The page number in the footer is not for bibliographic referencingwww.tandfonline.com/ojfp 40 Introduction This new section in the South African Family Practice Journal aims to help registrars prepare for the FCFP(SA) Part I examination (Fellowship of the College of Family Physicians), and will provide examples of the question formats encountered in the written examination, i.e. Multiple choice questions (MCQs), Modified essay question (MEQ) and Critical reading paper (evidence-based medicine). We will present each of these question types according to a theme, as well as a model answer. The themes for the MCQs will be based on the 10 clinical domains of Family Medicine. The MEQs will centre on the six family physician roles, and the critical reading section will include evidence-based medicine and primary care research methods. We trust that this section will fulfil its aim and also present a continuing medical education opportunity to qualified family physicians and general practitioners. Please visit the Colleges of Medicine of South Africa website for guidelines on the Fellowship examination, as well as the unit standards and national learning outcomes: http://www.collegemedsa.ac.za/ view_exam.aspx?examid=102 Please contact Klaus von Pressentin at kvonpressentin@sun. ac.za for feedback and suggestions. General adult medicine This edition’s theme is “General adult medicine”. 1. MCQs (multiple choice questions): general adult medicine A 60-year old man complains of epigastric pain for five weeks which wakes him at night, and which is relieved by meals. He is a smoker (10-15 cigarettes per day) and takes an aspirin-containing, over-the-counter preparation for frequent headaches. His haemoglobin (Hb) is 9.5 g/dl. His blood pressure is 135/80 mmHg and his heart rate is 70 beats per minute. His abdomen is soft on examination, with some tenderness in the epigastric region (no palpable mass). A rectal examination shows no melena. The most appropriate investigation is: A. No investigations indicated B. Arrange a gastroscopy C. Arrange a Helicobacter pylori antibody test D. Arrange an upper abdominal ultrasound scan E Arrange a Barium meal test 2. MEQ (modified essay question): the family physician’s role as consultant You are leading the morning ward round at the emergency centre of your rural district hospital. The community medical service officer who had been on call the previous night asks your advice on the further management of a 25-year-old woman, who works as a teacher at the local high school. She was admitted during his call, and he has treated her for a penetrating wound to the right anterior chest. A pneumothorax was treated with an intercostal drain. She is observed to be stable and the drain is working well the following morning. According to her file, she received treatment a month ago for a human bite wound to her lower lip. During a private conversation before the ward round, the junior colleague voices his concern about how to approach this survivor of intimate partner violence, as both wounds were inflicted by the patient’s boyfriend. The patient lives with her boyfriend and their two children aged four and one years. Discuss your approach to the development of a management plan for this patient in conjunction with your junior colleague. 3. Critical appraisal of research Answer the following questions on the methods used in the linked article: Mash B, Mayers P, Conradie H, et al. Challenges Abstract The new series, “Mastering your Fellowship”, provides examples of the question format encountered in the written examination, Part I of the FCFP(SA) examination. Examples of these question types (according to a theme) will be given in each printed edition of the journal. “General adult medicine” is the theme for this edition and model answers will be available online, but not in the printed edition. Keywords: FCFP(SA) examination, registrars, general adult medicine S Afr Fam Pract ISSN 2078-6190 EISSN 2078-6204 © 2015 The Author(s) REGISTRARS South African Family Practice 2015; 57(4):40-42 Open Access article distributed under the terms of the Creative Commons License [CC BY-NC-ND 4.0] http://creativecommons.org/licenses/by-nc-nd/4.0 Mastering your Fellowship KB von Pressentin* and B Mash Family Medicine and Primary Care, Stellenbosch University *Corresponding author: Klaus von Pressentin, e-mail: kvonpressentin@sun.co.za S Afr Fam Pract 2015;57(4):40-4242 The page number in the footer is not for bibliographic referencingwww.tandfonline.com/ojfp 42 to creating primary care teams in a public sector health centre: a co-operative inquiry: original research.  S Afr Fam Pract. 2007;49(1):17-17a. 3.1 Discuss three ways in which the study design of action research differs from more conventional health science research methods. 3.2 Critically appraise the quality of the reported methods for three key criteria of cooperative enquiry. 3.3 What particular ethical considerations are raised by this type of study? Please visit http://www.safpj.co.za/ for model answers to these questions. Model answers to the questions Question 1 Short answer: Option B. Long answer: This patient has symptoms of peptic ulcer disease and a number of features that suggest possible gastric cancer, i.e. he is older than 55 years of age, and he has upper abdominal pain and a low Hb. These features warrant referral for gastroscopy. An upper abdominal ultrasound scan is more useful when gallstones or pancreatic disease are suspected, and if the gastroscopy is negative. A Barium meal has inferior sensitivity and specificity to gastroscopy for the detection of oesophagitis, peptic ulcer disease and early gastric cancer. Lifestyle changes (quitting smoking and nonsteroidal anti-inflammatory drug cessation), and a proton-pump inhibitor with Helicobacter pylori eradication are recommended additional therapeutic steps. However, a gastroscopy is indicated as an investigation in this patient with suspected “red flag” cancer symptoms and signs. Further reading: Refer to the National Institute for Health and Care Excellence guidelines: • Suspected cancer: recognition and referral. NICE  guidelines [NG12].  National Institute for Health and Care Excellence [homepage on the Internet]. 2015. c2015. Available from: h t t p : / / w w w. n i c e . o r g . u k / g u i d a n c e / N G 1 2 / c h a p t e r / 1 - recommendations#upper-gastrointestinal-tract-cancers • Dyspepsia and gastrooesophageal reflux disease: Investigation and management of dyspepsia, symptoms suggestive of gastrooesophageal reflux disease, or both. NICE  guidelines [CG184].  National Institute for Health and Care Excellence [homepage on the Internet]. 2014. c2015. Available from: http://www.nice.org.uk/guidance/cg184 For South African guidance, please refer to: • Davis S. Eradication of Helicobacter pylori. S Afr Fam Pract. 2014;56(3) [homepage on the Internet]. c2015. Available from: http://www.safpj.co.za/index.php/safpj/article/ viewFile/4019/4889 • Lambiotte M, Van Rensburg CJ. Helicobacter pylori – a moving target: review.  South African Gastroenterology Review. 2013;11(1):12-15. • Naidoo VG. Proton-pump inhibitors: review. S Afr Fam Pract. 2015;57(3):34-38 [homepage on the Internet]. c2015. Available from: http://www.safpj.co.za/index.php/safpj/ article/view/4288/5143 Question 2 The family physician should use his or her position as a consultant to build capability in the clinical team by guiding colleagues towards improvement in the quality of care. The ethos of person- centred care and teaching is central to this approach. The aim of this shared consultation is twofold, i.e. ensuring an evidence- informed plan that is tailored to the patient’s needs and available resources in the context, and ensuring an optimal adult learning experience for the junior colleague. Ideally, the colleague remains the treating physician under the guidance of the family physician. The following steps apply in this management plan. The colleague’s level of experience and competence will determine the degree of input required by the family physician as consultant: 2.1 Establish rapport with the patient, and introduce yourself as a colleague in the management plan. Ask the patient’s consent to join the conversation, and ensure that the shared consultation takes place in privacy. Make sure that the patient’s condition is stable, and allow for the possibility of a follow-up conversation. 2.2 Review the three-stage history (individual, personal and contextual), physical findings and observations and investigations. 2.3 Screen for and confirm the presence of intimate partner violence (IPV) by asking: “Are you unhappy in your relationship?” If the answer is “Yes”, consider clinical aspects, such as human immunodeficiency virus, sexually transmitted infection and pregnancy. Enquire if a criminal case of assault has been reported, and ensure that a J88 form or forensic documentation has been completed. If the police are not yet involved, ensure complete documentation of all the injuries in the clinical notes as they may serve for future reference. 2.4 An effective multidisciplinary team approach is recommended for the management of IPV survivors. Think of other members in such a team who might be available to assist in the facility or community, e.g. a mental health nurse, social worker, legal advisor or victim empowerment unit member. 2.5 Complete a safety assessment. Enquire about the presence of a firearm in the house, any threat to her children, whether or not her partner is capable of killing, whether or not police intervention is necessary, and whether or not there has been any escalation in abuse severity. More drastic measures are warranted by any concern for the patient’s safety. Review her social support network, e.g. family, friends and local resources. Mastering your Fellowship 43 The page number in the footer is not for bibliographic referencingwww.tandfonline.com/ojfp 43 2.6 Consider the psychological aspects (screen for mental health problems), particularly depression, anxiety or post-traumatic distress disorder. 2.7 Consider the legal aspects, and recommend referal for a protection order. (This may be a more effective option than laying a criminal charge, and should be discussed with the patient and a social worker). Local resources include a legal aid nonprofit organisation (NPO), a counselling NPO, and a mental health/ psychiatric nurse or psychologist. 2.8 This patient study may highlight the generic learning need of your colleagues, an opportunity for community- orientated primary care, and an opportunity to improve the quality of care at your institution. Options include asking the junior colleague to present the patient as an anonymous patient study at your journal club, linking with community organisations to design a support programme for IPV survivors, and meeting with the management team to invest in training an in-facility IPV champion. Further reading: • Joyner K, Mash RJ. The value of intervening for intimate partner violence in South African primary care: project evaluation. BMJ Open. 2011;1:e000254 [homepage on the Internet]. c2015. Available from: http://bmjopen.bmj.com/content/1/2/ e000254.full • Joyner K, Mash R. Recognizing intimate partner violence in primary care: Western Cape, South Africa. PLoS One. 2012;7(1): e29540 [homepage on the Internet]. c2015. Available from: http://journals.plos.org/plosone/article?id=10.1371/journal. pone.0029540 • Joyner K, Theunissen L, De Villiers L, et al. Emergency care provision for, and psychological distress in, survivors of domestic violence. S Afr Fam Pract. 2007;49(3):15-15d. Question 3 3.1 As a methodology, Participatory Action Research (PAR) is embedded within the emancipatory-critical paradigm (ECP). With PAR, the reader is required to embrace a different research paradigm, with different values and assumptions to the more orthodox empirical-analytical paradigm of most medical research. The third research paradigm is interpretative-hermeneutic. The key differences between the three types of research paradigms are explained in Table 1. At heart, the ECP involves the creation of new knowledge by transforming or changing the world in which the research is embedded, and reflecting critically on what has been learnt in the process. People in the ECP are neither objects to be measured, nor subjects to be understood, but are rather participants in both the action and research. Contrary to conventional research, the researcher is also a participant in, and not an observer of, the research process. New knowledge in the ECP is generated as a consensus of participants’ learning, and participants may use both quantitative and qualitative techniques in this process. With ECP, the research usually starts with a question on how a particular problem can be solved, with the participants then aligning themselves with solving this problem. In so doing, they generate additional research questions, and in some cases, even redefine the nature of the problem as the process unfolds. The ECP closes the gap between evidence and practice as the learning is immediately put into practice as part of the process. 3.2 The following aspects (Table 2) of the Cooperative Inquiry Group (CIG) process are key quality criteria which could be considered and appraised. (Any three criteria may be used to answer question 3.2). 3.3 All of the usual ethical considerations apply, but some specific issues arise in PAR. Although members of the CIG give their consent to participate, the activities of the group inevitably impinge on other people in the practice environment. Therefore, consent must also be obtained before the group members make observations about others, or examine documents produced for another purpose. The confidentiality of everybody involved should be maintained. Often the group is facilitated by a researcher who is also intending to write up the work for a thesis and publication. Table 1: Key differences between the three main research paradigms Paradigm Empirical-analytical Interpretative-hermeneutic Emancipatory-critical Relationship of the researcher to “reality” Testing and measuring Exploring and interpreting Changing and transforming View of the researched person Object to be measured Subject to be understood Participant in the process View of the truth Correspondence with the facts Coherence within the data Consensus of each person’s learning The research process Predominantly quantitative measurement Predominantly qualitative measurements Participatory, using both quantitative and qualitative techniques The research question • Fixed hypothesis • Set by the researcher • Open-ended question • Set by the researcher • Open-ended question • Negotiated with the group and can evolve Implementation of the results • Recommendations made for action by other people • Generalisable • Insight offered for use by other people • Transferable • Findings implemented as part of the research • Transferable Source: Mash B. African primary care research: participatory action research. Afr J Prm Health Care Fam Med. 2014;6(1), Art. #585, 5 pages S Afr Fam Pract 2015;57(4):40-4244 The page number in the footer is not for bibliographic referencingwww.tandfonline.com/ojfp 44 This intention must be made clear to the group members at the beginning, and ownership of the findings and authorship explicitly discussed. Because of its participatory nature, the “development of the work must remain visible and open to suggestions from others”. Further reading: • Mash B. African primary care research: participatory action research. Afr J Prm Health Care Fam Med. 2014;6(1), Art. #585, 5 pages. Table 2: Key quality criteria of the Cooperative Inquiry Group process Key quality criteria in cooperative enquiry Critical appraisal of reported methods Alignment with purpose The purpose of the CIG is clearly stated, and the group appears to remain aligned with its purpose throughout Ownership of the enquiry process At least four of the six local people authored the paper which implies a significant degree of ownership of the enquiry process Development of reflectivity The group developed its reflections through reflective listening and clarification. Other reflective techniques are mentioned as well, including reflective writing, “blind” writing, free attitude interviews and drawing. The facilitators helped the CIG members to develop their reflective capacity Democratic and collaborative group process Attention to a collaborative and collaborative group dynamic is stated clearly Commitment to both action and reflection The establishment of two practice teams and the publication of an article with the findings indicate a high degree of commitment to action and research. Moreover, each individual had to commit him- or herself to specific action during each consecutive cycle. The two experienced facilitators kept the CIG members accountable with respect to their commitment Documentation of the process A description of how the group process was documented was given in the method section Building of consensus The article describes the process of building consensus in the group at the end of the group process. Instead, the two facilitators appear to have performed qualitative data analysis on the data arising from the CIG, and validated their interpretation with the CIG. The article includes a section in which limitations are debated as part of the overall discussion Transferability The study setting describes the community health centre characteristics, as well as the profile of the community served (disease burden). The findings of this study may be transferred to similar primary care settings in South Africa Construction of new knowledge Knowledge derived from the actions of the group is presented, including lessons learned from the CIG’s practical experience. The final consensus of learning is constructed as key themes and recommendations, which also reflects on the quality of the enquiry CIG: Cooperative Inquiry Group