Ultimate Finals List - GP, Public Health & Epidemiology

Epidemiology

• Read short summary of a prospective cohort study looking at the effect on breast cancer risk of eating fruit and vegetables. Non-significant findings. Asked to think of potential confounders - e.g. obese person eating less fruit causes confounding because real cause of increased cancer risk is earlier onset puberty and more oestrogen produced by peripheral fatty tissue

• Evaluation of evidence - trial abstract, case-control study, strengths & weaknesses, odds ratio, confidence intervals meant, bias, confounding & public health - benefits of exercise - individual, local and national level

• Evaluation of evidence - cross sectional studies

• Public health questions related to alcohol and MI

• Evaluation of evidence: Randomised Controlled Trial on exercise. Asked about study design and how to promote exercise at a National, Local and Individual level. // The woman kept banging on about what we would do if we could not double blind the patient...I went on about standardisation and randomisation but apparently this WAS ALL WRONG!

• Evaluation of evidence station - meta-analysis

• Epidemiology - Cohort study

• Epidemiology - ecological study - a topic we had been told not to learn so I said 'ermm' for ten minutes. Really annoying!!!

• Evaluation of Evidence and Public health: Shown a summary for a meta-analysis into the effectiveness of statins preventing cardiovascular events. Also a forrest plot. Asked what a meta-analysis is and what a Randomised control trial is. Discuss the forest plot. And the second part involves discussing how to implement the statins to the UK: eg Health needs assessment.

• All about what smr meant and what an smr of 244 meant. I didn’t know.

GP

• Diabetic foot check, stocking sensory loss, implications of sensory loss, controlling diabetes & risk factors

• Death certificate, causes of death, when you can actually certify as a HO, refer to coroner? We had been given a lecture on death certification in our revision week which had covered all of this and explained the pitfalls of e.g. putting 'heart failure' or 'old age', as, well as the relevant details and the importance of completing them accurately - 1) Cerebral haemorrhage, Hypertension, Could sign this certificate without any problems 2) I studied this second scenario for a long time (too long to be honest) and I could not find any good reason to refer to the coroner - I was the doctor who had clerked the patient in but he wasn’t actually under my care – I explained this to the examiner and when pressured for an answer at the bell I blurted out “yes!” Think that was wrong in reflection and I should have listened to myself when I was thinking “why can I not sign this?” just rang my friend (the clever girl who wins all the prizes yet thinks she fails…we all have them) and she said she didn’t send either to the coroner. // Death certificates 1) Adenocarcinoma of the prostate for ~ 5 years who developed bony mets and ?secondary to immobility developed bronchopneumonia // One was someone you had clerked in but not under your care since then. I said you could do it as the rules are unclear what "attended" means, apart from that you have see them 14 days before death, but that you would check with the consultant or the coroner to be sure. // all info from the lecture given in revision week. Can you respiratory failure type I & II but not heart/ kidney etc failure.

Public Health

• Needlestick injury - counselling a junior colleague and instructing him on what to do following a needlestick injury. Question about how risk of transmission of infectious diseases is assessed and the rates of transmission of Hepatitis B, C and HIV. - Tx for all ie Anti Rets HIV PEP <72hrs HB booster and HB immuneglobulin Don’t do anything for the Hep C

• Health promotion - alcoholic in hypertension clinic - discuss with him about alcohol, and assess motivation for change and all that stuff

• Health Promotion - encouraging pt to take BP medication

• Health Promotion - woman newly diagnosed with type 2 DM and placed on metformin (noted 'not keen') and given diet regulation advice. At her last check her HbA1c was 6 but this time it has gone up to 10 or so. You need to elicit that she is not taking her metformin but rather tries to control the illness with diet alone. She isn't keen on taking a pill for the rest of her life etc. The point ot this one was to recognise that she has made significant changes to her lifestyle and should be encouraged and congratulated but also needs to know that Metformin is essential etc.

• Health promotion: Asthmatic lady with worsening asthma not taking brown inhaler (because if you dig a bit you find out that she is worried about taking steroids). Still smoking. Asthma worsening. Came to practice nurse for review, and nurse refers on to you (the FY1 Foundation Dr at the practice). Had find out about symptoms and effect on her life, work etc, how she felt, what inhalers she was taking and why not takling brown one, and also smoking cessation advice.

•  Health promotion - advice lady with aortic stenosis to stop smoking, and need for surgery, discuss her fears and prognosis etc. Given sheet to read at beginning with all facts on so didn't have to know anything! // A bit tricky because in the information we were given we were told that if the patient did not have valve replacement when her aortic stenosis became severe she would have a lower life expectancy. The patient kept pushing me to say that she had no choice but to have the surgery and to say if she would die if she didn't have it but although I said this in the terms mentioned on the card I wasn't keen to state this any more bluntly for fear of upsetting her too much in 10 minutes. Besides it said on the card that she was about to meet with the consultant who surely would be better qualified than an FY1 to deal with this difficult discussion of risk/benefit balance?!