The page number in the footer is not for bibliographic referencingwww.tandfonline.com/ojfp 29

Introduction

This section in the South African Family Practice journal is aimed
at helping registrars prepare for the FCFP (SA) Final Part A
examination (Fellowship of the College of Family Physicians)
and will provide examples of the question formats encountered
in the written examination: Multiple Choice Question (MCQ) in
the form of Single Best Answer (SBA - Type A) and/or Extended
Matching Question (EMQ – Type R); Short Answer Question
(SAQ), questions based on the critical reading of a journal
(evidence-based medicine) and an example of an Objectively
Structured Clinical Examination (OSCE) question. Each of these
question types is presented based on the College of Family
Physicians blueprint and the key learning outcomes of the
FCFP programme. The MCQs will be based on the ten clinical
domains of family medicine, the MEQs will be aligned with the
five national unit standards and the critical reading section will
include evidence-based medicine and primary care research
methods.

This month’s edition is based on unit standard 1 (critically
appraising qualitative research and leading clinical governance
activities), unit standard 2 (evaluate and manage a patient
according to the bio-psycho-social approach) and unit standard
4 (facilitate the learning of others). The theme for this edition is
child health.

We suggest that you attempt answering the questions (by
yourself or with peers/supervisors), before finding the model
answers online: http://www.safpj.co.za/

Please visit the Colleges of Medicine website for guidelines on
the Fellowship examination:
https://www.cmsa.co.za/view_exam.aspx?QualificationID=9

We are keen to hear about how this series is assisting registrars
and their supervisors in preparing for the FCFP (SA) examination.
Please email us your feedback and suggestions.

1. MCQ (multiple choice question: single best
answer):

A three-month-old child, HIV exposed, with a negative birth
HIV PCR presents to the emergency centre with cough and
dyspnoea. His Z score is +1 and he has no feeding problems.
The respiratory rate is 56/minute, heart rate = 110/minute, and
oxygen saturation in room air is 97%. The child has lower chest
wall indrawing. Chest auscultation reveals scattered crepitations.
The most appropriate antibiotic/s for this child is/are:
a. Intravenous ampicillin
b. Intravenous ampicillin and gentamycin plus oral

cotrimoxazole
c. Intravenous ampicillin plus gentamycin
d. Oral amoxicillin
e. Oral amoxicillin and cotrimoxazole

Answer:

e) Oral amoxicillin and cotrimoxazole

This presentation is common in many public healthcare
institutions. One needs to ensure adherence to the antimicrobial
stewardship programme and the Hospital Level National
Department of Health Paediatric Guidelines (Standard Treatment
Guidelines) when managing this child. These guidelines make
provision for the classification of pneumonia in children as non-
severe, severe and very severe based on the criteria presented
in Table 1.

Based on the criteria outlined in Table 1, the child will be classified
as severe pneumonia and treated with high dose amoxicillin
45 mg/kg/dose for 5 days. In an HIV-exposed child less than one
year old one would add cotrimoxazole to the child’s treatment
and follow this by confirming the HIV status of the child with an
HIV PCR test. In many instances such children are admitted and
placed on intravenous antibiotics which can be quite traumatic
for the family. Table 2 outlines the antibiotic choices.

Abstract

The series, “Mastering your Fellowship”, provides examples of the question format encountered in the FCFP(SA) examination. The
series aims to help family medicine registrars and their supervisors prepare for this examination. Model answers are available
online.

Keywords: FCFP(SA) examination, family medicine registrars

S Afr Fam Pract
ISSN 2078-6190 EISSN 2078-6204

REGISTRARS

South African Family Practice 2019; 61(4):29-35

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,1 M Naidoo,2 LH Mabuza,3 RJ Mash,1 T Ras⁴

1 Division of Family Medicine and Primary Care, Stellenbosch University, South Africa
2 Department of Family Medicine, University of KwaZulu-Natal, South Africa
3 Department of Family Medicine, Sefako Makgatho Health Sciences University, South Africa
⁴ Division of Family Medicine, University of Cape Town, South Africa
Corresponding author, email: kvonpressentin@sun.ac.za

S Afr Fam Pract 2019;61(4):29-3530

The page number in the footer is not for bibliographic referencingwww.tandfonline.com/ojfp 30

Further reading:
• Zar HJ, Jeena P, Argent A, Gie R, Madhi SA. Diagnosis and

management of community-acquired pneumonia in
childhood-South African Thoracic Society Guidelines. S Afr
Med J 2005;95(12):5977-990. Part 2: Dec 2005.

• South African Department of Health. Hospital Level Paediatric
Standard Treatment Guidelines and Essential Medicines List.
Pretoria: National Department of Health 2017.

2. SAQ (short answer question): The family
physician’s role as leader and champion of clinical
governance within the domain of child health

As a district family physician, you have seen the need in the
district to ensure that children below six years are tested for
tuberculosis for their appropriate management.

2.1 As a clinical leader overseeing clinical governance in the
district, discuss how you would coordinate the relevant
team members, indicating the role of each to address this
need? (3 marks)

2.2 Describe how you would explain the pitfalls in the
performance and interpretation of the various Mantoux
test results to your clinicians. (7 marks)

2.3 One of the domains of the South African National Core
Standards addresses Patient Safety, Clinical Governance
and Clinical Care. Briefly outline five (5) relevant aspects
whereby you would demonstrate your clinical leadership in
the setting. (10 marks)

Total: 20 marks

Table 1: Classification of pneumonia in children

Non severe pneumonia Tachypnoea < 60 days old > 60/min

2-12 months old > 50/min

1-5 years old > 40/min

Severe pneumonia As for non-severe PLUS one of the following

Lower chest wall indrawing

Nasal flaring

Grunting

Very Severe Pneumonia As for severe PLUS one of the following

Oxygen saturation < 90%

Inability to feed

Convulsions or altered level of consciousness

Severe chest wall indrawing

< 60 days old

Criteria for admission All children younger than 2 months

Children > 2 months with Impaired level of consciousness

Inability to drink or eat

Cyanosis

Stridor in calm child

Grunting

Room air SaO2 ≤ 92% at sea level

Severe malnutrition

Family unable to provide appropriate care

Failure to respond to ambulatory care or clinical deterioration

Table 2: Antibiotic choices for pneumonia in children

Ambulatory management Inpatient management

Non-severe pneumonia Amoxicillin - oral high dose

Severe pneumonia Amoxicillin - oral high dose If child is unable to swallow or is vomiting:
Ampicillin, IV (change to oral as soon as able).

Very severe pneumonia Ampicillin IV and aminoglycoside IV, or
Ceftriaxone IV;
Switch to oral as soon as there is a response:
Amoxicillin/clavulanate, oral

HIV Add cotrimoxazole if PJP is suspected in an HIV-exposed child less than a year and in any HIV-infected child
not taking PJP prophylaxis.

Add an aminoglycoside to all hospitalised children known to be HIV-infected.

Staph Aureus S. aureus should be suspected in children who fail to respond to therapy within 48 hours or those with
suggestive CXR changes, add cloxacillin.

M. pneumoniae and Chlamydia spp. Suspect if no clinical response to a β-lactam within 48 hours of starting treatment, or if there is
wheezing in children older than 5 years of age, add azithromycin.

Mastering your Fellowship 31

The page number in the footer is not for bibliographic referencingwww.tandfonline.com/ojfp 31

Model answers

2.1 As a clinical leader overseeing clinical governance in
the district, discuss how you would coordinate the
relevant team members, indicating the role of each to
address this need? (3 marks)

The following team members should be considered:
a. Clinicians in all categories (registrars in family medicine,

MOs, community service doctors and interns) and nurse
clinicians. Ensure collaboration of the team with clear
roles; frequent scheduled meetings to monitor progress
and address challenges. The skill to execute and interpret
the screening test (Mantoux) to be mastered by all
clinicians and not relegated to the nurse fraternity.

b. Pharmacy department ensuring equipment and medical
supplies - in this case: the Mantoux test kits (alcohol
swabs, syringes and needles). Consistency in stock
availability to be ensured.

c. Involvement of facility management (CEO and clinical
manager) to ensure administration logistics and human
resources: ensuring staff complement.

2.2 Describe how you would explain the pitfalls in the
performance and interpretation of the various Mantoux
test results to your clinicians. (7 marks)
• The results should be read within 48-72 hours after

administrating the injection, but closer to the 72 hours to
avoid a false negative reading.

• It should be the horizontal induration (hard swelling)
that is measured, not just the visible skin change.

• The PPD result of less than 5 mm, though implies a
negative result, could also mean recent TB infection not
yet detectable by the test. It could also mean severe
immunosuppression leading to failure to mount an
immune response (severe malnutrition, corticosteroid
therapy, cancer therapy, infections (HIV, including severe
TB). In a child who is ill, a negative test does not exclude
infection with TB.

• In severe immunosuppression, a PPD result of 5 mm or
greater can be considered positive.

• A false positive PPD test can result from a previous natural
infection with M. tuberculosis, cross-reaction from non-
tuberculous mycobacteria or the BCG vaccine.

• False negatives in up to 20% of people may result from
immunosuppression, live vaccination from e.g. measles,
polio within the last four weeks, recent or current viral
infections and poor administration technique.

2.3 One of the domains of the South African National
Core Standards addresses Patient Safety, Clinical
Governance and Clinical Care. Briefly outline five (5)
relevant aspects whereby you would demonstrate your
clinical leadership in the setting. (10 marks)

The parameters of patient safety, clinical governance and
clinical care in the National Core Standards are outlined as:
a. Implementation of patient care guided by protocols

designed to meet patients’ needs. Proper screening
of children younger than six years is mandatory if they
present with symptoms and/or signs suggestive of TB,

have a positive contact history or leads to a high index
of suspicion among health workers, including those
with loss of weight and respiratory infections including
pneumonia.

b. Clinical management of priority health conditions –
entailing national priorities, including the United Nations
SDGs for maternal and child health, HIV and tuberculosis.
Proper screening of children for TB and other infections
leads to an increase in pick up rate, timeous management
and reduction of mortality and morbidity.

c. Clinical leadership provided by the health workers (in
this case the Family Physician and his/her team and the
support systems) is aimed at improving patient care.

d. Management of clinical risks and implementation of
preventive intervention, identification of patients with
special needs or at high risk, e.g. pregnant women,
children and the mentally ill. In this case, children below
six years are the high risk group for TB infection.

e. Infection prevention and control – which entails
implementing the Infection Prevention and Control
Program to reduce e.g. the spread of respiratory
infections, including TB.

Suggested answers:

3.1 Explain the concept of the “scientific value” of a
study? (2)

The scientific value of a study is based on the new knowledge
that the study adds to what is already known. The authors
must therefore summarise what is already known (1) in
order to argue for what is not known (the knowledge gap)
and what this study will contribute to the body of scientific
evidence.(1)

3.2 How do the authors argue for the scientific value of this
study? (2)

The aim of the study was to determine “the training needs
of CHWs in respect of childhood disorders and disabilities
in eThekwini”. The authors argue that a number of research
studies show deficiencies and variability in the training of
CHWs, although looking at the references none of these
focuses on childhood disorders specifically.(1) They argue
that CHWs can make an important contribution to child
health and that South African health policy acknowledges
this potential contribution, however, no studies have
specifically investigated their training needs in this area.(1)

No marks should be allocated for summarising the argument
for the social value of the study. The argument for the social
value of the study established the importance or relevance of
the study to society and the health system.

3.3 Explain the importance of giving a “thick description”
to the trustworthiness of qualitative research (2 marks,
any two). (2)

The idea of a “thick description” is related to the concept of
transferability of the study findings.(1) In order for readers to
decide if the findings can be transferred or applied to their
own context, the authors must give a sufficiently detailed
description of the context of the study (1) and profile of
the respondents.(1) If the reader understands who was
interviewed and what their context was, then this helps
them to decide if this is sufficiently similar to their own
context.

3.4 Critically appraise the extent to which the authors offer
a “thick description”. (2 marks, any two) (2)

The authors do not provide a detailed description of the
study context. The health services, communities and
CHWs are not fully described under the “setting”.(1) The
respondents who were interviewed are described in
some detail.(1) The authors appear to be confused as they
equate providing a “thick description” with the provision of
quotations to support the findings.(1)

3.5 Critically appraise the approach to sampling and
sample size. (4)

The authors state that they used criterion-based “purposive
sampling”, which is an appropriate approach to sampling
in a qualitative study.(1) The criteria listed, however, are so
broad that most of the CHWs would presumably meet the
criteria. It is difficult to judge this as the total number of
CHWs available is not described in the setting. The criteria
are more like broad inclusion criteria to define the study
population. How these 28 CHWs were selected on the basis
of pre-existing criteria from the total pool is not clarified.
(1) A similar critique can be made for the key informants.(1)
(2 marks, any two)

It is not clear in the section on “sampling strategy” how many
people the researchers planned to interview initially and
how they planned to make decisions on the sample size.(1)
It is just stated how many people were included in the study.
Later on under the “analysis” it is stated that after the fifth
focus group they decided to stop as saturation of their data
appeared to have been reached.(1) No such explanation is
given for the key informant interviews.(1) (2 marks, any two)

3.6 The authors mention the concepts of “credibility,
dependability and confirmability” to describe the
trustworthiness of the study. What do you understand
by these terms? (3)

Credibility is concerned with the validity of the conclusions
that are drawn from the data and how these conclusions
match the reality being reported on.(1)

Dependability refers to the extent to which similar findings
would be obtained if the study were repeated.(1)

Confirmability refers to the degree of objectivity of the
researcher in data collection and reporting.(1)

3.7 Critically appraise the authors’ argument for the
trustworthiness of the study in terms of credibility,
dependability and confirmability. (6)

The researchers argue that their study is credible because
they audio-taped the participants.(1) They also imply that
interviewing people with “various experiences” added to its
credibility.(1) This seems a somewhat superficial argument
and the credibility would depend on the scientific validity
of all the methods.(1) Specific techniques that can add to
the credibility of the methods might include, for example,
prolonged engagement, peer briefing, triangulation
and member checking.(1) This study has the potential to

Mastering your Fellowship 33

The page number in the footer is not for bibliographic referencingwww.tandfonline.com/ojfp 33

triangulate data that was collected using different interview
techniques and from different types of respondents; how
or if this was done is not mentioned by the authors.(1) (2
marks, any two)

The researchers argue that “dependability was ensured
through keeping a record of the processes of data collection
and methods of analysis.”(1) This refers to what is often
called an audit trail. In other words, an external auditor
could follow the trail of how data was collected through
to how it was analysed step by step.(1) The process of data
collection and analysis is fairly clearly defined. Aspects that
are less clear include how or if data was translated as well
as transcribed and if any software was used to assist the
analysis.(1) Triangulation can also improve the dependability
of the findings.(1) (2 marks, any two)

The researchers argue that “to ensure confirmability (that
the view of the participant was represented rather than the
view of the researcher), bracketing was completed by the
principal author data collection and analysis process.”(1)
The sentence has some grammatical hiccoughs, but more
importantly seems to assert that “bracketing was completed”
without any explanation of how this was actually done.
(1) How did the researchers account for and handle their
own preconceived ideas, expectations, judgements and
prejudices?(1) This is also referred to as one “reflexivity”.(1)
(2 marks, any two)

3.8 Critically appraise how the researchers account for the
limitations of their study. (2 marks, any two) (2)

It is standard practice when reporting on original research
to discuss the methodological limitations of your study
in the discussion section.(1) In this article there is no such
discussion.(1) The authors appear to tangentially discuss
the transferability of their findings in the conclusion, where
they state that the findings are contextualised to three
communities in one district in SA. However they do not
directly argue further for the transferability of the findings
to other contexts.(1)

3.9 The researchers make a number of recommendations
such as the need to train CHWs in “sign language,
physiotherapy exercises, epilepsy, mental health and
how to assist a blind person.” How and why might you
obtain further information to quantify these learning
needs? (2 marks, any two) (2)

Qualitative research is good at exploring the range of
possible learning needs when these are not known.
Qualitative research, however, cannot quantify the extent
to which these needs are shared by all CHWs in the study
population.(1) A descriptive survey of CHWs could measure
the extent to which the learning needs are experienced by
the whole population.(1) In exploratory mixed methods a
qualitative phase to explore a phenomenon is then followed
by a quantitative phase to quantify the issues raised.(1) The
researchers do not consider the need for further research in
the discussion.(1)

Further reading:
• Mabuza LH, Govender I, Ogunbanjo GA, Mash B. African

Primary Care Research: Qualitative data analysis and writing
results. African journal of primary health care & family
medicine. 2014;6(1):1-5.

• Kuper A, Lingard L, Levinson W. Critically appraising qualitative
research. BMJ. 2008;337:a1035.

• CASP Checklists. Critical Appraisal Skills Programme
[homepage on the Internet]. c2018. Available from URL:
https://casp-uk.net/casp-tools-checklists/.

• The Center for Evidence-Based Management. Critical Appraisal
of a Qualitative Study. Resources and Tools. [homepage on the
Internet]. c2018. Available from URL: https://www.cebma.org/
resources-and-tools/.

4. OSCE scenario: Child Health

Objective of station:

This station tests the candidate’s ability to identify and respond
to psychosocial complexity and counsel a mother on the in-
hospital treatment of severe acute malnutrition.

Type of station

Integrated consultation – clinical management, complex
consultation.

Equipment list:
1. Role player – young adult female

2. Road to Health Book information:
• NVD at term; good APGARs; birth weight in normal range
• HIV unexposed
• MUAC < 11.5 cm; Weight for Height z-score < -3

(marasmic)
• Normal growth up to 6 months
• All immunisations up to date

3. Manikin: baby, wrapped up

Instructions for candidate

History / context

On the ward round in the Emergency Centre of the District
Hospital, you see an 8-month-old baby girl with a lower
respiratory tract infection and Severe Acute Malnutrition (SAM).
You instruct the medical officer to manage and admit the baby.

Please consult with this mother, explaining the treatment plan
for her baby, and address any further issues that arise.

Instructions for the examiner

Objectives: This station tests the candidate’s ability to:

1. Identify and respond to psychosocial complexity

2. Counsel a mother on the in-hospital treatment of severe
acute malnutrition

This is an integrated consultation station in which the candidate
has 14 minutes.

Familiarise yourself with the assessor guidelines which details
the required responses expected from the candidate.

S Afr Fam Pract 2019;61(4):29-3534

The page number in the footer is not for bibliographic referencingwww.tandfonline.com/ojfp 34

No marks are allocated. In the mark sheet, tick off one of the

three responses for each of the competencies listed. Make sure

you are clear on what the criteria are for judging a candidate’s

competence in each area.

Please switch off your cell phone.

Please do not prompt the student.

Please ensure that the station remains tidy and is reset between
candidates.

This station is 15 minutes long. The candidate has 14 minutes,
then you have 1 minute between candidates to complete the
mark sheet and prepare the station.

Reference:

• Essential Medicine List, Paediatrics (2017). Chapter 2, Pages
60-70.

Marking template for consultation station

Exam number of candidate:

Competencies (delete what is not applicable) Candidate’s rating

Not competent Competent Good

1. Establishes and maintains a good doctor-patient relationship
Comments:

2. Gathering information
Comments:

3. Clinical reasoning
Comments:

4. Management
Comments:

5. Explaining and planning
Comments:

Overall Comments:

Examiner’s name: Examiner’s signature:

Mastering your Fellowship 35

The page number in the footer is not for bibliographic referencingwww.tandfonline.com/ojfp 35

Guidance for examiner

Competency is defined as the desired outcome of that domain,
achieved in a manner that is effective and safe.

1. Establishes a good doctor-patient relationship: The
competent candidate displays good communication skills,
putting the mother at ease and responding to her concerns.
The good candidate empathically engages with her,
bringing the well-being of the child as the key focus, and
reinforces the role of the mother in the therapeutic team.

2. Gathering information: the competent candidate gathers
sufficient information to identify the mother’s psychosocial
issues. The good candidate explores the link between these
psychosocial concerns and this presentation.

3. Clinical judgement: the competent candidate recognises
the ongoing risk to the child and persists with the admission.
The good candidate also recognises that the mother is at
risk.

4. Management: the competent candidate addresses all
key aspects of managing SAM. The good candidate also
identifies the opportunity to intervene in the psychosocial
issues while the baby is admitted.

5. Explaining and planning: the competent candidate
ensures that the mother understands the diagnosis and
rationale for the in-hospital management plan. The good
candidate also engages the mother on the psychosocial
risks she is facing.

Key issues to consider for examiner (see EML for detail):
1. Doctor-Patient relationship: clues in role-player

presentation – good communication skills needed
• Mother is reluctant to consider admission

2. Gathering information:
• Intimate partner violence by substance-abusing

partner
• Severe financial constraints – no grants in place

3. Clinical judgment:
• the child’s safety and health are of prime importance
• identifying the psychosocial areas for intervention

potentially improves the home environment,
preventing relapses

4. Management:
• Refer to the EML for details – candidate should mention

all important criteria (10-step plan, page 62) – details
of dosing not needed

• Candidate should know how in-patient course is
monitored (daily weighing) and discharge criteria
(page 70)

• Not expected that candidate should reel off list of
psychosocial interventions, rather just identify the
opportunity to intervene

5. Explanation:
• Is the candidate able to bring the mother ‘on board’

with the admission?
• Is the candidate able to make the link between the

clinical presentation and the psychosocial issues
explicit without alienating the mother?

Role play – Instructions for actor
You are a 19-year-old mother who brought your baby to the hospital
because the nurse at the clinic said the child is ‘undernourished’.
Now the doctor has said the child must stay in hospital. You are not
happy with this because you have responsibilities at home.

Opening statement

“Doctor, I know that my child is sick, but why does she need to stay
in hospital? I need to look after my house.”

If asked, tell the doctor:

Your concerns:
• You need to be at home – your boyfriend will return from work

soon and be angry if you are not there.

• What will they do in the hospital that you can’t do at home?
Insist that you want to understand why the hospital admission
is needed.

• When will your baby be discharged?

Your baby:
• Unplanned, but the pregnancy was normal – you gave birth at

the local clinic; she is the most important thing to you, and you
will do anything for her.

• Baby has been well, but in the last two weeks, she has been
irritable and tired, then she started coughing and breathing
funny a week ago.

• All her immunisations are up to date.

• You were breastfeeding, but then your milk dried up 3 months ago.
You’ve been giving the baby porridge (mealie meal), sometimes
with water, sometimes with milk.

Your life circumstances:

• You are unemployed, and financially dependent on your
boyfriend. You live in his shack.

• Sometimes when he is drunk, he beats you.

• Your mother kicked you out when she found out that you
were pregnant in Grade 11 last year – you did not finish
school.

Patient’s notes
S: Young mother, brought 8-month-old child with referral from

PHC clinic for ‘coughing and fast breathing’.

O: Thin, wasted female child. Awake and responsive, but irritable.
Signs of wasting - marasmus.

Temperature 37.7 0C. No skin rashes, no meningism.

Peripheral pulses easily palpable. Heart rate 128 beats/minute.

Tachypnoea, respiratory rate 44/minute. Oxygen saturation on
nasal prongs: 97%.

Intercostal recession, good air entry bilaterally, with course
crepitations left mid-zone.

Hemoglucose test: 4.6 mmol/L.

Haemoglobin: 9.8 g/L.

Some fall-off on growth charts – see RTHB: MUAC < 11.5cm;
Weight for Height z-score < -3.

A: Lower respiratory tract infection + SAM.

P: 1. Admit paediatrics ward – SAM protocol.

2. Start antibiotics – amoxicillin, gentamicin.

3. Review in ward.