Specialist Certificate Examination in Geriatric Medicine: Where Are We Now

1. Specialist Certificate Examination in Geriatric Medicine: Where Are We Now? Michael Vassallo Lead Physician SCE Geriatric Medicine

3. Why Do We Need Another Exam? As part of new curriculum PMETB require all StRs registering on or after 1 August 2007 to have formal assessment of competence including work placed based assessments eg mini-CEX and KBA To ensure that specialists dealing with patients have the appropriate knowledge of their specialty

4. Pilot Examination 2006 JCHMT in partnership with specialist societies ran KBA pilots in 4 specialties (cardiology, neurology, geriatric medicine and dermatology) Question writing training limited, limited question bank, in geriatric medicine standard setting not robust 100 best-of-five questions in 3 hours, paper based exam, sat on 2 dates in May 2006 one week apart 448 sat exam (411 SpRs (77%), 37 consultants)

7. Pilot Evaluation and Comments Questions? About right 64% Right amount of time? About right 70% Familiar with question format? Yes 80% Comments Poor questions: ambiguous, too long, negative (eg �which is least likely�) and double negative questions Too many questions Too many on falls, inappropriate orthopaedic questions Some questions not relevant to Scottish law

8. Pilot Evaluation Evaluation of pilot by JCHMT positive However for pilot KBA in Geriatric Medicine Cronbach�s coefficient alpha (measure of reliability) 0.67 (for high stakes exam should be 0.80 +, preferably 0.9+) (Spearman-Brown formula if 200 questions used alpha 0.81) .

9. Development of SCEs Federation of Royal Colleges proposed introducing this format as KBA for 13 major medical subspecialties in partnership with specialist societies split 75% v 25%. KBA called SCE in November 2008 Initial Proposals 2 diets a year 200 b-o-f questions, on-line (using DVLA theory test providers) Use infrastructure and expertise of MRCP (UK) to administer/organise exam Candidates with MRCP who pass SCE awarded MRCP (specialty) those without diploma. No differentiation in post-nominal Award for UK trainees from others. Cost �800 if sat in UK, �1000 if taken in an overseas centre

10. BGS Newsletter March 2007

11. Development of SCE Establishment of : Question Writing Groups - 25 BGS members (response to advert and email to Regional and Council reps) broad interests, non-academics and some academics, representation from all 4 nations, all trained and not paid! Examination Board - 10 members including Chair and secretary of SAC Standard Setting Group � several members with expertise in standard setting undergraduate examinations.

12. Relationship of 3 Groups

14. Where Are We Now? Specialist Societies � concerns formed a �Consortium of Specialist Societies� SAC committed to this form of KBA (insufficient time and Resources for alternative) plus MRCP exam expertise a big advantage Successfully negotiated award title change from Diploma to Certificate (avoids confusion with DGM). For UK trainees Award will convert to MRCP (specialty) at time CCT. On going concerns regarding business model and cost of exam to trainees, negotiations continue

15. Where Are We Now? 200 b-o-f questions (2 papers), same day, computer-based test, Pearson Vue 12 centres (centres in all 4 UK nations) initially one diet a year. �800 if taken in UK, �1000 if taken overseas BGS and other societies continue to negotiate on costs Gastroenterology held exam 24 June 2008. Geriatric Medicine 4 March 2009, followed by Nephrology and Respiratory Medicine Geriatric Medicine 2010 166 applicants .

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17. Eligibility Criteria and Curriculum JRCPTB Curriculum in Geriatric Medicine SCE regulations include exam �blueprint� Non UK candidates must have MRCP UK candidates ST3+, ideally pass it before PYA

19. Results to date To some extent, this variation can be put down to the small number of candidates Pass marks in the eight diets differed, ranging from 57�68%, but were all determined using an identical method of criterion referencing, and all standard setting groups were given identical instructions and guidance on what standard to expect. Each pass mark therefore reflected the average perceived difficulty for the borderline candidate of the questions in that specialty. Many candidates sitting these two exams in 2009 were older than expected, and the large majority had graduated at overseas medical schools. These associations should not be taken to imply that such characteristics are invariable determinants of poor performance, merely that we may not be able to predict the performance of future cohorts from these results alone.To some extent, this variation can be put down to the small number of candidates Pass marks in the eight diets differed, ranging from 57�68%, but were all determined using an identical method of criterion referencing, and all standard setting groups were given identical instructions and guidance on what standard to expect. Each pass mark therefore reflected the average perceived difficulty for the borderline candidate of the questions in that specialty. Many candidates sitting these two exams in 2009 were older than expected, and the large majority had graduated at overseas medical schools. These associations should not be taken to imply that such characteristics are invariable determinants of poor performance, merely that we may not be able to predict the performance of future cohorts from these results alone.

20. Feedback post exam over half felt they had underestimated the difficulty of the challenge anecdotal feedback from individual candidates has indicated that many expected the knowledge tested by the exam questions to reflect everyday clinical practice in the relevant specialty and that several years of clinical experience should have secured a body of knowledge adequate to ensure success.

21. Sample Questions

22. Best-of-five Question An 82-year-old woman had a 3 year history of urinary frequency, a sudden and overwhelming desire to urinate at times associated with incontinence, but no dysuria. She was on no medication and there were no abnormal findings on examination. Mid stream urine specimen was negative. The most likely cause for her symptoms is: A atonic bladder B autonomic neuropathy C detrusor instability D pelvic floor weakness E overflow incontinence

23. A 80-year-old woman presented with a 3-day history of increasing confusion and falls. On examination, There were coarse crackles at the right lung base. Her oxygen saturation measured by pulse oximetry was 95% when breathing air. Investigations: haemoglobin 11.5 g/dL (11.5�16.5) white cell count 15 ? 109/L (4�11) neutrophil count 12 ? 109/L (1.5�7.0) serum sodium 143 mmol/L (137�144) serum potassium 4.4 mmol/L (3.5�4.9) serum creatinine 143 �mol/L (60�110) urinalysis protein 1+ chest X-ray poor quality, rotated film What is the most appropriate next investigation? blood cultures blood gases CT scan of head lumbar puncture urine microscopy

24. A 69-year-old woman presented with a left Colles� fracture following a fall. She had a past medical history of hypertension. Her menopause had occurred at age 50. Her mother had had a hip fracture at age 89. Investigations: DEXA scan T score of �1.4 at the lumbar spine; T score of �2.0 at the left hip According to current guidelines, what is the most appropriate management? alendronic acid hormone replacement therapy no drug treatment raloxifene strontium ranelate

25. A 75-year-old, woman with no significant past medical history presented after having awoken suddenly with tightness in the throat and shortness of breath. She had been aware of a mild sore throat before going to bed. She had no past medical history of note and had a normal diet. On examination, she had a respiratory rate of 35 breaths per minute. She had stridor but a clear chest. Her throat appeared normal. Oxygen saturation was variable, dipping to 80%. What is the most likely diagnosis? carbon monoxide poisoning epiglottitis foreign body left ventricular failure tonsillar abscess

26. An 84-year-old woman was found to have atrial fibrillation. She had fallen on ice 4 months previously and broken her wrist. She was taking alendronate and calcium supplementation but no other medication. The general practitioner asked for advice about primary stroke prevention because of her risk of falls. Examination was normal, apart from an irregular pulse. Full blood count, urea, creatinine and thyroid-stimulating hormone concentrations were normal. What is the most appropriate recommendation? aspirin aspirin and dipyridamole clopidogrel warfarin warfarin and aspirin

27. A 73-year-old woman had undergone surgery for an obstructed bowel 2 weeks previously. Her Barthel Index was 13/20. Which variable contributes directly to the Barthel Index? get up and go hearing incontinence nutritional status power in the legs

28. A 78-year-old woman was referred with hypertension. She also had gout and osteoarthritis. Her current medications were candesartan, atenolol, paracetamol, and calcium and vitamin D. She was intolerant of many medications, such as amlodipine, perindopril and allopurinol. On examination, her blood pressure was 179/95�mmHg. Investigations: haemoglobin 14.6 g/dL (11.5�16.5) serum sodium 137 mmol/L (137�144) serum potassium 4.8 mmol/L (3.5�4.9) serum creatinine 71 �mol/L (60�110) urinalysis normal electrocardiogram sinus rhythm chest X-ray normal What is the most appropriate next investigation? ambulatory blood pressure monitoring echocardiogram renal tract ultrasound 24-h urinary catecholamines 24-h urinary cortisol

29. A 65-year-old diabetic woman presented to her general practitioner following sudden onset of right-sided weakness with speech disturbance resolving within one hour. On examination, her blood pressure was 160/96�mmHg and there were no positive neurological findings. In order to predict her risk of stroke, you want to calculate her ABCD2 score. What is her calculated score? 3 4 5 6 7

30. A 70-year-old man presented with a 4-month history of tiredness. He was not taking any medication. His examination was unremarkable. Investigations: serum sodium 119 mmol/L (137�144) serum potassium 3.9 mmol/L (3.5�4.9) serum creatinine 106 �mol/L (60�110) plasma osmolality 255 mosmol/kg (278�300) urinary osmolality 505 mosmol/kg (350�1000) urinary sodium 32 mmol/L What is the most appropriate next investigation? chest X-ray CT scan of abdomen CT scan of head short tetracosactide test water deprivation test

31. Changes in life expectancy globally have implications for all societies. By 2050 the world's population of 65 and older is expected to grow to what level? 8% 13% 16% 20% 24%

33. Best-of-five Question An 82-year-old woman had a 3 year history of urinary frequency, a sudden and overwhelming desire to urinate at times associated with incontinence, but no dysuria. She was on no medication and there were no abnormal findings on examination. Mid stream urine specimen was negative. The most likely cause for her symptoms is: A atonic bladder B autonomic neuropathy C detrusor instability D pelvic floor weakness E overflow incontinence

34. A 80-year-old woman presented with a 3-day history of increasing confusion and falls. On examination, There were coarse crackles at the right lung base. Her oxygen saturation measured by pulse oximetry was 95% when breathing air. Investigations: haemoglobin 11.5 g/dL (11.5�16.5) white cell count 15 ? 109/L (4�11) neutrophil count 12 ? 109/L (1.5�7.0) serum sodium 143 mmol/L (137�144) serum potassium 4.4 mmol/L (3.5�4.9) serum creatinine 143 �mol/L (60�110) urinalysis protein 1+ chest X-ray poor quality, rotated film What is the most appropriate next investigation? blood cultures blood gases CT scan of head lumbar puncture urine microscopy

35. A 69-year-old woman presented with a left Colles� fracture following a fall. She had a past medical history of hypertension. Her menopause had occurred at age 50. Her mother had had a hip fracture at age 89. Investigations: DEXA scan T score of �1.4 at the lumbar spine; T score of �2.0 at the left hip According to current guidelines, what is the most appropriate management? alendronic acid hormone replacement therapy no drug treatment raloxifene strontium ranelate

36. A 75-year-old, woman with no significant past medical history presented after having awoken suddenly with tightness in the throat and shortness of breath. She had been aware of a mild sore throat before going to bed. She had no past medical history of note and had a normal diet. On examination, she had a respiratory rate of 35 breaths per minute. She had stridor but a clear chest. Her throat appeared normal. Oxygen saturation was variable, dipping to 80%. What is the most likely diagnosis? carbon monoxide poisoning epiglottitis foreign body left ventricular failure tonsillar abscess

37. An 84-year-old woman was found to have atrial fibrillation. She had fallen on ice 4 months previously and broken her wrist. She was taking alendronate and calcium supplementation but no other medication. The general practitioner asked for advice about primary stroke prevention because of her risk of falls. Examination was normal, apart from an irregular pulse. Full blood count, urea, creatinine and thyroid-stimulating hormone concentrations were normal. What is the most appropriate recommendation? aspirin aspirin and dipyridamole clopidogrel warfarin warfarin and aspirin

38. A 73-year-old woman had undergone surgery for an obstructed bowel 2 weeks previously. Her Barthel Index was 13/20. Which variable contributes directly to the Barthel Index? get up and go hearing incontinence nutritional status power in the legs

39. A 78-year-old woman was referred with hypertension. She also had gout and osteoarthritis. Her current medications were candesartan, atenolol, paracetamol, and calcium and vitamin D. She was intolerant of many medications, such as amlodipine, perindopril and allopurinol. On examination, her blood pressure was 179/95�mmHg. Investigations: haemoglobin 14.6 g/dL (11.5�16.5) serum sodium 137 mmol/L (137�144) serum potassium 4.8 mmol/L (3.5�4.9) serum creatinine 71 �mol/L (60�110) urinalysis normal electrocardiogram sinus rhythm chest X-ray normal What is the most appropriate next investigation? ambulatory blood pressure monitoring echocardiogram renal tract ultrasound 24-h urinary catecholamines 24-h urinary cortisol

40. A 65-year-old diabetic woman presented to her general practitioner following sudden onset of right-sided weakness with speech disturbance resolving within one hour. On examination, her blood pressure was 160/96�mmHg and there were no positive neurological findings. In order to predict her risk of stroke, you want to calculate her ABCD2 score. What is her calculated score? 3 4 5 6 7

41. A 70-year-old man presented with a 4-month history of tiredness. He was not taking any medication. His examination was unremarkable. Investigations: serum sodium 119 mmol/L (137�144) serum potassium 3.9 mmol/L (3.5�4.9) serum creatinine 106 �mol/L (60�110) plasma osmolality 255 mosmol/kg (278�300) urinary osmolality 505 mosmol/kg (350�1000) urinary sodium 32 mmol/L What is the most appropriate next investigation? chest X-ray CT scan of abdomen CT scan of head short tetracosactide test water deprivation test

42. Changes in life expectancy globally have implications for all societies. By 2050 the world's population of 65 and older is expected to grow to what level? 8% 13% 16% 20% 24%

43. Summary PMETB required specialties to have a Knowledge Based Assessment in place for StRs registering from August 2007 onwards The Federation�s proposals offer an opportunity for a standardised approach to SCE for specialties, alternatives are few and utilising the MRCP infrastructure confers many advantages Negotiations on finances (linking to College subscriptions and �free resits�) continue

44. How do I pass? Become familiar with the Geriatric Medicine curriculum and blueprint Clinical experience has to be complemented by directed reading and private study

45. Useful Websites www.bgs.org.uk www.jrcptb.org.uk (curriculum, training) www.mrcpuk.org www.doctors.net.uk

46. Acknowledgements Thanks to Oliver Corrado Question writers Examination Board in particular Terry Aspray (Secretary) Standard Setting Group SAC Geriatric Medicine and BGS ETC