1

Theme: Audit
A Criterion
B Incident review
C Outcome
D Strategic
For each of the following situations select the most likely type of audit it would
be approprate to use from the above list. Each option may be used once, more
than once, or not at all.
Scenario 1
Assessment of trauma patients who are brought into the Emergency Department
unconscious and hypotensive to evaluate whether colloid fluids were given.

D - Strategic « CORRECT ANSWER

Audit is the systematic critical analysis of the quality of medical care, including the
procedures used for diagnosis and treatment, the use of resources, resulting outcome
and quality of life for the patient. A strategic audit quite literally looks at a strategy to
see if it is working. In the context of this question, the strategy is giving IV fluids and
the audit looks to see if they are being implemented appropriately.
Audit may be subdivided into:
medical audit (assessment of patient treatment by doctors)
and clinical audit (assessment of patient treatment by all healthcare professionals).

The audit cycle involves: 

• Observation of existing practice
• The setting of standards
• Comparison between observed and set standards
• Implementation of change
• Re-audit of clinical practice

There are many types of audit technique and each has its own pros and cons;
Basic clinical audit - throughput, morbidity, mortality
Incident review - critical incident reporting
Clinical record review
Criterion audit - retrospective analysis judged against chosen criteria
 Adverse occurrence screening
Focused audit studies - specific outcome
Global audit - comparison between units
National studies - e.g. NCEPOD
YOUR ANSWER WAS INCORRECT
Scenario 2
The use of emergency IVU.

D - Strategic « CORRECT ANSWER

Audit is an essential part of clinical practice. You have just completed one
looking at the availability of Oestrogen receptor status at the first post-operative
multidisciplinary team meeting (MDT) and intend on changing practice and
closing the loop.
Which of the following statements is true regarding clinical audit?
It is a way of assessing the superiority of a new treatment which has been
recommended by NICE
It is an optional part of the appraisal process
It is only valid as part of your appraisal folder evidence if you have completed the
audit and closed the loop
It is part of the process of clinical governance « CORRECT ANSWER
The availability of international guidelines as a benchmark is an essential starting
point of an audit
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
Guidelines and standards need to be available so that the audit has a benchmark but
these can be local, national or international. It differs from research (C) as it doesn’t
attempt to look at new treatments but rather looks at established processes. It is an
essential part of the appraisal process and forms one of the pillars of clinical
governance. Engagement with audit is necessary, completion is not!
 Audit cycle: Identify issue or problem
↓
1. Set criteria and define standards to be reviewed
↓
2. Collecting data
↓
3. Comparing performance against criteria and standards
↓
4.Implementing change
↓
5. Repeating the audit cycle

You are attempting to look at the readmission rates following emergency

appendicectomy in female patients under 35 to attempt to change practice.
Which of the following statements is correct regarding the principles of audit?
Single best answer - select one answer only
It evaluates the difference between two treatments before clinical application
It facilitates the evolution of guidelines for different procedures « CORRECT
ANSWER
It requires evaluation of current practice against national guidelines
Audit is a non-essential but important part of medical revalidation
It is not meant to influence clinical practice
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
Medical audit compares clinical practice against established 'gold standards'
and identifies areas for improvement which are usually applied locally (but not
always). These gold standards don't have to be national. Audit facilitates the
evolution of novel guidelines. It does not, however, facilitate new treatments
(this is research). Once any changes in practice are made following audit, it is
 important to repeat the process to close the loop. It is an essential part of
medical revalidation.

A 45-year-old, married gentleman undergoes reversal of Hartmann’s procedure with

formation of a loop ileostomy. He is admitted to intensive care whereupon after 24
hours he becomes unresponsive, requiring intubation. Brown fluid is noted from the
pelvic drain. A CT scan reveals intra-abdominal air and fluid. An emergency
laparotomy is considered. 

Who is the most appropriate person to consent to this procedure? 

Patient’s spouse
Patient’s father
Patient’s solicitor
Consultant-in-charge « CORRECT ANSWER
Duty manager of the hospital
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
In an unconscious adult patient it is the surgeon’s responsibility to act ‘in the
best interest of the patient’. So the emergency laparotomy can proceed without
written consent if it is deemed life saving. The law that allows this action is the
doctrine of necessity and procedures can be undertaken in an emergency
without consent if:
• There is a necessity to act while the patient is unable to communicate
• The action to be taken is consistent with the action that a reasonable person
would take given the circumstances
• The action is in the best interest of the assisted person
Although the relatives of the patient are unable to consent on behalf of the
patient it is good practice to seek their agreement without breaching
confidentiality. However their signature on a consent form is invalid.
 5

A Coroner
B Any medical practitioner
C Registrar of births and deaths
D Coroner's officer
E Medical practitioner who attended the patient during the last 14 days
F General practitioner
G Bereavement office in the respective NHS trust
H Medical director

From the list above select the person who is most likely to be legally permitted
to: (each option may be used once, more than once, or not at all)
Scenario 1
certify death
B - Any medical practitioner « CORRECT ANSWER
YOUR ANSWER WAS INCORRECT
Scenario 2
issue an immediate certificate of death
E - Medical practitioner who attended the patient during the last 14 days «
CORRECT ANSWER
YOUR ANSWER WAS INCORRECT
Scenario 3
call an inquest
A - Coroner « CORRECT ANSWER
YOUR ANSWER WAS INCORRECT
Scenario 4
send information concerning the cause of death to the office of Population Consensus
and Survey
C - Registrar of births and deaths « CORRECT ANSWER
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
 Death can be certified by any registered medical practitioner (in UK, a doctor registered
with the General Medical Council). Any doctor can also issue an immediate death
certificate if he/she is a registered medical practitioner; in practice this usually means
the doctor who attended the patient within 14 days of the death. Only the Coroner is
entitled to hold an inquest on any case that is reported to him. The Registrar of births
and deaths should send information concerning the cause of death to the office of
Population Consensus and Survey.

A 7-year-old boy has been brought in by helicopter having been involved in a severe
road traffic accident. He has sustained a blunt abdominal injury, a fractured pelvis and
a left haemopneumothorax. He is accompanied by his father who is relatively
unscathed. The family are practicing Jehovah’s witnesses. The child is exhibiting grade
IV shock. The father is adamant that he would rather see his child die than have his
son receive a blood transfusion. 

What is the correct management of this child?

Accept and respect the father’s wishes to avoid transfusion

Discuss the situation with the father but manage the child using ABC principles and
transfuse the child with “flying squad” blood whilst you await the results of a group and
save
Manage the child according to ABC first principles and use a non-blood
product for resuscitation,while seeking urgent legal advice to make the child a
ward of court.« CORRECT ANSWER
Telephone the elders of the father's community to schedule a meeting with the
father to discuss the situation further
Telephone the on-call Trust barrister to try to make the child a ward of the court
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
In the UK it is a fundamental principle that every individual’s body is inviolate,
and traditionally where the interests of a non-competent child are involved
parents have the right and duty to act as proxy. However, the wishes have to be
seen to be in the child’s best interests and are not absolute, with the ultimate
control resting with the judiciary. In this case, the child has life threatening
injuries and needs blood. It is sensible and necessary however to discuss this in
full with the father, and also involve the Trust's legal services at the earliest
opportunity.

Theme: Consent for surgical treatment

A Apply to make the child a ward of court
B No, surgery cannot proceed
C Obtain consent from patient
D Obtain consent from wife
E Yes, surgery can proceed
For each of the following situations, select the most likely answer from the
above list. Each option may be used once, more than once, or not at all.

Scenario 1
A 24-year-old man found unconscious by the roadside is brought to hospital by
ambulance. It is evident that the patient’s condition is rapidly deteriorating because of
an expanding extradural haematoma and he is unable to give consent. His wife had
been contacted and is at the hospital but has expressed her refusal to allow him to be
operated on. Would you proceed against her wishes?

E - Yes, surgery can proceed « CORRECT ANSWER

E – Yes, surgery can proceed
Surgery is needed for the preservation of life and can be performed despite the
patient’s inability to give consent. The patient’s wife cannot give permission or
stop her husband’s operation. No adult can act as legal proxy for any other in
the UK with regard to giving consent for surgical treatment.
YOUR ANSWER WAS INCORRECT
Scenario 2
A member of an extreme religious sect has brought their 11-year-old son to hospital
with generalised peritonitis from a perforated appendix. The child’s condition
deteriorates and he needs a laparotomy which both parents adamantly refuse, saying
that he will recover through the fervent prayers of members of the sect. Despite
repeated attempts by the surgical team to persuade the parents of this child, they
refuse to give consent for the surgical treatment that the surgeon deems to be
essential. What option is available to the surgeon?

E - Yes, surgery can proceed « CORRECT ANSWER

E – Yes, surgery can proceed
Surgery is needed for the preservation of life and can be performed despite the
patient’s inability to give consent. No adult can act as legal proxy for any other in
the UK with regard to giving consent for lifesaving surgical treatment. A parent
cannot act as a proxy for a child in denying access to lifesaving or essential
treatment. It is arguable that A and E are both true but as a matter of timing
ensuring the safety of the child (ie an operation) should be undertaken whilst the
application is being undertaken. Do not forget there is always an on call lawyer
who has access to an on call judge 24 hours.
YOUR ANSWER WAS INCORRECT

Scenario 3
A 70-year-old woman with severe psychiatric illness is undergoing compulsory
psychiatric treatment, having been sectioned under the Mental Health Act. She has a
fall in the psychiatry unit and sustains a fracture of the neck of the right femur for which
she is referred forsurgical treatment The orthopaedic surgeon thinks that internal
fixation of the fracture is the best management, in agreement with her psychiatrist. Her
psychiatric state does not allow her to give informed consent for surgery. What process
should follow?

E - Yes, surgery can proceed « CORRECT ANSWER

E – Yes, surgery can proceed
The Mental Health Act does not allow for the compulsory treatment of any
medical condition other than a mental disorder. The orthopaedic surgeon may,
however, proceed with surgery for the patient’s fractured femur if he or she and
the patient’s psychiatrist agree that it is the best form of management for her. It
is good clinical practice to also obtain a second consultant’s surgical opinion,
confirming the need for operative treatment and to involve the relatives in the
decision-making process where possible. Every clinician should make detailed
entries in the patient’s records and sign and date them.
YOUR ANSWER WAS INCORRECT

Scenario 4
A 63-year-old man with a brain tumour refuses any surgery and expresses his wish
formally in writing. He is judged to be mentally competent. The following day he enters
into a coma and his wife, who was abroad, arrives at his bedside and demands that
surgical treatment is commenced. Can surgery proceed?
B - No, surgery cannot proceed « CORRECT ANSWER
B – No, surgery cannot proceed
No. Before the deterioration of this patient’s condition he clearly refused to
consent to operative treatment. Therefore, surgery cannot be performed even
when he is unable to express his refusal for such a seemingly essential
intervention.

You are just finishing a period of research and have managed to obtain some
high quality clinical research. You send the paper to a major journal which
accepts it in principal pending minor revisions. You send this to your professor
who gives it back a week later with the corrections done but an additional name
is on the paper. When you question him he says it is his daughter who is
applying for CT1 jobs. He says she has read the paper for grammar.
What is the most appropriate course of action?
Discuss it with the director of research and clinical governance and ask for him to
deal with the situation
Discuss it with your professor and explain that you are not happy with the
addition of the additional name and ask that he takes it off before sending it in«
CORRECT ANSWER
Send the paper in to the journal as it is high quality research and she has
contributed to the paper
Send the paper in to the journal with a letter to the editor explaining what has
happened
 Take the additional name off the paper and send it into the journal
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
This is a breach of GMC research ethics. To be included on a research paper
each author needs to confirm that they have played a significant part in the
paper and reading it through for grammar does not count. If your professor does
not accept your concerns then the next port of call would be the R and D director
and following this the GMC. If you have concerns that this has happened several
times in the past it may be necessary to refer your professor anyway.

You are at an interview for an ST3 appointment and are being asked a question
on the different levels of evidence that you know of.
Which of the following is an example of level II evidence based medicine?
Single best answer - select one answer only

Care report
Case series
Cohort study with a high degree of selection bias « CORRECT ANSWER
Expert opinion
Randomised controlled trial
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question

 Level-1 evidence includes randomised controlled trials.

 Level-2 evidence includes all cohort studies regardless of the degree of
selection bias.
 Level-3 evidence includes case reports and case series.
 Level-4 evidence is based on expert opinion.
 10

You are reading a research paper which has attempted to evaluate the effect of
smoking on the incidence of pilonidal sinuses. As such they looked at two cohorts of
matched patients half of which had the disease and then evaluated their smoking
histories. 

Which is the correct description of the level of evidence this paper represents?

Level I
Level II
Level III « CORRECT ANSWER
Level IV
Level V
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question

This is an individual case control study where the authors are attempting to look
at the patients with pilonidal disease, (the cases), compared with those who did
not, (the controls), and how this related to smoking.
1 Systematic reviews (with homogeneity) of randomized controlled trials
a
1 Individual randomized controlled trials (with narrow confidence interval)
b
1c All or none randomized controlled trials
2 Systematic reviews (with homogeneity) of cohort studies
a
2 Individual cohort study or low quality randomized controlled trials (e.g. <80% follow-up)
b
2c "Outcomes" Research; ecological studies
3 Systematic review (with homogeneity) of case-control studies
a
 3 Individual case-control study
b
4 Case-series (and poor quality cohort and case-control studies)
5 Expert opinion without explicit critical appraisal, or based on physiology, bench research o
principles"

11

You are analysing data produced from your unit looking at the relationship
between age and renal function. This data follows a Gaussian (normal)
distribution.
Which of the following tests is appropriate for this purpose?
Mann-Whitney U test
Kruskal-Wallis test
Pearson’s correlation coefficient « CORRECT ANSWER
Spearman’s rank correlation coefficient
Wilcoxson signed-rank test
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
Pearson’s correlation coefficient analyses the strength of a relationship between
two continuous variables as is the case here. The other tests are non-parametric
tests.

12

Clinical governance has been an integral part of the NHS for many years. You are
revising the subject for your ST3 interviews.
Which of the following statements is true regarding this important subject?
It has a strong relationship with research and development « CORRECT
ANSWER
It is a yearly process
 It is entirely separate from clinical audit
It is only applicable to clinical members of staff
It is synonymous with clinical effectiveness
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
Clinical audit came to the fore following the Bristol heart scandal in 1995. It is a
continuous process which strives for “A framework through which NHS
organisations are accountable for continually improving the quality of their
services and safeguarding high standards of care by creating an environment in
which excellence in clinical care will flourish”G Scally and L J Donaldson, 'Clinical
governance and the drive for quality improvement in the new NHS in England' BMJ (4
July 1998)

It involves several key elements:

Education & Training
Clinical audit
Clinical effectiveness
Research & Development
Openess
Risk Management

13

Theme: Principles of trial design and conduct

A Cross-over design
B Detection bias
C Double-blinding
D Exclusion bias
E Factorial design
F Intention to treat
G Minimisation
H Null hypothesis
I Parallel group design
J Performance bias
K Power
L Selection bias
M Simple randomisation
N Single blinding
O Stratified randomisation
P Subgroup analysis
Q Type I error
R Type II error
The following are descriptions of terms used in the language of trial design.
Please select the most appropriate descriptive term from the list above. The
items may be used once, more than once, or not at all.
Scenario 1
In hypothesis testing: the term used to describe a situation in which we fail to reject the
null hypothesis when a difference is really present.
R - Type II error « CORRECT ANSWER
R – Type II error
This is the definition of a term used in the context of hypothesis testing.
A type I error in contrast is one in which we reject the null hypothesis when a
real difference is not present.
Type II we fail to reject the null hypothesis when a difference is really present.
These terms are most commonly cited in the context of study design where the
probability of type I and II errors can be reduced by performing a prior power
analysis in which the correct sample size is estimated on the basis of setting a
and ß values which represent the probabilities that a type II and type I error will
be committed.
NB the null hypothesis is the cornerstone of hypotheticodeductive reasoning
(Karl Popper) not a term describing a negative approach to research!

Scenario 2
An erroneous influence potentially effecting the conclusions of a trial caused by
systematic differences in withdrawals from the trial.

D - Exclusion bias « CORRECT ANSWER

D – Exclusion bias
 This is one of the four components of systematic bias (the others are in the list)
that should be eliminated/minimised by good trial design and conduct. So-called
‘drop outs’ or exclusions from trials can occur for many reasons and can
introduce bias quite easily since the tendency (even unintentially) is to exclude
participants to favour the outcome of the trial. Where exclusions occur, this
problem can be reduced by analysis on an ‘intention to treat’ basis (ie they are
still included in the analysis).
YOUR ANSWER WAS INCORRECT
Scenario 3
A method of allocation in comparative studies that provides treatment groups that are
very closely similar for several variables.

G - Minimisation « CORRECT ANSWER

G – Minimisation
This is an alternative to simple randomisation (the commonest method used to
reduce selection bias) when this might potentially introduce large differences in
the characteristics of comparison groups within a trial. Other methods include
stratified randomisation but this is usually used for single binary variables such
as sex.
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
(Resources for this subject may be obtained from the BMJ book by Trisha Greenhalgh
entitled How to read a paper.)

14

Theme: Death and the law

A Any medical practitioner
B Coroner
C Coroner’s officer
D Medical practitioner who attended during previous 14 days
E Registrar of births and deaths
For each of the statements below, select the most likely answer from the
 above list. Each option may be used once, more than once, or not at all.
Scenario 1
Certify death
A - Any medical practitioner « CORRECT ANSWER
A – Any medical practitioner
YOUR ANSWER WAS INCORRECT
Scenario 2
Issue immediate Medical Certificate of death
D - Medical practitioner who attended during previous 14 days « CORRECT
ANSWER
D – Medical practitioner who attended during previous 14 days
YOUR ANSWER WAS INCORRECT
Scenario 3
Call an inquest
B - Coroner « CORRECT ANSWER
B – Coroner
YOUR ANSWER WAS INCORRECT
Scenario 4
Send information concerning the cause of death to the Office of Population Censuses
and Surveys
E - Registrar of births and deaths « CORRECT ANSWER
E – Registrar of births and deaths
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
A doctor may issue a death certificate if he or she is a registered medical
practitioner. In practice, this usually means where the doctor attended within 14
days of the death. Only the coroner is entitled to hold an inquest on any case
that is reported to him/her.

15
 As a CT1 you are interested in teaching medical students to both improve your
knowledge and make an impact on doctors of the future.
Which of the following statements is correct regarding teaching and training in
the NHS?
Select one answer only
Any consultant who has been in post for more than 3 years can be an educational
supervisor
Any consultant who has been in post for more than 5 years can be a clinical
supervisor
Evidence of teaching is important and forms a formal part of the appraisal
process « CORRECT ANSWER
It is only recognised trainers who have taken part in the necessary training
themselves who can teach in the NHS
Workplace based assessments can only be undertaken by consultants
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
Educational and Clinical supervision can be undertaken by any consultant who
has passed the QUESP course (qualified educational supervisor programme) or
similar. It is essential that those clinicians who wish to supervise have
appropriate training. Anyone interesting in teaching however should be allowed
to teach but ideally they should also have requisite training. Workplace based
assessments can be completed by middle grade doctors and consultants.
Evidence of teaching forms an essential part of appraisals, as it forms part of
'Duties of a doctor'

16

A 31-year-old man is critically injured in a road traffic accident (RTA) and

requires an emergency laparotomy. He is intubated at the scene.
Which of the following statements regarding informed consent is correct?
Single best answer - select one answer only
 Informed consent must be obtained by the person doing the procedure
Informed consent must describe alternative options « CORRECT ANSWER
Informed consent can be gained from relatives or carers if the patient themselves
cannot give consent
Informed consent is the sole responsibility of the consultant in charge of the case
Previous expressed wishes of the patient made when they are competent are null
and void when subsequently presenting in a lowered state of consciousness if their life
is at risk
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
A valid consent must be voluntarily given by a competent patient making an
informed choice. For consent to be valid the patient must have the capacity to
understand, retain and process the information given. The amount of information
given will vary depending on the complexity of the decision and the needs of the
patient. In general, the information should follow that given by ‘a responsible
body of medical opinion’. This should include diagnosis, prognosis, untreated
prognosis, uncertainties about diagnosis, treatment options including no
treatment, explanation of procedures and side-effects including subsidiary
treatment, probability of success including lifestyle changes necessitated by
treatment, whether treatment is experimental, assessment of patient, name of
responsible doctor(s)/surgeon(s), whether trainees or students are involved and
any costs incurred. The patients should also be reminded that they have the
right to change their minds and to seek a second opinion and patients and
relatives should have been given an opportunity to ask questions. Informed
consent is the responsibility of the team looking after the patient, including
anaesthetists, scrub nurses and assistants. It can be taken by an assistant, as
long as they understand the risks and benefits of the procedure.
Where a patient is temporarily incapacitated the guiding principles are that any
treatment undertaken must be no more extensive than absolutely necessary at
the time and not at odds with any advanced wishes expreseed by the patient
before loss of capacity.

17
 You have walked into the doctors mess late at night and see your Registrar smoking
cannabis whilst on call. She says that she has had a very stressful week and has only
had one joint to help her relax. You believe her. What would you do?

As it is likely to be a quiet night, ask for her assurance that this is the last time and
carry on
Ask her to arrange for someone else to do her on call for her and nothing more will
be said
Ask her to discuss the matter with her consultant/supervisor in the morning and
carry on
Ask her to phone her consultant to self-report immediately « CORRECT
ANSWER
Phone the GMC on call line for advice
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
It is her Consultant's responsibility, out of hours, to deal with this in the first instance. It
is vital that the Registrar is removed from the clinical environment immediately and the
Consultant should facilitate this by 'stepping down' to act as the Registrar. Once the
situation is made safe, it is likely the Registrar will face both Trust and GMC
disciplinary proceedings in due course

18

Theme: Types of scientific evidence

A Case–control series
B Case series
C Cohort study
D Controlled clinical trial
E Cross-sectional survey
F Experimental research paper
G Guidelines
H Meta-analysis
I Non-systematic review
J Randomised controlled trial
K Randomised double-blind controlled trial
L Systematic review
M Uncontrolled trial
The following are descriptions of types of scientific evidence. Please select the
most appropriate descriptive term from the list above. The items may be used
once, more than once, or not at all.
Scenario 1
A statistical synthesis of the numerical results of several trials which all addressed the
same question.

H - Meta-analysis « CORRECT ANSWER

When reviewing the impact of new therapies, evidence can come from
several studies of modest size and with slightly differing conclusions. One
solution might be to carry out a definitive randomised controlled trial but
this might require considerable time, effort and expense. An alternative is
to combine data from several modest studies into a meta-analysis. By
combining studies in a coherent (statistically robust) way, conclusions can be reached
on a larger pool of subjects.
YOUR ANSWER WAS INCORRECT
Scenario 2
A study in which two or more groups of people are selected on the basis of differences
in their exposure to a particular agent and are followed-up to observe any differences
in outcome between the groups.

C - Cohort study « CORRECT ANSWER

This differs slightly from a randomised controlled trial in that it generally
takes two or more large cohorts of subjects (rather than a specific sample
size of patients) and follows them up long term for the effects of a certain
agent, eg an environmental factor on the basis of which they are selected.
An example is Sir Richard Doll’s work associating lung cancer with smoking by
observing a cohort of 40,000 doctors in four cohorts according to number of cigarettes
smoked over 10 years.
YOUR ANSWER WAS INCORRECT
Scenario 3
A study in which medical histories of more than one patient with a particular condition
are described to illustrate one interesting aspect of the condition or treatment.

B - Case series « CORRECT ANSWER

This is synonymous with a series of case reports which together illustrate
an interesting aspect of a condition or treatment. Although they are not
randomised, are rarely prospective, and represent a low relative weight in
the traditional hierarchy of evidence, they are easy for the less scientifically
minded to digest and can still convey very important information rapidly
before a definitive trial can be performed, eg McBride’s 1961 case series
of two infants with limb absence born to mothers taking Thalidomide first
alerted the world to this terrible drug complication.
(Resources for this subject may be obtained from the BMJ book by Trisha Greenhalgh
entitled How to read a paper.)

19

You are a registrar. You have just had your appraisal and despite having passed
you feel that you were woefully underprepared. As such, you are determined to
make your job easier for next year.
Which of the following is correct regarding the appraisal process?
Demonstration of reflection on any compliments or complaints is an essential
aspect of appraisal« CORRECT ANSWER
The maximum number of appraisals you can have is one per year
 You need to demonstrate 25 hours of continuing professional development (CPD)
points every year
You need to accumulate 50 CPD points per year
360 degree feedback is an essential part of the appraisal process
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
Appraisal needs to be carried out at least once a year but can be as frequent as
you want it to be. You may struggle to find an appraiser who has the time to do it
more than once yearly however!
Guidelines state that you should demonstrate an average of 50 CPD points per
year or a total of 250 points over the 5 year revalidation cycle. The difference
between an ordinary appraisal and a revalidation ready appraisal is the addition
of formal 360 degree feedback. This therefore is only necessary every 5 years
although most doctors will collect the data every year. Reflection on
compliments and complaints is mandatory.

20

An 89-year-old lady with alzheimers dementia is placed on an elective list for

excision of an ulcerated SCC to her check. Her son shows you he has a lasting
power of attorney (LPA) and will be able to consent to the treatment on her
behalf.
Which of the statements regarding an LPA and consent is correct?
Single best answer - select one answer only

A health & welfare LPA allows decisions to be made on the donor’s medical
care and life-sustaining treatment, daily care and living arrangements«
CORRECT ANSWER
A health & welfare LPA comes into effect as soon as it is registered
An LPA can be validly made by anyone 16 or over who has mental capacity at the
time of making the document
An LPA can be validly made by anyone 18 or over
If there is more than one attorney registered they must both give consent for
medical care decisions
 YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
An LPA is a legal document which may be made by a person (known as a donor)
in anticipation of losing the mental capacity to make decisions on their own
behalf. The document must be registered with the Office of the Public Guardian
(OPG) in order to be valid. An ‘attorney’ or ‘attorneys’ are appointed to make
decisions over either property & financial affairs; health & welfare affairs; or
both. The donor must be aged 18 or over at the time of creating the document
and have mental capacity. Whilst a financial LPA can come into effect, with the
permission of the donor, as soon as it is registered, a health & welfare LPA is
never valid until the donor loses the capacity to make such decisions in person.

A donor may have placed restrictions on the actions of the attorney either
specifically or by making an advance decision such as to refuse treatment in a
particular circumstance. An attorney acting under a health & welfare LPA must
act in the donor’s best interests when deciding upon medical treatments. If there
is any doubt about this the Court of Protection is able to adjudicate.

Depending on the terms of the LPA, where two or more people are acting as
attorney, they may be able to act individually or only with the consent of all
attorneys.

21

A 35-year-old man has been brought in by ambulance. He was found under a pile of
rubble at a building site and appears to have been there some time. His right thigh is
severely crushed and unsalvageable and he is disorientated and very confused. His
urine is very dark and tests positive for myoglobin. His wife has just arrived and states
that since his brother lost his leg in Afghanistan he has said several times that he
would rather go through anything than lose a leg. 

What is the correct management of this patient?

Manage the patient on ITU with aggressive fluid resuscitation waiting for the
patients conscious level to improve
 Manage the patient using ABC principles. Ask to speak to the patients brother to
corroborate the wife’s wishes and if both are in agreement then manage the patient in
the palliative setting
Manage the patient using ABC principles. Attempt to contact the on call legal team
and await their decision before embarking further
Manage the patient using ABC principles. Following discussion with the patient’s
wife book the patient for a below knee amputation with a consent form 4 in the first
instance
Manage the patient using ABC principles. Following discussion with the
patient’s wife book the patient for a high amputation with a consent form 4«
CORRECT ANSWER
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
This gentleman has a severe crush injury and is at significant risk of renal failure
and sepsis if the leg is not amputated. Although he may have said to his family
that he would not accept an amputation under any circumstances, without a
legally witnessed advance directive this unfortunately is hearsay. Your job is to
act in the best wishes of the patient whilst keeping the family involved as much
as possible.

22

THEME: STATISTICS

A Mann-Whitney test
B Paired t-test
C Unpaired t-test
D Chi squared (X ) test
E Wilcoxon's test

For each of the cases described below, select the single most appropriate test
from the options listed above. Each option may be used once, more than once,
or not at all.
Scenario 1
Na+ and urea pre- and post-operative, same individuals.

B - Paired t-test « CORRECT ANSWER

B - Paired t-test
For normally distributed data, t-tests may be used. The unpaired t-test is a
parametric test used to compare 2 independent samples from the same
population, whereas the paired t-test is a parametric test used to compare 2 sets
of observations on a single sample.
YOUR ANSWER WAS INCORRECT
Scenario 2
Non-gaussian data when comparing two unpaired groups.

A - Mann-Whitney test « CORRECT ANSWER

A - Mann-Whitney test
For non-parametric/non-gaussian data, Mann-Whitney or Wilcoxon’s tests are
used. The Mann-Whitney test is used to compare two unpaired groups.
YOUR ANSWER WAS INCORRECT
Scenario 3
Your hypothesis is that remaining nil by mouth prior to an operation causes significant
dehydration in children. You collect pre- and post-operative urea and electrolyte values
for 100 patients. The data is normally distributed.

B - Paired t-test « CORRECT ANSWER

B - Paired t-test
For normally distributed data, t-tests may be used. The unpaired t-test is a
parametric test used to compare 2 independent samples from the same
population, whereas the paired t-test is a parametric test used to compare 2 sets
of observations on a single sample.
YOUR ANSWER WAS INCORRECT
Scenario 4
Aspirin is thought to cause excessive bleeding following transurethral prostatectomy.
You calculate a fall in Hb for patients either taking or not taking aspirin. In both groups
the data includes several patients who suffer massive haemorrhages, and who thus
skew the distribution.
 D - Chi squared (X ) test « CORRECT ANSWER
D - Chi squared (X) test
The X2 test (binomial) is used to compare one group to a hypothetical value, or
two unpaired groups, or three or more unmatched groups.
YOUR ANSWER WAS INCORRECT
Scenario 5
Non-gaussian data when comparing paired group data.

E - Wilcoxon's test « CORRECT ANSWER

Wilcoxon's test
For non-parametric/non-gaussian data, Mann-Whitney or Wilcoxon’s tests are
used. Wilcoxon’s test is to used compare paired group data.

23

As you are aware the NHS has undergone significant change over the past years.
Which of the following statements is correct regarding the 'new NHS'?
Certain healthcare providers are exempt from regulation by the care quality
commission (CQC)
Commissioning is dealt with by Primary Care Trusts (PCT’s)
GPs commission all operative interventions from local hospitals
GPs have a vital role in commissioning services for their patients from
healthcare providers « CORRECT ANSWER
NHS healthcare can only be delivered by NHS hospitals
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
As part of the NHS reforms, the PCTs are being phased out and replaced by GP
commissioning units which are made up of large groups of GPs who commission
services from any willing provider both in the NHS and private sector. This is intended
to encourage the spirit of competition and drive improvements. All of these providers
however need to be registered with the CQC. Some of the more complex surgical
procedures e.g tertiary paediatric surgery services are commissioned directly from the
Department of Health.
 24

Theme: Death certificates

A Ask families for permission for a postmortem
B Ask the GP to issue a death certificate
C Issue a death certificate
D Order a hospital postmortem
E Report to the coroner
For each of the situations below, select the most likely answer from the above
list. Each option may be used once, more than once, or not at all.
Scenario 1
A 20-year-old man was found emaciated in a derelict building. On examination he had
two liver abscesses and was human immunodeficiency virus (HIV) positive, and died 5
days after admission to hospital

E - Report to the coroner « CORRECT ANSWER

E - Report to the coroner due to the mechanism of death being potentially
suspicious or complex

Scenario 2
A 50-year-old man was admitted with jaundice secondary to cholangiocarcinoma. His
tumour was resected, but the patient died 5 days later from a myocardial infarction (MI)

C - Issue a death certificate « CORRECT ANSWER

C – Issue a death certificate
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
Death should be referred to the coroner if: The cause of death is unknown. The
deceased was not seen by the certifying doctor either after death or within 14 days
before death. The death may be due to an accident. The death was unnatural, violent
or suspicious. The death may be due to self-neglect or neglect by others (as in
scenario 1). The death may be due to an abortion. The death may be a suicide. The
death may be occupational/as a result of industrial disease. The death occurred
during/after detention in police custody or prison. The death is during or within 24 hours
of an operation / anaesthetic / invasive procedure For scenario 2, it is common practice
to telephone the coroner to get advice for death following an operation. However,
according to the guidelines above, this is not strictly necessary.

25

Theme: Death certification

A Ask GP to issue death certificate
B Issue certificate yourself immediately
C Issue death certificate and request hospital postmortem examination
D Refer to coroner
E Order an inquest
For each of the scenarios below select the most appropriate option. Each option
may be used once, more than once, or not at all.
Scenario 1
A 24-year-old drug addict is found dead in his flat surrounded by syringes, needles and
empty bottles of alcohol. You certify as dead in A&E.

D - Refer to coroner « CORRECT ANSWER

YOUR ANSWER WAS INCORRECT
Scenario 2
A young man has been found in his flat, emaciated and with several liver abscesses. It
becomes known that he is HIV positive. The abscesses are drained but the patient dies
1 week later.

C - Issue death certificate and request hospital postmortem examination «

CORRECT ANSWER
YOUR ANSWER WAS INCORRECT
Scenario 3
A 70-year-old woman admitted with small bowel obstruction has a 2-month history of
weight loss and tiredness. At laparotomy, widespread disseminated cancer is found
and no further surgery is performed. She returns to the ward and dies 4 weeks later.
B - Issue certificate yourself immediately « CORRECT ANSWER
 YOUR ANSWER WAS INCORRECT
Scenario 4
A 52-year-old man came to hospital with jaundice and underwent successful
hepatobiliary surgery for a tumour. Three days after the surgery he develops chest pain
and an ECG shows signs of a myocardial infarction (MI). He is treated on the coronary
care unit but dies 2 weeks later.

B - Issue certificate yourself immediately « CORRECT ANSWER

YOUR ANSWER WAS INCORRECT
Scenario 5
A woman dies 72 hours after dynamic hip screw (DHS) operation for fracture of the
neck of the femur. She complains of chest pain and an MI is diagnosed shortly after
cardiac arrest. She is on a trial for a new cardiac drug but dies.

D - Refer to coroner « CORRECT ANSWER

YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
A doctor may issue a death certificate if he or she attended the deceased during the
last illness. In practice this means where the doctor attended within 14 days of the
death. In some cases when the doctor was attending the deceased regularly and had
seen the body after death, the certificate may be accepted even though the last
attendance was more than 14 days ago.

A practitioner who sees the deceased for the first time after death is not entitled to
issue a certificate.

If the medical practitioner knows the cause of death, and if, according to the law, the
above criteria have been met, the doctor must always issue a certificate even when the
cause is unknown or obviously unnatural. The Registrar would then notify the Coroner.
However, the usual practice in such cases is for the doctor to notify the Coroner
himself, and withhold the certificate. The doctor has no statutory duty to notify any
death to the Coroner. He complies with the law if he issues a death certificate, even
though the death is the result of an unnatural cause, and leaves the Registrar to inform
the Coroner. There is no official list of when to refer to the Coroner. A simple rule is to
refer all deaths known to be due to unnatural causes or when the cause is unknown,
 eg deaths from violence (accidental, suicidal), poison, during surgical procedure or
anaesthesia. Only the Coroner can order an inquest.

26

Your consultant asks you to obtain consent from his patients for his elective list
which is lengthy and you are short of time. You notice that one of the patients
signed a consent form about six months ago which covers all the issues you
would discuss now.
How would you proceed with this patient?
Single best answer - select one answer only
A consent form is legal proof that consent has been given, it will not be necessary
for the patient to sign again
A consent form signed in an out-patients’ department 6 months
preoperatively is technically valid but it is strongly advisable to obtain the
signature again on admission« CORRECT ANSWER
Having checked that all complications have been consented for in the document,
and that the patient had capacity to consent at the time of signature, no further contact
is required
Tell the patient they must re-sign the document
Verbal consent will be adequate in this scenario
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
The legal age of consent is 16 years. Verbal consent is adequate only if the
patient’s condition precludes giving written consent (eg broken arms). However,
as a general rule, it is advisable that the verbal consent is witnessed and
documented by another individual. There is no time limit upon consent, therefore
a consent form signed 6 months ago remains technically valid, however good
practice (and indeed many Trusts) require a counter-signature at the time of
surgery if the consent form has been completed over 2 weeks earlier. Ability to
retain the information forms an important part of the patient's capacity to give
valid consent. For consent to be valid it must be informed, voluntary and the
patient must be competent. Frequently occurring complications should be
 mentioned to the patient, as well as all serious complications regardless of their
incidence.

27

Your consultant is testing a new method of closing the abdomen using 5 layers
of sutures. When you ask how he heard about this technique, as you want to
read about it, he tells you that he leant it on a recent operative course.
What level of evidence is he using to inform his practice?
Level I
Level II
Level III
Level IV
Level V « CORRECT ANSWER
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
He is basing his change of practice on an expert opinion, the weakest level of
evidence.
1 Systematic reviews (with homogeneity) of randomized
a controlled trials

1 Individual randomized controlled trials (with narrow

b confidence interval)

1c All or none randomized controlled trials

2 Systematic reviews (with homogeneity) of cohort studies

a

2 Individual cohort study or low quality randomized controlled

b trials (e.g. <80% follow-up)

2c "Outcomes" Research; ecological studies

 3 Systematic review (with homogeneity) of case-control
a studies

3 Individual case-control study

b

4 Case-series (and poor quality cohort and case-control

studies)

5 Expert opinion without explicit critical appraisal, or based on

physiology, bench research or "first principles"

28

You are in the process of preparing for your appraisal and are collecting the
relevant evidence required. It will be the closest appraisal prior to your
revalidation date.
Which of the following statements is true regarding this appraisal?
A revalidation ready appraisal is required every 3 years for revalidation every 6
years
Feedback from colleagues has a lower weighting than feedback from patients
Your appraisal can be carried out by a non consultant grade doctor «
CORRECT ANSWER
Your appraisal can be carried out by any NHS consultant who has been on the
specialist register for 5 years
360 degree feedback is a desirable but not essential part of your appraisal
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
An annual appraisal is mandatory for doctors working within the NHS and is part
of the 5 yearly process of revalidation. The appraiser can be anyone who works
within the organisation and has had approved training and therefore doesn’t
need to be a consultant. They are usually senior clinicians or management,
however. Appraisal requires the demonstration of evidence that the clinician
satisfies all the aspects of “Good Medical Practice” but the difference between
an ordinary appraisal and a revalidation ready appraisal is the 360 degree
feedback. The clinician must collect anonymous feedback from patients and
colleagues (from all aspects of their working lives) which has equal weighting.
Once completed the appraiser then passes the information to the Trust's
“Responsible Officer” who then recommends the doctor to the GMC for
revalidation.

29

Theme: Basic statistics (taxonomy)

A Analysis of variance (ANOVA)
B c2 test
C Correlation
D False negatives
E False positives
F Likelihood ratio
G Negative predictive value
H Positive predictive value
I Power analysis
J Regression analysis
K Sensitivity
L Specificity
M t-tests
The following descriptions all refer to basic statistical methods that are
commonly employed in medical research. Please select the most appropriate
term from the above list. The items may be used once, more than once, or not at
all.
Scenario 1
A method of statistical analysis used for hypothesis testing where we wish to compare
proportions of categorical data.
B - x2 test « CORRECT ANSWER
B – c2 test
This is the correct test for categorical data, such as male/female, where we wish
to establish whether there is a significant difference in proportions between two
 or more groups (the Fisher’s exact test is similar but utilised for only 2 x 2-cell
tables with small numbers in each cell). In contrast, t-tests, such as the
Student’s t-test (parametric data) and the Mann–Whitney U-test (non-parametric
data) are used for comparing continuous numerical data.
YOUR ANSWER WAS INCORRECT
Scenario 2
In the assessment of a diagnostic test, the proportion of patients with negative test
results who are correctly diagnosed.

G - Negative predictive value « CORRECT ANSWER

G – The negative predictive value
The proportion of patients with negative test results who are correctly diagnosed
is the negative predictive value. In contrast, the proportion of patients with
positive test results who are correctly diagnosed is the positive predictive value.
Unlike specificity and sensitivity, the positive and negative predictive values give
a direct assessment of the usefulness of a test in practice. However in addition,
unlike sensitivity and specificity, the positive and negative predictive values are
strongly affected by prevalence (ie the proportion of patients with the
abnormality). The positive predictive value increases with increasing prevalence
and the negative predictive value decreases.
YOUR ANSWER WAS INCORRECT
Scenario 3
This may be calculated to indicate the value of a test for increasing certainty about a
positive diagnosis. It is numerically equal to the sensitivity/(1 – specificity).

F - Likelihood ratio « CORRECT ANSWER

F – Likelihood ratio
For any test result, one can compare the probability of getting that result if the
patient truly had the disease with the corresponding probability if they were
healthy. The ratio of these probabilities is the likelihood ratio, which can be
considered to indicate the value of a test for increasing certainty about a positive
diagnosis. It is numerically equal to the sensitivity / (1 – specificity).
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
 (Basic resources for this subject may be obtained from the chapter by Hugh Dudley in
the Clinical Surgery in General RCS Course manual or, for the more avid student, from
a book entitled Practical Statistics for Medical Research by Douglas G Altman.)

30

An essential part of clinical governance is risk management. Unfortunately, your patient

has been given flucloxacillin despite having a documented penicillin allergy. Thankfully
they have a moderate urticarial reaction which responds to piriton and steroids. 

Which of the following is correct?

Analysis of risk is a locally driven system

Clinical risk has a different reporting system than non-clinical risk
It is only the severity of the risk (ie green, amber or red rating) that is important
when assessing clinical risk
Reporting of clinical errors is at the discretion of the senior clinician, nurse or
manager on duty
Risk reporting has a direct impact on CNST payments « CORRECT ANSWER
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
An 'Organisation with a memory' published guidelines and advice regarding clinical and
non clinical risk reporting and management. Both of these are reported using the same
system and are a mandatory part of the NHS. It is confidential and centrally collated. It
is both the severity of risk and its frequency that is important. The frequency of error
and risk reporting is fed into the CNST (clinical negligence scheme for trusts) and may
affect the insurance premiums the Trust pays.

31

Theme: Consent
A Consent the patient
B Consent the parents
C Consent by proxy
D Cannot proceed
E Proceed without patient's consent
F Seek urgent medicolegal advice

Match the most appropriate option from the list above to each clinical situation
described below. Each option may be used once only, more than once or not at
all.
Scenario 1
A 20-year-old male with motorcycle injury – unstable and unconscious, and needs
operation.

E - Proceed without patient's consent « CORRECT ANSWER

YOUR ANSWER WAS INCORRECT
Scenario 2
A 9-year-old-boy with deteriorating health needs a blood transfusion, the parents
refused for religious reasons.

F - Seek urgent medicolegal advice « CORRECT ANSWER

YOUR ANSWER WAS INCORRECT
Scenario 3
A 21-year-old woman with Down's syndrome needs appendicectomy. She understands
all about the operation and accepts it.

A - Consent the patient « CORRECT ANSWER

YOUR ANSWER WAS INCORRECT
Scenario 4
A 12-year-old girl with iliac fossa pain and vaginal bleeding needs diagnostic
laparoscopy.

B - Consent the parents « CORRECT ANSWER

YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
In the unconscious patient the medical team is entitled to provide life-saving
procedures including surgery. In the case of parent’s religious view the doctors have a
duty to the child and must seek the court’s permission for further treatment if
necessary. If a patient is deemed to understand the procedure and any possible
complications they can give their own consent. If a patient is under 16 years then
usually consent is taken from the parents. The exception to this is when a child is
capable of fully understanding the procedure and consequences – Gillick’s
competence.

32

You are analysing data from your unit looking at local recurrence from breast
cancer over time in patients who express the gene AVS gene B. The two groups
are matched for other confounding variables.
Which of the following would be the correct statistical test to use?
ANOVA test
Chi squared test
Kaplan Meier test « CORRECT ANSWER
Mann Whitney U test
Paired student’s T test
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
The Kaplan Meier test plots events (in this cases recurrences) over time between
two groups with vertical drops over time. 

33

Theme: The language of the NHS

A Audit
B Clinical Governance
C Healthcare Commission
D Foundation hospitals
E Modernisation agency
F National Institute for Clinical Excellence (NICE)
G National service frameworks (NSFs)
H National targets
I NHS trusts
J Performance assessment framework (PAF)
K Primary-care groups (PCGs)
L Primary-care trusts (PCTs)
M Independent sector treatment centres (ISTCs)
N Strategic Health Authorities (SHAs)
The following are all brief descriptions of terms used within the language of the
new NHS. Please select the term that best fits each description from the above
list. The items may be used once, more than once, or not at all.
Scenario 1
Policies that set national standards and identify key interventions for a defined service
or care group.

G - National service frameworks (NSFs) « CORRECT ANSWER

1 G – National service frameworks (NSFs)
These, in addition to setting national standards, also put in place strategies to
support implementation and ensure progress within a reasonable timescale. It is
aimed that there will be one new framework per year and they include goals for
common and important diseases such as coronary heart disease and cancer.
They differ from ‘National Targets’, which address politically ‘hotter potatoes’
such as waiting times.
YOUR ANSWER WAS INCORRECT
Scenario 2
Organisation bringing together groups of health workers (doctors and nurses, dentist,
pharmacists and optometrists) with community-care organisations, including social
services, who are responsible for local shaping and commissioning of care.
L - Clinical Commissioning groups (CCGs) « CORRECT ANSWER
L – Clinical Commissioning Groups (CCGs)
 On April 1st 2013 the former Primary Care Trusts were replaced by Clinical
Commissioning Groups (CCGs) and local area teams (LATs). These groups will
share responsibility for commissioning services for local communities. There
will be 229 CCGs and 27 LATs
YOUR ANSWER WAS INCORRECT
Scenario 3
'A system through which NHS organisations are accountable for continuously
improving the quality of their services and safeguarding high standards of care, by
creating an environment in which clinical excellence will flourish .' (DoH 1998)

B - Clinical Governance « CORRECT ANSWER

B – Clinical governance
Beloved of interviews and vivas, this definition is as verbose as it is unhelpful. In
reality, clinical governance encompasses a range of clinical activities aimed at
improving safety for patients and is a quality control systme helping to monitor
the quality of care delivered within the NHS.
Originally, it had three components: clinical audit, adverse incident reporting
and continued professional development. It was described (presumably in a link
to wisdom) as having seven ‘pillars’ that were clinical audit, clinical risk
management, learning effectiveness, patient experience effectiveness,
communication effectiveness, resource effectiveness and strategic
effectiveness.
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
The Site Editor apologises for the inclusion of this question. However, it is a sad fact
that all of us involved in the delivery of health care (even including surgeons) within the
New NHS require some understanding of the current language of health-care delivery.
Such questions are also a favourite of SpR interview panels!

34

Theme: Scientific research techniques

A Cloning
B DNA fingerprinting
C DNA microarray
D DNA sequencing
E Hybridisation
F Linkage analysis
G Northern blotting
H Polymerase chain reaction
I Southern blotting
J Transfection
K Transformation
L Western blotting
The following are all brief descriptions of common molecular techniques utilised
in medical research. Please select the technique which best fits each description
from the above list. The items may be used once, more than once, or not at all.
Scenario 1
An automated method utilising microchip technology in which the differential
expression of thousands of genes can be estimated in a single experiment.

C - DNA microarray « CORRECT ANSWER

DNA microarray, or DNA chips, are fabricated by high-speed robotics, generally on
glass but sometimes on nylon substrates, for which probes with known identity are
used to determine complementary binding, so allowing massively parallel gene
expression and gene discovery studies. An experiment with a single DNA chip can
provide researchers with information on thousands of genes simultaneously.
YOUR ANSWER WAS INCORRECT
Scenario 2
A method to separate and detect proteins using a denaturing sodium dodecyl
sulphate–polyacrylamide gel with subsequent transfer to a membrane (usually
nitrocellulose) and detection using specific antibodies.

L - Western blotting « CORRECT ANSWER

Blotting is a descriptive term for the transfer of molecules out of a gel and onto a filter
membrane by a wicking action, although the term is now used for electrotransfers or
vacuum transfers. In the original description of blotting, Dr Edwin Southern developed
the technique to make the gelresolved nucleic acid more accessible to subsequent
manipulation, such as identification by hybridisation – this was Southern blotting.
Northern and Western blotting followed the original nomenclature (perhaps not very
helpfully). In Western blotting proteins are separated on a gel, and blotted (by
electrophoretic transfer) then detected with antibodies specific to the protein of interest.
Northern blotting is the similar separation and blotting of RNA antibodies to RNA.
YOUR ANSWER WAS INCORRECT
Scenario 3
An in vitro technique designed to isolate and amplify small, specific segments of DNA
between 105- and 108-fold from insignificant quantities of template.

H - Polymerase chain reaction « CORRECT ANSWER

This is a relatively well-established technique that has revolutionised many aspects of
molecular biology. It amplifies DNA to produce adequate amounts for subsequent use.
Two synthetic oligonucleotide primers, typically 20–25 nucleotides in length and
complementary to the flanking region of the target sequence to be amplified, are
orientated 5’ to 3’. They are hybridised to opposite strands of the target sequence and
extended using thermally stable DNA polymerases until the region between the two
primers is completely replicated. Initial hybridisation of the two oligonucleotides
requires heat denaturation of the double-stranded DNA
template. The temperature is then lowered to an optimum at which primers anneal to
their complementary sequences. Finally, polymerase elongation, again requiring an
optimal temperature, completes the synthesis which effectively results in doubling the
concentration of the target DNA segment. This cycle is repeated for 25–35 rounds
using commercially available
thermal cyclers.
YOUR ANSWER WAS INCORRECT
Scenario 4
The transfer of a DNA fragment of interest from one organism to a self-replicating
genetic element such as a bacterial plasmid, and its subsequent propagation in a
foreign host cell.

A - Cloning « CORRECT ANSWER

This technology has been widely used since the 1970s, and has become a
common practice in molecular biology laboratories today. To clone a gene, a DNA
fragment containing the gene of interest is isolated from chromosomal DNA using
restriction enzymes and then united with a plasmid that has been cut with the same
 restriction enzymes. When the fragment of chromosomal DNA is joined with its cloning
vector in the laboratory it is called a recombinant DNA molecule. Following introduction
into suitable host cells, the recombinant DNA can then be
reproduced along with the host cell DNA to produce sufficient quantity for
further studies.
(Resources for this subject may be obtained from the book by Bradley, Johnson &
Rubenstein entitledLecture notes on molecular medicine.)
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
(Resources for this subject may be obtained from the book by Bradley,Johnson &
Rubenstein entitled Lecture notes on molecular medicine.)