1. nMRCGP Dr Mark Metcalfe

2. nMRCGP Money AKT CSA

3. Money Become AiT£492 AKT£360 CSA£1260 Fee to PMETB£780 TOTAL£2892 Course£660 TOTAL£3552

4. Money If you have to retake your exams…. £5282 These are figures for this year…. They might increase

5. Registrar pay Basic salary£30660 plus 50%£15330 London weighting£2162 TOTAL£48152

6. Exams AKT Computer marked ‘multiple choice’ paper CSA Practical assessment of consulting skills

7. AKT Relevance: The AKT should be relevant to general practice; any topic covered can be one which occurs commonly or one which is significant but less common High prevalence: Low impact e.g. URTI High impact: Low prevalence e.g. meningitis Topical: e.g. Controlled drugs

8. Sources Clinical Evidence Cochrane Database BNF GP Curriculum NICE SIGN BMJ Review articles & original papers BJGP DTB

9. This is your friend

10. AKT Core clinical medicine and its application to problem solving in a general practice context – 80% of items Critical appraisal and evidence based clinical practice – 10% of items Ethical and legal issues as well as the organisational structures that support UK general practice – 10% of items

11. Stuff no one bothers with but features heavily in the exam… Regulatory frameworks Legal aspects, e.g. DVLA Social services, e.g. Certification Professional regulation, e.g. GMC Business aspects, e.g. GP contract Prescribing, e.g. Controlled drugs Appropriate use of resources, e.g. drugs Health & Safety, e.g. needlestick injury Ethical, e.g. Mental capacity, consent

12. Essentials for AKT Know latest guidelines Know the BNF Know basic stats Your core medical knowledge is probably already sufficient.

13. AKT 1164 candidates Mean score 76.5% Pass mark 69.85% Pass rate 83.7% Pass rate ST276% Pass rate ST388%

14. AKT – Areas of weakness Asthma COPD Certification Travel health (vaccinations and commonly used drugs) Management of dermatological problems National screening programs

15. CSA You must bring: BNF, Stethoscope, Ophthalmoscope, Auroscope, Thermometer, Patella hammer, Sphygmomanometer (aneroid or electronic), Tape measure, Peak flow meter and disposable mouthpieces There are no spares at the exam centre Anything else you need is provided

16. CSA You have your own room. You have a list of patients – your ‘surgery’ for the morning. The list contains brief info about the patient. It may or may not include PMH, drugs etc. You probably wont know why they are coming. You have never seen the patient before – but colleagues might have.

17. CSA Buzzer will sound and patient and examiner come in. You have 10mins after which buzzer will sound again. Anything said or done after this will not count. The patient and examiner then leave. There is no ‘1min/2min’ warning buzzer. There is a 2 minute break between patients. There is a 15min break after 7 patients seen.

18. CSA The examiner sits out of your line of site. Examiner does not participate in the consultation. Ignore them. All patients are played by actors who have been well briefed beforehand They will almost certainly not have any physical signs to elicit on examination

19. CSA – Exams and investigations If you want to examine the patient say so and say what you are going to examine. If they are testing this exam technique they will let you go ahead. They will then give you the exam findings. If they are not testing this exam they will just give you the findings and tell you not to examine. They will only give you results of exams you say you will do.

20. CSA – Exams and investigations Examination is what you would normally do as a GP. This means a lot of it can be done with the patient sitting in the chair. It does not have to be exhaustive. Eg. Chest exam – percussion and auscultation is fine.

21. CSA – Exams and investigations Any investigation results will be on the table in front of you or, more likely, will be brought in by the patient. It will list normal levels so you don’t have to remember them. Abnormal findings will be common GP tests. Eg. Hb, HbA1c, urinalysis etc. It will not be anything obscure.

22. CSA – Management plans If you want to prescribe a drug you don’t have to write a prescription All you need do is say Eg. I will give you omeprazole 20mg once a day. This is as good as having written it. There are prescription pads on the table. Do not let these distract you.

23. CSA – Management plans DON’T WRITE ANYTHING DOWN There is no time The prescription will be marked There is no penalty for just saying it You have to say what you are giving anyway

24. CSA – Management plans The same applies for blood tests and sick notes and any other forms you might write. Just say what you will do. If you want to make a referral, ask the patient to wait in the waiting room and you will bring the letter/form out to them. Leaflets can be ‘collected from reception’

25. CSA You have 10 minutes per case. ‘Shows poor time management’ is a reason they can fail you at the station. And they will. You MUST be consulting at 10 minutes.

26. CSA Each case is marked in 3 domains : – Data gathering, examination and clinical assessment skills – Clinical management skills – Interpersonal skills All domains have equal weighting Do not spend 8 minutes on history and examination – you will fail the station.

27. CSA But those domains have no meaning… What are they actually looking for?

28. CSA DATA-GATHERING, TECHNICAL & ASSESSMENT SKILLS Gathering & using data for clinical judgement Choice of examination Investigations & their interpretation Demonstrating proficiency in performing physical examinations & using diagnostic and therapeutic instruments

29. CSA CLINICAL MANAGEMENT SKILLS Recognition & management of common medical conditions in primary care Demonstrating a structured & flexible approach to decision-making. Demonstrating the ability to deal with multiple complaints and co-morbidity. Demonstrating the ability to promote a positive approach to health

30. CSA INTERPERSONAL SKILLS Demonstrating the use of recognised communication techniques to gain understanding of the patient's illness experience and develop a shared approach to managing problems. Practising ethically with respect for equality & diversity issues, in line with the accepted codes of professional conduct.

31. CSA The grades will be on a four point scale: Clear Pass Marginal Pass Marginal Fail Clear Fail There are no merits or ‘grades’ at the end for the exam as a whole. You pass or fail.

32. I Failed?

33. Data Gathering Disorganised and unsystematic in gathering information from history taking, examination and investigation Does not identify abnormal findings or results or fails to recognise their implications Data gathering does not appear to be guided by the probabilities of disease Does not undertake physical examination competently, or use instruments proficiently

34. Clinical management Does not make appropriate diagnosis Does not develop a management plan (including prescribing and referral) that is appropriate and in line with current best practice. Follow-up arrangements and safety netting are inadequate Does not demonstrate an awareness of management of risk, and health promotion

35. Interpersonal skills Does not identify patient’s agenda, health beliefs & preferences / does not make use of verbal & non- verbal cues Does not develop a shared management plan or clarify the roles of doctor and patient Does not use explanations that are relevant and understandable to the patient Does not show sensitivity for the patient’s feelings in all aspects of the consultation including physical examination

36. Global Disorganised / unstructured consultation Does not recognise the challenge (e.g. the patient’s problem, ethical dilemma etc.) Shows poor time management Shows inappropriate doctor - centeredness

37. Essentials for CSA Be in general practice for a few months Consult at ten minutes