nMRCGP

1. nMRCGP Dr Mark Feldman

2. nMRCGP • Money • AKT • CSA

3. Money • Become AiT £492 • AKT £414 • CSA £1389 • Fee to PMETB £78

4. Exams • AKT • Computer marked ‘multiple choice’ paper • CSA • Practical assessment of consulting skills

5. AKT • Relevance: The AKT should be relevant to general practice; any topic covered can be one which occurs commonly or one which is significant but less common • High prevalence: Low impact e.g. URTI • High impact: Low prevalence e.g. meningitis • Topical: e.g. Controlled drugs

6. Sources • Clinical Evidence • Cochrane Database • BNF • GP Curriculum • NICE • SIGN • BMJ Review articles & original papers • BJGP • DTB

7. This is your friend

8. AKT • Core clinical medicine and its application to problem solving in a general practice context • 80% of items • Critical appraisal and evidence based clinical practice • 10% of items • Ethical and legal issues as well as the organisational structures that support UK general practice • 10% of items

9. Stuff no one bothers with but features heavily in the exam… • Regulatory frameworks • Legal aspects, e.g. DVLA • Social services, e.g. Certification • Professional regulation, e.g. GMC • Business aspects, e.g. GP contract • Prescribing, e.g. Controlled drugs • Appropriate use of resources, e.g. drugs • Health & Safety, e.g. needlestick injury • Ethical, e.g. Mental capacity, consent

10. Essentials for AKT • Know latest guidelines • Know the BNF • Know basic stats • Your core medical knowledge is probably already sufficient.

11. AKT April 2009 • 1102 candidates • Mean score 71% • Top Score 92% • Pass mark 63.3% • Pass rate 83.8% Pass rate ST2 86.3% Pass rate ST3 83.8%

12. AKT April 2009 • Clinical medicine 74% • Evidence interpretation 68.2% • Administration 60.1%

13. AKT – Areas of weakness • Asthma – in childhood • Breast and skin disorders • Certification • Fitness to work and drive • Emergency medicine

14. CSA • You must bring: • BNF, Stethoscope, Ophthalmoscope, Auroscope, Thermometer, Patella hammer, Sphygmomanometer (aneroid or electronic), Tape measure, Peak flow meter and disposable mouthpieces • There are no spares at the exam centre • Anything else you need is provided

15. CSA • You have your own room. • You have a list of patients – your ‘surgery’ for the morning. • The list contains brief info about the patient. • It may or may not include PMH, drugs etc. • You probably wont know why they are coming. • You have never seen the patient before – but colleagues might have.

16. CSA • Buzzer will sound and patient and examiner come in. • You have 10mins after which buzzer will sound again. Anything said or done after this will not count. The patient and examiner then leave. • There is no ‘1min/2min’ warning buzzer. • There is a 2 minute break between patients. • There is a 15min break after 7 patients seen.

17. CSA • The examiner sits out of your line of site. • Examiner does not participate in the consultation. Ignore them. • All patients are played by actors who have been well briefed beforehand • They will almost certainly not have any physical signs to elicit on examination

18. CSA – Exams and investigations • If you want to examine the patient say so and say what you are going to examine. • If they are testing this exam technique they will let you go ahead. • They will then give you the exam findings. • If they are not testing this exam they will just give you the findings and tell you not to examine. • They will only give you results of exams you say you will do.

19. CSA – Exams and investigations • Examination is what you would normally do as a GP. • This means a lot of it can be done with the patient sitting in the chair. • It does not have to be exhaustive. • Eg. Chest exam – percussion and auscultation is fine.

20. CSA – Exams and investigations • Any investigation results will be on the table in front of you or, more likely, will be brought in by the patient. • It will list normal levels so you don’t have to remember them. • Abnormal findings will be common GP tests. • Eg. Hb, HbA1c, urinalysis etc. • It will not be anything obscure.

21. CSA – Management plans • If you want to prescribe a drug you don’t have to write a prescription • All you need do is say • Eg. I will give you omeprazole 20mg once a day. • This is as good as having written it. • There are prescription pads on the table. Do not let these distract you.

22. CSA – Management plans • DON’T WRITE ANYTHING DOWN • There is no time • The prescription will be marked • There is no penalty for just saying it • You have to say what you are giving anyway

23. CSA – Management plans • The same applies for blood tests and sick notes and any other forms you might write. • Just say what you will do. • If you want to make a referral, ask the patient to wait in the waiting room and you will bring the letter/form out to them. • Leaflets can be ‘collected from reception’

24. CSA • You have 10 minutes per case. • ‘Shows poor time management’ is a reason they can fail you at the station. • And they will. • You MUST be consulting at 10 minutes.

25. CSA • Each case is marked in 3 domains : • Data gathering, examination and clinical assessment skills • Clinical management skills • Interpersonal skills • All domains have equal weighting • Do not spend 8 minutes on history and examination – you will fail the station.

26. CSA • But those domains have no meaning… • What are they actually looking for?

27. CSA • DATA-GATHERING, TECHNICAL & ASSESSMENT SKILLS • Gathering & using data for clinical judgement • Choice of examination Investigations & their interpretation • Demonstrating proficiency in performing physical examinations & using diagnostic and therapeutic instruments

28. CSA • CLINICAL MANAGEMENT SKILLS • Recognition & management of common medical conditions in primary care • Demonstrating astructured & flexible approach to decision-making. • Demonstrating theability to deal with multiple complaints and co-morbidity. • Demonstrating theability to promote a positive approach to health

29. CSA • INTERPERSONAL SKILLS • Demonstrating theuseof recognised communication techniques to gain understanding of the patient's illness experience and develop a shared approach to managing problems. • Practising ethically with respect for equality & diversity issues, in line with the accepted codes of professional conduct.

30. CSA • The grades will be on a four point scale: • Clear Pass • Marginal Pass • Marginal Fail • Clear Fail • There are no merits or ‘grades’ at the end for the exam as a whole. • You pass or fail.

31. I Failed?

32. Data Gathering • Disorganised and unsystematic in gathering information from history taking, examination and investigation • Does not identify abnormal findings or results or fails to recognise their implications • Data gathering does not appear to be guided by the probabilities of disease • Does not undertake physical examination competently, or use instruments proficiently

33. Clinical management • Does not make appropriate diagnosis • Does not develop a management plan (including prescribing and referral) that is appropriate and in line with current best practice. • Follow-up arrangements and safety netting are inadequate • Does not demonstrate an awareness of management of risk, and health promotion

34. Interpersonal skills • Does not identify patient’s agenda, health beliefs & preferences / does not make use of verbal & non-verbal cues • Does not develop a shared management plan or clarify the roles of doctor and patient • Does not use explanations that are relevant and understandable to the patient • Does not show sensitivity for the patient’s feelings in all aspects of the consultation including physical examination

35. Global • Disorganised / unstructured consultation • Does not recognise the challenge (e.g. the patient’s problem, ethical dilemma etc.) • Shows poor time management • Shows inappropriate doctor - centeredness

36. Essentials for CSA • Be in general practice for a few months • Consult at ten minutes

37. Top tips – to avoid ambush ! • Be Flexible • Scales of the consultation - Weigh your words [ not too many closed questions]

38. Top tips • The magic questions • What can I do for you today ...? • Silence / body language • Is there anything else? • Silence / body language • Have you any thoughts / worries about what this might be ?