9 tips to reduce stress and prevent burnout during GP training

9 tips to reduce stress and prevent burnout during GP training

GP training can be a challenging time with the pressures of the clinical workload, keeping up to date with your e-portfolio and WPBA assessments and preparing for MRCGP exams combined with responsibilities in your personal life. In this article, Dr Mahibur Rahman looks at 9 ways to look after yourself, reduce stress and prevent burnout.

1. Eat, drink, take a break

It is easy to get caught up with seeing patients in clinic or the wards and the associated paperwork (referrals, discharge summaries, drug charts, repeat prescriptions, etc.). If you are not careful, you could find that you have gone without any food, drink or a rest and it is almost the end of the working day. Stay hydrated with water, tea / coffee throughout the day. It is easy to be overwhelmed by all the different tasks on your list, but it is important to take a break for a few minutes to recharge yourself. Apart from a cardiac arrest or something of similar urgency, most tasks can wait 5-10 minutes. Make sure that you have some proper food, away from a desk at lunchtime – if you can get some fresh air as well as a change of scenery, even better!

2. Plan ahead

Early on in each rotation, meet up with the other junior doctors in your department, or meet with your trainer if you are in a GP practice, and plan out your annual leave and study leave. This way, you can arrange any swaps that are necessary to allow you to get the time needed to go on relevant courses, and to manage your annual leave. This is particularly important when you start planning to take your MRCGP AKT or CSA – planning ahead so you have enough time to prepare will reduce the stress of these challenging exams and improve your chances of passing both at the first attempt.

Try to arrange your leave so you spread your time off throughout the rotation rather than one long break early on. When you are doing a busy job, knowing that you have a holiday coming up can give you something to look forward to and keep you going.

3. Ask questions, ask questions, ask questions!

Whenever you change rotation during training, it can take some time to adjust to your new role and there may be lots of things that you are not familiar with. Some things will be specific to that ward (like where they keep specific forms), some will be specific to that hospital, or specialty, some will even be specific to each consultant you work with. If there is anything you are unsure of, don’t be scared to ask. You may feel shy or embarrassed, but it is important to overcome this and ask so that you can do your job properly rather than pretend you know what to do or where to go and then cause problems. One of the most stressful things you can encounter is trying to cope with things that are outside your expertise – take the pressure off by asking questions or asking for help!

4. A problem shared is a problem halved

Sometimes you will have to deal with difficult situations at work – an angry or demanding patient or a patient that deteriorates very rapidly or unexpectedly. It is important to recognise that the emotions from one encounter can be transferred to the next one. If you have a difficult consultation or situation, it can be helpful to take a short pause to reflect and reset your emotions, and discussing how you feel, and any lessons you can learn with colleagues or clinical supervisor can be useful.

5. Do some regular exercise

We all know the many benefits of exercise, but it can be difficult to fit it in when in a busy rotation. Not everyone enjoys the gym (or has time for it) – be creative in how you build exercise into your routine.  Some registrars cycle to work or even do home visits by cycle! Try going to get your patients from the waiting room rather than calling them in via the tannoy, or when in hospital, take the stairs rather than the lift. The main thing is to incorporate something regular – even small things can make a huge different to your physical and mental well being.

6. Watch out for yourself and your colleagues

GP training can be stressful and there are comparatively high numbers of doctors that suffer from things like depression, stress, alcohol and drug dependence. As well as looking after yourself and ensuring you seek help from your own GP if you feel you are becoming unwell, watch out for any signs that your colleagues might need support. The NHS GP health service also offers confidential NHS service for GPs and GP trainees in England: http://gphealth.nhs.uk/

7. Seek help early

If you are finding your clinical workload unmanageable, or are struggling with the e-portfolio, or having health issues or finding any aspect of training particularly challenging, it is important to discuss this early with your trainer. They are there to support you as well as supervise you and may be able to help you identify why you are struggling, or make changes that may help. If you are still struggling, you may find it helpful to approach one of your training programme directors for advice.

8. Find your work life balance

Some doctors may find that managing the balance between work and home life can be difficult if they have additional responsibilities such as young children, caring for parents, or if they have health issues themselves. Many doctors train less than full time for part of their training – it may be that the same person that would burnout at full time will really thrive working at 60% or 80% of full time. If this is something that you would like to consider, you should discuss it with your trainer and your programme director.

9. Work hard – play hard

We are doing a job that comes with a lot of responsibility and involves lots of hard work. It is important to actively make time to do something that you enjoy regularly to help your mind to unwind – maybe a hobby, playing a sport you enjoy or meeting up with friends. Making time to enjoy things outside of work can help relieve stress and improve your morale when at work.


We work in a demanding job, and the added pressures of learning logs, assessments and examinations combined with caring for our patients can add up. It is important to make time for yourself and your own well being – if you don’t look after yourself, you can’t look after anyone else. I hope these tips are helpful – if you ever have any issues during training please do reach out and ask for support. As well as local support, you may find the GP Training Support group on Facebook helpful for networking with other trainees, and I am always happy to offer any help I can.

Dr Mahibur Rahman is a portfolio GP and the medical director of Emedica. He runs the GP Training Support Facebook group – a community of over 9,500 doctors with an interest in GP training willing to offer free advice and support on any aspect of training. You can join the group at https://goo.gl/bcoMKt

10 free resources every GP trainee should know about

GP training can be a hectic time and comes with lots of expenses – you have to pay for access to the e-portfolio, MRCGP AKT and CSA, business use car insurance for home visits and more. However there are lots of useful resources that won’t cost you anything. Here are 10 FREE resources every GP trainee should know about!

  1. GP Notebook – useful reference site for quick access during consultations to check investigations and management options. I regularly used this during consultations as a GP registrar!
  2. Induction APP – handy directory with numbers for different departments in your hospital. Covers most hospital trusts in the UK, and includes local guidance documents from some sites.
  3. NICE CKS –  useful for quickly looking up a specific guideline – more user friendly than the main NICE site.
  4. BNF and BNFC online: accessible without registration and from a non-NHS connection e.g. your mobile phone. Easy search function if you need to check drug doses during a consultation. This is often kept open in a tab in the background for quick access.
  5. Medical calculators: – quick access to 20 useful calculators for a wide range of situations. Includes CAGE, AUDIT, Well’s, 6CIT,  HAS-BLED, GCS, CHADS2VASC and more!
  6. Bradford VTS website: – lots of useful resources especially for MRCGP AKT and CSA, including free CSA cases to practise.
  7. Pennine VTS CSA resources: – large range of free videos and cases for CSA preparation.
  8. gptraining.info – free articles on topics related to all stages of GP training including  hospital and GP placements, up to date pay scales with take home pay for ST1, ST2 and ST3, MRCGP AKT / CSA and GP career options including portfolio GP careers. 
  9. Patient.info leaflets – handy printable patient information leaflets for pretty much any condition you can think of.
  10. GP Training Support Facebook Group – largest FB group dedicated to GP training with daily revision cards for AKT and CSA, and regular videos and articles on all aspects of training. Get support and answers to your questions from over 9,540 friendly members including trainees in every deanery in the UK as well as trainers and educators.

Are there any other sites, apps or resources that you find really helpful or use regularly as a GP trainee? Please do share them in the comments.

MRCGP Workplace Based Assessment (WPBA) in GP Training

Workplace based assessment (WPBA) is one of the 3 components of the MRCGP exam.  In this article, Dr Mahibur Rahman provides an overview of WPBA – what it covers, how to gather evidence for it, and when you need to complete certain milestones.

What is WPBA?

WPBA is a continuous assessment process throughout the 3 years of GP training. It is designed to support development through feedback on various competences both in hospital and GP posts.

It is based around 13 areas of professional competence:

  1. Communication and consultation skills – use of recognised consultation techniques to communicate effectively with patients
  2. Practising holistically – using physical, social and psychological context to provide holistic care
  3. Data gathering and interpretation – effective history taking, choice of examinations, investigations and their interpretation
  4. Making a diagnosis and making decisions – a conscious, structured approach to decision making
  5. Clinical management – recognition and management of common medical conditions in primary care
  6. Managing medical complexity and promoting health – aspects of care beyond managing straightforward problems, including management of co-morbidity, uncertainty, risk and focusing on health and well-being rather than just illness
  7. Organisation, management and leadership – understanding the use of computer systems in practice, change management, and the development of organisational and clinical leadership skills
  8. Working with colleagues and in teams – effective team working and the importance of the multi-disciplinary team
  9. Community orientation – management of the health and social care of the practice population and local community
  10. Maintaining performance, learning and teaching – maintaining performance and effective CPD
  11. Maintaining an ethical approach to practice – practising ethically, with professional integrity and a respect for diversity
  12. Fitness to practise – the doctor’s awareness of when his/her own performance, conduct or health, or that of others, might put patients at risk, and taking action to protect patients
  13. Clinical examination and procedural skills – competent physical examination of the patient with accurate interpretation of physical signs and the safe practice of procedural skills

These competences are assessed in different ways throughout training, the idea being that you should achieve the standard expected of a qualified GP in all of them before you complete training.

How do I meet the requirements for WPBA?

You will need to gather evidence that you have achieved the competences using various tools. Some are used only in the GP setting, some only in hospital while others can be used in both settings. The tools are:

Tool Hospital GP
Case-based Discussion (CbD)

A structured interview assessing professional judgement in clinical cases – based around real cases you have seen.

Consultation Observation Tool (COT)

A review of patient consultations by your trainer – either video recordings or direct observation in a joint clinic.

Multi-Source Feedback (MSF)

Collection and reflection on feedback from colleagues on your clinical and professional skills. This is from clinicians only in hospital, and both clinicians and non-clinicians when in GP.

Patient Satisfaction Questionnaire (PSQ)

Feedback from at least 40 patients on your empathy and relationship building skills during consultations.

Clinical Examination and Procedural Skills (CEPS)

Assessment of various clinical examination skills and competence in performing key procedures – this includes intimate examinations.

Clinical Evaluation Exercise (MiniCEX)

Assessment of clinical skills, attitudes and behaviours in a secondary care setting – based on direct observation of your interaction with a patient for around 15 minutes.

Clinical Supervisors Report (CSR)

A short, structured report from your clinical supervisor looking at the competences in 4 clusters: relationship, diagnostics, management and professionalism. This is usually completed for each hospital post, although it can be used in GP posts.

Learning Log

This is your personal learning record and should be used to reflect regularly on learning experiences. These can be linked to relevant curriculum headings.

Personal Development Plan (PDP) 

This is used to allow you to demonstrate that you can assess your learning needs and plan actions to meet them. Items in the plan should be reviewed with evidence to demonstrate that you have achieved them.

Are there a minimum number of assessments I need to complete?

You will usually meet your educational supervisor every 6 months for a review of your progress. You will be asked to complete a self-assessment prior to each meeting. The guidance of how often each tool should be used is shown below – remember that the quality of entries and assessments is as important as the quantity. Some doctors will need to do more than the minimum to reach a suitable standard. The minimum evidence given here is based on a 3 year rotation with 18 months in hospital and 18 months in practice for a full time trainee.

Year of training Minimum evidence

Prior to 12 month review

6 x mini-CEX (if in secondary care) / 6 x COT (if in primary care)
6 x CbD
2 x MSF (each with a minimum of 5 replies from clinicians plus 5 non-clinicians if in primary care)
1 x PSQ (if in primary care)
CEPS as appropriate
1 x CSR from each hospital post

Prior to 24 month review

6 x mini-CEX (if in secondary care) / 6 x COT (if in primary care)
6 x CbD
1 x PSQ (if in primary care and not already completed in ST1)
CEPS as appropriate
1 x CSR from each hospital post

Minimum prior to 36 month review

12 x CbD
12 x COT
2 x MSF (each with 5 clinicians and 5 non-clinicians)
1 x PSQ

Less than full time trainees, and those on 4 year rotations (including academic trainees) have different requirements – you can read more about this here: http://www.rcgp.org.uk/training-exams/mrcgp-workplace-based-assessment-wpba/less-than-full-time-trainees.aspx


WPBA is an important component of the MRCGP, and alongside the MRCGP AKT and CSA, assessed readiness for independent practice as a GP. It also offers a way to record your learning, gain feedback on areas to improve and to provide evidence of your achievements. It is important to keep on top of the different learning tools and gather the necessary evidence in a timely manner so you can successfully progress through training.

Further reading:

RCGP WPBA overview: http://www.rcgp.org.uk/training-exams/mrcgp-workplace-based-assessment-wpba.aspx

Starting out as a GP Registrar

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

Settling in

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

Practice Routine

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

Working with the team.

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

Practice Manager

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


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

Practice Nurse

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

Healthcare Support Worker

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

District Nurses

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

Health Visitors

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

Practice Secretary

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

Other doctors

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

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:


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.


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!

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.


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


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


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 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 AKT Exam – High Yield Topics from the April 2012 Exam

MRCGP AKT Exam – High Yield Topics from the April 2012 Exam

Dr Mahibur Rahman

After each MRCGP AKT examination, the examiners release a report highlighting key information from the last exam. This includes pass marks and rates, and also key topics – both those that were answered well, and those that GP trainees performed poorly on. These topics are frequently examined again in the next few sittings of the AKT exam, so it is worth ensuring that you have a good understanding of them.

As some of you may be starting your revision for the October 2012 MRCGP AKT Exam, we thought it would be helpful to look at the high yield topics from the latest examiners’ report.

Key facts from the April 2012 MRCGP AKT exam:

The top score was 93.5%
The mean score was 73.2%
The lowest score was 41%
The pass mark was 68.8%
The pass rate was 67.6%

Scores by domain:

Clinical medicine – 74.2%
Evidence interpretation – 70.2%
Organisational – 68.1%

High Yield Topics

The examiners’ report from the April 2012 diet of the MRCGP AKT exam highlighted the following key topics:

  • Prescribing for children – asthma, migraine
  • Normal childhood development
  • Data interpretation / statistics
  • Confidentiality – insurance reports / ABI / BMA guidance
  • Nice Hypertension guidelines 2011 – diagnosis and treatment
  • Spirometry – interpreting results
  • Cancer – 2 week referral guidelines

The MRCGP AKT is a comprehensive examinations, so it is important that you cover the entire curriculum. Remember that 80% of the marks are related to applying knowledge relating to clinical medicine in general practice, 10% to evidence interpretation and 10% to the organisational domain.

The highest scorer in the April AKT examination was Dr Razwan Ali. He attended the Emedica AKT course about a month before his exam. He will be sharing his AKT preparation tips on our blog soon.

Further reading:
Complete April 2012 AKT Summary report

MRCGP CSA Preparation – Tips to help you pass the MRCGP CSA exam

CSA Preparation – Tips to help you pass the MRCGP CSA examMRCGP CSA Exam Tips
Dr. Safiya Virji

The MRCGP CSA examination is a challenging exam. Dr Safiya Virji sat and passed the exam on her first attempt with one of the top scores in the country. In this article she shares some tips on preparing for the CSA exam.

An important step in successfully passing the CSA is to make a decision early on which sitting to go for, and actively work towards being thoroughly prepared by this time. I made the decision six months beforehand. I had just started my ST2 placement in GP and took this opportunity to practice various consultation styles until I found one that suited me and came more naturally to me.

I ensured that I was videoed frequently from very early on and did not let the embarrassment of watching myself on the screen stop me from getting vital feedback from my trainer. I was always conscious to encourage my colleagues to give constructive criticism so that I had identified specific points to improve over the coming weeks. I also gradually reduced my consultation times; starting at 20 minutes and gradually working down to 10 minutes about two months before the exam.

I found joint surgeries with my trainer and other partners at the surgery extremely beneficial. Not only can you see alternative ways of phrasing things, but it also gives you a chance to see how you are inclined to perform when you don’t know who or what is going to come through the door and you are being watched. Conducting these on a weekly basis meant by the time the exam came, I was already comfortable with the scenario of being watched conducting consultations I was not familiar with, so was less nervous then you would expect in such a weighty exam. This enabled me to perform to the best of my abilities when it really counted.

It is important to use all opportunities as exam practice. Every patient you see is an opportunity to practice explaining a diagnosis in layman’s terms or to ask about what they think may be causing their presenting complaint. Anything that goes wrong in your consultations is worth jotting down and discussing with your trainer afterwards. It could be the phrasing, or it could be bad choice of questions. I found the more that went wrong, the better I was getting, as I was prepared for all eventualities.

I was also part of the on-call rota and working on emergency patients with a seven minute consultation time from about four months before the exam. This in combination with the GP out of hours (OOH) gave an excellent opportunity to practice for the exam. I took the opportunity in OOH to ensure every patient I saw was observed by the trainer, timed and feedback was given.

I read a selection of case books including:
nMRCGP – Practice Cases, Clinical Skills Assesment – Raj Thakkar
CSA Scenarios – Thomas M Das
Consultantion Skills for the new MRCGP – P Naidoo & C. Monkley
Get Through New MRCGP: Clinical Skills Assessment – Bruno Rushforth (this was the best book for role play in my opinion)

I tried to use these for role plays with colleagues at least for a one hour session a week, increasing this to 2-3 hours a week in the last month before the exam. However, I also read these books in my own time to learn how simple presenting complaints can often have an unbelievable amount of depth, and how missing out one vital question can lead to missing the underlying point of that consultation.

Regarding examinations, I watched videos on how to do the examinations thoroughly yet quickly, and used my own equipment to perform these multiple times on family and friends in the week before the exam so examinations were fresh to hand if necessary.

In preparation for the exam, I set myself a target to complete all consultations within 8 minutes. Strict time management a month before the exam meant I was used to working at a fast enough pace that would ensure I would not over run in the exam, even with the unexpected cases which take a few seconds longer.
I ensured I was always trying to examine the patient by 5mins, and always kept a note of the start and finish time of each consultation to ensure I was always working to time.
In the exam, on several occasions I was still conversing with the patient when the bell rang. However, it seemed I covered enough material at the end of the 10 mins to pass well on each station.

Having sat the exam before all my colleagues, I was not exposed to many horror stories about the exam. This meant I was optimistic when exam time came. A combination of this, alongside minimal nerves and trying my best to apply a structure that worked for me when things were going to plan, and adapting my consulting style when I needed to be flexible, plus a happy face, lead to my passing with a score of 106/117. And I forgot to mention, when I sat the exam I was 38weeks pregnant!

One month before the exam I went on several courses, one of which was the Emedica MRCGP CSA course. I found the course useful as it tackled preparation slightly differently to other courses. The group was very small (courses take just 6 candidates per day). This meant there was time to focus on each trainee independently and specific feedback was given on their performance. By the time you go on any course, you have usually had experience of the simple well known cases, but the scenarios at the Emedica course were slightly more complex then average which meant you were prepared for the more challenging cases in the real exam.

Some of the cases in the CSA do throw you so having some practice at performing under pressure can mean the difference between a pass and fail. The feedback on the course was very useful as it was not based just around what was done well, but more on what needed to be improved on in order for you to pass, and pass well. For me, this approach was more beneficial as I always maintained the attitude that by taking constructive criticism on board, I was far more likely to pass as all my flaws would be ironed out by the time the exam came round. After the course, further reading material and links were provided, including videos of common examinations. This was very helpful as though it is not a huge part of the exam, when it does come up, it is essential they are performed fluently and effectively so that the correct diagnosis is made.

In summary, the my key tips to help you pass the MRCGP CSA exam are:

• Give yourself enough time to prepare – I started 6 months before the exam
• Use all opportunities as CSA practice opportunities – surgery, OOH, on call
• Be observed as much as possible – joint surgeries and video surgeries are both helpful
• Actively seek constructive feedback – and use it to develop your technique
• Create an effective structure that works for you and apply it as much as possible
• Get used to working under time pressure – being comfortable with 10 minute consultations really helps
• Don’t let stress on the day change your attitude toward exam consultations – keep calm and carry on

One last point, once you have finished with one patient, don’t analyse or get upset in the exam, move your focus onto the next one and give it your best!

Dr Virji is a GP Registrar (ST3) in Oxford Deanery. She passed the MRCGP CSA exam on her first attempt, and scored 106 marks out of a maximum of 117.

The Emedica MRCGP CSA Course includes teaching on the new CSA mark scheme including the 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.