The MRCGP examination can seem a daunting prospect for candidates, consisting of Workplace Based Assessment, an Applied Knowledge Test (AKT) and a Clinical Skills Assessment (CSA). Success in the MRCGP is essential for a candidate to obtain a certificate of completion of training (CCT).
The AKT accounts for a third of the MRCGP examination. It requires the candidate to have a good understanding of general practice within the UK and assesses whether they would be safe to practice at a high level independently. There are three sittings each year, taking place at 150 Pearson VUE centres across the UK. A candidate can attempt the test a maximum of 4 times, at any stage during or after ST2 level. It is also possible to do as part of GP induction and refresher schemes.
The MRCGP AKT Exam Breakdown
The MRCGP AKT is a computer-based exam that lasts three hours and ten minutes, with a total of 200 questions. The breakdown of the test is as follows:
- Clinical medicine 80%
- Administration and health information 10%
- Evidence-based and critical appraisal 10%
The current overall pass rate is about 75%. The exam is not negatively marked, so it is a good idea to attempt all questions.
The MRCGP AKT Question Styles
The question format of the AKT comprises the following:
- Extended Matching Questions (EMQ)
- Single Best Answer (SBA)
- Free text
- Rank Ordering
- Picture format
- Multiple Best Answer (MBA)
- Drag and Drop
The most frequent question types that appear in the AKT at present are SBAs and EMQs.
Single Best Answer Questions
Single best answer (SBA) questions require convergent thinking and the ability to come up with a single answer to a set problem. It is relatively easy for an examiner to test higher order thinking, such as application and evaluation of knowledge in this type of question.
Standard format SBA questions usually have three parts:
- A statement or a clinical scenario that the question will be asked about
- The question itself
- The answer options, which will include one single correct answer
The answer options in an SBA will contain one single correct answer and several other distracting options. The question commonly asks for the ‘single most likely diagnosis’ or the ‘most appropriate next management step’. In many SBA questions, several of the answer options are correct, but only one will be the ‘best’ answer.
Within the statement or clinical scenario, there will be many useful clues to point you towards the correct answer. It is worthwhile highlighting or underlining these clues while reading the scenario. Most clinical scenarios will include vital signs, history points, examination findings and/or results of investigations.
Here is an example of the sort of SBA question that you might expect to encounter in the AKT, with a model answer included:
A 66-year-old man presents with a history of palpitations. Following an ECG he is diagnosed with atrial fibrillation, and you use the CHADS-VASc to assess his stroke risk. He scores 3, and you decide to commence a direct oral anticoagulant.
Which DOAC is ranked as being most effective for reducing stroke and all-cause mortality? Select ONE answer only.
Answer: A. Apixaban
The 2014 NICE guidelines leave the choice up to the clinician, and warfarin or a DOAC can be used. By comparison, the 2016 ESC guidelines recommend DOACs to be used as the first choice because of increased safety, adherence, and improved efficacy.
A November 2017 Systematic review with network meta-analysis showed that DOACs as a class are more effective, safer and reduced all-cause mortality compared to warfarin. There is no current antidote for DOACs, but research has shown that they are still safer than warfarin, even without the potential for reversibility.
Apixaban 5 mg bd was ranked as the most effective DOAC for reducing stroke and all-cause mortality and was also the safest with the lowest incidence of bleeding. The bleeding risk is still significant though, at 1-2% annum.
DOACs are also cost-effective and, despite high drug costs, they are cost-effective overall due to the reduced risk of stroke and hospitalisation.
Idarucizumab is not a DOAC; instead it is a monoclonal antibody designed for the reversal of the anticoagulant effects of dabigatran.
Extended Matching Questions:
Extended matching questions (EMQs) first appeared in medical examinations 1993 after work by Case and Swanson. They have become an increasingly popular way of testing medical students and doctors over the past few years. MCQs and SBAs have received some criticism as it has been suggested that candidates can often guess the answer via a combination of what they partially know and utilisation of clues in the question. EMQs are designed to address some of these key flaws and are a better means of assessing higher knowledge as opposed to simple factual recall.
A standard EMQ generally has four parts:
- A theme that sets the stage for the questions
- A list of options from which the questions that follow can be answered
- A lead-in that gives the candidate instructions on how to answer the questions
- The questions, usually in the form of clinical scenarios but can also be statements of facts or data that require interpretation
EMQs generally require a greater knowledge base to answer all the parts than an MCQ or SBA would require. Distracters are often included to attempt to increase the complexity of the question and to help discriminate the better candidates. The difficulty is further increased by the fact that the same answer can be used more than once, increasing the number of potential answers for each part and removing the ability of the candidate to exclude options by a process of elimination.
It is a good idea to read all of the questions and attempt to formulate an answer for each without the options as guidance. If you then can see your proposed answer in the list of options you can answer with a greater degree of confidence. EMQs generally require a good understanding of the topics the question is assessing and are probably the most discriminatory method of testing the candidate in a multiple choice or multiple option type question style.
Here is an example of the sort of EMQ that you might expect to encounter in the AKT, with a model answer included:
Referral of skin conditions:
A. No referral necessary
B. Immediate referral for acute admission
C. Urgent referral (within 2 weeks)
D. Very urgent referral (within 48 hours)
E. Non-urgent referral
For each of the clinical scenarios below select a SINGLE best referral option from the list above. Each option may be used once, more than once or not at all.
Q1. A 60-year-old man with a history of psoriasis presents with intensely itchy, red, hot skin, covering over 90% of his body. He is systemically unwell, with a fever, and he is tachycardiac and hypotensive.
Answer: B. Immediate referral for acute admission
This patient has a presentation consistent with a diagnosis of erythroderma. Erythroderma is widespread, generalised erythema of the skin, affecting more than 90% of the body surface area. It can occur in atopic eczema, psoriasis, seborrhoeic dermatitis, drug reactions and, very rarely, cutaneous T-cell lymphoma.
Patients present intensely red, hot skin, which may be pruritic. There is usually associated systemic upset, with symptoms of fever, shivering, tachycardia, and hypotension frequently present.
Erythroderma is a medical emergency and should to be managed in hospital. Fluid balance is a primary concern, but other issues such as clotting abnormalities, secondary infection and multi-organ failure are also potentially life-threatening.
Q2. A 71-year-old woman presents with concerns about some unsightly skin lesions that are on her back. When you examine her, you see multiple brown raised areas on her back with a warty surface. They have a ‘stuck on’ appearance.
Answer: A. No referral necessary
The appearance and presentation of these lesions is highly consistent with a diagnosis of seborrhoeic keratoses. These lesions appear ‘stuck on’, and classically present with multiple brown raised areas with a warty surface. They are most common in older patients and are linked with sun exposure.
Seborrhoeic keratoses are benign tumours caused by overgrowth of epidermal keratinocytes, and no referral is necessary. Most cases require no treatment and the patient should be reassured.
Q3. A 56-year-old woman presents with a pigmented lesion on her left shoulder that has recently increased in size. The lesion is asymmetrical and has an irregular brown to black colour. The largest diameter of the lesion is 8 mm.
Answer: C. Urgent referral (within 2 weeks)
This presentation should concern you about a possible diagnosis of malignant melanoma. The current NICE guidelines recommend that patients are referred using a suspected cancer pathway referral (for an appointment within 2 weeks) for melanoma if they have a suspicious pigmented skin lesion with a weighted 7-point checklist score of 3 or more.
The weighted 7-point checklist is as follows:
- Major features of the lesions (scoring 2 points each):
- Change in size
- Irregular shape
- Irregular colour.
- Minor features of the lesions (scoring 1 point each):
- Largest diameter 7 mm or more
- Change in sensation
Q4. A 63-year-old woman presents with a pearly nodule containing easily visualised blood vessels on her left cheek. It is approximately 6 mm in diameter and has increased in size very slowly over the past few months.
Answer: E. Non-urgent referral
Basal cell carcinomas (also known as rodent ulcers) are the most common type of skin cancer seen in the UK. There are many different subtypes, but patients most commonly present with a pearly nodule containing easily visualised blood vessels. Most commonly affected areas are the sun-exposed, especially the head and neck.
Basal cell carcinomas rarely metastasise but they can be locally destructive, and therefore early treatment is beneficial. They are most common in the elderly population. There is a good prognosis with a recurrence rate of 5% at 5 years.
The current NICE guidelines recommend that patients are referred routinely if they have a skin lesion that raises the suspicion of a basal cell carcinoma.
A suspected cancer pathway referral (for an appointment within 2 weeks) should only be considered for people with a skin lesion that raises the suspicion of a basal cell carcinoma if there is particular concern that a delay may have a significant impact, because of factors such as lesion site or size.
Q5. A young mother brings in her 4-year-old daughter with concerns about several small skin marks on her legs that have been present for a couple of weeks. On inspection, you can see several bruises on her arms and legs. The child is unsure how she got the bruises and cannot recall any falls or injuries. She also looks quite pale, and her mother states that she has been very tired and fatigued over the past few weeks and not her usual self.
Answer: D. Very urgent referral (within 48 hours)
In a child with unexplained bruising and persistent fatigue a diagnosis of leukaemia should be excluded.
The current NICE guidelines state that a very urgent (within 48 hours) full blood count should be arranged for children or young people with any of the following:
- Persistent fatigue
- Unexplained fever
- Unexplained persistent infection
- Generalised lymphadenopathy
- Persistent or unexplained bone pain
- Unexplained bruising
- Unexplained bleeding
Preparing for the MRCGP AKT
To get a good grip of the topics covered takes a great deal of time and candidates should start preparing at least 3-4 months before the examination, and 6 months is preferable. Common reference materials include:
- GMC Good Medical Practice guidelines
- NICE guidelines
- SIGN guidelines
- RCGP content guide for the AKT
- RCGP GP curriculum guidelines
- BMJ articles
- Cochrane reviews
- DVLA guidelines
Once you have started to get to grips with the basics of each topic, it is sensible to begin to supplement your learning with regular question practice using resources such as our website. In general the more questions that you practice, the higher your score will be!
Try to isolate areas of weakness and concentrate on these areas; spend less time on your areas of strength. It is a good idea to use your performance in questions as a benchmark of your knowledge base in each area of the curriculum and use this as a means to support your revision planning. One of the more challenging areas of the exam for many candidates is the evidence-based medicine section, and using a good quality text for this section of the exam is highly recommended. There are many available on the market, and we suggest using ‘Evidence-Based Medicine and Statistics for Medical Exams’.
There are also a great many benefits to working in small groups. Just having others around you to talk to and discuss ideas with can help understanding and stimulate learning. Different members of the group will have different strengths and weaknesses, and working in a group together you can maximise your individual strengths and minimise each other’s weaknesses. Group learning can be dynamic, fast-paced and a lot of ground can be covered in a relatively short period of time. It can also be more fun than working alone, and organising regular group study sessions can provide a welcome relief from the solitude of regular study.
By the time each of you has qualified as a doctor, you will already have sat many exams and developed your own methods for preparing. It is a good idea to keep using the revision methods that you are used to when preparing for this exam. It is essential not to under-estimate the amount of work that is required and to spend plenty of time preparing!
Good luck with your exam preparation!
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Thank you to the joint editorial team of www.mrcgpexamprep.co.uk for this exam tips post.