Tutorial 17th. September 2018

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1	How to prepare. What to read. Revision system. Study buddies. Statistics. Urogynaecology.
2	RCOG’s sample questions & TOG CPD questions. The RCOG website has   sample obstetric & gynae questions, both EMQs and SBAs. They have featured in the exam. Go through all of them as they make for easy marks. TOG has CPD questions in every issue. They are written by the authors of the TOG articles and likely to be used in the exam. Make sure you can answer all of them from the last 2 – 3 years.
3	Role-play. How to introduce oneself. Really basic, but very important.
4	Role-play. Healthy, nulliparous. Brother with cystic fibrosis. Pre-pregnancy counselling.
5	EMQ. Cystic fibrosis.
6	EMQ. Montgomery & consent.
7	SBA.   Cowden syndrome.

1. How to prepare.

2. RCOG’s sample questions & TOG CPD questions.

3. Role-play. How to introduce oneself.

4. Role-play.

Candidate's Instructions.

This is a roleplay station. You are a year 4 SpR and are in the gynaecology clinic.

The consultant has just left you in charge as she is feeling unwell and has gone to lie down.

Your task is to deal with the patient as you would in real life.

GP referral letter.

Best Medical Centre,

High Road,

Anytown.

Phone: 01882 78998.  E-mail: besthealth@gmail.com

Practice Manager: Mary Wright. B.SC., RGN.

Phone:  01882 78998 ext. 23.

E-mail:  MWbesthealth@gmail.com

Re. Mrs. Bonnie Black,

25 Low Road,

Anytown.

DOB: 28 January 1990.

Phone: 07889 888 132.

Dear Doctor,

Please see Mrs Black who is planning her first pregnancy. Her main concern is that her brother has cystic fibrosis.

This was the first time I had met her although she has been registered with us for 5 years – her health is good and she has no history of serious illness or surgery.

I have explained that I don’t know much about the implications of the brother’s cystic fibrosis for her potential pregnancies and that she needs to talk to an expert. I have stressed that the risk of her having a child with cystic fibrosis is high and that she needs to be aware that there is a distinct likelihood that any pregnancy would be likely to be affected and need TOP.

Yours sincerely,

John P. Clatter.

5. EMQ. Cystic fibrosis.

There is no option list, so you have to decide the correct answer, thus behaving in a model fashion.

Question 1.

A woman is 8 weeks pregnant and known to be a carrier of cystic fibrosis.

Her husband is Caucasian. What is the risk of the child having cystic fibrosis?

Question 2.

A healthy woman attends for pre-pregnancy counselling. Her brother has cystic fibrosis.

Her husband is Caucasian. He has been screened for cystic fibrosis. The test was negative.

What is the approximate risk of them having a child with cystic fibrosis?

Question 3.

A healthy woman is a known carrier of cystic fibrosis. She attends for pre-pregnancy counselling. Her husband has cystic fibrosis.What is the risk of them having a child with CF?

Question 4.

A healthy woman attends for pre-pregnancy counselling. Her sister has had a child with cystic fibrosis. What is her risk of being a carrier?

Question 5.

A woman attends for pre-pregnancy counselling. Her mother has cystic fibrosis.

What is the risk that she is a carrier?

Question 6.

A woman attends for pre-pregnancy counselling. Her mother has cystic fibrosis.

The partner’s risk of being a carrier is 1 in X. What is the risk that she will have a child with CF?

Question 7.

A healthy Caucasian woman is 10 weeks pregnant. Her husband is a known carrier of cystic fibrosis. Which test would you arrange?

Question 8.

A woman attends for pre-pregnancy counselling. She has read about diagnosing CF using cffDNA from maternal blood. Is it possible to test for CF in this way?

Question 9.

A woman and her husband are known carriers of cystic fibrosis.

What is the risk of them having an affected child?

Question 10.

A woman and her husband are known carriers of cystic fibrosis.

What can they do to reduce the risk of having an affected child?

Question 11.

A woman and her husband are known carriers of cystic fibrosis.

Can CVS exclude an affected pregnancy?

Question 12.

A woman with cystic fibrosis is planning pregnancy. Her husband is a carrier of cystic fibrosis. What is the risk of having an affected child?

Question 13.

A woman with cystic fibrosis has a normal delivery of a healthy, 3.2 kg. baby at term. She has been advised not to breastfeed because her breast milk will be protein-deficient due to malabsorption.

Is this advice correct?

Question 14.

A woman with cystic fibrosis has a normal delivery of a healthy, 3.2 kg. baby at term. She has been advised not to breastfeed because her breast milk will contain abnormally low levels of sodium.

Is this advice correct? 

6. Montgomery.

Abbreviations.

BMA:    British Medical Association.

GMC:    General Medical Council.

Question 1.              

Which, if any, of the following statements are true?

Lead-in

A.	The Montgomery ruling largely replaces the Bolam ruling
B.	The Montgomery ruling largely replaces the Chester ruling
C.	The Montgomery ruling largely replaces the Sidaway ruling
D.	The Montgomery ruling is being contested in the European Court by the GMC as it infringes the rights of doctors
E.	The Montgomery ruling is being contested in the European Court by the BMA as it infringes the rights of doctors

Question 2.              

Which, if any, of the following statements are true?

Lead-in

A.	the level of risk, however small, must be disclosed if a patient requests it
B.	the level of risk of damage from a procedure need not be disclosed if < 1%
C.	the level of risk of damage from a procedure need not be disclosed if < 10%
D.	a material risk is one that would be reflected in damages > £100,000 if negligence were proved in court
E.	a material risk is one that would be reflected in damages > £1,000,000 if negligence were proved in court
F.	a material risk is one that involves anatomical damage, not emotional or psychological
G.	a material risk is one that a reasonable person in the patient’s situation would be likely to regards as significant

7. Cowden syndrome.

Scenario 1.

Lead in.

Which feature is associated with Cowden syndrome?

Option list.

A.     albinism

B.     hamartoma

C.     hammer-toe

D.     hypertrichosis

E.     stammer

Scenario 2.

Lead in. Which condition has the highest risk of occurrence in women with Cs?

Option list.

A.     breast cancer

B.     bowel cancer

C.     congenital absence of Müllerian tract derivatives

D.     hypertension

E.     hypothyroidism

Scenario 3.

Lead in. Which gynaecological cancer is a particular risk for women with Cs?

Option list.

A.     Bartholin’s gland cancer

B.     cervical cancer

C.     choriocarcinoma

D.     endometrial cancer

E.     vulval cancer

Scenario 4.

Lead in. Which cancer is more common in men with Cs?

Option list.

A.     breast cancer

B.     colon cancer

C.     melanoma

D.     renal cancer

E.      thyroid cancer

F.      all of the above

Tutorial 6th. September 2018

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6 September 2018

45	Role-play. Complaints
46	Role-play. Androgen insensitivity syndrome
47	Role-play. Shoulder dystocia
48	Viva. Enhanced recovery
49	Viva. Diathermy

45. Complaints.

Candidate’s instructions.

You are a 5^th. year SpR. The consultant responsible for risk management has asked you to teach a new O&G trainee about complaints.

46. Androgen insensitivity syndrome.

Candidate's Instructions.

This is a role-play station. The patient is Anastasia Johnstone. She is 17 years old. She attended the gynaecology clinic 1 month ago with primary amenorrhoea.

Clinical examination showed an apparently normal young woman with normal breast development but absent pubic and axillary hair. The external genitalia appeared normal. Vaginal examination was not attempted.

She has come today for the results of the ultrasound scan and blood results. The scan has shown absence of the uterus. There are no ovaries in the pelvis. There are bilateral groin masses that could be gonads. The blood tests are reported as: Karyotype. 46XY.

Your tasks are to explain the results and their implications and to answer her questions.

47. Shoulder dystocia.

Candidate’s instructions.

You are the on-call SpR for the labour ward. It is an unusually quiet afternoon, with only one patient in labour and she is a healthy para 1 with a previous normal delivery.

There is a new FY1 in the department. She was on call yesterday when there was a difficult delivery due to shoulder dystocia. The baby needed to be resuscitated and the mother sustained a 4^th. degree tear. The FY1 felt completely useless and would like an introduction to shoulder dystocia so that she can be of some practical use the next time she is involved with a case.

The examiner will not react, respond to questions or offer advice.

48. Enhanced recovery.

Candidate's instructions.

You are a newly-appointed consultant. The Clinical Director has asked you to develop a programme for enhanced recovery for inpatient gynaecological surgery.

As a first step, she has asked you to deliver a talk to a unit meeting (all staff can attend) to outline the key features of enhanced recovery. She suspects that little is known by most of the staff about the subject and hopes that your talk will encourage their enthusiastic participation. The examiner will ask you 9 questions pertinent to your talk.

49. Diathermy.

Candidate’s instructions.

This is a structured viva station about diathermy and its uses and complications.

The examiner will ask you 8 questions.

When you have completed an answer you are not allowed to return.

Tutorial 3 September 2018

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41	EMQ. Risk management.
42	Viva. Risk management
43	Role-play. Complaint. Mis-filed combined Ds test report.
44	Role-play. Teach breech delivery
45	Viva. Diathermy

41. Risk management. EMQ.

Lead-in.

The following scenarios relate to risk management / disciplinary procedures.

Pick one option from the relevant option list.

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

Abbreviations.

BMA:   British Medical Association

DOH:    Department of Health.

FY:         Foundation year trainee

GMC:   General Medical Council

MDU:   Medical Defence Union

Option list 1.

A.             allow the practice to continue

B.             stop the practice until a full investigation has been done

C.             stop the practice permanently

D.            arrange an investigation by a senior consultant from another hospital

E.             decide the practice does not involve added risk

F.              declare the risk to be acceptable

G.            cancel admissions for surgery

H.            arrange adverse incident analysis

I.               arrange audit

J.               arrange research

K.             arrange a formal warning for the doctor

L.              arrange retirement for the doctor

M.          arrange dismissal for the doctor

N.            consult the on-call consultant

O.            consult the Clinical Director

P.             consult the Educational Supervisor / College Tutor

Q.            consult the Medical Director

R.             consult the Chief Executive

S.              consult the Postgraduate Dean.

T.             consult the hospital’s lawyer

U.            write to Her Majesty at Buckingham Palace

V.             consult your Medical Defence Body

W.          consult the British Medical Association

X.             consult the RCOG

Y.             report the matter to the GMC

Z.              allow return to work

AA.        allow return to work, but offer support

BB.         arrange a “return to work” package specific to the doctor

CC.         none of the above

Option list 2.

	call for help from the senior midwife
	go back to the labour ward and pretend that nothing has happened
	go back to the labour ward and inform the senior midwife
	phone the GMC
	phone the on-call consultant anaesthetist
	phone the on-call consultant obstetrician
	phone the police
	put the anaesthetist in the recovery position and remove the mask
	none of the above

Scenario 1

You are the Clinical Director. 1 62-year-old Consultant colleague has been off work for 8 weeks with a broken arm sustained in a skiing accident. He sends you a certificate from his specialist to say that he is now fit to return to work. He indicates that he wishes to return to work immediately. What action will you take? Use Option list 1.

Scenario 2

You are the Clinical Director. 1 62-year-old Consultant colleague has been off work for 8 weeks with a severe bereavement reaction to the suicide of a family member. He sends you a certificate from his GP to say that he is now fit to return to work. He indicates that he wishes to return to work immediately. What action will you take? Use Option list 1.

Scenario 3

You are the Clinical Director. 1 62-year-old Consultant colleague has been off work for 6 months after having a coronary thrombosis. He sends you a certificate from his specialist to say that he is now fit to return to work. He indicates that he wishes to return to work immediately. What action will you take? Use Option list 1.

Scenario 4

You are the Clinical Director. A 62-year-old Consultant has returned to work after four months’ sick leave after a coronary thrombosis. He has three cases on his first operating list and all have complications reported by the Sister on the gynaecology ward. What action will you take? Use Option list 1.

Scenario 5.

A Consultant has been in her first consultant post for two months. Three of the four patients on a single operating list develop post-operative wound infections. What action will you take? Use Option list 1.

Scenario 6.

You have recently been appointed Clinical Director. A consultant has been in post for ten years and prefers to operate with the same nurse assistant. No complications have been reported. What action will you take? Use Option list 1.

Scenario 7.

You are the Clinical Director. A consultant has an operating  list in a peripheral unit 20 miles from the main hospital. There is no resident doctor with post-operative care being provided by nurses. The cases dealt with on the list traditionally were minor, day-cases.  You have been told that the consultant, who was appointed 6 months ago, has recently been doing hysterectomies and prolapse repairs to get the waiting list down.  What action will you take? Use Option list 1.

Scenario 8.

You are the Clinical Director. The blood bank informs you that there is a problem with supplies and fully cross-matched blood cannot be guaranteed for tomorrow’s arranged surgical cases. What action will you take? Use Option list 1.

Scenario 9.

You are the on-call SpR. It is 8 pm. The blood bank informs you that there is a problem with supplies and fully cross-matched blood cannot be guaranteed for tomorrow’s arranged surgical cases. What action will you take? Use Option list 1.

Scenario 10.

An SpR is half an hour late for starting his duties on three occasions in one week. His consultant wishes to have this dealt with as a disciplinary matter to “nip it in the bud” and teach him a lesson. He reports it to you, the Clinical Director asking you to discipline the doctor. What action will you take? Use Option list 1.

Scenario 11

An SpR gets into an argument with the senior midwife on the labour ward and in the heat of the moment slaps her across the face. You are the Clinical Director and the matter is reported to you next day. Use Option list 1.

Scenario 12

Your consultant is the Clinical Director and a nasty man. You apply 6 months in advance for study leave for the week before the written part of the Part Ii MRCOG exam. He tells you that he plans to go on holiday at that time and you are not going to get any leave. In addition, he tells you that if you complain about this he will give you a terrible reference and tell all his consultant friends that you are a waste of space in order to ruin your career. What action can you take? Use Option list 1.

Scenario 13

A SpR fails an OSATS, but falsifies his records to indicate that it has been completed satisfactorily. You are the Educational Advisor and this is brought to your attention. What action will you take ?  Use Option list 1.

Scenario 14

You are the Clinical Director. A SpR2 uploaded reflective practice putting himself in a good light after a case which had been handled sub-optimally by him. What action will you take?

Use Option list 1.

Scenario 15

You are an FY2 and assist the senior consultant at a hysterectomy. The operation goes well initially, but then there is a lot of bleeding and a ureter is cut. The consultant urologist attends and repairs the ureter. The woman bleeds vaginally that evening and is taken back to theatre by another consultant and ends up in the ICU. You became convinced during the operation that you could smell alcohol on the consultant gynaecologist’s breath. What are your responsibilities? Use Option list 1.

Scenario 16

When do you need to inform the Consultant on-call? There is no answer on the option list – make your own list.

Scenario 17

When do you need to inform the Clinical Director? There is no answer on the option list – make your own list.

Scenario 18

When do you need to inform the Medical Director? There is no answer on the option list – make your own list.

Scenario 19

When do you need to inform the GMC? There is no answer on the option list – make your own list.

Scenario 20

What are the roles of the BMA and MDU? There is no answer on the option list – make your own list.

Scenario 21

What are the differences between verbal and written warnings? There is no answer on the option list – make your own list.

Scenario 22.

Lead-in.

You are the SpR for the delivery unit. During a quiet moment you head for the staff room adjacent to the operating theatre for a coffee. As you pass the anaesthetic room you hear loud snoring. You look in and find the on-call anaesthetic registrar unconscious on his back on the floor with an anaesthetic mask by his face attached to a cylinder of nitrous oxide.

What action will you take? Pick one option from option list 2.

Scenario 23.

Lead-in.

You are the SpR for the delivery unit. During a quiet moment you head for the staff room adjacent to the operating theatre for a coffee. As you pass the anaesthetic room you hear loud snoring. You look in and find the on-call anaesthetic registrar unconscious on his back on the floor with an anaesthetic mask by his face attached to a cylinder of nitrous oxide.

What action will you take next? Pick one option from option list 2.

Scenario 24.

Lead-in.

You are the Clinical Director. It is the morning after the events in scenarios 22 and 23.

The on-call consultant obstetrician comes to see you are reports what has happened.

What action will you take?

Option list.

	discuss the case with the Chief Executive
	discuss the case with the Medical Defence Union
	discuss the case with the BMA
	discuss the case with the Medical Director
	discuss the case with the most senior person in the personnel department
	discuss the case with the Postgraduate Dean
	report the anaesthetic registrar to the GMC
	resign from being Clinical Director to avoid stress
	summon the anaesthetic registrar to give him a severe telling-off

42. Risk management. Viva.

Candidate’s instructions.

This is a viva station. The topic is the principles underlying risk management.

The viva is unstructured: the examiner will not ask questions.

43. Complaint. Mis-filed combined Ds test report.

Candidate's Instructions.

You are the SpR in the ante-natal clinic. The consultant has been called to the labour ward to help with a case of placenta accreta and you have been put in charge of the clinic.

Mrs Jones had a “combined test” at 11 weeks which gave a risk of Down’s syndrome of 1: 40. The report had been filed in the notes in error by a clerk without being shown to any of the medical or midwifery staff. She attended today for the routine 20 week scan. The ultrasonographer found the report in the notes, realised that no action had been taken and sent her to see the midwife in the antenatal clinic. The midwife told her the result and made arrangements for the patient to see you today.

44. Breech delivery.

Candidate’s instructions.

You are the SpR on call for the delivery unit. It is still unusually quiet. The on-call consultant has been told that you did a brilliant job of explaining normal labour and delivery on a previous occasion. She has asked you to explain vaginal breech delivery to a new FY2, who is keen on a career in O&G.

45. Diathermy.

Candidate's Instructions.

This is a ‘structured conversation’ station about diathermy and its uses and complications.

The examiner will ask you 8 questions.

When you have completed an answer, you are not allowed to return.