Abstract
Applied Knowledge Test resources
A lot of emphasis is put by trainers and trainees on passing the Clinical Skills Assessment. A new exam has inevitably meant new concerns about teaching to the right level and adapting teaching processes to the new assessment tools. Similarly, Workplace-based Assessment has all been new stuff for Associates in Training (AiTs) and trainers to get used to and so has pulled their attention in this direction.
Less emphasis may have been placed on passing the Applied Knowledge Test (AKT) as this is a slightly modified version of the old multiple choice question (MCQ) paper; there could have been an assumption, at least in some places, that this is all old hat. However, not all deaneries have been scoring as well as others and as a result of some local concerns about pass rates, we have looked at the actions that can be taken by all concerned to address AKT preparation.
A lot of the work for AKT is individual learning that the trainee needs to do him or her self. The point from which each person comes will be different and so it is difficult to provide blanket teaching to enable people to do well without the possibility of significant wastage of time. However, as well as individual learning, there are resources out there that can help, and it is important that trainers and AiTs keep emphasizing the importance of knowledge as a base for effective GP care.
What can we do?
The following are a range of possible resources and ways to approach the problem. There is not a sudden expectation that all trainers and trainees will take on all these!
A. Trainees
Start checking knowledge base early in ST1 and building on this AKT-type questions are published each month on the RCGP's InnovAiT website. These questions are free to all AiTs and InnovAiT subscribers and are based on the articles featured in that month's journal. Several hundred AKT-type questions are now available. Visit www.rcgp-innovAiT.oxfordjournals.org. Use the free go at the college nPEP (available to all AiTs) to make an assessment of areas that need further work. (It is possible to redo the college nPEP though this may be chargeable.) The standards in this and other resources mentioned here are not necessarily the same as AKT, but are in the same ball park; www.npep.org.uk/. Use the RCGP's e-GP, a free e-learning resource specifically designed to support GP trainees learning the RCGP curriculum. The modules are interactive and have knowledge tests built in, which will help with AKT and completed e-learning sessions are automatically, recorded in the ePortfolio. Access the e-GP e-learning now at www.e-GP.org. Take the RCGP's ‘Essential Knowledge Challenge’—each Challenge contains 50 AKT-type questions based on the accompanying ‘Essential Knowledge Update’, a 6-monthly update of new and changing knowledge relevant to general practice. Each update also includes multiple-choice questions. Available free to AiTs and RCGP members at http://elearning.rcgp.org.uk. Demonstrate knowledge learning through reading entries, e-module entries and learning from debriefing, etc. throughout training Use the exceptional potential of each consultation in GP or elsewhere. Keep thinking what are the Patient Unmet Needs and translate these into Doctor Educational Needs. (Every time you get away by knowing just enough, think what you need to know to have a confident response rather than a scrape by!) For more information and attribution go to, for example http://learning.bmj.com/learning/channels/gp/punsanddens.html. Use the National Health Service clinical knowledge summaries and other recognized sources for information; http://cks.library.nhs.uk/home
Use the details on the college website to look for college-approved courses for preparation for the AKT (especially if you are leaving taking this until the middle of ST3). Note that in most Deaneries, schemes will only pay for college-approved courses and will not pay for a course outside their deanery if there is a local course happening at the same exam window period. Many courses are designed for use several months before the AKT and not last-minute preparation though different deaneries support different courses. Prepare for the critical appraisal bits by using our appraisal knowledge (journal clubs in hospital or practice) and getting used to the meaning of the statistical terms. Some have recommended the Nottingham VTS Critical Appraisal Dictionary available on the excellent Nottingham VTS site www.nottm-vts.org.uk/ReferenceMaterial/ReferenceDocuments/Evidence/How%20to%20critically%20appraise%20a%20paper.doc.
Remember the split of AKT questions is currently 80% clinical management, 10% health administration, informatics and the organizational structures that support UK general practice and 10% on critical reading and appraisal Remember examiners are jobbing GPs and so are likely to identify questions from recent UK guidelines for which they may have just updated the practice protocol, etc. (But they must be guidelines that are well known in all four countries in the UK.) Form a (virtual?) AKT revision group to compare how you are doing and keep up the momentum to keep at the revision. (How many hours did you manage today?) There is more information on this at www.rxpgonline.com/. Some people recommend using a group to look at the NICE and SIGN guidelines—it is hard to do this alone and such groups can produce useful notes for each other. Make sure that you have looked at recent NICE and similar guidelines Look at the feedback on AKT exam bulletins that are produced after each exam detailing where candidates have performed less well and make sure you cover these areas (the feedback is on the college website) Do concentrate on areas that are normally managed by practice nurses as these are areas you still need to have up-to-date knowledge on despite getting less day-today rehearsal of this knowledge There are some areas that come up regularly and can be prepared for like cremation forms, death certification, rashes and fitness to return to school, travel, sick notes and certification/reports, Driving and Vehicle Licensing Authority, fitness to fly and early chapters of British National Formulary There are some drug types that are asked about because they are particularly important, are new areas of responsibility, have implications for patient safety or are in the news. You could brainstorm these as a group. For instance, favorites might include methotrexate, statins, bisphosphonates, asthma preventers and drugs for neuropathic pain.
Use the preparation resources that most trainees have found useful early. My deanery cannot formally endorse particular sites and other resources but we can pass on the following tips from colleagues.
www.passmedicine.com comes strongly recommended by many trainees as a useful and probably appropriately challenging test site. (There is a charge but it may be worth it.)
www.onexamination.com is also recommended by some trainees though there were also some suggesting the challenge level is different from the AKT. Oxford handbook of General Practioners is found by many to be a useful resource—but may not have the latest guidelines sometimes, so the advice is to use it for the management bits and summaries of consultation models, etc. Last-minute people have found the new MRCGP in a Box useful revision (RSM Press, not RCGP)
Do some timed exams—there is not a lot of time to do it all, so get used to doing it under timed conditions. Particularly, if you have language difficulties, you may find that you need to allow more time than you think. This is because you will be given brief scenarios that you have to read and understand before answering a series of questions in the paper. As you revise, keep a list of the areas that you often forget and will need to cram for in the last days before the exam
It is important to have a clear planned approach to taking the exam. There is a delay between each question, so plan for this.
An approach that several AiTs have recommended is
Go through the questions that you are sure you know, flagging the others Second pass at the flagged questions, answering the ‘I think’ questions Final third pass at the remainder of the questions, making your best guess, based on not being penalized for wrong answers
There are other approaches but possibly the key element here is to plan how you will manage the ‘Oh, I have not got a clue’ moment that will come at some point.
B. Trainers and educational supervisors
Keep checking knowledge as part of debriefing and where there are gaps, set specific but appropriately challenging targets of areas of learning (chunks that are achievable) Use the question types that are shown in the August 09 Crammer's Corner on ‘AKT—what to ask the trainee’ Assess knowledge through regular random case analysis, pulling out the threads of the knowledge gaps that are identified and ensuring these are added to the learning plan/addressed on the log diary Use results of investigations to look at why these were done, what the justification is, how predictive is this result, what are the options for managing it, etc. Encourage trainees to challenge the trainer's knowledge and well-established habits with some evidence-based questioning Identify the gaps in knowledge when doing Case-based Discussion (CbD; the opportunity here is limited because extension questions such as ‘what if… ?’ are not part of the assessment and so CbD will only contribute thin slices of more formal feedback) Track evidence of learning identified through debriefing and CbD onto the ePortfolio in the form of reading notes or summaries or e-modules Maintain an expectation that there will be evidence of reading especially through ST1 and 2 and that this reading supports the GP curriculum Continue to expect evidence of learning from online resources often in the form of e-modules on a regular and continuing basis especially until knowledge base has been demonstrated through completion of AKT Discuss early on when is the most appropriate time for each AiT to use their free go at the college e-PEP which will give the trainee an assessment of the areas that they are weaker on clinically
C. Schemes
Ensure that areas like statistics and critical appraisal are covered effectively on schemes Ensure that there is appropriate teaching of (or system for covering) relatively specialist but commonly seen in GP areas like Ear, Nose and Throat and Ophthalmology and Dermatology Keep encouraging the formation of small groups to learn and support learning together Remind people of resources and courses, and check regularly from early on what preparation is being done to prepare for AKT Do games like ‘Just a minute’ on medical topics (‘You have 1 minute to talk without deviation, repetition or hesitation on causes, presentation and management of…’ and registrars all put in to a hot short topics, e.g. acute glaucoma, gout, CKD3, etc.) Encourage or set-up in scheme time a reading/journal club and encourage use of and discussion of journals using the relevant statistical terms Some AiTs have suggested that schemes should have an annual practice AKT examination to keep them concentrating on this assessment and help them to be more aware of how they are doing in their preparations Encourage those providing the teaching on the release course (whether GPs, AiTs or consultants) to provide MCQ questions on some of the knowledge that is needed for the session—ideally in advance of the session—so that the release course time is using knowledge that at least some of the AiTs have been looking at already
Footnotes
Acknowledgements
This work was done with support from Drs Amar Rughani, Vikki Varley, Arun Davangere, Ammar Hussain, Claire Pinches, Malcolm Swallow, Jim Walker, Christopher Parry, Jahanzeb Ali, Saqib Shah and others.