Mastering your fellowship

The series, ‘Mastering your Fellowship’, provides examples of the question format encountered in the written and clinical examinations, Part A of the FCFP (SA) (Fellowship of the College of Family Physicians [SA]) examination. The series is aimed at helping family medicine registrars (and their supervisors) prepare for this examination. Model answers are available online.

A. Amitriptyline B. Bed rest C. Blood tests D. Exercise and posture modification E. Psychotherapy F. Refer to the orthopaedic surgeon G. Spinal manipulation H. Traction I. X-rays of the spine Short answer: 1 D, 2 I

Background information to clarifying the underlying reasoning behind the short answers
Lower back pain (LBP) is a common symptom in primary care and clinical practice guidelines evolve with time as new evidence is thrown into the 'meta-analysis mixer'. However, basic principles of evaluation form the cornerstone in the management of LBP. The history and examination are critically important in excluding red flags which include the following: • Malignancy: A history of a diagnosed malignancy or specific alarming symptoms (local symptoms such as pain at night/bone pain, or constitutional symptoms such as unexpected weight loss) may point in this direction. Evaluation of the LBP should also consider the following yellow flags: • Beliefs that pain and activity are harmful.
• Treatment preferences that do not fit with the best practice. • Lack of social support.
Examination of the back uses the 'look, feel, move' approach: Look: The evaluation of the backache can follow the flowchart in Figure 1.
Practice guidelines around the world vary, but most programmes recommend a multimodal approach to spinal rehabilitation. This includes patient education, pharmacotherapy, weight loss, posture modification, exercise therapy to strengthen core muscles and improve strength and flexibility, cognitive behaviour therapy and spinal manipulation therapy (SMT). Spinal manipulation therapy has shown some promise when evaluated in several metanalyses but must be tailored to suit the specific need of the patient. Other physiotherapy modalities evaluated have not been met with any firm evidence-based recommendations.

Back to the extended matching questions
The first patient is overweight, has no red flags and his occupation places him at risk of poor posture and poor physical conditioning. Hence, the recommended next step after patient education would be postural modification and exercise prescription. The second patient is an elderly, post-menopausal woman. She is at risk of osteoporosis. So one needs to exclude a spinal fracture; hence the need for a plain X-ray.

Short answer question: The family physician's role as care provider and consultant
The South African Social Security Agency (SASSA) medical officer (MO) who assesses Disability Grant (DG) applicants at the district hospital where you work as the consultant raises a concern regarding hand disabilities resulting from injuries from fireworks that were managed at the hospital. The SASSA MO requests you to address the management of such injuries at the hospital to prevent or minimise disabilities.
(Total: 20 marks) 1. What would be your immediate response to the SASSA medical officer? (2 marks) 2. As a clinician and consultant family physician at the hospital, what actions would you personally take to try to address the management of fireworks hand injuries at the hospital? (12 marks) 3. On further discussion with the SASSA medical officer, how could you address this problem in the community? (4 marks) 4. As a specialist, how would you utilise the results of the actions you took to address the management of hand injuries at the hospital? (2 marks)

Model answers
1. What would be your immediate response to the SASSA medical officer? (2 marks) • Thank the SASSA MO for the concern and the request. Offer to assist the SASSA MO to have the concern raised with the hospital clinical manager/management. • Thank the MO for highlighting the problem. • I would fulfil my role as a leader of clinical governance responsible for ensuring quality of clinical care, with roles including ensuring clinical competence of staff and capacity building. I would serve as a bridge between the clinicians and management of the hospital, ensuring teamwork to resolve problems and building an enabling working environment and organisational culture.
• I would request more specific information from the MO on gaps in the clinical management noted -inadequate history/examination/investigations/management and rehabilitation? • I would also want to know how big the problem is. How many such hand injuries has he seen? Over what period? What were the extend of the injuries?
2. As a clinician and consultant family physician at the hospital, what actions would you personally take to try to address the management of fireworks hand injuries at the hospital? (12 marks) The consultant family physician is expected to be able to take clinical governance actions to try to address and improve the management of fireworks hand injuries at the hospital such as follows: • Review of current literature and evidence-based management of firework related hand injuries and their management (see further reading suggestions below). • Carrying out an audit of fireworks hand injuries seen and managed at the district hospital. • Conducting morbidity and mortality meetings to review cases where management was inappropriate and potentially landed up in complaints/claims/litigation. • Carrying out quality improvement cycles to address structure/process/clinical outcome issues in the hospital/ skills availability audit for the management of fireworks hand injuries at the district hospital. • Capacity building in collaboration with the referral hospital orthopaedic surgeon to organise a multidisciplinary continuing professional development (CPD) meeting on the management of fireworks hand injuries at the district hospital. This CPD meeting should include the multidisciplinary team, including nursing, occupational therapy and physiotherapy. It may also include more practical sessions on examination of hands, acute management (correct casts), referral pathways, and rehabilitation. • Assessing new staff for clinical competence in management of hand injuries. • Development of protocols, in collaboration with the referral hospital orthopaedic surgeon, for the management of fireworks hand injuries at the district hospital.

On further discussion with the SASSA medical officer, how could you address this problem in the community? (4 marks)
A family physician is expected to be versed in community oriented primary care (COPC) and be able to address health problems like fireworks hand injuries at the community level in a collaborative manner such as teaming-up with the SASSA MO to initiate a community education programme on fireworks safety in the district. The COPC approach could include the following steps: • Approach important role players in the community (ward counsellor, teachers, church).
• Form a team including important role players to address priority issues in the community (you would raise firework related injuries as a problem highlighted from the hospital). • Do an institutional analysis of available resources in the community to assist those with permanent hand injuries/ education. • Implementation of ideas from the team (community education). • Monitoring and reassessment/evaluation.

As a specialist, how would you utilise the results of the actions you took to address the management of hand injuries at the hospital? (2 marks)
As a specialist, the consultant family physician is expected to be able to share experiences with the wider scientific community by the following ways: • Presentation of the audit findings and quality improvement initiatives to the local and district management teams. • Engagement with local community leaders and community newspapers and media to highlight the problem of injuries caused by fireworks. • Conference presentations and publications in scientific journals (providing that ethical approval has been obtained).
Further reading:

Critical appraisal of quantitative research
Read the accompanying article carefully and then answer the following questions (total 40 marks). As far as possible use your own words. Be guided by the allocation of marks with respect to the length of your responses. identify three sentences/phrases that best reflect the authors' starting point, from which the rationale for the research is further explained and/or elaborated on (more than one correct answer possible). (3 marks) 3. Comment critically on the sample used in this study. Were the groups (cases and controls) comparable and were these groups matched appropriately? Comment critically on the authors' choice of performing a secondary analysis of an existing dataset from a primary study. (6 marks) 4. Comment critically on whether objective and validated measurement methods were used to measure the exposure and outcomes? (6 marks) 5. Were confounding factors identified and were strategies to deal with confounding factors stated? (4 marks) 6. 'Subjects with a VF (vertebral fractures) had a significantly lower median BMD (bone mineral density) at spine compared with subjects without a VF (

Model answers to questions
Model answers:

What research question did the authors attempt to answer in this study? Comment on whether this was a clearly focused question with reference to the PICO framework (Population of interest, Intervention or Issue of Interest, Comparison intervention of interest, primary Outcome of interest). (5 marks)
In the text, the authors state that the aim of the study is to further define the prevalence and risk factors for vertebral factors (VFs) in women and men in South Africa -there is no mention of age or limitation to a few facilities in KwaZulu-Natal. However, in the abstract they state that the study was undertaken to compare the demographic profile, clinical risk factors and bone mineral density (BMD) in subjects aged 60 years and over with and without morphometric VFs. The term 'morphometric VFs' was not clearly defined -the only explanation was with reference to the radiological assessment, namely when 'thoracic and lumbar vertebrae were deemed abnormal'. Using the PICO framework for this study, the population of interest (P) would be adult patients (women and men) aged 60-years and older; the issue of interest (I): the presence of morphometric VFs and its associated risk factors. Although there is no explicit comparison intervention of interest, the context (C) is that of five public sector regional hospitals in the eThekwini area, KwaZulu-Natal, which provide an orthopaedic service. The outcome of interest (O) would be the presence of morphometric VFs and its associated risk factors, especially with regard to demographic profile, clinical risk factors and BMD.
This study therefore aimed to answer a specific question. At this stage of the critical appraisal process, it remains to be seen if this focused research question would be able to provide sufficient evidence to further define the prevalence and risk factors for VFs in women and men. 3. Comment critically on the sample used in this study. Were the groups (cases and controls) comparable and were these groups matched appropriately? Comment critically on the authors' choice of performing a secondary analysis of an existing dataset from a primary study. (6 marks)

Considering the introduction section in this article
The study population comprised 197/200 of the control subjects enrolled in a primary study who had vertebral radiographs. The initial study was conducted in five public sector regional hospitals in the eThekwini area, KwaZulu-Natal, which provide an orthopaedic service. For this subsequent analysis presented in this article, the cases are those healthy volunteers from the initial study who have incidentally diagnosed, missed VFs; and the controls for the subsequent analysis are those health volunteers without VFs.
These control subjects were volunteers who were able to give informed consent and did not have a prior history of osteoporosis or hip fractures. However, osteoporosis is often only diagnosed when someone has a fracture. So, a prior history does not exclude the diagnosis of osteoporosis.
In the methods section no details are given on the sample size that is needed to achieve the power necessary to reach conclusions which can be extrapolated to the study population. It is not clear whether a sample size of 197 is sufficiently powered.
Sources of bias could therefore include sampling bias, namely the non-probability sampling technique to sample the controls for the primary longitudinal study undermines the external validity (the ability of the study's results to be generalised to the entire population). As they wanted to establish the prevalence, they could have used a crosssectional study rather than trying to match those with established osteoporosis with those who may not have osteoporosis. Therefore, this article describes an analysis of historical data from a previous study which aimed to match healthy volunteers as controls to patients with osteoporotic hip fractures (cases). Interestingly, no reference is provided to the previous primary longitudinal study on osteoporotic hip fractures, from which the historical dataset is drawn.

Comment critically on whether objective and validated measurement methods were used to measure the exposure and outcomes? (6 marks)
For a research tool or tool to be used in a study, it must be validated for the study setting. The authors used the same criteria for identification of cases and controls, namely the diagnosis of VFs using radiological assessment. Anteroposterior (AP) and lateral radiographic views of the thoracic https://www.safpj.co.za Open Access and lumbar spine were acquired using a standardised protocol. All radiographs were reported by a single blinded experienced specialist radiologist. Thoracic and lumbar vertebrae were deemed abnormal (morphometric fracture), using the 'semi-quantitative Genant method'.
The methods to determine the presence of risk factors included a structured questionnaire which was used to collect demographic details, education level, clinical risk factors for osteoporosis and gynaecological history. The authors did not state whether the Danish Health and Morbidity Survey (to assess alcohol use) and the World Health Organization (WHO) Monitoring Trends and Determinants in Cardiovascular disease scale (MONICA scale) (to determine smoking exposure), were validated for the South African context. Similarly, it is not clear whether the International Osteoporosis Foundation (IOF) calcium intake diary (to quantify calcium intake) was valid for the local context. The authors did state that functional level was assessed using the validated Physical Self-Maintenance Scale (PSMS) and the Lawton Instrumental Activities of Daily Living scale (IADL) scales, which have 'good inter-rater reliability at 0.87 and 0.91, in multiple studies, respectively'. It is not clear from these references (20 and 21), whether these reliability tests were performed in the South African or similar context.
It is not clear how the structured questionnaire was administrated (self vs. researcher). From the results section, we learn that around 40% of respondents had no schooling or had only primary level schooling. Usually, the education level of the survey population should be considered when thinking about how easy it will be for the respondents to interpret and answer a question. Ordinary and everyday language is preferred. Participants with poor English language ability may have required support or an interpreter.
Weight and height were recorded, and body mass index (BMI) was calculated. Presumable these measurements were obtained at the five hospitals, and it is not clear if the researchers ensured calibration and consistency in these measurements.
Fortunately, the BMD measurements at the hip and spine were performed in a standardised manner. To ensure reliability a spine phantom was scanned weekly to determine the coefficient of variation, which was < 1.5%. Bone mineral density T-scores were categorised according to the WHO diagnostic criteria.

Were confounding factors identified and were strategies to deal with confounding factors stated? (4 marks)
Confounding is often referred to as:  The potential for confounding should be considered in the design, implementation and analysis stages of the study. Factors which might be associated with the outcome need to be measured. Multivariate statistical analysis allows for adjustment of multiple variables simultaneously via mathematical modelling, can also be used to 'control' for confounding. In this study, inferential statistics were applied to compare cases and controls. The odds ratio (OR) is the 'measure of association' for a casecontrol study. It quantifies the relationship between an exposure (such as eating a food or attending an event) and a disease in a case-control study. The OR is calculated using the number of case-patients who did or did not have exposure to a factor (such as a particular food) and the number of controls who did or did not have the exposure. The OR tells us how much higher the odds of exposure are amongst casepatients than amongst controls.

'Subjects with a VF (vertebral fractures) had a significantly lower median BMD (bone mineral density
Conversely, the hazard ratio (HR) is a comparison between the probability of events in a treatment/case group, compared to the probability of events in a control group. The HR has also been defined as the ratio of (risk of outcome in one group)/(risk of outcome in another group), occurring at a given interval of time (typically used to compare time to event data between two treatment groups). A HR of 1 means that both groups (case and control) are experiencing an equal number of events at any point in time.
In this study, the authors aimed to describe the risk factors associated with the presence of VFs in the cases subjects.
Confusingly, the authors used the combined 'OR/HR' term in the inferential statical results table (Table 4 of Esaadi et al. 2021). It would have been helpful to the reader to use either the OR or HR in the table and/or text, to guide the interpretation. The median BMD at spine was significantly lower in case subjects with VFs (a median of 0.75 g/cm 2 in cases, compared to a median of 0.87 g/cm 2 in controls). An OR of 0.137 should therefore imply that the odds of having a lower BMD at the level of the spine were lower in cases (subjects who were experiencing the event of interest, VFs) compared to the control group, which is a false interpretation, as a lower BMD should be resulting in more VFs. Logically speaking, it would make more sense to interpret this result as an HR instead; the HR of having a VF was 0.137, reflecting the reduced risk of having a VF associated with a low BMD in the control group.
The Mann-Whitney U-test was used to compare differences between the two independent groups (it is used when the dependent variable is either ordinal or continuous, but the data is not normally distributed or non-parametric).
Because only a sample of the population can be measured, confidence intervals (CIs) (precision) give a range in which you think the real answer lies with a given degree of certainty. For the OR/HR in relation to BMD and screening positive for VFs, we can be 95% certain that the CI of 0.02 -0.95 contains the true population parameter for the OR/ HR. In general, the larger the sample size, the smaller the CI, and vice versa. When the CI of a ratio crosses 1, that is, the range encompasses values showing increased and decreased risk, the statistical significance of the given ratio is weakened.
In descriptive statistics, the interquartile range (IQR), also called the midspread or middle 50%, is a measure of statistical dispersion, being equal to the difference between 75th and 25th percentiles, or between upper and lower quartiles. The IQR is used to describe the statistical dispersion of a nonparametric variable.

Using the acronym READER (Relevance, Education, Applicability, Discrimination, Evaluation and Reaction) to analyse this article's applicability to your own context (take home message). (10 marks)
The READER format may be used to answer this question: • Relevance to family medicine and primary care?
• Education -does it challenge existing knowledge or thinking? • Applicability -are the results applicable to my practice?
• Discrimination -is the study scientifically valid enough? • Evaluation -given the above, how would I score or evaluate the usefulness of this study to my practice? • Reaction -what will I do with the study findings?
The answer may be a subjective response but should be one that demonstrates a reflection on the change possible changes within the student's practice within the South African public healthcare system. It is acceptable for the student to suggest how his or her practice might change, within other scenarios after graduation (e.g. private general practice). The reflection on whether all important outcomes were considered is therefore dependant on the reader's own perspective (is there other information you would have liked to see?).
A model answer could be written from the perspective of the family physician employed in the district health system: This study is relevant to the African primary care context, as screening, diagnosing and treating osteoporotic VFs in a comprehensive manner represent core aspects of a highquality, team-based PHC approach. The authors (Esaadi et al. 2021) stated that: VFs usually … develop insidiously over time, and at presentation patients may have multiple prevalent fractures, with progressive loss of stature and disability. Due to their silent nature, most fractures are undiagnosed and not referred for appropriate treatment.
The authors did not describe the appropriate treatment options available in the public health sector, but this approach supports the preventative and promotive aspects of comprehensive PHC.
In terms of discrimination, the methodological concerns raised (sampling, validity of some of the questionnaires for the South African context and sample size) make any conclusions drawn questionable. Several of the findings in the study were not statistically significant because of the small sample size, and the sample was skewed towards Indian and African individuals. The study setting was also confined to public sector regional hospitals with orthopaedic services in an urban South African city. It would therefore not be possible to generalise the study findings to the wider South African setting, especially the primary care or district health services.
The authors motivated for an increased awareness and screening for osteoporosis in all South Africans, regardless of ethnicity. The authors recommended further studies to determine the population-based prevalence and clinical risk factors of VFs in SA to guide screening and management protocols. The study may be discussed with the local clinical team and used as a basis for creating awareness regarding the undiagnosed and potentially unmet need of osteoporosis in PHC. It is unlikely that this study will affect a change in policy direction, largely because of its limitations, but it could help make the case for further research of a more robust design. The individual primary care provider and his or her team may be reminded about the potential risk factors for osteoporosis, specifically in patients who present with known risk factors. Access to BMD measurements and osteoporosisrelated medical therapy at PHC level is a significant constraint at primary care level. This will necessitate careful planning and care coordination in consultation with the specialist colleagues at the referral hospital.

Objective of station:
This station tests the following: • Ability to gather information, synthesise an assessment, and develop a management plan for a patient with chronic musculoskeletal pain. • Application of relevant knowledge in the diagnosis and management of lumbar radiculopathy.

Type of station: Simulated consultation
Equipment list: • Middle aged role player • Clinical examination findings • X-ray image

Instructions to candidate:
You are working in the outpatient department of the community health centre, and consult with the following patient, referred to you by the nurse practitioner.
Your task: • Conduct a consultation with this patient, developing a comprehensive assessment and management plan. • Write down your assessment and management plan.

Instructions for the examiner
This station tests: • Ability to gather information, synthesise an assessment, and develop a management plan for a patient with chronic musculoskeletal pain. • Application of relevant knowledge in the diagnosis and management of lumbar radiculopathy.
This is an integrated consultation station in which the candidate has 15 min.
Familiarise yourself with the Assessor guidelines which details the required responses expected from the candidate.
No marks are allocated. In the mark sheet (Figure 2), 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 cellphone.
Please do not prompt the student.
Please ensure that the station remains tidy and is reset between candidates.

Guidance for assessors
Competency is defined as the ability to complete a task in a safe and effective manner. The examiner as an expert uses his or her judgement to categorise the candidate's performance. Examiners must be well versed with the case, and the content matter.
Establishes doctor-patient relationship: • The 'competent' candidate is respectful, listens carefully to the patient narrative, and elicits emotional cues. The 'good' candidate engages empathically with the patient's suffering, facilitates the patient narrative, and responds compassionately.

Gathering information:
• Key findings on history: pain started about a year ago, progressive worsening, starts in lower back and radiates Exam number of candidate:

Competencies
Not competent Competent Good to foot, worse when sitting for some time, no perineal or bladder impairments, impacts on function as a truck driver, breadwinner. • Key findings from examination: increased BMI (38 kg/ m 2 ), limited straight leg raise on left, decreased ankle jerks on affected side, and left-sided calf muscle wasting. • Key findings from x-ray: multi-level degenerative changes in lumbar spine (Figure 3). • The competent candidate identifies sufficient information to develop a working diagnosis of lumbar radiculopathy and some aspects of the psychosocial dimensions/impact of the problem. The good candidate elicits sufficient information to make a comprehensive three stage assessment, with clear identification of ongoing risk factors.
Clinical reasoning: • The competent candidate makes a working diagnosis that includes key elements (L5-S1 radiculopathy + high BMI + occupational impact). The good candidate develops a comprehensive three stage assessment, and identifies opportunities for health promotion.
Explaining and planning: • The competent candidate uses non-technical language to explain the diagnosis and management plan. The good candidate shares information and actively elicits questions, provides options for intervention and cocreates a plan that is acceptable and feasible to the patient.

Management:
• The competent candidate has a management plan that will adequately address the key problem, incorporating pharmacological and non-pharma modalities, including the need for surgical referral. The good candidate has a comprehensive plan that includes pain management, proactively addresses ongoing risks and health promotion, within a multidisciplinary framework.

Patient:
You are a 59-year-old man/woman.

Opening statement:
'Doctor, please help me … I have this problem which is making my life very difficult!' Openly share: • Started on its own about 1 year ago -no accident or injury that you remember. • Getting worse, to the point now that it is affecting your sleep. • You have tried 'everything' that you could find, but nothing seems to be helping.
Respond only if asked: • Pain started originally in lower back, but for the last few months, also pain in back of thigh, calf and foot. • Used Panado, Brufen, Voltaren tablets, and sometimes got Stilpane from neighbour. • Better when you stand or walk around but can only sit for about 20 min before the pain is bad. • No problems with bladder or bowel control, and no pins and needles around your anus or private parts. • Habits: Drink alcohol occasionally -special occasions only. Stopped smoking 15 years ago. You realise that you are overweight, but accept it -not young anymore, so not really worried about weight or fitness -work is enough exercise. Not sleeping well, because pain is really bad. • Work: Drive a delivery truck for a furniture company -you don't carry the furniture -key worry: will I be able to continue working? Only person working in the family -two children are still studying at college, and spouse not working -key worry: I am the breadwinner, so can't stop working.