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December 2006: Structure your answers for the written paper

How do you answer laterally to maximise marks?

What is meant by 'providing evidence'?

How do you handle the critical appraisal questions with confidence?

How do you answer laterally to maximise marks?

What is meant by 'providing evidence'?

How do you handle the critical appraisal questions with confidence?

The written module of the exam takes place twice a year, after the multiple choice paper.

Sitting two papers in a day, each lasting at least three hours, is hard work for the brain and writing hand. Candidates mostly complain about this and the toilet queues, but, reassuringly, do not usually complain about the fairness and appropriateness of the question content.

Exam format

There are 12 questions, usually consisting of two critical reading questions, two evidence-based questions and eight short essay-type questions.

The total time allocated to this paper is three and a half hours, which gives you 15 minutes to answer each question, with an extra half an hour to read the question stem and, in particular, the extracts from a journal that will be the basis for the critical reading questions.?

Here are some suggestions:

• It is good exam technique to write short, neat, bullet-pointed lists for an answer. Waffle or repetition will not gain you extra marks.
• If you limit yourself initially to 10 minutes per question, it will force you to write short notes and keep to time.
• Try to avoid the pitfall of answering your two favourite questions in great detail and finding you have inadequate time to answer the other questions. Generally, the first things you write down are more likely to gain you marks than extra detail at the end of an answer.
• Make sure you think widely and laterally when answering any of the questions. It's easy to concentrate on a clinical answer to a question about the management of an overweight eight-year-old boy, but this will only be one part of the examiner's expected answer. What about the psychosocial aspects of home and school? Any relevant cultural differences that might affect the consultation? The difficulties of the consultation itself? The involvement of other health agencies or professionals? The educational needs of the consulting doctor?

Viewpoints

Every question can be contemplated from various, possibly contrasting viewpoints – the patient, doctor, practice, family, primary care organisation, the educationalist, the ethicist and society in general.

You don't need to force every answer into this sort of artificial framework, but it should be used to help broaden your answer where needed.

If you're stuck put yourself into the position of an expert in that field. Remember, you are an expert in general practice. Faced with this situation at work, what would you do? What options would you consider and where would you get help from? This is how you should construct an answer.

You cannot second-guess exactly how the examiners expect you to answer and there is no point wasting time worrying about this. You can, however, predict that there will be more than one central theme to a good answer.

Don't forget, a group of examiners discuss and research each question thoroughly, so they have had plenty of time to decide what a good (not perfect), broad answer is. You only have 10 minutes, but so does everyone else.

Nevertheless, each year some amazing answers are written, and if you write something appropriate that was not considered by the examiners who set the paper, additional marks can be given over and above those in the agreed marking schedules.

Objectives

What are your objectives? At least passing, or passing with merit and improving your care of patients? On the day, you want to make absolutely sure

that your main objective (passing) is straightforward, so keep to time. Even if you know that you can get an outstanding mark for the first question, stop if you've run over time and come back at the end. Remember that each question is marked by a different examiner and so they have no knowledge of what you have written in the other 11 answers.

Quoting evidence

The one or two questions concerning ‘evidence' tend to be the most factual questions, and are clearly set with three or four explicit sections to the answer. These are a chance to show how you can interpret and apply relevant evidence from the past two years from the BMJ or BJGP.

Candidates often ask ‘what is quotable evidence?' The answer to this is not just a list citing ‘BMJ, BJGP, BNF, NICE, NSF' and so on. It is important that the answer includes an understanding of current evidence, and that it is appropriately applied and interpreted. The exact reference is irrelevant, but it is better to cite the source if known.

Clearly it is not possible to revise every journal in the world, but you can use articles that impressed you as a GP, especially if they are relevant to wide topics such as the evidence for alternative medicine, delayed prescriptions or patient recall of facts.

Major studies such as ALLHAT or HOPE may be relevant, but you cannot selectively revise as general practice gives the examiners a wide scope of possible question subjects.

The better candidates make use of appropriate evidence well, and score highly for doing so, but if your mind goes blank, don't turn the page. Stop and think: ‘What would I say or think if I were advising an MS patient about treatment in my consulting room now?'

Critical reading

41137585The two critical reading questions are the least popular, and, unless you like them, it is advisable to leave the two questions and the attached reading material to last. It will feel better to have got the majority of the questions out of the way, and it will be more constructive to tackle them in this frame of mind.

If you have kept to strict timekeeping, you now have up to 60 minutes to read the attached material and write your answers. It is definitely worthwhile spending a bit of time in preparation – the questions are bound to have statistical interpretation in them, as it is acknowledged that the critical appraisal skills of doctors are generally weak. This is borne out in the exam each year, with candidates often scoring the least well on these questions.

There will either be an extract or abstract from a qualitative or quantitative paper. You need to recognise the difference and review each article accordingly. Critical appraisal requires you to show the strengths and weaknesses of the paper. The examiners are likely to include a paper that clearly has some good as well as not so good points, rather than a paper that is very good or very flawed.

Day-to-day, real-life interpretation of current evidence often centres on how well a paper helps a doctor with a patient in front of them, and this can be how you answer:

• Is the paper relevant locally?
• Is it trustworthy?
• What do the results show?

It is beyond the scope of this article to look at critical appraisal in depth, but you may find the references listed at the end of this article helpful.

Final points

41137586Having just completed 10 questions of 10 minutes each and spent 60 minutes on critical reading, if you are efficient there will still be 50 minutes left to go back through your answers amending, clarifying and expanding them by lateral thinking.

Further reading

Trish Greenhalgh How to read a paper, BMJ Publishing 1997

Michael Harris and Gordon Taylor Medical statistics made easy, Martin Dunitz 2003

www.clinicalevidence.com and click 'resources' www.npc.co.uk/non_medical/ presentations
www.cebm.utoronto.ca
www.cebm.net
www.nntonline.net/ebm/main_pages/home.asp

Author

Dr Chris Elfes
MRCGP
GP, Swanage, Dorset, GP trainer, MRCGP examiner, nMRCGP assessor

Table 1: Example written questions Table 2: Example question MRCGP_written_tab3 toptips_MRCGPwritten

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