1

Quantitative measures, such as blood pressure and blood test levels, have to be
summarised using two descriptive statistics – a measure of central tendency and
a measure of dispersion. The Arithmetic mean is such a descriptive statistic.
What do you understand by this term?
Single best answer - select one answer only

It is the average deviation

It is the most commonly occurring value
It is the nth root of the product of the observations (where n is the number of
observations)
It is the sum of the observations divided by the number of observations «
YOUR ANSWER
It is the value which divides the observations into two equal halves when they are
arranged in order of increasing value
YOUR ANSWER WAS CORRECT
 The Answer
 Comment on this Question
The arithmetic mean is the sum of the observations divided by the number of
observations

(3+1+1+2+12+1+7+2+4+1+2+4+1+3+1)/15=45/15 = 3

The mode is the most commonly occurring value (in the above example ‘1’) 

The geometric mean is the nth root of the product of the observations and is
only used when the observations are positively skewed and can be assumed to
have a log-Normal distribution.

The average deviation is the value which divides the observations into two equal
halves when they are arranged in order of increasing value.
 2
Medical statistics deals with the analysis, interpretation and presentation of data.
Which of the following statistical tests are appropriate for analysing parametric
(normally distributed) data?
Single best answer - select one answer only
Chi-squared
Kruskall–Wallis
Mann–Whitney 
Two-way ANOVA
Student t-test  YOUR ANSWER
YOUR ANSWER WAS CORRECT

 The Answer

 The one-way ANOVA and Student t-test are both examples of statistical
analysis suitable for normally distributed data (parametric).
 Kruskall–Wallis, Mann–Whitney and Chi-squared tests are examples of
non-parametric statistical analysis.

3
You are at journal club where your colleague presents a paper on the effects of a
new drug on pain control. A cross-over study has been used.

Which of the following is an advantage of using within patient comparison?

Single best answer - select one answer only

All confounders are eliminated « YOUR ANSWER

More patients are needed which strengthens the validity of the result
There may be an advantage when examining the effects of long-acting drugs
They are always free from carry-over effects
They reduce errors associated with individual differences « CORRECT
ANSWER
 YOUR ANSWER WAS INCORRECT
 The Answer

Allocating the same individual to both new and standard treatments, in random
order, has the advantage that between-patient confounders are removed
however the possibility of ‘carry-over effects’ ie the effect of the first treatment
remaining active partially or wholly when the second treatment is started,
remains a potential confounder. A washout or drug-free period may be
necessary between the treatments to ensure that the effects of the first drug are
not carried over to the other treatment period. Accordingly, this type of study is
probably suitable only for treatments with short-term benefits in patients with a
chronic but relatively stable disease as the wash-out periods need to be of
adequate length between treatments and so patients may have to be in the study
for a considerable period of time. Fewer subjects are required as subjects act as
their own controls.

Their usage is limited to conditions that are not cured by the first treatment. 
.

4
You are the core trainee and have just reviewed the case of a 30-year-old patient
on the ward who has died following an emergency operation for a bowel
perforation.
Cases that should be referred to the coroner in England include which one of the
following?
Select one answer only

Death from a bowel perforation

Death from a notifiable disease such as meningitis
death from AIDS or HIV related illnesses
Death in a patient under 50 years of age
Death related to industrial or occupational disease in former employment «
YOUR ANSWER
YOUR ANSWER WAS CORRECT
 The Answer
 Comment on this Question
Deaths reportable to the coroner include :

dead on arrival deaths occurring as a result of

an accident;
deaths within 24 hours of unnatural, criminal or
emergency admission to suspicious deaths, including
hospital those caused by neglect,
suicide or abuse
deaths during or within 24 and deaths from poisoning,
hours of an drugs or acute or chronic
operation/anaesthetic/invasive alcohol abuse.
procedure;
deaths from medical or the death of a prisoner while in
surgical mishap should also hospital;
be reported
stillbirths deaths where the police are
involved
Industrial or occupational deaths in public places, fires,
diseases leading to death, police custody or prison;
cases of hypothermia leading deaths where a property has
to death been broken into;

Notifiable diseases have to be reported to the Consultant in Communicable

Disease Control (CCDC). At present, the reporting of AIDS to the CCDC is 

5
A study examines the stature of school children. The conclusion states that
there is a relationship between the heights of siblings shown by the tendency of
tall boys to have tall sisters (r = 0.57, P < 0.001).
In statistics, what does ‘r’ refer to?
Select one answer only
Indicates the probability that the result is highly significant
 'r' is the probability of having a risk factor if one has a disease « YOUR
ANSWER
'r' is the risk of developing a disease for people with known exposure compared to
risk of developing a disease without exposure
The symbol 'r' represents the correlation coefficient « CORRECT ANSWER
Where 'r' is less than one, a negative correlation has been demonstrated
YOUR ANSWER WAS INCORRECT
 The Answer

The heights of boys and their sisters have been compared. The correlation
coefficient has been calculated, this is denoted by 'r' (i.e. D is true). Values of 'r'
less than zero indicate that one height increases as the other falls; this is known
as a negative correlation (hence E is False). The 'P' value indicates that the
correlation is highly significant. The correlation coefficient indicates how closely
the data points lie to a line, it does not give any information as to the slope of the
line. So, although the quoted 'r' and 'P' values indicate that as the boy's height
increases then so does his sister's, there is no information as to how much her
height increases for a given increase in his height. The statement P < 0.001
shows that the results would have been observed less than 1 time in 100 if there
were no linear relationship whatsoever between the heights of boys and their
sisters. Option C is the relative risk ,and option B is the Odds ratio .

You are in the urology clinic and a patient is asking about a screening test for
prostate cancer they have read about in the newspapers.
In devising a suitable screening test for malignant cancer, which of the following would
be most useful?
Select one answer only
The natural history of the disease should not be known
The test should have high sensitivity « YOUR ANSWER
The test should have low specificity
The tumour should be of anaplastic type
The tumour should have a short latent phase
 YOUR ANSWER WAS CORRECT
 The Answer
 Comment on this Question
Preconditions for a good screening test include:
The disease must be an important health problem.
There should be an accepted treatment.
Facilities for diagnosis and treatment must be available. 
There should be a latent stage.
The screening test should have both high sensitivity and specificity.
The test should be acceptable to the population.
The natural history of the disease should be adequately understood.
There should be an agreed policy on which patients should be treated.
Diagnosis and treatment should be relatively cost-effective.
The screening should be an ongoing process.
For a screening test to be effective, early detection and treatment must lead to
fewer deaths. An anaplastic carcinoma would carry such a poor
prognosis that any screening test would make no difference to the outcome.
Similarly, earlier detection of tumours with a short latent stage is unlikely to
help.

7
Medical audit
encourages self-evaluation

True False CORRECT
facilitates the evolution of guidelines for different procedures

True False CORRECT
is an essential prerequisite for accreditation of surgical training posts by The Royal
College of Surgeons of England

True False CORRECT
can contribute towards the basis of a successful medico-legal defence

True False CORRECT
is not meant to influence clinical practice

True False CORRECT

YOUR ANSWER WAS CORRECT

 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).
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.

As part of his research protocol a medical student is looking at the correlation of

height to glove size in a population of surgeons. The data is assumed to be in a
normal distribution pattern.

Which of the following tests would be most useful?

Select one answer only

Kaplan-Meier test

Mann–Whitney test « YOUR ANSWER

Kruskal-Wallis test

Unpaired t-test « CORRECT ANSWER

Wilcoxon test

YOUR ANSWER WAS INCORRECT

 The Answer

t-tests are examples of parametric tests and can be used to assess Gaussian
(normally) distributed data. ANOVA (analysis of variance) tests are also
parametric tests. If a measure cannot be assumed to have a Normal distribution,
 the non-parametric equivalent of the one-way ANOVA is used and this is the
Kruskal-Wallis test. The Wilcoxon and Mann–Whitney tests are non-parametric
tests and are used for non-Gaussian data.
The Kaplan-Meier test is used to describe and analyse survival data.

9
Your consultant is participating in a trial of a new chemotherapy agent for breast
cancer and asks you to help her collect the data. 

In a single blind trial who will be aware of the treatment allocation?

Single best answer - select one answer only

Both the assessor and the patient will be aware of the treatment being used «
YOUR ANSWER
Neither the patient nor the assessor knows which treatment an individual is
receiving
Usually only the patient will be unaware of which treatment they have been
given « CORRECT ANSWER
Usually only the assessor will be unaware of which treatment the patient has
received
Usually only the person analysing the study results will be unaware of the treatment
allocation
YOUR ANSWER WAS INCORRECT
 The Answer

In single blind trials, patients are randomly allocated to treatment or

placebo/standard groups. Either the patient or the investigator (usually the
patient) is unaware of the group to which they have been allocated. The
randomisation should be designed so that each patient, regardless of any
individual features (age, sex, disease-state or whatever) has an equal chance of
being assigned to any of the treatments. Without a placebo or standard care
group we could never be sure that any improvements in the treated group were
due to the treatment. Patients may have improved with time anyway, the
weather/change of diet due to disease etc could be possible reasons. Also the
psychological affect of 'being treated' with drugs or a pill has been shown to
 have an affect in many cases. Having randomly allocated patients to treatments,
their outcomes should be compared according to the group to which they were
allocated i.e. if a patient stops taking the treatment or even changes to the
alternative they should still be included in their initial group for the purposes of
statistical analysis. This is known as 'intention-to-treat' analysis and is
particularly important when patients withdraw or change treatment because their
allocated treatment produced undesirable side-effects.

The larger the sample for a given trial, the more power it has to detect
differences between the groups of a given size. If there is only clinical interest in
detecting large differences between the groups then a small sample may have
sufficient power. A small sample does not imply that there is statistical power.

10

Medical statistics deals with the analysis, interpretation and presentation of data. A
false-positive result occurs if the null hypothesis is rejected when it is actually true.

What sort of error is this?

Single best answer - select one answer only

Experimental design error

Observer bias error
Selection bias error
Type I error « YOUR ANSWER
Type II error
YOUR ANSWER WAS CORRECT
 The Answer

A type I error (false-positive result) occurs if the null hypothesis is rejected when
it is actually true (eg the treatments are interpreted as having different effects
when they do not).

A type II error is a false-negative result and occurs if the null hypothesis is

 accepted when it is actually false (eg the treatments are interpreted as having
equal effects when they are actually different.

Observer bias occurs where for example knowledge of the type of treatment
being given or received alters the perception of its effect. For example a patient
knowingly given a placebo for pain relief may over-rate their pain.

Selection bias occurs when patients are allocated to the interventions

sequentially so it is known in advance which treatment the next patient recruited
will receive so a clinician may pre-select a specific patient for a particular
intervention.

An experimental design error would be likely to result in statistical bias – factors

which will influence the results have not be subject to adequate control
measures.

11

You are in breast clinic reviewing a patient with a lesion detected via the national
screening programme. You have read a recent article regarding the need to be
conscious of bias in such screening programmes.
In general screening programmes for cancer are susceptible to which one of the
following?
Select one answer only
Calculation bias
Detection bias
Interobserver bias
Lead-time bias « CORRECT ANSWER
Population bias « YOUR ANSWER
YOUR ANSWER WAS INCORRECT
 The Answer

Results of screening programmes for cancer are limited by

selection,
 length
and lead-time bias.
Selection bias arises from the tendency of people who enrol on screening
programmes to be more health-conscious and are therefore atypical of the
general population.
Length bias is the tendency for screening to detect a disproportionate number of
cancers which are slow-growing and have a better prognosis anyway.
Lead-time bias occurs when screening advances the date at which diagnosis is
made.
This, therefore, lengthens the calculated survival time without necessarily
altering the date of death.

12

You are clerking an overweight male in the preoperative clinic and decide to read
about the relationship between blood pressure and weight. A journal article
examines the systolic blood pressure and weight in a group of males aged 30–40
years. The two variables are compared using a regression method as part of this
cross-sectional study and there is a positive correlation coefficient with p value
= 0.014.
Which one of the following will be true regarding this study?
Select one answer only

Information regarding the incidence of systolic hypertension in this age group will be
obtained
The value of the regression coefficient is dependent on whether the age is
expressed in months or years« CORRECT ANSWER
The results allow the likely systolic blood pressure of a 60-year-old man who weighs
78 kg to be predicted
Weight affects systolic blood pressure « YOUR ANSWER
Systolic blood pressure affects weight
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
 Systolic blood pressure and weight have been collected on 30–40 year old
males. This will give information on the prevalence of systolic hypertension in
this group, but not the incidence (A is false).
From this sample it will only be possible to make inferences about other men in
the same age group (C is false).
The regression coefficient (or the slope of the line) will give the average increase
in systolic blood pressure for a unit increase in weight and will therefore change
if weight is expressed in different units (B is true – changes in the units of age
will be completely separate from the regression equation linking systolic blood
pressure and weight).
The value P = 0.014 is evidence that average systolic blood pressure changes
with weight. However, this does not suggest that the relationship is causal (D is
false, E is false).

13

A patient does not attend for their clinic appointment and in the spare 15
minutes you are reading a journal article comparing a new antibiotic for the
treatment of diverticulitis to an older antibiotic. The study looks at the numbers
of patients cured as opposed to not cured in each group and uses the 'Chi
squared' statistic. In the trial of this new antibiotic the cure rates appeared to
improve when compared to the old treatment regimen (χ 2= 4.2; P < 0.01).
Which of the following would you bear in mind regarding this study?
Select one answer only
The improvement seen with the new treatment must be clinically significant «
YOUR ANSWER
the mean survival time was significantly longer for those given the new antibiotic
age may have been a confounding factor « CORRECT ANSWER
the trial implies that a difference in response of 4.2 times was observed
the results may have occurred by chance 1 time in 20
YOUR ANSWER WAS INCORRECT
 The Answer
 The chi-square test was used to compare the proportion who were cured using the new
antibiotic with the proportion cured on the old treatment regimen (B is false, mean
times were not compared).
The chi-square statistic is 4.2; by referring this to statistical tables a P-value of <0.01 is
obtained. The number 4.2 has no interpretable meaning as such (D IS FALSE). 
P < 0.01 means that the difference in cure rates would have occurred less than 1 time
in 100 by chance if the treatments were equally effective (E is false).
The result is statistically significant but this does not imply clinical significance (A is
false).
If one of the treatment groups was older and age affected cure rate then age would be
a confounding factor in the analysis (C is true).

14

In a small randomised double-blind trial of a new treatment in acute myocardial

infarction, the mortality in the treated group was half that in the control group,
but the difference was not significant.
What can we conclude?
Select one answer only

The treatment is useless

There is no point in continuing to develop the treatment
Reduction in mortality is so great that we should introduce the treatment «
YOUR ANSWER
We should keep adding cases to the trial until the test for the comparison of two
proportions shows a significant difference
We should carry out a trial of much greater size « CORRECT ANSWER
YOUR ANSWER WAS INCORRECT
 The Answer
 Comment on this Question
A halving of mortality attributable to a new treatment would almost certainly be
clinically significant.
Since the difference was not statistically significant the treatment may be
useless, and the observed reduction was due to random variation, or it MAY
actually improve survival.
 The study has been inconclusive, a larger sample would be needed to identify
whether the drug actually does work (A is false, B is false, C is false, E is true). If
we keep adding cases to the trial and retesting, then the probability of obtaining
a falsely significant result will increase. Sequential trials need to be specially
designed to take account of multiple testing (D is false).

15

The Gaussian distribution is used in statistical analysis to determine two limits within which an observation will fall.
Which of the following is correct about Gaussian distribution?
Single best answer - select one answer only

The median value may be less than the mean « YOUR ANSWER

The standard deviation (SD) is a measure of how accurately the calculated mean approaches the true population
mean

The ANOVA test may be used to compare this set of values with one further set provided they are also normally
distributed

The modal value is always equal to the mean « CORRECT ANSWER

25% of the values will have numerical values that are smaller than the mean value minus 5.96 standard deviations

YOUR ANSWER WAS INCORRECT

 The Answer
 Comment on this Question
The Gaussian distribution is more usually referred to as Normal distribution and is characterised by being 'bell-shaped'
(unimodal) and symmetrical about its central value. Accordingly themean=median=mode. The standard deviation (SD) is a
measure of the spread of the data values. 95% of observations lie within 1.96 standard deviations. Hence, 5% lie outside the
interval, 2.5% less than mean - 1.96 SD and 2.5% greater than mean + 1.96 SD. Student's t-test is an appropriate way of
comparing the means of two groups of normally distributed values. When the same group of individuals is assessed on three
or more occasions, the assessment times can be compared in pairs using either paired t-tests or Wilcoxon matched pairs
rank-sum tests as appropriate. However the number of comparisons needed is large if there are many groups to be compared
and the risk of a type I error (false positive result) increases rapidly. If the measure can be assumed to have a Normal
distribution, the assessment times can all be compared simultaneously using a repeated measures analysis of variance
(ANOVA).

16

In a trial to test the effectiveness of a new drug against the standard treatment for improving forced expiratory volume in 1 s
(FEV1) amongst asthmatics, the members of age- and sex-matched pairs are randomly allocated to the new or standard
treatment. The difference (new-standard) in forced vital capacity (FVC) between the pairs one hour after treatment was 0.5 ±
0.2 (mean ± standard error), P <0.005.
What are the chances of this difference having occurred by chance?

Single best answer - select one answer only

Less than one time in 100

Less than one time in 500

Less than one time in 1000

Less than two in 1000

 Less than five in 1000 « YOUR ANSWER

YOUR ANSWER WAS CORRECT

 The Answer
 Comment on this Question
P <0.005 shows that the observed differences would have occurred less than five times in 1000 if the new drug was no more, or less,
effective than the standard (5 times in 1000 = 1 time in 200).

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