Making the grade

MOST GP trainees will naturally feel a degree of anxiety about the compulsory MRCGP exams. The process can be stressful and expensive, especially as doctors must achieve a pass in order to become certified to practise as a GP.

But if you can get the timing right, understand what the examiners are looking for, and prepare well, you should be able to take them in your stride.

The new MRCGP examination was introduced in 2007 and is compulsory for entry to the General Medical Council’s GP register. It comprises three parts: the Applied Knowledge Test (AKT), the Clinical Skills Assessment (CSA) and the Workplace-Based Assessment (WPBA). I will focus on the AKT and CSA and the recent changes that have been introduced to these components of the exam.

AKT

The AKT is a three-hour, 200-item multiple-choice, pass/fail exam which tests application of knowledge and ability to interpret information. Question writers are MRCGP examiners, who are all practising GPs. They base questions on everyday clinical work, including clinical problems, guidelines and practice management. Although most of the AKT is concerned with GP clinical medicine, a fifth of the questions cover critical appraisal and ethical/legal/organisational issues.

Although candidates often worry most about statistics and critical appraisal questions, in many ways these are the easiest to revise for as the subject area is quite specific and there are many books and e-learning aids available. Make sure you read GP-related articles in the BMJ and BJGP as many of these come into the questions on evidence-based practice. It's also a good idea to participate fully in any practice team meetings to pick up tips on how to manage non-clinical problems that GPs might face in the surgery.

Questions come in different formats, mainly single best answer with some extended matching questions. Newer question formats such as video clips, and questions requiring “free text” responses will be introduced once they have been trialled.

The secret to success is good preparation and time management during the exam. Practise the different question formats by going through up-to-date AKT books. During the exam, check frequently that you are on track to cover all the questions in time. Don’t waste time agonising over difficult questions – these can always be electronically highlighted and returned to later.

After you have registered with the RCGP to sit the AKT, you must book a test at one of the invigilated centres (also used for driving test theory exams) – act quickly to make sure you get allocated to a centre of your choice. You can take the AKT up to three times a year, but it now cannot be taken before your ST2 stage of training. AKT passes are no longer valid for only three years – essentially there is now no limit. A maximum number of four attempts are allowed and the best timing for it is usually at the end of ST2 or early ST3. After the exam, you will receive detailed scores and feedback through your e-portfolio.

CSA

The CSA tests both clinical and consultation skills in a circuit of 13 cases taken from everyday general practice. All consultations are marked by experienced examiners observing each 10- minute case, whilst trained role-players act as ‘patients’. The examiners are testing ability to gather information, apply knowledge of disease processes, demonstrate evidence-based decisions, person-centred care and effective communication with patients and colleagues.

Each case is marked in three domains:

1. Data gathering, examination and clinical assessment skills

2. Clinical management skills

3. Interpersonal skills

Domain 1

Here the key to success is focused historytaking, using a hypothetical-deductive approach. Make sure you have a realistic list of differential diagnoses – practise doing this in real life. Read the patient notes and use them appropriately – avoid repeating the facts back to the patient but incorporate relevant ones in the consultation.

You may be given clinical measurements and test results but not every piece of information supplied has the same priority for a given consultation. Target your choice of physical examination to the patient, and remember you are only expected to do what is reasonable in a 10-minute GP consultation. A new RCGP learning resource is available on eGP to guide you in this. Don’t do whole systems examinations, and handle instruments correctly to avoid hurting the patient.

Domain 2

Clinical management and how a patient is involved in the decision-making are areas where many candidates fall down. Examiners look for the recognition and management of common medical conditions in primary care. You should be able to deal with patients with multiple complaints, appropriately prioritising items on both your and the patient’s agenda. Management plans should be realistic, reflecting appropriate knowledge of evidence-based medicine.

You must be aware of the wide scope of the curriculum, and try to actively seek experience to cover areas of weakness and ones where you have less exposure. This might include patients from different ethnic, cultural or social backgrounds, physically or mentally handicapped patients, and angry or upset patients. Health promotion, though important, may only be a priority in some of the consultations – do this sensitively to achieve a desired outcome.

Domain 3

This domain also includes professional attitudes and ethical behaviours. Being patient-centred is very important but this does not mean automatically giving the patient what they want, and not all consultations require patientcentredness. You should try to really understand the patient’s illness experience and health beliefs and take these into account. It is essential to develop a rapport, demonstrate active listening skills, and share ideas and concerns. Show respect for others – examiners want to know that you can interact with staff and colleagues courteously and effectively.

It is important for you not to consult differently during the exam, as this may result in an artificial consulting style. Instead, focus on the nub of the case, using good consultation skills to add structure and manage time efficiently.

The new marking system

For the CSA, the pass mark will be set using the borderline group method, where each case will have its own pass mark, rather than the previous system of needing to pass eight cases out of 12. Examiners will mark all three domains and give a final global score. Before, only the global score actually counted but now the domain grades will count towards the candidate’s final mark, and the overall case grade will not.

Each candidate will end up with a numerical score for each case and these are added up to create their total CSA exam mark. The pass mark will be set every day by the new method to reflect the varying difficulty of cases, which makes it fairer to candidates. In a similar way to the AKT, you will be informed of your overall score alongside the pass mark for the CSA on that day.

Changes that apply to AKT passes obtained after August 1, 2010 also apply to the CSA, in that a CSA pass will no longer be subject to a three-year validity limit. You can now take the CSA a maximum number of four times, and only when you have achieved at least ST3 stage of training. If you started your GP training before August 2009, transition arrangements apply – details are on the RCGP website.

In summary, the exams are really quite straightforward and are very much focused on general practice. Make use of your trainer as much as possible to give you feedback on your progress and whether you are at the right stage to take the exams. Learning for the exams should be no different from learning to be a good GP, and should not be too stressful if you have done your homework!

Dr Mei Ling Denney is an MRCGP examiner, and is currently Deputy Chief Examiner/ R&D lead for the MRCGP assessment