Geriatrics and Palliative Care
Geriatrics is about function and complexity, not single diseases: atypical presentation, multimorbidity, polypharmacy, falls, cognitive impairment and continence. Palliative care adds symptom control and goals-of-care conversations. The Board tests comprehensive assessment, drug safety and end-of-life communication.
Core rules
- Comprehensive geriatric assessment covers medical, functional (activities of daily living, gait and balance), cognitive, psychological, social and environmental domains, and produces a written care plan.
- Atypical presentation: infection may cause confusion or falls without fever; myocardial infarction may present as breathlessness or fatigue; hypothyroidism as depression.
- Polypharmacy: review every drug against indication, dose, interactions and renal function. Use Beers or STOPP/START criteria. Anticholinergics, benzodiazepines, long-acting sulfonylureas and NSAIDs are common offenders; deprescribe with tapering where needed.
- Falls: multifactorial assessment (vision, footwear, home hazards, postural hypotension, sedatives, lower-limb strength, vitamin D) with intervention, not just advice to be careful.
- Delirium: acute onset, fluctuating attention and consciousness, often triggered by infection, drugs, pain, constipation or dehydration. Use the 4AT for detection and treat the cause.
- Palliative care: WHO defines it as improving quality of life of patients and families facing life-threatening illness, through early identification, impeccable assessment and treatment of pain and other physical, psychosocial and spiritual problems. It is not limited to the last days.
- Pain: follow the analgesic ladder, use morphine for moderate-severe cancer pain with regular plus breakthrough dosing, and always prescribe a laxative; do not withhold opioids for fear of addiction in terminal illness.
Worked example
An 82-year-old on seven drugs is admitted after a fall. Reasoning: do not stop at the fracture. Check postural blood pressure, review sedatives and antihypertensives, screen cognition with 4AT, assess vision and home hazards, check vitamin D and bone health for osteoporosis treatment, and document a falls prevention plan. Any benzodiazepine should be tapered, not stopped abruptly.
Traps that cost marks
- Attributing confusion in an older patient to dementia when delirium is present.
- Ignoring constipation prophylaxis when starting morphine.
- Equating palliative care with terminal sedation.
Dermatology and Minor Procedures
Family physicians manage most skin disease and many minor procedures. The Board tests accurate morphological description, recognition of common conditions and melanoma red flags, plus the safe conduct of biopsy, suturing, cryotherapy and incision and drainage.
Core rules
- Describe before diagnosing: site and distribution (flexural, extensor, sun-exposed, dermatomal), morphology (macule, papule, plaque, vesicle, bulla, pustule, nodule, wheal), colour, surface, border, symmetry and associated nails or mucosa.
- Common patterns: tinea has an annular scaly edge with central clearing and is confirmed on KOH microscopy; eczema is flexural, itchy and treated with emollients plus topical steroid of appropriate potency; psoriasis has well-demarcated plaques with silvery scale over extensor surfaces; scabies itches at night with burrows in web spaces, treated with permethrin, and all close contacts must be treated simultaneously; impetigo is honey-crusted and treated with topical mupirocin or oral flucloxacillin.
- Melanoma: ABCDE - asymmetry, border irregularity, colour variation, diameter over 6 mm, evolving change. Any changing pigmented lesion needs urgent dermatology referral and ideally dermoscopy.
- Local anaesthesia: lidocaine maximum 3 mg/kg plain, 7 mg/kg with adrenaline; avoid adrenaline in digits and toes in some protocols, but modern evidence supports it carefully. Buffer with bicarbonate reduces injection pain.
- Suturing: use non-absorbable monofilament on face and trunk, absorbable for mucosa; remove facial sutures in about 5 days and limb sutures in 10 to 14 days. Clean and debride before closure; never close a contaminated bite primarily without assessment.
- Abscess: incise and drain under local anaesthetic, pack if large, and give antibiotics only with cellulitis or systemic upset.
- Infection control: hand hygiene, sterile gloves for invasive procedures, correct sharps disposal, and cold sterilisation never substitutes for autoclaving instruments.
Worked example
A 60-year-old has a 9 mm pigmented lesion on the calf that has darkened and grown over six months. Reasoning: evolving lesion with colour variation and diameter over 6 mm - suspicious for melanoma. Do not shave-excise it; refer for full-thickness excisional biopsy with margins, and photograph rather than repeatedly biopsying.
Traps that cost marks
- Shave biopsy of a suspected melanoma, which prevents accurate Breslow thickness measurement.
- Treating a fungal infection with a steroid alone.
- Failing to treat contacts in scabies, producing recurrent infestation.
Medical Ethics, Professionalism and Medico-legal Issues
This domain tests how you justify decisions, not what you know. Expect scenarios on consent, capacity, confidentiality, disclosure of error, documentation and negligence. The examiner looks for a structured ethical argument using the four principles and the law of the land.
Core rules
- Four principles: respect for autonomy, beneficence, non-maleficence and justice. They guide reasoning but rarely resolve a dilemma alone; balance them explicitly.
- Informed consent requires capacity, adequate and understandable information (diagnosis, options, risks, benefits, consequences of refusal), voluntariness, and consent to the specific procedure. Document the discussion. A signed form is evidence, not the consent itself.
- Capacity is decision-specific: the patient must understand, retain, weigh and communicate the decision. A patient with capacity may refuse treatment even if the refusal seems unwise, provided they understand consequences.
- Confidentiality may be broken with consent, when required by law (notifiable disease, court order), or in the public interest with minimum necessary disclosure. Tell the patient first where possible.
- Negligence requires four elements: a duty of care, a breach of the standard of a reasonable practitioner, causation and resulting harm. A bad outcome alone is not negligence.
- Errors: disclose promptly and honestly to the patient and family, apologise for the harm, explain what happened and what will be done, and record it. Hiding an error compounds the harm.
- Documentation: contemporaneous, legible, factual, dated and signed. Records are medico-legal documents; alterations must be made by addendum, not erasure.
- Consent in minors and adults lacking capacity follows national law; in emergencies, treat under the doctrine of necessity to prevent serious harm.
Worked example
A competent 70-year-old with a gangrenous foot refuses amputation. Reasoning: assess capacity formally, ensure the information given is adequate and understanding is demonstrated, treat pain and infection, involve family only with consent, and respect the refusal. Record the capacity assessment and the discussion. Do not proceed on family request alone.
Traps that cost marks
- Confusing dissent from a competent adult with incapacity.
- Equating a complication with negligence.
- Breaching confidentiality without considering necessity and proportionality.
Practice Management
Practice management covers how a family health unit or private practice runs safely and efficiently: appointment systems, records, teamwork, prescribing economy, referral quality and staff wellbeing. The Board tests systems thinking rather than finance formulas.
Core rules
- Access and flow: appointment systems with triage slots, defined walk-in capacity and reduced waiting time improve both satisfaction and outcomes. Measure did-not-attend rates and address causes (reminders, flexible hours).
- Medical records: legible, problem-oriented, structured (SOAP), with allergies and current medication prominent. Electronic records should have controlled access and backup; paper records need a tracking system.
- Team roles: define competencies for nurses, community health workers, pharmacists and administrative staff; task-shift routine measurement, counselling and screening where protocol allows, with supervision and clear referral triggers.
- Prescribing economy: follow a local formulary, prescribe generically, review repeat prescriptions at defined intervals, and monitor high-risk drugs (anticoagulants, insulin, opioids).
- Referral quality: a good letter states the clinical question, relevant history and results, treatment already given and what is requested; loop the outcome back to the record.
- Inventory: minimum stock levels, expiry-date rotation, cold-chain monitoring, and a register for controlled drugs.
- Patient safety basics: hand hygiene, sharps disposal, oxygen and emergency drugs checked, defibrillator or emergency plan, infection control and waste segregation.
- Staff wellbeing: burnout is a quality issue; manage workload, provide supervision, debrief critical incidents and support continuing professional development.
Worked example
A unit has 40% did-not-attend for its diabetes clinic. Reasoning: audit the reasons - transport, long waits, no reminder, work hours. Introduce SMS reminders, batch appointments by locality, extend evening slots and allow the community health worker to follow up non-attenders. Re-audit after three months and compare attendance and HbA1c control before claiming improvement.
Traps that cost marks
- Judging quality by volume of patients seen rather than outcomes and safety.
- Treating management as pure administration with no link to clinical outcomes.
- Ignoring documentation of tasks delegated to nursing staff.
Quality and Evidence-Based Medicine
This domain tests whether you can improve care systematically and appraise evidence. Expect Donabedian's framework, the audit cycle, quality improvement methods, levels of evidence, critical appraisal of trials and guideline use.
Core rules
- Donabedian: structure (staff, equipment, facilities), process (what is done), outcome (health result). Quality statements should specify all three.
- Clinical audit compares practice with an explicit standard, feeds back and re-audits to close the loop. It is not research; research creates new knowledge, audit checks whether known best practice is being delivered.
- Quality improvement: PDSA cycles (plan, do, study, act) test small changes, then scale. Root cause analysis and the Swiss cheese model explain how system failures combine to produce harm.
- Evidence hierarchy: systematic reviews and meta-analyses of randomised trials at the top, then randomised controlled trials, cohort studies, case-control studies, case series and expert opinion. The best design depends on the question - aetiology, diagnosis, therapy, prognosis, harm.
- Critical appraisal of an RCT: randomisation and allocation concealment, blinding, completeness of follow-up, intention-to-treat analysis, baseline comparability, effect size with confidence intervals, and applicability to your population.
- GRADE separates the strength of recommendation from the quality of evidence and weighs benefits, harms, values and cost.
- Guidelines: use the most recent national or international guideline suited to your setting, note the date, and individualise. A guideline does not replace clinical judgement.
Worked example
Your unit's records show that only 45% of diabetics have had an annual urine albumin-creatinine ratio. Reasoning: define the standard (90%), measure a sample, analyse causes with the team (no protocol, test not stocked, no reminder in the record), introduce a checklist and a nurse-led reminder, run a PDSA cycle for four weeks, then re-audit. Present the run chart of proportions over time rather than a single before-and-after figure.
Traps that cost marks
- Presenting audit as research or needing ethics approval for routine audit when local policy says otherwise.
- Confusing statistical significance with clinical importance or applicability.
- Quoting a guideline without checking its date and applicability.