The general practice exam book
The
general practice
exam book
Kath O’Connor Robin Park Fabian Schwarz Tammra Warby Yashar Aliabadi Zadeh
The
general practice
exam book Kath O’Connor Robin Park Fabian Schwarz Tammra Warby Yashar Aliabadi Zadeh
Published by General Practice Registrars Australia Ltd Medical Editor: Dr Kath O’Connor Editor: Denese Warmington
The general practice exam book Disclaimer All efforts have been made to ensure that material presented in this publication was correct at the time of printing and published in good faith. GPRA does not accept liability for the use of information within this publication.
General Practice Registrars Australia Ltd Level 1, 517 Flinders Lane Melbourne Victoria 3001 ABN 60 108 076 704 © 2015 GPRA. All rights reserved. Except as expressly provided in the Copyright Act, no part of this publication may be reproduced, distributed, stored in any retrieval system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior written permission from the publisher, General Practice Registrars Australia Ltd. National Library of Australia Cataloguing-in-Publication entry Creator: O’Connor, Kath author, editor. Title: The general practice exam book / Kath O’Connor, Robin Park, Fabian Schwarz, Tammra Warby, Yashar Aliabadi Zadeh; medical editor: Dr Kath O’Connor; editor: Denese Warmington. ISBN: 9780992453619 (paperback) Subjects: Physicians (General practice)--Examinations, questions, etc. Medicine--Examinations, questions, etc. Medicine--Scholarships, fellowships, etc.--Australia. Medicine--Ability testing. Examinations--Study guides. Other Creators/Contributors: Park, Robin, author. Schwarz, Fabian, author. Warby, Tammra, author. Zadeh, Yashar Aliabadi, author. Warmington, Denese, editor. Dewey Number: 610.76 Publisher: General Practice Registrars Australia Ltd CEO: Sally Kincaid Medical Editor: Dr Kath O’Connor Editor: Denese Warmington Graphic Designer: Jason Farrugia Project Coordinator: Nicole Bonne Printed by McPherson’s Printing Group
Foreword The general practice exam book has been written to assist candidates preparing for Australian general practice fellowship exams. The sensible general advice provided is also applicable to candidates preparing for postgraduate family medicine exams in any country of the world. Practical advice includes the value of forming a study group and the importance of balancing study with work and family commitments. Using examples from The Royal Australian College of General Practitioners assessment components, the guide looks at common problems candidates face in both written and clinical exams and provides practical assistance to avoid common pitfalls. In addition, the guide provides invaluable practice questions and practice case scenarios to assist candidates in their exam preparation. There is also advice on what to do if you don’t succeed in passing the exams the first time around. I know from past experience that sometimes you need to attempt something more than once in order to achieve success. This is not uncommon in postgraduate medical exams and we can learn from our first attempts and then redouble our efforts to maximise the opportunities for success the next time around. I commend this guide to you, and I wish you every success in your own exams, and in your future career in general practice. Professor Michael Kidd AM President, World Organization of Family Doctors Past President, The Royal Australian College of General Practitioners Patron, General Practice Registrars Australia
Contents Preface Acknowledgements
III
Note to readers
V
Chapter 1. Planning and practicalities
1
Introduction
3
Preparing for general practice exams
5
Formulating a study plan
6
Study groups
10
Exam preparation courses
11
Online resources
11
Countdown to the exams
12
Where should I be six months before the written exams?
12
Where should I be 2–3 months before the written exams?
13
Where should I be 12 months before the clinical exams?
13
Where should I be three months before the clinical exams?
14
Where should I be one month before the clinical exams?
14
The day before each exam
14
On the day of each exam
14
Doctors under the Specialist Pathway Program
15
What to do if you fail one of the exams
17
Tip for success
18
Chapter 2. The Applied Knowledge Test
19
Introduction
21
Developing a study plan
22
On the day of the exam
23
How to perform well in the AKT
25
Single best answer MCQs
25
Extended match MCQs
27
Tips for success
F
I
29
Chapter 3. The Key Feature Problems exam
35
Introduction
37
Preparing for the exam
37
Developing a study plan
38
Putting in the practice
39
Resources for preparation
39
A suggested approach to the exam
39
Tips for success and common pitfalls
41
Chapter 4. The Objective Structured Clinical Exam
53
Introduction
55
Preparing for the exam
56
In your daily practice
56
Utilising resources
58
Communication skills
58
Study groups and clinical support
58
On the day of the exam
60
Tips for success
61
Approach to short cases
63
Approach to long cases
65
Chapter 5. Staying sane
69
Introduction
71
Staying grounded in the present moment
72
Staying physically healthy
75
Staying emotionally and spiritually healthy
76
Maintaining perspective
79
References – Chapters 1 to 5
81
Appendix 1. Applied Knowledge Test – practice questions
85
Appendix 2. Key Features Problems – practice cases
107
Appendix 3. Objective Structured Clinical Exam – practice case scenarios Appendix 4. Resources
149 233
H
Preface General Practice Registrars Australia is the peak voice for the next generation of general practitioners. General Practice Registrars Australia is a not-for-profit organisation representing medical students, prevocational doctors and general practice registrars by advocating for and supporting their journey to becoming a general practitioner. The general practice exam book is the result of a member-identified need for a relevant and accessible preparation resource to assist candidates preparing for Australian general practice fellowship exams. The general practice exam book was initiated and written by recently fellowed General Practice Registrars Australia members based on their own exam experiences. The book underwent a significant peer review process prior to publication. General Practice Registrars Australia is proud to support this initiative and the valuable addition it provides to the range of resources it produces to support future general practitioners at all stages of their general practice training.
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Acknowledgements Many people have contributed to the conception, planning, preparation and success of this publication. General Practice Registrars Australia would particularly like to thank the families of the authors for their patience and understanding, the case study authors, the supervisors who reviewed the case studies to ensure clinical accuracy, the educators who provided invaluable feedback, and the numerous colleagues whose appraisal of the content was critical to the integrity of this book. General Practice Registrars Australia would specifically like to thank the following people for their contribution: Dr Alex Harris
Dr Georgina Whiting
Dr Ashe Nicholas
Dr Jason Ong
Dr Chrystal Fong
Rachel Oommen
Dr David Chessor
Dr Sangeetha Bobba
Dr Eugene Wong
Dr Skye Boughen
Dr Fay Ferdinands
III
Note to readers While this book is intended to assist all candidates preparing to undertake general practice exams, much of the information contained within this book is tailored towards candidates in the Australian setting working toward Fellowship of The Royal Australian College of General Practitioners. It is important to acknowledge the bi-college nature of general practice training in Australia, with registrars also able to study toward Fellowship of the Australian College of Rural and Remote Medicine. While the content of this book will still be of relevance to the Australian College of Rural and Remote Medicine candidates, it is important to note that there are crucial differences in assessment between the two colleges. General Practice Registrars Australia continues to develop exam preparation resources for the Australian College of Rural and Remote Medicine candidates, which will be regularly updated on the General Practice Registrars Australia website. General Practice Registrars Australia highly recommends that all candidates consult the extensive exam information available on both college websites.
V
Chapter 1
Planning and practicalities
1
Written by Yashar Aliabadi Zadeh MBBS, FRACGP With contributions by Kath O’Connor, Robin Park, Fabian Schwarz and Tammra Warby
2
Chapter 1. Planning and practicalities
Introduction Congratulations on your decision to undertake general practice fellowship exams. These exams are an important step on the pathway to becoming a vocationally registered general practitioner. You may be aiming for The Royal Australian College of General Practitioners (RACGP) or the Australian College of Rural and Remote Medicine (ACRRM) fellowship, or sitting similar exams in a country other than Australia. Whatever your eventual goal, the resources in this book are designed to help you to maximise your learning in the art and science of being a general practitioner and to eventually succeed in your exams. You will also need to put in a fair bit of hard work, apply lots of common sense and work together with peers and educators to ensure your success. By choosing to train and work in general practice, you will be joining the ranks of a motivated, dedicated and highly educated group of people who care for patients in the context of their own diverse communities. It is a challenging and immensely rewarding role. We hope you enjoy the ride. General practice fellowship exams are designed to assess your readiness to work as a general practitioner in a safe and professional manner, and unsupervised. For the RACGP Fellowship this can be achieved by passing1: • the Applied Knowledge Test (AKT) • the Key Feature Problems exam (KFP), and • the Objective Structured Clinical Exam (OSCE).
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The general practice exam book
The AKT and KFP exam are both written exams (completed via a computer), aimed at assessing your medical knowledge (the AKT) and decision-making skills and clinical reasoning (the KFP exam). The OSCE is a practical exam with a focus on clinical skills. The AKT and the KFP exams are held several months prior to the OSCE. Candidates must pass the AKT in order to be eligible to sit the OSCE. However, candidates must also pass the KFP exam before they can practise unsupervised. You can enrol in all three exams at once or each section separately. You will be allocated to sit the exams at a venue in a major city or regional centre based on your preferences when you apply. However, there are limited numbers in each centre, so to avoid disappointment plan and book early. It is possible to sit the AKT and the KFP exam on the same day. Some candidates prefer to do this in order to get rid of two exams in one go! Others may find being under exam pressure for an entire day too physically and mentally challenging. Candidates in rural (particularly remote) areas have the option of applying to sit the AKT and KFP exam in a different location (this does not apply to the OSCE, which must be taken in a major city). Rules on this vary, so refer to the RACGP exam handbook.1 If you are pregnant or have special needs, make sure that this is addressed at the time of your exam enrolment. For the ACRRM Fellowship, assessment modalities have been ‘designed to provide candidates with a valid and reliable assessment of their knowledge, skills and attitudes that comprehensively reflects the educational outcomes of the training program and are relevant to the rural and remote context’.2 There are five summative assessments that must be passed in order to achieve fellowship of ACRRM2: • the Multiple Source Feedback (MSF), which assesses the candidate’s interpersonal and professional behavior, development and clinical skills • the Mini Clinical Evaluation Exercise (miniCEX), which assesses the candidate’s core skills in history taking and physical examination
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Chapter 1. Planning and practicalities
• the Multiple Choice Question (MCQ) exam, which provides an assessment of the candidate’s recall, reasoning and applied clinical knowledge. (The MCQ is similar to the RACGP AKT in that a single best answer is chosen for each question) • the Structured Assessment using Multiple Patient Scenarios (StAMPs) – a traditional viva vocé exam – where candidates have the opportunity to explain what they do and demonstrate their clinical reasoning • the Procedural Skills Logbook, which assesses the candidate’s key procedural skills at the level of competency required for independent rural and remote practice. Candidates must also obtain a Pass grade in each of the assessments of their chosen Advanced Specialised Training Discipline. More detail regarding the AKT, the KFP exam and the OSCE is available in Chapters 2, 3 and 4. For more detail regarding ACRRM Fellowship exams, please see the ACRRM Handbook for Fellowship Assessment.2
Preparing for general practice exams Generally speaking, the earlier in your general practice training you become ‘exam orientated’ the better. Having a structured plan for exam preparation across the duration of your training will not only improve your exam performance, but will also reduce stress and give you a feeling that you are in control of both your training and the exams. It is important to remember that the exams are designed to assess your ability to practise safely as a general practitioner. As such, your direct general practice experience in the clinic is central to both passing exams and emerging as a capable, safe general practitioner. Preparation for both starts from day one with a safe and evidencebased approach to whatever is seen in your everyday consultations. Make your daily clinical routine a core part of your exam preparation.
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The general practice exam book
You can attempt the exam after 12 months of clinical work if your training provider believes you are ready. This means that within a standard vocational training time of 24 months, you will have three opportunities to sit the exam. Some candidates prefer to sit the exam in their third general practice term because this allows for a second attempt in the fourth term if unsuccessful. However, your choice about when to start studying will be individual depending on your work commitments and life plans. It can be helpful to use the first few months of training to settle into the rhythm of general practice, to learn about how the system works (especially for overseas trained doctors where the system may be very different to what you are used to) and to identify your study needs. As you see patients in the clinic, it can be helpful to note down any areas you were less confident in managing and why. This will help you to formulate a study plan. Also, discussing patients with your supervisor can help you develop management plans with a focus on the key features of the case. This can be helpful for getting your mind in gear for the KFP exam (see Chapter 3).
Formulating a study plan In order to succeed in your general practice exams you need to put some thought into how and what to study. Over time, most medical practitioners develop special interests and, as a result, may be more proficient in these areas while other areas may be overlooked. This may also occur due to the type of practice and the demographic of the patients an individual doctor sees. It is important to ascertain your own areas of interest and focus. The brain tends to naturally like the familiar, which can result in studying more in the areas that we are already familiar with and less in the less familiar areas. One way to make sure you are studying efficiently is to carefully plan your study with equal attention to all general practice related topics. In the Australian setting, the RACGP general practice exams are structured
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Chapter 1. Planning and practicalities
using the Bettering the Evaluation and Care of Health (BEACH) study data.3 The BEACH study, a continuous study of clinical activity in Australian general practice, has been running for over 30 years and has collected data from over 100 000 patient encounters. The RACGP uses BEACH data to help determine what proportion of the exam should be allocated to each clinical topic (eg. cardiology or paediatrics) so that it accurately reflects the common presenting problems encountered in Australian general practice. Importantly, the general practice exams also have a focus on patient safety and the emergency presentations that general practitioners encounter rarely, but must know how to manage. For ACRRM candidates, assessments are based on a broad curriculum and cover areas that are beyond the scope of the BEACH data, including anaesthetics, obstetrics, palliative care, and emergency and hospital care. It is important to note that in order to pass the exams, candidates are required to have an acceptable range of knowledge and clinical skills in order to practise safely and effectively across the full range of general practice presentations. You do not need to be outstanding in all areas, or even in some areas. The RACGP Curriculum for Australian General Practice4 bases lifelong teaching and learning on five domains. These domains can help you to work out the breadth (and limits) of required knowledge on a given topic. These domains are outlined in Table 1. In the rural setting, ACRRM adds to these traditional domains with the seven domains of rural and remote practice. These domains are outlined in Table 2.5 See Table 3 for a list of tasks to help you formulate a suitable study plan. Once you have developed a list of topics, each topic can be given a timeframe within your overall study plan, depending on its weighting in BEACH, and including a focus on patient safety and important emergency presentations. The actual timeframe will vary for each
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The general practice exam book
candidate, depending on other commitments, the type of study done and how fast it takes to assimilate the information. Depending on how much time you have at work or after seeing patients, you should also try to use your patients to direct your study. For example, a patient with chronic obstructive pulmonary disease (COPD) is the perfect opportunity to review your approach using the COPD-X guidelines.6 Reinforcing your study with actual cases will always enhance your ability to retain and recall information.
Table 1. The five domains of general practice according to the RACGP curriculum4
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Domain 1
Communication skills and the patient-doctor relationship (eg. communication skills, patient centredness, health promotion, whole-person care)
Domain 2
Applied professional knowledge and skills (eg. physical examination and procedural skills, medical conditions, decision making)
Domain 3
Population health and the context of general practice (eg. epidemiology, public health, prevention, family influence on health, resources)
Domain 4
Professional and ethical role (eg. duty of care, standards, self appraisal, teacher role, research, self care, networks)
Domain 5
Organisational and legal dimensions (eg. information technology, records, reporting, confidentiality, practice management)
Chapter 1. Planning and practicalities
Table 2. The seven domains of rural and remote practice according to the ACRRM curriculum5 Domain 1
Provide medical care in the ambulatory and community setting
Domain 2
Provide care in the hospital setting
Domain 3
Respond to medical emergencies
Domain 4
Apply a population health approach
Domain 5
Address the health care needs of culturally diverse and disadvantaged groups
Domain 6
Practise medicine within an ethical, intellectual and professional framework
Domain 7
Practise medicine in the rural and remote context
Table 3. Tasks to help you formulate a study plan Look at the BEACH data and brainstorm the common general practice presentations that fall into each category. You may find it helpful to do this with a study group Compare your list of presentations to your college curriculum. Ensure that you haven’t missed any key areas Look at sample case questions for common general practice presentations. These are available on the GPRA website and in the appendices of this book Ask yourself: What are my weakest areas and how should I fill the gap? Sit a mock exam with your college or training provider and then review the report. If you don’t feel comfortable with a particular case, this is a sign that you need to do more work in that area
Consider how much time daily or weekly you can devote to your study and what times of the day or night suit you best. Look for times when you will get minimal interruptions and are unlikely to have other commitments. For example, you could start with 1–2 hours a day in the evenings on
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The general practice exam book
five days of the week, or two 3-hour sessions on a weekend. The time you spend studying can then be increased as you get into the swing of things. Another approach is to be less time-based and more goal focused, such as reading an article a day or a guideline a week. It is important to give some thought to the available educational resources that would suit your study style. There is no use reading volumes of information if you are a visual learner who would do better with a slideshow of pictures and shorter amount of written words. Similarly, you might do better with podcasts you can play on the drive to work if you are more of an aural learner, or YouTube™ videos if you are more of a visual learner. While everyone learns differently, one helpful strategy may be to develop a bank of concise notes on important general practice topics. The process can help with committing key areas to memory and the notes can then be a useful tool for reviewing topics prior to the exams. Notes should not be so detailed as to resemble a textbook in volume, and not so brief as to miss important study points. Your note-taking system should be portable and allow you to add notes to your existing file at any time. There are many devices and software applications available to help you to do this, or the good old-fashioned way of using paper and pen! See what works best for you.
Study groups It is highly recommended that you organise a study group of between 3–6 candidates (assuming not everyone will be able to make every session). A study group will keep you motivated and on-track and is particularly important for OSCE preparation. Most groups meet once a week. The format will differ depending on which exam you are preparing for at the time. Using Skype™ might be an option for those living in an isolated or remote area. Some candidates find it helpful to network via GPRA or their training provider to set up a study group, particularly those in rural or remote areas.
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Chapter 1. Planning and practicalities
Exam preparation courses Exam preparation courses run by GPRA, the colleges or your training provider can be extremely helpful. These courses offer an opportunity to learn more about the exam format, what will happen on the day, and to attempt a practice exam. This can help you to gauge how you are going and help you to direct your study better.
Online resources • ACRRM provides online support, including mock exams, for candidates undertaking the StAMPS. • GPRA offers support via their website, with a great list of clinical cases, hints, tips and webinars. They can also put you in touch with people who have recently sat the exams to find out what their experience was like. • The RACGP website offers Exam Support Online for candidates leading up to the exam. • Your training provider may also provide online exam resources. See Appendix 4 for links to all these programs. Appendix 4 also provides a comprehensive list of resources and links that may be helpful in preparing for the general practice exams covered in this book.
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