Once you have finished training, there are many career options open to you. Some are obvious – become a principal in a partnership, take a salaried post, or work as a freelance (locum) sessional GP. However there are other options that you may not be aware of, or may not have considered. These include the Flexible Careers Scheme, the GP Retainer Scheme or even becoming a full time Out of Hours (OOH) doctor. What you decide to do will depend on your personal circumstances, including factors such as whether you are single or in a relationship (and what your partner is doing), your finances, the opportunities in the area you wish to work in and how you like to work.
This article will outline the different options in brief. More detailed articles on each option will be published soon.
Freelance (Locum) Sessional GP
This option gives you the most control over where and when you work, and can potentially be very lucrative. You are self employed, so are responsible for your own tax, national insurance and pension contributions. You can either arrange sessions yourself with practices locally, join a chambers, use an introduction service or work through one of the many GP locum agencies.
Salaried GP
This option will provide you with a fixed timetable and a fixed income. You are an employee, so have certain rights and protections (sick pay, holiday pay and maternity / paternity), and you will not have to worry about tax, NI or pension contributions as this will be taken care of by your employer. Pay varies according to region and from practice to practice.
Partnership / Principal
This option provides stability and is often very attractive financially, although it is a big commitment and you may have to “buy in” to become a partner. You will share responsibility for running your own business. This option often gives you the most control or say over how the practice develops, but also comes with the most responsibility. As well as clinical work, you will be responsible for the business – this can include management, staff, the building and ensuring you meet all the legal requirements in the running of the practice.
GP Retainer Scheme
This scheme often suits those who wish to work part time only. You can work a maximum of four sessions, and if you wish to do extra work, this must be approved. Practices get some of your salary costs reimbursed, and contracts are usually for a maximum of 5 years. The contract includes protected time for CPD.
Out of Hours GP
Many GPs still do some OOH work as it is now well paid, and you can often choose shifts that suit you. This may be an attractive option for new GPs to combine with another option (e.g. salaried or one of the part time schemes). However, some doctors may choose to work for some time as full time OOH doctors, working for PCT or one of the private companies that have taken over OOH provision in some areas. This is extremely well paid (up to £140k per year for 40 hours per week), but the downside is that you will always be working in the evenings and weekends, in what can be a more stressful environment than daytime practice. Working nights / weekends may suit some people (to fit in with family commitments), and there is usually scope to work part time if necessary.
Options, options, options
As you can see, the end of your training is just the beginning of a new journey in General Practice. You have many choices, and your preference may change as your circumstances do. Remember that choosing one option does not usually close the others off to you, so you may locum for a few months or years to see how different practices work, before taking a salaried job. At some point you may choose to join a partnership or combine one of these options with other part time options as part of a portfolio GP career.
For the more adventurous among you, you might think about working abroad, volunteering in the developing world, or even combining luxury travel with work by becoming a ship’s doctor. These options will be looked at in another article.
There is no “one size fits all” solution – none of these options are better or worse, it is about finding what suits you and your situation – this may change over time. You should discuss some of these options with your trainer a few months before the end of your GP Registrar year.
Workplace based assessment (WPBA) is one of the 3 components of the MRCGP exam. In this article, Dr Mahibur Rahman provides an overview of WPBA – what it covers, how to gather evidence for it, and when you need to complete certain milestones.
What is WPBA?
WPBA is a continuous assessment process throughout the 3 years of GP training. It is designed to support development through feedback on various competences both in hospital and GP posts.
It is based around 13 areas of professional competence:
Communication and consultation skills – use of recognised consultation techniques to communicate effectively with patients
Practising holistically – using physical, social and psychological context to provide holistic care
Data gathering and interpretation – effective history taking, choice of examinations, investigations and their interpretation
Making a diagnosis and making decisions – a conscious, structured approach to decision making
Clinical management – recognition and management of common medical conditions in primary care
Managing medical complexity and promoting health – aspects of care beyond managing straightforward problems, including management of co-morbidity, uncertainty, risk and focusing on health and well-being rather than just illness
Organisation, management and leadership – understanding the use of computer systems in practice, change management, and the development of organisational and clinical leadership skills
Working with colleagues and in teams – effective team working and the importance of the multi-disciplinary team
Community orientation – management of the health and social care of the practice population and local community
Maintaining performance, learning and teaching – maintaining performance and effective CPD
Maintaining an ethical approach to practice – practising ethically, with professional integrity and a respect for diversity
Fitness to practise – the doctor’s awareness of when his/her own performance, conduct or health, or that of others, might put patients at risk, and taking action to protect patients
Clinical examination and procedural skills – competent physical examination of the patient with accurate interpretation of physical signs and the safe practice of procedural skills
These competences are assessed in different ways throughout training, the idea being that you should achieve the standard expected of a qualified GP in all of them before you complete training.
How do I meet the requirements for WPBA?
You will need to gather evidence that you have achieved the competences using various tools. Some are used only in the GP setting, some only in hospital while others can be used in both settings. The tools are:
Tool
Hospital
GP
Case-based Discussion (CbD)
A structured interview assessing professional judgement in clinical cases – based around real cases you have seen.
☑
☑
Consultation Observation Tool (COT)
A review of patient consultations by your trainer – either video recordings or direct observation in a joint clinic.
☑
Multi-Source Feedback (MSF)
Collection and reflection on feedback from colleagues on your clinical and professional skills. This is from clinicians only in hospital, and both clinicians and non-clinicians when in GP.
☑
☑
Patient Satisfaction Questionnaire (PSQ)
Feedback from at least 40 patients on your empathy and relationship building skills during consultations.
☑
Clinical Examination and Procedural Skills (CEPS)
Assessment of various clinical examination skills and competence in performing key procedures – this includes intimate examinations.
☑
☑
Clinical Evaluation Exercise (MiniCEX)
Assessment of clinical skills, attitudes and behaviours in a secondary care setting – based on direct observation of your interaction with a patient for around 15 minutes.
☑
Clinical Supervisors Report (CSR)
A short, structured report from your clinical supervisor looking at the competences in 4 clusters: relationship, diagnostics, management and professionalism. This is usually completed for each hospital post, although it can be used in GP posts.
☑
(☑)
Learning Log
This is your personal learning record and should be used to reflect regularly on learning experiences. These can be linked to relevant curriculum headings.
☑
☑
Personal Development Plan (PDP)
This is used to allow you to demonstrate that you can assess your learning needs and plan actions to meet them. Items in the plan should be reviewed with evidence to demonstrate that you have achieved them.
☑
☑
Are there a minimum number of assessments I need to complete?
You will usually meet your educational supervisor every 6 months for a review of your progress. You will be asked to complete a self-assessment prior to each meeting. The guidance of how often each tool should be used is shown below – remember that the quality of entries and assessments is as important as the quantity. Some doctors will need to do more than the minimum to reach a suitable standard. The minimum evidence given here is based on a 3 year rotation with 18 months in hospital and 18 months in practice for a full time trainee.
Year of training
Minimum evidence
GP ST1
Prior to 12 month review
6 x mini-CEX (if in secondary care) / 6 x COT (if in primary care)
6 x CbD
2 x MSF (each with a minimum of 5 replies from clinicians plus 5 non-clinicians if in primary care)
1 x PSQ (if in primary care)
CEPS as appropriate
1 x CSR from each hospital post
GP ST2
Prior to 24 month review
6 x mini-CEX (if in secondary care) / 6 x COT (if in primary care)
6 x CbD
1 x PSQ (if in primary care and not already completed in ST1)
CEPS as appropriate
1 x CSR from each hospital post
GP ST3
Minimum prior to 36 month review
12 x CbD
12 x COT
2 x MSF (each with 5 clinicians and 5 non-clinicians)
1 x PSQ
WPBA is an important component of the MRCGP, and alongside the MRCGP AKT and CSA, assessed readiness for independent practice as a GP. It also offers a way to record your learning, gain feedback on areas to improve and to provide evidence of your achievements. It is important to keep on top of the different learning tools and gather the necessary evidence in a timely manner so you can successfully progress through training.
Talking to the families of your patients can be one of the more difficult parts of your life as a doctor, but you can make it one of the most rewarding. It is part of everyday life for doctors to be asked to discuss a patient’s care with a relative or carer. In this article, Dr Mahibur Rahman looks at some key things that can really help, whether you are breaking bad news or just updating the family on management plans.
Be prepared
You need to be fully aware of all aspects of the current situation before beginning a discussion with a family – incorrect information can produce problems later on. Arrange a time (even if it’s only five minutes later), and go over the case notes to remind yourself of exactly what has happened, what is happening now and what is going to happen. If you are breaking the news of a patient’s death, make sure you know as much about the events surrounding the death as possible (cause, time, people present etc.). Consult with other members of the team (especially nursing staff). If possible, ask someone to hold your pager while you deal with the relatives. Make sure you get permission (where appropriate) from the patient to discuss their care with relatives.
Set the scene
It is essential that any discussions take place in a suitable environment – ideally a quiet side room or office where you won’t be disturbed. Holding a discussion around the bed is very rarely a good idea. There should be adequate seating for everyone. Standing when you are talking to someone can give the impression that you don’t have much time, and need to rush off somewhere else. Try to bring a member of the ward staff with you – someone who can stay afterwards and explain or reinforce anything that you said.
What to say.
Honesty is one of the factors that relatives values the most when dealing with doctors. They need the truth to make their personal adjustments and their plans. Make sure that you do not stray from the facts, and if you are unsure about something, NEVER make it up. Instead, offer to find out and leave the details with the ward staff, or arrange another meeting.
How to say it
At all times, be polite and patient. Remember that the family will be under great strain. Explain things in language that the relatives can understand, avoiding medical jargon as much as possible. The relatives are much more likely to understand “your father has had a stroke”, than “the CT scan has shown an ischaemic CVA”. Where the family have a grievance about anything do not be defensive and never raise your voice – this will make the situation worse. An apology a day keeps the lawyers away.
Say it again, Sam
You may have to explain things more than once, and relatives sometimes have their own ideas about what is going on. Allow them to air their concerns. Always ask if they would like you to go over anything, and offer them a chance to ask questions. The wording of this is very important – saying “is there anything I haven’t explained clearly?” is better than “is there anything you didn’t understand?”. Although having essentially the same meaning, the first does not demean the relatives in any way, where the second might be taken as an insult to their intelligence.
And in the end.
Finally, leave a means of contact if they want to follow up your discussion – this can be by leaving a message with the ward clerk or a member of the nursing team, or via your pager (only give this out if you genuinely don’t mind relatives bleeping you – it is usually better to call them so that you are properly prepared for any conversation).
You will find that family members are often very grateful for the time you take to discuss their relative’s care. And doing this well will give a huge boost your job satisfaction.
Summary
Here are some of the keys to successfully dealing with family members or carers.
Look and speak the part
Make sure you know the case well – read over the notes carefully
Turn off your phone and hand over your bleep so you aren’t disturbed
Use a quiet room with adequate seating
Explain the facts clearly, avoiding medical jargon
Offer to go over diagnoses and management
Leave time for relatives to ask questions
Offer to find out things you don’t know
Make notes and record what was said in the patient’s notes
This article has been adapted from one first published in Februray 2005 and is reproduced with the kind permission of Hospital Doctor, who retain the copyright.
The Specialty Recruitment Assessment (SRA) plays in important part in the shortlisting and assessment process for 6 different specialties: GP, Radiology, Ophthalmology, Obstetrics and Gynaecology, Psychiatry and Neurosurgery. It is also known as the Multi Specialty Recruitment Assessment (MSRA).
It will be done entirely on computer, and consists of two parts lasting a total of 3 hours 5 minutes – a clinical problem solving section and a professional dilemma section. Each specialty uses the results of the SRA in a slightly different way in the recruitment process for ST1 / CT1 posts.
Clinical Problem Solving
This is a 75 minute assessment with 97 questions testing your clinical knowledge and ability to apply it in practice. This paper is set at the level of knowledge expected for a Foundation Year 1 doctor at the END of their first year. The paper is very broad, covering almost all the medical and surgical specialties. There are a variety of question types, including:
Extended matching questions (EMQ)
Single best answer (SBA)
Multiple best answer (MBA) – there are up to 3 correct answers
Picture questions – this could include skin lesions, fundoscopy, blood reports, ECGs etc.
Algorithm questions – you may have to drag boxes into the right part of the algorithm or select the correct answer from a list. Algorithms could include BLS / ALS / important guidelines etc.
Question may relate to diagnosis, investigation or management of both common and important diseases as well as rare but serious presentations.
There are some example of the 2 most common question types (EMQ and SBA) below:
EMQ – Investigations for back pain
A 25 year old man is involved in a road traffic accident. He was on a bike and hit from the side. He did not want to attend the hospital, and was taken home by his friends. He now complains of severe pain in his lower back and cannot pass water. He has tingling in his legs below the knee. Select the most suitable investigation from the list.
A
X-ray of the lumbar spine
E
Routine MRI scan lumbar spine
B
X-Ray of sacro-iliac joints
F
Urgent MRI scan lumbar spine
C
Routine CT scan lumbar spine
G
DEXA scan
D
Urgent CT scan lumbar spine
H
No investigations needed
A 68 year-old woman with known osteoporosis. She has had a fractured neck of femur in the past after a fall in her garden. She now complains of pain in her lower back, but does not have much muscular tenderness. She has no bowel or bladder symptoms. She has no neurological symptoms. Select the most suitable investigation from the list.
A
X-ray of the lumbar spine
E
Routine MRI scan lumbar spine
B
X-Ray of sacro-iliac joints
F
Urgent MRI scan lumbar spine
C
Routine CT scan lumbar spine
G
DEXA scan
D
Urgent CT scan lumbar spine
H
No investigations needed
A 40 year old labourer attends complaining of severe low back pain after finishing his shift. He does not have any bowel or bladder problems, and on examination has a straight leg raise of 90 degrees in both legs. He has no other significant medical history. Select the most suitable investigation from the list.
A
X-ray of the lumbar spine
E
Routine MRI scan lumbar spine
B
X-Ray of sacro-iliac joints
F
Urgent MRI scan lumbar spine
C
Routine CT scan lumbar spine
G
DEXA scan
D
Urgent CT scan lumbar spine
H
No investigations needed
SBA – Allergic reactions
A 35 year old man has a severe allergic reaction while in hospital. He has no history of past allergic reactions. Which ONE of the following is most likely to cause a reaction WITHOUT prior exposure or sensitization? Select ONE answer only.
This is a 110 minute assessment with 58 situational judgement test questions (SJT). Questions test judgement and decision making in a workplace context. It also assesses knowledge of important ethical and medicolegal guidance from the GMC. Questions assess 3 domains – empathy and sensitivity, coping with pressure, and professional integrity.
There are two types of SJT questions in equal proportion. The questions in section 1 ask you to rank 4 or 5 actions from best to worst in the context of a workplace scenario. The questions in section 2 ask you to select 3 actions that taken together make the best response to the situation. There are up to 8 options to select from in this type of question.
Sample ranking question:
You have just started a job as a medical F2 in a new hospital. Your partner has a chest infection, and is not yet registered with a GP and has asked you to prescribe antibiotics.
Rank the following options 1-5, 1 being the most effective / best option, 5 being the least effective / worst option:
A. Prescribe the medication as a private prescription, and arrange for your partner to register with a GP the following week.
B. Tell your partner to register with a GP locally.
C. Prescribe the medication on a hospital take home prescription with your partner’s details on it.
D. Prescribe the medication on a hospital take home prescription with one of your patient’s details on it. Collect the medication from the hospital pharmacy.
E. Pressure one of your FY1 colleagues to write a prescription on a hospital take home script without seeing your partner.
Sample selection question:
You are an F2 in Orthopaedics. An 80 year old lady has a fracture of her right neck of femur. You have been asked to consent her prior to surgery but on talking to her she seems confused. Her daughter tells you she has dementia and this is confirmed in the notes. She is first on the morning list. Select the THREE most appropriate actions to manage this situation:
A. Ask her daughter to sign the consent form and state that she is the daughter.
B. Inform your consultant she has dementia and ask him to complete the consent form.
C. Encourage the patient to sign the form as the procedure is in her best interests.
D. Exclude any acute causes that could be worsening her confusion.
E. Discharge the patient as she will be unable to have surgery without consent.
F. Cancel the patient’s operation.
G. Ring the theatre to rearrange the list so this lady is lower down on the list.
H. Complete the consent form on the patient’s behalf as it is in her best interests.
It is important to allow enough time to prepare for both papers – some specialties use the scores as part of a ranking process to determine eligibility for interview / selection rather than as a pass / fail criterion. In some cases the SRA score carries over to the next stage and is added to the interview score to determine overall rank so it is important to do as well as possible. Try to combine reading to cover the key clinical theory (Oxford Handbook of Clinical Medicine and Oxford Handbook of Clinical Specialties) and understand key GMC ethical guidance with practising sample SRA questions to develop exam technique and get a feel for the different types of questions. As you get nearer the time of the exam, you will benefit from doing a timed mock exam to get used to the pressure of the exam.
I hope this article has given you a clearer understanding of what to expect in this important assessment. I wish you every success with your revision and in getting a place on your chosen rotation.
Dr Mahibur Rahman is medical director of Emedica, and has helped thousands of doctors prepare for this type of assessment since 2007. He teaches on the popular Specialty Recruitment Assessment Crammer course which covers both papers. You can get a £20 discount on the course which carries 6.5 CPD credits by using the code srapass at http://courses.emedica.co.uk/acatalog/GP_ST_Entry_Stage_2_Exam_Crammer_.html
The Situational Judgement Test (SJT) for final year medical students plays an important part in your ranking for the applications for Foundation training (FPAS). Whether you have a great Educational Performance Measure (EPM) score or not, the SJT will influence which placement you get.
In this article, Dr Mahibur Rahman discusses some key tips to help you improve your score so you can get the placement that you want.
1. Understand the basics
The exam lasts 2 hours and 20 minutes and has 70 questions, although only 60 of the questions are marked – the other 10 are pilot questions. Pilot questions are mixed in with the examined ones, so you need to treat them all as live questions.
There are two types of question – ranking and selection. In a ranking question, candidates will be presented with a scenario and 5 options – the options need to be ranked from best (1) to worst (5). This format makes up two thirds of the exam, with each question being marked out of 20.
Selection questions have 8 options, and candidates should select the 3 options that taken together make the best response to the scenario. This format is a third of the exam, with each question marked out of 12.
Sample questions for each type are given below:
Sample SJT ranking question
While working on the medical wards as an FY1 you are asked by a nurse to complete the discharge paperwork for a patient you are not familiar with. This includes a summary of the admission as well as drugs to be taken home when discharged. You are in a hurry and on the post-take ward round. The rest of the team is about to start discussing the next patient that was admitted overnight.
Rank in order the following actions in response to this situation (1= Most appropriate; 5= Least appropriate)
A – Ask the nurse what drugs the patient needs and the diagnosis, so you can quickly note this on the discharge paperwork and keep up with the ward round
B – Explain that you are busy at the moment but that you will come back and do it as soon as the ward round is complete
C – Sign the paperwork and ask the nurse to complete the summary and medication while you join the rest of the team
D – Check the patient’s notes and complete the paperwork with a summary of the admission and all required medication – you can catch up with the ward round later
E – Ignore the request. The nurse knows you are on the post-take round and can ask you later
Sample SJT selection question You are an FY1 working in obstetrics and gynaecology. You see a lady on the labour ward who is having a massive postpartum haemorrhage. In the last few minutes she has become very unwell and is now unresponsive and continuing to bleed. From reading her notes you know she is a Jehovah’s Witness and has signed a form in antenatal clinic stating she declines all blood products even if her life is threatened. The midwife looking after her states that she asked the lady a few minutes before she became unresponsive if she would accept blood products if her life was threatened and again she said no. Her husband is holding his new born daughter and states you must do everything you can to save her even if that means giving her blood.
Choose the THREE most appropriate actions to take in this situation
A. Give blood products as this is an emergency and they may be life saving
B. Do not give blood products even if it means she comes to harm
C. Put aside the patient’s wishes as her decision suggests a lack of capacity
D. Explain to the husband that you have to respect the patient’s decision
E. Ask the husband to give formal consent on behalf of his wife to give blood products
F. Do everything else you can to save the patient’s life
G. Do nothing else as she will inevitably die without blood products
H. Contact your consultant and ask them for permission to give blood products in the best interests of the patient
2. Learn the domains being tested The SJT questions are written to test whether you have the attributes deemed important to be a good Foundation doctor. These are divided into 5 domain areas. A good first step in your preparation would be to understand the key attributes and behaviours being tested. Learning what is being assessed will help you pick between options based on how well they demonstrate these attributes. The domains and some of the key attributes are: Commitment to professionalism – punctuality, honesty, taking responsibility for own actions, challenging unacceptable behaviour, ethical practice, respecting confidentiality. Coping with pressure – remaining calm and in control when dealing with difficult situations, good judgement, seeking support when required, dealing with confrontation appropriately. Effective communication – sensitive use of language, adapting communication according to the needs of patients and relatives, using clear and understandable language, good written communication. Patient focus – empathetic towards patients, showing respect to patients, putting the patient at the centre of care, providing reassurance appropriately, willing to spend time with patients and relatives, considering patient safety at all times. Effective team working – understanding the roles of team members, willing to take direction, showing respect to colleagues, delegating and sharing tasks effectively, sharing knowledge and expertise with colleagues.
The full list is available in the official SJT monograph
3. Revise the core knowledge being tested While the SJT does not test clinical knowledge, there are questions that assess knowledge of what is deemed to be good practice based on core guidance from the General Medical Council (GMC). Most of this comes from Good Medical Practice and some of the explanatory guidance published by the GMC. This includes areas such as confidentiality, maintaining boundaries, care of children and younger people, raising concerns, end of life care and advanced directives, and even the use of social media. The SJT asks you to answer what you “should do” rather than what you “would do” – i.e. what does the guidance say a good doctor should do in the ideal situation. This is much easier to do with a good working knowledge of the key guidance.
4. Spend time on the ward A useful technique to deal with scenarios in the SJT is to try to picture the situation in your mind. This is much easier if you have spent lots of time on the wards. Try to observe how the doctors communicate with patients and relatives, how the team interact with each other, and the roles of different members of the multidisciplinary team. If there are areas from the GMC guidance that you are unclear about, it can be really helpful to talk through potential issues with a junior doctor – they may have encountered similar situations in real life and can talk you through approaches they used to deal with it.
5. Work through the official practice paper The official Foundation Programme SJT practice paper is a complete 70 question SJT paper. There is an interactive version that you can do on a computer, and also a paper version. Doing the paper version, and getting used to completing the paper marking sheet will help familiarise you with the format and improve speed on the day. There is a marking key with detailed explanations so you understand the rationale behind why some questions are ranked the way they are.
6. Read the scenario carefully Sometimes keywords have a big impact on the best response in both ranking and selection questions. Try underlining important words as you read. For example, your approach may differ in a situation where you suspect inappropriate behaviour compared to when you are certain of inappropriate behaviour. This small difference might change where you ranked waiting to gather more information, compared to raising an issue with a senior colleague for example. For ranking questions, there are different types of question – most ask you to rank from most to least appropriate, but some ask you to rank according to the order in which you would do things, how important considerations are to the situation or how much you agree with different statements.
7. Use only the information provided in the question
In some scenarios there will be limited information. In real life, it might be possible to get clarification or gather more information from the patient or a colleague. In the exam, your answers should be based only on what you are told in the scenario and the options. Do not make any assumptions – an incorrect assumption may lead you to a poor response. 8. Look at all the options before assigning any rankings (ranking questions) For ranking questions, it is important to go through and consider all the options before you start deciding on the order. If you read the first option and decide it is a “bad” option, you may mentally place it last. This may then impact your thinking when reading other options – you may not remain objective and could end up fitting other options around the preconception that option A is the worst. The ranking questions are comparative not absolute – so rather than “good” or “bad”, it is about comparing one option to the other possibilities – “better” or “worse”.
9. Make sure your choices make sense when taken together (selection questions). In the selection questions, all 3 options that you select should be looked at together as a combined response to the scenario. In some cases you can eliminate options if they would contradict each other or would not make sense when taken together. If you are confident that an option that suggests seeing a patient when a chaperone is available is correct, then you could eliminate another option that suggested seeing the patient immediately without a chaperone. A good way to check if your answer is likely to be correct is to read all 3 options back together and see if they make sense together. If they don’t you should consider changing at least one of the options.
10. Double check you have marked the correct options. The SJT paper is machine marked so check that you have marked the answer sheet correctly – transcription errors are a silly way to lose marks. In ranking questions, if you accidentally marked option A and option E as the best options (rank 1), you will be awarded zero marks for BOTH these options. In the selection questions, if more than 3 options are marked, the total score for the entire question will be zero. If you transcribed the answers to question 1 to the box on the answer sheet for question 2, it would be possible to accidentally mark all the later questions in the wrong box and have a serious impact on your overall score.
11. Keep to time
To complete the entire paper, you have just 2 minutes per question. Try to be disciplined – if you are not entirely sure of the best answer, it is better to put down your best guess and move on. You will still get marks for answers that are not perfect but close to the best answer. For ranking questions, you get 8 marks for the worst possible ranking. If you are fairly close, but not quite perfect, you can still get 16 or 18 marks. Spending an extra 2 minutes to get the perfect answer may only increase your score for that question from 18 to 20 (2 extra marks) – whereas using that 2 minutes to answer another question will get you at least 8-20 extra marks. Even worse – the question you spent a long time on could turn out to be one of the pilot questions, and so carry no marks.
Summary
The Foundation SJT plays an important part in determining where you will be placed for your first two years after qualifying. Understanding the attributes that are being tested, and learning the core GMC guidance will give you the basic tools to help you prepare. Practising sample questions and getting used to the format and time pressures will help you to get the best possible score on the day.
Dr Mahibur Rahman is a portfolio GP and a consultant in medical education. He is also the medical director of Emedica. Emedica has been offering courses to help medical students prepare for the Foundation SJT since 2012. We have helped students from every UK medical school prepare, with 94% getting one of their top 3 rotations in 2016.
The Foundation SJT is an important part of the application process for entering the Foundation Programme (FPAS). In this article, Niamh Rogers explains how she managed to score amongst the top 2% of over 8,000 candidates that took the SJT for Foundation Programme entry in her year. She scored 45.42 and got a place in her 1st choice Foundation Programme, Northern Ireland.
The Foundation SJT
The Situational Judgement Test (SJT) is an exam that is now faced by all final year medical students hoping to gain a Foundation Programme training place in the United Kingdom. As the exam itself has only recently been brought in as a method of selecting candidates to training posts, a lot of speculation and anxiety surrounds the test. The fact that the SJT accounts for 50% of all marks available means that for most students this exam is the single most determining factor in allocation of foundation schools and house officer jobs. I was lucky enough to achieve a high score, placing me in my first choice deanery with my choice of jobs. Here is my experience of preparing for the situational judgement test and hints and tips for performing well on the day.
I booked one SJT preparation course, Emedica, to tackle the SJT. I choose Emedica because although the SJT is new for medical students, it has been used for doctors in GP training since 2007, and Emedica has been running courses for it since it began. As my SJT assessment date was in December I made sure to book the earliest course in October to give myself sufficient time to practice.
The course itself was excellent and gave me both the confidence and knowledge to know how to prepare for the exam. Emedica explained the different types of question styles, how to go about structuring your time (in what was an extremely time pressured exam) and to rank each option for the question at face value.
The mock test at the end of the day was a good insight into the process of the exam and the mark obtained was translated into points like in the real SJT.
Preparing for the Exam
The SJT isn’t an exam you can cram for! Speaking from the biggest crammer of every exam going, I soon realised that the SJT was more a “way of thinking ” than something you could learn with intense days of revision before the test. As I was revising for medical finals and doing A&E placements I knew that I would have to schedule some time to practice questions. I found that by doing around 30/45 minutes of questions 3/4 evenings a week, after I had finished revision for the evening, very manageable.
This is where going to the Emedica SJT course came into its own. There are vast numbers of SJT books with hugely varying quality between them. The Emedica course provided you with a question bank that was split into smaller sections- perfect for completing small stints of practice. The questions accurately reflected the content, length and difficulty of questions in the exam.
Initially I didn’t practice timed- I wanted to thoroughly understand why each option was in the order stated. I felt that by understanding why exactly the options ranked in a certain order , it would give me a better insight into what the exam was testing. With about two weeks to go I started timing myself and always tried to use blank answer sheets so that it would become second nature on the day.
I printed out the sample paper online along with a blank mark sheet, and over the course of my revision I did this exam x3 times. I felt that repeating questions helpful as often I was getting the same questions wrong .
In order to focus for the exam I had an early night’s sleep, went for a run that morning and made sure to have a good breakfast before the exam. The exam is long and timing is a big factor. I made a mental note of what question I should be on at 30 min intervals and wrote this down on the front of the exam paper when I sat down. Make sure you use the bathroom before you start as the exam is 2 hours 20 minutes long!
I highlighted key words in each question (each word is used specifically as the exam is developed by subject experts and psychologists) . I numbered my order on the exam paper and once happy with my answer, transferred it to the answer sheet. I found using a ruler helped focus my eye and made sure I wrote my answer in the correct box. I went through the paper systematically. I circled some questions that I felt I could spend more time on and returned to them at the end.
In summary, the SJT is a high stakes exam that can be prepared for. Practice little and often can boost your score and give you confidence on the day of the exam. Being extremely familiar with the format of the paper and the answer sheet and preparing mentally to focus for an intense 140 minutes are key factors to succeeding in the SJT.
Best of luck!
Niamh Rogers
Final Year Medical Student Norwich Medical School
Niamh scored 45.42 (within the top 2% in the country) and got a place in her 1st choice Foundation Programme, Northern Ireland.
These are the current payscales for GP trainees in England and Wales in effect from August 2016 onwards. Current trainees in England will start to be moved to the new junior doctor contract from October 2016 onwards – we will publish an update if this is implemented, once full details are available. For hospital posts, total pay will depend on the banding (jobs with more on call / antisocial hours carry a higher supplement). The GP Registrar supplement is currently fixed at 45% – this is for all posts when based in a practice, regardless of the year of training, or the number of on call or out of hours shifts completed. Payscales for Northern Ireland are not yet published, but are likely to be similar to these. Payscales for trainees in Scotland are slightly higher.
GP Trainee Payscales 2016-2017
If you are entering GP training from another training post, you should start on the paypoint with basic pay that is closest to your current basic pay. E.g. if your current basic is £29,500, you will move onto the StR Min scale, with a basic pay of £30,302 and so on. You will move onto the next point on the scale on the anniversary of your increment date (this should be on your last payslip). If you are entering training from a non training post, then you may be entitled to pay protection if you are in a nationally recognised career grade post (e.g. consultant, specialty doctor, staff grade). Career grade doctors moving from a local grade (e.g. trust grade, trust registrar, clinical fellow) do not get pay protection.
When you are on paypoint StR3 or higher (shown in cream above), you are entitled to an extra 5 days of annual leave – so you will get 30 days instead of 25 in addition to bank holidays (in hospital you may get 2 additional days leave per year). Please note that StR3 is NOT the same as being in your ST3 year. The paypoint is based on past NHS experience, NOT your year of training. For example, a doctor entering GP training straight from Foundation Year 2 will go onto the StrMin payscale during their ST1 year, then StR1 in their ST2 year, and StR2 in their ST3 year. They will have 25 days annual leave in all 3 years of the rotation. A doctor entering GP training having already completed 2 years of core medical training would start on the StR2 payscale (while in the ST1 year). They would have 25 days leave in this year. In the ST2 year, they would be on the StR3 payscale and get an additional 5 days leave, and so on.
GP Registrar Salary – Net Monthly Pay
Most GP rotations now have 16-18 months in general practice. As there are a lot of costs during the latter part of your GP training, we thought it would be helpful to look at estimated NET pay (i.e. take home pay after Tax and National insurance). This might help you plan and budget so you can meet the costs of sitting the MRCGP AKT Exam and MRCGP CSA Exam (about £2,100 together) as well as other final year costs such as CCT, indemnity etc.
*These figures are estimated monthly take home pay net of income tax and national insurance. They have been rounded down to the nearest pound, and are based on a standard tax code. As your pay may change during the tax year, the actual amount may differ. Pay in the first month of a new job is often lower as you may be put on an emergency tax code (BR) which may reduce your take home pay until corrected. You can get an accurate monthly calculation here (external link). These figures do not include deductions for the NHS pension – although you can put pension into the calculator to get an accurate amount. If you are paying into the NHS scheme, expect a take home pay around £200-£300 a month lower than the figures above depending on the paypoint.
GP Registrar’s medical indemnity will be reimbursed less the amount they would have paid for a hospital job.
When starting GPST, if you have to move house (i.e. your new job is in a different area), there are certain expenses that you can claim. These are covered briefly here, you can download the full guidance documenthere or at the bottom of the page. If your first post is in hospital, you should contact medical staffing to get hold of the local expenses policy. If your first post is based in practice, then your local Primacy Care Organisation (Health board, Local Health Board or Area Team / Primary Care Finance) will usually reimburse you, either directly or via the practice. In some areas, the deanery deals with this centrally. You should make contact to approve any large expenses before committing, and make sure you keep all receipts to claim back your money. You may have to satisfy the relevant body that your house move is necessary.
So what can you claim?
Actual removal expenses
This includes the cost of moving your furniture and effects, and includes the cost of storing furniture during the move if necessary. This includes ordinary household items such as bicycles, computers etc., but not items requiring specialist removal like your grand piano! Removal of domestic pets are included, but not livestock (so you can’t relocate your whole farm, sheep intact!). These costs can be upwards of a thousand pounds, and the HA will want three different quotes. You do not have to accept the lowest quote, but you will only be reimbursed this amount (so if you wish to take a more expensive service, you pay the difference).
Costs of searching for accommodation
You can claim the cost of traveling to the new area to look for suitable housing. One return journey and up to four nights accommodation and subsistence can be reimbursed. This is paid at the same rate as when on study leave – about £75 per day maximum including accommodation.
Legal and estate agent fees
If you purchase a house in the new area, and it is your first permanent unfurnished accommodation there, or if you sell a house immediately prior to the move, you can claim the following fees:
solicitor’s fees
stamp duty
land registration fees
incidental legal expenses
expenses in connection with a mortgage or loan, including guarantee and survey fees
legal expenses incurred in mortgage redemption, and house agents’ or auctioneers’ fees
costs of a private survey
electrical wiring test
a drains test
Tenancy
If you rent furnished accommodation in the new area, you can claim the costs of a tenancy agreement, estate agents fees for referencing, and the cost of a drains test. These expenses are not reimbursed to registrars who move into rented lodgings (a room in an house or flat).
Miscellaneous expenses grant
This covers some of the costs of moving into a new permanent accommodation, and include:
installing a television aerial
plumbing in a washing machine/dishwasher
connection of cooker
alteration of curtains and pelmets
cleaning of property
reasonable telephone calls made in the course of seeking accommodation
Travel allowance
One single journey from the old residence to the new area is covered, and one further return journey if you have to return to supervise the removal of your effects. You should also be able to claim travel expenses for your interview.
There are many more allowances, and you can download the full guidance here. (from Department of Health website).
The MRCGP AKT exam is a challenging exam, testing applied knowledge relevant to UK general practice. In this article, Dr Mahibur Rahman discusses some key tips to help you prepare for and pass the exam.
Understand the basics
The exam lasts 3 hours and 10 minutes, and consists of 200 questions. 80% of the questions relate to clinical medicine, 10% to evidence based practice, and 10% the organisational domain. The exam is computerised, and there is now access to a basic on-screen calculator if needed. The majority of questions are single best answer and extended matching questions. Other formats include algorithm questions, short answer (you type the correct answer into a box), video questions, and picture based questions.
Fail to prepare, prepare to fail
Allow enough time to revise all material in the exam – most candidates need 3 or 4 months to be able to cover everything sufficiently well to pass the exam. A common finding amongst candidates that failed the exam is that they had not realised how long it would take to prepare, and did not have enough time to complete their revision. The curriculum is large and covers a broad range of topics – try to have a systematic approach to allow you to cover all the important topics adequately. The RCGP has produced an AKT topic review which details the key areas and subjects covered in the exam. The MPS has produced a more concise checklist of key topics that frequently feature in the exam as part of their free MRCGP Study Guide.
Focus on the clinical domain
Aim to spend the majority of your revision focusing on the clinical domain – this makes up 80% of the marks and questions (160 questions). Someone who scored very poorly in this area (under 60%) would usually fail the exam – even with 100% in the other domains. Overall, a poor score in this domain is the most common cause of failure in the AKT exam. This domain also takes the longest amount of time to cover as the bulk of the curriculum is focused on clinical topics. Questions from the clinical domain can include those relating to making a diagnosis, ordering and interpreting tests, disease factors and risks, and management. It is important to have a good knowledge of key guidelines – NICE, SIGN, BTS etc. for common and important disease areas as they are frequently tested.
Revise core statistics and evidence based practice
10% of the exam is evidence based medicine, including basic statistics, graphs and charts and types of study. These offer easy marks if you make sure you have a good grasp of the basic concepts and can interpret common charts and graphs. Make sure you can calculate averages (mean, mode, median), numbers needed to treat, sensitivity and specificity as well as understanding absolute and relative risk, odds ratios, p values, 95% confidence intervals and standard deviation. You should be able to interpret scatter plots, L’Abbe plots, Forest plots, funnel plots as well as Cates plots. Finally, you should be able to understand the usage of common study types including cross sectional surveys, case control studies, cohort studies and randomised controlled trials.
Don’t forget the organisational domain
This makes up another 10% of the exam, and is the area that candidates tend to do worst on. These areas can be dull to read, but learning about practice management, QOF, certification, DVLA guidelines and legal duties of doctors will not only get you easy marks, it will be useful when you qualify.
Learn from other people’s mistakes
Read through the examiners’ feedback reports to see which topics caused trainees problems, as they are usually retested in the next few exams. Having analysed every feedback report published so far, it is interesting to note that the same subjects get featured repeatedly! In the last feedback report, there was not a single topic that had not already featured as an area of poor performance in a previous report.
Make the most of your revision time
Effective revision should combine reading with practising questions. Try to practise questions to time, as time pressure is a big issue with this exam – you have about 57 seconds for each question! If you get a question wrong, try to read more broadly about the subject to gain a deeper understanding. By relating it to a question you have just answered, you are more likely to retain the information. Concentration drops dramatically after an hour, so try to revise in chunks of no more than an hour at a time. Take a short break – even 10 minutes to make a hot drink, or get some fresh air is often enough to refresh you and improve concentration for the next burst of revision.
Learn the subject, not the question
Some candidates approach AKT revision by picking an online revision service and then go through all the questions multiple times. This can lead to a false sense of security and ultimately failure in the exam. Repeating the SAME questions multiple times provides very little additional benefit. Often complex questions such as data interpretation are answered the second time by remembering the pattern rather than understanding the subject. In the exam, you will not get the same question, but a different one testing knowledge of the subject. While your mark will improve with each repeated attempt at the same questions, your knowledge may have only improved marginally (having seen the correct answers the first time, it is not surprising that you get most of them correct the next time). A better approach is to read up on the subjects and explanations after doing a set of questions, and then once you complete all the questions, move on to a different set of questions from a different service or book. This will give you a better idea of how well you have understood the topic and retained the knowledge.
Read the question carefully
Many candidates that have a good knowledge base still fail the AKT by a few marks. This can be owing to poor exam technique. It is really important to read the question carefully to prevent losing marks for silly mistakes. This can relate to the instructions – some questions ask you to drag the right answer into a certain part of the screen. Clicking the right answer instead of dragging it will gain no marks. It is important to watch out for and to understand certain keywords – if the question asks for a characteristic feature, it means it is there in almost every case (90% or more) – whereas if it asks for a feature that is commonly seen in a condition, it only needs to be there in around 60% or more of cases. Some questions are negatively framed – “which of the following is not part of the Rome III criteria for diagnosing irritable bowel syndrome?” – candidates that fail to spot the “not” in this question could easily select the wrong answer despite knowing the Rome III criteria.
Keep to time
To complete the entire paper, you have just 57 seconds per question. Try to be disciplined – if you are not entirely sure of the best answer, it is better to put down your best guess after about 55 seconds and move on. You can flag questions for review, so you could try to come back if you finish a little early to look at those are unsure of. By being strict with your time, you will at least pick up all the easy marks for topics that you have covered in your revision. Candidates that spend 2-3 minutes struggling with a few really challenging questions often end up unable to complete the paper. They may have missed easy marks from questions at the end of the paper that they did not see. It is useful to have some pace checkpoints – try to finish 33 questions every 30 minutes. At this pace, you will have completed 66 questions after 1 hour, 99 at 1.5 hours, and complete the whole paper with just under 10 minutes left to go over any questions flagged earlier.
Summary
The MRCGP AKT is a challenging exam with a significant failure rate – over 1 in 4 candidates fail each exam, with the long term mean pass rate around 73%. It covers a large curriculum, so it is important to allow enough time and to have a plan to enable you to prepare in a systematic way. A lot of the knowledge gained from preparing will help you not only in everyday practice, but also for the MRCGP CSA examination. By mixing reading with practice questions, you should have both the knowledge and the exam technique to allow you to pass well.
The MRCGP CSA is a challenging exam, acting as an exit exam for GP training in the UK. In this article, Dr Mahibur Rahman discusses some key tips to help you prepare for and pass the exam.
Understand the basics
The exam is based on a simulated surgery consisting of 13 cases played by simulated patients. The cases will include a range of disease areas and case types, with at least 1 child health case, and at least 2 cases that will significantly test prescribing knowledge. You will have 2 minutes to read the case notes before each consultation, and exactly 10 minutes for the consultation itself. There will be a different examiner with each simulated patient, assessing the same 3 domains in every case: data gathering (history and examination), clinical management (including diagnosis, management, follow up and safety netting), and interpersonal skills (clear explanations, empathy and sensitivity and having a patient-centred approach).
Each domain is graded as either clear pass (3 marks), pass (2 marks), fail (1 mark) or clear fail (0 marks). The total score from all 13 cases determines whether you pass or fail the exam. The pass mark is adjusted each day to take account for the level of difficulty of the cases, but usually ranges from 72-78 out of 117. The total score is the only thing that determines if you pass or fail – there is no minimum score in each case. A candidate that scored 9 in several cases could get 0 in some cases and still pass i.e. you pass or fail the exam as a whole, rather than individual cases.
Join a study group
Forming a study group early on in your preparation for CSA – 6-9 months prior to your exam – can help in many ways. A good number to meet for a study session is 3 – one to be the doctor, one the patient, and one to observe and provide feedback. Some candidates find that being observed makes them nervous and affects their performance – having a colleague observe and be the “examiner” can simulate some of that pressure and over time, help to overcome it. It is also easier for someone observing and making notes to give useful feedback. Agree in advance the importance of being honest and constructive when giving feedback – some registrars feel shy to say anything critical and just focus on the positives when observing others. While this might make you feel good, it won’t help you improve.
Putting yourself in the role of the examiner with a clearly defined mark scheme can also help give an insight into the importance of clearly demonstrating the criteria in the different domains.
Seek feedback regularly
Try to get feedback on your consulting whenever possible. This can be through consultation observation tool (COT) assessments, joint surgeries, during out of hours (OOH) sessions and also during tutorials. Video can be a useful tool – you can watch a few recorded consultations with your trainer, but it can also be helpful to watch some of these back later yourself to pick up on things like body language and non-verbal cues from the patient. It can be helpful to get different perspectives, so ask for other doctors at your practice to observe you and give feedback.
Observe how others consult
Try to do some “reverse” joint surgeries – where you sit in and observe your trainer and other team members consult. This can be a good way to pick up useful tips and good habits from experienced colleagues. You may have a doctor in the team that has a lot of women’s health experience, and may be able to tweak how you explain certain conditions based on their approach. Sitting in with the practice nurse during an asthma clinic might give you some ideas on things like demonstrating inhaler technique or discussing spirometry. Don’t feel that you have to do everything the same way your colleagues do – it is important that you consult in a way that is comfortable and natural to you. You may find that you can adapt your own style and add in what works from others.
Prepare for challenging cases
It is important identify areas you find challenging and actively prepare for them. If you find it difficult to take sexual health history because you get embarrassed when asking sensitive but important questions relating to risk factors for sexually transmitted infections, you should practise this until you can do it confidently. If you do not see many women with gynaecological issues, you could go through important areas of the history and examination in a tutorial or with your study group. Equally, if you have not treated many patients with testicular problems, or erectile dysfunction, you should revise the key parts of the history, examination and management. Try going through the CSA case checklist in the MPS MRCGP Study Guide and go over any areas that you are not confident in. Practise telephone consultations as it can be challenging taking a history when you do not have some of the non-verbal cues that we rely on in clinic.
Learn to manage your time effectively
You have 2 minutes to read the case notes, and exactly 10 minutes to get through each case. Candidates that regularly struggle to complete cases will often get a low score for the management domain, as they may not have had time to discuss treatment options, or to talk about follow up and safety netting. Try to get comfortable with getting through your consultation in 10-12 minutes the month before sitting the exam. You may still be on 15 minute slots, but try to use the last few minutes to type up your notes. It is very difficult for a candidate who regularly needs 16-17 minutes per case in surgery to suddenly shave several minutes from their consulting time in the exam.
Remember all 3 domains are marked in every case
A common myth about the CSA is that it is all about communication skills. While good communication is an essential part of being a good GP, this is only a third of the marks in each case – the other two thirds relate to clinical areas.
Data gathering is about history and examination – it is important to be able to take a focused, systematic history. If you spend too long on the history by asking vague or irrelevant general questions you may find that you get a poor mark for data gathering, and also run out of time and get a poor score for the clinical management domain. Candidates often lose marks in this domain by failing to ask about relevant red flag symptoms to exclude rarer but serious conditions, or forgetting to request an essential examination.
There is a lot to cover in the management domain to get a clear pass – you need to allow enough time to go through the diagnosis, discuss management options, cover other important risks, and to discuss follow up and safety netting. This will usually take 3-4 minutes to cover well. You can also lose marks if your proposed management plan is not in line with current evidence – a good knowledge of current guidelines is very important.
In the interpersonal domain, you may lose marks if you do not build a good rapport, or take on board the patient’s agenda. Work on being able to explain investigations, diagnoses and results in clear, concise language without using technical jargon. Pay attention to both verbal and non-verbal cues – it is important to explore them as there may be an important symptom or issue that will only come out when the cue is explored.
It’s not enough to know it, to get marks you have to show it
Examiners can only mark observed behaviours, so it is important to demonstrate your knowledge and skills clearly in each domain. For example, in the clinical management domain for a case of newly diagnosed Stage 2 hypertension in a 50 year old, a candidate that informed the patient that they would be “starting a once daily tablet for your blood pressure” would not get the marks for correct management. A candidate that made it clear that they would be starting the patient on a suitable dose of an ACE inhibitor would. Similarly, a patient with a transient ischaemic attack (TIA) with high risk of stroke needs to be seen within 24 hours by a specialist according to the current guidelines. A candidate that did not make the timeframe clear may not get the marks. For example, saying “I will arrange for the specialists to see you urgently” is unclear in this situation – as a 2 week referral is urgent, but not appropriate for a patient at high risk of stroke. Making it clear that you would arrange for the specialists to see the patient “within the next 24 hours” would be much better.
Treat the exam like a regular clinic
Treat the CSA as a regular 13 patient clinic, with the benefit of a break halfway through, and without having to write up any notes on the computer. Do not do any acting – the only person doing any role play should be the simulated patient. You should be doing the same things you would do with a similar case in real life. Some candidates make up false options that they would never offer in real life or pretend to write a prescription rather than using the sample prescription on the table. This looks awkward and unnatural, and can be embarrassing when the patient points out that there is nothing there! Imagine the examiner is not there – do not look at them, talk to them, or try to engage them in any way – they are there to mark the case, not to influence the outcome. You should focus on the patient, and give them your full attention – just as you would in surgery. If you think there is a relevant examination, you should ask the patient if you can examine, rather than asking the examiner. If you would offer a chaperone for an examination in real life, offer one in the exam. Getting regular practice in your study group or in a joint surgery can help you get used to consulting with an observer in a way that does not affect your focus on the patient.
Focus only on the case at hand
In an exam with 13 cases, it is quite normal to have 1 or 2 cases that either don’t go as well as you would have liked, or that include a rare or high challenge presentation. Remember that a bad performance in any case can be compensated by doing well in others. Just do your best to listen carefully to the patient, try to be safe, and to communicate clearly. At the end of the case, take a deep breath, clear your mind and go into the next case with a positive attitude – otherwise 1 poor case can go on to affect how you score on the next few and have a much bigger impact on your overall score.
Summary
The MRCGP CSA is a challenging exam with a significant failure rate. To pass, you need to demonstrate that you have the skills and knowledge to practise safely without supervision – from taking a structured history and focused examination to being up-to-date with your management. You need to show that you can communicate clearly and effectively with the patient, and engage them appropriately. Finally, you need to be able to manage your time well to get through everything in 10 minutes. Like any skill, consulting well improves with practise – you can get this by seeing patients in clinic, with your trainer in a tutorial and in a study group with your colleagues. Best wishes with your exam!
As you can see, the end of your training is just the beginning of a new journey in General Practice. You have many choices, and your preference may change as your circumstances do. Remember that choosing one option does not usually close the others off to you, so you may locum for a few months or years to see how different practices work, before taking a salaried job. At some point you may choose to join a partnership or combine one of these options with other part time options as part of a portfolio GP career.
