10 tips to help you pass the MRCGP AKT exam

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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. Make the most of your revision time

shutterstock_247056754Effective 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.

  1. 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.

  1. 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 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 criteria.

  1. 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.

Dr Mahibur Rahman is a portfolio GP and a consultant in medical education. He has been the medical director of Emedica since 2005 and has taught over 30,000 delegates preparing for GP entry exams, MRCGP and on GP careers. He teaches an intensive 1 day MRCGP AKT preparation course in London, Birmingham and Manchester that covers all 3 domains. The course includes key theory and high yield topics, exam technique as well as mock exams in timed conditions. You can get a £25 discount by using the code passmrcgp

Details of the course are available at http://courses.emedica.co.uk/acatalog/nMRCGP_AKT_Preparation.html

MRCGP AKT Course

GP career options: an overview

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

compassAs 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.

Dr Mahibur Rahman is a portfolio GP and the medical director of Emedica. He is the author of “GP Jobs – A Guide to Career Options in General Practice”. He will be teaching at the Life after CCT: GP Survival Skills course which includes a session with practical advice about different GP career options for new GPs.

Expenses claimable when relocating to start GP training

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 document here 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

spending moneyYou 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).

10 tips to help you pass the MRCGP CSA

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.

  1. 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.

  1. 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.

  1. 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.

  1. Observe how others consult

shutterstock_98521166Try 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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!

Dr Mahibur Rahman is a portfolio GP and a consultant in medical education. He has been the medical director of Emedica since 2005 and has taught over 29,500 delegates including those preparing for GP entry exams, MRCGP and on GP careers. He teaches an intensive 1 day MRCGP CSA preparation course in London and Birmingham that includes key theory and high yield topics, exam technique as well as plenty of practise with professional role players in CSA exam conditions. 

Useful links and further reading:

MRCGP Exam Preparation: A revision guide for the AKT and CSA – MPS (includes CSA topic checklist)

Emedica MRCGP CSA Preparation course

Emedica MRCGP CSA Online package – video lectures, high scoring consultations + 52 CSA cases to practise (4 full CSA exam circuits):

MRCGP AKT Examination – an overview

The AKT (Applied Knowledge Test) is one of the assessments required to gain Membership of the Royal College of General Practitioners (MRCGP) and can be taken in ST2 or ST3 years of GP training. It is available 3 times each year, in October, January and April. Most candidates sit the exam for the first time at some point in ST2.

The examination questions are all drawn from the GP Curriculum, and the test is completed on computer at a Pearson Vue professional testing centre (there are centres all over the UK).

The exam lasts for 3 hours and 10 minutes and consists of around 200 questions. You can mark questions for review later to go back over those that you are unsure of.

The pass rate is variable and based on a set pass standard for each exam, with a variable pass mark that has ranged from as low as 67% to as high as 71.5% (average is around 68%). The pass rate has a long term mean of just over 73%.

Question formats

studying girlThe majority of questions are Extended matching questions (EMQs) and Single Best Answer questions (SBAs). Other question formats include Multiple Best Answer (MBA), Algorithm questions, seminal trial questions (focusing on important research relevant to primary care), picture questions, video questions and short answer questions.

The makeup of the exam is:

  • 80% – Clinical medicine relevant to GP
  • 10% – Critical appraisal / evidence based practice
  • 10% – Health informatics and administrative issues

The RCGP has produced a set of sample questions you can view the answers alongside the questions here.

Examiner’s reports

The panel of examiners produce a report after each sitting outlining key areas that canidates performed poorly at, and this is very helpful in highlighting important topics to include in your revision. You can access the reports from the RCGP website.

Starting out as a GP Registrar

Making the change from what may have been several years in hospital medicine as a junior doctor to becoming a GP registrar can take some getting used to. So what can you expect once you become a registrar?

Settling in

Apart from the obvious differences in setting and the range of patients seen, there are changes in the level of responsibility and autonomy you have. Although you will initially be seeing patients with your trainer, you will very quickly find you have your own booked surgeries, and you will largely be working independently (although with help close at hand whenever you need it). This can be both daunting and very satisfying – you’ll be amazed at both how much you do and don’t know! One of the most pleasant changes from hospital medicine is the continuity of seeing patients over a long period of time, and getting to know them. Most registrars also love the freedom of not having a pager after so long.

Practice Routine

hands-desk-office-working-largeYou will soon find out that the work day is slightly different in practice compared to in hospital. No more starting the day with a long ward round and then working through the morning and perhaps a clinic in the afternoon – interspersed with trips to the ward to resite cannulas and complete TTOs. Instead, you are likely to have a morning and afternoon surgery, with plenty of paperwork in between, some home visits, the odd tutorial and regular practice meetings. You will soon find out which days you are on call (home visits etc.), and which clinics happen on which days (baby clinic, smear clinic, diabetic clinic, COPD clinic etc.).

Working with the team.

Finally, although you will be in your room seeing your own patients a lot of the time, you will find that in primary care there is a large team of staff with various skills and roles that you have to fit into. You need to find out how to make the best use of the resources available. Some of the members of the team include:

Practice Manager

Very important member of the team! Will sort out your pay, training on practice systems, may be involved in sorting out contracts, expense claims, study leave and rota. Normally involved in keeping an eye on progress with QOF points.

Receptionists

Practices could not run without good receptionists. They will help you locate the right forms, supplies for your room, take home visit requests and send you messages relating to your list and patients. They will also be responsible for letting patients know when you are going to be videoing or having joint surgeries for your assessments. Be nice to them, and they may even make you a nice cup of tea!

Practice Nurse

Most practices now have nurse led clinics for various things – CHD, COPD, diabetes, asthma etc. May also see patients with minor ailments, as well as dealing with removal of sutures, immunisations, and assisting in minor surgery.

Healthcare Support Worker

Many practice employ a HCSW to take bloods, and help the practice nurses with clinics etc.

District Nurses

May be attached or directly employed by the practice, usually involved in care of terminally ill patients, community management of DVT, care of housebound patients.

Health Visitors

Involved in child health surveillance, including developmental assessments, hearing assessments and home visits to children and new mothers.

Practice Secretary

Where would you be without someone to type and send all your dictated referral letters? Probably still at surgery until late. In some practices you will type your own referrals, so there may not be a secretary, or they may have other duties.

Other doctors

Remember that your trainer is not the only one that you can learn from. The other doctors may be involved formally or informally, and should be able to offer help and advice when you are unsure of a diagnosis or when to refer.

Writing a good referral letter

Most of the patients that you see you will manage on your own. A few you will need a second opinion or advice from your trainer, and every once in a while you will have to refer a patient for a specialist opinion. The content and style of the referral letters you send may affect the ability of the Consultant to accurately prioritise the patient – and they will definitely give an impression of you as a doctor. This article looks at what makes a good referral letter, and how to answer the three key questions – “should I refer this patient?”, “what do I want to achieve from this referral?” and “where / who should I refer to?”.

Appropriate referrals

The first thing to establish is “does this patient need a referral?”. Over 10% of hospital referrals are inappropriate. Sometimes who you refer will depend on your own confidence in the diagnosis and management of a condition. It may also be affected by the experience of the other doctors in the practice and locally available services – if you or a partner are confident at injecting joints you may do them during a consultation – if not they may be referred. Some doctors refer all skin lesions that require minor surgery, others do a lot of these themselves. It is important to know who has expertise in what in the practice.

Once you have established that a referral is needed, the next question to ask is “what do I want to achieve from the referral?”, as this will help you decide “where should I refer?”. Good knowledge of local services is important here – in some areas you might refer a patient with fibromyalgia to a rheumatologist, where in other areas this might be dealt with by a chronic pain service. A child with suspected autism might be referred to a community paediatrician or a paediatric neurologist, or a child psychologist with a special interest. You trainer will be able to guide you in the early months until you get to know the areas services better.

writing-notesWriting the letter

Poor referrals reflect badly on you as a doctor and on your practice. A good letter should include the following:

•  Clear identification of patient including name, age, DOB, sex, address and NHS number

•  If this is a private referal make it clear at the start

•  Presenting problem

•  Brief Summary of history

•  Treatments already tried and how the patient responded

•  Results of investigations and details of pending investigations [to avoid duplication]

•  Expectations / reasons for referral are you looking for help with diagnosis? Does the patient need a specific treatment?

•  Current drug history – you can get this automatically from the Clinical System

The length of the letter requires you to balance the need to provide enough information without becoming tedious to read, yet being so concise that you miss out important relevant information. Over time this balance becomes easier.

Finally

Check you haven’t missed any key information, that the letter reads well and that it is signed, dated, and has your contact details.

Computer systems in general practice

One of the big differences you’ll notice in practice is the importance of the computer systems. The main systems are EMIS Web, SystmOne, and Vision. Athough all have the same basic functions, they differ in the layout, the functionality and the amount of additional content (such as built in medical reference texts, patient information leaflets, etc.) that they offer. On top of this, each practice may have customised the layout and added templates specific to that practice.

The computer systems are an integral part of general practice, in a much larger way than in most hospitals (where you may only use them for blood results and imaging via PACS). Many practices are paperlight or even paperless, with additional documents such as clinic letters, blood results and imaging reports being scanned and added to the electronic record by members of the practice staff. In some practice you will also use them to generate electronic prescriptions and sick notes.

Make sure you get adequate training in the first few days to at least manage the basic functions of the system – checking your appointments, adding and printing prescriptions (or sending them electronically), and entering blood pressure, weight and other measurements. You will find that you learn more as you go along, and you should be able to organise further training through the practice manager. Once you are familiar with the basic functions, you will learn the importance of coding your entries correctly, and of making a detailed entry into the records. You may also need to be trained on other software that links into the main record – such as DocMan which can be used to access letters and reports electronically.

PC monitorMost systems have a whole host of advanced features. You can write your own referral letters with data from the medical record automatically transferred to Microsoft Word or other word processor. You can check a patient’s historical use of a drug to see if they are using too much or not complying. You can set up macros to make common tasks (such as entering BP) easier, and use templates to make sure you don’t forget to check important markers (like BP and smoking history for someone on the pill).

Another great thing about having a computer to hand is that you can quickly access reference texts online – there are many free resources available, and some of the clinical systems have extensive reference materials built into the system. Another common use is to print off relevant Patient Information Leaflets (PILs) to give out straight away – again, these are integrated and regularly updated with some of the clinical systems.

Finally, you can keep a list of problems and interesting patients that you see throughout the day, so you can discuss them with your trainer and do some reading later on. This is also important for appraisals. There are some excellent online tools for maintaining a Personal Development Plan (PDP), which can be used as part of your appraisal.

Composing good clinic letters

Dr Mahibur Rahman

One of the problems in the NHS is the communication between primary and secondary care. As a GP you will appreciate the importance of good quality clinic letters so as a junior doctor training in hospital, start making an effort to send out good letters. This is a quick guide to what you should include:

Basics

Make sure that the following are clear from a quick glance:

•  Patient details: name, address, hospital and NHS number
•  Date and name of clinic
•  Consultant
•  Your name and contact details

Clinical details

The doctor receiving your letter wants to know 5 things from your letter, so make sure they can find all 5 quickly :

•  Diagnosis
•  Current state of disease
•  Any investigations or changes in management (include current meds / new meds)
•  Next follow up
•  What you would like the reader to do

The last is particularly important for all parties involved: you, the patient and the GP. If you have started new medications and need the GP to prescribe repeats or to monitor bloods / BP after a certain period of time, make this clear. A note on professional etiquette here: please request this rather than demand it: you are dealing with a colleague (who is likely to be more experienced/senior to you), not a child. Don’t request your colleague to do tasks that are part of your responsibility – if you have ordered investigations as part of the clinic visit, it is your responsibility to follow up the results and act on the findings.

Finally

Signing clinic letter

The secretary will probably type the letter and return it to you for signing. Read through the letter before signing to make sure there are no errors and that you have included the basics and key details.

Making a successful presentation

Dr Mahibur Rahman

Giving presentations has become a routine part of any trainee’s life, and these can make a significant impression on those around you. Here is some guidance on how to do it well.

The difference between a poor presentation and a successful one lies mainly in the preparation. This takes time and work, but your efforts will be richly rewarded.

Fail to prepare, prepare to fail

Before you can begin to put the elements of your presentation in place, there are a few bits of key information that you need to gather:

  • What are you going to present? This sounds obvious, but the more information you can get on the scope of your presentation, the easier it is to prepare – “Managing malignant hypercalcaemia in a hospital setting” is very different from “Hypercalcaemia”.
  • Who is your audience? The content of your presentation will vary considerably depending on whether the audience consists of students, academics, consultants, or a mixture of doctors and nurses. Students probably won’t want to know about the latest trial chemotherapy regimes, while a group of consultant oncologists is unlikely to benefit from a talk on the basics of taking a cancer history. Likewise, an informal presentation to a group of four or five colleagues needs a different approach to a formal Grand Round slot in front of a hundred people.
  • How long is your presentation to be? 10 minutes or half an hour? What you can put over in each is very different.
  • Where are you going to present? If at all possible, go and see the venue – and always find out exactly what facilities are available. Assuming that PowerPoint is available on a laptop and just turning up with a CD or disk can become more than embarrassing when all they have is an overhead projector.

When you’ve done all the background, it’s time to look at the content. The best presentations are those that engage the audience, have a clear message and are well structured. There should be a clear beginning, middle and end.

Tell them what you’re going to tell them

The first part of your presentation should introduce the audience to yourself, the subject, and the format of the presentation. Start by telling them who you are, and what you are going to discuss. Let the audience know how you will present the material – a didactic lecture, an interactive discussion, a question and answer session. This helps in getting and holding their attention.

Tell it

The main content of the presentation should be delivered in a logical manner. For a research paper, this means going through the aims, methods, results and discussion. A case should follow the established history, examination, investigations, differential diagnosis and conclusions format. If using slides, keep them uncluttered. Avoid reading the slides word for word – the audience can read, and it is extremely dull to watch someone go through several paragraphs of small text of the screen. Learn your material so that you can display key points, and talk around these. Engage the audience, by putting questions or by canvassing opinions. This will help them stay alert and interested. Keep the content focused – trying to cover too many points often loses the listeners.

Asking the audience if they have questions is one way to bring some interactivity to the presentation. You must be ready to answer most of the questions yourself, but be prepared to divert any difficult ones to a member from your team, or open it up to the floor – seniors often love to provide answers when a colleague is stumped!

Tell them what you’ve told them

It is important to have a definite ending to your presentation – the best way to do this is to summarise what has been covered. It may be preferable to do this after the questions and answers, as it allows you to bring the audience back to the key messages. Discussions and debates from questions often go off on a tangent Research shows that the first and last parts of any presentation are the most likely to be remembered, so you may wish to leave the audience with a short “take home” message – one line or sentence that you want to stay with them.

Summary

In summary, preparation is the key to a good presentation; make sure you have done your research.  When giving the presentation, have a structured format with a clear start, middle and end.  Here are some dos and don’ts for presentations using Powerpoint (which most of you will be using).

5 Dos for preparing PowerPoint presentations

  • DO Use colour schemes that are easy to read: White text on Blue, Black on White
  • DO Use a large clear font: at least 28 point size is recommended
  • DO Keep slides uncluttered – no more than seven bullet points. Five is better
  • DO Use images appropriately: better to show an X-Ray than to describe it
  • DO Rehearse your presentation – aim for about 1 minute per slide

5 Don’ts for preparing PowerPoint presentations

  • DON’T use colours that clash- yellow text on green is out
  • DON’T use too many slides – running late or rushing both leave a bad impression
  • DON’T use sound unless absolutely necessary – many people find it irritating
  • DON’T use too much animation – people tire of it quickly
  • DON’T put large amounts of text on the screen and then read it out word for word

Further reading

Tay V , Preparing for presentations . Successful Learning Issue 3, Centre for Development of Teaching & Learning, 2000.

Feierman A , The Art of Communicating Effectively. Presenting Solutions.

This article was first published in February 2005 and is reproduced with the kind permission of Hospital Doctor, who retain the copyright.