Prepare for Practice Assessment

2020 Exit Examination HKCFP

11 April 2019

Nature of Practice Assessment

Workplace based (family medicine clinic)

Organize and

manage

Application of skills

knowledge

Practice Assessment consists of two Sessions

Session I Today’s main theme

Session II

PMP report

Clinical supervisor

PA Examiners

• Practice setting (Part A)

• Clinic management (Part B)

• Pharmacy (Part C)

• Dangerous drug management (Part CII)

• Random check (PMP review)

• Dangerous drug management (Part CII)

• Medical records (Part D)

• Investigations (Part E) Workshop in August

for more…

Session I

Use the latest version

(April 2019)

• Worked in the practice

for at least three months

• Must be the same as the

Session II

Assessment Tool

higher training

Family Medicine

HKCFP

Prepare your PMP report

You

Higher FM training clinical supervisor

Any day between May 1, 2019 and Oct 31, 2019

Practice Management Package (PMP): marking principle, Appendix

NA

Knowledge of the candidate

Practice in the workplace

Appendix:

References offered

to candidates;

available at

HKCFP website

Practice Management Package (PMP): Attachment

What are these?

Attachments (1 to 11) • Clinic’s information • Operation protocols • PRACTICAL !! • Submitted with the PMP report at

Exit Examination application

Attachment 12 and 13: • For Session II • To be compiled in a specified

period in September to October • Refer to Candidate’s Workshop in

August for details

Practice Management Package (PMP): Attachment

Prepare them now!

Practice Management Package (PMP) items marked with *

Mandatory for passing the respective Part (A / B / C) of the PMP

The whole Part (A / B / C) of the PMP will be marked ‘fail’

Practice Management Package (PMP) Part A (Practice setting)

Sample Sample

Practice Management Package (PMP) Part A (Practice setting)

Sample Sample

Practice Management Package (PMP) Part A (Practice setting)

Sample Sample

Practice Management Package (PMP) grading and comment by assessor

Part B (Clinic Management): same principle as marking Part A

Sample Sample

Sample

Part C (Pharmacy and Drug Labeling) same principle as marking Part A

Sample Sample

Part C II (Dangerous Drugs Management): checklist

Sample Sample

Your knowledge/ practice on five areas:

1. Authorized persons 2. DD receptacle 3. DD storage, check for

expiry 4. Expired DD 5. DD register

Part C II (Dangerous Drugs Management)

Part C II (Dangerous Drugs Management)

Sample

Practice Management Package (PMP) report

Clinical supervisor’s name and signature

Pass grade in: • Part A, B, C, CII • Overall

PMP report

• Submitted with the Exit Examination Application

(deadline: the 1st working day of November)

• Prerequisite to proceed Session II of PA Segment

• Random check (PMP review) in Session II will be based on

your PMP report

Prepare PMP, Random Check, Part CII

• Study well

o Instrument, set-up, facilities, clinic operation / workflows listed in PMP

o Understand, familiar, and able to confidently tell your medical colleagues on

How they work

Their service record keeping and documentations

• At PMP visit (Session I): if you discover something not right

o Try to amend, improve it,

o liaise with your clinic team members / clinic in-charge / Service head

• At the Exam (Session II): if you discover something not right:

o Keep calm

o Point that out in a non-confrontation manner

o Discuss on the way to amend/ improve it

• Relying on the (copies of) materials used by previous

candidate(s) in your clinic

• At Session II (Random Check, Part C II):

o Utter in answering questions

o Needed your clinic staff to give lots of supplementary

information to the PA Examiners

o Search around as if looking for a lost item in the clinic

o Flip back and forth the clinic menu as if never read it before

Prepare PMP, Random Check, Part CII

Session II Random Check (PMP review)

Part C II (dangerous drugs

management)

Part D (Medical Records)

Part E (Investigations)

Random Check (PMP review) What will be

assessed

At your clinic: • Answer the Examiners’ questions

with demonstration as applicable • Similar to PMP visit / Session I

Examiner’s making sheet (PA rating form)

Items selected from: two Parts of the PMP report (A or B; and C) Including relevant Attachments

Your PMP report

What will be

assessed

Examiner’s making sheet (PA rating form) Your PMP report

Part C II (Dangerous drugs management)

Part C II

At your clinic: • Answer the Examiners’ questions

with demonstration as applicable • Similar to PMP visit / Session I

Part D: What are required

1. Collect 300 Medical records of the

patients that had consulted you within a

six-week-period in September / October

2. Summarized them (Attachment 12)

3. On the exam date: provide a room of

adequate audio-visual privacy allowing

up to 3 examiners to read and assess

your record

What to

prepare

Will be announced in August

Part D: areas of assessment What will be

assessed You can show the examiners basic layout of your

medical record

They will read and assess the records in the

room you provided in your absence

They will mark independently according to PA

rating form on 4 areas:

oD1 Legibility

oD2 Basic information

oD3 Anticipatory / preventive care in the recent

12 months

oD4 Consultation notes

300 patients

(headcount) Consulted you during the six-week period in September to October inclusive

For Examination purpose, the medical records, according to your practice, can be:

OR Handwritten records from

the shelf Print-out from

computer system

Part D: collecting suitable records for exam

Should be readily available upon Examiners’ request

May be required to verify on their genuineness e.g. through the clinic computer record system, relevant personnel

What to

prepare

Part D: the 300 medical records What to

prepare

Preventive care

Consultation note Dr. Candidate

Consultation note Dr. Co-worker B

Consultation note Dr. Candidate

Consultation note Dr. Co-worker A

For print out format, each of them should at least include:

Lab report

Referral letter

Patient information

Chronologically the previous five consultations’ notes (as applicable):

For examiner’s reference

The date seen by you as stated in your Attachment 12

Some information in the past consultation notes e.g. Blood pressure, BMI; chronic medications usage, control of medical condition(s) under your clinic’s attention may affect the examiner’s judgement of your consultation note

D2

D3

D4 on those results you handled / followed up in D4 (as applicable)

those you issued in D4 (as applicable)

Part D: Attachment 12 What to

prepare Standard format

Suggested page layout:

~ 20 cases per page

Confidentiality: Do not include

patient’s name, HKID

Examiners will tell you to retrieve ten records from this list for Part D examination

Good medical record keeping

Allow safe, efficient continued care of the patients by you or your co-workers

Standard proposed by

Tips on Good

practice

D1 (Legibility)

the whole case will not be marked

pro-rata mark deduction in total score of Part D

Use abbreviations sensibly • Understood by most general practitioners • Can prepare a ‘reference list of abbreviations’ for

the Examiners: but subject to the Examiner’s judgement

Tips on Good

practice

What will be

assessed

General Expectation on D2 (basic information) and

D3 (anticipatory / preventive care in recent 12 months)

• Organized; template/ summary table preferred

• Should have significant ‘negatives’ e.g. Allergy:

nil known

• ‘blank’ on the template/ table could be regard

as not documented

• Information should be:

o dated

o updated

o consistent across the medical record

Tips on Good

practice

What will be

assessed

D2 (Basic information)

PA rating form (Part D)

• At least 2 generations • Show index patient • Family members: health condition, cause & age of death

if deceased • Show members who are living together

Score in (D2) • Global mark of the ten cases • Pass: ≥ 6.5 out of 10 • Fail: area(s) of deficiency that have

impact to the clinic practice/ patient care

e.g. regular medications from your clinic

Tips on Good

practice

What will be

assessed

D3 (Anticipatory/ preventive care in recent 12 months)

PA rating form (Part D)

Score in (D3) • Global mark of the ten cases • Pass: ≥ 6.5 out of 10 • Fail: area(s) of deficiency that have

impact to the clinic practice/ patient care

Growth chart for all your children patients

e.g. on BMI/ overweight; high BP; smoking

Appropriate to patient’s age / contemporary risk

Tips on Good

practice

What will be

assessed

Attachment 12 (Part D) Serial no.

Patient record number

Patient initials

sex age diagnosis Date of the consultation

Date of first attended the clinic

1 3216 NFK F 25 URTI 20 SEP 2011 18 OCT 2010

2 8839 LKF F 46 DEPRESSION 20 SEP 2011 25 JUL 2011

3* 292 KPW M 87 DM, HT, HYPERLIPIDEMIA

21SEP 2011 18 SEP 1999

If this case (e.g. no. 2) is chosen by the Examiners

D4 (Consultation notes)

This consultation record (i.e. 20 Sep 2011) will be assessed (D4)

PA rating form (Part D)

20/9

What will be

assessed

Tips on Good

practice

D4 (Consultation notes): about good history taking

“a good history” must mean an appropriate and suitably

discriminating history

“this means asking the right question, not every question

(Hoffbrand 1989)

From: Robin C. Fraser. Clinical Method: A general practice approach. 3rd edition

D4 (Consultation notes): Clinical findings

PA rating form (Part D)

Relevant History, Physical Examination;

• Positives: leading to the diagnosis/ working diagnosis

• Important negatives: showing that other significant differential

diagnoses had been considered

• Follow up of significant issue(s) / problem(s) raised in previous visits;

e.g. overweight, smoking, elevated blood pressure

Idea/ concern/ expectation could be important if:

• Volunteered by the patient/ relatives

• In complicated situations: e.g. suboptimal chronic disease control,

diagnostic difficulty, distressed patient

Avoid loaded with irrelevant past information

Tips on Good

practice

D4 (Consultation notes): Diagnosis/Working diagnosis

PA rating form (Part D)

For episodic complaints:

• For straightforward cases, state the diagnosis best derived from

the clinical findings usually sufficient;

• If not possible list two to three most likely differential

diagnoses; e.g.

o Dizziness; ddx: BPPV, vestibulitis

o Weight loss; ddx: bowel pathology?, hyperthyroid

o LUTS, mainly hesitancy; ddx: BPH, Co-existing UTI?

For chronic medical follow ups:

• current status of disease control; e.g. HT, stable; DM suboptimal

control, lipids at target on statin

Add psycho-social status as appropriate; e.g.

• Dx: dementia, care-taker (wife) stress

• Dx: depression, recently employed

Tips on Good

practice

D4 (Consultation notes): Management

PA rating form (Part D)

Score in (D4) • Global mark of

the ten cases • Pass: ≥ 6.5 out of

10 • Fail: area(s) of

deficiency that have impact to the clinic practice/ patient care

Tips on Good

practice

In-line with the diagnosis/ working diagnosis/ ddx

Non-pharmacological advice; e.g.

• on preventing/ treating the problem

• Investigations

• Referrals

Medications prescribed or changed (dose, frequency, directions

for use, duration)

Follow up arrangement

• Fixed: for review of current problems

• ‘Open’ with appropriate advice: for episodic problems e.g. “to

return if no improvement within (a set period of time e.g. one

week) or if (dramatic change in the condition e.g. rash)

develop”

What will be

assessed

1. Ten patients’ records as specified

2. Summarized them (Attachment 13)

3. On the exam date: provide a room of

adequate audio-visual privacy allowing

up to 3 examiners to read and assess the

ten medical records

What to

prepare

Part E: What are required

Part E: areas of assessment

Examiners will assess the ten

records in the room you provided in

your absence

They will mark (independently) your

medical records according to PA

rating form on four areas:

E1 Documentation of the

investigation indication

E2 Justification (50%)

E3 Documentation of the results

E4 Follow up (50%)

i.e. not the Attachment 13

What will be

assessed

Part E: collecting the ten records

They had:

1. investigations initiated and ordered by you; and

2. results of such investigations followed up by you from XX September to YY October, 2019 inclusive (in the same six weeks collection period for Part D)

They can come from the 300 cases listed in your Attachment 12 (Part D)

The investigations can be related to:

Patient’s complaint(s) in episodic/ regular visit

Monitoring of existing / chronic medical conditions

The investigations cannot be, for the sole purpose of:

Health screening / Medical assessment

Monitoring of possible side effects of medication/ treatment in asymptomatic patients, e.g. RFT after using ACEI; Blood liver enzymes after statins; CBP to screen neutropenia on carbimazole

The investigations can be initiated/ ordered before the designated period

What to

prepare

What to

prepare

For each case • assign an ICPC-2 code to the Provisional diagnosis / Chief condition that necessitate the

investigation(s); e.g. T90, R74 • show the code on your summary (Attachment 13)

Among the ten cases • No more than two cases should belong to the same ICPC - 2 “Chapter” (the alphabet)

bi-axial structure; “Chapters” and “components” Chapters

A: General B: Blood, immune system D: Digestive F: Eye H: Ear (hearing) L: Musculoskeletal (locomotion) N: Neurological P: Psychological R: Respiratory S: Skin T: Metabolic, endocrine U: Urology W: Women’s health, pregnancy, family planning X: Female genital Y: Male genital Z: Social problems

Components 1. Complaints and symptoms (code: 01 – 29) 2. Diagnostic, screening and preventive (code: 30 – 49) 3. Medication, treatment, procedures (code: 50 – 59) 4. Test results (code: 60 – 61) 5. Administrative (code: 62) 6. Referrals (code: 63 - 69) 7. Diagnostic/ disease (code: 70 – 99)

• Infectious • Neoplastic • Injuries • Congenital anomalies • Other

Part E: give ICPC-2 code to the ten cases

otherwise total score in Part E will be deducted pro-rata

What to

prepare

must be:

• The results of such investigations followed up by you during the six weeks

period of XX September 2018 to YY October, 2018 inclusive

can be:

• doctor-patient consultation, OR

• telephone or other electronic communications documented on the medical

record as appropriate

Part E: follow up of the results

otherwise total score in Part E will be deducted pro-rata

What to

prepare

For computer print out format, each of them should at least include:

Lab report Date: 4 Sep 2019

Referral letter To: Geriatrics SOPC

What to

prepare

Part E: presenting the ten medical records for Examination

Preventive care

Patient information

Consultation note Dr. Candidate

1 Sep 2019

Retired seafarer With wife. C/O: progressive poor memory 6/12 …..

e.g. confused on date/ events…

…..ADL independent, went out for lunch / market by self…

Quitted smoking / drinking since retired age 60

Exercise: nil regularly

PE: GC sat, normal gait BP 129/78 P 89 euthyroid….

--- AMT 6/10

Imp: cognitive impairment/ ? Dementia or MCI

Mx:

Brief explain cogn. Impairment with pamphlet

Bld test (CBC, L/RFT, FBS, Lipids, TFT, Vit B12,folate, VDRL)

FU 3/52

Consultation note Dr. Candidate

21 Sep 2019

with wife and daughter today

Consult. 1/9/ 2019 refers;

Dementia bld work up (4 Sep 2019): CBC, L. RFT, TFT, Vit B12, folate: N; VDRL: no-reactive

Daughter concerned ….

Imp: cognitive impairment/ likely MCI

Mx:

Suggest SFI CT brain; relatives need time to think about

Encourage regular social activities / exercise. : e.g. visit nearby elderly community center

Refer:

Occ therapist (assessment and training)

Geri SOPC

FU 12/52

Patient: XXX M/72 No: GK 123984

Patient: XXX M/72 No: GK 123984 E1

E3

E3

E4

E4 If applicable

E2: Examiner’s assessment on E1

Please note: the consultation notes content are simulated and not implying a standard of pass or fail in the Exam

Part E: Attachment 13

Confidentiality: Do not include patient’s name, HKID

And

Case no

Diagnosis/ conditions requiring investigation

ICPC-code Tests ordered

1 Generalized malaise

A04 weakness/ tiredness CBC, L/RFT, FBS, TFT, urine C/ST, CXR

2 Anemia ? large bowel pathology

B82 anemia other / unspecified

CBC, Fe profile, CEA, Stool OB X 3

3 Postprandial dyspepsia

D07 dyspepsia / indigestion

OGD, US upper abdomen

4 Annual HT check K86 uncomplicated hypertension

RFT, FBS, Lipid profile, Urine protein

5 Annual HT check K86 uncomplicated hypertension

RFT, FBS, Lipid profile, Urine protein

6 Low back pain L03 low back symptoms / complaints

XR LS spine

7 Hyperlipidemia, newly started on statins

T93 lipids disorder Lipid profile, ALT (medication side effects monitoring)

8 Dystrophic toenails

S22 nail symptoms / complaints

Nail clipping for fungal culture

9 Amenorrhea, pregnancy test negative

X05 menstruation absent / scanty

FSH, LH, Prolactin, TFT, US pelvis PAP smear (opportunistic screening)

10 Hyperthyroidism on treatment (carbimazole)

T85 hyperthyroidism Free T4, TSH

Summary table

Case no: 1

Patient initials:

Clinic record number:

Sex: Age:

Provisional diagnosis / Chief condition requiring investigations: (date of the consultation: DD/MM/YYYY):

ICPC-2 code

Investigations performed:

Results:

Follow up: (date: DD/MM/YYYY)

Comments:

What to

prepare In specified format

Serve to assist the Examiners in assessing the ten medical records

Cases summaries of the ten patients

Case No: 6 Patient initials: LKH Clinic record number: GOSY 1810XY21 Sex: M Age: 83

Provisional diagnosis / Chief condition requiring investigations: (date of the consultation: DD/MM/YYYY): Weight loss, ? Bowel pathology C/O Weight loss 6 to 7 Ib in last 3/12 B O change from daily to once every 3/7 PE GC sat, mild pallor, abd soft non-tender / no mass….PR: empty no mass felt

ICPC-2 code

Investigations performed: CBC, CEA, thyroid function (TSH), stool Occult blood X 3

Results: CBC: Hb 9.8 (low), WBC 4.8, Platelet count 345, CEA 2.0 (ref < 3.0), TSH normal, Stool OB +ve X 1

Follow up: (date: DD/MM/YYYY) Results informed Discussed with patient and daughter… Mx: referral to Surgical SOPC (seek early appointment)

Comments:

T08 (weight loss)

• The code that best describe the case; • Also put down description of the code

• Optional; marks will not be deducted for leaving this section blank • For discussion on investigation justification, limitations of the performance, area of improvement, possible

remedial actions • Preferably avoided: clinic protocols, departmental guidelines, literature references, expert opinions; or general

summary from the medical record • Less than 300 words #

Attachment 13: Case Summary example

• Concise summary from the medical record

• Less than 300 words #

# Section(s) grossly exceed the words limit may be blocked and cannot be seen by Examiners

What to

prepare

• Concise summary from the medical record

• Less than 300 words #

Case no Diagnosis/ conditions requiring investigation ICPC-code Tests ordered

1 Generalized malaise A04 weakness/ tiredness CBC, L/RFT, FBS, TFT, urine C/ST, CXR

2 Anemia ? large bowel pathology B82 anemia other / unspecified

CBC, Fe profile, CEA, Stool OB X 3

3 Postprandial dyspepsia D07 dyspepsia / indigestion

OGD, US upper abdomen

4 Annual HT check K86 uncomplicated hypertension

RFT, FBS, Lipid profile, Urine protein

5 Annual HT check K86 uncomplicated hypertension

RFT, FBS, Lipid profile, Urine protein

6 Low back pain L03 low back symptoms / complaints

XR LS spine

7 Hyperlipidemia, newly started on statins

T93 lipids disorder Lipid profile, ALT (medication side effects monitoring)

8 Dystrophic toenails S22 nail symptoms / complaints

Nail clipping for fungal culture

9 Amenorrhea, pregnancy test negative

X05 menstruation absent / scanty

FSH, LH, Prolactin, TFT, US pelvis PAP smear (opportunistic screening)

10 Hyperthyroidism on treatment (carbimazole)

T85 hyperthyroidism Free T4, TSH

okay

What to

prepare

Attachment 13: Summary Table example

okay

Proposed standard about using investigations:

Workplace Based Assessment (WPBA)

Need further development

• Employs examination and

investigations that are

broadly in line with the

patient’s problems

• Identifies abnormal findings

and results

Competent

• Choose examinations and

targets investigations

appropriately and efficiently

• Understands the significance

and implications of findings

and results, and take

appropriate action

Excellent

• Uses a stepwise approach,

basing further enquires,

examinations and tests on

what is already known and

what is later discovered

MRCGP Examination

On training assessment

Areas of professional competence

Data gathering and interpretation: For clinical judgement, choice of physical examination and investigations and their interpretation

Competency rating

Tips on Good

practice

E2

E4

Tips on Good

practice

About investigation justification (E2)

Investigation can be performed for a number of reasons, some diagnostic,

others therapeutic (House, 1983):

• To confirm or to make more precise a diagnosis suspected …

• To exclude an unlikely but important and treatable disease, …

• To monitor the effect or side effect of medicine, ….

• To screen asymptomatic patients, e.g. cervical cytology …

• To reassure an anxious patient that nothing is seriously wrong, …

• To convince a sceptical patient that something is wrong and that lifestyle

amendments should be made, e.g. liver function in a heavy drinker.

From: Robin C. Fraser. Clinical Method: A general practice approach. 3rd edition

But please note: Asymptomatic

patients of these two groups should not be included in

the Part E of Practice

Assessment

Tips on Good

practice

From: Robin C. Fraser. Clinical Method: A general practice approach. 3rd edition

About investigation justification (E2)

The decision to investigate a patient, as with the decision to

refer, is bases on clinical judgement, which is influenced by

many factors – the clinical findings on history and examination

(including social and psychological factors), the doctor’s

temperament and attitudes, the doctor-patient relationship,

and organizational factors such as the availability of diagnostic

services, the time of the day or night, etc. such decisions are

often finely balanced. In public setting,

consider self-finance basis in

appropriate situations

Tips on Good

practice

From: Robin C. Fraser. Clinical Method: A general practice approach. 3rd edition

About investigation justification (E2) …clinicians should ask themselves before requesting an investigation…

• Why am I ordering this test?

• What am I going to look for in the result?

• If I find it, will it affect my diagnosis?

• How will this affect my management of the case?

• Will this ultimately benefit the patient?

In general, investigations should be performed only when the following criteria are

satisfied:

• The consequence of the result of the investigation could not be obtained by a cheaper,

less intrusive method, e.g. taking a more focused history or using time

• The risks of the investigations should relate to the value of the information likely to be

gained

• The result will directly assist in the diagnosis or have an effect on subsequent

management

E1: Investigation indication documentation E2: Justification

Tips on Good

practice

What will be

assessed

Pitfalls:

• Investigation(s) not in-line with the clinical findings

• Included unnecessary tests / tests of unclear indication (over-investigation)

• Omitted important / discriminating tests (under-investigate); e.g. urine

(micro-)albumin tests in DM patients

• Not the best investigation modality

• Follow up test not performed at appropriate interval

Score in (E2) • Global mark of

the ten cases • Pass: ≥ 6.5 out of

10 • Fail: area(s) of

deficiency that have impact to the clinic practice/ patient care

The investigation ordered by the candidate (you)

Clinical findings and the investigation ordered: documented in the record

Otherwise the whole case will not be marked pro-rata mark deduction

E3: Results documentation E4: Follow up

Tips on Good

practice

What will be

assessed

About the results: • the significance of the results • implication to the patient e.g. FBS 7.3 in a obese patient with

elevated blood pressure Management of comorbidity Pitfalls: • Delayed follow up e.g. fracture cases • Not well considered implication of the results to the patient; e.g.

FBS 7.3; FU: recheck A1c, FBS 3/12. Not managed the high BP and BMI 30, not considered lipids check

• Not managed comorbidity; e.g. Cough 1/12; results: CXR normal. FU: patient reported symptoms resolved. No management on the incidentally found high BP

Score in (E4) • Global mark of

the ten cases • Pass: ≥ 6.5 out of

10 • Fail: area(s) of

deficiency that have impact to the clinic practice/ patient care

The investigation report (copy) available to Examiners; and

The results documented in the record

Otherwise E4 (follow up) of the case will not be marked

pro-rata mark deduction

Prepare for Part D and Part E: Conduct pilot before the cases collection period

• e.g. try to collect cases for one week in your clinic, following the exam requirement

• seek colleagues/ seniors to review your cohort • Advantage:

1. Familiar with the examination format/ requirement that may differ from your usual practice o Use of summary templates (D2, D3) o Collect cases with the investigations meet the

requirement (Part E) o Writing case summaries (Attachment 13) o Presentation of record for examination

2. Identify areas need to improve, e.g. o Consultation documentation (D4) o Discriminating use of investigations (E2) o Follow up of the patient with the given results (E4)

3. Allow estimate of your: time spent / workload / clinic’s affordability (e.g. availability of imaging report during the cases collection period)

To prepare yourself physically

and psychologically

for the case collection

Tips on Good

practice

Enquiry

Specialty Board secretary:

alkyyu@hkcfp.org.hk

Tel: 2871 8899(Alky or John)