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Getting to grips with the GPhC framework in the pre-reg exam

Do you struggle with understanding the GPhC framework and how to apply it effectively to your upcoming registration exam?

Knowing the General Pharmaceutical Council (GPhC) framework will help you to keep on track with your revision and avoid wasting time.

What is the registration assessment framework?

The GPhC registration assessment framework explains what is being tested in the registration exam. The registration assessment tests some, but not all, of the learning outcomes set out in Future pharmacists: standards for initial education and training of pharmacists. Other outcomes not tested during the assessment will be tested during the MPharm degree and during the pre-registration training year.

Part 1 of the exam is the calculations assessment. Questions in part 2 of the assessment that relate to clinical care are mapped to key therapeutic areas, and a question may map to multiple therapeutic areas. The framework has a list of high risk drugs and therapeutic areas, which can be used to identify the topics to learn and revise for paper 2. Paper 2 will contain at least one question from each topic. Topics are broad, and candidates should ensure they keep their knowledge up-to-date and in line with current practice. Around 20% of questions in the assessment will relate to paediatrics.

Paper 1: calculation exam

For paper 1, a list of calculations topics is provided in the framework. Each assessment is likely to include at least one calculation question involving each of the following:

  • doses and dose regimens
  • dosage and unit conversions
  • estimations of kidney function
  • displacement volumes and values
  • concentrations (eg expressed as w/v, % or 1 in x)
  • dilutions
  • molecular weight
  • using provided formulae
  • infusion rates
  • pharmacokinetics
  • health economics
  • quantities to supply

Some questions in part 2 may require some calculation.

Outcome weightings

The GPhC uses an outcomes weighting system to highlight the proportion of questions for the various topics included in the exam blueprint. Topics in the syllabus are weighted as high (60-70%), medium (25-35%) and low (up to 10%).

Aspects of the syllabus that have a high outcome weighting will have more questions in the GPhC exam. More specifically, areas of the syllabus with a high weighting account for 60-70% of the questions in the exam, whereas areas with low weighting will account for up to 10% of the questions. 

High-weighted therapeutic areas include:

  • cardiovascular system
  • nervous system
  • endocrine system
  • infection

Medium-weighted therapeutic areas include:

  • genito-urinary tract system
  • gastro-intestinal system
  • respiratory system
  • immune system and malignant disease
  • blood and nutrition

Low-weighted therapeutic areas include:

  • musculoskeletal system
  • eye
  • ear, nose and oropharynx
  • skin
  • vaccines
  • anaesthesia

Each assessment is likely to include at least one question on each of the following high-risk drugs or drug groups:

  • antibiotics
  • anticoagulants
  • antihypertensives
  • chemotherapy
  • insulins
  • antidiabetic drugs
  • drugs with a narrow therapeutic index
  • non-steroidal anti-inflammatory drugs
  • methotrexate
  • opiates
  • parenteral drugs
  • valproate

The estimated number of questions for each weighting is shown in Table 1 below. Knowing this information should enable you to use your time effectively. For example, you should spend more time understanding and learning the areas with high weighting first, followed by medium- and low-weighted areas.

Table 1: Paper 2: Weighting, percent proportion and estimated number of questions

Weighting Percentage (%) Number of questions (n)

High

60% to 70%

70 to 84

Medium

25% to 35%

30 to 42

Low

up to 10%

Up to 12

Total

100%

120

 

Registration assessment outcomes

It is the registration assessment outcomes that some pre-reg and prov-reg pharmacists miss and yet it is a vital list that can help you to identify what information is needed for the exam. This list shows the weighting, future pharmacists’ outcome and indicative assessment topics. It is very important to apply the information in this list to all the areas you study.

To understand this, we can take the topic hypothyroidism as an example to explain the registration assessment outcomes in greater detail. Hypothyroidism is part of the endocrine system, which is high-weighted. Part of the registration assessment outcomes states that pre-registration pharmacists are expected to:

  • Identify and employ the appropriate diagnostic or physiological testing techniques in order to promote health
  • Identify appropriate advice on the use of medicines and devices
  • Recognise and manage adverse effects of medicines
  • Know circumstances in which prescribed medicines are contra-indicated
  • Identify interactions that occur between medicines (either prescribed or purchased), and between these medicines and food or other substances.

If we apply this to hypothyroidism, the key study points are summarised in Table 2 below.

Table 2: Registration assessment outcomes for hypothyroidism

The registration assessment outcome Hypothyroidism

Identify and employ the appropriate diagnostic or physiological testing techniques in order to promote health

This means we are expected to understand and know the steps taken to diagnose hypothyroidism. To help aid in the diagnosis of hypothyroidism, the following points are considered:

  • Does the individual display clinical features of hypothyroidism? So, as part of your revision you should know the key symptoms, signs and complications of hypothyroidism.
  • Thyroid function test – this is a blood test that is used to check thyroid function and measures triiodothyronine (T3), free thyroxine (FT4) and thyroid-stimulating hormone (TSH). Therefore, it is important to know what this test consists of and how to interpret the blood test results. 
  • Whether the individual is taking drug treatment that can impact thyroid function? This means as part of your revision you should be covering the drugs that can exacerbate or affect thyroid function.
  • Whether the individual is displaying signs and symptoms of other conditions that closely resemble hypothyroidism? So, you should be aware of how to differentiate hypothyroidism from other clinical conditions.

Identifying appropriate advice on the use of medicines and devices

Levothyroxine (T4) is offered as first line treatment for patients with overt hypothyroidism. As part of the framework, you are expected to know appropriate advice that should be given to patients on the use of levothyroxine. For example, taking the medication on an empty stomach in the morning before other food or medication and avoidance of tea or coffee at the time of taking (drug-food interaction).

Recognise and manage adverse effects of medicines

It is important to recognise the common side effects that occur with levothyroxine therapy and understanding why such effects occur will make retaining the information easier. For instance, diarrhoea, tremor and rapid pulse can commonly occur with excessive dosage of levothyroxine.

Know circumstances in which prescribed medicines are contra-indicated

It is essential to know the key contraindications of the medication used in each clinical area highlighted in the framework. The main contraindication of levothyroxine is thyrotoxicosis (which is where there is an excess of thyroid hormones in the bloodstream).

Identify interactions that occur between medicines (either prescribed or purchased), and between these medicines and food or other substances

As part of your revision, you should be identifying and understanding the most significant interactions that occur with medication. For example, iron salts, antacids, proton pump inhibitor and orlistat can reduce the absorption of levothyroxine, which may result in hypothyroidism. Coffee and tea taken at the same time with levothyroxine can reduce its absorption.

Single best answer questions

Let us now look at the single best answer (SBA) question below, which demonstrates how the framework has been used to create the question and how you could tackle it.

Question 1. Hypothyroidism (part of endocrine system: high-weighted)

A 40-year-old woman has attended the GP practice for a medical review. She is complaining of cold intolerance, feeling tired and menstrual irregularities. The PMR shows that she is taking: ferrous sulphate 200mg tablets 1BD, lansoprazole 15mg capsules 1OD and levothyroxine 75mcg tablets 1 daily. You ask her how she takes the medications and she tells you that she takes them together at the same time first thing in the morning before breakfast. Her laboratory blood test results are as follows [results in brackets are reference values]: Sodium, Na+ =  135 mmol/L (135-145); Potassium, K+ =  3.6mmol/L  (3.5 - 5.0); Mean corpuscular volume, MCV = 82  femto-litre (81.2 - 95.1); Haemoglobin, Hb = 15g/dL (13.5 -17.5); Ferritin 20ng/mL (18 -270); Tri-iodothyronine, T3  (ng/dL) =  70  (80-200) ; Free thyroxine, FT4 (ng/dL) =  0.8  (0.93-1.7); TSH (microIU/mL) = 11 microIU/mL (0.27-4.7).

What advice or action is most appropriate?

A: take levothyroxine first thing in the morning and other drugs 3-4 hours after

B: take levothyroxine first thing in the morning and other drugs 4-5 hours after

C: the dose for levothyroxine needs to be increased

D: the dose of ferrous sulphate needs to be increased

E: stop lansoprazole

Answer and explanation: The correct answer is B but, before we provide an explanation, let’s look at the registration assessment outcomes and indicative assessment topics relevant to this question. We will put comments next to each area.

Under registration assessment outcomes, the relevant sections are:

  • 10.2.1: Access and critically evaluate evidence to support the safe, rational and cost effective use of medicines; implementing health policy; Interpreting and applying information to improve patient care
  • 10.2.2: Identify and employ the appropriate diagnostic or physiological testing techniques in order to promote health; Normal ranges for test results, and actions to take when results are out of the normal range.
  • 10.2.2: Instruct patients in the safe and effective use of their medicines and devices; Identifying appropriate advice on the use of medicines and devices
  • 10.2.2: Clinically evaluate the appropriateness of prescribed medicines; Appropriateness of prescribed medicines, for example in the context of presenting conditions, associated diseases, and test results
  • 10.2.2: Clinically evaluate the appropriateness of prescribed medicines Interactions that occur between medicines (either prescribed or purchased), and between these medicines and food or other substances

Comments: In the question above, you should use evidence-based resources to inform your management options for hypothyroidism based on the presented history such as a recent British National Formulary, the National Institute for health and Care Excellence and Clinical Knowledge Summary guidelines as indicated in 10.2.1. Interpret diagnostic test results to rule out other causes of the presenting problems as in 10.2.2. Use knowledge of drug interactions to predict that the patient may be experiencing symptoms of hypothyroidism due to inadequate absorption of levothyroxine. Finally, choose the most appropriate management option from a range of others that seemed plausible as required in 10.2.2.

So, the correct answer is B and the explanation is that the patient is displaying signs and symptoms of hypothyroidism and laboratory results support this. Other laboratory results such as electrolytes and tests for anaemia are normal. So, the most plausible explanation is reduced absorption of levothyroxine due to drug interactions with ferrous sulfate and lansoprazole. The most appropriate advice to manage this interaction is to take other drugs such as proton pump inhibitor and iron salts 4-5 hours after a dose of levothyroxine.

Applying the same understanding and method as this example to other topics when you revise will help you to keep your revision in the right direction.

It is important to note that the registration assessment outcomes list contains other areas that do not fall under a therapeutic area and these areas can easily be missed by pharmacist trainees. These include some areas of pharmacy practice such as understanding and applying the principles of clinical governance, demonstrating how the science of pharmacy is applied in designing and developing medicines and devices as well as knowing how to respond to different medical emergencies. The full list is available in the framework.

Summary

It is important to know and understand the GPhC framework, taking into consideration the weighting, future pharmacists’ outcomes and indicative assessment topics. It is useful to know what each of the items on the framework mean, so that you can narrow your revision to those aspects that are really important, saving you time and keeping you on track. We do hope you find this information useful and good luck in your forthcoming exam.

References

Authors

  1. Maryam Khorsandi: Resident Pharmacist at Imperial College Healthcare NHS Trust
  2. Luso Kumwenda: MSc Community Pharmacy (Cardiff), B Pharm Hons (Zimbabwe), Independent Prescriber, MRPharms, Mentor at UKBPA & RPS, CEO at Focus Pre-Reg Revision
  3. Yolanda Chikomba: MPharm (Cardiff) Clinical pharmacist at Gloucester inner city PCN 

Acknowledgements: Question 1: Hypothyroidism (part of endocrine: high-weighted) was kindly provided by Focus Pre-Reg Revision

Disclaimer: The questions and explanations presented here are for educational purposes only and do not replace your training, knowledge and application of professional judgement as a pharmacist or pre-reg or prov-reg pharmacist. The views in this article are our own and do not represent the views of any organisations we are associated with.

 

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