The applied knowledge test (AKT) is one of the three essential summative assessments you need to pass in order to gain the MRCGP. The other two are the clinical skills assessment (CSA), which you will sit at the RCGP headquarters, and the workplace-based assessment (WPBA), which is accessed and assessed through your ePortfolio.
The AKT is a computer-based assessment that can be sat at any time during your ST2 or ST3 years. The exam currently costs ether £450.00 or £501.00 to sit, depending on when you registered as an AiT, and can be attempted up to four times.
Registering to sit the exam is a two-stage process – you initially register via the RCGP website and pay up front. Once this payment is processed you are sent a login to allow you to book a slot at the centre of your choosing. The exam is sat at Pearson VUE centres throughout the UK. These are the centres that also offer the driving theory test and there are currently 150 centres offering the exam. You can find your nearest office via the Pearson website.1 It’s worth bearing in mind that the RCGP state that it can take up to two days from registering with them to the arrival of your login.
The exam is currently offered three times a year and is invigilated by Pearson staff. Slots are allocated on a ‘first come, first served’ basis, so plan ahead to have the best chance of sitting the exam at the site and time of your choice.
The AKT lasts 3hr 10m. In this time you have to answer 200 questions, presented sequentially. Questions can be in a number of formats – most are the single best answer and extended matching question format that you will remember from finals, but there are also ‘picture quizzes’, drag and drop lists, rank ordering and free text questions. There are also questions on graphs and data interpretation, and an on-screen calculator is supplied to help with these. Questions can be skipped and returned to later or flagged, allowing you to highlight those you are unsure of in order to revisit them if there is time at the end of the exam.
The RCGP offers 50 sample questions2 and Pearson provide an interactive practice exam which can be installed on your PC.3 Both of these should be considered essential preparation. So too, should the RCGP presentation on the AKT, which gives examples of the various question formats.4
Eighty per cent of the questions (160 questions) relate to clinical medicine, 10% (20 questions) test critical appraisal and knowledge of administrative issues, and 10% (20 questions) cover health informatics. These content areas are explored in more detail below. The AKT aims to test higher order problem solving rather than simple regurgitation of facts.
After completion, the exams are anonymously marked and results will appear in your ePortfolio. Pass marks are set using a statistical technique known as the Angoff process4 and so vary sitting to sitting, but the mean score in October 2018 was 72%. Of those taking the exam, 70.7% passed, this number rising to 85.7% for UK trainees taking it for the first time. The RCGP states that the cumulative pass rate after three attempts is 98%.4
The RCGP has developed a content guide for the AKT, which is essential reading.5 At 54 pages long, it’s easy to be daunted by this document, especially as the RCGP stresses that this is an abbreviated guide. This is where the ‘G’ in GP comes in. You are training to become a generalist, and you will fulfil arguably one of the most versatile generalist roles in the world. Any of the conditions listed in the guide could walk into your consulting room at any time. So, you are going to have to put in the leg work now.
But don’t be put off. The rewards and satisfaction of bringing this level of immediate access primary care generalism to your chosen community is worth the slog. Remember, you don’t have to be an expert in all areas, but you are expected to have a good general coverage of knowledge.
So don’t fear the content guide, it is there to help you.
Break the document down into easily managed chunks and use it to guide targeted revision of areas you are unsure of. For most of us there were (and still are) areas of medicine we are so unfamiliar with that we don’t know what we don’t know. The content guide will point these areas out to you, so make it an early port of call and act accordingly.
Specific pointers for the three sections of content are considered below.
1. Clinical Medicine (80% of the questions)
When revising for the exam, remember always that the A in AKT stands for applied. This is not about medical school essays but about real world, hands-on knowledge. The RCGP want to prepare you to be a GP, not an academic clinical fellow. Make sure that the knowledge you are building reflects this – focus on diagnostics and therapeutics, rather than intricacies. The content guide lists all the conditions you are expected to know but, as well as condition-specific knowledge such as diabetes and ulcerative colitis, you will also need to be comfortable managing common presentations like abdominal pain, cough, shortness of breath, fever etc. This is what you will be doing every day of your career, so it’s worth getting into this mindset. For each condition/presentation, the guide says you should ‘consider the following within the context of primary care’:5
- 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
- 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.
Don’t be too daunted – you already know a lot of this stuff. Look for the gaps in your knowledge and fill them.
Knowledge of emergencies in general practice
True life-threatening emergencies are relatively rare in general practice, but when they do come up (and to be absolutely clear, they do) you need to know how to manage them. Unlike your hospital rotations, you are generally managing these on your own, sometimes in the patient’s home. A fluent ‘fingertips’ knowledge of managing common emergencies is therefore essential if you are to practise safely. Try not to rely on the internet – it has a habit of breaking down when you need it most. Colleagues may be on hand but don’t rely on their knowledge – the chances are that you will be the team member who has the most recent experience of emergency medicine. In fact, you may find that it is you who is called on by them to add the expertise during an emergency or lead the resuscitation. So make sure you have some knowledge to share.
For the AKT, knowledge of the following situations is specifically required:
- Features of mental health emergencies and factors suggestive of a high risk of harm to self or others
- Features of serious illness requiring an immediate response (meningitis, respiratory compromise, circulatory shock, septic shock, anaphylaxis, etc.)
- Features of severe or life-threatening injuries
- Management of emergency situations, such as drug dosages, national guidance
- Symptoms and signs of acute illness in adults, including patients with intellectual disabilities, dementia, communication problems
- Symptoms and signs of the acutely ill child.
Prescribing and pharmacokinetics
Firstly, ensure you are working from an up-to-date BNF and spend some time getting to know your way around it. It contains a wealth of knowledge beyond just drug doses, including latest guidelines and treatment algorithms. Also spend a minute finding out what the various symbols and abbreviations used in it mean – this sort of thing is classic AKT question material.
Also, if you rely on your computer to autofill your prescribing doses then it is time to start paying attention and learning the common ones.
Be aware of (and read the BNF sections on) guidance relating to prescribing in pregnancy and breastfeeding. Know your way around palliative prescribing and antibiotic prescribing. Look up and learn common drug interactions and contraindications and the monitoring regimes of common drugs requiring this such as warfarin, lithium and the DMARDs. Also know your way around controlled drugs prescribing and storage rules.
Do remember that you will also need to be at ease with paediatric prescribing, so get a copy of the BNF for children. Practice your dose calculations by weight, dose adjustment for age and get to grips with the common paediatric doses of common medicines as well as guidelines for common conditions like asthma.
2. Research, statistics and epidemiology (10% of questions)
Can you interpret and analyse data? Can you use this process as the basis of developing your clinical practice and decisions? Can you sift good evidence from bad and make decisions about guidelines? Are you familiar with the principles of research design and the hierarchy of data?
If the answer to the above questions is a resounding ‘no’ then don’t panic – many people’s brains freeze up when statistics are mentioned. I have even heard people say that they will sacrifice this section of the exam and not revise statistics.
I just can’t condone this – 10% is too much to throw away.
You may never learn to have a love of this stuff but the fact remains – part of your job is to explain risk to patients to facilitate their (and your) decision making. In fact, you are to be the community expert on this.
That said, being pragmatic, you cannot spend all your time revising this at the cost of clinical medicine, which accounts for a far greater percentage of the marks. Strike a balance – look through the content guide and target areas that you are going to concentrate on and make sure you know your way around the basic principles of statistical significance and the common calculations of evidence-based practice (see box), as they always feature.
Common evidence-based practice calculations.
- Number needed to harm (NNH), number needed to treat (NNT)
- Odds, odds ratio (OR)
- Predictive value – negative predictive value (NPV), positive predictive value (PPV)
- Risk – absolute risk (AR), absolute risk increase (ARI), absolute risk reduction (ARR), relative risk (RR), relative risk increase (RRI), relative risk reduction (RRR), hazard ratio (HR), specificity, sensitivity.
This section also covers epidemiology and screening, so make sure you know Wilson’s criteria and the various screening programmes currently rolled out in the UK. You should also be familiar with the UK immunisation schedules.
3. Administration, ethical and regulatory frameworks (10%)
You are also expected to have a good working knowledge of the administrative architecture of general practice and the NHS as a whole. This includes familiarity with the GP’s role in clinical governance and knowledge of the frameworks and associated bodies, such as complaints procedures and the CQC.
Understandably, the RCGP would like you to have a particular awareness of the administrative tasks that a ‘normal GP’ is involved in. This is an area in which AKT candidates consistently perform poorly.4
The content guide states:
‘It is important that GPs have a broad working knowledge of general practice administration, ethical and regulatory frameworks. The topics are those that a GP is likely to encounter in normal working practice, although some may occur infrequently. Candidates would be well advised to ask their trainer to show and discuss these administrative tasks when they arise, for example, completion of insurance reports.’
This is an interesting statement – not only is this the sort of hint that cannot be ignored, it also acknowledges that this stuff is hard to learn – there are no textbooks on it. Having your trainer (and I would also say practice manager) keeping an eye out for these tasks and teaching you ‘on the job’ is invaluable. Ensure that you discuss this requirement with them as soon as practicable. It would also make an ideal tutorial/series of tutorials.
Of course, if you are sitting the AKT in your ST2 year then this will be even harder to cover and I would recommend addressing this point with your trainer to see if it could be the topic of one of your release days in the practice.
The content guide gives a list of practice management areas that you should be familiar with, so print this out and go armed with it – that way they can help you work through this sometimes nebulous area in a systematic fashion.
The various certification processes that GPs are involved in can, and are, tested in the AKT. There are more of these than you think and include death certification, power of attorney, notification of infectious disease, mental capacity and mental health acts, termination of pregnancy, fit notes, benefits and allowances, private certificates (fit to fly, firearms), private medicals (HGV, adoption) and registration of visual impairment. Again, look at the content guide and work through these.
Ethics is also covered in this section, and the GMC guidance to ‘Good Medical Practice’ is your friend here. Make sure you are looking at the current edition. The content guide lists the following specific areas to consider:
- Beginning of life issues including termination, adoption, surrogacy, antenatal diagnosis of disease.
- Capacity including power of attorney/mental capacity/advanced decisions to refuse treatment. Awareness of differences between the devolved nations
- Children including capacity, safeguarding, confidentiality
- Consent and dissent including requests for treatment on religious grounds
- End of life care including withholding and withdrawing life-prolonging treatments
- Ethics of genetic testing
- Medical management and working with colleagues
- Probity, for example gifts, conflicts of interest, financial probity, effect of payment by results such as referral management and other targets
- Raising and acting on concerns about patient safety, whistleblowing
- Referral to other healthcare practitioners including self-referral
- Research ethics
- Safeguarding including children, elderly and vulnerable adults, domestic violence
- Welfare of practitioners such as health, conduct issues.
Dr Matt Burkes is a GP partner and trainer in Chichester, West Sussex. He has written on many aspects of GP training and co-edited ‘The Good GP Training Guide’ (RCGP Press, 2014) and was a contributor to the Oxford Handbook of General Practice (OUP, 2014).
1 Pearson VUE. Locate your test centre.
2 RCGP. AKT Sample questions. 2017
3 Pearson VUE demo test
4 RCGP. Exams overview. MRCGP AKT.
5 RCGP. AKT Content Guide. 2014.