ST2 Induction & Preparing for AKT

Aug 2021

What we’ll cover

• What is expected of you in ST2

• Safeguarding

• AKT

• Why are trainees unsuccessful?

• Question styles

• Preparation

WPBAs (1)

Mini-CEX/COTAny setting (face to face, telephone, or video)

ST2:

4

CBD / CAT ST2:

4CbD

MSF ST2:

1 (with 10 responses)

CSR ST2:

1 per post*

PSQ ST2:

0

CEPS ST2:

Ongoing

Learning logs ST2:

36 Case reviews

https://www.rcgp.org.uk/training-exams/training/new-wpba/assessment-requirements.aspx

WPBAs (2)Placement planning meeting ST2:

1 per post

QIP ST2: 1 (in GP) – if not done in ST1

Quality improvement activity All trainees must demonstrate involvement in Quality

Improvement at least once a year

Significant event Only completed if reaches GMC threshold of potential

or actual serious harm to patients.

Learning Event Analysis (LEA) ST2: 1

Prescribing review ST2: 0

Leadership ST2: 0

Interim ESR ST2: 1**

ESR ST2: 1

CPR & AED Use (BLS) ST2:

Competence in CPR and AED use for all placements

Child and Adult Safeguarding ST2:

Knowledge and Reflection***

Safeguarding

• All trainees require in date evidence of level 3 safeguarding for both adult and child safeguarding from the start or early part of their training in ST1 and thereafter throughout their training.

• Going forwards all trainees then need a knowledge update annually and this needs to include a demonstration of their knowledge, key safeguarding information and the appropriate action to take if there are any concerns.

• In addition, all trainees require a minimum of one participatory piece of learning and reflection for both adult and child safeguarding in each training year.

• Evidence of learning for both the knowledge component and reflective exercises need to be documented in the trainees learning log.

• https://www.rcgp.org.uk/gp-training-and-exams/training/workplace-based-assessment-wpba/cpr-aed-and-child-safeguarding.aspx

Safeguarding

• Safeguarding: process that

protects children and adults from harm,

abuse, and neglect.

• It is the duty of every staff member

to safeguard all adults and children who

are unable to protect themselves from

abuse, harm and neglect.

6 principles of safeguarding

1. Empowerment: People being supported and encouraged to make their own decisions and informed consent

2. Prevention: It is better to take action before harm occurs.

3. Proportionality: The least intrusive response appropriate to the risk presented.

4. Protection: Support and representation for those in greatest need.

5. Partnership Local solutions through services working with their communities. Communities have a part to play in preventing, detecting and reporting neglect and abuse.

6. Accountability: Accountability and transparency in safeguarding practice.

Types of abuse

• Physical• Domestic violence• Sexual• Psychological/Emotional• Financial/Material• Neglect or acts of omission• Modern Slavery

• Discriminatory• Organisational/Institutional

Female Genital Mutilation

• Female Genital Mutilation (FGM) is illegal.

• It is a form of child abuse and violence against women.

• FGM comprises all procedures involving partial or total removal of the external female genitalia for non-medical reasons.

• Mandatory reporting duty to report ‘known’ cases of FGM in under 18s which they identify in the course of their professional work to the police.

AKT

AKT

• Can sit at any point from ST2 onwards• £459 • 200 Qs• 80% Clinical• 10% Evidence Based Medicine (“Statistics”)• 10% Organisation and Administration (“Management”)• 3 hours 10 minutes…. Additional time if learning needs e.g. dyslexia

= ~57 seconds/mark• No negative marking… Answer everything• Each Mark/Q is independent of the previous,• All marks are equal

• Overall mark is what counts

AKT Content guide

• https://www.rcgp.org.uk/gp-training-and-exams/mrcgp-exam-overview/~/media/Files/GP-training-and-exams/AKT%20page/Content%20Guide%20August%202013.ashx

Clinical Medicine (80%)

• Clinical Medicine…. Breadth of general practice

• Appropriate and relevant investigations • Diagnostic features and differential diagnoses • Interpretation of test results • Management including self-care, initial, emergency and continuing care, chronic

disease monitoring • Patient information and education including self-care • Prognosis • Recognition of ‘alarm’ or ‘red flag’ features • Recognition of normal variations throughout life • Risk factors • The natural history of the untreated condition including whether acute or chronic • The prevalence and incidence across all ages and any changes over time • Typical and atypical presentations

Statistics (10%)

• Applying evidence, critical appraisal

• Study designs

• Statistical terminology

• Graphical representation

• Simple calculations

• Research ethics/governance

• Epidemiology

• Screening

Management (10%)

• Ethics and duties of a doctor (GMC good medical practice)

• Certification (fit notes, death certs, driving rules, forms etc.)

• Medico-legal (e.g. Mental health act, power of attorney, access to records etc.)

• Practice management• Clinical governance• Revalidation• Finance

Q types

Single Best Answer (SBA)

Extended Matching Questions (EMQ)Table/Algorithm

Picture/Video Format

‘Hot spot’

Calculation

Free text

Question: Why do you think trainees fail?

• Underestimate breadth of curriculum

• Only reading guidelines without application

• Only answering question banks without understanding guideline

• Try to cram; Insufficient time

• Poor technique

• Failure to appreciate nuance of English language

• Not declaring disability

• Over revise one area

• Neglect revising particular areas

• Too much going on personally/ poor rota

• Switching from another specialty to GP

• Practicing as per international/local standards rather than national UK standards

• Desire to ‘do something’- overtreat/investigate rather than adopt ‘watch and wait’/do nothing

• Not engaging with e-portfolio/ HDR programme… “Presenteeism”

Approaching a Question

‘Cover test’

• Do you know the answer before you’ve looked at the options?

• Q. An overweight man has become progressively thirsty and complains of passing urine more frequently than normal…… what is the diagnosis

• If you thought “Type 2 diabetes” and find it in the options before you even look, it’s probably correct

You see a patient who has broken their arm. On enquiring how it happened, they burst into tears and say their partner beats them. What kind of abuse is this?

• A. Emotional

• B. Financial

• C. Neglect

• D. Physical

• E. Sexual

Spot diagnosis

• Some Questions will require you to have a good knowledge of pictures/images

• Derm

• ENT

• Ophthalmology

• Genetic pedigree symbols

• You either know it, or you don’t….

• A patient presents to you because their relative commented on how their eye looked. They ask you what your diagnosis is?

A. CataractB. Corneal arcusC. EpiscleritisD. Pterygium E. Scleritis

• You examine a patient’s buttocks. They are unable to turn over unaided and their carer is not always available.

• What is the most likely explanation for this appearance?

• A. Cellulitis

• B. Nappy Rash

• C. Pressure sore

• D. Psoriasis

• E. Sunburn

Rote learning

• Some questions will require simply memorising facts.

• Unlikely to be shortcuts, but some mnemonics or aide memoires may exist

• Encourage trainees to be aware of this; vaccines, emergency drugs, sick day rules.

• Don’t leave too late, ?review days before exam

• A 5 year old child looks very sick with a non-blanching rash. You suspect meningitis and decide to give an emergency antibiotic. The child has a recorded allergy to penicillin, which has caused an urticarial rash.

• Which ONE of the below intramuscular antibiotics would you give Stat?

• A. Benzylpenicillin 1.2g

• B. Benzylpenicillin 600mg

• C. Benzylpenicillin 300mg

• D. Cefotaxime 1g

• E. Cefotaxime 500mg

• Under what age is it mandatory to disclose to the police with or without the patient’s consent if a woman has undergone female genital mutilation?

• Under 18

Calculations

• Trainees should expect these to come up

• Usually simple maths

• E.g. calculate mean

• Calculate alcohol units/smoking pack years

• Drug dosage

• Candidates have access to an online calculator

• A patient is concerned about their drinking. In taking a history, you establish they drink 1L of 40% vol. Vodka and 4 bottles of red wine (750ml, 12% vol.) per week.

• Write how many units they consume PER WEEK ……………………………………………………

• 76 units

• (1L of 40% = 40 units, + 4x750=3000ml x 12%= 36)

• A patient is not being fed by their carer. On examination, they weigh 50kg and are 1.75m tall.

• Calculate their BMI to 1 decimal place

• 50kg/ (1.75x 1.75)

• = 50/ 3.0625

• = 16.3 kg/m2

Interpreting signs and symptoms

• Questions may mix clinical history with examination findings.

• Be prepared to incorporate the two together to reach a diagnosis/management

• The clinical findings may be sealing the deal, or might change what you think from the history

A 30 year old music teacher with cystic fibrosis attends because of concern about hearing loss in the right ear. They are embarrassed but admit to using a cotton bud because it “worked last time”. You use a tuning fork, the results below:

Rinnes: Air conduction > Bone Conduction

Webers: Heard louder in the left ear

• Which diagnosis best explains these findings?

A. Eustachian Tube Dysfunction

B. Impacted Earwax

C. Otosclerosis

D. Ototoxicity

E. Presbycusis

Distractors

• Distractors- another option that is incorrect, but enough to make you doubt.

• What can separate passing and failing candidates.

• There will be Qs where you have narrowed down to 2-3 very good options….. Think:

• What is most likely (probability) in this patient? (think epidemiology)

• E.g. Is the 25 year old female with new onset bloating IBS or ovarian Ca?

• What is most serious (what shouldn’t I miss)?

• E.g. Is the 65 year old female with new onset bloating IBS or ovarian Ca?

• What is the most appropriate thing to do first (e.g. Xray chest before you CT?)

• Is do nothing (or watch and wait) appropriate rather than Ix/Rx?

Distractors

• A 35 year old patient is easily influenced by others, and always likes to be the centre of attention. They are very well presented and are eager to ensure you are impressed by them. They are friendly towards you, and are interested in the watch you are wearing. Which of the following personality disorders would be most consistent with their behaviour?

A. Borderline (Emotionally Unstable)

B. Dependent

C. Narcissistic

D. Histrionic

E. Schizotypal

What did you narrow it down to?

What makes one more likely than the other?

Best option

• Sometimes multiple options are acceptable- but which is the BEST of the lot.

• Sometimes the 1st choice isn’t there, what is the next best alternative?

• E.g. A 70 year old newly diagnosed hypertensive, otherwise fit and well has tried lifestyle advice without success, what is the best antihypertensive to commence?

• A) Ramipril

• B) Spironolactone

• C) Bendroflumethiazide

• D) Atenolol

• E) Methyldopa

• In reality, you would probably go with a CCB e.g. Amlodipine, but it is not there…. The next best option in the list is ramipril

Stereotypes, Buzzwords and association

• Certain words or phrases that usually mean one thing.

• Barking, seal like cough…. Croup

• Unvaccinated child is drooling.... Epiglottitis

• Elevated calcium pyrophosphate…. Pseudogout

• Food poisoning after eating reheated rice…. Bacilus cerues

• “Bag of worms”….. Varicocele

• https://www.cram.com/flashcards/medical-buzzwords-797326

• Be aware of words (or a word) that can change everything

• Leg pain walking uphill- PVD?

• Leg pain walking downhill- spinal stenosis?

Varying difficulty and next steps…

• Q: A patient shows you their eye (see picture) What condition is it?

• Q: “A patient shows you their eye…they also have used steroids for sometime” What condition is it? (Easier)

• Q: “A patient shows you their eye… what treatment would you advise for this condition?” (Harder)

• A Q can be made easier by giving more context.

• A Q can be made harder by asking not what the diagnosis is (cataract), but what the management of ‘this condition’ is…. In this case, know 1st what the diagnosis is…. then 2nd what the management is.

• A 60 year old man presents to you with a rash that has appeared over the last 2 days after walking his dog in the New Forest. He shows you a picture of it. He has no known allergies or other significant medical problems. What treatment would you recommend?

A. AciclovirB. Cetraben ointment C. Doxycycline D. Elocon (mometasone furoate 0.1%) ointmentE. Reassure, no treatment is needed

Narrowing it down

• Some Qs you may not have any idea what the answer is.

• It may be testing ability to exclude something, rather than knowing the answer….

• Q. A patient with antisocial personality disorder has be sentenced by a judge to go to hospital instead of prison after committing a crime. Which mental health act section will the judge use?

• A) Section 2

• B) Section 3

• C) Section 5(2)

• D) Section 17

• E) Section 37

Narrowing it down

• Q. A patient with antisocial personality disorder has be sentenced by a judge to go to hospital instead of prison after committing a crime. Which mental health act section will the judge use?

• A) Section 2

• B) Section 3

• C) Section 5(2)

• D) Section 17

• E) Section 37

• Hopefully you would know S2, 3 and 5(2) and that these involve a Dr

• You might know that S17 lets someone have leave from hospital….

• You probably have never heard of s37, but by process of elimination…… it is the only one left if you knew the others.

• Even if you didn’t know s17, you’ve hopefully gone from 1:5 to 1:2 chance.

Do nothing

Read MRCGP feedback reports

• https://www.rcgp.org.uk/training-exams/mrcgp-exams-overview/mrcgp-examination-summary-reports-statistics/mrcgp-applied-knowledge-test-akt-summary-reports-and-statistics.aspx

• Regular areas of underperformance• Clues on what will always be tested (e.g. drug

calculation)

• Always worth a read

Preparation

Suggestions when starting revision

• Print the RCGP AKT content guide. • Look at past RCGP AKT reports. Hints of

what will always be examined (drug calculations) and what has been poorly answered (e.g. Death certs)

• Prepare a plan: How long have you got to go? Holiday/breaks? On-call? What do you need to cover and when will you do it?

• Realistic goal: How many guidelines/Qs can you manage per day/week?

Material

• RCGP Content Guide + sample Qs

• NICE CKS guidelines (and specialty guidelines e.g. BTS)

• BNF (CDs, symbols)

• RCGP InnovAiT journals

• Oxford Handbook of General Practice

• Good Medical Practice

• Masterpass Statistics

• Question banks and books

• A must read for all trainees

• Last 6 pages for stats & admin

A note about question banks/books

• Check they are in date (“nMRCGP”)

• Worth diversifying; one book/bank will tend to use one style.

• Excellent to help self-appraise and consolidate knowledge

• Beware misleading yourself; answering same Qs over and over until you get it correct= false reassurance and answering what you think is being asked, rather than what is actually being asked….

Eportfolio: Work Smart

• Continue working on e-portfolio alongside AKT

• 2 birds, 1 stone• Learning log entry: Reading + tick

competencies• Present a guideline at a practice meeting• CBD

• Put them together=PDP

What else should I think about?

• Talk to trainer about when to take it

• Take a mock (AKT Day 18/8/21)

• How do you compare to your cohort?

• Consider rotations/life events.

• Be aware of books becoming out of date

• Consider if you have particular needs that allow more time (e.g. dyslexia)- Let RCGP know!

RCGP AKT Info and FAQs

• https://www.rcgp.org.uk/training-exams/mrcgp-exams-overview/mrcgp-applied-knowledge-test-akt.aspx

• Look at the content guide for AKT curriculum and FAQs!

Lastly…

• 2WW• 2WW• 2WW

• If the option of “do nothing” or “watch and wait” exists, and it seems entirely reasonable, it’s probably correct.

• Has any guideline changed recently (asthma?) or been promoted?

• 14fish AKT resource https://www.fourteenfish.com/about/akt

Good Luck!