Swansea Bay VTS MRCGP Oral Exam sample questions Updated B.

.Weatherill 9/8/05 Dont 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 isnt 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 ? Idiots Guide to the Ethical Framework ! A B C D E is for AUTONOMY apply to patient and doctor is for BENIFICENCE (non malificence) do no harm to yourself / pt / society is for CONFIDENTIALITY must be respected but in certain circumstances can be broken is for DUTY duty of care to self / to patient / to colleagues in profession / to society 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 helprejecter / 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 Jehovahs 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. Whats 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. Cant 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 wont 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. Societydr has a duty to protect society from false claims. GPs have lowest sickness rates in the country paradox of certificationcould 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 / coroners 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 dont 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. ( Wheres 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 wouldnt 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 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. Mens 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? 50. What as a GP are your (doctors own) boundaries as regards your patients? 1. Comment on the quality of the BJGP as a journal. What could be done to improve it? 2. Care of patients. - How do you deal with antibiotic expectations? - Angry patient with sore throat. 3. If you are going to replace someone who is retiring what challenges will you meet? SWOT analysis. What is it?

4. Paperless practice - what factors will you face? 5. Women of 50 have been advised to attend for a routine mammography. What issues arise? Conflicting evidence - WHO guidance that at present mammography is helpful. What are the stages in your mind regarding the decision? What fear may she have re mammography? Do you think that mammography is an effective screening disease? 6. How do you feel that we should measure quality in Primary Care? 7. A patient phones at the end of surgery/day and says she has been on the Atkins diet for 1/12 and lost 1 stone. She is worried that her friends in work said it was dangerous. Advise. There are 100,000 people in this diet.

8. The doctors role in society has changed a lot over the last 20 years. How do you think this influences our relationships with patients? 9. 50 year old man - 2 uncles have AAA 20. - Patient wants advice - Health beliefs / PMHx - What does he understand by AAA Puns and Dens Scan comes back with 4cm aneurysm. What do you do? 10. Small group practice, after audit you find 1 doctor has prescribed 3x antidepressants to every one else. Why? - Doctor may see more depressed patients than everyone else - GIPSI, over prescribing Do you prescribe antidepressants for everyone? Explain - other options - counsellor - anti depressant - complimentary medicine - ref to psychiatrist. How do you stratify depression. What people are more likely to commit suicide. 11. How should GPs decide when to practice defensive medicine? What is the difference between defensive medicine and good clinical practice. Ethical issues & framework 12. Your practice has just been asked to take undergraduate training. What are the issues? 13. Practice nurse says she would like you to prescribe Vit C to everyone with a leg ulcer. How do you react? - Would prefer to r/v evidence, ask nurse to go over evidence Discuss over lunch with practice. How would you search the evidence? - Trip database - BMJ.com - Cochrane -Medline Bandolier. There is no evidence but nurse is adamant. What issues/problems does this raise? 14. Partner says we need a practice web site, what goes through your mind? 15. Partner and his wife are patients. She comes in and says: Hes never at home /and he is always distracted She is angry and feels it is you who is never at the practice that means her husband works hard. You know this is not true. How do you react? 16. What are your views on attending patients funerals? 17. You are approached by a newspaper for an interview. How do you respond? 18. At the end of the consultation a little old lady gives you 1000 -how do you react? 19. A heroin addict asking for sick note for which your partner has written stress / anxiety on the note when he is really detoxing. How does this influence your decision if he is a bus driver? 20. What do you understand as a " hidden agenda" ? - how do you recognise one? Change management cycle - Change - not interested - pre-contemplation - contemplating change lets have a go. 21. The practice manager has been doing blood tests on herself and family members who are not in your practice. What are the issues? How do you deal with the patient who in requesting the inappropriate housecall? The woman appears to be drunk Does this alter your MX? 22. How would you react to your partner wanting to bring a dog to work?

23. A heroin addict asking for sick note for which your partner has written stress / anxiety on the note when he is really detoxing. How does this influence your decision if he is a bus driver? 24. A patient writes in to complain they had to wait 3 weeks to see you. How do you feel 25.One of practice nurses decides she wants to train as nurse practitioner - what are the issues - what can a nurse practitioner do that a nurse can't? Do you think that NP may be a threat to GPs? October 2003 Llinos 1. The usual....what do you do if your colleague comes in to work smelling of alcohol? 2. How would you react if one of your patients asked you to give a talk to the community about a medical topic? 3. What would your reaction be if a father phoned to ask if you could inform him of every surgery visit his children made? 4. How would you feel if a friend of yours was your patient? 5. When would you ever consider deleting information from patients notes? (Different scenarios bombarded) 6. What are the disadvantages of not seeing drug reps? 7. How do you implement change in practice? What is a dysfunctional meeting? 8. How would you set up a Living Will? 9. Would you dish out medication to a friend?.....diclofenac?....prozac? What's the difference? October 2003 1. MODELS: What is your favourite model? Explain summarizing in model What do you learn for Pts? How well do you think you manage chronic disease? Practice website pros & cons Prescribing non-licensed drugs e.g. consultant letter asking you to prescribe amandene for childs warts what do you do? what do I think of sabatticals? Dr wanting to go surfing for 3/12 What is my PDP How do I identify my learning needs? Voting in practice meeting. Difference between consensus and Majority voting. Son asks for cholesterol lowering tablets for father - ? issues Father moves abroad requesting medicine for 9/12 to take abroad. Mother attends baby clinic, refusing MMR. What are the issues? You are asked by a local TV station to do a regular 10 min slot. What are the issues? Do you always admit a mistake to a patient? A member of staff reports one of your partners has been smelling of alcohol over the past month how do you deal with this? What are the issues raised by GPs with specialised interest?

Do you think GPs should be involved in the treatment of drug abuse patients and what issues are raised? Oct 03 cont What consultation concepts do you make use of during the consultation? A male patient becomes angry and aggressive during the course of the consultation. Which model of consultation would be most appropriate?

In 1990 Calman suggested that rationing be included in the Hippocratic oath. What are your views on this? What do you read? 3 sources of information. Do you read everything? How do you decide? Do you run a critical analysis of papers is important? Why not just use Cochrane database etc. What article have you read recently changed practice. A group of patients approach you and want to set up a patient participation group. What are the implications? They want to help the elderly in the area with support groups, shopping etc. implications. What are the practicalities/implications of converting to a paperless practice? What about reluctant senior partner? A patient telephones requesting a home visit for a toddler having spoken to your partner half and hour ago who decided a home visit was not needed. What issues does this raise? How will you deal with it? You decide to visit and the child is dehydrated and needs hospital admission. How will I proceed? How will my partner feel? How will I address this? What do you understand by the term multidisciplinary training. What are the pros and cons? How do you set an Agenda for learning needs over the next 6 months. What do you think could be done to aid recruitment retention in the NHS. Got around to discussing New contract what do you feel specifically about the out of hours proposal? Ethics + rationing together in same questions. What ethical framework. Specifically What do you feel about justice in the context of rationing? Drugs + rationing. When is it OK and when not? Discuss communication with a non English speaking patient. What issues does this raise? How do you feel about interpreters? How does this affect consultation. What do you feel about using a child as an interpreter? How would you modify your consultation technique to ensure you had all the facts. A 14 year old boy attends surgery asking for a medical to clear him to box. How would do you feel about this? How would you go about setting up help for young people in the community? Who would you involve? Senior Partner (or New partner) offers you a joint. What issues are raised? Should be encourage telephone consultations? You visit an elderly patient with dementia in a Nursing Home who has pneumonia. What issues does this raise? What do you think about league tables for General Practice? You think one of your partners is stressed. How do you address this? You find that one of your partners is prescribing 3 times as much amphetamines as your other partners. How do you approach this issue? A 14 year old girl comes to see you unaccompanied she is depressed. What issues arise? Would you treat her? 1) Discuss the changing role of nurses in primary care. (went into nurse practitioners, nurse prescribing, nurse triage etc) 2) What do you understand by the terms "personal development plan" and "practice development plan"?..... Why should be bother with these things?..... What are the challenges of forming a practice development plan? 3) Your senior partner is telling patients not to have the MMR as it is "harmful". How would you approach this situation? 4) A married man tests positive for chlamydia. What would you do? ( went into consultation skills, confidentiality issues, when can you break a pts confidentiality etc) 5) A taxi driver has a raised GGT. How would you approach this situation?.........During the consultaion you notice that he smells strongly of alcohol. On leaving the room he forgets his car keys, then comes back in to ask for them. What would you do now? (went into consultation skills, defusing potentially volatile situations, DVLA notification, acting in best interest of society etc)

6) A depressed patient that you have been seeing commits suicide. How would you feel?..... What do you understand by the term "significant event analysis" and how could it apply to this situation? 7) An old man has an infected leg ulcer which is not responding to oral antibiotics, but he refuses to be admitted saying he "would rather die than go to hospital". What would you do in this situation?...............2 days later he is confused and more unwell. What would you do now? (went into ethical priciples, esp autonomy, also competence and how to assess it etc) 8) Which consultation model do you use most often in practice. Tell me the negative points about this model.................If you could give one piece of advice to hospital Drs about consultation skills, what would it be?

Vivas June 04. 1. Issues surrounding gift of 100 by patient. 2. How to assess competence of 15 yr old asking for MAP. led to child protection procedures. 3. A patient with CHD refuses to take statin - how do you deal with the issues arising. 4. Are GPs political and how. 5. What quality markers should be published? Who decides? What happens if you are below nations targets? led to NICE/EBM 6. Transactional analysis and transference??? 7. Do you dislike your patients and how do you deal with it.
1) Partner has a complaint made against them. How do you manage this situation? 2) How do I feel about research in GP. Went on to talk about drug company sponsorship etc. 3) Your practice decides to introduce advance access. How do you go about it? 4) What is the difference between consent in primary and secondary care? 5) A new patient wants to see his medical records so he can sue his previous GP. How do you manage this situation? Went on to say there is a letter saying he has a personality disorder - do you take it out and do you tell him you've taken a letter out. 6) How do you know if you're a good prescriber? 7) An Asian woman wants a TOP note removed from her records as she is moving to a practice that is run by a family friend and the note will definitely not be kept confidential. What do you do? 8) You leave a patient in your room to get something and return to find the patient doing through your drawers. How do you handle the situation? Also asked if you off-list him do you tell his new practice what happened? 9) Tell me about the advantages and disadvantages of seeing drug reps. 10) A nurse injects a baby with the wrong medication. No harm done. How do you handle it. Do you invite the parent to the significant event meeting. You've implemented change and the same thing happens again. She is also underperforming in other areas. What do you do now?
1. How do you communicate with a deaf patient. then went into using a sign language interpreter, how do you know all the info gets through? 2. Notice a colleague made a simple but potentially serious mistake, how do you deal with that? What if it's a locum? e.g locum won't prescribe more than 5mg warfarin. Who do you report to? How does the NCAA assess doctors (has a suitably blank expression at that moment in time!) 3. When do you off list patients. if violent does it make a difference if mental health problem? 4. Home visit to 2 month old baby, mum obviously drunk. what do you do. 5. Neighbour asks you to treat their child. went into duty of care etc.. 6. Someone in practice wants to ban email as a means of communication between people. how do you

decide. how confidential is it. otherwise of communicating. 7. You receive a complaint about your communication in a consultation. how do you feel. what do you do. went into dealing with complaints, and how can assess own communication and improve. 8. Good old favourite- visit to 75yr old man terminally ill- asks for euthanasia. PAS week later asks for 5 boxes of MST - wanted answer if would prescribe 5 boxes or not. 9. Positive aspects of smoking!. went into tax. Then health beliefs model (again blank expression and unfortunately was the same examiner!). Cycle of change. how do you assess where someone is on cycle of change. 10. Partner wants to take 3 month sabbatical. issues. what if for sailing holiday not medical. Again pushed for my opinion- yes or no. went into how decide- practice agreement/ voting etc.. 1) 25 year old with breast lump refuses referral/treatment - issues/implications/what to do etc/what consultation model? 2) Mother of 24 year old mentally handicapped patient wants her to be sterilised as shes sexually active issues/implications etc and your final decision 3) Occupational hazards of being a GP. If you were boss of NHS how could you reduce burnout. 4) Pros and cons of a practice website - went onto advertising on the site/?sponsored site 5) Drug reps etc. Pharmaceutical company nurses offers clinics at your practice -implications/pros/cons/etc etc etc etc etc. 6) Your 55 year old practice partner seems muddled,what do you do? (then twist and turn ad nauseum) 7) What do we do for our patients? (bit of a metaphysical one that) 8) Your practice nurse gives saline instead of MMR.what happens now? Then she does it again what happens NOW? 9) Whats your opinion of a Practice Development Plan? Went onto practice meetings/leadership etc The police are asking about information on a patient they would like to question. What do you do? Onto confidentiality/responsibility to society etc.

1.) A lady arrives with 2 children and wants blood tests for coeliac disease because her brother has been diagnosed with it. What do you do ,do you test the children? 2.)A patient you diagnose with IBS is subsequently diagnosed with bowel cancer,how is your practice affected? 3.) How do you improve general practice recruitment?, should clinical , lifestyle status or ? be the main thrust of your recruitment drive? I mentioned consultants (old school ) denegrating general practice so they asked how this can be changed? 4.)How do you use your consulting skills to deal with the non compliant patient? 5.) A 3 year old child is brought in to see you at 5 to six on a friday(always late on a friday- it must have been a busy one since every scenario was at that time), by his grandmother who is convinced that he is b eing abused by her son inlaw whom she actively dislikes, he has 1 small bruise on his arm. How do you respond., note no other problems in his notes, normal growth and development, no previous fractures and no prev cause for concern. 6.)How do you use your consulting skills (not models) to deal with a heart sink patient and when will you use a doctor centred approach as `opposed to a patient centred approach.?

7.)You are asked to speak to a patient interest group from your patients about OOH's under the new system, lead to them presenting you with a petition of 10000 patients wanting the old out of hours system returned how and what do you do and say? 8.)Your practice nurse asks you for a reference for a new job, You have had cause to give her a number of warnings`with respect to her clinical competance ,what do you include in her reference.? 9.)You are put in charge of training in the practice, who should be included and how do you establish the educational needs of your practice members , not the doctors? 1/ house visit to a patient who has taken 50 paracetamol for back pain what are the issues? then she refuses admission.
2/ physiotherapist asks you, as a GP, to teach her consultation skills. do you do it or not? 3/ whilst filling up petrol you hear that a child you know has been sexually abused by another person you know. what do you do? what if they were your patients? 4/ doctors as patients. issues from this. family and friends as patients. 5/ practice nurses. changing roles of nurses. 6/ 48 hour access and how to implement changes.

1.Can you explain the placebo effect, when would you use it? 2.You are visiting a two month old baby and realise that her mother is drunk, what do you do? 3.What are the disadvantages of appraisal process, what made doctors realise there is a need for appraisal and revalidation? 4.When would you offlist a patient? 5.Ethical issues for the patients in the new contract 6.Health issues for teenagers, how to encourage teenagers to come to see a doctor? 7.Your practice nurse is complaining about one of the senior partners, how do you respond? 9.Do you think that doctors should be dressed in a certain way, what are the implications, what have you read about it? 10.Sixty year old lady is coming to see you after viral illness requesting a prescription for multivitamins to reduce her tiredness, do you prescribe? 11. Your senior partner is suffering from burnout what do you do? You hear from another person that your new partner has an alcohol problem how do you proceed? What are the pros and cons of a practice website? What are the implications of a 17 yr old child coming to see you alone? What are the advantages of publishing the practice audit results to patients? Should patients be involved in a doctors revalidation process? What are the Occupational hazards of being a GP? How do you prevent burnout? What factors influence your prescribing of a new drug? Influence of drug reps / cost benefit analysis What can you learn from patients? What are expert patients? How do you identify and prioritise learning needs? A pt asks you to prescribe a drug in their daughters name so that they dont have to pay. How do you respond? A pt makes a complaint about a locum in the practice. How do you deal with this? 1. What do you understand by the term 'patient-centredness' and how do you facilitate.. advantages and disadvantages of this 2. 85yr old man diagnosed with Cancer, family dont want you to tell him what do you do.. went into capacity / confidentiality / automomy etc

3. question about practce development plans - cant remember exactly but went into resources/rationing.. bit on how do you know you are providing a good service.. 4. How does the way GP's dress affect their practise / communication etc 5. Should the government offer Single vaccine for MMR (I thought this was dead and buried - obviously not!!) went into expalining risk to patients 6. How would you define 'heartsinks' strategies for coping / consultation models 7. Patient joins practice on Methadone programme.. how do you react. (Ethical principles).. someone comments that they have seen hanging around school, what do you do? child becomes unwell what to you do?? went on and on. breaking confidentiality 8. Patients ask practice to publish figures on diabetic clinic do they can compare which practise to choose. Ethical issues surrounding this. bit on patient groups and 'choice' 1. A lady comes requesting yearly smears, discuss issues. He then lead onto rationing. 2. Child with recurrent headaches mum insisting on head scan discuss 3. You find out one of your partners is reg smoking cannabis, discuss issues 4. Are you a good prescriber 5. Asked something like should you publish your audit results to patients. Also about website qualities, should there be internet access in practice 6. elderly patient with frac femur refusing to into hospital 7.Patient ask you to get involved in protest about the proposed closing of local gynae oncology department June 2005 Viva questions

What factors might influence a doctor to go off sick? Evidence-based medicine how do you use it? Can you think of a recent paper where the evidence has influenced your practice? (Million Women given as answer) How would you persuade your colleagues to change their prescribing? How can you assess any changes made? Your female senior partner is a big fan of HRT, she thinks its fantastic & doesnt want to change her prescribing of HRT how might you deal with this? What if she still wont change? A 14 year old girl attends your surgery asking for a prescription for the combined oral contraceptive pill what issues does this raise? Now a 14 year old girl attends your surgery asking for a termination of pregnancy is this different? What if her parents disagree?

You take a phone call from a nursing home regarding one of your patients. The chiropodist has attended to cut her toenails but when he attempts to do this she screams & becomes unco-operative. They are asking for you to sedate her to allow the chiropodist to cut her toenails. What would you do? A man attends your surgery for the result of his PSA test which was 84 how would you deal with this? How do you discuss risk with patients? What level of risk do you think we should tell patients about? Do you think doctors are good at communicating risk? So, a lady attends with her young child who has a sticky eye. You consider prescribing chloramphenicol ointment what do you tell mum about risk?

smelly staff nurse... benefits/disadv of employing salaried GP vs partner how do you as a patient choose which surgery to register at? old lady in nursing home has a cva how do you decide what to do with her?...er ...ask her...lead on to competence and ethical framework etc patients ask you to do a talk on the new GMS to them -would you? drug company wants to sponsor an info leaflet of the practice-would you be up for that?

an elderly lady has been dishing out tenners to your snr partner each week
for yrs to give to his little cherubs - you do a housecall and she wants to give you a tenner now - what do you do?

1) Discussion on benefits of doing out of hours- how would I persuade someone to do it 2) Practice nurse having complaints- how would I deal with this 3) GP as a career- benefits vs hospital work. How do I see the future of GP developing 4) Prescribing unlicensed drugs- how would I decide what to do What are the occupational Hazards of being a GP?......burnout etc A patient of yours is moving surgery and wants her TOP deleted from the record. Her new GP is her father in law to be..... How do you handle a complaint about a locum in your practice?...issues re employing locums etc, assessing colleagues...reporting to GMS etc.. Do you talk to a drug rep who visits your practice?......do you let them provide a nurse....issues re drug companies.....etc A wealthy patient wants to communicate with you by email only.Do you agree?issues re net,IT,consultation models,confidentiality and styles A patient taking OTC aspirin wants plavix prescribed as she has heard on the news that it is better. What do you say?issues re communication risk,rationing, media ,education of patients, consultation styles etc A muslim couple want their 6 months old child referred for circumcision. How do you respond?ethics/What about female circumcision? A senior partner sits on the LHB. What issues does this rise?

The Government is encouraging increasing no.s of GPSIs. How do you feel about this......nurse practitioners.... A girl comes to you after having had a diagnosis of optic neuritis whilst on holiday. How would you handle this consultation? The mother of a 20 year old schizophrenic asks you to change her sons rpt medication from tablets to liquid as it is easier to hide in his food - what are the implications of this? You are asked to give a talk to school kids. What do you want to know? You notice that a woman had a smear 6mths ago which showed CIN 3 . This wasnt followed up by the practice - what do you do? Do you think appraisal is a good means of assessment for revalidation. A fork lift driver is having hypos frequently which he's not aware of. What do you do. ( NB driving on private land) A patient asks your opinion on acupuncture. What do you say. How would you feel if a partner in your two man practice wanted to do it. Is it ever ok to have sex with your patients? A 20 year old girl says that she was having sex with a partner at a neighbouring practive in exchange for diazepam scripts. What do you do? A doctor with back pain approaches you and asks to be pushed up the list for physio. Would you? The Government is encouraging increasing no.s of GPSIs. How do you feel about this......nurse practitioners.... A girl comes to you after having had a diagnosis of optic neuritis whilst on holiday. How would you handle this consultation?
1) How do patients assess quality in the community? 2) What would you do if you went to do a house call on a mother of a 4 week old baby, and the mother smells of alcohol. 3) How do we use ethical principles in day to day practice - give examples. 4) What place does PSA screening have/ how would you address the patients concerns about psa screening? 5) How would you react to being asked to give a talk to a patient group? What are the pros and cons. 6)What roles are required in meetings. Leadership skills brought into it. They were also interested in the importance and role of the chairperson. 7) What sort of mistakes would you bring to a significant event analysis?

1. Does EBM make a difference 2. How do you choose between different guidelines 3. A nursing home staff complains about a patient being disruptive at night, and asks for some sedation to put in their tea - how do you respond 4. Which consultation model do you use 5. A patient asks for a sick note because a friend has dies who had no family, and wants time to make the funeral arrangements. What do you do. 1) Difference between compliance and concordance. How they can be improved?? 2) Scenario - family member of an elderly pt requesting tx for Dementia / Alzheimers dx. Would u prescribe it?? what are the issues?

3) Husband diagnosed with chlamydia wants u to test wife ( who is coming down for cervical smear in 1 wk ) for chlamydia. been involved in extramarital relationship. he is not keen on breaking the news himself. what do u do 4) Funding issues - allocation of resources/ league tables/quality controll etc 5) Change- how u bring about / why ?? 6) Pts hidden agenda, why they may not be forthcoming with information, how to tell if not telling the truth. 7) Deprived area - how to bring about new Drs 8) Classic scenario - Pt depressed wants to die - issues / management etc 1. You are involved with drug testing at the local school. One of your tests comes back positive - what would you do?.....What if the child was one of your patients? 2. Do doctors have any health needs? 3. How do you feel when you see a doctor as a patient? 4. Your patient participation group wants you to open until 9pm. What do you do? What do you tell them? 5. How do you feel about data concerning your practice being made available to patients? Led on to the pros and cons of league tables. 6. Your suspect that your practice manager is underperforming. How would you assess this? I. How would you bring a new idea to your practice? What would you do first? Mentioned teamworking Belbin etc 2. You notice one of your partners is constantly late for afternoon surgery. One of the receptionists comments that he is smelling of alcohol. What do you do? He says he has been going out for lunch with drug reps. What issues does this raise9 lie refuses to change his behaviour. Who can you turn to for help/advice? 3. How can you best influence obese patients to lose weight? Who in practice can be utilised for anti-obesity advice? Who is best at it? What services could you offer? How would you advertise these? 4. A patient is going for a new job wants you to delete an episode of depression from his summary. What do you do? Episode was 10 years ago following the death of his father. Needed antidepressants for 6 months. No episodes since. Does this change your view9 Patient insistent if record not amended will not get job, and is desperate for mortgage, bills etc. 5. A 14 year old girl attends alone wanting contraception. What are the issues? What further things would worry you? (ie abuse / underage sex) 6. Practice patient group wants you to have surgeries starting at 7am to facilitate commuters needs. What are the issues9 How do deal with it? What would you do? 7. What is burnout? (mentioned stages of burnout) How do you avoid it as a GP If you were the secretary of state for health what would you do to avoid burnout in the workforce? 8. How would you feel if a elderly widower wanted an advance directive9 How would you know if it was valid? How do you determine consent and capacity? What if he was depressed when making it What if he was treated for depression and still wanted it? 9. A patient who you know well makes a complaint about a locum you use regularly. How would you deal with it? It is regarding a clinical issue, and is not the first time. What would you do? Who can you turn to for help / advice? Locum denies any wrongdoing and refusing help. Who can you refer him/her to? ( PCT / NCAS / GMC etc)

10. What does society want from GPs? Two edged sword a named doctor, but quick access and 24 hour care what do you think is best? Can we give society what it wants from GPs?

Winter 2005 the ones I can remember. Whats the difference between appraisal and revalidation? A father requests a circumcision for his son for religious reasons how do you respond? Describe your approach for dealing with a depressed patient? A new community of refugees arrives in your practice area and the LHB asks you to enlist them what are the pros and cons of this?