The simulated surgery--an alternative to videotape submission for the consulting skills component of the MRCGP examination: the first year's experience

BACKGROUND

The simulated surgery was developed to examine the consulting skills of general practice (GP) registrars by observing their consultations with standardized patients. It was introduced in 1997 as an alternative to videotape submission in the consulting skills component of the Membership of the Royal College of General Practitioners (MRCGP) examination for those candidates who are unable to prepare a videotape.

AIM

To describe the methodology of the examination and to report on the first year's experience.

METHOD

The development of the cases and the techniques of marking and standard setting in the simulated surgery are described.

RESULTS

Thirty-eight GP registrars took part in pilot examinations and 37 candidates were examined for the MRCGP. The distribution of their marks and the resulting pass/fail decisions are reported. The reliability of the 20-case simulated surgery, using Cronbach's alpha coefficient, is greater than 0.85.

CONCLUSION

The simulated surgery is a feasible, valid, and reliable examination of consulting skills. Cost and manpower requirements remain a problem, but these are being addressed by current plans.

Transcranial Doppler detection of microemboli during percutaneous transluminal coronary angioplasty

BACKGROUND AND PURPOSE

The use of percutaneous transluminal coronary angioplasty (PTCA) to treat coronary artery disease is now commonplace. The occurrence of microemboli during invasive procedures such as cardiac angiography and bypass surgery is well documented, although neurological complications are relatively uncommon. To date, no investigation has been undertaken of the frequency or nature of microemboli occurring during PTCA or of the correlation with aortic atheroma.

METHODS

Twenty patients having elective PTCA underwent examination by transcranial Doppler ultrasonography (TCD) to detect left middle cerebral artery microemboli occurring during the procedure. Blinded off-line analysis correlated microembolic signal counts on TCD with the components of each stage of the PTCA. Patients later underwent transesophageal (TEE) echocardiography, with measurements made of the thickness of the intima and atheroma in the ascending and descending thoracic aortic arch by cardiologists blinded to the TCD results.

RESULTS

A total of 973 microembolic signals were detected (mean+/-SD, 48.7+/-36.7 per patient); 196 (20%) occurred on movement of the PTCA catheter and wire around the aortic arch, 84 (9%) with other PTCA catheter-associated movements, and 679 (70%) in association with injection of solutions (eg, saline and contrast). Mean signal counts during contrast injection were significantly greater than during the other 3 phases (P<0.001). No neurological events occurred in the study. Although not statistically significant, there was a trend toward greater microembolic signal counts with the number of times the catheter was passed around the aortic arch and the amount of arch atheroma detected by transesophageal echocardiography.

CONCLUSIONS

Microemboli detected on TCD are a common occurrence during PTCA but are largely asymptomatic. The majority of microembolic signals are most probably gaseous in origin and do not appear to be related to the extent of aortic atheroma or to clinical events.