MRCS Questions

MyPasTest » MRCS A Online - Jan Exam 2015
13. Principles of Surgery in General; Management & Legal Issues in Surgery (34Qs)
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01. As you are aware the NHS has undergone significant change over the past years. Which of the
following statements is correct regarding the 'new NHS'?
Certain healthcare providers are exempt from regulation by the care quality commission (CQC)« YOUR
ANSWER
Commissioning is dealt with by Primary Care Trusts (PCT’s) Page |
GPs commission all operative interventions from local hospitals
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GPs have a vital role in commissioning services for their patients from healthcare providers« CORRECT
ANSWER
NHS healthcare can only be delivered by NHS hospitals.
As part of the NHS reforms, the PCTs are being phased out and replaced by GP commissioning units
which are made up of large groups of GPs who commission services from any willing provider both in the
NHS and private sector. This is intended to encourage the spirit of competition and drive improvements.
All of these providers however need to be registered with the CQC. Some of the more complex surgical
procedures e.g tertiary paediatric surgery services are commissioned directly from the Department of
Health.
02. Clinical governance has been an integral part of the NHS for many years. You are revising the subject
for your ST3 interviews. Which of the following statements is true regarding this important subject?
It has a strong relationship with research and development « YOUR ANSWER (Correct Answer)
It is a yearly process
It is entirely separate from clinical audit
It is only applicable to clinical members of staff
It is synonymous with clinical effectiveness.
Clinical audit came to the fore following the Bristol heart scandal in 1995. It is a continuous process
which strives for “A framework through which NHS organisations are accountable for continually
improving the quality of their services and safeguarding high standards of care by creating an
environment in which excellence in clinical care will flourish”G Scally and L J Donaldson, 'Clinical
governance and the drive for quality improvement in the new NHS in England' BMJ (4 July 1998)
It involves several key elements:

1. Education & Training
2. Clinical audit
3. Clinical effectiveness
4. Research & Development
5. Openess
6. Risk Management
03. A 45-year-old, married gentleman undergoes reversal of Hartmann‟s procedure with formation of a
loop ileostomy. He is admitted to intensive care whereupon after 24 hours he becomes unresponsive,
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Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
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requiring intubation. Brown fluid is noted from the pelvic drain. A CT scan reveals intra-abdominal air and
fluid. An emergency laparotomy is considered. Who is the most appropriate person to consent to this
procedure?
Patient’s spouse« YOUR ANSWER
Patient’s father Page |
Patient’s solicitor 1079
Consultant-in-charge« CORRECT ANSWER
Duty manager of the hospital.
In an unconscious adult patient it is the surgeon‟s responsibility to act „in the best interest of the patient‟.
So the emergency laparotomy can proceed without written consent if it is deemed life saving. The law that
allows this action is the doctrine of necessity and procedures can be undertaken in an emergency without
consent if:
1. There is a necessity to act while the patient is unable to communicate
2. The action to be taken is consistent with the action that a reasonable person would take given the
circumstances
3. The action is in the best interest of the assisted person.
Although the relatives of the patient are unable to consent on behalf of the patient it is good practice to
seek their agreement without breaching confidentiality. However their signature on a consent form is
invalid.
04. You are reading a research paper which has attempted to evaluate the effect of smoking on the
incidence of pilonidal sinuses. As such they looked at two cohorts of matched patients half of which had
the disease and then evaluated their smoking histories. Which is the correct description of the level of
evidence this paper represents?
Level I« YOUR ANSWER
Level II
Level III« CORRECT ANSWER
Level IV
Level V.
This is an individual case control study where the authors are attempting to look at the patients with
pilonidal disease, (the cases), compared with those who did not, (the controls), and how this related to
smoking.
1a Systematic reviews (with homogeneity) of randomized controlled trials
1b Individual randomized controlled trials (with narrow confidence interval)
1c All or none randomized controlled trials
2a Systematic reviews (with homogeneity) of cohort studies
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2b Individual cohort study or low quality randomized controlled trials (e.g. <80% follow-up)
2c "Outcomes" Research; ecological studies
3a Systematic review (with homogeneity) of case-control studies
3b Individual case-control study
4 Case-series (and poor quality cohort and case-control studies) Page |
Expert opinion without explicit critical appraisal, or based on physiology, bench research or "first 1080
5
principles"
05. Your consultant is testing a new method of closing the abdomen using 5 layers of sutures. When you
ask how he heard about this technique, as you want to read about it, he tells you that he leant it on a
recent operative course. What level of evidence is he using to inform his practice?
Level I« YOUR ANSWER
Level II
Level III
Level IV
Level V« CORRECT ANSWER.
He is basing his change of practice on an expert opinion, the weakest level of evidence.
1a Systematic reviews (with homogeneity) of randomized controlled trials
1b Individual randomized controlled trials (with narrow confidence interval)
1c All or none randomized controlled trials
2a Systematic reviews (with homogeneity) of cohort studies
2b Individual cohort study or low quality randomized controlled trials (e.g. <80% follow-up)
2c "Outcomes" Research; ecological studies

3a Systematic review (with homogeneity) of case-control studies
3b Individual case-control study
4 Case-series (and poor quality cohort and case-control studies)
Expert opinion without explicit critical appraisal, or based on physiology, bench research or "first
5
principles"
06. A 35-year-old man has been brought in by ambulance. He was found under a pile of rubble at a
building site and appears to have been there some time. His right thigh is severely crushed and
unsalvageable and he is disorientated and very confused. His urine is very dark and tests positive for
myoglobin. His wife has just arrived and states that since his brother lost his leg in Afghanistan he has
said several times that he would rather go through anything than lose a leg. What is the correct
management of this patient?
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Manage the patient on ITU with aggressive fluid resuscitation waiting for the patients conscious level to
improve« YOUR ANSWER
Manage the patient using ABC principles. Ask to speak to the patients brother to corroborate the wife’s
wishes and if both are in agreement then manage the patient in the palliative setting
Manage the patient using ABC principles. Attempt to contact the on call legal team and await their decision Page |
before embarking further
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Manage the patient using ABC principles. Following discussion with the patient’s wife book the patient for a
below knee amputation with a consent form 4 in the first instance
Manage the patient using ABC principles. Following discussion with the patient’s wife book the patient for a
high amputation with a consent form 4« CORRECT ANSWER.
This gentleman has a severe crush injury and is at significant risk of renal failure and sepsis if the leg is
not amputated. Although he may have said to his family that he would not accept an amputation under
any circumstances, without a legally witnessed advance directive this unfortunately is hearsay. Your job
is to act in the best wishes of the patient whilst keeping the family involved as much as possible.
07. Theme: The language of the NHS

A Audit
B Clinical Governance
C Healthcare Commission
D Foundation hospitals
E Modernisation agency
F National Institute for Clinical Excellence (NICE)
G National service frameworks (NSFs)
H National targets
I NHS trusts
J Performance assessment framework (PAF)
K Primary-care groups (PCGs)
L Primary-care trusts (PCTs)
M Independent sector treatment centres (ISTCs)
N Strategic Health Authorities (SHAs).
The following are all brief descriptions of terms used within the language of the new NHS. Please select
the term that best fits each description from the above list. The items may be used once, more than once,
or not at all.
Scenario 1
Policies that set national standards and identify key interventions for a defined service or care group.
A - Audit« YOUR ANSWER
G - National service frameworks (NSFs)« CORRECT ANSWER.
These, in addition to setting national standards, also put in place strategies to support implementation
and ensure progress within a reasonable timescale. It is aimed that there will be one new framework per
year and they include goals for common and important diseases such as coronary heart disease and
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cancer. They differ from „National Targets‟, which address politically „hotter potatoes‟ such as waiting
times.
Scenario 2
Organisation bringing together groups of health workers (doctors and nurses, dentist, pharmacists and
optometrists) with community-care organisations, including social services, who are responsible for local shaping Page |
and commissioning of care.
B - Clinical Governance« YOUR ANSWER 1082
L - Clinical Commissioning groups (CCGs)« CORRECT ANSWER.
On April 1st 2013 the former Primary Care Trusts were replaced by Clinical Commissioning Groups
(CCGs) and local area teams (LATs). These groups will share responsibility for commissioning services
for local communities. There will be 229 CCGs and 27 LATs.
Scenario 3
'A system through which NHS organisations are accountable for continuously improving the quality of their
services and safeguarding high standards of care, by creating an environment in which clinical excellence will
flourish .' (DoH 1998)
C - Healthcare Commission« YOUR ANSWER
B - Clinical Governance« CORRECT ANSWER.
Beloved of interviews and vivas, this definition is as verbose as it is unhelpful. In reality, clinical
governance encompasses a range of clinical activities aimed at improving safety for patients and is a
quality control systme helping to monitor the quality of care delivered within the NHS.
Originally, it had three components: clinical audit, adverse incident reporting and continued professional
development. It was described (presumably in a link to wisdom) as having seven „pillars‟ that were clinical
audit, clinical risk management, learning effectiveness, patient experience effectiveness, communication
effectiveness, resource effectiveness and strategic effectiveness.
The Site Editor apologises for the inclusion of this question. However, it is a sad fact that all of us
involved in the delivery of health care (even including surgeons) within the New NHS require some
understanding of the current language of health-care delivery. Such questions are also a favourite of SpR
interview panels!
08. Theme: Death and the law

A Any medical practitioner
B Coroner
C Coroner‟s officer
D Medical practitioner who attended during previous 14 days
E Registrar of births and deaths.
For each of the statements below, select the most likely answer from the
above list. Each option may be used once, more than once, or not at all.
Scenario 1
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Certify death
A - Any medical practitioner« CORRECT ANSWER.
Scenario 2
Issue immediate Medical Certificate of death
B - Coroner« YOUR ANSWER Page |
D - Medical practitioner who attended during previous 14 days« CORRECT ANSWER.
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Scenario 3
Call an inquest
C - Coroner’s officer« YOUR ANSWER
B - Coroner« CORRECT ANSWER.
Scenario 4
Send information concerning the cause of death to the Office of Population Censuses and Surveys
D - Medical practitioner who attended during previous 14 days« YOUR ANSWER
E - Registrar of births and deaths« CORRECT ANSWER.
A doctor may issue a death certificate if he or she is a registered medical practitioner. In practice, this
usually means where the doctor attended within 14 days of the death. Only the coroner is entitled to hold
an inquest on any case that is reported to him/her.
09. Theme: Types of scientific evidence

A Case–control series
B Case series
C Cohort study
D Controlled clinical trial
E Cross-sectional survey
F Experimental research paper
G Guidelines
H Meta-analysis
I Non-systematic review
J Randomised controlled trial
K Randomised double-blind controlled trial
L Systematic review
M Uncontrolled trial.
The following are descriptions of types of scientific evidence. Please select the most appropriate
descriptive term from the list above. The items may be used once, more than once, or not at all.
Scenario 1
A statistical synthesis of the numerical results of several trials which all addressed the same question.
A - Case–control series« YOUR ANSWER
H - Meta-analysis« CORRECT ANSWER.
When reviewing the impact of new therapies, evidence can come from several studies of modest size and
with slightly differing conclusions.
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One solution might be to carry out a definitive randomised controlled trial but this might require
considerable time, effort and expense. An alternative is to combine data from several modest studies into
a meta-analysis. By combining studies in a coherent (statistically robust) way, conclusions can be
reached on a larger pool of subjects.
Scenario 2 Page |
A study in which two or more groups of people are selected on the basis of differences in their exposure to a
particular agent and are followed-up to observe any differences in outcome between the groups. 1084
B - Case series« YOUR ANSWER
C - Cohort study« CORRECT ANSWER
This differs slightly from a randomised controlled trial in that it generally takes two or more large cohorts
of subjects (rather than a specific sample size of patients) and follows them up long term for the effects of
a certain agent, eg an environmental factor on the basis of which they are selected. An example is Sir
Richard Doll‟s work associating lung cancer with smoking by observing a cohort of 40,000 doctors in four
cohorts according to number of cigarettes smoked over 10 years.
Scenario 3
A study in which medical histories of more than one patient with a particular condition are described to illustrate
one interesting aspect of the condition or treatment.
C - Cohort study« YOUR ANSWER
B - Case series« CORRECT ANSWER.
This is synonymous with a series of case reports which together illustrate an interesting aspect of a
condition or treatment. Although they are not randomised, are rarely prospective, and represent a low
relative weight in the traditional hierarchy of evidence, they are easy for the less scientifically minded to
digest and can still convey very important information rapidly before a definitive trial can be performed,
eg McBride‟s 1961 case series of two infants with limb absence born to mothers taking Thalidomide first
alerted the world to this terrible drug complication. (Resources for this subject may be obtained from the
BMJ book by Trisha Greenhalgh entitled How to read a paper). (Resources for this subject may be
obtained from the BMJ book by Trisha Greenhalgh entitled How to read a paper.)
10. You are analysing data from your unit looking at local recurrence from breast cancer over time in
patients who express the gene AVS gene B. The two groups are matched for other confounding variables.
Which of the following would be the correct statistical test to use?
ANOVA test« YOUR ANSWER
Chi squared test
Kaplan Meier test« CORRECT ANSWER
Mann Whitney U test
Paired student’s T test.
The Kaplan Meier test plots events (in this cases recurrences) over time between two groups with vertical
drops over time.
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11. Your consultant asks you to obtain consent from his patients for his elective list which is lengthy and
you are short of time. You notice that one of the patients signed a consent form about six months ago
which covers all the issues you would discuss now. How would you proceed with this patient? Single
best answer - select one answer only.
A consent form is legal proof that consent has been given, it will not be necessary for the patient to sign
again« YOUR ANSWER Page |
A consent form signed in an out-patients’ department 6 months preoperatively is technically valid but it is 1085
strongly advisable to obtain the signature again on admission« CORRECT ANSWER
Having checked that all complications have been consented for in the document, and that the patient had
capacity to consent at the time of signature, no further contact is required
Tell the patient they must re-sign the document
Verbal consent will be adequate in this scenario.
The legal age of consent is 16 years. Verbal consent is adequate only if the patient‟s condition precludes
giving written consent (eg broken arms). However, as a general rule, it is advisable that the verbal
consent is witnessed and documented by another individual. There is no time limit upon consent,
therefore a consent form signed 6 months ago remains technically valid, however good practice (and
indeed many Trusts) require a counter-signature at the time of surgery if the consent form has been
completed over 2 weeks earlier. Ability to retain the information forms an important part of the patient's
capacity to give valid consent. For consent to be valid it must be informed, voluntary and the patient must
be competent. Frequently occurring complications should be mentioned to the patient, as well as all
serious complications regardless of their incidence.
12. An essential part of clinical governance is risk management. Unfortunately, your patient has been
given flucloxacillin despite having a documented penicillin allergy. Thankfully they have a moderate
urticarial reaction which responds to piriton and steroids. Which of the following is correct?
Analysis of risk is a locally driven system« YOUR ANSWER
Clinical risk has a different reporting system than non-clinical risk
It is only the severity of the risk (ie green, amber or red rating) that is important when assessing clinical risk
Reporting of clinical errors is at the discretion of the senior clinician, nurse or manager on duty
Risk reporting has a direct impact on CNST payments« CORRECT ANSWER.
An 'Organisation with a memory' published guidelines and advice regarding clinical and non clinical risk
reporting and management. Both of these are reported using the same system and are a mandatory part
of the NHS. It is confidential and centrally collated. It is both the severity of risk and its frequency that is
important. The frequency of error and risk reporting is fed into the CNST (clinical negligence scheme for
trusts) and may affect the insurance premiums the Trust pays.
13. Theme: Principles of trial design and conduct

A Cross-over design
B Detection bias
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C Double-blinding
D Exclusion bias
E Factorial design
F Intention to treat
G Minimisation
H Null hypothesis Page |
I Parallel group design
J Performance bias 1086
K Power
L Selection bias
M Simple randomisation
N Single blinding
O Stratified randomisation
P Subgroup analysis
Q Type I error
R Type II error.
The following are descriptions of terms used in the language of trial design. Please select the most
appropriate descriptive term from the list above. The items may be used once, more than once, or not at
all.
Scenario 1
In hypothesis testing: the term used to describe a situation in which we fail to reject the null hypothesis when a
difference is really present.
A - Cross-over design « YOUR ANSWER
R - Type II error« CORRECT ANSWER.
This is the definition of a term used in the context of hypothesis testing. A type I error in contrast is one in
which we reject the null hypothesis when a real difference is not present. These terms are most
commonly cited in the context of study design where the probability of type I and II errors can be reduced
by performing a prior power analysis in which the correct sample size is estimated on the basis of setting
a and ß values which represent the probabilities that a type II and type I error will be committed. NB the
null hypothesis is the cornerstone of hypotheticodeductive reasoning (Karl Popper) not a term describing
a negative approach to research!
Scenario 2
An erroneous influence potentially effecting the conclusions of a trial caused by systematic differences in
withdrawals from the trial.
B - Detection bias « YOUR ANSWER
D - Exclusion bias « CORRECT ANSWER.
This is one of the four components of systematic bias (the others are in the list) that should be
eliminated/minimised by good trial design and conduct. So-called „drop outs‟ or exclusions from trials
can occur for many reasons and can introduce bias quite easily since the tendency (even unintentially) is
to exclude participants to favour the outcome of the trial. Where exclusions occur, this problem can be
reduced by analysis on an „intention to treat‟ basis (ie they are still included in the analysis).
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A method of allocation in comparative studies that provides treatment groups that are very closely similar for
several variables.
C - Double-blinding « YOUR ANSWER
G - Minimisation « CORRECT ANSWER.
This is an alternative to simple randomisation (the commonest method used to reduce selection bias) Page |
when this might potentially introduce large differences in the characteristics of comparison groups within
a trial. Other methods include stratified randomisation but this is usually used for single binary variables 1087
such as sex. (Resources for this subject may be obtained from the BMJ book by Trisha Greenhalgh
entitled How to read a paper.)
14. You have walked into the doctors mess late at night and see your Registrar smoking cannabis whilst
on call. She says that she has had a very stressful week and has only had one joint to help her relax. You
believe her. What would you do?
As it is likely to be a quiet night, ask for her assurance that this is the last time and carry on« YOUR
ANSWER
Ask her to arrange for someone else to do her on call for her and nothing more will be said
Ask her to discuss the matter with her consultant/supervisor in the morning and carry on
Ask her to phone her consultant to self-report immediately« CORRECT ANSWER
Phone the GMC on call line for advice.
It is her Consultant's responsibility, out of hours, to deal with this in the first instance. It is vital that the
Registrar is removed from the clinical environment immediately and the Consultant should facilitate this
by 'stepping down' to act as the Registrar. Once the situation is made safe, it is likely the Registrar will
face both Trust and GMC disciplinary proceedings in due course.
15. Theme: Death certification

A Ask GP to issue death certificate
B Issue certificate yourself immediately
C Issue death certificate and request hospital postmortem examination
D Refer to coroner
E Order an inquest.
For each of the scenarios below select the most appropriate option. Each option may be used once, more
than once, or not at all.
Scenario 1
A 24-year-old drug addict is found dead in his flat surrounded by syringes, needles and empty bottles of alcohol.
You certify as dead in A&E.
A - Ask GP to issue death certificate« YOUR ANSWER
D - Refer to coroner« CORRECT ANSWER.
Scenario 2
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A young man has been found in his flat, emaciated and with several liver abscesses. It becomes known that he is
HIV positive. The abscesses are drained but the patient dies 1 week later.
B - Issue certificate yourself immediately« YOUR ANSWER
C - Issue death certificate and request hospital postmortem examination« CORRECT ANSWER.
Scenario 3 Page |
A 70-year-old woman admitted with small bowel obstruction has a 2-month history of weight loss and tiredness. At
laparotomy, widespread disseminated cancer is found and no further surgery is performed. She returns to the 1088
ward and dies 4 weeks later.
C - Issue death certificate and request hospital postmortem examination« YOUR ANSWER
B - Issue certificate yourself immediately« CORRECT ANSWER.
Scenario 4
A 52-year-old man came to hospital with jaundice and underwent successful hepatobiliary surgery for a tumour.
Three days after the surgery he develops chest pain and an ECG shows signs of a myocardial infarction (MI). He
is treated on the coronary care unit but dies 2 weeks later.
D - Refer to coroner« YOUR ANSWER
B - Issue certificate yourself immediately« CORRECT ANSWER.
Scenario 5
A woman dies 72 hours after dynamic hip screw (DHS) operation for fracture of the neck of the femur. She
complains of chest pain and an MI is diagnosed shortly after cardiac arrest. She is on a trial for a new cardiac
drug but dies.
E - Order an inquest« YOUR ANSWER
D - Refer to coroner« CORRECT ANSWER.
A doctor may issue a death certificate if he or she attended the deceased during the last illness. In
practice this means where the doctor attended within 14 days of the death. In some cases when the
doctor was attending the deceased regularly and had seen the body after death, the certificate may be
accepted even though the last attendance was more than 14 days ago.
A practitioner who sees the deceased for the first time after death is not entitled to issue a certificate. If
the medical practitioner knows the cause of death, and if, according to the law, the above criteria have
been met, the doctor must always issue a certificate even when the cause is unknown or obviously
unnatural. The Registrar would then notify the Coroner. However, the usual practice in such cases is for
the doctor to notify the Coroner himself, and withhold the certificate.
The doctor has no statutory duty to notify any death to the Coroner. He complies with the law if he issues
a death certificate, even though the death is the result of an unnatural cause, and leaves the Registrar to
inform the Coroner. There is no official list of when to refer to the Coroner. A simple rule is to refer all
deaths known to be due to unnatural causes or when the cause is unknown, eg deaths from violence
(accidental, suicidal), poison, during surgical procedure or anaesthesia. Only the Coroner can order an
inquest.
16. Audit is an essential part of clinical practice. You have just completed one looking at the availability of
Oestrogen receptor status at the first post-operative multidisciplinary team meeting (MDT) and intend on
changing practice and closing the loop. Which of the following statements is true regarding clinical audit?
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It is a way of assessing the superiority of a new treatment which has been recommended by NICE« YOUR
ANSWER
It is an optional part of the appraisal process
It is only valid as part of your appraisal folder evidence if you have completed the audit and closed the loop
It is part of the process of clinical governance « CORRECT ANSWER
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The availability of international guidelines as a benchmark is an essential starting point of an audit. 1089
Guidelines and standards need to be available so that the audit has a benchmark but these can be local,
national or international. It differs from research (C) as it doesn‟t attempt to look at new treatments but
rather looks at established processes. It is an essential part of the appraisal process and forms one of the
pillars of clinical governance. Engagement with audit is necessary, completion is not!
Audit cycle: Identify issue or problem

↓
1. Set criteria and define standards to be reviewed
↓
2. Collecting data
↓
3. Comparing performance against criteria and standards
↓
4.Implementing change
↓
5. Repeating the audit cycle.
17.
A Coroner
B Any medical practitioner
C Registrar of births and deaths
D Coroner's officer
E Medical practitioner who attended the patient during the last 14 days
F General practitioner
G Bereavement office in the respective NHS trust
H Medical director
From the list above select the person who is most likely to be legally permitted to: (each option may be
used once, more than once, or not at all)
Scenario 1
certify death
A - Coroner« YOUR ANSWER
B - Any medical practitioner« CORRECT ANSWER.
Scenario 2
issue an immediate certificate of death
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B - Any medical practitioner« YOUR ANSWER
E - Medical practitioner who attended the patient during the last 14 days« CORRECT ANSWER.
Scenario 3
call an inquest
C - Registrar of births and deaths« YOUR ANSWER Page |
A - Coroner« CORRECT ANSWER.
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Scenario 4
send information concerning the cause of death to the office of Population Consensus and Survey
D - Coroner's officer« YOUR ANSWER
C - Registrar of births and deaths« CORRECT ANSWER.
Death can be certified by any registered medical practitioner (in UK, a doctor registered with the General
Medical Council). Any doctor can also issue an immediate death certificate if he/she is a registered
medical practitioner; in practice this usually means the doctor who attended the patient within 14 days of
the death. Only the Coroner is entitled to hold an inquest on any case that is reported to him. The
Registrar of births and deaths should send information concerning the cause of death to the office of
Population Consensus and Survey.
18. Theme: Consent

A Consent the patient
B Consent the parents
C Consent by proxy
D Cannot proceed
E Proceed without patient's consent
F Seek urgent medicolegal advice.
Match the most appropriate option from the list above to each clinical situation described below. Each
option may be used once only, more than once or not at all.
Scenario 1
A 20-year-old male with motorcycle injury – unstable and unconscious, and needs operation.
A - Consent the patient« YOUR ANSWER
E - Proceed without patient's consent« CORRECT ANSWER.
Scenario 2
A 9-year-old-boy with deteriorating health needs a blood transfusion, the parents refused for religious reasons.
B - Consent the parents« YOUR ANSWER
F - Seek urgent medicolegal advice« CORRECT ANSWER.
Scenario 3
A 21-year-old woman with Down's syndrome needs appendicectomy. She understands all about the operation
and accepts it.
C - Consent by proxy« YOUR ANSWER
A - Consent the patient« CORRECT ANSWER.
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Scenario 4
A 12-year-old girl with iliac fossa pain and vaginal bleeding needs diagnostic laparoscopy.
D - Cannot proceed« YOUR ANSWER
B - Consent the parents« CORRECT ANSWER.
In the unconscious patient the medical team is entitled to provide life-saving procedures including
Page |
surgery. In the case of parent‟s religious view the doctors have a duty to the child and must seek the 1091
court‟s permission for further treatment if necessary. If a patient is deemed to understand the procedure
and any possible complications they can give their own consent. If a patient is under 16 years then
usually consent is taken from the parents. The exception to this is when a child is capable of fully
understanding the procedure and consequences – Gillick‟s competence.
19. THEME: STATISTICS

A Mann-Whitney test
B Paired t-test
C Unpaired t-test
D Chi squared (X ) test
E Wilcoxon's test.
For each of the cases described below, select the single most appropriate test from the options listed
above. Each option may be used once, more than once, or not at all.
Scenario 1
Na+ and urea pre- and post-operative, same individuals.
A - Mann-Whitney test« YOUR ANSWER
B - Paired t-test« CORRECT ANSWER.
For normally distributed data, t-tests may be used. The unpaired t-test is a parametric test used to
compare 2 independent samples from the same population, whereas the paired t-test is a parametric test
used to compare 2 sets of observations on a single sample.
Scenario 2
Non-gaussian data when comparing two unpaired groups.
B - Paired t-test« YOUR ANSWER
A - Mann-Whitney test« CORRECT ANSWER.
For non-parametric/non-gaussian data, Mann-Whitney or Wilcoxon‟s tests are used. The Mann-Whitney
test is used to compare two unpaired groups.
Scenario 3
Your hypothesis is that remaining nil by mouth prior to an operation causes significant dehydration in children.
You collect pre- and post-operative urea and electrolyte values for 100 patients. The data is normally distributed.
C - Unpaired t-test« YOUR ANSWER
B - Paired t-test« CORRECT ANSWER.
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For normally distributed data, t-tests may be used. The unpaired t-test is a parametric test used to
compare 2 independent samples from the same population, whereas the paired t-test is a parametric test
used to compare 2 sets of observations on a single sample.
Scenario 4
Aspirin is thought to cause excessive bleeding following transurethral prostatectomy. You calculate a fall in Hb for Page |
patients either taking or not taking aspirin. In both groups the data includes several patients who suffer massive
haemorrhages, and who thus skew the distribution. 1092
D - Chi squared (X ) test« CORRECT ANSWER.
The X2 test (binomial) is used to compare one group to a hypothetical value, or two unpaired groups, or
three or more unmatched groups.
Scenario 5
Non-gaussian data when comparing paired group data.
E - Wilcoxon's test« CORRECT ANSWER.
For non-parametric/non-gaussian data, Mann-Whitney or Wilcoxon‟s tests are used. Wilcoxon‟s test is to
used compare paired group data.
20. An 89-year-old lady with alzheimers dementia is placed on an elective list for excision of an ulcerated
SCC to her check. Her son shows you he has a lasting power of attorney (LPA) and will be able to consent
to the treatment on her behalf. Which of the statements regarding an LPA and consent is correct? Single
best answer - select one answer only.
A health & welfare LPA allows decisions to be made on the donor’s medical care and life-sustaining
treatment, daily care and living arrangements« YOUR ANSWER (Correct Answer)
A health & welfare LPA comes into effect as soon as it is registered
An LPA can be validly made by anyone 16 or over who has mental capacity at the time of making the
document
An LPA can be validly made by anyone 18 or over
If there is more than one attorney registered they must both give consent for medical care decisions.
An LPA is a legal document which may be made by a person (known as a donor) in anticipation of losing
the mental capacity to make decisions on their own behalf. The document must be registered with the
Office of the Public Guardian (OPG) in order to be valid. An „attorney‟ or „attorneys‟ are appointed to make
decisions over either property & financial affairs; health & welfare affairs; or both. The donor must be
aged 18 or over at the time of creating the document and have mental capacity. Whilst a financial LPA can
come into effect, with the permission of the donor, as soon as it is registered, a health & welfare LPA is
never valid until the donor loses the capacity to make such decisions in person.
A donor may have placed restrictions on the actions of the attorney either specifically or by making an
advance decision such as to refuse treatment in a particular circumstance. An attorney acting under a
health & welfare LPA must act in the donor‟s best interests when deciding upon medical treatments. If
there is any doubt about this the Court of Protection is able to adjudicate.
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Depending on the terms of the LPA, where two or more people are acting as attorney, they may be able to
act individually or only with the consent of all attorneys.
21. Theme: Basic statistics (taxonomy)

A Analysis of variance (ANOVA) Page |
B c2 test
C Correlation 1093
D False negatives
E False positives
F Likelihood ratio
G Negative predictive value
H Positive predictive value
I Power analysis
J Regression analysis
K Sensitivity
L Specificity
M t-tests.
The following descriptions all refer to basic statistical methods that are commonly employed in medical
research. Please select the most appropriate term from the above list. The items may be used once, more
than once, or not at all.
Scenario 1
A method of statistical analysis used for hypothesis testing where we wish to compare proportions of categorical
data.
A - Analysis of variance (ANOVA) « YOUR ANSWER
B - x2 test« CORRECT ANSWER
B – c2 test
This is the correct test for categorical data, such as male/female, where we wish to establish whether
there is a significant difference in proportions between two or more groups (the Fisher‟s exact test is
similar but utilised for only 2 x 2-cell tables with small numbers in each cell). In contrast, t-tests, such as
the Student‟s t-test (parametric data) and the Mann–Whitney U-test (non-parametric data) are used for
comparing continuous numerical data.
Scenario 2
In the assessment of a diagnostic test, the proportion of patients with negative test results who are correctly
diagnosed.
C - Correlation « YOUR ANSWER
G - Negative predictive value« CORRECT ANSWER.
The proportion of patients with negative test results who are correctly diagnosed is the negative
predictive value. In contrast, the proportion of patients with positive test results who are correctly
diagnosed is the positive predictive value. Unlike specificity and sensitivity, the positive and negative
predictive values give a direct assessment of the usefulness of a test in practice.
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However in addition, unlike sensitivity and specificity, the positive and negative predictive values are
strongly affected by prevalence (ie the proportion of patients with the abnormality). The positive
predictive value increases with increasing prevalence and the negative predictive value decreases.
Scenario 3 Page |
This may be calculated to indicate the value of a test for increasing certainty about a positive diagnosis. It is
numerically equal to the sensitivity/(1 – specificity). 1094
B - x2 test« YOUR ANSWER
F - Likelihood ratio « CORRECT ANSWER.
For any test result, one can compare the probability of getting that result if the patient truly had the
disease with the corresponding probability if they were healthy. The ratio of these probabilities is the
likelihood ratio, which can be considered to indicate the value of a test for increasing certainty about a
positive diagnosis. It is numerically equal to the sensitivity / (1 – specificity.
(Basic resources for this subject may be obtained from the chapter by Hugh Dudley in the Clinical
Surgery in General RCS Course manual or, for the more avid student, from a book entitled Practical
Statistics for Medical Research by Douglas G Altman.)
22. Theme: Death certificates

A Ask families for permission for a postmortem
B Ask the GP to issue a death certificate
C Issue a death certificate
D Order a hospital postmortem
E Report to the coroner.
For each of the situations below, select the most likely answer from the above list. Each option may be
used once, more than once, or not at all.
Scenario 1
A 20-year-old man was found emaciated in a derelict building. On examination he had two liver abscesses and
was human immunodeficiency virus (HIV) positive, and died 5 days after admission to hospital
A - Ask families for permission for a postmortem« YOUR ANSWER
E - Report to the coroner« CORRECT ANSWER
E - Report to the coroner due to the mechanism of death being potentially suspicious or complex.
Scenario 2
A 50-year-old man was admitted with jaundice secondary to cholangiocarcinoma. His tumour was resected, but
the patient died 5 days later from a myocardial infarction (MI)
B - Ask the GP to issue a death certificate« YOUR ANSWER
C - Issue a death certificate« CORRECT ANSWER.
Death should be referred to the coroner if: The cause of death is unknown. The deceased was not seen by
the certifying doctor either after death or within 14 days before death. The death may be due to an
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accident. The death was unnatural, violent or suspicious. The death may be due to self-neglect or neglect
by others (as in scenario 1). The death may be due to an abortion. The death may be a suicide.
The death may be occupational/as a result of industrial disease. The death occurred during/after
detention in police custody or prison. The death is during or within 24 hours of an operation / anaesthetic
/ invasive procedure For scenario 2, it is common practice to telephone the coroner to get advice for Page |
death following an operation. However, according to the guidelines above, this is not strictly necessary.
1095
23. You are analysing data produced from your unit looking at the relationship between age and renal
function. This data follows a Gaussian (normal) distribution. Which of the following tests is appropriate
for this purpose?
Mann-Whitney U test« YOUR ANSWER
Kruskal-Wallis test
Pearson’s correlation coefficient« CORRECT ANSWER
Spearman’s rank correlation coefficient
Wilcoxson signed-rank test.
Pearson‟s correlation coefficient analyses the strength of a relationship between two continuous
variables as is the case here. The other tests are non-parametric tests.
24. You are at an interview for an ST3 appointment and are being asked a question on the different levels
of evidence that you know of. Which of the following is an example of level II evidence based medicine?
Single best answer - select one answer only.
Care report« YOUR ANSWER
Case series
Cohort study with a high degree of selection bias« CORRECT ANSWER
Expert opinion
Randomised controlled trial.
Level-1 evidence includes randomised controlled trials. Level-2 evidence includes all cohort studies
regardless of the degree of selection bias. Level-3 evidence includes case reports and case series. Level-
4 evidence is based on expert opinion.
25. You are in the process of preparing for your appraisal and are collecting the relevant evidence
required. It will be the closest appraisal prior to your revalidation date. Which of the following statements
is true regarding this appraisal?
A revalidation ready appraisal is required every 3 years for revalidation every 6 years« YOUR ANSWER
Feedback from colleagues has a lower weighting than feedback from patients
Your appraisal can be carried out by a non consultant grade doctor« CORRECT ANSWER
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Your appraisal can be carried out by any NHS consultant who has been on the specialist register for 5 years
360 degree feedback is a desirable but not essential part of your appraisal.
An annual appraisal is mandatory for doctors working within the NHS and is part of the 5 yearly process
of revalidation. The appraiser can be anyone who works within the organisation and has had approved Page |
training and therefore doesn‟t need to be a consultant. They are usually senior clinicians or management,
however. Appraisal requires the demonstration of evidence that the clinician satisfies all the aspects of 1096
“Good Medical Practice” but the difference between an ordinary appraisal and a revalidation ready
appraisal is the 360 degree feedback. The clinician must collect anonymous feedback from patients and
colleagues (from all aspects of their working lives) which has equal weighting. Once completed the
appraiser then passes the information to the Trust's “Responsible Officer” who then recommends the
doctor to the GMC for revalidation.
26. A 31-year-old man is critically injured in a road traffic accident (RTA) and requires an emergency
laparotomy. He is intubated at the scene. Which of the following statements regarding informed consent
is correct? Single best answer - select one answer only.
Informed consent must be obtained by the person doing the procedure« YOUR ANSWER
Informed consent must describe alternative options« CORRECT ANSWER
Informed consent can be gained from relatives or carers if the patient themselves cannot give consent
Informed consent is the sole responsibility of the consultant in charge of the case
Previous expressed wishes of the patient made when they are competent are null and void when
subsequently presenting in a lowered state of consciousness if their life is at risk.
A valid consent must be voluntarily given by a competent patient making an informed choice. For consent
to be valid the patient must have the capacity to understand, retain and process the information given.
The amount of information given will vary depending on the complexity of the decision and the needs of
the patient. In general, the information should follow that given by „a responsible body of medical
opinion‟.
This should include diagnosis, prognosis, untreated prognosis, uncertainties about diagnosis, treatment
options including no treatment, explanation of procedures and side-effects including subsidiary
treatment, probability of success including lifestyle changes necessitated by treatment, whether
treatment is experimental, assessment of patient, name of responsible doctor(s)/surgeon(s), whether
trainees or students are involved and any costs incurred. The patients should also be reminded that they
have the right to change their minds and to seek a second opinion and patients and relatives should have
been given an opportunity to ask questions.
Informed consent is the responsibility of the team looking after the patient, including anaesthetists, scrub
nurses and assistants. It can be taken by an assistant, as long as they understand the risks and benefits
of the procedure. Where a patient is temporarily incapacitated the guiding principles are that any
treatment undertaken must be no more extensive than absolutely necessary at the time and not at odds
with any advanced wishes expreseed by the patient before loss of capacity.
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27. You are just finishing a period of research and have managed to obtain some high quality clinical
research. You send the paper to a major journal which accepts it in principal pending minor revisions.
You send this to your professor who gives it back a week later with the corrections done but an additional
name is on the paper. When you question him he says it is his daughter who is applying for CT1 jobs. He
says she has read the paper for grammar. What is the most appropriate course of action?
Discuss it with the director of research and clinical governance and ask for him to deal with the situation« Page |
YOUR ANSWER
1097
Discuss it with your professor and explain that you are not happy with the addition of the additional name and
ask that he takes it off before sending it in « CORRECT ANSWER
Send the paper in to the journal as it is high quality research and she has contributed to the paper
Send the paper in to the journal with a letter to the editor explaining what has happened
Take the additional name off the paper and send it into the journal.
This is a breach of GMC research ethics. To be included on a research paper each author needs to
confirm that they have played a significant part in the paper and reading it through for grammar does not
count. If your professor does not accept your concerns then the next port of call would be the R and D
director and following this the GMC. If you have concerns that this has happened several times in the past
it may be necessary to refer your professor anyway.
28. You are attempting to look at the readmission rates following emergency appendicectomy in female
patients under 35 to attempt to change practice. Which of the following statements is correct regarding
the principles of audit? Single best answer - select one answer only.
It evaluates the difference between two treatments before clinical application« YOUR ANSWER
It facilitates the evolution of guidelines for different procedures« CORRECT ANSWER
It requires evaluation of current practice against national guidelines
Audit is a non-essential but important part of medical revalidation
It is not meant to influence clinical practice.
Medical audit compares clinical practice against established 'gold standards' and identifies areas for
improvement which are usually applied locally (but not always). These gold standards don't have to be
national. Audit facilitates the evolution of novel guidelines. It does not, however, facilitate new treatments
(this is research). Once any changes in practice are made following audit, it is important to repeat the
process to close the loop. It is an essential part of medical revalidation.
29. As a CT1 you are interested in teaching medical students to both improve your knowledge and make
an impact on doctors of the future. Which of the following statements is correct regarding teaching and
training in the NHS? Select one answer only.
Any consultant who has been in post for more than 3 years can be an educational supervisor« YOUR
ANSWER
Any consultant who has been in post for more than 5 years can be a clinical supervisor
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Evidence of teaching is important and forms a formal part of the appraisal process« CORRECT ANSWER
It is only recognised trainers who have taken part in the necessary training themselves who can teach in the
NHS
Workplace based assessments can only be undertaken by consultants.
Page |
Educational and Clinical supervision can be undertaken by any consultant who has passed the QUESP
course (qualified educational supervisor programme) or similar. It is essential that those clinicians who 1098
wish to supervise have appropriate training. Anyone interesting in teaching however should be allowed to
teach but ideally they should also have requisite training. Workplace based assessments can be
completed by middle grade doctors and consultants. Evidence of teaching forms an essential part of
appraisals, as it forms part of 'Duties of a doctor'
30. A 7-year-old boy has been brought in by helicopter having been involved in a severe road traffic
accident. He has sustained a blunt abdominal injury, a fractured pelvis and a left haemopneumothorax. He
is accompanied by his father who is relatively unscathed. The family are practicing Jehovah‟s witnesses.
The child is exhibiting grade IV shock. The father is adamant that he would rather see his child die than
have his son receive a blood transfusion. What is the correct management of this child?
Accept and respect the father’s wishes to avoid transfusion« YOUR ANSWER
Discuss the situation with the father but manage the child using ABC principles and transfuse the child with
“flying squad” blood whilst you await the results of a group and save
Manage the child according to ABC first principles and use a non-blood product for resuscitation,while
seeking urgent legal advice to make the child a ward of court.« CORRECT ANSWER
Telephone the elders of the father's community to schedule a meeting with the father to discuss the situation
further
Telephone the on-call Trust barrister to try to make the child a ward of the court.
In the UK it is a fundamental principle that every individual‟s body is inviolate, and traditionally where the
interests of a non-competent child are involved parents have the right and duty to act as proxy. However,
the wishes have to be seen to be in the child‟s best interests and are not absolute, with the ultimate
control resting with the judiciary. In this case, the child has life threatening injuries and needs blood. It is
sensible and necessary however to discuss this in full with the father, and also involve the Trust's legal
services at the earliest opportunity.
31. Theme: Scientific research techniques

A Cloning
B DNA fingerprinting
C DNA microarray
D DNA sequencing
E Hybridisation
F Linkage analysis
G Northern blotting
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H Polymerase chain reaction
I Southern blotting
J Transfection
K Transformation
L Western blotting.
The following are all brief descriptions of common molecular techniques utilised in medical research.
Page |
Please select the technique which best fits each description from the above list. The items may be used 1099
once, more than once, or not at all.
Scenario 1
An automated method utilising microchip technology in which the differential expression of thousands of genes
can be estimated in a single experiment.
A - Cloning « YOUR ANSWER
C - DNA microarray « CORRECT ANSWER.
DNA microarray, or DNA chips, are fabricated by high-speed robotics, generally on glass but sometimes
on nylon substrates, for which probes with known identity are used to determine complementary binding,
so allowing massively parallel gene expression and gene discovery studies. An experiment with a single
DNA chip can provide researchers with information on thousands of genes simultaneously.
Scenario 2
A method to separate and detect proteins using a denaturing sodium dodecyl sulphate–polyacrylamide gel with
subsequent transfer to a membrane (usually nitrocellulose) and detection using specific antibodies.
B - DNA fingerprinting « YOUR ANSWER
L - Western blotting« CORRECT ANSWER.
Blotting is a descriptive term for the transfer of molecules out of a gel and onto a filter membrane by a
wicking action, although the term is now used for electrotransfers or vacuum transfers. In the original
description of blotting, Dr Edwin Southern developed the technique to make the gelresolved nucleic acid
more accessible to subsequent manipulation, such as identification by hybridisation – this was Southern
blotting. Northern and Western blotting followed the original nomenclature (perhaps not very helpfully). In
Western blotting proteins are separated on a gel, and blotted (by electrophoretic transfer) then detected
with antibodies specific to the protein of interest. Northern blotting is the similar separation and blotting
of RNA antibodies to RNA.
Scenario 3
An in vitro technique designed to isolate and amplify small, specific segments of DNA between 105- and 108-fold
from insignificant quantities of template.
C - DNA microarray « YOUR ANSWER
H - Polymerase chain reaction« CORRECT ANSWER.
This is a relatively well-established technique that has revolutionised many aspects of molecular biology.
It amplifies DNA to produce adequate amounts for subsequent use. Two synthetic oligonucleotide
primers, typically 20–25 nucleotides in length and complementary to the flanking region of the target
sequence to be amplified, are orientated 5‟ to 3‟. They are hybridised to opposite strands of the target
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----------------------------------------------------------------------------------------------------------------------------
sequence and extended using thermally stable DNA polymerases until the region between the two
primers is completely replicated.
Initial hybridisation of the two oligonucleotides requires heat denaturation of the double-stranded DNA
template. The temperature is then lowered to an optimum at which primers anneal to their complementary
sequences. Finally, polymerase elongation, again requiring an optimal temperature, completes the Page |
synthesis which effectively results in doubling the concentration of the target DNA segment. This cycle is
repeated for 25–35 rounds using commercially available thermal cyclers. 1100
Scenario 4
The transfer of a DNA fragment of interest from one organism to a self-replicating genetic element such as a
bacterial plasmid, and its subsequent propagation in a foreign host cell.
D - DNA sequencing « YOUR ANSWER
A - Cloning « CORRECT ANSWER.
This technology has been widely used since the 1970s, and has become a common practice in molecular
biology laboratories today. To clone a gene, a DNA fragment containing the gene of interest is isolated
from chromosomal DNA using restriction enzymes and then united with a plasmid that has been cut with
the same restriction enzymes. When the fragment of chromosomal DNA is joined with its cloning vector in
the laboratory it is called a recombinant DNA molecule. Following introduction into suitable host cells, the
recombinant DNA can then be reproduced along with the host cell DNA to produce sufficient quantity for
further studies.
(Resources for this subject may be obtained from the book by Bradley, Johnson & Rubenstein entitled
Lecture notes on molecular medicine). (Resources for this subject may be obtained from the book by
Bradley,Johnson & Rubenstein entitled Lecture notes on molecular medicine.)
32. Theme: Audit

A Criterion
B Incident review
C Outcome
D Strategic.
For each of the following situations select the most likely type of audit it would be approprate to use from
the above list. Each option may be used once, more than once, or not at all.
Scenario 1
Assessment of trauma patients who are brought into the Emergency Department unconscious and hypotensive to
evaluate whether colloid fluids were given.
A - Criterion« YOUR ANSWER
D - Strategic« CORRECT ANSWER.
Audit is the systematic critical analysis of the quality of medical care, including the procedures used for
diagnosis and treatment, the use of resources, resulting outcome and quality of life for the patient. A
strategic audit quite literally looks at a strategy to see if it is working. In the context of this question, the
strategy is giving IV fluids and the audit looks to see if they are being implemented appropriately. Audit
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may be subdivided into: medical audit (assessment of patient treatment by doctors) and clinical audit
(assessment of patient treatment by all healthcare professionals).
The audit cycle involves:

1. Observation of existing practice
2. The setting of standards Page |
3. Comparison between observed and set standards
4. Implementation of change 1101
5. Re-audit of clinical practice.
There are many types of audit technique and each has its own pros and cons;
Basic clinical audit - throughput, morbidity, mortality
Incident review - critical incident reporting
Clinical record review
Criterion audit - retrospective analysis judged against chosen criteria
Adverse occurrence screening
Focused audit studies - specific outcome
Global audit - comparison between units
National studies - e.g. NCEPOD.
Scenario 2
The use of emergency IVU.
B - Incident review« YOUR ANSWER
D - Strategic« CORRECT ANSWER
33. Theme: Consent for surgical treatment

A Apply to make the child a ward of court
B No, surgery cannot proceed
C Obtain consent from patient
D Obtain consent from wife
E Yes, surgery can proceed.
For each of the following situations, select the most likely answer from the above list. Each option may be
used once, more than once, or not at all.
Scenario 1
A 24-year-old man found unconscious by the roadside is brought to hospital by ambulance. It is evident that the
patient’s condition is rapidly deteriorating because of an expanding extradural haematoma and he is unable to
give consent. His wife had been contacted and is at the hospital but has expressed her refusal to allow him to be
operated on. Would you proceed against her wishes?
A - Apply to make the child a ward of court« YOUR ANSWER
E - Yes, surgery can proceed« CORRECT ANSWER.
Surgery is needed for the preservation of life and can be performed despite the patient‟s inability to give
consent. The patient‟s wife cannot give permission or stop her husband‟s operation. No adult can act as
legal proxy for any other in the UK with regard to giving consent for surgical treatment.
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Scenario 2
A member of an extreme religious sect has brought their 11-year-old son to hospital with generalised peritonitis
from a perforated appendix. The child’s condition deteriorates and he needs a laparotomy which both parents
adamantly refuse, saying that he will recover through the fervent prayers of members of the sect. Despite
repeated attempts by the surgical team to persuade the parents of this child, they refuse to give consent for the
surgical treatment that the surgeon deems to be essential. What option is available to the surgeon? Page |
B - No, surgery cannot proceed« YOUR ANSWER
E - Yes, surgery can proceed« CORRECT ANSWER. 1102
Surgery is needed for the preservation of life and can be performed despite the patient‟s inability to give
consent. No adult can act as legal proxy for any other in the UK with regard to giving consent for
lifesaving surgical treatment. A parent cannot act as a proxy for a child in denying access to lifesaving or
essential treatment. It is arguable that A and E are both true but as a matter of timing ensuring the safety
of the child (ie an operation) should be undertaken whilst the application is being undertaken. Do not
forget there is always an on call lawyer who has access to an on call judge 24 hours.
Scenario 3
A 70-year-old woman with severe psychiatric illness is undergoing compulsory psychiatric treatment, having been
sectioned under the Mental Health Act. She has a fall in the psychiatry unit and sustains a fracture of the neck of
the right femur for which she is referred forsurgical treatment The orthopaedic surgeon thinks that internal fixation
of the fracture is the best management, in agreement with her psychiatrist. Her psychiatric state does not allow
her to give informed consent for surgery. What process should follow?
C - Obtain consent from patient« YOUR ANSWER
E - Yes, surgery can proceed« CORRECT ANSWER.
The Mental Health Act does not allow for the compulsory treatment of any medical condition other than a
mental disorder. The orthopaedic surgeon may, however, proceed with surgery for the patient‟s fractured
femur if he or she and the patient‟s psychiatrist agree that it is the best form of management for her. It is
good clinical practice to also obtain a second consultant‟s surgical opinion, confirming the need for
operative treatment and to involve the relatives in the decision-making process where possible. Every
clinician should make detailed entries in the patient‟s records and sign and date them.
Scenario 4
A 63-year-old man with a brain tumour refuses any surgery and expresses his wish formally in writing. He is
judged to be mentally competent. The following day he enters into a coma and his wife, who was abroad, arrives
at his bedside and demands that surgical treatment is commenced. Can surgery proceed?
D - Obtain consent from wife« YOUR ANSWER
B - No, surgery cannot proceed« CORRECT ANSWER.
No. Before the deterioration of this patient‟s condition he clearly refused to consent to operative
treatment. Therefore, surgery cannot be performed even when he is unable to express his refusal for such
a seemingly essential intervention.
34. You are a registrar. You have just had your appraisal and despite having passed you feel that you
were woefully underprepared. As such, you are determined to make your job easier for next year. Which
of the following is correct regarding the appraisal process?
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Demonstration of reflection on any compliments or complaints is an essential aspect of appraisal« YOUR
ANSWER (Correct Answer)
The maximum number of appraisals you can have is one per year
You need to demonstrate 25 hours of continuing professional development (CPD) points every year
You need to accumulate 50 CPD points per year
Page |
360 degree feedback is an essential part of the appraisal process. 1103
Appraisal needs to be carried out at least once a year but can be as frequent as you want it to be. You
may struggle to find an appraiser who has the time to do it more than once yearly however!
Guidelines state that you should demonstrate an average of 50 CPD points per year or a total of 250
points over the 5 year revalidation cycle. The difference between an ordinary appraisal and a revalidation
ready appraisal is the addition of formal 360 degree feedback. This therefore is only necessary every 5
years although most doctors will collect the data every year. Reflection on compliments and complaints is
mandatory.
Editor:
Dr Mohammed Shamsul Islam Khan
MBBS (CMC); FCPS-II (Neuro-Surgery)
Medical Officer, Clinical Neuro-Surgery
National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh.
Mobile: +880 1713 455 662, +880 1685 811979.
E-mail: drsikhan@gmail.com
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MyPasTest » MRCS A Online - Jan Exam 2015

It involves several key elements:

2c "Outcomes" Research; ecological studies

07. Theme: The language of the NHS

08. Theme: Death and the law

09. Theme: Types of scientific evidence

13. Theme: Principles of trial design and conduct

15. Theme: Death certification

Audit cycle: Identify issue or problem

18. Theme: Consent

19. THEME: STATISTICS

21. Theme: Basic statistics (taxonomy)

22. Theme: Death certificates

31. Theme: Scientific research techniques

32. Theme: Audit

The audit cycle involves:

33. Theme: Consent for surgical treatment

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