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

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):