Tutorial 31 January 2011

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Tonight we managed 3 of the 4 proposed topics.

51           With regard to adhesions and gynaecological surgery:

1.            Critically evaluate the importance of adhesion formation after surgery.                 8 marks

2.            Justify the steps you would take to reduce the chance of adhesion formation.     12 marks

52           A healthy, nulliparous woman of 35 years attends for pre-pregnancy counselling. Her brother has cystic fibrosis.

1.            Justify the advice will you give about her risk of being a carrier of cystic fibrosis.     

2.            Justify the advice will you give about her risk of having a child with cystic fibrosis if she is found to be a carrier.

3.            What other advice will you give her?

4.            Justify the tests will you arrange.

5.            Critically evaluate the advice you will give about screening the pregnancy for cystic fibrosis.

53           A recently-arrived immigrant woman is referred to the booking clinic at 8 weeks gestation in her first pregnancy. Her GP has investigated a chronic cough and a chest x-ray taken a few days ago has been reported as showing probable tuberculosis.

1.            Critically evaluate the effects of tuberculosis on pregnancy.                

                                                                                                       2 marks.

2.            Critically evaluate the effects of pregnancy on tuberculosis.       

                                                                                                       2 marks

3.            Justify your management in the booking clinic.                  10 marks

4.            Justify your management plan for the remainder of the pregnancy and the puerperium.                                                                                     6 marks              

54           How may the morbidity and mortality associated with vasa previa be reduced?     

We will discuss this subject on Thursday.

There is a  SOGC guideline that is worth reading.   

And a  TOG article from 2008.

Tutorial 27th. January 2011

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Podcast

Tonight we discussed 4 essay topics.

47           Discuss how the risk of malaria in pregnancy can be reduced.   

 There is a Green-top guideline, so you need to prepare this.

48           A primigravid woman attends the antenatal booking clinic at 5 weeks’ gestation. She smells strongly of alcohol. She admits to consuming at least ½ bottle of vodka each day.

1.            Outline the health problems linked to maternal consumption of large amounts of alcohol in pregnancy.                                                                                           8 marks

2.            Justify your management  in the booking clinic.                           8 marks

3.            Justify your management of the remainder of the pregnancy.  4 marks                                                                     

 There is a lot of stuff about this including an RCOG "statement" which replaced a Green-Top.

49           Critically evaluate screening for ovarian cancer.              

50           A nulliparous woman of 18 years attends A&E. She has missed taking her contraceptive pill. You are the SpR in O&G and have been asked to see her.

1. Justify the history you will take.                         4 marks.

2. Justify the investigations you will arrange.      4 marks.

3. Justify the advice you will give.                          12 marks.                

Contraception is a real pain as it is not something gynaecologists practise in the UK. But you have to know it. I have a problem remembering all the Pills and rules and this topic would certainly be on my last-minute-revision list.

Tutorial 24th. January 2011

Website: www.drcog-mrcog.info.

Tutorial 24th. January 2011

Tonight we discussed 4 topics. As usual, there were a number of things that we were not sure about and will need to look up. A visit to the BSCCP is called for to get guidelines for recommended follow-up after diagnosis / treatment of CIN. And this would be something to add to the ever-growing list of things to revise in the weekend before the exam.

I have now got the relevant paper about European guidelines for follow-up. You can find it here:
http://www.bsccp.org.uk/docs/public/pdf/European%20Guidelines%20mgt%20of%20abnormal%20cytology%20Part%202.pdf.

The topics were:

1. Critically evaluate screening for gynaecological cancer.

2.   A nulliparous woman with menorrhagia and fibroids is considering uterine artery ablation. She is concerned about the possible adverse effects of UAE on her fertility and any pregnancy that might ensure.

1.       Critically evaluate the potential impact of UAE and alternative treatment options for the menorrhagia and fibroids on her fertility.                                    8 marks

2.       Critically evaluate the potential effects of UAE on pregnancy.     12 marks

This topic is covered in MCQ paper 9, question 37.

3. A woman books at 8 weeks’ gestation in her first pregnancy. She is concerned because she works in a nursery where there has been an outbreak of cytomegalovirus infection.

1.       Why is CMV important in relation to pregnancy? What  is the probability that she is immune? How is CMV transmitted? What is the incubation period of CMV infection? What are the symptoms of CMV infection in the adult?                                   6 marks

2.       Critically evaluate the management in the booking clinic.                              8 marks

3.       Critically evaluate the management of the remainder of the pregnancy.                6 marks

 

This topic is covered in MCQ paper 1, question 5.

 

4.   This question is about CIN and hysterectomy for non-malignant conditions. A woman is listed for hysterectomy for menorrhagia and fibroids.

1.       Critically evaluate the issues related to CIN that should be considered pre-operatively?                            4 marks

2.       Critically evaluate the management if she has been on routine recall for smears and the pathology report shows no sign of CIN.                                                     2 marks

3.       Critically evaluate the management in the event of the pathology report showing the unexpected presence of CIN3 with apparently complete excision.       6 marks

4.       Critically evaluate the management in the event of the pathology report showing the presence of CIN3 with apparently incomplete excision.                      8 marks

 Write an essay under exam conditions and send it to me and I'll send my version, once I get it written.

Tutorial 20 January 2011

Website: www.drcog-mrcog.info. 

Podcast: http://soundcloud.com/drtmcf/tutorial-20-january-2011

Tonight we discussed an EMQ, which I wrote a couple of hours before.
If you find any errors or bits that are not clear, please let me know.

Botulinum toxin has been the subject of a couple of Green-top guidelines, so is a possible essay topic. Mug it up, there is not much to it and it would be an easy essay to answer. 

EMQ Paper 1, Question 7. Ulipristal.

Lead-in.

The following scenarios relate to ulipristal. For each, select the most appropriate answer from the option list.

Each option can be used once, more than once or not at all.

Scenario 1.

What type of drug is ulipristal?

Scenario 2.

How is ulipristal broken down / excreted?

Scenario 3.

What is the half life of ulipristal?

Scenario 4.

Which drug may prolong the half life of ulipristal?

Scenario 5.

What is the main use of ulipristal?

Scenario 6.

What is the dose of ulipristal?

Scenario 7.

What time-scale applies to the licensed use of ulipristal?

Scenario 8.

What contraceptive advice is given to those using ulipristal?

Scenario 9.

What advice is given to women who are breast-feeding?

Scenario 10.

Can treatment with ulipristal be repeated within 1 month?

Option list.

GnRH analogue.

Selective serotonin reuptake inhibitor.

19-nortestosterone-derived progestogen.

21-hydroxyprogesterone-derived progestogen.

mifepristone derivative.

Selective oestrogen receptor modulator.

Selective progesterone receptor modulator.

Urinary excretion.
Evaporation.

Metabolised by renal cytochrome P450 enzyme system.

Metabolised by hepatic cytochrome P450 enzyme system.

30 mg. with dose repeated if vomiting occurs within 3 hours.

100 mg. with dose repeated if vomiting occurs within 3 hours.

150 mg. with dose repeated if vomiting occurs within 3 hours.

phenobarbitone

valium

erythromycin

12 hours.

18 hours.

32 hours.

72 hours.

120 hours.

Depot-contraception.

Depression.

Emergency contraception.

Menorrhagia.

Termination of pregnancy.

Yes.

No.

Maybe.

Continue.

Discontinue for 36 hours.

Discontinue for 72 hours.

May interfere with contraception containing progestagen.

May interfere with contraception containing oestrogen.

No action if LARC being used.
Changed my mind - I'm going to become a dermatologist.

I deliberately made it a huge list to discourage you from looking there to find an answer before you have made up your mind about what the answer should be.

Then we discussed plans for some essays.
The subjects for the tutorials are not prepared.
The aim is to simulate the exam and you don't get forewarning of the essay topics from the RCOG.
The idea of writing plans or complete essays is to develop technique.
The tutorials are meant to be discussions about what should go into an answer.
And how to add value and meet the requirement to "justify" or "critically evaluate".
It is also good for me to come to the discussions without preparation.
It reminds me of stuff that I need to revise.
But, remember. Nobody knows everything and all of us have errors stored in our heads.
If we agree on something that you know is wrong, let me know.
I wrote the questions shortly before the tutorial, so the markings may need to be adjusted.

A 16-year-old virgin is referred with dysmenorrhoea. You are the SpR and see her in the gynaecology clinic. She is accompanied by her mother.

a.            justify the history you will take.                                 6 marks

b.            justify the investigations you will arrange.                  4 marks

c.            critically evaluate your management.                         8 marks.              

A nulliparous 24-year-old woman presents with hirsutism. You are the SpR and see her in the gynaecology clinic.

a.      justify the history you will take.                          6 marks

b.     justify the investigations you will arrange.            6 marks

c.      justify the management you will suggest.             8 marks               

A 15-year-old girl attends the A&E department on a Sunday afternoon requesting emergency contraception. She is unaccompanied. You are the SpR on call for gynaecology. The A&E consultant has asked you to deal with the problem.

a.      on your way to A&E, you make a list of the crucial issues to address in the consultation. Justify your inclusions in the list.                                           6 marks

b.     justify the investigations you will undertake.       4 marks

c.      critically evaluate your management.               10 marks

        

With regard to botulinum toxin therapy:

a.      describe the mode of action and contra-indications.            4 marks

b.     critically evaluate it use in uro-gynaecology.                         8 marks

c.      critically evaluate its use in general gynaecology.                  8 marks               

We discussed all but the last.

 Send me your answers and I'll send my thoughts.

Tutorial 17 January 2011

Website: http://www.drcog-mrcog.info/.
Podcast: http://soundcloud.com/drtmcf/tutorial-17-january-2011

Tonight we discussed 3 topics:

1.            With regard to smoking in pregnancy:

a.      outline the hazards to the mother                            4 marks

b.     outline the hazards to the fetus / child                      6 marks

c.      critically evaluate how smoking cessation programmes can be made more effective.

                                                                                         10 marks

2.            A 30-year-old woman is referred by her General Practitioner with a breast lump which is thought likely  to be a malignancy.

a.      outline the initial management                                                                  6 marks

b.     outline the management if a diagnosis of breast cancer is made              10 marks

c.      outline the advice you will give re breastfeeding, contraception and subsequent pregnancy.
                                                                                                                     4 marks

                                                                                                                                                                  This lead to the realisation that we needed a fair amount of technical information about breast cancer to produce a really good essay. Back to the drawing board!

3.            Critically evaluate neonatal screening.
It may seem an unlikely topic, but it has changed a lot in recent years and patients would be might ask you about it and expect an answer. This makes it a potential MRCOG topic. It is fully covered in the MCQs. Paper 12, question 10.

 

The podcast can be accessed by clicking on "Tutorial 17 January 2011" above.

Tutorial 13 January 2011

The website is here: www.drcog-mrcog.info.

Tonight we wrote 4 essays. We ran out of steam just before 9 and had a bit of a discussion. The essays were:

A.   A 35-year-old woman presents to A&E at 8 weeks’ gestation with left calf pain and leg swelling. Deep vein thrombosis is suspected.

1.    critically evaluate the immediate management             8 marks

2.    critically evaluate the management of the remainder of the pregnancy and delivery                                                                           8 marks

3.    critically evaluate the advice you will give postnatally   4 marks        

B.   Critically evaluate the prognostic factors in choriocarcinoma          

C.   Discuss the ten top recommendations in the 2003-2005 maternal mortality report.        

D.   A 36-year-old woman presents with amenorrhoea of 3 months.

1.    justify the key facts you will elicit in taking her history.  5 marks

2.    justify the investigations you will arrange.                     5 marks

3.    justify the management you will propose.                   10 marks            

Write your versions under exam conditons and send them to me. I'll send mine. Don't waste your time and mine by cheating by preparing or spending longer than you'll get in the exam.

If you are looking for the podcast, click on "Tutorial 13 January 2011" above.
The website is here: www.drcog-mrcog.info.

Tutorial 10 January 2011

Click on "tutorial 10 January 2011" above to go to the podcast.

You need some background material before you listen - you will find it below.

Tonight's Skype was a disaster. No one could hear anything. I have since tested the microphone I was using and it doesn't work, although it was OK the other night. I'll replace it for Thursday.

We started with a labour ward prioritisation station, such as you would get in an OSCE. There is a technique, which will be demonstrated in the tutorial. The idea is to start practising this technique every time you are in charge of the labour ward. Then such a station will be easy in the exam. I have e-mailed the station we discussed to everyone on my list. If you don't get an e-mail, let me know.

We then discussed a plan for an answer to this question:

"A woman of 48 is referred with erratic vaginal bleeding for six months. She has had an intra-uterine contraceptive in place for five years. She has occasional hot flushes.

1. Justify the things you will focus on in taking her history.

                                                    6 marks

2. Justify the investigations you will perform.     6 marks

3. Justify the advice you will give.                8 marks

Finally we discussed a plan for an answer to this question:
"critically evaluate vitamin supplementation in relation to pregnancy".

Tutorial 6th. January 2011

Tonight we had a bit of discussion about the essays from Monday. Then we looked at plans for a couple of essays. Finally we looked at taking an obstetric history, which you might be asked to do in an OSCE.
It is a good idea to start practising the basic communication techniques you will use in the exam. There is some advice here: http://www.drcog-mrcog.info/communication.htm. If you are not in the UK, you are going to have to get a friend or colleague to act as the patient. With this exercise, it is about introducing yourself, then agreeing the shape of the consultation with the woman and then doing it. If you don't have a plan and just take the history as things come into your head, it will be obviously chaotic to the examiner, who will not be impressed, and you are likely to miss important elements. So, start practising.
I have still not sorted out what equipment I need toimprove the sound quality of the recording. You might ask: "what about improving the content"? My old brain is doing its best! I'll try to get some advice over the weekend to see what can be done.
The podcast of the tutorial is here:

http://soundcloud.com/drtmcf/tutorial-6-january-2011

Tutorial 3.01.2011

Last night we had a mock exam instead of the usual tutorial. As a result, there was little or no conversation on Skype and there is no podcast.
I have e-mailed the topics. Please write answers under exam conditions: no preparation, one A4 sheet of paper and only 26 minutes. Ideally put aside 105 minutes and write all the essays in one session. This will let you see how important it is to have good time-management. It also allows you to experience the physical stress of writing at speed for so long and the need for you to choose a comfortable pen. And may lead you to realise that you need a few similar sessions to build up the stamina in your hand and arm to prevent cramp.
A lot of those who have been in contact or joining in via Skype has not sent me any essays. I fear for you in the exam! I know that writing essays under such circumstances is horrible. It is not what we are used to doing. Then you have to send them to me and you worry that I will think you are stupid and useless. I know how difficult it is to write these essays - I try to write my own. So, I won't think badly of you if your early efforts are not up to the standard. When we do the OSCE training, one of the topics we discuss is the doctor-patient communication barrier, which has many elements. One is the difference in status and the patient's desperate desire to feel that the doctor thinks highly of them. We display similar reactions and needs in this essay-writing business, so it should help give some insights when we get round to this training. In the meantime, it may encourage you to swallow your pride and get on with this most important exercise.
If you don't practise writing essays under exam conditions, you will then do so for the first time in the exam. You will have no idea of the problems involved and you won't have developed the techniques to cope.
You will fail because pride prevented you from preparing properly. Now, that would be really stupid, not the failure to shine in an essy on a topic you have not read for ages or at all.
Please don't send me essays that have clearly been prepared from various sources. You are wasting my time as well as yours. And don't imagine that I am so advanced in my dotage that I will not see what is going on.
The important part of the essay-writing is you going through the process, not my feedback, though I hope that will help you to develop good technique. Practice will let you see the difficulties and your large brain will come up with solutions.
Once I have sent you my reply, you need to write a model answer that you can use in the exam. Use my reply, the MCQs and any other suitable source to get the information you need. But edit it so that it is of a size that you can write in 23 or 24 minutes. This means that you gain some extra time to deal with the essay you have not prepared. Extract the key facts from the model and put them into your revision system, be it cards or whatever, so that you can test your recall.
If you did not get the e-mail with the topics, send me an e-mail and I'll send them.