Passing the MRCGP - AKT and CSA

RCGP AKT

What your Registrar needs to know!

Outline

Format and content of exam

Rules

Scoring

Computer based testing

Revision strategies

Examples

No stats teaching here……but…..

Format

Designed to test knowledge and interpretation of data

Three hours 200 item multiple choice test

No multiple true false questions

No negative marking

Delivered on computer terminal at invigilated test centre – runs Oct, Jan, May.

Rules

No limit on number of attempts

Pass only valid for three years

Can attempt any time during VTS training but best sat during year three.

Scoring

Pass mark approx 68% 85.5% pass first time. 95.2% after second attempt.For Registrar yr 3Overall pass rate 75% This includes multiple sitters. Pass rate clinical medicine 73.9%, evidence interpretation 73.2%, organisational 67.9% NB

Construction

Relevance – covers high prevalence low impact e.g. UTI and low prevalence high impact e.g. meningitis

Scenarios from clinical work, practice issues and topical issues. E.g. CD regs

All question writers are working GPs

Reference material

Clinical evidenceCochraneBNFGP curriculumNICESIGNBMJ review articles and original papersBJGPDrugs and therapeutics bulletin

Subject content

Core clinical medicine and its application to problem solving in GP context 80% of items

Critical appraisal and evidence based clinical practice 10% of items

Ethical and legal issues organisational structures supporting G Practice 10%

Clinical medicine

Subdivided into groups of body systems in approx equal numbersEach group will have sections on disease factors, symptoms, investigation, and managementCovers CVS, Dermatology, Endocrinology, ENT, Gastroenterology, Genetics, Haematology, Immunology, Infection, Mental health and learning disabilities, Musculo-skeletal, Opthalmology, Neurology, Paediatrics, Renal, Reproductive medicine, Respiratory,Therapeutic indications and adverse reactions.

Research Epidemiology and Statistics

Principles and application of audit

Application of critical appraisal skills and interpretation of research data

Application of terms used in both interferential statistics and EBM e.g. as in appendices of clinical evidence BMJ

www.clinicalevidence.org

Administration and management

Regulatory frameworks e.g. DVLALegal aspects – e.g. DVLASocial services e.g. certificationProfession regulation e.g. GMCBusiness aspects e.g. GP ContractPrescribing e.g. CDsAppropriate use of resources e.g. drugsHealth and safety e.g. needlestick injuryEthical e.g. mental capacity consent etc

So what are the learning needs?

State benefits, sickness certification, incapacity, disability benefits and fitness to drive.

Dermatology – esp acne, eczema, psoriasis

Eye problems e.g. visual loss, approp management

Prophylaxis against pandemics e.g. flu

Meningococcal disease

Evidence based management of high prevalence conditions

Contraception.

And yet more learning needs….

Loss of consciousnessDiagnosis and management of serious neonatal problemsClinical risk management about working in a safe clinical environmentChildren –prescribing, development, chronic disease.Access to medical recordsTravel medicine

Question formats

Single best answerExtended matching questionsTables and algorithms e.g. BTS algorithmPicture format – e.g. alopecia areataData interpretation – complex data, risk tablesSeminal trials – ASCOT etcAll scored equally 1 mark each correct answer No negative marking

Single best answer

According to national guidelines –not local practice

Often using clinical scenario

Only one answer is correct

Other options may be plausible.

Example cardiac anatomy

The way to a mans heart is….

single most likely answer….

Through his aorta

Down the M6 and off at Junction 4

Through his pulmonary arteries

Though his pulmonary veins

Though his stomach

Example resp disease

17 year old develops chest pain and SOB after swim. Hyper reonance an decreased breath sounds on the right side

Single most likely diagnosis is….AsthmaPneumothoraxPulmonary embolusLVFPulmonary haemorrhage

Example extended matching question

List of possible options

3 or more scenarios

Most appropriate option should be chosen

Options can be used several times or not at all.

EMQ food and drinkfor each food listed select the single most appropriate drink

Asti spumanteShirazBaroloCeylon teaChablisChiantiChilled vodkaMexican beerSherrySauternes

Coq au vin

Crème brulee

Kipper

Nuts

Oysters

Snapper

Wild duck

Cucumber sandwiches

EMQ e.g. certificationFor each patient described pick the single most applicable certificate

Med 3

Med 4

Med 5

Med 6

RM 7

SC 1

SC 2

Private cert

See pt with back pain off work 7 days needs cert from the day he sees you

Pt on long term sick for 6/12 and has a questionnaire prior to all work test Wants a cert…

Regarding data…

Quantitative, qualitative, meta-analyses and systematic reviewsHierarchy of evidence – as in NICEEssential stats – mean, median, mode, normal distribution, confidence intervals, p values, ARR and RRR, NNT and NNH, sensitivity and specificity, positive and negative predictive values!!! Oh and forest plots, funnel plots, scattergrams and homogeneity and heterogeneity!

Feedback to candidates.

Their result – overall score, the pass mark, their performance in each of the three areas.

Pass is overall and not for each of the three areas

General feedback to Deaneries also placed on RCGP web site.

The practicalities..

150 test centres -first come first served.Register and phone to book inDemonstration tutorial – www.pearsonvue.com/rcgp/ AKT does start with short tutorialSecurity identity checks, invigilated, once in cannot leave, no phones, notepads.Confidentiality document signed. No late entries. Test forms downloaded on day of test. Never the same on consecutive days.

Revision strategies..

Small revision groups- share workloadPractice timed MCQs Exam website has samples syllabus and feedbackHow to read a paper Trish Greenhalgh, RCGP website materialTime management – is everythingSkip difficult onesGuess at the endCover test – answer before reading options.

Trainers can help by..

Broad an experience as possible

Target areas of need e.g. medicolegal

Question clinical decisions and look for evidence

Use clinical evidence

Cover Stats and critical reading

Familiarise with algorithms.

CSAFormat of exam

What candidates must know

Venue, examiners, cases

Candidate experience

Exam preparation and timing

Format

3 parallel circuits trice daily13 simulated patient stationsCases last 10 minutesCandidates stay in own room as a real surgeryRole player accompanied by an assessor throughoutPrescription pads, certificates, test forms provided.

Timing and security

Circuit lasts 3.5 hours.

15 minute break

Case 10 mins 2 min break and so on

Monitored during break –no talking!!

Separate am and pm candidates

Confidentiality agreement signed

Candidates must….

Not be late!!

Remember ID

Bring Drs bag and BNF – clean!!

No mobiles = disqualification

Read patient record thoroughly

Own food and drink – no canteen.

Examiners

260 many are GP trainers

Hands on Drs, team player, not prejudiced.

Selection and training in place

Idea is good representation form Primary Care

QA of assessors and role players to ensure fairness.

Remote cameras in place.

Cases

600 written

Change daily

Reflect spectrum of General Practice

Designed to fill 10 minute slot

Costs a lot of money to run.

Scope

Wide clinical scopeDiffering contexts all from GPRange of ages including children by proxyEthnicity and disabilityBreaking bad newsEmotional problems, depression. May have a body part to examineConsultations with health professionalsNo manikins or models - almost

Trainers should cover…

Telephone consulting

Home visits

Different ethnicities

Disabled patients

Difficult patients

Uncertainty

Pitfalls…

Jumping to conclusions too soon.

Mechanistic consulting – irrelevant stock phrases

Forgetting examination skills 33% need hands on examining- remove clothing!!

Looking for non-existent hidden agenda

Rigid, Dr centred consulting.

Standard expected..

That of GPR at end of 3 years. Safe for independent practice. Feedback form candidates – fair, centre fit for purpose, actors realistic, reflects real life experience, stressful,CSA exam fees are high!!Feedback to candidates – pass – excellent or fail, number of cases passed, which cases failed, formative feedback statements. Fed into E Portfolio.

Key messages for registrars

Revise from curriculum statements

No assumptions based on previous candidates experience.

Read the case paperwork

Manage time

Structure consultations

Trainers can help by..

Allow Reg to experience wide variety of cases.

Short practice swaps

Use the COT as a way of assessing

10 minute consulting in practice a must.

Use info on web site – dummy cases

Wessex DVD RCGP book coming

Marking schedule for CSA

Each vase is marked in three domains Data gathering examination and assessment skillsClinical management skillsInterpersonal skillsOverall grade only counts. 8 passes to get through – no compensation. One bad mistake does not fail, cover all domains in all cases, watch the timing.

Data technical and assessment

Positives

Clarifies problem

Accept uncertainty

Use of time good

Systematic approach to information gathering

Selective choice of enquiries, examination and investigations

Identifies abnormal findings

Uses instruments well

Appropriate interpretation of information

Negatives

Immediate assumptions made

Interventional

Data gathering not related to probablilty of disease

Fails to identify abnormal data or interpret it.

Unsure re instruments

Disorganised unsystematic

Clinical management skills

PositivesRecognises presentations of common problemsPlans reflect natural history of common problemsFeasible appropriate management optionsAppropriate assessment of riskRefers appropriately co-ordinates care with team membersManages risk, safety nettingManages multiple problemsEncourages improvement rehab recoveryEncourage patient participation

Negatives Does not consider common conditions

Patient not made aware of risks or different possible approaches

Inappropriate decisions

Referral inappropriate

Follow up not planned

Co-morbidity not considered

No problem list No prioritisation

No enhancement of patients coping strategies.

Interpersonal skills

PositivesExplore patients agenda

Alert to verbal and nonverbal cues

Explores impact of illness on patients life

Works in partnership

Psych and social info elicited

Responds to pt preferences feeling and expectations

Shared management plan

Respect. Inclusive.Open Non-judgemental Sensitive to pts feelings

Consent consent confidentiality

NegativesMisses patient perspective

Misses verbals and non verbals

Misses psychosocial context

No empowerment

Inappropriate language

Little understanding

No compassion

Own views paramount

Prejudiced Patronising. Paternalistic.

Embarrasses patient.

Candidates comments

Cases favoured chronic conditions

Real interesting enjoyable!!!

So lets try some cases and see if we agree!!

Group rules

Idea is to get a feel for the casesNot to judge colleagues performanceNeed one patient one registrar and one observer. Timing- 10 minutes to do, 10 to chat then change over cases if time!Use generic indicators sheet to assist. Confidentiality please.

2 cases to try…

Mrs Smith

Cleaner mid 50s married

C/o fluid retention bloating

In reality just getting fatter

FH NIDM brother and CCF Father

Wants water tabs and tests

Bloods 2 weeks ago normal

Mrs Jones

mid 50s smoker

C.Of increased sob at rest and on exertion

No chest pain or ankle oedema

BP controlled with ACE

Father had lung cancer

Worried she may have something serious

Wants a CXR