MRCGP
Applied Knowledge Test
AKT Background
The AKT:
• Is a summative assessment of the knowledge base that
underpins independent UK general practice.
• Tests the application of this knowledge
• Tests the critical interpretation of information
• Is mapped to the Curriculum
Each question is intended to explore a topic of
which an ordinary GP in the UK could be expected
to have a working knowledge
Format
• A 3-hour, 200-item multiple-choice test
• No multiple true/false questions
• No negative marking
• Delivered on a computer terminal at an
invigilated test centre
• Offered three times a year:
Jan/Feb, April/May, Oct/Nov.
Rules
• Only trainees in the ST2 and ST3 stages of
training will be eligible to take the AKT
• A maximum number of four attempts will be
permissible in the AKT
Jan 2013
The pass mark for AKT 17 was set at 132 with pass rates as
below:
Candidates (numbers) pass rate
• All candidates (1248) 68.7%
• ST2 first-time takers (755) 79.6%
• ST3 first-time takers (115) 71.3%
Asthma guidelines, antibiotic guidelines, non-medical
prescribers and diagnosis of DM were all done poorly
Common Reference Material
• GP Curriculum
• Content guide for the AKT
• BNF
• GMC Good Medical Practice
• RCGP Essential Knowledge Updates
• NICE guidelines
• SIGN guidelines
• BMJ Review articles & original papers
• BJGP
• Cochrane
GP Curriculum + AKT Content Guide
• The AKT Content guide is a new learning resource which is
designed to be used in conjunction with the curriculum
How to use the Content Guide
• Don’t be put off by the lengthy list of topics!
• Do use the guide as a needs assessment tool
• In particular, carefully review the sections:
• Organisational –including administrative, statutory, ethical
and regulatory frameworks
• Evidence interpretation – including research, statistics
and epidemiology
AKT content
80% of questions
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Core clinical medicine and its application to problem
solving in a general practice context
10% of questions
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Critical appraisal and evidence based clinical practice
10% of questions
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Ethical and legal issues as well as the organisational
structures that support UK general practice
Clinical Medicine
• Common, low impact – e.g. sore throat, otitis
media, impetigo
• Rare, high impact – e.g. child abuse, meningitis,
phaeochromocytoma
• Topical – e.g. MRSA, Type 2 diabetes management
Critical appraisal and evidence-based clinical
practice
• Understanding the principles of audit and its
application in assessing the quality of care
• Understanding the application of critical
appraisal skills which will be tested in a number
of formats including:
• the interpretation of research data
• the understanding of terms used in both statistics and
evidence based medicine
• understanding epidemiology relevant to general
practice
Ethical, Legal & Organisational
• NHS organisation
• Legal aspects e.g. DVLA
• Medical certification e.g. death certificates
• Professional regulation, e.g. GMC
• Business aspects e.g. GP contract
• Prescribing e.g. controlled drugs
• Appropriate use of resources e.g. drugs
• Health & Safety e.g. needle stick injury
• Social services e.g. safeguarding
• Ethical e.g. mental capacity, consent
Question Formats
• Single Best Answer (SBA)
• Extended Matching Questions (EMQ)
• Table/Algorithm
• Picture/Video Format
• Drag and drop
• Hotspot images
• Data interpretation
• Free text
• Rank ordering
Single Best Answer (SBA)
• “According to national guidelines” means
recommended by nationally accepted guidelines
or the BNF, not local practice
• Often uses a clinical scenario
• Only ONE answer is correct
• Other options may be plausible but not “MOST
LIKELY”
SBA example: Respiratory disease
A 17-year-old student suddenly develops chest pain
and dyspnoea after a morning swim. There is
hyper-resonance and decreased breath sounds on
the right side.
Which is the SINGLE MOST likely diagnosis?
Select ONE option only.
A. Asthma
B. Pneumothorax
C. Pulmonary embolus
D. Left ventricular failure
E. Pulmonary haemorrhage
Extended matching questions (EMQ)
• These questions have a list of possible options
• There will usually be 2 or more scenarios
• Choose the MOST appropriate option that BEST matches each
given scenario
• Each option can be used once, more than once, or not at all.
EMQ example: Double vision
A Berry aneurysm
E Ischaemic stroke
B Cerebral glioma
F Multiple sclerosis
C Drug induced
G Myasthenia gravis
D Graves’ disease
For the patient described, select the SINGLE MOST
likely diagnosis from the list of options.
1. A 35-year-old man who is a non-smoker, suddenly
develops a severe headache and double vision. His
right pupil is fixed and dilated.
EMQ example: Double vision
A Berry aneurysm
E Ischaemic stroke
B Cerebral glioma
F Multiple sclerosis
C Drug induced
G Myasthenia gravis
D Graves’ disease
For the patient described, select the SINGLE MOST
likely diagnosis from the list of options.
2. A 48-year-old woman has transitory double vision
towards the end of most days. She smokes 10
cigarettes/day. She has vitiligo and hypothyroidism.
Algorithm example:
Medical management of menorrhagia
Nonhormonal
1 _______
2 _______
Hormonal
therapy
Combined
oral
contraceptive
pill
3 _______
For each of the numbered gaps above, select ONE option from the list to complete the algorithm, based on
current evidence.
Each option may be used once, more than once or not at all.
A
Cyclical norethisterone
B
Copper-bearing intra-uterine device
C
Inert intra-uterine device
D
Levonorgestrel releasing intra-uterine system
E
Medroxyprogesterone acetate
F
Mefenamic acid
G
Nonoxinol ‘9’
H
Tibolone
I
Tranexamic acid
Picture Format example:
Skin disease
• A 32-year-old man has
noticed painless nonitchy patches of hair
loss on his beard area
and scalp.
Picture Format example:
Skin disease
Which is the SINGLE MOST likely diagnosis?
Select ONE option only.
A
B
C
D
E
Ref: Dermnet.com
Alopecia areata
Eczema
Lichen sclerosis
Tinea infection
Vitiligo
Data Interpretation
• Interpretation of data, e.g. for groups of patients
with chronic conditions
• Interpretation of research and audit results
• Understanding and application of common
statistical terms, e.g. sensitivity and number
needed to treat (NNT)
Data Interpretation example
• The summary findings
of a systematic review
which included six
separate studies are
shown opposite.
Ref: BMJ 2007;335:473
Data Interpretation example
Which SINGLE study suggests the WEAKEST
association between increased whole grain
intake and a risk of type 2 diabetes?
Select ONE option only.
A Fung
B Meyer
C Montonen
D NHS1
E Van Dam
Free text questions
• Require the candidate to generate the correct
answer without a list of options to choose from e.g:
• dose calculation
• name of first-line medication
• Eliminates guessing from a list of answers
• All answers are screened manually to check for
acceptable misspellings
Free text example
Which SINGLE vitamin is administered to reverse
the anticoagulant effect of warfarin?
Give ONE answer only
Vitamin _____
Scoring
• All question formats have equal weighting
• Each correctly answered question is awarded one
mark
• Total score on the paper is the number of correct
answers given
• No negative marking – it is important to answer all
the questions
Feedback to candidates
• The following feedback will be provided to every
candidate with their result
• Their overall score
• The pass mark
• Their performance in each of the 3 main subject areas
Further preparation
• Small revision groups to share the workload
of reviewing national guidance, BNF chapters
etc
• Learn from clinical experience – check the
guidelines and references
• Exam website feedback (summary reports
published for every AKT sitting)
• Exam website sample material
• RCGP website – Essential Knowledge
Updates and Challenges
Advice from successful trainees:
• Samples of AKT questions are provided every month, linked to the curriculum
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coverage, in the InnovAiT Journal provided free to AITs by the RCGP.
PEP (RCGP) AKT style questions linked to curriculum statements and
explanations
PassMedicine Course http://www.passmedicine.com/akt/index.php Large
question bank with feedback to place your mark in tests against others
applying to AKT, plus teaching notes. Can set yourself practice exams and
helps you get used to thinking quickly
PasTest offer both online courses and revision books
NB GP Update Course http://www.nbmedical.co.uk/ One day course. Review
of recent developments. Useful course book provided.
NICE Guidelines- the exam is very up to date!
RCGP Essential Knowledge Updates
Dot medic
On Examination (BMA)
EBM & Stats & Critical Appraisal
T D. Sackett “Evidence Based Medicine” Churchill
Livingstone
Greenhalgh articles or book “How to read a paper” 1997
BMJ Books
How to read a paper: A series in the British Medical Journal
on database searching and article appraisal adapted from
the book. BMJ 1997
Medical Statistics Made Easy- book
Slow readers/ some IMGs
• www.irisreading.com
• If you think reading speed is slower than average this
website can help to speed it up
Practice Management
• Oxford Handbook of General Practice
Risk of hip fracture
• A cohort study is conducted to evaluate the relationship between dietary calcium supplementation and
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the occurrence of hip fractures in post-menopausal women.
The study examines the hip fracture rate in 100 women taking calcium supplements and 100 women
taking placebo over three years.
Over the three year period, five women have hip fractures in the calcium group and ten women have
hip fractures in the placebo group. The 95% confidence interval is 0.18 to 1.4.
What is the RISK of a hip fracture in the TREATED group? Select ONE option only.
A 0.01
B 0.05
C 0.1
D 0.5
E 1.0
What is the RISK RATIO? Select ONE option only.
A 0.01
B 0.05
C 0.1
D 0.5
E 1.0
Child growth
• An eight-month-old baby girl’s routine measurements have fallen from the 50th
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centile growth line to below the 25th centile growth line over the past three
months. She has a history of minor respiratory infections and recurrent
gastroenteritis.
Which is the SINGLE MOST appropriate INITIAL investigation? Select
ONE option only.
A Chromosome analysis
B Glucose-6-phosphate dehydrogenase level
C Jejunal biopsy
D Sweat test
E Thyroid function test
Childhood illness
A seven-year-old girl has a fever associated with a sore throat and loss of
appetite. She has small red ulcers in her mouth and itchy spots on the palms of
her hands and soles of her feet.
Which is the SINGLE MOST likely virus causing her symptoms? Select
ONE option only.
• A Coxsackie A
• B Herpes simplex
• C Measles
• D Parvo-virus B19
• E Varicella-zoster
Epidemiological measures
• A primary care organisation requires information to estimate the typical
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duration of hospice services required for patients with pancreatic
cancer.
Which is the SINGLE MOST appropriate epidemiological measure
for the situation described above? Select ONE option only.
A Case fatality
B Incidence
C Median survival
D Mortality
E Prevalence
Epidemiological measures
• Which is the SINGLE MOST appropriate epidemiological measure to
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estimate the rate at which the new cases of papilloma virus infection
occur among students on a college campus? Select ONE option only.
A Case fatality
B Incidence
C Median survival
D Mortality
E Prevalence
Medical standards of fitness to drive
• A 65-year-old retired man had a routine coronary artery angioplasty and stent
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insertion one week ago. He is now well and asymptomatic. He asks you for
advice about driving.
According to DVLA guidance, which is the SINGLE MOST appropriate
advice with regard to driving? Select ONE option only.
A He may resume drive immediately
B He may resume driving after a further week
C He may resume driving one month after the angioplasty
D He may resume driving six months after the angioplasty
E He must inform the DVLA and await their decision before resuming driving
Skin rash
Skin rash
• A 34-year-old woman has developed this rash on her buttock over the
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past two days. It is sore to touch and she has no rash elsewhere. She
says this has happened on at least three previous occasions and the
rash is always in the same place.
Which is the SINGLE MOST likely diagnosis? Select ONE option
only.
A Chickenpox
B Coxsackie virus infection
C Dermatitis herpetiformis
D Herpes simplex
E Herpes zoster
Skin rash
Skin rash
• A 45-year-old man asks you to check this mole which is on
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his back and catches on his clothing. It has been present
for many years and has not changed in appearance
Which is the SINGLE MOST likely diagnosis? Select
ONE option only.
A Benign pigmented naevus
B Blue naevus
C Malignant melanoma
D Pyogenic granuloma
E Seborrhoeic keratosis
Adverse drug reaction
• A 55-year-old man is diagnosed with ischaemic heart disease,
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hypertension and hyperlipidaemia. Shortly after starting treatment, he
develops wheezing at night and on exertion.
Which is the SINGLE MOST likely drug to have caused these
symptoms? Select ONE option only.
A Aspirin
B Bendroflumethiazide
C Bezafibrate
D Enalapril
E Simvastatin
The investigation of infertility
• A 25-year-old woman has been infertile for three years. She has had recurrent pelvic pain due to
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endometriosis. Investigations in primary care are reported as follows:
Full blood count – normal
Thyroid function – normal
Sex hormone profile - normal
Rubella serology – immune
Day 21 progesterone – normal
Chlamydia swab – negative
Her partner’s semen analysis is reported as normal.
A referral to secondary care is agreed and she asks what is likely to happen next.
According to current guidelines, which is the SINGLE MOST appropriate NEXT investigation?
Select ONE option only.
A Cervical cytology
B Hysterosalpingogram
C Hysteroscopy
D Laparoscopy
E Post-coital test
Contraception
• Which ONE of the following is an ABSOLUTE
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contraindication to the use of medroxyprogesterone
acetate as a contraceptive? Select ONE option only.
A Diabetes mellitus
B Breast cancer diagnosed in the previous five years
C Past history of ovarian cysts
D Previous ectopic pregnancy
E Smoking
Breast disease
A 28-year-old woman has asymmetric nodularity of the right breast. Her
mother and aunt have been treated for breast cancer.
According to current national guidance, which is the SINGLE MOST
appropriate NEXT management option? Select ONE option only
• A Arrange mammography
• B Arrange ultrasound
• C Reassure
• D Refer to breast clinic
• E Review in six weeks
Study design
• A research study is proposed to reach a summary conclusion regarding
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the results of several investigations of exposure to environmental
tobacco smoke and risk of lung cancer.
Which is the SINGLE MOST appropriate study design? Select
ONE option only.
A Case control study
B Cohort study
C Correlation study
D Descriptive study
E Meta-analysis
Research methodologies
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Case control study
B
Case report
C
Cohort study
D
Cross sectional survey
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Randomised controlled trial
For each of the investigations outlined below, select the SINGLE MOST
appropriate research methodology from the list of options above. Each option
may be used once, more than once or not at all.
1
To identify a new adverse drug reaction
2
To demonstrate the value of a screening test to pick up prostate cancer at a
pre-symptomatic stage
3
To determine the efficacy a new drug treatment for hypertension
4
To assess the prognosis of prostate cancer picked up at an early stage
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To assess whether high blood pressure can get better over time
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To assess whether helicobacter pylori causes gastric cancer
Evaluation of tinnitus treatment
50 patients with severe tinnitus of at least 1 year’s duration were given either an active device or
placebo device. After one week they were examined subjectively on their response and objectively by a
pure tone audiogram, tinnitus pitch and loudness matching.
Improved Total
Subjective Active
15
30
Placebo
2
20
Objective Active
12
30
Placebo
4
20
For each of the numbered gaps in the critique below interpreting the results from the table, choose ONE
from the following list which best completes the sense, and mark the corresponding lozenge on your
answer sheet.
For the subjective measure the number needed to treat (NNT) was ___ and for the objective measure
the NNT was ___ .
A
B
C
D
2.5
3.3
4
5
F
G
H
15
100
1000
Screening for ovarian carcinoma
OVARIAN CARCINOMA
Test result positive
Test result negative
Condition present
100
75
Condition absent
150
175
A new radiological scanning test for the early detection of ovarian carcinoma was used to evaluate 500 patients. The results were as
above.
Now look at this critique, interpreting the results from the table.
This test has a sensitivity of (17) ………………… with a specificity of (18) …………………… The positive predictive value is (19)
……………….. which reflects the (20) …………………… of the disease. The negative predictive value is (21) ……………. The
results indicate this is not a (22) ………… screening test.
For each of the numbered gaps in the critique choose ONE ANSWER from the following list which best completes the
sense, and mark the corresponding lozenge on your answer sheet.
A
100 / (100+75)
B
100 / (100+150)
C
150 / (100+150)
D
150 / (150+175)
E
175 / (75+175)
F
175 / (150 + 175)
G
Incidence
H
Precise
I
Prevalence
J
Reliable