MRCGPApplied 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 2013The 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• Core clinical medicine and its application to problem

solving in a general practice context

10% of questions• Critical appraisal and evidence based clinical practice

10% of questions• 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. AsthmaB. PneumothoraxC. Pulmonary embolusD. Left ventricular failureE. 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.

A Berry aneurysm

B Cerebral glioma

C Drug induced

D Graves’ disease

E Ischaemic stroke

F Multiple sclerosis

G Myasthenia gravis

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

B Cerebral glioma

C Drug induced

D Graves’ disease

E Ischaemic stroke

F Multiple sclerosis

G Myasthenia gravis

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.

EMQ example: Double vision

Algorithm example:Medical management of menorrhagia

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 norethisteroneB Copper-bearing intra-uterine deviceC Inert intra-uterine deviceD Levonorgestrel releasing intra-uterine systemE Medroxyprogesterone acetateF Mefenamic acidG Nonoxinol ‘9’H TiboloneI Tranexamic acid

Non-hormonal

Hormonal therapy

1 _______ 2 _______ Combined oral contraceptive pill

3 _______

Picture Format example:Skin disease

• A 32-year-old man has noticed painless non-itchy 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 Alopecia areata

B Eczema

C Lichen sclerosis

D Tinea infection

E Vitiligo

Ref: Dermnet.com

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 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 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 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 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 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 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 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 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, 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

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 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 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•  • A Case control study • B Case report • C Cohort study • D Cross sectional survey • E 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 • 5 To assess whether high blood pressure can get better over time • 6 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 2.5 F 15B 3.3 G 100C 4 H 1000D 5  

Screening for ovarian carcinoma

OVARIAN CARCINOMA 

Condition present Condition absentTest result positive 100 150Test result negative 75 175

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 IncidenceH PreciseI PrevalenceJ Reliable