform realistic medicine in a timely manner by using a pragmatic approach focusing on the needs and goals of the patient. It will require identification of research questions and assessment of the best methodology required. It will likely need input from clinicians and researchers and input from front-line staff. Resource: Mercer S, Gillies J, Calderwood C et al. A new kind of research. InnovAiT 2018; 11(9): 495-499.

While your practice manager is off, a new receptionist comes to you for advice. A 53-year-old gypsy traveller is requesting to register with the practice. He currently lives in his trailer which is parked in a car park and has no fixed address. He doesn't know how long he is staying in the area. Which SINGLE MOST appropriate option? Select ONE option only. Select one: A. Direct him to the nearest NHS walk in centre B. Refuse registration as proof of address is essential for full registration C. Advise the patient to register with the local homeless surgery D. Register the patient as a temporary resident E. Fully register the patient

The correct answer is: Fully register the patient-Answer justification and feedback: No patient should be refused registration on the grounds of a non-fixed address. NHS England and the British Medical Association (BMA) have published a guidance for doctors which states that if a patient is not able to provide identity documents, it is not reasonable grounds to refuse to register them. This applies across England, Scotland and Wales. It is good policy to fully register Gypsy Traveller patients when they are in the area for any length of time to ensure that they are included in routine screening and child health surveillance. Patients should not be de-registered if they are away travelling for a few weeks. Resources: Cleemput P. Health needs of gypsy travellers. InnovAiT 2018; 11(12): 681-688. BMA. Overcoming barriers to refugees and asylum seekers accessing care Doctors of the World. GP registration and NHS number Policy Brief. 2021

Referral rates vary widely between GPs. With respect to urgent referrals for suspected cancer, which of the following statements is true? Select ONE answer only. Select one: A. Higher urgent referral rates result in lower cancer mortality B. Higher urgent referral rates have a lower conversion rate C. Urgent referral rates make no significant difference to cancer mortality rates D. Lower urgent referral rates result in lower cancer mortality E. Lower urgent referral rates have a higher conversion rate

The correct answer is: Higher urgent referral rates result in lower cancer mortality Answer justification and feedback: Results of a recent study show there is clinically relevant association between the low use of urgent referral pathways for suspected cancer in general practices and increased risk of death among patients with cancer. For the subgroup of patients registered in practices with low use of the urgent referral pathway, there was a 7% increased mortality rate. The conversion rate (the proportion of urgent referrals which led to a cancer diagnosis) was not associated with high or low use of the urgent referral pathway.

Which ONE of the following conditions is MOST likely to exhibit a BIMODAL age distribution? Select ONE option only. Select one: A. Osteoarthritis B. Pityriasis rosea C. Hodgkin's lymphoma D. Bronchiolitis E. Carcinoma of the prostate

The correct answer is: Hodgkin's lymphoma Answer justification and feedback: Hodgkin's lymphoma has a bimodal age distribution, with two peaks of incidence, that differs geographically and ethnically in industrialised countries; the early peak occurs in the middle to late 20s and the second peak after age 50 years. In developing countries, the early peak occurs before adolescence

A 24-year-old woman requests a repeat prescription for lactulose. On inspection of her medical record you note that she was issued a prescription for 500 ml of lactulose one week ago and that she has been issued with four 500 ml bottles of lactulose in the last two months. She has previously attended with concerns regarding her weight and you now suspect laxative abuse. What is the SINGLE MOST likely metabolic effect of laxative overuse in this patient? Select ONE option only. Select one: A. Hypokalaemia B. Hypoglycaemia C. Hypomagnesaemia D. Hypophosphataemia E. Hyponatraemia

The correct answer is: Hypokalaemia Answer justification and feedback: Excessive doses of laxatives can lead to diarrhoea and if prolonged, electrolyte disturbances such as hypokalaemia. Excessive doses of bulk-forming laxatives, or inadequate fluid intake with bulk-forming laxatives, cause intestinal obstruction rather than diarrhoea.

The General Medical Council (GMC) offers professional guidance on the disclosure of information to the relatives of patients with genetic conditions without the patients' consent. Which statement best incorporates this advice? Which option is the SINGLE MOST appropriate? Select ONE option only. Select one: A. Even if you feel the at-risk relative could have inherited a genetic condition, you must not disclose this information if the patient specifically forbids you from doing so B. If a patient refuses consent to disclosure to at-risk relatives, you will need to balance your duty to make the care of your patient your first concern against your duty to help protect the other person from serious harm C. If you are aware that the at-risk relative could have inherited a genetic condition, you have a duty to tell them regardless of the patient's wishes D. The patient does not have any legal standing in disclosure of genetic information and consent can be overruled by a clinician for the safety of the at-risk relative E. If the at-risk relative is your patient as well, you can disclose genetic information without the patient's consent because you have a duty of care towards the at-risk relative too

The correct answer is: If a patient refuses consent to disclosure to at-risk relatives, you will need to balance your duty to make the care of your patient your first concern against your duty to help protect the other person from serious harm-Answer justification and feedback: This is a very difficult position and there is limited UK case law regarding genetic disclosure. There are many reasons why disclosure does not take place including misunderstanding about what guidelines allow clinicians to do, fear of negligence claims, concerns about what the GMC criteria of 'serious harm' entails as well as others. The GMC guidance gives the discretion to disclose if deemed appropriate by the clinician. Resources: Lucassaen A, Farsides B. Ethical issues in genetic medicine. InnovAiT 2017; 10(8): 481-488.

Which term describes the situation where survival will appear to be better in cases detected by screening without there necessarily being a real difference between the survival of screened and unscreened populations? Select ONE option only. Select one: A. Lead time bias B. Exclusion bias C. Inclusion bias D. Publication bias E. Selection bias

The correct answer is: Lead time bias Answer justification and feedback: Lead time is the length of time between the detection of a disease and its usual clinical presentation and diagnosis. Lead time bias results in an apparent increase in survival due to a health condition, such as cancer being detected at an early stage, when there is no actual effect of early detection on survival. The patient just lives for a longer period with the diagnosis. When evaluating the effectiveness of the early detection and treatment of a condition, the lead time must be subtracted from the overall survival time of screened patients to avoid lead time bias. Historically, this has been a flaw in the evaluation of cancer screening programmes and, in particular, breast cancer screening programmes, resulting in inflated claims of effectiveness. Selection bias is the phenomenon of selecting individuals, groups or data for analysis in such a way that proper randomisation is not achieved, ultimately resulting in a sample that is not representative of the population. Exclusion and inclusion bias are examples of selection bias. Publication bias refers to when the likelihood of a study being published is affected by the findings of the study. Note to self: Lead time is the time between the early detection of cancer by screening and its usual clinical presentation and diagnosis. For colorectal cancer, lead time has been estimated to be at least 2 years, probably longer. Note to self: lead time i.e time ahead. ( before the clinical presenation i.e early detection)

15 Drug Monitoring Flag question Question text An 85-year-old man has metastatic prostate cancer. He is currently being treated with oral cyproterone acetate 200 mg daily. Which is the SINGLE MOST appropriate blood monitoring test? Select ONE option only. Select one: A. Urea and electrolytes B. Serum glucose C. Serum calcium D. Serum iron E. Liver function tests

The correct answer is: Liver function tests Answer justification and feedback: Cases of direct hepatotoxicity, including jaundice, hepatitis and hepatic failure has been reported in patients treated with cyproterone acetate especially at doses of 100 mg and above. Most reported fatal cases were in men with advanced prostatic cancer. The British National Formulary (BNF) recommends monitoring blood counts initially and throughout treatment and adrenocortical function regularly. Toxicity is dose related and develops usually several months after treatment has begun. Liver function tests should be done before treatment, at regular intervals during treatment and whenever any symptoms or signs suggestive of hepatotoxicity occur. If hepatotoxicity is confirmed, cyproterone acetate should normally be withdrawn, unless the hepatoxicity can be explained by another cause, e.g. metastatic disease, in which case it should be continued only if the perceived benefit outweighs the risk. Resource BNF. Cyproterone acetate

You receive a discharge letter regarding a 64-year-old man who was admitted to hospital with an acute exacerbation of chronic obstructive pulmonary disease (COPD). The discharge letter states: MUST score: 2. The MUST score is used to screen for which ONE of the following conditions? Select ONE option only. Select one: A. Malnutrition B. Dementia C. Pressure ulcers D. Falls E. Thromboembolism

The correct answer is: Malnutrition Answer justification and feedback: The Malnutrition Universal Screening Tool (MUST) is a five-step screening tool to identify adults who are malnourished, at risk of malnutrition, or obese. It also includes management guidelines that can be used to develop a care plan.

A patient presents to you in the surgery with several articles about his condition which he has taken from the internet. He wishes your opinion about the scientific robustness of these studies. You agree to read them in your spare time and report back to him. Which ONE of the following methods would you weight MOST HIGHLY in basing your opinion? Select ONE option only. Select one: A. Expert opinion B. Randomised control study C. Case control study D. Meta-analysis E. Cohort study

The correct answer is: Meta-analysis Answer justification and feedback: Meta-analysis is the systematic review of randomised controlled trials. This is the highest level of evidence. Resources: RCGP. Curriculum Topic Guides: evidence based practice, research and sharing knowledge. 2019.

There are requirements for monitoring of controlled drugs due to their potential for abuse and this classification governs the requirements for prescribing of controlled drugs. Which of the following medications are classed under schedule 3? Select ONE option only. Select one: A. Oxycodone B. Pethidine C. Codeine D. Zopiclone E. Midazolam

The correct answer is: Midazolam Answer justification and feedback: The misuse of drug regulations lists drugs under specific schedules with requirements governing their prescription, amongst other things. Midazolam is a schedule 3 drug. Codeine is listed under schedule 5. Zopiclone is a schedule 4 drug. Oxycodone and pethidine are schedule 2 drugs. Resource: Gleeson D. Benzodiazepines: dependence and addiction in general practice. InnovAiT 2019; 12(11): 656-663.

Five yearly National Health Service (NHS) Health Checks are MOST LIKELY to increase the prevalence of which one, if any, of the following conditions? Select ONE option only. Select one: A. Chronic kidney disease (CKD) B. Coronary heart disease (CHD) C. Diabetes D. Hypertension E. NHS Health Checks do not have a significant impact on morbidity or mortality

The correct answer is: NHS Health Checks do not have a significant impact on morbidity or mortality

When considering the risk of sensitivity to non-steroidal anti-inflammatory drugs (NSAIDs) in people with asthma, which additional clinical feature is the SINGLE MOST likely to indicate those at highest risk of reaction? Select ONE option only. Select one: A. Allergic conjunctivitis B. Nasal polyps C. Cow's milk allergy D. Allergic contact dermatitis E. Atopic eczema

The correct answer is: Nasal polyps Answer justification and feedback: Clinical features that suggest an increased risk of sensitivity to NSAIDs in asthmatics include female sex, middle age, severe asthma accompanied by chronic nasal congestion and profuse rhinorrhoea, and a history of nasal polyps. Resource: Sanak M, Szczeklik A. Genetics of aspirin induced asthma. Thorax 2000; 55: 45-47.

When evaluating the effectiveness of a screening test, how does LEAD TIME BIAS effect morbidity and mortality? Select ONE option only. Select one: A. No effect on morbidity B. Increases mortality C. No effect on mortality D. Decreases morbidity E. Decreases mortality

The correct answer is: No effect on mortality Answer justification and feedback: Lead time bias occurs when two tests for a disease are compared and although one of the tests diagnoses the disease earlier, this does not translate in to a survival benefit (i.e. it does not affect the outcome of the disease). The disease may appear to prolong survival but it actually only results in an earlier diagnosis. Morbidity (including patient anxiety and potential treatment side-effects) is increased as the patient must live with the knowledge of the disease for longer. Lead time bias is an important factor to consider when evaluating the effectiveness of a specific screening test.

What does the following symbol ( A BLACK TRIANGLE WITH ITS HEAD POINTED DOWNWARDS ) denote when it appears adjacent to a drug name in the British National Formulary (BNF)? Select ONE option only. Select one: A. Preparations that are available without a prescription B. Preparations that are considered to be least cost-effective C. Preparations that are unlicensed and currently undergoing trials D. Preparations that are available to purchase only in a pharmacy E. Preparations for which there is limited experience of use

The correct answer is: Preparations for which there is limited experience of use The symbol is used to denote preparations for which there is limited experience of the use. Only limited information is available from clinical trials on the safety of new medicines. Further understanding about the safety of medicines depends on the availability of information from routine clinical practice. The black triangle symbol identifies newly licensed medicines that require additional monitoring by the European Medicines Agency. The black triangle symbol also appears in the Patient Information Leaflets for relevant medicines, with a brief explanation of what it means. Products usually retain a black triangle for five years, but this can be extended if required. For medicines showing the black triangle symbol, the Medicines and Healthcare products Regulatory Agency (MHRA) asks that all suspected reactions (including those considered not to be serious) are reported through the Yellow Card Scheme. An adverse reaction should be reported even if it is not certain that the drug has caused it, or if the reaction is well recognised, or if other drugs have been given at the same time.

A pharmaceutical company has developed a new topical anaesthetic. It is aimed at the paediatric market but they plan to trial it with volunteer adults first. They propose to use it prior to venepuncture, with one group randomly assigned to receive a non-active (placebo) cream and the other the new trial cream. The person applying the cream, and the participant receiving it, will not know which is being applied. Which SINGLE clinical trial type is being utilised in the above study? Select ONE option only. Select one: A. Cohort study B. Crossover trial C. Case series D. Case control trial E. Randomised controlled trial

The correct answer is: Randomised controlled trial Answer justification and feedback: A randomised controlled trial is considered the most appropriate research paradigm for studying an intervention. In this study paradigm neither the subject nor the researcher know whether the placebo or trial agent is being used, which reduces bias; the other research paradigms are less favoured in this context. Resources: Oxford Centre for Evidence-Based Medicine. Study designs. RCGP. Research ready.The correct answer is: Randomised controlled trial

Which ONE of the following terms best describes the ability of the test to correctly identify patients with the disease? Select ONE option only. Select one: A. Positive predictive value B. Sensitivity C. Specificity D. Absolute risk E. Negative predictive value

The correct answer is: Sensitivity Answer justification and feedback: The sensitivity is the ability of a test to correctly identify those with a condition, i.e. the true positives, whereas test specificity is the ability of the test to correctly identify those without the condition (true negatives). Sensitivity and specificity are characteristics of the test. The population size does not affect the result The positive predictive value (PPV) is the proportion of people who test positive that truly have the condition, whereas the negative predictive value (NPV) is the proportion of those that test negative who truly do not have the condition. Positive and negative predictive values are influenced by the prevalence of disease in the population that is being tested. If we test in a high prevalence setting, it is more likely that persons who test positive truly have disease than if the test is performed in a population with low prevalence.

=v.imp= Which ONE of the following terms best describes the ability of the test to correctly identify patients with the disease? Select ONE option only. Select one: A. Positive predictive value B. Sensitivity C. Specificity D. Absolute risk E. Negative predictive value

The correct answer is: Sensitivity Answer justification and feedback: The sensitivity is the ability of a test to correctly identify those with a condition, i.e. the true positives, whereas test specificity is the ability of the test to correctly identify those without the condition (true negatives). Sensitivity and specificity are characteristics of the test. The population size does not affect the result The positive predictive value (PPV) is the proportion of people who test positive that truly have the condition, whereas the negative predictive value (NPV) is the proportion of those that test negative who truly do not have the condition. Positive and negative predictive values are influenced by the prevalence of disease in the population that is being tested. If we test in a high prevalence setting, it is more likely that persons who test positive truly have disease than if the test is performed in a population with low prevalence. Resources: RCGP. Curriculum Topic Guides: evidence based practice, research and sharing knowledge. 2019. Loong T W. Understanding sensitivity and specificity with the right side of the brain. BMJ 2003;327:716 The correct answer is: Sensitivity

Your attached medical student asks you about the following symbol that she has seen in the Health and Safety policy document at your practice: NUMBER TWO IN A CIRCLE ND CROSSED OVER What is the correct meaning of this symbol? Select ONE option only. Select one: A. Single-use product, do not re-use B. Product not to be mixed with other drugs C. Product not to be used after two years of opening D. Product not suitable for children aged two years or under E. No fewer than three staff members to be on the premises at any one time during practice opening hours

The correct answer is: Single-use product, do not re-use Answer justification and feedback: A device designated as 'single-use' must not be reused (e.g. tongue depressor). It should only be used on an individual patient during a single procedure and then discarded. It is not intended to be reprocessed and used again, even on the same patient. The reuse of single-use devices has legal implications - anyone who reprocesses or reuses a device intended by the manufacturer for use on a single occasion, bears full responsibility for its safety and effectiveness.

Which ONE of the following general practice projects would require approval by a Research Ethics Committee? Select ONE option only. Select one: A. The GP specialty registrar conducts face-to-face interviews with all patients who have become new mothers over the past six weeks, to determine their views on the breastfeeding support provided to them B. The practice implements a new policy to switch to a newly licensed cholesterol-lowering agent 'Tricholstop' for all patients with diabetes C. The practice participates in a regional trial comparing the efficacy of acupuncture with oral ibuprofen in the treatment of acute lower back pain . D. The practice sends out a postal questionnaire asking patients' opinions regarding the new online appointment booking system E. The local Clinical Commissioning Group (CCG) conducts a telephone survey of patients regarding their alcohol consumption. The results are used to compare practices within the CCG.

The correct answer is: The practice participates in a regional trial comparing the efficacy of acupuncture with oral ibuprofen in the treatment of acute lower back pain . Answer justification and feedback: The National Research Ethics Service (NRES) provides guidance regarding which projects require Research Ethics Committee (REC) review. Clinical audit and service evaluation do not warrant mandated REC review, but research does. If randomisation is used, it is research (e.g. a clinical trial). In this question, options A and D are essentially examples of service evaluation. Options B and E are essentially examples of clinical audit. Option C is a clinical trial (research), and would require REC review. .

=v.v.v.important= Which SINGLE definition best describes the POSITIVE PREDICTIVE VALUE of a test? Select ONE option only. Select one: A. The proportion of those who test negative who do not have the disease B. The proportion of true positives correctly identified by the test C. The proportion of true negatives correctly identified by the test D. The proportion of those who test positive who actually have the disease E. The number of patients who must be treated for one of them to benefit

The correct answer is: The proportion of those who test positive who actually have the disease Answer justification and feedback: Positive predictive value is the probability that subjects with a positive screening test truly have the disease. Notes to self: Note that both PPV and sensitivity are the proportion of true positives ((((NOW THE DIFFIRENCE IS THE SECOND DIMENTION OF THE SENTENCE, EITHER IT GOES LIKE: identified by the test -> then it is sensitivity, OR IT GOES LIKE: Who truly have the disease -> PPV

According to a large study, 'individuals who were prescribed antipsychotic drugs in the previous two years had a 32% greater risk of venous thromboembolism (VTE) than non-users'. Which is the SINGLE MOST appropriate interpretation of this risk for patients who have taken regular antipsychotic medication over the past two years? Select ONE option only. Select one: A. 32 of every 100 patients on an antipsychotic for two years will get a VTE B. Patients on antipsychotics are 32 times more likely to have a VTE C. The odds of having a VTE are approximately 1:3 D. The risk of a VTE is 1.3 times that of a patient not taking an antipsychotic E. None of the above

The correct answer is: The risk of a VTE is 1.3 times that of a patient not taking an antipsychotic Answer justification and comment: This risk is 'the likelihood that a VTE will happen' and the quoted abstract is using 'relative' rather than 'absolute' risk increase. A relative risk of 1.0 indicates that the risk is the same in the exposed and control groups. A relative risk greater than 1.0 indicates that there is an increased risk in the exposed group compared with the control group, whereas a relative risk less than 1.0 indicates a reduction in the risk in the exposed group compared with the control group. For example, a relative risk of 1.5 means that the risk of the outcome of interest is 50% higher in the exposed group than in the control, while a relative risk of 3.0 means that the risk in the exposed group is three times as high as in the unexposed group. Conversely, a relative risk of 0.8 means that the risk in the exposed group is 20% lower than in the unexposed group. In this example, the relative risk is increased by 32%, i.e. around 1.3 times' higher for patients taking atypical antipsychotics over the period stated. It is important to look beyond the headline figures - in fact, details from the study show that the absolute risk of a VTE in one year for such patients was 4 in 10,000.

Screening tests must satisfy specific criteria before being introduced to the target population. For any given test, which of the following criteria would make it UNSUITABLE to use as a screening tool? Select ONE option only. Select one: A. Treatment in the early stages of the disease is proven to be beneficial B. The test has a high positive predictive value C. The disease is an important health problem D. The benefits of screening outweigh the risks of screening E. The test has a low negative predictive value

The correct answer is: The test has a low negative predictive value Answer justification and feedback: Wilson-Jungner published criteria which are required of screening tests prior to their introduction in to the population. These include: Disease is an important health problem Natural history of disease is understood Early detection is possible Early treatment is beneficial Tests are acceptable to the target population Benefits outweigh risks (including cost) Adequate services are available to screen and treat the identified cases An ideal screening test will have high sensitivity and high specificity. It should also have a high positive predictive value and a high negative predictive value. A low negative predictive value means that a negative test will not reliably exclude the disease.

You are asked by your primary care organisation to present the pros and cons of screening for a malignant condition that is prevalent in the locality. Which ONE of the following statements would be desirable in your screening programme? Select ONE option only. Select one: A. Improving screening should always take priority over improving treatment B. Treatment should ideally be carried out late in the natural history of the condition C. Cost is irrelevant providing some benefit is shown D. The test should have low specificity E. The test should have high sensitivity

The correct answer is: The test should have high sensitivity Answer justification and feedback: sensitivity is the ability of a test to correctly identify those with the disease (true positive rate), whereas specificity is the ability of the test to correctly identify those without the disease (true negative rate). The ideal test is both sensitive and specific. Wilson-Jungner criteria for appraising the validity of a screening programme: 1. The condition being screened for should be an important health problem2. The natural history of the condition should be well understood3. There should be a detectable early stage4. Treatment at an early stage should be of more benefit than at a later stage5. A suitable test should be devised for the early stage6. The test should be acceptable7. Intervals for repeating the test should be determined8. Adequate health service provision should be made for the extra clinical workload resulting from screening9. The risks, both physical and psychological, should be less than the benefits10. The costs should be balanced against the benefits In addition the WHO criteria (2003) specify:-"All other options for managing the condition should have been considered (for example, improving treatment and providing other services), to ensure that no more cost-effective intervention could be introduced or current interventions increased within the resources available".

The following table shows the positive likelihood ratios and confidence intervals of common presenting features for oesophagogastric cancer. Presenting features in primary care Likelihood ratio Confidence intervals Dyspepsia 0.79 0.55 to 1.15 Nausea/vomiting/bloating 1.07 0.52 to 2.19 Reflux 0.78 0.47 to 1.78 Weight loss 5.46 3.47 to 8.60 Based on the above information, which presenting feature is MOST predictive of oesophagogastric cancer? Select ONE option only. Select one: A. Reflux B. Dyspepsia C. Weight loss D. Nausea/vomiting/bloating

The correct answer is: Weight loss Answer justification and feedback: Weight loss not only has the highest positive likelihood ratio of the presenting features listed in the table, but is the only listed feature with statistically significant confidence intervals. Resources: RCGP curriculum. Curriculum Topic Guides: evidence based practice, research and sharing knowledge. 2019 note to self: very important article for understanding https://hbr.org/2016/02/a-refresher-on-statistical-significance a quotes from the article the lower the p-value, the less likely the results are due purely to chance. (( update: the link is not totally relevant) A good youtube video https://www.youtube.com/watch?v=0gMIL-s5kSU P values and Confidence Intervals in less than 4 minutes | Statistics | Statistical Significance From the video: IMPORTANT NOTE TO SELF: THE ODDS RATIO OR ( statistically significant confidence intervals.) IS STATISTICALLY SIGNIFICANT AS LONG AS IT DOES NOT CROSS THE LINE OF NO EFFECT WHICH IS ONE

A theatre nurse in the local hospital presented to you several weeks ago stating that he fell into an at-risk category for human immunodeficiency virus (HIV) infection. After counselling, you arrange a test. This has now come back positive. You discuss with him the physical and social implications of the condition and how it will be managed. He is unsure about whether he should inform his employer of his diagnosis. In this regard, what is the SINGLE MOST appropriate action to take? Select ONE option only. Select one: A. You ask him to inform the occupational health department B. You inform, anonymously, the occupational health department C. You agree to review the issue after an interval D. You inform, openly, the occupational health department E. You agree to disclose the issue to no-one

The correct answer is: You ask him to inform the occupational health department Answer justification and feedback: This is indeed a difficult position and every efforts should be made to encourage the patient to inform their employers before breaking confidentiality. If you know, or have good reason to believe, that a medical colleague or a health care worker who has, or may have, a serious communicable disease, is practising, or has practised, in a way which places patients at risk, you must inform an appropriate person in the health care worker's employing authority, for example an occupational health physician, or where appropriate, the relevant regulatory body. It is also good practice to inform the patient that you will be disclosing the information in this case. Resources: RCGP Curriculum. Consulting in General Practice. 2019. GMC. Confidentiality: good practice in handling patient information. 2017. BMA. Confidentiality Toolkit. 2021.

The Motability Scheme gives disabled people the opportunity to own or lease a car at an affordable price. Which ONE of the following statements regarding this scheme is correct? Select ONE option only. Select one: A. You can propose up to two other people as your driver B. You can propose up to one other person as your driver C. You can apply for a car as a passenger D. Parents cannot apply on behalf of their children E. It is only available if the disabled person can drive

The correct answer is: You can apply for a car as a passenger-Answer justification and feedback: The Motability Scheme enables disabled people to use their government-funded mobility allowance to lease a new car, scooter or powered wheelchair every three years, or a Wheelchair Accessible Vehicle (WAV) every five years. Vehicle adaptations are also available through the Motability Car Scheme to help with vehicle access, equipment loading and driving. Even if the person affected cannot drive, it is possible to nominate up to three other people to drive on their behalf and parents can apply on behalf of children over the age of three. Resource: Motability. Making a Difference: information for advisors and professionals.

3. A study looking at the clinical effectiveness of topical intranasal corticosteroids in children aged 4-11 years presenting with bilateral otitis media with effusion

The most appropriate design for the third question is a randomised controlled trial. Randomised controlled trials are often considered to be the 'gold standard' for determining the efficacy or effectiveness of various types of medical interventions. Participants are randomly assigned into experimental or control groups and observed over a specific time interval for development of a particular outcome. Their disadvantages is that they can be expensive to run, subject to bias and ethical limitations.

According to current Driver and Vehicle Licensing Agency (DVLA) rules, after a first unprovoked seizure, for what INITIAL time period MUST that person stop driving a car? Select ONE option only. Select one: A. Six months B. 12 months C. Three months D. Five years E. Three years

Your answer is correct Answer justification and feedback: The affected person should notify the DVLA and stop driving for six months from the date of the seizure. If there are clinical factors increasing the risk of a further seizure, the time period is 12 months. Resources: DVLA. Assessing Fitness to Drive: a guide for medical professionals. 2016. The correct answer is: Six months

You are doing a weekend telephone triage shift for the local GP out-of-hours service. A 22-year-old man calls telling you that his own GP diagnosed him with mumps yesterday. He asks you for advice regarding how long he needs to remain off work for. What is the SINGLE MOST appropriate advice to give to this patient? Select ONE option only. Select one: A. 24 hours B. 9 days C. 3 days D. 5 days E. 7 days

Your answer is correct. Answer feedback and justification: Mumps is transmitted via direct contact with infected droplet nuclei or fomites contaminated with infected saliva and possibly urine. The incubation period is about 18 days (may vary between 14 to 25 days), patients are infectious from three days before the onset of symptoms to seven days afterwards. It is important to note that even asymptomatic patients may be infectious. Mumps is a notifiable disease and patients should be advised to stay off school or work for 5 days after the initial development of parotitis. The correct answer is: 5 days

Which of the following decisions might be considered inappropriate when managing uncertainty? Select ONE option only. Select one: A. Deciding to reassure a 35-year-old patient with rectal bleeding who has had a normal colonoscopy and investigations in secondary care B. Requesting blood tests to confirm menopause in a 52-year-old lady with a two-year history of amenorrhoea and vasomotor symptoms C. Negotiating smoking cessation plan with a 79-year-old patient with chronic obstructive pulmonary disease (COPD) D. Referring a patient with symptomatic gall stones for a laparoscopic cholecystectomy E. Asking a colleague to review a skin lesion when you are uncertain of the diagnosis

Your answer is correct. Answer justification and feedback: All of the above scenarios are appropriate except for arranging blood tests to confirm menopause. It would be more appropriate to manage on the basis of symptoms rather than proceeding with investigations that may not add much to the clinical picture. Examples of dysfunctional ways out of uncertainty includes: Premature reassurance not justified by the clinical situation See a (fe)male GP Over reliance on tests and investigations Stick with a previous diagnosis Under appreciation of the frequency of a 'functional' condition Poor referrals and cascades of investigations Blaming the patient Blaming the system Passing the buck Retreating because it is 'too hard' Burnout, depersonalisation and unkindness The correct answer is: Requesting blood tests to confirm menopause in a 52-year-old lady with a two-year history of amenorrhoea and vasomotor symptoms

VERY IMPORTANT=You see a 42-year-old man who has been asked to attend your afternoon surgery by your practice nurse following a routine diabetic review. She is concerned that he may be depressed and has asked him to complete a patient health questionnaire (PHQ-9). He has no previous history of psychiatric illness. His PHQ-9 score is 6. What is the SINGLE MOST appropriate management for this patient? Select ONE option only Select one: A. Amitriptyline B. Computerised cognitive behavioural therapy (CCBT) C. Fluoxetine D. St John's wort E. Routine referral to a psychiatrist

Your answer is correct. Answer justification and feedback: Depression severity can be graded using the PHQ-9 score: 0-4 none 5-9 mild 10-14 moderate 15-19 moderately severe 20-27 severe Consider offering one or more of the following low-intensity psychosocial interventions to patients with persistent subthreshold depressive symptoms or mild-to-moderate depression, and to patients with subthreshold depressive symptoms that complicate the care of their chronic physical health problem: A physical activity programme (modified for the particular physical health problem) A peer support programme in a group of patients with a shared physical health problem Individual guided self-help based on cognitive behavioural therapy (CBT) principles Computerised cognitive behavioural therapy (CCBT) Watchful waiting is an option as a management strategy in selected patients with mild depression. Do not use antidepressants routinely to treat subthreshold depressive symptoms or mild depression, but consider them for patients with one of the following: A previous history of moderate or severe depression Mild depression that complicates the care of the physical health problem Initial presentation of subthreshold depressive symptoms present for at least two years Subthreshold depressive symptoms Mild depression persisting after other interventions The correct answer is: Computerised cognitive behavioural therapy (CCBT)

One of the consulting techniques below has shown evidence for improved patient understanding of information given during consultations. Which SINGLE option is MOST appropriate? Select ONE option only. Select one: A. 'Elicit-provide-elicit' technique B. 'Ask me three' technique C. 'SPIKES' technique D. Calgary-Cambridge model E. 'Teach back' technique

Your answer is correct. Answer justification and feedback: Poor health literacy is common. Patients do not understand and remember as much as doctors think about the information they are given. Ensuring patients are fully informed about their health status is important. After receiving new information which is surprising, patients will often better recollect further details given. They should be encouraged to ask questions if they do not understand. The 'ask me three' technique suggests that patients should be encouraged to ask three questions at the end of their appointment, such as 'what is my main problem', 'what do I need to do' and 'why is it important for me to do this'. Resource: Reilly J. Health literacy. InnovAiT 2020; 13(8): 490-494. The correct answer is: 'Ask me three' technique

A 52-year-old woman attends for a discussion regarding her recent diagnosis of bladder cancer. Her hospital discharge letter comments that histology has confirmed carcinoma in situ. In addition to transurethral resection of bladder tumour (TURBT), what further treatment is the SINGLE MOST likely to be offered to this patient? Select ONE option only. Select one: A. Brachytherapy B. Intravesical Bacillus Calmette-Guérin (BCG) C. No further treatment D. Annual monitoring E. Radiotherapy

Your answer is incorrect. Answer justification and feedback: Carcinoma in situ (CIS) is a superficial tumour, but it has strong potential to become muscle-invasive so is treated differently to less aggressive superficial tumours. Maintenance therapy with intravesical Bacillus Calmette-Guérin (BCG) should be considered to improve local control and reduce the incidence of progression. Resource: NICE. Bladder cancer: diagnosis and management (NG 2). 2015. The correct answer is: Intravesical Bacillus Calmette-Guérin (BCG)

Forest analysis picture should be there. present in the 09.07.22 attempt question #4 From the information in the forest plot above, which of the following statements is TRUE. Select ONE OR MORE statements. Select one or more: A. The heterogeneity of the meta-analysis trials is significant B. Overall warfarin is more effective at preventing stroke than DOACs C. Three of the four trials used in the meta-analysis showed no significant difference between warfarin and DOACs D. The risk of bleeding is greater with DOACs than warfarin E. Overall DOACS are more effective at preventing stroke than warfarin

nd asdfasfThe correct answers are: Three of the four trials used in the meta-analysis showed no significant difference between warfarin and DOACs, AND Overall DOACS are more effective at preventing stroke than warfarin. Answer justification and feedback: The hazard ratio (HR) gives information about whether patients taking DOACs or warfarin are more likely to have a stroke. If the risk is the same in both populations, the HR is 1. When looking at the individual trials included in the meta-analysis, for all four trials the box indicating the mean difference of effect is to the left of the HR = 1 line favouring DOACs over warfarin. However, although all four trials favour DOACs over warfarin, only one of those trials is significant. For the other three trials, the confidence interval (CI) indicated by the box 'whiskers' crosses the HR=1 line, and the null hypothesis (that there is no difference between the two treatments) cannot be excluded. The summary diamond (in blue) using combined data from the four trials included in the meta-analysis is to the left of the line indicating HR = 1 indicating that DOACs are more effective than warfarin in reducing the risk of stroke and systemic embolism in patients with non-valvular AF. aThis result is significant as the confidence interval, indicated by the horizontal points of the diamond, does not cross the HR = 1 line. This meta-analysis does not provide any information about the risk of bleeding with DOACs or warfarin. The heterogeneity is a measure of how different the studies included in the meta-analysis are. Ideally they should be as similar as possible and any difference in effect should be due to sampling error alone. However, in reality, studies done at different times in different places may be very different. Using Higgins I2, a value of 0% indicates statistical homogeneity. Significant statistical heterogeneity is often considered to be present if I2 is 50% or more. The I2 value for this study is 31%. Resources: Sedgwick P. How to read a forest plot in a meta-analysis. BMJ 2015; 351: h4028. Lewis S, Clarke M. Forest plots: trying to see the wood and the trees. BMJ 2001; 322: 1479.