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.

GP ST Selection Centre / Stage 3 Assessment Preparation – Tips

For those of you that get to the Selection Centre / Stage 3 Assessment for GP ST entry, here are a few helpful tips on what to expect.

All deaneries use the same national format for Stage 3 Assessments. This consists of a 4 part assessment. These include:

Simulated consultation with a patient
Simulated consultation with a relative / carer
Simulated consultation with a colleague
Written prioritisation exercise

The consultations last 10 minutes each including reading time, and the written exercise lasts 30 minutes. All 4 parts are equally important.

The selection centre is designed to assess the following competences throughout the different assessments:

  • Empathy and sensitivity
  • Communication skills
  • Conceptual thinking and problem solving
  • Professional integrity

Written prioritisation exercise

This typically gives you a list of things that need to be addressed (usually 5), and asks for you to list them in order of importance / priority, and then to give justifications and to describe the actions you would take. There is no one right answer / order, so it is important NOT to get hung up on that. Usually there is at least one that is clearly of high clinical importance. It is important to discuss both your REASONING and justifications, and what actions you would take in detail. Answers should relate to the competencies being tested, and be specific to the information provided and in what you would do. A good answer will have a good number of points for each of the 5 tasks to be addressed and show positives for all the competences being assessed. Written communication including spelling, punctuation and grammar as well as structured explanations are assessed in this task.

Simulated consultations

You will do 3 different simulated consultations – 1 with a patient, 1 with a relative or a carer, and 1 with a colleague.

shutterstock_391358626The simulated consultations could include various communication issues – an ethical scenario, breaking bad news, explaining an investigation or diagnosis, etc. In these cases, remember the basics will get you some easy marks – introduce yourself, try to establish rapport, ask about the other person’s Ideas, Concerns and Expectations. Check their understanding and try to be person centred.

Clinical knowledge is not being assessed, however if you demonstrate a clear lack of basic clinical expertise, or tell the patient something that is clearly unsafe, this may affect your overall mark.

The role players are not there to assess you – the examiner will be either a GP trainer or a consultant, however they do provide the examiners with some feedback which may be considered in deciding your final marks.

Time can be very tight, as you only have 10 minutes including reading time. One way to use your time more effectively is to become familiar with the format of the information provided – you will see that half the text on the page is the same for all cases – once you know what this says, you can ignore it in the exam, reducing your reading time.

Practise makes perfect

The selection centre assesses skills, rather than just knowledge, so it is really important to try to get as much practise for each station as possible before the exam. Forming a study group to work through sample cases and practise together can be a useful way to improve. If you can get specific feedback on your communication and consultation skills this can help you work on making improvements.

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!

Applying for GP Training

The process of applying to GP comprises the following stages:

Longlisting (formerly known as Stage 1) is based on the submission of your application via Oriel. To be longlisted, you need to meet the eligibilty criteria. The main ones are:

– Eligible for full registration with the GMC
– 2 years post graduation experience
– Evidence of Foundation Year 2 competences

Read the FULL eligibility critera in the National Person Specification from the National Recruitment Office site.

Multi Specialty Recruitment Assessment (formerly known as Stage 2) is a computer based exam comprising both clinical and professional dilemma multiple choice questions.

– Professional dilemma paper – 58 Situational Judgement Test questions in 110 minutes. These questions are in 2 formats – ranking SJTs and multiple selection SJTs – they test professional attributes, judgement and decision making.
– Clinical problem solving paper – 97 clinical questions in 75 minutes. These questions are in various formats and test broad clinical knowledge at the level of a doctor who has completed FY1. Subjects covered in this paper include

  • Cardiovascular
  • Dermatology / ENT / Eyes
  • Endocrinology / Metabolic
  • Gastroenterology / Nutrition
  • Infectious disease / Haematology / Immunology / Allergies / Genetics
  • Musculoskeletal
  • Paediatrics
  • Pharmacology / Therapeutics
  • Psychiatry / Neurology
  • Reproductive (male and female)
  • Renal / Urology
  • Respiratory

You can download the official SRA sample questions from the National Recruitment Office to get an idea of the type of question in each paper.

Candidates will be shortlisted to Stage 3 based on how they score in the SRA – the application, past experience, additional qualifications are not considered. If you score 575+ combined, you will be exempt the next stage and given a direct offer.

Selection Centre (formerly known as Stage 3) involves 3 simulated consultations (1 with a simulated patient, 1 with a relative or carer and 1 with a colleague) and a written prioritisation exercise (essay style question). You can download the official stage 3 sample cases / questions from the NRO to see examples of the type of thing to expect.

GPST Flow Chart

NRO Guidance for Applicants

There are three rounds of recruitment each year for GP training, dates as follows:

Round 1 – applications open in autumn/winter (November/December) for jobs starting the following August. The SRA is usually first week of January, with the Selection Centre taking place in the first 2 weeks of February.

Round 1 Re-advert – applications open in the spring (March/April) for jobs starting in August the same year. The SRA is usually late April with the Selection Centre in early May. This used to be known as Round 2.

Round 2 – applications open in August for jobs starting the following February. The SRA is in mid-September and the Selection Centre about 2 weeks later. This was previously known as Round 3.

Jobs that are unfilled from Round 1 are available in Round 1 Re-advert for both new applicants and those who applied in Round 1 but were unsuccessful. All jobs start in August.

The jobs available in Round 2 are jobs unfilled by the previous two rounds of recruitment – jobs start in February.

GPST Timeline

NRO Key Dates

Being a better teacher

Dr Mahibur Rahman

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

Teaching is an integral part of being a doctor regardless of the stage you have reached in your career or the specialty you are following. Whether you are a house officer teaching medical students basic skills or a consultant training specialist registrars on advanced surgical techniques, there are some universal techniques that can help make you a better teacher.

Set clear learning objectives

Setting out early on the educational objectives that you would like to achieve, makes it easier to plan what and how to teach. Objectives that are clear and specific are the best, especially if set within a realistic timeframe. This helps both learner and teacher monitor progress. Setting too many objectives, or using a very difficult to achieve timeframe can lead to feelings of failure, or make the learning experience feel like a series of boxes that need ticking. Vague objectives make it difficult to gauge if you are progressing well, or if you need to make extra efforts in one part of your training.

Timetable your teaching activities

When working in a busy clinical environment, you may often find that there aren’t enough hours in the day to fit in all the demands on your time. Teaching, and preparing to teach is time that can become easy to sacrifice – juniors may find it difficult to raise objections (unlike managers!). If your teaching time is written into your timetable, and protected, this is less likely to happen, and trainee and teacher will both benefit. Don’t forget that preparation time is as important as the teaching itself.

Give useful feedback

We all need feedback so we know how we are doing. This is an essential part of the learning process – if we are doing something well, it is good to know that we are on track, and when we could improve our knowledge or skills, or are making mistakes, we may never correct them unless we realise the error. For feedback to be useful, it must be constructive – the feedback should include suggestions for improvements rather than criticism alone. Some ways to provide useful feedback are to:

  • Ask the learner to reflect on what they have done well and what they feel could be improved.
  • Always start with the positive things first.
  • Give feedback as close to the event as possible – you will both remember what happened more clearly.
  • Give clear and specific feedback about why something was not up to standard, and ways to improve it in the future.

Giving feedback that is very subjective, that is vague, ambiguous or that relates to something that cannot be changed is of little benefit, and may cause the learner to become demotivated and affect your teacher / student relationship. Feedback should never be given in a way that demeans or undermines your trainee – this is unprofessional and will only reflect poorly on your abilities as a teacher.

Keep up to date

To be a good teacher you must know your subject well. This may seem like a very obvious statement, but in the fast paced world of medical knowledge, things are constantly changing. It is important that you are not teaching concepts and methods that are no longer considered best practice. This means keeping your own skills and knowledge up to date, and updating your teaching materials (slides, handouts, tutorials) regularly. Not only will this make you a better teacher, it will make you a better clinician.

Enjoy yourself

The best teachers are those that enjoy the teaching experience and learn from it themselves. If you find that you dread every teaching slot, you might consider the need to change some aspects of your teaching style, reduce the number of trainees you are responsible for, or check if you have given yourself enough time to prepare.

Finally, if you feel that teaching is something that you really enjoy and wish to improve your skills further, you may consider pursuing a postgraduate certificate or diploma in medical education.

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

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