PREPARING FOR THE AKT
The AKT is a mandatory exam for MRCGP and it is a computer marked paper testing APPLICATION of knowledge in a general practice setting.
The exam is 200 questions over 3 hours 10 minutes and is held at a Pearson Vue test centre. The pass mark is usually around 70% and just over two thirds of those sitting the paper pass at any one sitting.
80% of questions are clinical medicine, 10% are organizational and 10% are evidence interpretation (statistics)
Preparing to sit the AKT – How do I pass?
A – Prepare well
- Study habits
The RCGP Curriculum contains advice on preparation in each topic area and also examples of how the topic may be tested in the AKT. It’s a large document but may help when focusing in on weaker areas. (super condensed guides really helpful)
As with preparation for all exams be organized and focus on a specific area to achieve at each revision session. Studying regularly for an hour each day will achieve more than longer periods of time. Sitting and doing 100 questions will not help you to be focused.
- Focus on your weaker areas – “The Nightmare List”
The curriculum is vast and to cover it all methodically would be impossible in a limited time. In order to look at where to focus your attention its worth constructing a nightmare list, which will differ between DiTs due to previous experience. When studying we will often cover topics we are strongest in first as we feel more comfortable with these.
It helps instead to write a list of your weaker areas and focus on these as you will add more value this way. Educational theory suggests read, recall and then test is an effective way of retaining what you have learned.
Read - read through guidance and resources, watch video etc.
Recall – get a blank piece of paper and write everything you have read and learned. This is a good way of storing and making meaning of the learning.
Test – Have a think about how what you have read may be tested. Write some questions.
Eg COPD questions could include next steps for treatment or treatment of acute episodes.
Activity – What would the top 5 nightmare subjects be for you, and how would you approach learning these?
- “Will definitely come up List”
This should probably be called the “you are daft if you don’t list”!
It includes chronic diseases and common conditions, diabetes, hypertension, depression. Make sure you are up to date on these areas as there will be a significant number of questions on them.
You must know about common medications which require monitoring.
Examiners love a photo of a skin condition, diagram or retinal fundus. Remember however this is an applied knowledge test so for example a photo of molluscum will be accompanied by a scenario such as: -
A seven-year-old child is brought in by their mother with a number of lesions on their upper leg which look like the picture below…. What is the most appropriate management for this condition?
- Feedback list
The RCGP publishes a summary report on their website after each exam. The reports give information on areas that DiTs struggled with and how revision in these areas may be approached. My advice is to look at the last 3 or 4 summaries and ensure that you are confident in these areas at they will be tested again.
The RCGP has also produced a summary of the last 5 years feedback with suggested areas to focus on.
- Use the most appropriate resources (see resources document)
Helpful resources include:
- BNF – good summaries at the beginning of the book and start of each chapter. Good also for looking at drug monitoring (on every exam) and common indications and contraindications. Online version also.
- Essential knowledge updates and challenges – RCGP. Guidelines and questions written in the style of AKT.
- NICE CKS
- Guidelinesinpractice.co.uk – easy free access to up to date guidance, and there’s an app for your phone.
- Fourteen fish – great for those who need to learn smartly with detailed video summaries in common areas. Most videos are less than 1 hour but you do need to focus as lots of detail. Mock tests to check readiness to sit. Not intended to be used as a question bank.
- PUNs and DENs in daily practice.
- DVLA, GMC good medical practice.
- RCGP InnovAiT.
- CQC mythbusters – excellent resource for practice management
- The best resource - Preparing in practice!
If you reflected more deeply on one or two of the activities you do each day then you would naturally populate your working knowledge and be able to apply things to everyday practice. Some examples.
Thyroid blood result – TSH high, T4 low. The initial management should be straightforward, but
- Would your starting dose of thyroxine be the same for each patient?
- What if the T4 was normal and the TSH high?
- Do you know when to check autoantibodies and their relevance?
- Do you know management of hyperthyroidism?
- How would you explain hypothyroidism to a patient including treatment and ongoing management, and prescription exemption (who says you can’t revise for RCAat the same time?)
Request for repeat salbutamol inhaler in a child with asthma.
- Look at other medication and what step of asthma management they are on.
- What would be the next step in management?
- How would this differ in adults?
- Do you know what QOF requirements are for asthmatics?
- How would you explain management of an acute attack of asthma in a child to their parent? (RCA prep)
- Moving on from this what do you know about smoking cessation, what interventions work and how would you approach a change management conversation with a patient…. Or a parent!
Consultation with a woman in their 20s requesting emergency contraception
- What options should you offer and what is the guidance on prescribing each?
- Are there any other medications or conditions that would affect your decision?
- What if the patient was 15?
Activity – During your next surgery pick 2 patients you see who have a chronic disease. (this may not be the reason why they have attended). What are the guidelines for management of these conditions and what is the next step in management? How would you explain this patient’s condition to them?
B – Do not sweat the stats
Statistics is an area that really worries DiTs but interestingly they consistently perform higher in this part than the other 2 areas of the exam. The focus has changed recently in this area and it is now called data and evidence interpretation. The professional topic guide on the curriculum “Evidence based practice, research and sharing knowledge” makes it clear what you need to know.
There is a also good section on the RCGP website under “How to prepare” and I would recommend reading this. There are RCGP AKT preparation courses run in the North West and some also specifically for statistics. I wouldn’t get too hung up on this as it is only 10% of the exam and most DiTs do pretty well in this section.
Activity - Asking the practice manager for documentation which is sent to practices by CCGs and medicines management, what does it tell you? Look at a couple of recent journal papers and how they may be interpreted.
C – Organisational questions
There is a good summary of resources within the RCGP curriculum professional Topic Guides on leadership and management discussing areas you should be familiar with for the AKT.
There is a 14 fish video on practice management and also one on DVLA/fitness to fly.
D – Perfect your technique
Most DiTs don’t pass or fail by a large margin. In any cohort about 15% are within 5% below the pass mark. Good technique is worth marks and it may be worth reflecting on how you approach the paper.
- Understanding the computer system. When you arrive at the test centre, before the exam starts you will work through a tutorial which explains how to navigate the computer. This video tutorial is also available on the RCGP website in the AKT section. It may help to view the tutorial a few days before, when you are not as nervous, then on the day it is just revision.
- Speed. The paper is time limited and you have about 1 minute per question. You need to find a balance between taking time to read things properly and not dwelling too long on individual questions. It is also worth taking time the first time you work through the paper because reviewing later is unlikely to make much difference to your score (see “reviewing” below). Keep an eye on the clock, if you are about 70 questions in after the first hour you are doing fine. You MUST answer all questions as you go along as you may not have much time at the end.
- Individual questions. Read the question and then reread the question. I can’t stress this enough. I have examples when doing AKT workshops of whole rooms full of people who went for the wrong answer because they read the question quickly and missed something important. It is also worth using the cover test when you are deciding on an answer (especially in single best answer questions). There is evidence that this works. Basically, read the question without looking at the answers and decide what you think the likely answer will be. If it is on the list, then that’s the answer. Reread the question to check you’ve not missed anything and mark it and move on. This also works for situations where you vaguely know the answer. Don’t mark these questions for review.
- What if you don’t know the answer. It is OK to guess as the paper is not negatively marked. Even if you do not know the answer you can probably whittle it down to a choice of a couple by working out what is definitely not correct or would not be usual actions in GP. You can then guess between 2 or 3. Don’t mark these for review, because you will spend time later that is unlikely to increase your score.
- Calculations. There will be a couple of calculation questions on the paper, often drug dose questions. The maths will be simple and you shouldn’t need the calculator provided. If you are unsure then put an answer and tick for review so you can check again later.
- According to NICE guidance…. Don’t be distracted by these types of questions, they are basically asking what you would do in a general practice scenario.
- Most likely, most appropriate – These are questions which test your ability to come up with a list of differential diagnoses taking into account all information presented.
For example, the most appropriate management of a 25-year-old man with dyspepsia which persists after 1 month of PPI and lifestyle modification is h pylori testing, whereas in a 70-year-old man it will be different.
- It may be that the correct answer is to do nothing or monitor the patient especially with minor blood result abnormalities.
- Reviewing. You can mark questions to return to later and get the opportunity to reflect on your answer and change it. This is great if you are a positive reviewer as you will change more wrong answers to right ones, but a disaster if you are a negative reviewer. (There is some evidence that those with dyslexia may be more positive reviewers as the additional time helps them to process the question better.) Most people are neutral reviewers and therefore time spent looking at these questions again makes little difference, so you don’t need to leave much time for reviewing at the end. The best advice I can give you is to only review those questions where you feel a bit more time would be helpful or to check a calculation, and to answer all questions as you go along. If you do not know you can find out what kind of reviewer you are by doing a fourteen fish mock test under exam conditions.
E – Do not rely on Question Banks
Most DiTs subscribe to a question bank. I don’t think you need to, but I would be naïve to think I could persuade you of this. Suffice it to say that question banks are not usually written by GPs and doing lots of questions as your only method of revision can provide a false sense of security. In fact, some DiTs who fail have been achieving high scores on question banks and have completed 1000s of questions.
They may be of use when you have done the learning as a method of testing to highlight areas of deficiency or to work on speed and technique.
Interestingly some DiTs who have passed the AKT say to us that question banks were their main method of revision. It is likely that they are quite self-regulated and have been learning as they go along.
Trainers feedback essential
The more time you spend in general practice before sitting the better prepared you will be. Research has shown that GP trainers who sit the exam with no preparation pass. This is thought to be due to experience of making decisions in and a working knowledge of general practice. They get different questions correct to DiTs as they have not had the time to revise specific guidance and targets. Some recent research where trainers had the chance to study alongside their DiTs in advance of the exam showed trainers got a better mark than their DiTs demonstrating time in GP being of real value.
HENW AKT support
HENW run regular booster sessions for the AKT which are currently run on line. Ask your local educator team who to contact for this.
HENW also run bespoke support for DiTs who have not passed the exam having sat it. This is called SOX and you will be invited to this if you are in this group. I would strongly recommend you take the opportunity when it is offered.
Preparation for exam day
There are a number of Pearson Vue test centres so it is really important you check where you are going and know the route. Parking is notoriously difficult at most venues so make sure you are prepared. Set off super early as you will likely be travelling at a busy time then you can go for a short walk when you get there rather than being late and stressed. If you are even a few minutes late you will not be allowed into the exam and your months of preparation will be wasted.
You will need to take ID to the centre. Check on the RCGP website for the most up to date guidance on this as if your ID is not sufficient you will not be allowed to sit the exam.
Get some sleep the night before, your learning has been done already. Have a good breakfast and let a relative or your partner take the children to school. You need to be calm.
I didn’t pass the exam – why might this be?
About 30% of those sitting the exam will not pass. It is really important that you are honest with yourself about the reasons and then they can be addressed.
- Taking the exam at the wrong time. It is so important you sit this exam when you are ready. See advice above on taking at the right time.
- Insufficient preparation. We know GPs pass this exam due to having a working knowledge and experience of GP. GP DiTs have not had the time in GP to get to this point so will need to spend some time learning. A minimum of 3 months of an hour a day of smart learning is felt to be sufficient time. It is really important that you are self-regulated focusing on your weaker areas and also guidelines for common conditions (see “3 lists” above)
- Doing lots of questions. It is not uncommon for DiTs to be scoring highly on common question banks sometimes over 80% and then to fail the AKT. This is because the questions are not written by AKT examiners and are not representative of what comes up in the exam. Also, educational theory points out that effective learning should take place before any testing.
- Poor technique. This includes not finishing the exam and not reading the questions. Negative reviewing can also be an issue. Some DiTs are confused by some of the wording in the question eg, most likely…., single best….
- “I’ll just take it and see how I get on”. I’m not sure why anyone would do this, as the exam costs almost £500! If you are self-regulated and learn as you go along you may pass, but if you don’t the effect of failure is damaging.
- Unwell Concentrating for more than 3 hours is difficult at the best of times, even more so when you are not well. You should not sit the exam if you are unwell. Please speak to your ES or Programme director and refer the RCGP website for advice.
- Dyslexia More than 5% of the population are thought to have dyslexia. If you fail the exam you should perform a dyslexia screen (using the tool recommended by the lead employer), especially if you have failed more than once and your mark isn’t increasing. If your screening is positive speak to your Programme Director and they will refer for a formal assessment. There is evidence that when dyslexia is diagnosed, the additional time allowed in the exam leads to an increased score. For dyslexia screening, please contact the Lead Employer:https://leademployer.sthk.nhs.uk/disability-support
AKT support including AKT SOX
Current AKT DiT support provided by HENW includes
- AKT virtual sessions provided to all DiTs who wish to attend. These are usually timetabled 3 months before each AKT sitting
- Trainer and educator sessions delivered at conferences and trainers groups.
- 14 fish package provided from study leave budget.
- Regional teaching sessions on AKT, run through special education programmes.
- AKT SOX
This is a programme developed by HENW in collaboration with East of England deanery.
We know that a bespoke individualised approach such as has been seen with the RCASOX process has seen significant improvement in performance and pass rates.(Video) "Corporate Wealth or Public Health?" | Robert Lustig
The current AKT sessions run for all DiTs have shown improvement in scores and it is hoped that this individualised approach will further help performance in this exam.
The AKT SOX model will support both the DiT and the trainer in improving outcomes in the exam. The aim is that this will integrate into the differential attainment work being done regionally.