Tutorial 27 October 2014

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Tonight we are having a tutorial on how to criticise a paper by Julie Morris.
The papers she will discuss have been e-mailed and are on Dropbox.
She usually takes about an hour.
Depending on the time remaining, we will try to get through the following topics.

45	How to criticise a paper. Julie Morris.
46	Viva. Non-medical skills.
47	Role-play. Write a prescription
48	Role-play. Fragile X syndrome.

45.   How to criticise a paper. Julie Morris.

         Julie talks about 2 papers that I will send in advance of the tutorial. You won’t get much from the session unless you have read the papers and tried to do a critique.

46.   Candidate's Instructions. Non-medical skills.

         This is a viva station.

It is an unstructured viva and the examiner will not ask any questions other than to confirm your candidate number.

Trainees spend years developing the medical skills necessary to perform well as a consultant. But there are other skills that a good consultant possesses. Outline your views on what these are and how they may be acquired.

47.   Write a prescription.

See separate sheet.

48.   Fragile X syndrome.            

Candidate’s instructions.

You are about to see Mary White who has been booked in with her first pregnancy by the midwife in the antenatal clinic. The midwife has asked you to see her as Mary has told her that there is a family history of Fragile X syndrome.

Your task is to discuss Fragile X syndrome and the implications for Mary, the pregnancy and her father.

Tutorial 23 October 2014

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40	Viva.          Uterine inversion.
41	Role-play. Stillbirth. 6/52 follow-up.
42	Role-play. Sterilisation request.
43	Role-play. Cochrane.
44	Role-play. Neonatal screening.

40.   Uterine inversion.

Candidate's Instructions.

This is a viva station.

The examiner will ask you 7 questions.

1.     What are the risk factors for uterine inversion?

2.     What are the clinical features?

3.     What is the differential diagnosis?

4.     What are the diagnostic features?

5.     What would be your immediate management?

6.     What would be your subsequent management?

7.     What would be your management after the uterus has been replaced and the woman has been resuscitated?

41.   Role-play. Stillbirth. 6/52 follow-up.

Candidate's Instructions.

This is a role-play station.

This is a roleplay station.

Mrs. Brown has come for follow-up 6/52 after delivery of a stillborn baby.

Reduced fetal movements had been noted at 38 weeks.

She was admitted and FDIU was confirmed.

The scan also showed IUGR.

She opted for induction of labour.

Prostin was used and she had a normal delivery 12 hours later.

Effective analgesia was provided by epidural anaesthesia.

There were no complications.

Full investigation, including PM, was normal apart from the birthweight, which was < 5^th. centile.

Your task is to explain the results and advise about the next pregnancy.

42.   Role-play. Sterilisation request.

Candidate's Instructions.

You are a 5^th. year SpR. You are about to see Mrs. Mary Fecund in the gynaecology clinic. There is a referral letter from the GP.

Read the letter and then conduct the consultation with Mrs. Fecund as you would do in the clinic in your hospital.

Perfect Health Centre,

Paradise Lane,

Slagheap.

SLH 678.

Your ref: BRI 07/54843.

Re. Mary Fecund,

The Shoe, High Street, Slagheap.

Dear Doctor,

Please see Mrs Fecund who has too many children. She wishes to be sure she has no more and has asked to be sterilised – one of her friends was sterilised recently which has put her in the mood to have it done.

Yours sincerely,

Dr. John Williams.

43. Role-play. Cochrane.            

Candidate’s instructions.

You are a SpR in year 5.

1.     You have been asked to explain the Cochrane Collaboration and Cochrane Reviews to a new trainee. The trainee will ask 7 questions suggested by the Consultant.

2.     Explain the main elements and findings of the Forest plot below.

44.   Role-play. Neonatal screening.

Candidate’s instructions.

You are a SpR in year 5.

You are in the antenatal booking clinic and about to see Mary Eccles. She has been booked in by a midwife at 10 weeks’ gestation and all is well. She has recently arrived in the UK from the USA and asked about the routine neonatal screening that is done in the UK. She will be having the baby in the UK.

Tutorial 20 October 2014

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35.	Viva. MBRRACE.
36.	Viva. Obstetric surveillance systems.
37.	Role-play.  Request for labial reduction.
38.	Viva. Waiting list prioritisation.
49.	Role-play. Teach trainee fetal blood sampling.

35.   MBBRACE.

Candidate's Instructions.

This is a viva station.

The examiner will ask you 3 questions.

1. What is MBRRACE?                                                  2 marks

2. What is the role of MBRRACE?                              4 marks

3. How will MBRRACE differ from its precursor?   14 marks

36.   Obstetric surveillance systems.

Candidate's Instructions.

This is a viva station.

The examiner will ask you 2 questions.

1. What general data collection systems exist in the UK?                                    4 marks

2. What obstetric surveillance systems exist in the UK and what do they do?   16 marks                 

37.   Role-play. Request for labial reduction.

Candidate's Instructions.

You are the SpR in the gynaecology clinic. Your consultant is on holiday.

You are about to see Mary Adams. The GP letter reads: “Please see Mary who is convinced that her labia are too large and is adamant that she wishes to have them reduced. I have not examined her. Please see and advise”.

Your task is to take a relevant history and advise about investigation and management.

38.   Viva. Operation waiting list prioritisation.

Candidate’s instructions.

Your consultant is away. The waiting-list manager comes to see you. The following patients have been listed by junior staff. The waiting-list manager wants you to:

a. confirm the appropriateness of the proposed treatment,

b. decide the degree of urgency,

c. confirm the appropriateness of the proposed venue,

d. decide any special requirement(s) for each patient.

Name	Age	Clinical Problem	Proposed operation	Venue	Special Needs	Urgency
JK	5	chronic discharge. ? foreign body	EUA	Main theatre
JM	32	1ry. infertility	Laparoscopy + tubal patency tests	Main theatre
GN	77	Vulval cancer. Coronary thrombosis x 2. Unstable angina.	Radical vulvectomy agreed at MDT.	Main theatre
RU	55	PMB x1. Weight 20 stones. (127 kg.) 1 kg. = 2.2 lb. 1 stone = 14 lb.	D&C.	DCU.
LD	32	Menorrhagia. Fibroids. Anaemia.	Vaginal hysterectomy.	Main theatre.
DT	22	Does not want children.	Lap. Steril.	DCU
HB	14	Unwanted pregnancy at 10/52.	TOP	DCU. TOP list.	.
JY	44	GSI.	Anterior colporrhaphy.	Main theatre.
JS	23	Vaginal discharge. Cervical ectropion.	Diathermy to cervix.	DCU
DT	55	3 cm. ovarian mass.	Laparoscopy ? proceed to Hyst + BSO.	Main theatre.
EV	32	CIN3.	Cone biopsy.	DCU
UW	34	Endometriosis	Laparoscopic ablation	DCU
HT	88	Cystocoele/ rectocoele/ 2nd. degree uterine prolapse	Manchester Repair.	Main theatre.
KN	58	Haematuria	Cystoscopy	DCU
JW	18	Menorrhagia & copes badly with menstrual hygiene. Has Down’s syndrome. Sexually active.	Hysterectomy	Main theatre
TB	30	Menorrhagia. 2nd. degree uterine descent. Been sterilised. Jehovah’s witness.	Vaginal hysterectomy and repair.	Main theatre.
BM	55	Stage Ib cancer cervix. Been discussed at MDT. For Wertheim’s hysterectomy. Factor V Leiden. VTE on Pill. On warfarin.	Wertheim’s hysterectomy.	Main theatre.
NU	60	Recurrent rectocoele.	Posterior colporrhaphy.	Main theatre.

39.   Role-play. Teach trainee fetal blood sampling.

Candidate’s instructions.

You are the SpR for the labour ward. Things are temporarily quiet. A new FY2 has joined the department and the Consultant has asked you to teach her the basics of fetal blood sampling.

Tutorial 16 October 2014

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Tonight's topics

31.	Viva. Adverse incident report. 4th. degree tear.
32.	Viva. Neonatal jaundice.
33.	Viva. Write a model for taking an obstetric history for tutorial.
34.	Viva. Headache
35.	Role-play. Pre-menstrual syndrome. Use prepared papers.

31. Viva. Adverse incident report. 4^th. degree tear.

Candidate’s instructions.

Mrs Penelope Jane Brown sustained a 4^th. degree tear after the delivery of her second baby.

Dr. James Peter White conducted the delivery and was asked to write a statement for the Risk Management Team (RMT), to whom the incident has been reported as an adverse clinical incident.

You have been asked to look at Dr. White’s report, comment on it and identify issues that the RMT needs to explore further. You have 15 minutes to read Dr. White’s report, after which you will have a viva with the examiner. The examiner will not lead the discussion and will simply listen to what you have to say.

Dr. White’s Report.

I am Dr. J. White. I have been SpR in obstetrics and gynaecology at the Royal Infirmary for over a year.

On the 27^th. September I was bleeped by a midwife on the labour ward and asked to see a Mrs Brown who needed to be delivered as there had been delay in the second stage and she was becoming exhausted.

On arrival on the labour ward I felt that Mrs Brown was not trying very hard to deliver the baby naturally and that the midwives were not making much effort to encourage her. I advised that they should get her pushing properly and that I would go for a coffee and return in half an hour.

I returned in 50 minutes, having had an important phone call from my wife about arrangements for our forthcoming holiday which was under threat of cancellation. The situation was unchanged and I was not impressed with either the woman’s endeavours or the midwives’ encouragement of her efforts.

Examination showed the head to be mid-cavity. I felt that it could get it out using forceps. The midwives told me that her bladder was empty. I applied the forceps with ease. The baby delivered in good condition. I then noted that she had a 4^th. degree tear. I repaired this in the usual way.

I went on holiday the next day for two weeks and did not see this woman again.

32. Viva. Neonatal jaundice.

Candidate's Instructions.

This is a viva station.

The examiner will ask you 5 questions.

33. Viva. Write a model for taking an obstetric history for tutorial.

Candidate’s instructions.

You are to conduct a tutorial with hospital’s junior obstetricians and midwives about how to take an obstetric history.

You have 15 minutes to prepare the headlines you would put in a model for taking an obstetric history and to consider how you would conduct the tutorial.

Then you will have a viva with the examiner.

The examiner will ask 4 questions.

1. What are your headings?

2. Which clinical situations do you envisage covering?

3. Which teaching methods would you consider for use in the tutorial?

4. Which teaching methods would be most suitable and why.

34. Viva. Headache.

Candidate's Instructions.

This is a viva station.

The examiner will ask you 13 questions!

35. Role-play. Pre-menstrual syndrome.

Candidate’s Instructions.

You are a 5^th. year SpR and about to see Jane Williams in the gynaecology clinic.

You are to take a relevant history and advise her about management of her problem.

Referral Letter.

The Surgery,

Main Road,

Blacktown,

Herts.

Phone 0845 689 432.

Re. Mrs Jane Williams,

35 High Street,

Blacktown.

BK88 4EU

d.o.b. 1 January 1990.

Dear Doctor,

Please see Mrs Williams who has pre-menstrual syndrome. She has tried vitamin B₆ with no benefit.

Yours sincerely,

John P. Evans MRCGP, DRCOG.