MRCGP AKT Revision Tips based on January 2016 Feedback

Here are a few tips to help you in your revision towards the AKT exam. We have based most of the information here upon feedback from the January 2016 AKT feedback, but a lot of it is universal to all AKT sittings.

Our Revision Tips cover:

- Safe prescribing and prescribing errors
- Monitoring errors
- Fields not encountered in day to day work
- Lack of familiarity for notification of certain infectious diseases
- Paediatric questions
- Contraception
- Ophthalmology
- Diabetes
- Management of Parkinson’s disease
- Dermatology

Safe Prescribing and Prescribing Errors

The RCGP regularly set questions around safe prescribing, and this is particularly important where the clinical situation is complex. The college stated that they have seen improvements in recent AKT exams, but in AKT 26, according to RCGP “candidates found a scenario difficult which involved a patient with acute gout, who was also on a range of medication to treat long term conditions. In particular there was a lack of awareness of drug interactions”.

How do you address this in your revision? There are a number of key resources that you can use:

The GMC PRACtICe study looked at specific areas in primary care prescribing to identify common pitfalls and errors in prescribing. Although many prescribing errors occurred as a result of system errors, the study was useful in highlighting the most common drugs to be associated with prescribing errors. These drugs are:

1) Simvastatin
2) Amoxicillin
3) Influenza vaccine
4) Prednisolone
5) Betamethasone Valerate
6) Diclofenac Sodium
7) Ibuprofen
8) Aciclovir
9) Allopurinol
10) Flucloxacillin

Interestingly, the RCGP highlighted that gout treatment – in particular, a lack of awareness of drug interactions with a range of medications used in the treatment of long term conditions – featured in the January 2016 AKT. Looking at the PRACTiCe study, Prednisolone, Diclofenac, Ibuprofen and Allopurinol all feature in the list of medications that cause the most prescribing errors.

With regard to Allopurinol, you should familiarise yourself of how and when to start allopurinol in the context of an acute attack of gout. What to do if a patient is already taking allopurinol during an attack and what to do following an acute attack if you wish to start allopurinol. You should be careful starting allopurinol in a patient with renal impairment. The BNF advises a maximum dose of 100mg daily in a patient who is renally impaired (reducing further if there is severe impairment). Allopurinol is associated with a number of interactions and whilst you wouldn’t be expected to know them all, you should be familiar with the most important, such as with Azathioprine and a possible effect on a patient’s INR if taking warfarin.

NSAIDs can be a particular problem and it’s no surprise that they feature in the list of medications most known to cause problems. The most important considerations are for patients who have a history of heart failure, renal disease and GI ulceration but there are also many significant interactions, including patients taking ACE inhibitors, Warfarin and Lithium.

Prednisolone can also result in GI ulceration as well as interacting with warfarin. It should not be given at high doses at the same time as live vaccines.

Monitoring Errors

Another area where safe prescribing can be compromised relates to monitoring errors. The top 10 drugs most commonly associated with monitoring errors are as follows:

1) Simvastatin
2) Warfarin
3) Ramipril
4) Bendroflumethiazide
5) Furosemide
6) Azathioprine
7) Atorvastatin
8) Perindopril
9) Candesartan
10) Amiodarone

Statins should be used with caution in patients with a history of liver disease and avoided when there are unexplained persistent elevations in serum transaminases. There are also a number of important interactions and problems when co-prescribed with a range of medications including fibrates, nicotinic acid, fusidic acid, macrolides, antifungals.

Fields not Encountered in Day to Day Work

Some areas of the curriculum cause difficulties for candidates because they represent fields that they may not encounter in their day to day work. These could be clinics, such as antenatal clinics, which in many regions are now midwife led (and therefore little exposure for GPs in training). However, in the January 2016 exam, the RCGP highlighted administrative tasks such as the completion of personal medical attendant reports.  There are a wide range of reports that you will encounter as a GP and the best way to familiarise yourself with these would be to ask your Trainer if you can go through them to see the sorts of questions that are asked. You may be asked about a patient’s ability to complete certain tasks (and need to be sure that you have enough knowledge of the patient to be able to do this) or checking factual information for the DVLA or insurance providers. Bear in mind issues of confidentiality if referring to members of the patient’s family.

Lack of Familiarity for Notification of certain Infectious Diseases

Along similar lines, within this curriculum map heading, they also highlighted a lack of familiarity with the requirements for notification of certain infectious diseases. We have commissioned a number of questions to test you on this subject matter but you can find further information about this at Public Health England and government health websites. It’s a common topic for testing in the AKT. It’s also worth noting that questions are often topical, so your knowledge into recent outbreaks of scarlet fever, pertussis and measles may be tested in your exam. The college also stated in their January 2016 feedback that you need to keep up to date with identification and management of new or evolving infectious diseases, where these are relevant to the UK – such as multiresistant bacteria or advice to travellers to regions affected by Zika virus.

Paediatric Questions

Paediatric questions will always crop up in the exam because they form a large part of a working GP’s workload. In the January 2016 exam, they mentioned questions about mild labial adhesions but the important “take home” points here are that there is often poor knowledge about the management of minor conditions (so don’t forsake familiarity with common “bread and butter” conditions to revise the very rare fascinomas) and conditions that may not require significant intervention. This point is, again, a common theme. Don’t assume that the correct answer is the one where you have to actively treat or do something – “doing nothing” may well be the most appropriate course of action. Have a think about the things you see in your surgery where the best advice is to observe or leave well alone (minor skin lesions or self-limiting conditions for example).

Contraception

Contraception is another popular area for testing in the exam. Whilst candidates have performed well in recent exams, there seems to have been difficulty when dealing with more complicated scenarios including serious adverse events. There are a number of ways of revising for this. Besides the questions that we have prepared, you should consider attending one of the many family planning presentations that are held across the country. BMJ Learning also have a number of useful modules for you to try. You should also read through the relevant chapters of the BNF, noting contraindications and interactions. You may find it helpful to arrange to sit in on a few sessions at the local family planning clinic. The Faculty of sexual and reproductive health also have a useful website which outlines the current guidelines and many AKT examination questions have tested candidates’ knowledge of this (Quick start contraception being one example).

Ophthalmology

For many students, ophthalmology takes up very little time in their undergraduate curriculum and their lack of knowledge and exposure to this area often carries through to GP training. This may be compounded by reduced exposure to eye problems since the advent of acute eye services by Opticians in many regions. It’s not surprising, therefore, that this is often cited as an area of poor performance. Again, we have supplemented our resource with a great deal of questions that test your knowledge of diagnosis and management of common eye conditions. You should familiarise yourself with red flags as well as the more common conditions such as macular degeneration. Since this is a very visual speciality (sic) it helps to look at lots of pictures of eye conditions as well as retinal photographs to ensure that you are familiar with the appearances of common eye problems. It crops up a lot and your revision is likely to be rewarded with a question in the exam!

Diabetes

Of all the subjects tested in the exam, diabetes is one of the most important. Not only is this a common and increasingly large part of a GP’s workload, but there are often questions in the AKT exam and candidates often struggle. If your training practice holds diabetic clinics, be sure to schedule in a few sessions sitting in with a colleague. You should familiarise yourself with the latest diagnosis definitions and know how to manage diabetes – and this includes advice that would normally be given by diabetic nurses such as managing basal bolus regimens. Time spent with a good diabetic nurse will be well spent. Whilst questions will test your knowledge of national rather than regional guidelines (and this applies to other areas of the exam as well), you may find this resource from Leicestershire diabetes useful.

Management of Parkinson’s Disease

Candidates found difficulty with questions about the management of Parkinson’s disease – in particular advice and support as well as the range of difficulties that such patients may experience. You should be mindful of the need to adopt a multidisciplinary approach involving the SALT team and physiotherapists as well as familiarising yourself with some of the common complications such as falls, infections (e.g. aspiration pneumonia), bowel and bladder disorders and contractures. This is summarised in a good article by guidelines.

Dermatology

Dermatology is a popular topic for examination questions, not least because it provides a rich source of material for photographs to include in examination questions. You should not only be confident in making a diagnosis by looking at a photograph but also taking into account the description and features of what you are seeing. Whenever you are presented with a photograph, the history will include details that will help you to make a diagnosis – such as timescales, risk factors and co-morbidity. Again, “doing nothing” may be an option but you should be able to recognise and refer with the correct level of urgency any conditions which demonstrate red flags (either in appearance or history). DermNZ stands out as an excellent resource for revision about dermatological conditions and includes a number of useful photographs to aid your revision.

Feedback AKT Sittings 24-26

Examiners gave a summary of feedback over several AKT sittings (24-26) in their January 2016 feedback. There are three important areas that have cropped up in a number of exams and have demonstrated a poor area of knowledge:

1) Administration and regulatory frameworks
2) Diagnosis and management of common eye conditions
3) Diabetes – both type 1 and 2

This first area is difficult because it’s not as clear cut as the more clinical domains. There are a number of sources of information that you should read to revise on this as well as shadowing your trainer when they are spending time on admin tasks. The BMA site includes lots of useful advice about regulatory frameworks and legal issues. The MHRA website is worth reading, especially for topical matters. Also, Health Protection England provides useful advice about health protection matters, many of which are applicable to all areas of the UK.  BMJ Learning have a number of modules on common eye problems, including how to manage the sticky eye, to quick tips on managing red eye.

In addition to the above, hot topics for revision include safe prescribing and interactions (check out also the first few chapters of the BNF, such as prescribing in palliative care) and normality in childhood development.

Revision Advice

In summary:

1) Common things are common and will be tested in a primary care exam, but familiarise yourself with red flags and situations where urgent intervention is required
2) Active intervention is not always necessary and the college are keen to test your ability to recognise normality and situations where doing nothing may be an option.
3) Answers will usually fit with consensus or national guidance and you should tailor your revision accordingly
4) Remember that questions may be set on topics that may not be encountered easily during training – examples being family planning, antenatal or diabetes clinics, especially where they may be nurse led. Try to sit in on as many of these clinics as you can to familiarise yourself with common problems and appropriate management. Nurses often give advice to patients on more “practical” matters of management and this may be reflected in AKT questions.
5) Administrative and regulatory questions are difficult to revise. Ask your trainer if you can sit in on any admin sessions or practice/CCG meetings to become familiar
6) Take a look at the first few chapters of the BNF and look at highlighted areas in each chapter that deal with potential prescribing errors or sources of significant interaction. These are often tested
7) When sitting the exam, try to think of the answer before looking at the options – the first answer you think of is usually correct and the options are there to confuse you and make you think again
8) There’s often more than one possible answer and your task may be to select the most appropriate course of action – it may not be a case of one correct and four incorrect options. Incorrect options may be plausible too

Finally, our primary care team has over 15 years experience of writing and providing questions for AKT revision. We take a lot of care to make sure that our questions closely match the curriculum map domains and concentrate also on rectifying deficiencies highlighted in examination feedback. We work closely with registrars to ensure that our questions accurately reflect popular examination themes and we draw upon the expertise available within the British Medical Journal to reference our material to make sure that it is of the very highest standard. Our questions are not set to give you what we think you like, but to accurately reflect the tone of the exam and pitching the questions at the correct level to make you think about the topics that you are studying and to allow you to iron out any deficiencies in your knowledge before you sit the exam.

Dr Geraint Preest May 2016

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Top Tips on How to Pass your Medical Exams

Get the right mind-set

The exams are challenging and represent an important stage in your career. The key is to commit to trying them, make the time, and be consistent in your effort.

Have the right knowledge

Think of your memory as a kitchen shelf. You can only put so much in your exam-prep memory at any one time. Time your memory to make sure you have the most useful stuff and don’t try and cram it with a load of other things. Make sure it's the right time in your career. Are you on a busy rotation? You don’t want these things taking over space in your mind and overloading it. You want an even distribution of knowledge and not just lots of one subject such as cardiology. Just like a kitchen shelf make sure your exam shelf has the right ingredients.

Think like an examiner what would they do?

They are just a few years ahead in their career and they are all around you, consultants in NHS hospitals across the UK and internationally. Every hospital has a senior doctor keen to teach. Talk to them and understand how to prepare for the exam.

Practice basic science questions

It’s most important to practice, practice for basic science questions. They generally don’t change and there will be a good section of them in the exam and will be based on the same sorts of topics.

Know the guidelines

Many exam topics will be  based on guidelines. Make sure you get to know where the guidelines for your specialty can be found.

Spot patterns in the questions

The language that is used in the exam papers is something that you can become familiar with. The more you practice the more you will notice they will ask questions in certain ways and they use particular words more often than you would use in other writing.

Common question lead ins

The words ‘may, might and always’ have particular meaning in these exams. If you practice them you will be able to see how you should interpret them when you come across them in the exam. ‘What's the appropriate next step’, comes up often and it's not necessarily a test of knowledge but is asking you to make a judgement as to what may  be the safest or most cost effective answer. Certain types of phrases and patterns in questions can help you answer them correctly.

Know your enemy

Think of your College as your enemy and plan your attack accordingly. You should know them. Read their exam reports, read about the exam on the College website and read through the exam syllabus.

Stuck with a question

If you are really stuck with a question and about to give up think of these tips;

  • As you would when you are on the ward go back over the history, read through the question stem again.
  • Try hiding the options and just answer the question.
  • Try and get into the examiner’s head. Is the diagnosis actually given (in which case they are asking for management) or hidden (in which case you need to work it out first then answer the question).
  • Try analysing the options. Is there something there that gives you a clue to the area of medicine you are being tested on? You can try and exclude the answers that are definitely wrong rather than definitely right.

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