Abstract
Background
The Applied Knowledge Test (AKT) is one of three components of the licensing exam. Many people think that it is the only component that is intended to test knowledge, but this is not the case. In fact, because knowledge is the foundation of clinical reasoning, it is tested in Clinical Skills Assessment where it is possible to fail if, for example, the knowledge of differential diagnosis and probability is not up to the required standard.
Knowledge is also tested in the workplace through clinical encounters and through discussions with the trainee, for example, in debriefs and random case analysis. There is a potential barrier here because as a profession, GPs are not used to probing the factual knowledge of colleagues. It feels threatening but, if done by mutual agreement, it can be highly productive in helping trainees to uncover their knowledge gaps well before it is exposed through the exam!
Key message: do not assume that preparation for AKT is simply the trainees' responsibility. There is a lot that educators can do to help.
What are the areas covered by the AKT?
The AKT tests topics that are common and/or important in three main categories:
Core clinical medicine and its application to problem solving in a general practice context, 80% Critical appraisal and evidence-based clinical practice, 10% Health administration, informatics and the organizational structures that support UK general practice, 10%
Key messages: the exam is mostly about ‘applied’ knowledge in a ‘clinical’ context, not knowledge per se. The performance of examinees in critical appraisal is generally very poor. A little knowledge in this area can therefore earn valuable marks.
What questions can I ask the trainee?
The AKT tests a number of clinical decision-making competences. The most important of these are shown below, along with examples of the types of question that you could use. These are only suggestions, so try thinking of questions and approaches of your own. The questions may seem to have a rather narrow focus. This is deliberate because they are designed to probe knowledge rather than the wider aspects of clinical management.
1. Recognize the presentation of common/important conditions
What are the early symptoms and signs of secretory otitis media? What would make you think that this was benign positional vertigo rather than labyrinthitis? What features would make you suspect chronic obstructive airways disease (COPD)? This patient has spasms of abdominal colic and occasional diarrhoea, but no blood. Which conditions go through your mind?
2. Apply a knowledge of probability based on prevalence, incidence and natural history
This 50-year-old patient has a painful left shoulder with progressive restriction of movement over the last few weeks. What are the likely diagnoses? Why did you not think that rheumatoid arthritis was likely? Supposing a 28-year-old patient had vaginal irritation. What is it likely to be and what would you do? This 58-yr-old woman has had a persistent hoarse voice for the past 2 weeks with no positive physical findings. How would you decide whether it is safe to watch and wait?
3. Choose examinations and target investigations appropriately
Why did you choose those particular tests and investigations? How do they help you to establish the diagnosis? Why did you choose ‘not’ to do xxx? Which are the most useful tests for this condition? Why? Which are the serious conditions that you are trying to exclude? Which tests might help you to do this? Looking at the test results, how useful was it to request x, y, z?
4. Identify and interpret abnormal findings and results
What does this test result tell you? Does it exclude this condition or make it less likely? What picture is emerging from the collection of test results that you have? This test result is marginally raised. What would you do next? This patient is breathless and has some fine basal crepitations. How does that physical finding help you?
5. Appropriately apply rules or plans
The random blood sugar is slightly raised. What would you do next? What do the national guidelines say? You have added an inhaled steroid to this teenager's beta-agonist treatment. What would you do if the asthma still was not satisfactorily controlled? How have the recent national guidelines for the management of condition xxx changed? This patient has low mood. How do the guidelines help you to decide if he is clinically depressed?
6. Prioritize management approaches based on an assessment of patient risk
This 60 year old has mild prostatism. Should you now refer him for further investigation? How would you decide? How would you decide whether to give antiplatelets or warfarin for a patient with atrial fibrillation? What are the significant psychosocial factors that might sway your decision? We had a significant event meeting about a patient with a delayed diagnosis of bacterial endocarditis. What did you learn from that meeting that might change your future clinical management?
7. Knowledge of evolving clinical practice and contemporary medical issues
What are the pros and cons of prostate specific antigen screening for men over 50? How does the sensitivity and specificity of the test help you to decide how strongly to recommend this? What have you read in the journals in the past month that might change your practice?
In what situations can I ask the trainee?
The key situations are those in which the trainee has not prepared for the questions/discussion. Questions could be asked in Case-based Discussion, but this is not the usual forum for impromptu excursions from the main topic.
However, it would be easy and legitimate in debriefing and in random case analysis to change the scenario and ask questions such as ‘What if…?’
Remember not to rely on what comes out of consultation alone when thinking about areas of knowledge to probe. This is because important parts of the knowledge base of general practice are not routinely seen in the consultation and because many areas underpin the clinical management that has been devolved to nurses.
For example, you may want to use a prompt from consultation to question about travel immunization, death certification, cremation forms, sickness certification, etc.
You may want to probe areas (especially of chronic disease management) that nurses now do, for example by asking:
You saw this man for his arthritis but I see that he is on treatment for his COPD. What level/stage of COPD is he being treated at and what measures might you have added if this was worse? What monitoring of his disease would the practice nurse be expected to do and how often?