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MRCGP Vivas

By Anne Patterson,2014-08-12 13:25
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MRCGP Vivas ...

Swansea Bay VTS

MRCGP Oral Exam sample questions

     Updated B.Weatherill 9/8/05

Don‟t panic about the number of questions attached. You will notice as you scan through them that there are

    several recurring themes. The last few pages are from the last 2 years worth of orals so that you can get an

    idea of what keeps coming up.

    The viva tests how you “think on your feet” – YOU MUST KNOW THE ETHICAL FRAMEWORK

    Ref : The Practical Guide to Medical Ethics and Law : Baxter et Al : Pastest should be in your practice

    library.

    You should also look at www.bma.org.uk , www.gmc.org.uk and at www.abi.org.uk ( look under Information

     lots on Health and Insurance Issues)

The main objective is to identify

    1) The issues

    2) The people involved : the doctor , the patient and society

    3) The implications of the issues for each person or group

    So there often isn‟t a “right” or a “wrong” answer – just a set of dilemmas to identify and attempt to address. (We will be doing a session on ethics next term)

     Identify 1) 2) and 3) above and apply the ethical framework

    If you do this you will always have something to say in reply to any of the attached questions. Easy or what ?…

Idiot‟s Guide to the Ethical Framework !

A is for AUTONOMY apply to patient and doctor

    B is for BENIFICENCE (non malificence) do no harm to yourself / pt / society

    C is for CONFIDENTIALITY must be respected but in certain circumstances can be broken D is for DUTY duty of care to self / to patient / to colleagues in profession / to society E is for EQUITY equity of resources what is available across UK to dr / pt / society

Goals

    1. To understand ethical principles and values

    2. To understand that ethical and legal issues occur in everyday practice 3. To understand that ethical and legal reasoning and critical reflection are natural and integral components

    of clinical decision making

    4. To be able to think clearly about ethical issues in medicine

    5. To know the main professional obligations of doctors

Topics

    1. Consent and refusal of treatment ( Competence issues)

    2. Truth and trust

    3. Confidentiality

    4. Research

    5. Reproductive medicine

    6. Genetics

    7. Children

    8. Mental disorder

    9. Life and death issues

    10. Professional responsibilities

    11. Resources and rationing

    12. Rights

Other useful Viva type things :

    You must know at least 3 consultation models. Consultation models come up again and again.

To practice for the orals get 2 ” examiners” to sit across a table from you in a formal fashion and time your

    questions / answers. By practising in semi exam conditions hopefully it will all seem less threatening on the

    day.

MRCGP Oral - sample questions

    Swansea Bay VTS : Updated August 05.( B. Weatherill )

    The end of this list contains the questions asked of candidates over the last 2 years. There are a lot of repetitions but they give you a flavour of how the examiners minds are working. The end of the list has the most recent dated questions

1.How would you tell a patient he /she is depressed?

    Establish rapport / could choose a consultation model. Explore ICE

    Explore understanding of term "depression" vs low mood

    Use empathy/verbal + non-verbal communication skills. Use simple language.

    Explain + relate to pts own understanding. Be prepared for "denial"

2. What sort of patients makes you feel bad?

    Breaking bad news / terminally ill .Violent /aggressive patients. Patients you are unable to help /cure. "Groves" 1951 described " heartsink " patients. (Dependant clinger / entitled demander /manipulative help- rejecter / self destructive denier. Coping mechanisms include recognising own feelings / Balint groups / discussion with peers / housekeeping.)

3. What do you understand by the term "housekeeping"?

    Originally described by Roger Neighbour. Final stage in his consultation model (connect / summarise / hand-over / safety-net / house-keeping) Dr ensures is emotionally and physically ready for next patient. e.g. take a break , discuss with partners, noting PUNS + DENS ,sport , holidays etc.

4.What do you think of walk in centres?

    Not yet in Wales. PROS- convenience for patients / no appt needed / take burden from routine 9-5 work / more flexibility for Drs /2nd opinion for pts. CONS- increasing consumerism / no continuity of care / dual records / reduces "gatekeeper" role of GP.

5.How would you identify your learning needs?

    Self awareness during consultation noting PUNS and DENS

    Feedback from colleagues. 360degree feedback . Peer groups discussion / complaints from patients SWOT analysis / Audit /Critical event analysis / Video / mentor

    Educational meetings ok but now a move away from PGEA towards a more personalised approach. Concept of personal portfolio as part of appraisal / revalidation.

6. Is there a difference between a good and bad GP?

    "Good" doctor very difficult to define. Can be assessed by patients /peers, higher bodies, GMC have issued guidance in booklet "Good medical practice"* 7 main areas suggested* know these as follows : Good

    clinical care / keeping up to date / personal development / communication with patients/communication with colleagues / teaching / probity and health. These form basis of appraisal now. GPC also written guidance as to the behaviour of "unacceptable GP".

7. What facilitates good teamwork?

    Adequate training / time for education for all team members. Common aim / purpose. Pooling of knowledge + skills. Each member understands own function and where overlaps occur. Responsibility assigned. No "collusion of anonymity". Good leadership. Clear delegation of tasks. Good communication at all levels. Commitment and enthusiasm for change. A good leader is democratic / good listener / approachable /communicates well.Belbin.

8.How would you define health?

    Some say " absence of disease" GP= more holistic approach Patients have differing expectations and perception of health ls very personal One definition is “ a state of social.psychological and physical

    well-being.” There are limitations to drs ability to provide social help.

9.When do you use a chaperone?

    All patients have right to a chaperone but there are obvious time and staff limits. Who is trained to be a chaperone? Where do they position themselves during an examination? Nurses time too precious / Reception staff not trained and uncomfortable.

    Patients may feel more uncomfortable with 2 people present /confidentiality issues.

    Generally should always offer if examining patient/implied consent.

    More likely to use chaperone with pts of opposite sex / intimate exams / previous psych history

10.Can you think of any screening programme that has worked?

    Wilsons Criteria know them Define “worked” ! Evidence base?

    Antenatal screening with routine blood testing reduced incidence of rubella / syphilis / rhesus mismatch / anaemia Breast / cervical screening evidence is controversial. A few figures would help you Could talk about CHD / DM NSFs

11.How do you assess a clinical guideline?

    List in Trish Greenhaugh re assessing a guideline

    Can be practice / local health group / national level. eg NICE , NSFs, eguidelines website - clinical help. Should have aim clearly stated / who is it written by /who is it written for / who is responsible /are they evidence based /safety net eg refer if inadequate resources. At local level need ownership, resources and implementation plans( Give example eg Could refer DM cases back to hosp as GP DM clinics

    inadequately resourced.) Can be useful but may increase pressure on gp and restrict autonomy / patients are individual. Financial restraints. Are they legally binding?.

12. Would you treat a patient without consent?

    Ethical dilemma.See GMC guidelines (www.gmc.org.uk ) Consent can be explicit or implied. Patient

    generally should be fully informed but can Rx without consent if mental incapacity /emergency situation eg unconscious. If thought to be in best interest . Children of Jehovah’s witness etc. Should respect patient autonomy but other part of ethical framework eg beneficence may take precedence.

13.Does private practice have any place in general practice today?

    Pros and cons for Dr and patient. Increasing burdens on NHS mean inadequate resources /increasing waiting times etc Private practice may reduce overall burden but is this "justice"? Increases choices for both patients and drs. May widen inequalities in health between social classes which already exist. Change in Dr / pat relationship. 16% UK pop estimated to have private insurance thru work or personally. Very low % in S. Wales Recent government initiatives eg specialist gps.

14. A patient makes a complaint against a receptionist during a consultation. What are the issues raised?

    Issues re duty to patients /relationship with staff. Need to be sympathetic to both parties. Refer pt to standard complaints procedure after listening. Empathise. Do not take sides. Do not admit liability. Practice manager will progress.Find out more info?trivial ?surgery waiting times ?recurrent problem. Does receptionist need help /retraining etc. How much do partners get involved with a management issue? Know complaints procedure

15.How do you feel about patients who self-medicate?

    Lots of implications. What’s available OTC ? What sort of medication? / herbal etc Patient- may encourage

    self reliance,ownership of and responsibility for illness. Doctor-why are they self-medicating ? changes to dr/pt relationship. May reduce burden from drs,dr will need to be aware of all drugs eg potential interactions eg St Johns Wort. Practice- may reduce costs Society- patients may become better informed. Issues around complementary med / internet

16.What are the difficulties in looking after deprived populations?.

    Know Jarman index. Deprivation is associated with poorer social ,psychological and physical health. More disease / increased psychiatric morbidity / may increase no. of consultations / increase prescribing. Whole PHCT will have increased workloads. Increased smoking and alcohol rates. Teenage pregnancy. Poor housing / high unemployment. More crime / violence. May be more difficulties achieving smear / immunisation targets. Difficulty in recruiting staff . Isues about premises vandalism / poor investment for

    dr. if owns premises. Need for good basic comm. skills n.b. illiteracy and learning disability in practice popn. Can’t recruit Drs

17.What are the constraints on a doctors autonomy?

    From patients and higher bodies. Increasing pt awareness and demands/consumerism Government initiatives /guidelines / NSFs / NICE. Lack of resources. Drug budgets. Fear of litigation. Time/shorter consultations. Appraisal / revalidation. Talk about assessing guidelines

18.What are the occupational hazards of being a GP?

    Physical - infection risk / violence / exhaustion . Psychological- burn-out stress,depression,suicide. Social-increased alcohol / drug usage,poor home relationships. Need for GPs to accept they are human / being a patient / confidentiality / no Occ Health Service for GPs

19.Your GP partner is suffering from burn out (or a health issue ) - what would you do?

    Difficult dilemma / responsibility to patients and also relationship with partner. Assess if patients are at risk . Discuss with the partner /offer help and support. ? Underlying problem with health / relationships etc Discuss with other partners in practice. Consider reducing workload /ooh / holiday etc If patients are at risk will need to take situation further. Dilemmas of “whistle blowing”. Advice from : colleagues / LMC Sec / MDU / Primary Care Adviser / ? local appraisal mechanisms / NCAA

20.How would you persuade your practice team about the value of audit?

    Communication skills and teamworking / leadership skills. Organise a meeting. Find out and try to address their particular concerns. Explain now part of clinical governance / reimbursement / appraisal / should improve patient care / outcomes. Highlight benefits. Could audit own practice initially. Be

non-threatening.Use listening skills. Address training needs of all concerned. Lead by example do some

    audits / New contract

21.How would you react if your partner had a serious complaint made against them?

    Find out more info / be supportive at personal level / could it have been avoided? Health of partner / ? underlying problem / ?Practice meeting. Some practices review all complaints on a regular basis. Consider critical event analysis Are pts at risk? Offer help to colleague ? needs time off ? burnout / contact MDU / GMC for advice

22.A man attends asking for info re his 22yr old son.

    Confidentiality issues. Communication issues. Need more info - what are the concerns about? Need to try to maintain good relationship with him but pt confidentiality is paramount. If over 18 and competent adult can only disclose info if serious crime /sex offence / public interest / infectious disease and then only to

    appropriate body eg courts / police / social services.

23.How would you advise a 50 yr woman asking for information about mammography?

    Establish rapport. Discuss ICE. What are her concerns ask re symptoms / F history etc. Screening programme routinely from 50- 63 but over 64 can request at will . Be aware of evidence for routine marnmography screening.(controversial) Pt needs to be aware of limitations of screening..nb False negatives and positives. Could refer her to Breast Test Wales for further information.

24.A patient presents prior to a holiday with haemoptysis

    Acknowledge potentially difficult and time consuming consultation. Patient needs to be aware of all facts to make a fully informed decision. Take hx + exam. Where travelling to and for how long will affect advice given. Good rapport / trust with patient is essential. Patient issues- will travel put him at more risk /insurance claims. Dr- self-awareness ,potential implications Society- is there a possibility of a communicable disease.

25.You are asked to talk about sexual health to a group of 13yr old pupils in a local school

    Mixed feelings. Why me? What is expected? What are the local teenage preg rates? Could be a good opportunity to talk to teenagers re sexual health / general health promotion but: big responsibility /needs to be accurate and appropriate / not offend parents etc. time and financial issues. Will parents be offended? How confident re presentation skills? Advice from partners / GUM consultant.

26.One partner is prescribing 4x amount of CDs as other partners

    Potentially a difficult situation. Do not jump to conclusions / may have an interest in terminal care etc.consider may be prescribing harm minimisation /reduction programmes. Find out more. Audit ? PACT data , Prescribing adviser , be open, ? confront partner. How is CD use documented within practice etc. If are suspicious could discuss with other partners/would have a duty to report / investigate further.duty to colleague lsociety.

27. Name three websites you have found useful

    1. MRCGP site Information re exam,video criterior etc / Info re jobs, post VTS posts etc / Hot topics Discussions/debates

    2. Practice web sites Own site. guidelines,practice protocols,patient information leaflets Tutorials for registrars eg Well Close Square, Abersychan

    3.Evidence based medicine sites choose from:

    BMJ site. Papers, editorials, on-line bookshop / Medline / Cochrane / Bandolier / Trip database 4. www.gpnotebook.co.uk - everything!

28.What do you understand by the term "informed consent?

    For consent to treatment to be valid : 1) patient must be competent 2) must have sufficient information to make an informed choice ( this suggests that the doctor must have adequate knowledge to explain to the patient…) must bear in mind different patients may have varying levels of understanding related to education and ability 3) consent must be given voluntarily ( ie no coercion by the dr.). Inflicting examination or rx on a patient without informed consent can be considered assault. Consider prescribing as an example reality of explanations to patients re new medication…

29.Issues surrounding living wills

    Respect for patient autonomy. Patient can state in advance of becoming incompetent that they wish to authorise or refuse certain treatments. Started by VES ( Voluntary Euthanasia society ) ask the Terence Higgins Trust (AIDS)or buy one in WHS. Morally but not legally binding. Should be signed and witnessed /competence assessed by psychogeriatrician if in doubt / include family and carers if poss /review at reg intervals max 5 yrs / inform relatives and gp keep 3 copies relatives / gp / nursing or res home/ revocable /

    not preclude basic care. / beware outside interests.

30.What are the implications of whistle blowing?

    Patient - should protect pts from dangerous drs. Dr.- increasing stress / may not be correct/ dr may be ill, burnout/public and professional humiliation/loss of job. Whistleblower. - guilt, suspicion from other colleagues,duty to society. Practice- workload ,dynamics. Society- blame culture ,transparent health service.

31.Offer of a cash gift of ?1000 from a patient

    Difficult situation. Do not want to harm Dr/pt relationship. Accepting a personal gift only if appropriate to situation. Consider bribe/ genuine gratitude / relative may be stressed, bereaved. Will change future dr pt relationship. May cause bad feeling with other partners. Options to delay / set up patient fund in surgery for equipment etc.

32.What impact has the internet had on GP?

    Patients - more informed but unsolicited info / may increase expectations. Doctors-easier access to up to date evidence but nb time consuming. Benefits also from intranet within the practice/communication etc Practice websites /info leaflets for pts or advise website ( NHSDirect) / NHS net aids communication with 2ary care / path results etc But: concerns over confidentiality/ disadvantge for technophobes / information overload for PHCT.

33.Legalisation of cannabis

    Implications for Dr / patient /. Society. May have therapeutic benefits eg chronic pain , MS, but need more evidence,eg long-term harm? Evidence limited + not prescribable. However use is widespread: will it be easier to monitor use if legal or is it a "gateway"drug?

34.Who should ration health care?

    Rationing can occur at a dr / practice / local or national level. Gps know needs of their particular popnl / role of gatekeeper / finite resources , more pressure on gps. Government not in best position to assess need , NICE etc reduces drs autonomy but rationing is explicit so drs do not take blame. Consider ethical framework. limited finance limits autonomy / justice- doing good for greatest no. of people vs very expensive Rx for handful. How much of a role does society in general have? emotional responses from ill informed

    enthusiasts…

35.You notice a possible SCC on the cheek of a passer-by

    Difficult dilemma. No actual legal responsibility but possible moral duty. Potentially life-threatening condition so should pass on knowledge but difficult to establish rapport /pt may already have seen gp and may consider it an intrusion/may not wish to know. Ethical framework, pt can only be autonomous if fully informed, beneficence( doing good )but informing may cause anxiety (malificence).

36. 100 Iraqi refugees are allocated to your list. What are the issues?

    Refugees - increased physical + psychological illness. May suffer prejudice. Resentment / violence from indigenous popn. Poor living conditions, violence, refugee status. Not allowed to work .Dr. -may increase workload - difficult long consultations, language, cultural differences , translators ( NHS Language Line nb

    confidentiality). Implications for other patients on list. Workload ,targets,smears etc. Need special liaison with LHG / PCT to organise care with proper resources. Forced allocations a major problem in some areas.

37.A gentleman with a few days to live asks you to help him die.

    Difficult situation. Illegal. Explore ICE. Ask why / is he in pain? /is he depressed / afraid? Good rapport. Palliative Care Team. Regular visits. Give any help available eg symptom management, night sitters, pain management. " Double effect". If measures to relieve physical suffering cause premature death it is legal if the drs intention was to relieve distress. Involve family in his care if poss.

38.Is there an article or book that has changed your practice?

    There will be now won’t there?….

39. What does the term “Clinical Governance” mean to you?

40.What may have gone wrong when a patients hosp appt is not received and whose responsibility is it?

    Doctor forgot / dictated a blank tape for sec / Sec missed typing it / lost in post to hosp. Patient- change of address, not informed surgery. Hospital - wrong department / long waiting list lost in hospital. Discuss mechanisms to avoid problems eg data entry of referral and 2 weekly audit that letter has left surgery. Consider critical event analysis.

41.What is "patient-centeredness"?

    Partnership between Dr and pt. Move away from paternalistic approach Involve pt in own health and outcomes. Exploring ICE and health beliefs and incorporate these into fully informing the pt and sharing

    options. Concept of risk analysis difficult and time consuming with many pts /Discuss autonomy of dr vs pt. Is it more stressful to be patient centred?

42. What do you think of GPSIs?

    Pros- enables partners to develop skills / specialise. More job satisfaction.Easier access for pts than hospital, may reduce hospital wait. Learning from partners. Specialist GPs / Training / Payments from LHG for extra services which protect Sec Care. Cons - may undermine pts confidence in yourself, less variety for partners, ? increase overall practice workload which is not resourced. Are there enough drs?

43.Patient participation groups.

    Pros - encourages pts contribution,empowerment of patients May identify local needs. Increased transparency, better pt education, ? better service planning. Cons - only select motivated people. Inverse care law,better educated likely to get involved. Less understanding of resource issues.. Usually want more appts at weekends etc / "want not need”. Who attends from the practice?- dr / manager / funding likely to

    be OOHs.

44.Discuss the implications of giving sick notes.

    Patient -may encourage " sick role" Difficult for dr to assess pt fully in short consultation, dr /pt relationship

    may be conflict of interest, feeling pressurised / potential of abuse of system, moral duty to oneself. Society- dr has a duty to protect society from false claims. GPs have lowest sickness rates in the country

    paradox of certification…could lead into occupational health service for drs.

45.What do you think of the career structure in General Practice?

    Much better than it used to be. Postgrad posts / varied and changing / lots of opportunities / part time / flexible. Salaried / PM&GMS. Easy to develop special interests in practice (GPSIs) or outside ( Clinical assistant in hospital / police surgeon / Occ Health.) Education expanding in Primary Care. Study leave to do higher degrees. Job satisfaction. Management. New Contract.

46. A patient requests a home delivery. What are the issues?

    WelshAssGov is supporting a move to 10% home deliveries. Role of midwife in practice. Implications for pts, gp, PHCT, hospital, ambulance services. Find out why pt wants one Are they making a fully informed decision? Pros - may be safe for low risk pregnancy, familiar surroundings / pt autonomy Cons Drs not

    experienced / no OOH cover / BOLAM test / high risk if complications / emergency transfers.

47.You discover that a prospective partner has a stable psychiatric condition. What are your thoughts?

    Several implications. How did I come by this information / confidentiality for doctors as patients issues. Partner: Will he/she be able to cope? What is the diagnosis prognosis? May have more empathy with patients. Disability Rights. Equal Opportunity legislation. Consider possible implications for you. Need to be open minded / judge on merits as a GP, but acknowledge may affect myself if periods of sick leave. Practice meeting. Inevitable concerns need to be raised. Depends on competition for job.

48.Practice staff as patients

    Dr- difficult to be dr and employer / may not be objective./ may feel more pressure /expectations. Conflict of interest re sick leave. Patient - concern re confidentiality. May not disclose all personal info. Practice - sick leave of staff. Practice policy re changing Dr if become employee in some practices. Confidentiality of records from other staff almost impossible.

49. A patient with ME asks to be referred to the Bristol Homeopathic Hospital. How do you respond?

    Standard therapies / Complimentary Therapies / “Alternative Medicine” / Feelings engendered in doctor / lack of knowledge / lack of evidence / dr/pt relationship / licensing bodies for homeopaths / what is available in the NHS? Admit to relief if you feel it. ME patients very difficult.

50. Discuss revalidation

    GMC organising - to restore public confidence post Bristol and Shipman , better care, better education, more confidence in colleagues, self awareness. Cons : time , resources / whistleblowing / grnc fees , stress , who will appraise + how? How: Linked to GMC registration / evolving concept / portfolio + appraisal will feed revalidation. Appraisal vs Fitness to Practise. NCAAuthority. Know the GMC 7 “Good Medical Practice” headings.(See q.6 above)

51. What is the function of practice meetings?

    Business : Varying sizes of partnership / communication / managerial issues / staffing / finance / premises / complaints / clinical issues tend to be out in educational meetings for whole PHCT / air frustrations / need for arbiter ?prac manager

52.Patient taken 100 paracetamol / refuses admission / mother requests help.

    ?age of patient / gather more info. Circumstances surrounding event. Does the patient want help.? Previous history? Depressed? Assess competence of patient. Ensure pt is aware of consequences. Seek Psychiatric consultant advice. Would have to respect autonomy if fully competent and not Sectionable. If in doubt act in pts best interest : " beneficence".

53. A 6 week old baby is found dead at home. What are your thoughts?

    Initially shock / sadness,sympathy,empathy. Acknowledge will be difficult / emotional / time consuming Be supportive/ contain own emotions / consider ? suspicious circumstances. Before visit gather family info quickly from comp and HV. Confirm death /coroners advice do not move baby until obtained / coroner’s

    officer will advise / police attendance mandatory /give any immediate help needed / post SIDS support groups / visits you, HV / help-lines / CONI / house keep for your self distressing situation for all

    concerned

54. A solicitor requests the release of a patients notes.

    Must have pt consent / Consider why ?complaint against practice ? injury / Costs to practice / fees Pt issues: autonomy, confidentiality :Is he fully aware of possibilities in notes consent form from solicitor

    refers to (eg) RTA pt unaware that whole record released. Dr : If complaint can it be resolved informally ? How do you store your data now ? How do you check that all relevant info is printed out? Review notes, access must be given within X days, refuse if harm to pt / remove third party comments. Issues re tampering with notes.

55. What are the benefits of being detached?

56. Describe a consultation model. How would you use this in a consultation?

57.A receptionist resigns. What are the issues?

    Find out more info ? why? Working environment ? Pay? Conditions? can it be resolved? Place of regular appraisals / meetings of staff with manager. Clear line management. What if your manager is the problem? Training issues. Need to provide cover / are staff valued etc Possible need to change aspects of the practice. Advertise job. Consider sig event analysis to prevent recurrence.

58.Your partner requests 2 months study leave to study Chinese herbal medicine

    Mixed response. Why ? are they serious ? made plans ? what is practice agreement / contract clause re study leave? Consider own feelings re Chinese medicine? Evidence ? local need?

    Practice : cover for study leave / income for practice / discuss in practice meeting / review contract. Likely to be increasing scenario with improved access to MSc courses. May be different support if course more evidence based and more obviously beneficial to pts

59.Discuss Continuing Professional Development

    Practice or personal level. Need money and time allocated to this. Practice: should involve whole team. Many PCTs and LHBs organise practice based education ( Swansea does now go along to at least one of

    these sessions) Practice Plan for next few years ( “vision”) NSFs / prescribing / audit / targets / patient satisfaction / appt system / availability / CEA / clinical governance. Personal : see previous puns /dens / portfolios / appraisal. Mention option of study leave for GPs to do certs / diplomas and degrees

60.Patient has new diagnosis of epilepsy and works as an HGV driver

    Difficult situation. Empathise. Need good rapport / try to persuade pt to inform DVLA : livelihood / right to confidentiality / autonomy dr: overall duty to protect public. This is one of the recognised reasons for breaking confidentiality. Dr legally obliged to disclose if pt refuses. May be easier for Dr to tell pt that the Dr is obliged to inform the DVLA anyway as pt may say they will inform and then don’t – v diff for Dr to check.

    Discuss regs and future prospects re driving seek specialist DVLA advice ( Can look at www.dvla.gov.uk

    or speak to a DVLA medical adviser)

6I.Elderly pt with a life threatening condition refuses rx.

    Ethical dilemma. Address pts feelings and your own. Beneficence - dr wants to preserve life vs pt autonomy. Is pt competent + fully aware of consequences? Explore ICE / encourage family involvement. Assess competence ( ? involve psychogeriatrician). Final decision lies with pt. Clear documentation needed. Pt may have Advance Directive. Be supportive of patient decision (and of family) if absolute. Promote symptom relief / involve palliative care team. If in Nursing Home be sensitive to feelings of staff.

62.50 yr old widow requests IVF

    Acknowledge your own feelings. Why now ? recent life event ?

    Consider: own prejudice / pt autonomy / limitations of NHS and who should ration

    Knowledge of local referral guidelines / postcode lottery still in place re IVF.

    Is she fully aware of likely reduced chances of conception and more complications. GPs role to ration ? Refer or not?

    Role of area or national guidelines in such dilemmas

63. An 18 yr old expresses concem that her 13 yr old sister is being sexually abused.

    Rapport. Communication. What are the perceptions / facts? Take her seriously. Is sister your patient?Child protection issue so duty to investigate further.Confidentiality issues / father may be a patient. Sister will also need support. Has she been abused herself?

    Gather all possible facts Seek advice from Child Protection Team asap.

64. What are your thoughts on the shift of work from Secondary to Primary care?

    Essentially a resource issue. Increasing demand in an ageing population. Move from treatment to screening in NHS as whole. Need funds and time to train GPs and Practice Nurses / more GP specialist skills / more job satisfaction / holistic approach.Insufficient shift of resources to follow pt.( Diabetic clinics a lovely example) expectations ? time ? pts bring mixed agendas to gps. Dilemmas of guidelines (NICE / NSFs etc ) dictating priorities which may be inappropriate. ( Where’s the NSF for hip and knee replacements?…)

65.Should all 45yrs + be screened for DM?

    Screening question. Know screening (Wilsons) criteria and be able to state them. Evidence for DM screening? cost effective? Any screening mechanism may increase anxiety. Balance of resources for management of disease vs prevention. Primary care slowly moving away from disease model towards prevention but not funded for this behaviour. Increase societies expectations / drown PHCT in work too

    busy to see the sick.

66.How do you decide whether to sign a firearms certificate ?

    Need long term knowledge of pt to consider this / find out why. sport / hunting / farming / look at current life events and current mental stability. Psychiatric history ? Need to maintain dr / pt relationship but protect society. Some drs now refuse to sign these at all. Is it unreasonable to ask us? Could the cert include a statement re police record check? Why should the doctor take the risk?

67. What is the difference between a boss and leader?

    Boss: Autocratic / Hierarchy and kudos important / gets other people to do what he or she wants Leader: Involved in team / has respect of team / common goal / gets people to do what they want to do because they have been shown its value / values team contributions / delegates appropriately / good at giving and receiving feedback

68.How do you decide if an elderly patient is autonomous?

    Depends on decision to be made. Hx of confusion / poor memory / pt word is often unreliable. Involve family and carers but be aware of possible bias. Involve psychogeriatrician / CMHT / CPN /. Scoring systems for mental abilities. Power of Attorney. Advance Directives

    69.One of your partners wants to go on a course for acupuncture to use in your practice. What are the issues?

    Consider implications for the patient, yourself, practice, legal issues

    1.patient. Why do patients turn to complimentary medicine? Dr failure? Perceived safety? Time issues? Holistic approach?] Would there be a demand locally? 2.Yourself, Consider own personal feelings/prejudice re complimentary medicine Extent of knowledge e.g. recent metaanalysis in Bandolier stated no overall benefit for management of low back pain.

    3.Practice.Other partners opinions / Surgery times / Space / Funding

    4.Legal issues. Is it evidence based + possible harms studied. Is there a regulatory body?

69.When would you suggest giving up smoking to a patient?

    GP in a good position. Be non-judgemental. Consider :if presents with smoking related illness / pt seeks advice / new pt check / ocp /antenatal . Stott - Davis model recommends opportunistic HP but time is an issue in most consultations. Know pros and cons for tabs / patches / gum and current evidence.

70.Salaried GPs

    Pros : choices for Drs, flexibility / experience eg in deprived areas / recruitment inducements to deprived areas , no financial commitments with premises , less on -call commitments. Cons : less continuity , less satisfaction, less comitment to practice (eg targets), less autonomy. Now “Freelance GPs”

71.Dilemmas of dispensing gps

    Pt convenience. Dr time / potential of financial gain conflict of interest ? training ? dispenser or GP

    potential for increased errors

72.Prescribing methadone for drug misusers

    Pros : may decrease crime, drs can discuss harm minimisation / address physical problems / daily dosages so ? less drugs on street. Cons : Drs feel lacking in experience,?violence towards gps /pts in practice, consider practice policies.(Say you wouldn’t do it unless part of a substance misuse team / clinic with

    structured care and follow up)

73.Possible inappropriate relationship with a patient

    Why inappropriate? Who has behaved in what way / use of chaperones / Misinterpreted messages / consider discussion with partners ? previous history ? consider if you wish to confront the patient with third party present / may be difficult continuing to Rx pt / consider suggesting partner or new practice. Know

    complaints procedure. Know your own rights. Police if patient harassing dr.

75.What use do we make of our sense of smell in the consultation?

    Smoking, alcohol, unkempt-hygiene problems. Consider psychiatric problem and general coping mechanisms. May need SW assessment and support. “ Supreme squalor syndrome” ( more likely to be house call consultation ) in the elderly. Urinary or faecal incontinence. Medical conditions eg keto-acidosis

76.What do you feel about medical reps?

    Pros-can give useful info about their drug, SFX etc, educational meetings, new evidence. But : feel obliged to prescribe / gifts / tirne ?accurate evidence or from a company study

77.Changing role of nurses in Primary Care

    Increasing nos of practice nurses and nurse practitioners needed for more varied roles. Recruitment problem. No career structure for Practice Nurses. Nurses as Primary care Educators. NHS direct. May reduce burden on gps. Recent evidence shows nurses can effectively and safely manage minor illness. Nurse consultations are longer. Specialist nurses at “interface” eg CHD nurses locally / nurse prescribing / nurse autonomy but where does responsibility for errors lie?

    78. A 26 yr old man attends to ask you to delete his Hepatitis B Pos status from his medical record as he is concerned that it will compromise his life insurance and mortgage applications. How do you respond?

    Access and “ownership” of medical records / rights and autonomy of patient and of doctor / duty of care to self and society / can request advice from GMC or MDU/MPS / can look on www.abi.co.uk site. Can

    complete forms but indicate that pt has requested that you hold back information

Questions from the MRCGP viva November 2002 as remembered by the candidates

1.What do you understand by patient autonomy?

2.How can we find out if the LHB is working effectively?

3. In what circumstances would you practice outside evidence based medicine?

4. Where do you obtain your evidence from?

5.Tell me about a significant event analysis you have taken part in.

6.In what circumstances would you break confidentiality?

7. Are you a leader?

8.Tell me about a consultation model you use regularly.

9.How do you use non-verbal cues in a consultation?

10. What do you think are the main stresses on GPs?

11.You notice a partner smells of alcohol. What do you do ?

12.How would you recognise a dysfunctional consultation?

    13.Your practice nurse is telling patients not to have the MMR vaccine. What do you do?

14.How do you feel about your pts taking part in drug trials?

15.What are the ethical issues raised by screening?

16.What do you feel about drs as patients?

17.What types of consent do you encounter in GP ?

18.How do you deal with uncertainty?

19.How can the LHB monitor quality in practices?

20.What issues affect different referral rates between different GPs?

21.What forms of appraisal do you know of?

22.How do computers affect the consultation?

    23.A patient requests info re TOP be removed from her notes. What are the issues? Apply the ethical framework.

    24.A HIV +ve patient requests you do not inform his partner, who is also your patient. What are the issues?

    25.How would you facilitate change in your practice? The senior partner is very resistant.

26.Tell me about 3 medical internet sites you use regularly.

27. What types of team players can be involved in a team? (Know Belbin )

28.What do you think about lawyers?

    went on to doctors being sued / why are most GPs sued, how can you prevent this? Blame culture

    etc

    29. A young health man asks for a sick note as his wife is terminally ill. What do you say?

30. This question is about well informed patients. What are the implications?

    31. What do you do to reduce stress in colleagues - what do you do if you recognise this?

    32. A young man asks for injections to help build his upper body. What do you say?

    33. An Asian patient who has been your pt for many years brings in his father of 72 ( who got off the plane in Heathrow this morning and is being seen as a Temp Res)with severe abdominal pain. During the consultation it becomes apparent that the old gentleman has been told in India that he has a bowel cancer and needs surgery. What issues are raised?

34. Ethical questions on Drug Trials in GP with GP recruiting patients

35. What do you understand by “Professional values”

     How would you deal with an underperforming GP?

36. What are the implications of going off sick within a partnership?

37. Tell me your strengths and weaknesses SWOT analysis. What is it?

38. In what ways do doctors make pts ill?

39. What is a Young Principals Group for?

40.How is health advertised?

    How does General Practice here compare with America?

41.Should there be rationing in the NHS?

    How would you set up a group to ration - who would be on it?

42. Nurse Prescribing / Formularies

43. Men‟s Health: What are the major issues?

44. Chronic Disease Management. What are the major issues?

    45. National Service Frameworks. Tell me about one of the NSFs - Who / what / why / implications for Primary Care

    46. NICE. Tell me about a NICE Guideline that you read recently _ Who / what / why / implications for Primary Care

47. Delegation what factors are involved?

     Clear lines of responsibility / Training needs addressed / Protocols

    48. Patient information how do you give it in a consultation? Written info / literacy skills / comm. skills / clarity of info / Websites which are validated? / National Self Help groups / Diabetes UK fantastic / NHS Direct / Expert patients concept

    49. A partner requests a violent patient be removed from the list. - How should we look after violent patients?

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