Approach to RACGP Exam

It is almost exam time again. I am hoping that this website will provide some information on how to tackle the exam, and eventually help myself passing the exam.

The exam has three components:
1. Applied knowledge test (AKT)
2. Key Feature Problems (KFP0
3. OSCE

The followings are information about the fellowship exam and you can access this information from the Fellowship Exams Candidate Handbook

Applied knowledge test (AKT)

• To assess the breadth and application of contextual knowledge required for certification to enter unsupervised general practice.
• It contains 150 clinical questions with 2 questions types:
• Single best answer
• Extended matching questions 
• Multiple choice test conducted online for 4 hours.
• Held twice per year. 
• Must pass the AKR as a per-requisite to undertaking the OSCE. From 1January 2017, candidates must pass the AKT and KFP as a pre-requisite to undertaking the OSCE.

Key Feature Problems (KFP) 

• To assess clinical decision making skills in general practice cases 
• A key feature is a critical step in the resolution of a clinical problem in the context of everyday general practice. A KFT question consists of clinical case scenario followed by questions that focus only on those critical steps
• It contains 26 cases of equal value and 2 questions types 
• Write in questions (short answer questions)
• Completion questions (select responses from a list)
• Each question specifics how many responses candidates should provide. For 'write-in' questions candidates will receive a weighted reduction in score in the overall exam for all extra responses they provide. For 'completion' questions candidate will be penalised for extra responses.
• It is a 3 and 1/2 hr exam.

OSCE

• To assess applied knowledge, clinical reasoning, clinical skills, communication skills and professional attitudes in the context of consultations, patient exams and peer discussions. This is a clinical consulting performance assessment. 
• The OSCE includes 14 clinical cases of either 8 minutes or 19 minutes duration, with rest stations interspersed between the clinical stations. It takes around 4 hours to complete the exam. 
• The 8 minute consultation stations require candidates to focus on one or two aspects of a consultation, these consultation stations are not intended to represent whole consultations.
• The 19 minute consultation stations resemble standard general practice consultations and usually require the candidate to focus on a number of tasks.

Preparation for the exam

• RACGP Curriculum for Australian General Practice (RACGP Curriculum handbook) 
• Frequency and patterns of problems in general practice (BEACH. Here is the link to a decade of Australian general practice activity from 2005 to 2015)
• Pre-exam courses
• Check program (access available as a financial member of the college)
• gplearning (access available as a financial member of the college) 
• AKT and KFP online practice exams (available 1 month before the actual exam) 
• 2014 Thursday evening pre-exam tutorial series on DVD (Can borrow from John Murtagh library if you are a member of the RACGP) 
• Clinical Skills scenarios DVD - cases for GP educators or learners (The DVD can be purchased Here)

Some ideas on study topics using BEACH data:
Most frequently managed problems by categories
Most frequently managed problems from 2005 to 2015
Most frequently managed chronic problems from 2005 to 2015
Most Frequently prescribed medications from 2005 to 2015


Exam tips from various training providers and college:
Sturt Fleurieu exam tips 
Valley to coast GP training exam tips

Exam resources from the college:
Candidate handbook
RACGP Curriculum
Beach data

Approach to drug addiction

It is a common presentation in GP land. It is not as bad in the hospital system but once you step into GP practice. Every 5 patients, there is at least one person who is on opioid or benzo long term. How do we get to this stage ? What happened to our medical practice? The recent check program takes on addiction medicine and explores the complex issue of addiction. Personally, I think the best way to deal with this problem is to not prescribe benzodiazepam or morphine without a plan of stopping them.

Key points:

- In Australia, about sever million prescriptions for benzodiazepines are written each year. (7 million! This number is ridiculous) Of patients aged 65 years or older, 15% were prescribed at least one benzodiazepine. Of these, 45% were prescribed more than once and 15% of these for longer than six months.

- There is little evidence that long-term benzodiazepine use is effective for the management of insomnia, anxiety or depression, and other modalities have better effectiveness and safety.

- The effects of caffeine can be directly weakened by smoking. smokers traditionally drink more than twice as many caffeinated drinks as non-smokers.

Chronic Obstructive Airway disease management: 10 fast facts

COPD

10 Fast facts

1. COPD-X is the mneumonic for COPD management. 
1. C: Case finding and confirm diagnosis 
2. O: Optimising function: pharmacological and non pharmacological 
3. P: Prevention 
4. D: Develop a plan
5. X: management of exacerbation 
2. Screen adults over the age of 35 and smokes. Spirometry remains under utilised in GP. 
3. Definition of COPD : Post bronchodilation FEV1/FVC < 70 %
4. Chest x-ray has no diagnostic value but it helps to exclude other possible diagnosis
5. Stop smoking is the most effective strategy in treating COPD, other non pharmacological interventions should be offered to all other patients. 
6. Pharmacological treatment: please refer to step guided treatment. Bronchodilator should be started on anyone with Mild COPD. 
7. Only use ICS/LABA in mod to severe COPD as it increases the risk of pneumonia. 
8. Make sure patient has Flu Vax and Pneumococcal vaccine 
9. When it is appropriate, discuss advance care plan with them 
10. Prednisolone 50 mg x 5 days is good, any longer than that has no extra benefits 
11. Don't forget non pharmacological intervention: smoking cessation, pulmonary rehabilitation, nutrition, GP management, immunisation and exercise.

References:

- Lung fundation 

- COPD - X 

Approach to the eye

GPs are often asked to check the eyes. It is difficult. First, there are no formal trainings for GPs to deal with eye problems. Second, we don't have the equipments which are often required for a proper eye examination, such as a slit lamp.

This post is to deal with some of the common eye problems and emergencies which could present to GP clinic or appear in the exam. John Murtagh's general practice book has two chapters on this topic, sydney eye hospital published an eye manual on how to deal with common eye emergencies, victoria eye hospital also published 35 golden eye rules to help GPs.

This post may be a little bit long but I am hoping to make this the only post a GP registrar needs to read for the exam and daily practice.

As with most things in medicine, history and examination are the key. In Murtagh, there is a section called questions directed to specific symptoms. It is a bit too simplistic but give some basic structure to what questions need to be covered during history taking.

• Presence of floaters --> normal ageing (esp.>55) with posterior vitreous detachment or may indicate haemorrhages or choroiditis
• Flashing lights --> normal ageing with posterior vitreous detachment or indicates traction on the retina 
• Coloured haloes around lights --> glaucoma, cataract
• Zigzag lines --> migraine
• Vision worse at night or in dim light--> retinitis pigmentosa, hysteria, syphilitic retinitis
• Headache --> temporal arteritis, migraine, benign intracranial hypertension 
• Central scotomata --> macular disease, optic neuritis 
• Pain on moving eye --> retrobulbar neuritis
• Distortion, micropsia, macropsia --> macular degeneration 

Diseases/disorders to exclude or consider 

• DM
• Giant cell arteritis
• Hypopituitarism
• Cerebrovascular ischaemia/carotid artery stenosis
• MS
• Cardiac disease 
• Anaemia 
• Marfan syndrome (subluxated lenses) 
• Malignancy (the commonest cause of eye malignancy is melanoma of the choroid) 

Examination. In ophthalmology, there are three vital signs. Visual acuity, Pupils and Tonometry. I am not sure how many GP clinics have a tonometry (my clinic does not), so I have a very low threshold of referring people to ophthalmologist or optometrist. A proper examination should at least include the following:

• visual acuity 
• pupil reacitons 
• confrontation fields 
• colour vision 
• amsler grid 
• fundus examination with dilated pupil 

Common conditions that result in visual loss:

• Central retinal artery occlusion 
• Central retinal vein thrombosis
• Retinal detachment 
• Vitresous haemorrhage 
• Macula degeneration 
• Temporal arteritis 
• Retinal migraine 
• Posterior vitreous detachment
• Optic neuritis

Management of trauma

• hyphema

Common eye conditions that can cause red and tender eye :

• Conjunctivitis (bacterial, viral or allergic)
• Glaucoma
• Uveitis
• Corneal ulcer
• Herpes simplex keratitis
• Microbial keratitis (e.g. fungal, amoeba and bacterial)
• Herpes oster ophthalmicus
• Penetrating injury
• Endophthalmitis
• Orbital cellulitis 
• Scleritis/Episcleritis
• Blepharitis
• Foreign body 

Red Flags

• Beware of unilateral red eyes
• Irritated eyes are often dry
• Never use steroids if herpes simplex is suspected
• A penetrating eye injury is an emergency
• Consider an intra-ocular foreign body
• Beware of herpes zoster ophthalmic if the nose is involved
• Irregular pupils: think iritis, injury and surgery
• Never pad a discharging eye
• Refer patients with eyelid ulcers
• If there is a corneal abrasion look for a foreign body

References:

John Murtagh 

Sydney eye hospital: eye manual 

Victoria eye hospital: 35 golden eye rules 

Approach to doctors as patients

Why do doctors don't want to be patient or don't have a GP?
- embarrassment, concerns about confidentiality
- the culture of medicine is one of working through illness; an image of invincibility is encouraged and vulnerability is denied.

What are the pitfalls for the doctor treating a doctor patient?
- Treating the doctor - patient more as a colleague than a patient
- Having higher expectations for recovery, compliance and participation in treatment
- Corner may be cut in assessment, examination explanation and follow up as a result of the collegiate relationship

What other differences are there when you are looking after a doctor as patient?
- Ensure that your doctor patient is fit to work and is not putting patients at risk. If you think that he/she is unfit to work, you may have to report them to the relevant authority. This issue has to be handled carefully and reporting them to the relevant authority does not mean that they can't practice. It means that they may need to practice under certain condition.

References:
- http://www.gmc-uk.org/doctorswhoarepatientsjanuary2010.pdf_62126868.pdf

Approach to clinical errors

It has a detrimental effect on the treating doctor. Doctors often experience feeling of being incompetent, lost of confidence and fear. We are all fear of litigations but most patients are not out there to get us. Most of them only want good medical care and find out why the error occurr in the first place. I was told by one of my GP supervisors that it eventually comes down to trust. If the patient trusts you and you develop a good relationship with the patient, they will forgive you most of the time.

The following outlines my approach to clinical errors:
1. Acknowledge the mistake
2. Express regret or apologise that it has happened
3. Open disclosure of the event/incident
4. What can be done now ?

References:
- Check program: challenging clinical situations

Approach to aggressive patients

Dealing with angry/aggressive patients.

Is there any difference between anger and aggression?
- Anger is an emotion
- Aggression is a behaviour

What is your approach to angry patient?
- I adopt the RACGP check program approach, using the acronym LASSIE which stands for:

- L : listen
- A: Acknowledge, agree and apologise. It doesn't mean you need to agree with the other person but simply saying I am sorry that has happened to you may help to diffuse the situation
- S: separate. Bring the person to a quiet area
- S: Sit down. Aggression is more difficult in a sitting position
- I: indicate options. Provide options for patient to choose
- E: Encourage choice. Get the patient to choose what is available. Give him/her the feeling that they are in control

How would you follow up the patient?

- Patients often react very differently to GPs and receptionists but GPs can't function without the help with receptionist and other staff members. It is important that we protect them and discourage bad behaviour
- The issue needs to be brought up with the patient at the next appointment, re-stating the fact that this sort of behaviour is not acceptable and if it happens again, we may terminate the patient and doctor relationship. (From the check program, there is a behaviour contract template for GPs to use)

References:
check program

Approach to Scabies

key points:

1. Usually present with intense itching
2. Caused by Sarcoptes scabiei. The female mite burrows beneath the skin in order to lay eggs. The eggs hatch into tiny mites and spread out over the skin and live for only about 30 days
3. The mite antigen, in its excreta, causes a hypersensitivity rash.
4. Diagnosis is by microscopic examination of skin scrapings or by response to treatment
5. Usually spread through close contacts. Children need to be kept away from school until they complete the course of treatment.
6. According to therapeutic guideline, the treatment of choice is permethrin 5% leave on for at least 8 hours or benzyl benzoate for 24 hrs repeat after 1 week. Usually permethrin is better tolerated and less drying.
7. In kids less than 6 months, the current recommendation from therapeutic guideline is still permethrin 5 % but it also stated that permethrin is currently not licensed to be used for this purpose.
8. Other treatment for children under 6 months: sulphur 10%in white paraffin once daily for 2-3 days or chromatin 10% topically once daily for 2 -3 days
9. In immunocompromised patients, it can become crusted scabies, essentially means huge number of mites in the body known as norwegian scabies. Try to get expert opinion, treat with ivermectin 200 mcg/kg as a single dose plus topical treatment.

References:
John murtagh 5th edition
eTG

Treatment for head lice

Head lice is a common problem is school aged children.
GPs need to have an approach in dealing with this problem. Give clear instruction to parents of how to deal with it. Usually diagnosis is via clinical examination. Visualisation of nits and live lice in the hair is diagnostic.

Key points:

1. It is caused by the louse pediculus humanus capitis.
2. Patients can present with significant itching on the scalp and neck.
3. Wet combing: apply generous amount of hair conditioner and comb with fine toothed comb. The conditioner stunt the lice and stops them from crawling for 20 minutes. The method only has around 40 % successful rate.
4. permethrin 1% topically, leave for a minimum of 10 minutes; repeat treatment in 7 days (there are other treatment options, please see therapeutic guideline). Use the wet combing method the day after treatment to check for live lice. If live lice are found despite treatment, that means the lice are resistant to the product used.
5. In between treatments, use the wet combing method twice to remove all eggs less 1.5 cm from the scalp.
6. Wet combing should be repeated weekly for few weeks to ensure complete clearance.
7. Bed sheets and linens should be washed with hot water 60 degrees.
8. Treat all household members
9. Notify school but can still go to school after treatment
10. Treatment resistant: use a different product or ivermectin 200 mcg/kg as a single dose with fatty food, repeat in 7 days.

References:
- eTG
- John murtagh 5th edition

Approach to complaints

It is a difficult situation but almost unavoidable. We need an approach on how to deal with it at the exam and in real life.

We can essentially divide process of handling complaints into three steps:

First step: acknowledge injured feelings and investigate the complaint
Second step: explore options and consequences
Third step: resolving the issues 

First step: acknowledge injured feelings and investigate the complaint

• usually the clinic has a protocol in place to deal with complaints (e.g. third party involvement)
• It is important to take the complaint seriously and to give patient sufficient time to ventilate his/her concerns. 
• Remain calm
• Thank the patient for coming to discuss the issue, and acknowledge that the situation has caused her worry and concern. Demonstrate active listening by posture and verbal responses, and convey that you have understood by repeating, paraphrasing, clarifying and open ended inquiry.
• Make sure at the end of the consultation that the person receives a clear message that you are taking issue seriously and you will investigate. 

Second step: explore options and consequences

• Gather the facts: review notes, copies of reports etc. 
• If it is necessary, may need to contact MDO
• Arrange a meeting to explore what the patient wants
• provide the patient with the information you gather 
• Keeps patients informed about the investigation progress

Third step: resolving the issues 

• Clarify what will happen next 
• provide summary of what has happened so far
• explain if any changes or improvement will happen
• reach an agreement

References:
1. Check program: challenging consultations
2. Dealing with complaints by Avant

RACGP Exam

After studying and preparing for the exam for nearly 6 months, I have the chance to do an assessment today. It was a complete failure. I obviously neglected the OSCE component of the exam, so I didn't do well in the OSCE. My poor time management only left me around 15 minutes for around 10 questions in the KFP, so I needed to quickly rush through them and I don't I did well either.

After today's formative assessment, I identified some weaknesses in my knowledge:

1. Critical appraisal of journals
2. No structured approach to difficult patients e.g. angry patient, complaints against doctors
3. Poor time management
4. Poor understanding of endocrinology
5. Have not read the exam handbook
6. Does not know how to answer questions in KFP

Still has around 2 months to go. I will try to fill in those gaps before the AKT.