ST1 Induction Day
The MAC
Thursday 24.9.2015
Talk to your neighbour for a couple of
minutes…
• If you were suddenly to develop an illness that
caused you to have regular contact with your
GP, what sort of hurdles would you want to
know that your GP had jumped, so that you
could feel confidence in his / her ability to
look after you competently and in an up-todate manner?
Exams in training years
• AKT – often done end of ST2 or early ST3
• CSA – usually done in ST3
• AKT – taken at Pearson Vue centre
• CSA – taken at RCGP
Context of exams
• Miller’s Pyramid
The 3rd exam….
• Or “the coursework”
• WBA – the EP as a demonstration of
competency and readiness for independent
practice
• Still needs to be deemed satisfactory for
progression every 6m, for transition at end of
each ST year, and for CCT
Fees for exams
• AKT – £489
• CSA - £1642
• WPBA – the price of your time!
AKT – applied knowledge test
• The Applied Knowledge Test is a summative
assessment of the knowledge base that
underpins independent general practice in the
United Kingdom within the context of the
National Health Service.
• Trainees who pass this assessment will have
demonstrated their competence in applying
knowledge at a level which is sufficiently high
for independent practice.
What is the AKT?
• The test takes the form of a three hour computerbased test consisting of 200 question items.
• It is delivered three times a year at 150 Pearson VUE
professional testing centres across the UK.
• Approximately 80% of question items will be on clinical
medicine, 10% on critical appraisal and evidence based
clinical practice and 10% on health informatics and
administrative issues.
• All questions address important issues relating to UK
general practice and focus mainly on higher order
problem solving rather than just the simple recall of
basic facts.
Recent changes to AKT – from Oct
2014
• 1. Professor John Norcini, who conducted a review of
the AKT, suggested that the RCGP should consider
increasing the amount of time candidates have
available to complete the AKT. Although there is no
evidence that time constraints in the AKT contribute in
any way to the differential pass rates, they might pose
more of a challenge for those candidates who are less
proficient in the English language.
• The GMC gave permission to increase the duration of
the AKT by 10 minutes on these grounds, and this
came into effect in the AKT in October 2014.
2nd change
• 2. In addition to the extra time, an on-screen
calculator is now available. This is being
provided at the request of candidates, but any
calculation within the AKT will require only
simple basic arithmetic, and most candidates
will not need to use the calculator.
• The additional time provided for the AKT will
not change the standard required to achieve a
pass in the AKT.
When can you take the AKT?
• The AKT can be taken during or after the ST2
stage of GP training.
• A maximum number of four attempts will be
permitted for those who have entered GP
Specialty Training on or after 1 August 2010.
Resources
• Online question bank (e.g. Pass medicine,
Onexamination)
• AKT courses e.g. Emedica
• AKT question books
• Guidelines
• BNF
• Statistics books
PDF on RCGP website
• http://www.rcgp.org.uk/trainingexams/mrcgp-exams-overview
Knowledge of basic statistical
terminology including the following:
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Absolute risk reduction (ARR) Meta-analysis
Association Mode
Bayesian probability Negative predictive value
(NPV)
Bias Nondirective interview
Blinding Null hypothesis
Case control Number needed to harm (NNH)
Case fatality Number needed to treat (NNT)
Cohort Odds & Odds Ratio
Confidence intervals Positive predictive value (PPV)
Confounding Prevalence
47AKT CONTENT GUIDE
August 2014
Correlation Probability
Crossover p-values
Cross-sectional QALY (quality adjusted life year)
DALY (disability adjusted life year) Randomised
controlled trial (RCT)
Data types (categorical, ordinal, continuous) Range
Delphi Relative risk reduction (RR)
Discrimination Reliability
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Distributions (normal and non-parametric) Risk
ratio
Ethnography Risk reduction (RR)
Event rate Sampling
Focus group Sensitivity
Generalisability Specificity
Grounded theory Standard deviation (SD)
Hazard Ratio Standardised mortality rates and ratios
Incidence Systematic review
Inclusion/exclusion criteria Trends
Inductive reasoning Triangulation
Likelihood ratios Type 1 and 2 errors
Mean Validity
Median
Basic inferential statistical concepts to enable
clinical interpretation of results from common
statistical tests used for parametric data e.g:
o Bayesian probability
[Candidates would not be expected to be able to
conduct these tests.]
o t-tests, analysis of variance, multiple regression)
and non-parametric data (e.g. chi
squared, Mann-Whitney U)
Research design
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Qualitative research and quantitative research:
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The hierarchy of design and the advantages and disadvantages of study designs
including:
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Differences in forms of research and when each is appropriate
Techniques such as pilot studies, questionnaire design, field observations,
interviews, focus groups and analysis of transcripts of narrative material,
ethnography and observation, action research, case study; consensus methods such
as Delphi or nominal groups
systematic reviews and meta-analysis;
experimental: randomised controlled double blind
quasi-experimental: non-randomised control group;
observational: cohort (prospective, retrospective), case-control, cross-sectional
The most appropriate research design to examine the hypothesis proposed in
prospective and retrospective studies:
– the limitations and strengths of research methodologies
– knowledge of the “hierarchy of evidence” ranging from case reports through case control and
cohort studies to randomised controlled trials and systematic reviews and meta-analyses
Lethargy
A 50-year-old man has become increasingly tired and lethargic
over the past six months and has developed erectile
dysfunction. His wife comments that he looks tanned even
in the winter months. His serum ferritin and transferrin
levels are significantly raised, but his haemoglobin is
normal.
Which is the SINGLE MOST likely diagnosis? Select ONE option
only.
A. Addison’s disease
B. Chronic active hepatitis
C. Diabetes mellitus
D. Haemochromatosis
E. Hypothyroidism
Visual disturbance
A 20-year-old woman notices bright lines of light in both
visual fields followed shortly afterwards by a partial loss of
her vision. Her visual symptoms resolve after one hour but
she has slight nausea.
Which is the SINGLE MOST likely diagnosis? Select ONE option
only.
A. Acute glaucoma
B. Migraine
C. Optic neuritis
D. Retinal detachment
E. Vitreous detachment
Drug dose calculation
A three-year-old girl has recurrent urinary tract infections
and the paediatricianhas recommended trimethoprim
prophylaxis at a dose of 2 mg/kg at night. She weighs
12.5 kg and trimethoprim suspension is available as 50
mg/5mls.
What volume of suspension (in mls) should the child’s
mother give her every evening?
Type your answer in the following text box. Use figures
NOT words. Percentages and fractions are NOT
acceptable.
Disorders of glucose metabolism
A.
B.
C.
D.
E.
F.
G.
H.
Gestational diabetes
Impaired fasting glycaemia
Impaired glucose tolerance
Maturity Onset Diabetes of the Young (MODY)
Normal
Prediabetes
Type 1 diabetes
Type 2 diabetes
For the patient described, select the
SINGLE MOST likely diagnosis from
the list of options.
A 47-year-old overweight woman had a
screening blood test because of her family
history of type 2 diabetes. Her result is as
follows: HbA1c 40 mmol/mol
A 15-year-old obese boy has significant
glycosuria on more than one occasion. He is
well with no symptoms. His father and brother
both have diabetes. Random blood glucose 12
mmol/L Blood ketones negative
Consent for disclosure of medical information
Which TWO of the following statements are the MOST APPROPRIATE
considerations when providing information to third parties such as
insurers?
Select TWO options only.
A.
B.
C.
Disclose all information written in the medical record
Do not disclose the content of the report to your patient
Ensure the patient has sufficient information about the likely
consequences of disclosure
D. Relevant information can be withheld under certain circumstances
E. Use the proforma provided by the third party
F. Patient consent can be automatically assumed by receipt of the
insurers’ request
Statistics from April 2015 – 1487
candidates sat AKT
Scores in AKT 24 ranged from 89 to 184 out of 200
questions with a mean overall score of 72.9%.
The mean scores by subject area were:
– ‘Clinical medicine’ 74.0% (160 questions)
– ‘Evidence interpretation’ 76.5% (20 questions)
– ‘Organisational’ 60% (20 questions)
The pass mark was set at 134 - pass rates as below:
All Candidates
1487
74.4%
ST2 First time takers
ST3 First time takers
1058
82
81%
74.4%
Our record
Here in S Bham we have some very high
achievers on the record
E.g. we gained the top marks (>90%) in AKT at
the last 2 sessions
No pressure!
CSA – Clinical Skills Assessment
• The CSA is a summative assessment of a doctor’s
ability to integrate and apply clinical,
professional, communication and practical skills
appropriate for general practice.
• Simulating a typical NHS surgery clinic the CSA
assesses a range of scenarios from general
practice relevant to most parts of the curriculum
which can also target particular aspects of clinical
care and expertise.
RCGP – 30 Euston Square
Inside…..
CSA – type of OSCE
• Morning or afternoon exam
• 13 x 10mins consultations, with a break
between 7 & 8
• Role player and examiner enter room,
candidate stays in room
• May be a telephone triage or home visit
scenario
CSA room
Equipment
• You should bring your doctor’s bag containing the usual diagnostic
equipment with you, including:
• BNF
• BNF for children
• Stethoscope
• Ophthalmoscope
• Auroscope
• Thermometer
• Patella hammer
• Tape measure
• Peak flow meter and disposable mouthpieces (N.B. These must be EU
standard)
• Please note that there is no need to bring a sphygmomanometer
CSA - marking
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Marked by 13 different examiners
Marked in 3 domains of equal weighting:
Data gathering
Clinical management
Interpersonal skills
Feedback given, and breakdown of marks for
scenarios
Resources for CSA
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Books of case scenarios
CSA cards
Joint surgeries / video analysis w trainer
Courses
Feedback from COTs
Practice with people who have recently
passed!
• Pennine VTS website cases
CSA May 2015: Results summary
550 candidates sat CSA examinations during eight days in May.
358 candidates were successful resulting in an overall pass
rate of 65.1%. 40.5% (223) of the candidates were sitting
the examination for the first time, the pass rate for this
particular group being 73.1%.
The mean score for the entire cohort was 77 out of 117 with
the highest mark on this occasion being 109, which was
achieved by a candidate sitting the examination for the first
time. A further 11 candidates scored 100 marks or more, 10
of whom were making a first application. Of the lowest
scoring candidates, 11 obtained overall scores of 20 marks
or more below the passing threshold for the day on which
they sat the examination, and all but two of this group
were re-sitting.
Name of Patient: John Major
Description of the patient & instructions to simulator:
• John is 56, married with two children who have now left home. He developed foot
drop 5 years ago and was diagnosed as having MS. Over the years his foot drop and
gait have become worse. He was a keen walking until this. His neurologist
recommended physio which has not helped, a leg brace which was a ‘nightmare’
(caused more trouble that it was worth) and then functional electrical stimulation but
this has been no help. He struggles to walk any distance as he has to lift his foot high
resulting in an abnormal gait. He was reading in the Daily Mail about a new medication
called ‘Wundercin’ in which a chap with MS and foot drop was transformed by this new
medication. In the article that chap was able to go back to fell walking just after three
months! It said in the Daily Mail that it had been through a number of trials, all
showing the same results.
You have booked an appt with your GP to see if you can start ‘Wundercin’.
• SH – Married, non smoker, 14 units per week of alcohol. Retired last year (early
retirement) from teaching. Frustrated but not depressed with disability.
• PMH – Foot drop & MS
• DH – none
• Allergies none
• Ideas- Wundacin might help his foot drop
• Concerns – It might not be funded in Pennine
• Expectations – GP will know something about it and might prescribe it
Name & age of patient John Major 56
Summary Card
• PMH: MS and foot drop
• DH: None
• Allergies: None
• BP/BMI/ Non smoker
Case Notes - Last few entries in records:
• Upset that FES had not helped his foot drop – rev
prn
• Patient Name: John Major
• Examination findings: Foot drop
CSA Case Marking Sheet
Case Name: John Major Case Title: The
unknown drug
Context of case
How a GP deals with a request for a drug
unknown to him
1. Data-gathering, technical and
assessment skills
Positive descriptors:
• Finds out what the patients knows about MS and the symptoms he has.
• Identifies what impact the foot drop has caused
• Explores prior treatments he has had
• Explores the content/details of the article, what was said in the article re
benefits, risks, numbers in the trial etc
• Identifies ICE: Ideas - Wundacin might help his foot drop. Concerns – it
might not be funded in Pennine. Expectations – GP will know something
about it & might prescribe it
Negative descriptors:
• Fails to explore patients knowledge and personal experience of MS
• Fails to find out what was in the article
• Fails to identify psychosocial impact of MS
• Fails to identify ICE
2.Clinical Management Skills
Positive descriptors:
• Identifies patients knowledge re ‘Wundercin’
• GP admits lack of knowledge
• Agrees on what the patient might do e.g. drop off the article/find out
more.
• Agrees with the patient what the GP might do e.g. Read the article the
patient drops off, ‘google’ the drug, phone local neurologist, speak to the
lead pharmacist etc
• Shares with the patient that the outcome may indicate that a) it may not
be available, b) the risks may out weight the benefits c) If available may
require him to see his neurologist
• Arranges to see the patient with the outcome
Negative descriptors:
• Unable to identify a suite of options
• Unable to come to a shared management plan
• Fails to safety net
3. Interpersonal skills
Positive descriptors:
• Explores ICE with sensitivity
• Establishes and maintains rapport
• Expresses sympathy for his position
• Able to come to a mutually agreed management plan.
Negative descriptors:
• Dismissive about the article
• Not sympathetic with his situation
• Failure to establish and maintain rapport
• Doctor centred approach
Other aspects …..
e.g. time keeping, consultation structure,
comment on consultation skills etc
Positive descriptors:
Negative descriptors:
Lucinda Smythe
Description of the patient & instructions to simulator:
• 17 year old. Living with mum and dad. Doing A levels and hoping to go to
University.
• Opening line – “I want to start the pill”. - In a ‘stable’ relationship for last 6/52 with
boyfriend, also 17. Not using any contraception and not used any previously.
• LMP 5/52 ago, last unprotected intercourse 3/52 ago.
• No contraindications for the pill, no previous STIs or related symptoms. Non
smoker.
• Real reason for attendance – she thinks she is pregnant – do not mention this
unless directly asked about LMP/pregnancy/concerns.
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Ideas – she might be pregnant
Concerns - she might be pregnant and if so mum will go ballistic and it will destroy
her University aspirations
Expectation – Preg test and if negative – the pill but if positive a Termination of
Pregnancy.
When other methods of contraception mentioned quickly refuse as needle phobic,
not interested in coil or having something in your arm, friend had patches, they
just fell off. Solely wanting contraceptive pill.
Lucinda Smythe - 17 year old female
Summary Card
• PMH: None
• DH: None
• Allergies: None
• BP/BMI/ ?smoking and alcohol hx: Not known (as
infrequent attender)
Case Notes - Last few entries in records:
• Jan 2006 – pain in left ear, temp – otitis media,
conservative management.
Lucinda Smythe
Examination findings:
• Pregnancy test negative
• BP 124/78
• BMI 24
Case – Lucinda Smythe
Case Title: Contraception
Context for the Case:
• Using Ideas (I might be pregnant) Concerns (If I’m
pregnant mum will go ballistic) and Expectation
(a pregnancy test and if that ok the cocp) to
explore reason for attendance
• Sharing preg test & safe sex & contraceptive
options
• Clear explanation of chosen option
Data gathering, technical and
assessment skills
Positive descriptors:
• Clear structure to consultation
• Good history, covering relevant points – sexual
hx, STIs, LMP, unprotected intercourse etc
• Using ICE to focus consultation
Negative descriptors:
• Not eliciting full history or taking sexual history
• No structure shown
• ICE not explored
Clinical Managemnent Skills
Positive descriptors:
• Gaining consent for PT
• Examination – BP, BMI
• Clear explanation , S/E, missed pills etc
• Safety netting, review dates explained
Negative descriptors:
• Starting pill without full history, examination or
exploring ICE.
• Not sharing options
• Confusing explanations, no safety netting
Interpersonal Skills
Positive descriptors:
• Emphathic and non judgemental approach
• Using ICE to find out real concern
Negative descriptors:
• Judgemental attitude
Global comments
• Positive descriptors:
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Well structured consultation, history, ICE,
examination, shared options, safety netting
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Use of leaflets to reinforce explanation
• Negative descriptors:
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Not taking full history or not finding out
real concerns.
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Starting medication inappropriately
Look at …
• http://pennine-gp-training.weebly.com/csacase-scenarios.html
WPBA
• Think of it as “the coursework”
• You don’t have to rely on memory for it, and it
is relatively easy to do well if you follow
guidance and engage with it
• A GP who knows the academic stuff but is not
a team player or does not get on well in a
practice situation is going to struggle
Any questions?