MEDICAL ONCOLOGY SAUDI FELLOWSHIP PROGRAM FELLOWSHIP FINAL CLINICAL EXAMINATION OF MEDICAL ONCOLOGY (2016)

MEDICAL ONCOLOGY SAUDI FELLOWSHIP PROGRAM FELLOWSHIP FINAL CLINICAL EXAMINATION OF MEDICAL ONCOLOGY (2016)

I Objectives a. Determine the ability of the candidate to practice as a specialist and provide consultation in the general domain of his/her specialty for other health care professionals or other bodies that may seek assistance and advice. b. Ensure that the candidate has the necessary clinical competencies relevant to his/her specialty including but not limited to history taking, physical examination, documentation, procedural skills, communication skills, bioethics, diagnosis, management, investigation and data interpretation. c. All competencies contained within the specialty core curriculum are subject to be included in the examination. II Eli gibility a. Passing Fellowship final written examination and fulfilling program requirements. b. Candidates are allowed a maximum of three attempts to pass final specialty clinical examination within a period of 5 years provided that evidence of continuing clinical practice is presented and approved by the subspecialty scientific committee. c. If the candidate did not pass the three attempts, an exceptional attempt may be granted upon the approval of the scientific and executive councils, provided evidence of continuing clinical practice is presented. d. A candidate who failed to pass the clinical examination including the exceptional attempt has to pass final written examination again, after which he/she is allowed to sit the final specialty clinical examination only once provided that evidence of continuing clinical practice is presented and approved by the scientific council. e. After exhausting above attempts candidate is not permitted to sit the Saudi Fellowship final specialty clinical examination. III General Rules a. Saudi Fellowship final specialty clinical examination will be held once each year within 4-8 weeks after written examination. b. Examination dates should be provided by the specialty examination committee in accordance with the fixed annual schedule submitted by the examination department. c. If the percentage of failure in the clinical examination are 50% or more the examination shall be repeated after 6 months. Upon the approval of the General Secretary and at the discretion of the specialty examination committee, the clinical examination may be repeated even if failure is less than 50%. d. Specialty clinical examinations shall be held on the same day and time in all centers, however if multiple consecutive sessions are used, suitable quarantine arrangements must be in place. e. If examination is conducted on different days, more than one exam version must be used. IV Exam Format a. The Medical Oncology final clinical examination shall consist of 8 graded stations each with 10 minute encounters. b. The 8 stations consist of 8 Structured Oral Exam (SOE) stations with 2 examiners each. c. All stations shall be designed to assess integrated clinical encounters. d. SOE stations are designed with preset questions and ideal answers.

DOMAINS FOR INTEGRATED CLINICAL ENCOUNTER V Final Clinical Exam Blueprint* DIMENSIONS OF CARE Health Promotion & Illness Prevention 1±1 Station(s) Acute 4±1 Station(s) Chronic 2±1 Station(s) Psychosocial Aspects 1±1 Station(s) # Stations Patient Care 6±1 Station(s) Patient Safety & Procedural Skills 1±1 Station(s) Communication & Interpersonal Skills 1±1 Station(s) 1 3 2-6 - 1-1 - - - 1 1 Total Stations 1 4 2 1 8 *Main blueprint framework adapted from Medical Council of Canada Blueprint Project VI Definitions Dimensions of Care Health Promotion & Illness Prevention Acute Chronic Psychosocial Aspects Focus of care for the patient, family, community, and/or population The process of enabling people to increase control over their health & its determinants, & thereby improve their health. Illness prevention covers measures not only to prevent the occurrence of illness such as risk factor reduction but also arrest its progress & reduce its consequences once established. This includes but is not limited to screening, periodic health exam, health maintenance, patient education & advocacy, & community & population health. Brief episode of illness, within the time span defined by initial presentation through to transition of care. This dimension includes but is not limited to urgent, emergent, & life-threatening conditions, new conditions, & exacerbation of underlying conditions. Illness of long duration that includes but is not limited to illnesses with slow progression. Presentations rooted in the social & psychological determinants of health that include but are not limited to life challenges, income, culture, & the impact of the patient`s social & physical environment.

Domains Patient Care Patient Safety & Procedural Skills Communication & Interpersonal Skills Reflects the scope of practice & behaviors of a practicing clinician Exploration of illness & disease through gathering, interpreting & synthesizing relevant information that includes but is not limited to history taking, physical examination & investigation. Management is a process that includes but is not limited to generating, planning, organizing care in collaboration with patients, families, communities, populations, & health care professionals (e.g. finding common ground, agreeing on problems & goals of care, time & resource management, roles to arrive at mutual decisions for treatment) Patient safety emphasizes the reporting, analysis, and prevention of medical error that often leads to adverse healthcare events. Procedural skills encompass the areas of clinical care that require physical and practical skills of the clinician integrated with other clinical competencies in order to accomplish a specific and well characterized technical task or procedure. Interactions with patients, families, caregivers, other professionals, communities, & populations. Elements include but are not limited to active listening, relationship development, education, verbal, non-verbal & written communication (e.g. patient centered interview, disclosure of error, informed consent). VII Passing Score a. The pass/fail cut off for each SOE station is determined by the exam committee prior to conducting the exam using a Minimum Performance Level (MPL) Scoring System. b. Each station shall be assigned a MPL based on the expected performance of a minimally competent candidate. The specialty exam committee shall approve station MPLs. c. At least two examiners independently mark each SOE. d. To pass the examination, a candidate must attain a score >/= MPL in at least 70% of the total stations. VIII Score Report a. All score reports shall go through a post-hoc item analysis before being issued and approved by the SCFHS Assistant Secretariat for Postgraduate Studies and SEC within two weeks of the examination. IX Exemptions a. SCFHS at present has no reciprocal arrangement with respect to this examination or qualification by any other college or board, in any specialty.

Candidate instructions Station title: Time allowed: 10 minutes A 50-year-old male patient, diagnosed 3 years ago with early renal cell carcinoma, underwent left nephrectomy, pathology showed clear cell type, presented with shortness of breath and cough for last three weeks. On examination, PS 1, no adenopathy, normal cardiac and chest examination, no organomegaly, a recent CT scan done reveals multiple bilateral lung lesions Task: You are asked to complete a needed investigations, the examiner will provide you with all the results You will outline the next step in his management 1

Examiner instructions Station title: Advanced Renal Cell Carcinoma Time allowed: 10 minutes Construct: This station tests the fellow s ability to work up and manage advanced Renal cell carcinoma and to justify options of systemic treatment Instructions for examiner: Greet the fellow and give him the written instructions. Ask the fellow regarding further investigations: Bone scan: shows multiple vertebral metastasis, CT-guided biopsy reveals clear cell RCC Other blood work: Hb 14, LDH 230 (Normal ),calcium 2.3 normal Ask the fellow about MSKCC risk stratification (low karnofsky performance (<80%), high LDH,Low Hb, High serum calcium,absence of nephrectomy ) Favorable 0 Intermediate 1-2 High risk 3 Ask the fellow briefly about pathway involved in biology of RCC: VHL gene inactivation mtor pathway Ask the fellow about histological subtypes of RCC o Clear cell 75%, papillary type 1: 5 %, papillary 2 : 10%, chromophobe 5%, and oncocytome 5% Ask the fellow what is the role of nephrectomy in patients with metastatic RCC : o SWOG 8949/EORTC 30947, median survival 13.6 months with nephrectomy vs 7.8 months w/o nephrectomy 2

Ask the fellow what are the options of first line? o Targeted therapy with Sutent or pazopanib, if not available then what other options as IFN-α and Avastin according to CALGB 90206 and AVERON studies Ask the fellow what would be the first option if this patient presents with high risk MSKCC? o Temsirolimus ( Hude et al NEJM 2007 ) Ask the fellow what are the options of 2nd lines if progressed on first line with Sutent? o Post Cytokines : Axitinib, pazopanib, sutent or sorafenib. o Post TKI è Axitinib or Everolimus Ask the fellow to List some of Targted therapy toxicity ( for TKI and mtor inhibitors ) o TkI Fatigue, diarrhea, HTN, Hand foot-syndrome and hypothyrodism o mtor Inhibitors Fatige, metabolic ( hyperglycemia, hypercholesterolemia, hypertriglyceridaemia and hypophosphatemia ) and interstitial pneumonitis 3

Marking Sheet STUDENT NAME: Station title: Advanced Renal Cell Carcinoma Time allowed: 10 minutes Item Further investigation ( Bone scan ) and other blood work (CBC, LDH, Ca) Performed Completely Performed but not fully completed NUMBER: Not Performed 2 1 0 MSKCC 2 1 0 Biology of RCC 2 1 0 Types of RCC 2 1 0 Role of nephrectomy 2 1 0 First option 2 1 0 Other options as first line 2 1 0 Second line therapy 2 1 0 Frist line in poor risk group 2 1 0 TKIs toxicity 2 1 0 mtor toxicity 2 1 0 Overall performance 2 1 0 Total Marks: /24 NAME OF EXAMINER: SIGNATURE: NAME OF EXAMINER: SIGNATURE: 4