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.

A day in the life of a GP Registrar

The working life of a registrar is very different to a junior doctor in hospital. Although the routine will be different from practice to practice, most will be based around having two surgeries (AM and PM), time for going over the patients and problems you have seen, administration (including dictating referrals and completing forms), and on some days, home visits.

Here is a breakdown of a typical day in practice early on in your ST3 year:

08.30-08.45

Arrive at surgery (most days!), turn your computer on, login to the clinical system, check if there are any messages or queries for you with the reception team.

09.00 – 11.30 

Morning surgery, 15 minute appointments. Try to dictate referral letters as I go, while all details fresh in my mind, and to save time later (not always possible if a busy surgery).

11.30 – 12.30

Complete all paperwork, outstanding referrals and sign stack of repeat prescriptions. Discuss difficult cases with trainer. Go over home visit requests. Call some of the patients to clarify details / give advice. Where appropriate, ask patients to attend the surgery.

12.30 – 13.30

Home visits (1-2 visits), look through letters from clinic, blood reports, imaging results via DocMan or clinical system.

13.30-14.30

Practice meeting with all partners, practice manager and pharmacist. Review of progress on QOF points. Lunch provided if you are lucky! If no meeting, you may have time to pop out to grab some lunch, or have lunch with some of the team in the staff room.

14.30 – 15.30

Tutorial with trainer, or take part in specialised clinics some weeks e.g. baby clinic, diabetic clinic, asthma / COPD clinic. If no tutorial or clinic, you may have time to enter some learning log entries in your e-portfolio.

15.30 – 17.30

Afternoon surgery, often with a few less booked patients than the moring clinic.

17.30 – 18.00

Admin from afternoon clinic, go over cases with trainer, then HOME! May finish later if on call. Your practice may take part in extended hours, so you may do an evening clinic once a week – this could finish as late as 7.30pm.

Of course, you won’t necessarily be doing home visits every day (although it is likely most days as a trainee), and one half day every week you should have protected VTS teaching with other registrars from your training scheme (AKA “playschool”). As well as this, you should be having regular tutorials with your trainer in practice. You also have one session a week for self directed learning. You may be able to use this to oragnise a chance to go to clinics to fill any gaps in your rotation e.g. ENT, musculoskeletal medicine, ophthalmology etc. As you progress through your training you will eventually work towards seeing patients in 10 minute appointments with clinics similar to the qualified GPs in the practice.

Every practice has a slightly different way of operating their clinics. Some will have longer surgeries in the morning, some do more telephone triage and there may be a different mix of appointments booked in advance and those booked on the day (which may have more acute presentations). In some cases you may take part in extended hours and have an early morning or evening clinic.

You will also have to do at least 72 hours of Out of Hours (OOH) per 12 months in practice to get signed off – this could include evening, night or weekend shifts.

What is your working day like as a GP registrar? If you are in a practice that does a lot of telephone consultations or triage, how do you find it? How often do you have home visits? We’d love to hear from you so please do leave a comment or discuss it on our Facebook group!

Coping with paperwork

Dr Mahibur Rahman

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

We all have to deal with paperwork everyday – from referrals to other specialties, to clinic letters or discharge summaries, it can all build up. Sometimes it can seem that we spend more time dealing with paperwork than dealing with patients. This article looks at ways of coping with paperwork effectively so that you can free up more time for clinical work or relaxing in the mess.

Organise the paper mountain

The first step to dealing with paperwork is knowing exactly what you have to deal with. To do this, you need to organise the stack of papers into some sort of order. If you have let a large amount to build up, this can be very painful at first, but the rewards in the long term make it worthwhile. If you have paperwork in more than one place, it may help to gather it together in one place. Once you have everything together, you need to sort it into categories:

•  Clinical (referrals received, referrals to others, discharge summaries etc.)
•  Non-clinical work related – study leave applications, annual leave, exams, GMC annual fee payment, etc.
•  Other – tax returns , drug company literature, unsolicited mail, invitations to meetings, etc.

Prioritising the workload

We can’t do everything asked of us all at once (although many people expect this), so you have to prioritise the workload. Having organised the paperwork makes this easier to do. Each category can now be sorted into URGENT, PRIORITY, and ROUTINE (much like prioritising new referrals for a clinic). URGENT work is that which needs to be done immediately, PRIORITY work is work that should be done within a day or two at most, and ROUTINE work is work that can wait until you have spare time, without affecting the outcome.

You can now focus your mind on getting the most important things done first – this will normally be the URGENT clinical work. This might be arranging an appointment for someone with a suspected malignancy, or a transfer letter for a patient going for further treatment in another hospital. Dealing with some paperwork may require immediate action – such as checking blood results or pathology reports.

Remember that the importance of paperwork can change with time – a routine non-clinical task such as completing your tax return can become a priority when the deadline draws close!

Keeping on top of the paperwork

Once you have organised yourself and worked through the backlog, it is important to keep on top of the paperwork so it does not build up and become unmanageable again. There are many simple things you can do that can help ease the burden. These include:

•  Dictate clinic letters after each patient wherever possible – the details are all fresh in your mind, and you won’t have to look back at the notes.
•  Write or dictate discharge summaries as soon as possible after the event – again, this reduces the time spent looking back through the notes.
•  Keep a list of outstanding paperwork so that nothing “slips through the net” and gets forgotten.
•  Don’t forget about important non-clinical paperwork – it is easy to overlook – you need study leave and annual leave to maintain your skills and your sanity.
•  Try to set aside time every day or every week specifically for paperwork.  You are more likely to do it when it is timetabled, and regular small amounts prevent large build ups. Even half an hour helps.

Don’t forget about electronic paperwork – these days, you may receive or send correspondence (including referrals) by email, and soon this may become routine.

Finally remember, that no matter how high the paper mountain gets, it can be managed if broken down into smaller chunks.

Dealing with relatives

Dr Mahibur Rahman

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

Talking to the families of your patients can be one of the most 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 junior staff to be asked to discuss a patient’s care. Although this may set off panic alarms inside your head, there are a few 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

elderly-personHonesty is one of the factors that relatives value the most when dealing with doctors. They need the truth to make their personal adjustments to 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.

…and 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 relatives.

  • 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

10 tips to help you pass the MRCGP AKT exam

Dr Mahibur Rahman MRCGP AKT exam tips

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. We help a lot of candidates prepare when they are resitting 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

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.

  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 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.

  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 20,000 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 and includes key theory and high yield topics, exam technique as well as mock exams in timed conditions. Details of the course are available at http://courses.emedica.co.uk/acatalog/nMRCGP_AKT_Preparation.html

akt_course

MRCGP AKT exam 2014 – key changes

MRCGP AKT Mock ExamDr Mahibur Rahman

The MRCGP AKT exam was introduced in 2007 as part of the new MRCGP examination. Since then it has been through a few minor changes relating to question formats and the passing standard. From October 2014, some important changes are being implemented. This article looks at the exam format, including the new changes.

Exam basics

The Applied Knowledge Test (AKT) is one part of the MRCGP examination. It can be taken in the ST2 year of training or later. It is a computerised test consisting of 200 questions, and can be attempted a maximum of 4 times. The major change being implemented in 2014 is that the time allowed for the exam is being increased by 10 minutes – candidates will now have 3 hours and 10 minutes to complete the exam. The other change is a minor one – an on screen calculator will be available if needed.

Exam content

The exam is based around UK general practice, with all questions being drawn from areas within the RCGP GP curriculum. The breakdown of the questions are as follows:

  • 80% (160 questions) – clinical medicine relevant to general practice
  • 10% (20 questions) – organisational – this includes administrative issues, medicolegal, practice management, GP contract, certification etc.
  • 10% (20 questions) – evidence based practice – statistics, types of study, graphs and charts etc.

Question formats

The majority of questions (about 90%) are of two formats – extended matching questions (EMQs) and single best answer questions (SBA). Candidates sitting the AKT will be familiar with this type of question from the GP Stage 2 assessments used as part of GP recruitment. The remaining question formats include:

  • Algorithm question – testing knowledge of specific guidelines or protocols – sometimes you will be required to drag the correct answer into the relevant box.
  • Picture question – this will have a scenario with a related image – ranging from an investigation, blood result, audiogram, skin lesion, otoscopy or a photo of a clinical sign.
  • Video question – this will involve a short clip (20 – 30 seconds) with a relevant question. This could show an abnormal gait, a test for a sign, a physical abnormality etc.
  • Seminal trial – this will test knowledge of a specific trial that has had a significant impact on general practice.
  • Rank ordering question – this is a relatively new format, and will ask you to order options from best to worst e.g. most secure password to least secure password
  • Short answer question – this will provide a question and then a blank space into which you have to type the correct answer. Typically the answer will be one or two words.
  • Calculation – this may involve calculating a paediatric drug dosage, converting one opioid to a different formulation, or working out the sensitivity or specificity of a test. The maths is usually limited to basic arithmetic, although an no screen calculator is now available.

Preparation

The AKT is a challenging exam, and most candidates will need at least 3 months revision to be able to cover the entire curriculum thoroughly. Combining reading with practising exam level questions to time will help make your revision more effective. The Emedica AKT preparation course offers comprehensive coverage of the curriculum, with a focus on the challenging areas highlighted by examiners from previous sittings. This includes statistics and evidence based practise made simple, the organisational domain, and over 100 core clinical topics including high yield topics from previous examinations. You can get a £20 discount by using the code alumnimrcgp

Useful links:

RCGP AKT Content Guide

MRCGP AKT tips for effective preparation – from a registrar with the highest score in the country

Improving feedback from the MRCGP CSA examination

Improving feedback from the MRCGP CSA examination

Dr Mahibur Rahman

We are often contacted by GP registrars or GP trainers requesting support with understanding the feedback from the MRCGP CSA. Many doctors have commented that they find the feedback difficult to interpret. This has been recognised as an important issue and recently a motion was passed at the LMCs conference calling for immediate improvement in the feedback from the CSA. In this article Dr Mahibur Rahman looks at the current feedback, the areas that could be improved and suggestions on ways to make the feedback clearer and more helpful for both trainers and registrars.

Understanding the current CSA feedback

Currently there are 2 main sections to the feedback from the CSA. The top part gives the candidate’s total score from all 13 cases (out of 117), with the pass mark for the date they sat the exam. This total score is based on the summative part of the assessment, which is based on 3 domains for every case: data gathering, clinical management, and interpersonal skills.

For each domain, a candidate is graded with a score attached to each grade as follows: Clear pass: 3 marks, Pass: 2 marks, Fail: 1 mark, Clear fail: 0 marks. This gives a total score for each case of between 0 and 9.

To gain a pass, a candidate must get an overall score equal to or above the pass mark for a given day. This is adjusted each day using the borderline group method to ensure the standard of the exam remains the same each day. The actual pass mark is variable with a usual range between 72 and 77 out of 117.

The second part of the feedback is formative – it relates to the 16 feedback statements provided by the RCGP in a grid. This grid can provide information on consulting areas that a candidate could improve on. It is important to understand that this part does NOT determine the score or whether a candidate has passed or failed – it is formative, and aimed at helping doctors identify areas of their consulting that they could improve. The current feedback looks like this:

CSA feedback current

What are the problems with the current feedback?

There is no breakdown of the marks awarded from each case (out of 9), and no way for a candidate or trainer to see clearly if marks were dropped in data gathering, clinical management or interpersonal skills for each case, or as a general trend over the course of the whole exam.

In some cases, the formative feedback can help identify areas to work on, but in some cases it can lead to confusion. A common source of confusion relates to the fact that candidates with the same number of crosses can have very different scores. Finally, where a candidate has no crosses relating to a specific case, many candidates think that it means they must have scored very well, or at least gained 6 or more marks out of 9. However it is impossible to tell how well or poorly they have performed in that case from the lack of crosses– they could have scored anywhere from 0 to 9. This is because:

  • The formative feedback does NOT determine the score for a case – this is determined by the performance in the 3 domains being assessed. Scores for these are not provided in the current feedback as standard – candidates that want to access these scores can request their mark sheets under the Data Protection Act.
  • Only feedback statements that were flagged in 2 different cases show up in the feedback provided to candidates – there are hidden crosses where a statement was only flagged in a single case. A candidate with no crosses could actually have had several crosses relating to feedback statements that did not occur again in other cases. This could have led them to score very poorly in that case, but they would not know it from looking at the feedback.

This candidate failed the CSA by a few marks – look at the formative feedback for their first 3 cases:

CSA formative feedback - current

This candidate scored 7/9 for the first case (joint problems), and 2/9 for the second case (acute illness), but there would be no way to know that they had performed really poorly in the second case from the current feedback. There were actually 3 feedback statements that were flagged in this case, but they don’t show up because those statements did not apply to any other case (and currently these statements are hidden).

How could the feedback be improved?

The GPC motion called for “the feedback from the MRCGP exams to be improved immediately”. Here are 3 simple ways that the feedback could be made clearer and more effective in helping identify areas to work on to improve performance. They can all be introduced using data that is already collected in the exam, and so could be implemented quickly with little additional cost.

1. Provide a breakdown of total marks for each domain as well as the total score. In the AKT, candidates get a breakdown of their scores in the 3 domains (clinical medicine, organisational, and evidence interpretation). This will give a clearer indication of any weaker areas overall:

New CSA feedback - summative

This candidate and their trainer can immediately see that they could make improvements in all parts of the consultation, but that the clinical management domain was their weakest overall. This may allow more targeted work on this part of the consultation. Without this information, this candidate (and their trainer) may focus more on the interpersonal domain, without realising that although this could be improved further, this is actually their strongest domain overall.

2. Provide the domain scores for every case as well as the formative feedback. Taking both the summative and formative feedback together provides more meaningful information and will allow easier identification of both consulting skills and curriculum areas that need improving. This could be provided by adding a separate table for the domain scores:

CSA domain feedback for individual cases

Looking at this, it is clear that this candidate had 2 cases where they performed very poorly – the young adult female with an acute illness, and the middle aged female with a women’s health issue. These may be areas that they struggle with, and indetifying them will allow focused improvement in knowledge.

3. Provide details in the formative feedback section of ALL statements that were flagged, even when this only applied to a single case. This will allow candidates to identify all areas that examiners felt they could work on – even candidates that have done well can benefit from knowing areas that they could improve. Combined with the summative feedback above, this would also make it easier to separate a candidate that is below the pass standard in multiple areas of multiple cases from one that had a couple of really poor cases due to poor knowledge of a specific curriculum area, or because they missed something key in that case. Here is the formative feedback from those first 3 cases that we looked at earlier; the second image shows all crosses (those that were previously hidden are shown in red for clarity):

Current feedback:

CSA formative feedback - current

Proposed feedback:

Proposed feedback showing all crosses

You can see that taking this with the domain scores, it is immediately clear why this candidate got such a low score in the acute illness case, and that had they performed better in this case, they may have passed. This would also help candidates understand their performance better. From the current feedback they may think that this was one of their better cases when actually it is their worst. Providing this extra information does not give any information that will jeopardize case security, but it does provide more meaningful information for someone trying to improve.

How it would look together

All the feedback would fit onto 1 A4 page, allowing quick cross referencing between the different sections. This is how the new feedback could look in the e-portfolio.

New CSA feedback - summative

CSA domain feedback for individual cases

New CSA feedback

Summary

It is clear that further research needs to be carried out to investigate the possible reasons behind the differential pass rates in different groups – however this will take time. By improving feedback immediately, we can ensure that candidates and trainers have clearer, more effective feedback. All these changes can me made using data that is already being collected, so this could be implemented quickly and with little additional cost. Hopefully this will enable more focused work on the key consultation skills that an individual doctor may need to work on to help them improve and pass the exam.

Are you a GP trainer or a GP registrar? What do you think about these ideas for improving the feedback from the CSA? Please share your thoughts!

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GP ST Payscales including GP Registrar pay / salary 2013 – 2014

These are the current payscales for GP trainees in effect from April 2013 – April 2014. It includes the 2013 pay award of 1%. The GP Registrar supplement is currently 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.

GP Trainee Payscales
GP ST Pay
GP Specialty Training Salary Scales 2013-2014

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 £30,002 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).

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.

GP Registrar Salary – Net Monthly Pay

All GP rotations now mandate at least 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.

GP Registrar Pay
GP Registrar Payscales (Practice Based) 2013-2014

*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.  You can get an accurate monthly calculation here (external link).  These figures do not include deductions for the NHS pension.

GP Registrar’s medical indemnity will be reimbursed less the amount they would have paid for a hospital job.

MRCGP CSA Exam Feedback and Summary – February 2012 exams

MRCGP CSA Exam Feedback and Summary – February 2012 exams

Dr Mahibur Rahman

After each MRCGP CSA examination, the examiners release a report highlighting key information from the last exam. This includes pass marks and rates for the sitting, along with the number of candidates sitting the exam. Since the February 2012 exam they also started releasing a feedback report highlighting key areas that candidates found challenging.

These topics are likely to continue to feature in future CSA sittings, as there is a common case bank, so it is worth ensuring that you have a good understanding of how to tackle them.

If you are thinking of sitting the MRCGP CSA in November 2012 or January / February 2013, then you have probably started preparing. As the January / February sitting is the most popular each year, we thought it would be helpful to look at the feedback and challenging areas from this sitting in 2012. The sumary report for the May 2012 CSA exam is not yet available.

Key facts from the February 2012 MRCGP CSA exam:

Number of candidates: 2074

Proportion sitting the CSA for the first time: 92.5%

Overall pass rate: 71.8% (1490 candidates passed, 584 candidates failed)

The top score was 111 out of 117
The mean score was 81 out of 117
The lowest score was 37 out of 117
97 candidates (4.7%) scored 100 or more out of 117
67 candidates (3.2%) scored 20 or more marks below the pass mark.

Challenging areas

The examiners’ report from the February 2012 diet of the MRCGP CSA exam was released in April, and highlighted the following areas that caused candidates difficulty:

Genetics in primary care

Cases involving genetics regularly cause CSA candidates problems in the exam. Examples of cases you should be prepared to handle include:

Prenatal counselling for risk of single gene disorders – e.g. sickle cell disease, Huntington’s, neurofibromatosis, cystic fibrosis etc.

An asymptomatic patient requesting a colonoscopy with a family history of colon cancer.

While you do not need to have an in depth knowledge of specific genetic disorders, you should be able to take a good history and draw a family tree. You should also be able to explain the difference in risk for autosomal dominant and autosomal recessive disorders, and know when it is appropriate to refer to a genetics counselling service.

Examinations

In some cases in the CSA you will actually perform a physical examination. In some cases, candidates lost marks for being unable to be focused in their choice of examination, or not being able to perform the examination proficiently. Examples of a lack of focus would include requesting a full physical examination in someone with hearing loss – it would be more appropriate to examine the ears, and to perform a Rinne and Weber test. Examples of an inadequate examination highlighted by the examiners included listening to a patient’s chest with through their shirt! Most examinations in the CSA are fairly straightforward – you should try to practice all the common examinations with a study group until you are fluent. Ask your trainer to observe you and to provide feedback.

The MRCGP CSA is a challenging, comprehensive examination, so it is important that you start preparing for it early. Try to get as many observed consultations as possible with your trainer, and form a study group early on.

Further reading:
Complete February 2012 CSA Summary report

The Emedica MRCGP CSA Course includes teaching on the new CSA mark scheme including the new 2012 CSA feedback statements. Each course only takes 6 GP registrars, with a strong emphasis on practice with individual feedback. Practice sessions are donw in groups of 3, allowing each candidate to have 4 mock CSA practice cases. There is detailed, constructive 1 to 1 feedback after each case using the new marking criteria. Our mock CSA cases are done in a realistic setting with professional simulated patients and timed in the same way as the real exam.