Teaching in general practice

January/February 2012

Clinical challenge

Volume 41, No.1, January/February 2012 Pages 79-80

Single completion items

DIRECTIONS Each of the questions or incomplete statements below is followed by five suggested answers or completions. Select the most appropriate statement as your answer.

Questions for this month's clinical challenge are based on articles in this issue. The style and scope of questions is in keeping with the multiple choice questions of the RACGP Fellowship exam. The quiz is endorsed by the RACGP Quality Improvement and Continuing Professional Development Program and has been allocated 4 Category 2 points per issue. Answers to this clinical challenge are available immediately following successful completion online at www.gplearning.com.au. Clinical challenge quizzes may be completed at any time throughout the 2011–13 triennium, therefore the previous months answers are not published.

Case 1

Melissa Knight

Melissa is a final year medical student at your inner city practice. Although she is doing well, you feel her clinical reasoning skills could be improved.

Question 1

Clinical reasoning includes which of the following:

  1. integration of knowledge
  2. weighing of evidence
  3. critical thinking
  4. reflection
  5. all of the above.

Question 2

According to Elstein's recent theory, which of the following combinations of skills are used in clinical reasoning:

  1. intuition and calculation
  2. intuition and analysis
  3. deduction and feedback
  4. hypothesis generation and investigation
  5. teaching and hypothesis generation.

Question 3

In teaching Melissa clinical reasoning, which of the following statements is true:

  1. Melissa should pick up clinical reasoning as she goes along
  2. feedback should be given at the end of the consulting session
  3. an understanding of theoretical concepts is not likely to be useful
  4. clinical reasoning is less helpful in patients well known to the doctor
  5. automation of clinical reasoning may result in missed diagnoses.

Question 4

In teaching Melissa clinical reasoning you would like to:

  1. allow Melissa to attempt a consultation demonstrating her clinical reasoning
  2. deconstruct a consultation focusing on clinical reasoning
  3. undertake a consultation, pausing to allow Melissa to explain the clinical reasoning occurring
  4. undertake a consultation at normal speed.

In what order would it be best to undertake these activities:

  1. 1, 2, 3, 4
  2. 4, 2, 3, 1
  3. 1, 3, 2, 4
  4. 3, 2, 4, 1
  5. 2, 3, 4, 1.

Case 2

Michael Sanderson

Michael is a new Prevocational General Practice Placements Program (PGPPP) intern at your outer suburban practice. You have been asked to supervise him over the next 3 weeks.

Question 5

You wish to give Michael feedback. Which of the following is NOT considered a principle of good feedback:

  1. transmission of information from teacher to learner
  2. facilitating self assessment
  3. positive motivation and self-esteem
  4. providing opportunities to close the gap
  5. using feedback to improve teaching.

Question 6

You provide positive motivation to Michael. Learners can be classified according to their belief patterns. Which of the following statements is true of this classification:

  1. an incremental view describes those who believe there is a limit to what they can achieve
  2. an entity view describes those who believe their ability is dependent on their effort
  3. an entity view learner is more likely to ask for help
  4. entity view leaners should be particularly encouraged to engage in self regulated learning
  5. an incremental view learner has ego involvement in the task.

Question 7

You undertake a random chart review with Michael. Which of the following statements is true regarding feedback:

  1. five feedback comments should be given at each review
  2. random chart reviews allow for delayed feedback
  3. feedback should be provided in relation to predefined criteria
  4. random chart reviews allow for teacher assessment only
  5. feedback should discuss the learner's personal abilities.

Question 8

Which of the following would be a potential 'alarm bell' characteristic of Michael:

  1. self rating his performance lower than his actual performance
  2. unable to justify his mistakes
  3. not learning from past mistakes
  4. always asking for help
  5. constantly seeking feedback
  6. .

Case 3

The teaching practice

Your clinic is a busy practice in a growing regional town. At a recent practice meeting you agreed to consider taking on general practice registrars and medical students some time in the future.

Question 9

You consider your supervisor role. Which of the following statements is true:

  1. teaching registrars usually adds 7 hours per week to a supervisor's session
  2. it is only possible to supervise one level of trainee
  3. time demands on supervisors is usually greatest for registrars
  4. teaching time needs to be incorporated into supervisors' patient schedules
  5. teaching is unlikely to benefit supervisors.

Question 10

You are concerned about patient opinions and safety when there are trainees in the practice. Which of the following statements is true:

  1. most patients dislike being involved in a teaching consultation
  2. consent is not required from patients when seeing a registrar
  3. patients dislike the longer consultation necessary when trainees are involved
  4. patients often view teaching practices negatively
  5. patients should consent to trainee involvement at the time of booking their appointment.

Question 11

The practice manger is concerned about providing orientation for trainees. Which of the following statements is NOT true of orientation:

  1. orientation is of minimal importance for risk management
  2. orientation minimises disruption in the practice
  3. orientation allows trainees to be familiar with practice systems
  4. orientation should include information to reception staff on booking patient appointments with trainees
  5. multiple staff members can be involved in orientation.

Question 12

The business manager wants to know how trainees will affect the practice income. Which of the following statements is correct:

  1. teaching subsidies are available for medical students only
  2. registrars are paid a set weekly wage
  3. junior doctors are not able to bill Medicare items
  4. registrars are employed according to minimal terms and conditions
  5. a provider number is not needed for registrars to bill for Medicare items.

Case 4

Grace Cummings

Grace, aged 14 years, presents to your practice with fever and polyarthritis following a sore throat. You consider acute rheumatic fever in your differential diagnosis.

Question 13

Which of the following statements is true of acute rheumatic fever:

  1. acute rheumatic fever predominantly affects people aged 45–60 years
  2. the incidence of acute rheumatic fever is 250–350 per 100 000 people
  3. acute rheumatic fever is more common in urban areas
  4. acute rheumatic fever occurs 3 days to 3 weeks after a streptococcus infection
  5. acute rheumatic fever only affects Aboriginal or Torres Strait Islander people.

Question 14

Grace describes 3 days of fevers, lethargy and an asymmetrical polyarthritis of her large joints. She had a sore throat 3 weeks ago. Which of the following examination features and investigations would be LESS suggestive of acute rheumatic fever:

  1. subcutaneous nodules
  2. temperature of 38.6°C
  3. c-reactive protein <5 mg/L
  4. prolonged PR interval
  5. positive anti-deoxyribonuclease-B titre with practice systems

Question 15

Which of the following is a minor manifestation of acute rheumatic fever:

  1. fever
  2. polyarthritis
  3. erythema marginatum
  4. subcutaneous nodules
  5. carditis.

Question 16

Grace is diagnosed with acute rheumatic fever. How long does Grace need IM benzathine penicillin G for as secondary prophylaxis:

  1. 1 year
  2. 2 years
  3. 5 years
  4. 10 years
  5. lifelong.

Correspondence afp@racgp.org.au

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