1. MRCGP Applied Knowledge Test

2. AKT Background The AKT:
Is a summative assessment of the knowledge base that underpins independent UK general practice.
Tests the application of this knowledge
Tests the critical interpretation of information
Is mapped to the Curriculum
Each question is intended to explore a topic of which an ordinary GP in the UK could be expected to have a working knowledge

3. Format A 3-hour, 200-item multiple-choice test
No multiple true/false questions
No negative marking
Delivered on a computer terminal at an invigilated test centre
Offered three times a year:
Jan/Feb, April/May, Oct/Nov.

4. Rules
Only trainees in the ST2 and ST3 stages of training will be eligible to take the AKT
A maximum number of four attempts will be permissible in the AKT

5. Jan 2013
The pass mark for AKT 17 was set at 132 with pass rates as below:
Candidates (numbers) pass rate
All candidates (1248) 68.7%
ST2 first-time takers (755) 79.6%
ST3 first-time takers (115) 71.3%
Asthma guidelines, antibiotic guidelines, non-medical prescribers and diagnosis of DM were all done poorly

6. Common Reference Material
GP Curriculum
Content guide for the AKT
BNF
GMC Good Medical Practice
RCGP Essential Knowledge Updates
NICE guidelines
SIGN guidelines
BMJ Review articles & original papers
BJGP
Cochrane
Emphasise the BNF – beginning chapters, current edition and updates

7. GP Curriculum + AKT Content Guide
The AKT Content guide is a new learning resource which is designed to be used in conjunction with the curriculum
How to use the Content Guide
Don’t be put off by the lengthy list of topics!
Do use the guide as a needs assessment tool
In particular, carefully review the sections:
Organisational –including administrative, statutory, ethical and regulatory frameworks
Evidence interpretation – including research, statistics and epidemiology
Check latest
Add Content Guide

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

9. Clinical Medicine
Common, low impact – e.g. sore throat, otitis media, impetigo
Rare, high impact – e.g. child abuse, meningitis, phaeochromocytoma
Topical – e.g. MRSA, Type 2 diabetes management 9

10. Critical appraisal and evidence-based clinical practice
Understanding the principles of audit and its application in assessing the quality of care
Understanding the application of critical appraisal skills which will be tested in a number of formats including:
the interpretation of research data
the understanding of terms used in both statistics and evidence based medicine
understanding epidemiology relevant to general practice

11. Ethical, Legal & Organisational
NHS organisation
Legal aspects e.g. DVLA
Medical certification e.g. death certificates
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. needle stick injury
Social services e.g. safeguarding
Ethical e.g. mental capacity, consent
Content Guide Chapter +++

12. Question Formats Single Best Answer (SBA)
Extended Matching Questions (EMQ)
Table/Algorithm
Picture/Video Format
Drag and drop
Hotspot images
Data interpretation
Free text
Rank ordering

13. Single Best Answer (SBA)
“According to national guidelines” means recommended by nationally accepted guidelines or the BNF, not local practice
Often uses a clinical scenario
Only ONE answer is correct
Other options may be plausible but not “MOST LIKELY”

14. SBA example: Respiratory disease
A 17-year-old student suddenly develops chest pain and dyspnoea after a morning swim. There is hyper-resonance and decreased breath sounds on the right side.
Which is the SINGLE MOST likely diagnosis? Select ONE option only.
A. Asthma
B. Pneumothorax
C. Pulmonary embolus
D. Left ventricular failure
E. Pulmonary haemorrhage

15. Extended matching questions (EMQ)
These questions have a list of possible options
There will usually be 2 or more scenarios
Choose the MOST appropriate option that BEST matches each given scenario
Each option can be used once, more than once, or not at all.

16. EMQ example: Double vision
A Berry aneurysm
B Cerebral glioma
C Drug induced
D Graves’ disease
E Ischaemic stroke
F Multiple sclerosis
G Myasthenia gravis
For the patient described, select the SINGLE MOST likely diagnosis from the list of options.
1. A 35-year-old man who is a non-smoker, suddenly develops a severe headache and double vision. His right pupil is fixed and dilated.
Berry aneurysm and stroke possible but age and non-smoker make aneurysm MOST likely

17. EMQ example: Double vision
A Berry aneurysm
B Cerebral glioma
C Drug induced
D Graves’ disease
E Ischaemic stroke
F Multiple sclerosis
G Myasthenia gravis
For the patient described, select the SINGLE MOST likely diagnosis from the list of options.
2. A 48-year-old woman has transitory double vision towards the end of most days. She smokes 10 cigarettes/day. She has vitiligo and hypothyroidism.
Myasthenia Gravis 17

18. Algorithm example: Medical management of menorrhagia
Non-hormonal
Hormonal therapy
1 _______
2 _______
Combined oral contraceptive pill
3 _______
For each of the numbered gaps above, select ONE option from the list to complete the algorithm, based on current evidence.
Each option may be used once, more than once or not at all.
A Cyclical norethisterone
B Copper-bearing intra-uterine device
C Inert intra-uterine device
D Levonorgestrel releasing intra-uterine system
E Medroxyprogesterone acetate
F Mefenamic acid
G Nonoxinol ‘9’
H Tibolone
I Tranexamic acid
This would be a “drug and Drop” format on computer and candidates will have chance to practise on a tutorial

19. Picture Format example: Skin disease
A 32-year-old man has noticed painless non-itchy patches of hair loss on his beard area and scalp.
If a question was a ‘hotspot’ format, the candidate would be asked to mark the correct area on the picture

20. Picture Format example: Skin disease
Which is the SINGLE MOST likely diagnosis? Select ONE option only.
A Alopecia areata
B Eczema
C Lichen sclerosis
D Tinea infection
E Vitiligo
Ref: Dermnet.com

21. Data Interpretation
Interpretation of data, e.g. for groups of patients with chronic conditions
Interpretation of research and audit results
Understanding and application of common statistical terms, e.g. sensitivity and number needed to treat (NNT)

22. Data Interpretation example
The summary findings of a systematic review which included six separate studies are shown opposite.
Ref: BMJ  2007;335:473 
All the studies show reduced risk with increased intake of whole grain but Montenen reaches the line of no effect therefore has the weakest association

23. Data Interpretation example
Which SINGLE study suggests the WEAKEST association between increased whole grain intake and a risk of type 2 diabetes?
Select ONE option only.
A Fung
B Meyer
C Montonen
D NHS1
E Van Dam 23

24. Free text questions
Require the candidate to generate the correct answer without a list of options to choose from e.g:
dose calculation
name of first-line medication
Eliminates guessing from a list of answers
All answers are screened manually to check for acceptable misspellings 24

25. Free text example
Which SINGLE vitamin is administered to reverse the anticoagulant effect of warfarin?
Give ONE answer only
Vitamin _____ 25

26. Scoring All question formats have equal weighting
Each correctly answered question is awarded one mark
Total score on the paper is the number of correct answers given
No negative marking – it is important to answer all the questions 26

27. Feedback to candidates
The following feedback will be provided to every candidate with their result
Their overall score
The pass mark
Their performance in each of the 3 main subject areas

28. Further preparation
Small revision groups to share the workload of reviewing national guidance, BNF chapters etc
Learn from clinical experience – check the guidelines and references
Exam website feedback (summary reports published for every AKT sitting)
Exam website sample material
RCGP website – Essential Knowledge Updates and Challenges

29. Advice from successful trainees:
Samples of AKT questions are provided every month, linked to the curriculum coverage, in the InnovAiT Journal provided free to AITs by the RCGP.
PEP (RCGP) AKT style questions linked to curriculum statements and explanations
PassMedicine Course Large question bank with feedback to place your mark in tests against others applying to AKT, plus teaching notes. Can set yourself practice exams and helps you get used to thinking quickly
PasTest offer both online courses and revision books
NB GP Update Course One day course. Review of recent developments. Useful course book provided.
NICE Guidelines- the exam is very up to date!
RCGP Essential Knowledge Updates
Dot medic
On Examination (BMA)

30. EBM & Stats & Critical Appraisal
T D. Sackett “Evidence Based Medicine” Churchill Livingstone
Greenhalgh articles or book “How to read a paper” 1997 BMJ Books
How to read a paper: A series in the British Medical Journal on database searching and article appraisal adapted from the book. BMJ 1997
Medical Statistics Made Easy- book

31. Slow readers/ some IMGs
If you think reading speed is slower than average this website can help to speed it up

32. Practice Management
Oxford Handbook of General Practice

33. Risk of hip fracture
A cohort study is conducted to evaluate the relationship between dietary calcium supplementation and the occurrence of hip fractures in post-menopausal women.
The study examines the hip fracture rate in 100 women taking calcium supplements and 100 women taking placebo over three years.
Over the three year period, five women have hip fractures in the calcium group and ten women have hip fractures in the placebo group. The 95% confidence interval is 0.18 to 1.4.
What is the RISK of a hip fracture in the TREATED group? Select ONE option only.
A 0.01
B 0.05
C 0.1
D 0.5
E 1.0
What is the RISK RATIO? Select ONE option only.
Risk= 5/100= 0.05
Risk Ratio= risk in the treated group/ risk in the control group= 0.05/ 0.1= 0.5

34. Child growth
An eight-month-old baby girl’s routine measurements have fallen from the 50th centile growth line to below the 25th centile growth line over the past three months. She has a history of minor respiratory infections and recurrent gastroenteritis.
Which is the SINGLE MOST appropriate INITIAL investigation? Select ONE option only.
A Chromosome analysis
B Glucose-6-phosphate dehydrogenase level
C Jejunal biopsy
D Sweat test
E Thyroid function test
Sweat test

35. Childhood illness
A seven-year-old girl has a fever associated with a sore throat and loss of appetite. She has small red ulcers in her mouth and itchy spots on the palms of her hands and soles of her feet.
Which is the SINGLE MOST likely virus causing her symptoms? Select ONE option only.
A Coxsackie A
B Herpes simplex
C Measles
D Parvo-virus B19
E Varicella-zoster
A = Coxsackie A= hand, foot and mouth disease

36. Epidemiological measures
A primary care organisation requires information to estimate the typical duration of hospice services required for patients with pancreatic cancer.
Which is the SINGLE MOST appropriate epidemiological measure for the situation described above? Select ONE option only.
A Case fatality
B Incidence
C Median survival
D Mortality
E Prevalence
Median survival

37. Epidemiological measures
Which is the SINGLE MOST appropriate epidemiological measure to estimate the rate at which the new cases of papilloma virus infection occur among students on a college campus? Select ONE option only.
A Case fatality
B Incidence
C Median survival
D Mortality
E Prevalence
Incidence

38. Medical standards of fitness to drive
A 65-year-old retired man had a routine coronary artery angioplasty and stent insertion one week ago. He is now well and asymptomatic. He asks you for advice about driving.
According to DVLA guidance, which is the SINGLE MOST appropriate advice with regard to driving? Select ONE option only.
A He may resume drive immediately
B He may resume driving after a further week
C He may resume driving one month after the angioplasty
D He may resume driving six months after the angioplasty
E He must inform the DVLA and await their decision before resuming driving
A (need to have 1 week off work only- no need o tell the DVLA)

39. Skin rash

40. Skin rash
A 34-year-old woman has developed this rash on her buttock over the past two days. It is sore to touch and she has no rash elsewhere. She says this has happened on at least three previous occasions and the rash is always in the same place.
Which is the SINGLE MOST likely diagnosis? Select ONE option only.
A Chickenpox
B Coxsackie virus infection
C Dermatitis herpetiformis
D Herpes simplex
E Herpes zoster
Herpes Simplex

41. Skin rash

42. Skin rash
A 45-year-old man asks you to check this mole which is on his back and catches on his clothing. It has been present for many years and has not changed in appearance
Which is the SINGLE MOST likely diagnosis? Select ONE option only.
A Benign pigmented naevus
B Blue naevus
C Malignant melanoma
D Pyogenic granuloma
E Seborrhoeic keratosis
Seborrhoeic keratosis

43. Adverse drug reaction
A 55-year-old man is diagnosed with ischaemic heart disease, hypertension and hyperlipidaemia. Shortly after starting treatment, he develops wheezing at night and on exertion.
Which is the SINGLE MOST likely drug to have caused these symptoms? Select ONE option only.
A Aspirin
B Bendroflumethiazide
C Bezafibrate
D Enalapril
E Simvastatin
Aspirin

44. The investigation of infertility
A 25-year-old woman has been infertile for three years. She has had recurrent pelvic pain due to endometriosis. Investigations in primary care are reported as follows:
Full blood count – normal
Thyroid function – normal
Sex hormone profile - normal
Rubella serology – immune
Day 21 progesterone – normal
Chlamydia swab – negative
Her partner’s semen analysis is reported as normal.
A referral to secondary care is agreed and she asks what is likely to happen next.
According to current guidelines, which is the SINGLE MOST appropriate NEXT investigation? Select ONE option only.
A Cervical cytology
B Hysterosalpingogram
C Hysteroscopy
D Laparoscopy
E Post-coital test
D= laparoscopy

45. Contraception
Which ONE of the following is an ABSOLUTE contraindication to the use of medroxyprogesterone acetate as a contraceptive? Select ONE option only.
A Diabetes mellitus
B Breast cancer diagnosed in the previous five years
C Past history of ovarian cysts
D Previous ectopic pregnancy
E Smoking
Breast Cancer

46. Breast disease
A 28-year-old woman has asymmetric nodularity of the right breast. Her mother and aunt have been treated for breast cancer.
According to current national guidance, which is the SINGLE MOST appropriate NEXT management option? Select ONE option only
A Arrange mammography
B Arrange ultrasound
C Reassure
D Refer to breast clinic
E Review in six weeks
D= refer to breast clinic

47. Study design
A research study is proposed to reach a summary conclusion regarding the results of several investigations of exposure to environmental tobacco smoke and risk of lung cancer.
Which is the SINGLE MOST appropriate study design? Select ONE option only.
A Case control study
B Cohort study
C Correlation study
D Descriptive study
E Meta-analysis
E= meta-analysis

48. Research methodologies
A Case control study 
B Case report 
C Cohort study 
D Cross sectional survey 
E Randomised controlled trial 
For each of the investigations outlined below, select the SINGLE MOST appropriate research methodology from the list of options above. Each option may be used once, more than once or not at all. 
1 To identify a new adverse drug reaction 
2 To demonstrate the value of a screening test to pick up prostate cancer at a pre-symptomatic stage 
3 To determine the efficacy a new drug treatment for hypertension 
4 To assess the prognosis of prostate cancer picked up at an early stage 
5 To assess whether high blood pressure can get better over time 
6 To assess whether helicobacter pylori causes gastric cancer
1= B (case report)
2= D (cross-sectional survey)
3= E (RCT)
4= C (cohort study)
5= C (cohort study)
6= A (case control study)

49. Evaluation of tinnitus treatment
50 patients with severe tinnitus of at least 1 year’s duration were given either an active device or placebo device. After one week they were examined subjectively on their response and objectively by a pure tone audiogram, tinnitus pitch and loudness matching.  
Improved Total 
Subjective Active
Placebo
Objective Active
Placebo
For each of the numbered gaps in the critique below interpreting the results from the table, choose ONE from the following list which best completes the sense, and mark the corresponding lozenge on your answer sheet.
For the subjective measure the number needed to treat (NNT) was ___ and for the objective measure the NNT was ___ .
NNT- 1/ RRR
Subjective: active risk 15/30= 0.5 placebo risk 2/20= 0.1 so RRR= 0.4 hence NNT= 1/0.4= 2.5 (A)
Objective: active risk 0.4 placebo risk 0.2 so RRR=0.2 hence NNT= 1/0.2= 5 (D)
A 2.5
F 15
B 3.3
G 100
C 4
H 1000
D 5

50. Screening for ovarian carcinoma
Condition present
Condition absent
Test result positive
100
150
Test result negative 75
175
A new radiological scanning test for the early detection of ovarian carcinoma was used to evaluate 500 patients. The results were as above.
Now look at this critique, interpreting the results from the table.
This test has a sensitivity of (17) ………………… with a specificity of (18) …………………… The positive predictive value is (19) ……………….. which reflects the (20) …………………… of the disease. The negative predictive value is (21) ……………. The results indicate this is not a (22) ………… screening test.
For each of the numbered gaps in the critique choose ONE ANSWER from the following list which best completes the sense, and mark the corresponding lozenge on your answer sheet.
A 100 / (100+75)
B 100 / ( )
C 150 / ( )
D 150 / ( )
E 175 / (75+175)
F 175 / ( )
G Incidence
H Precise
I Prevalence
J Reliable
Sensitivity is defined as the proportion of people with disease who have a positive test result. Specificity is defined as the proportion of people without disease who have a negative test result.
17: 100/ (100+75)
18: 175/ ( )
How likely is someone with a positive test result to actually have the characteristic (positive predictive value)?
How likely is someone with a negative test result to actually not have the characteristic (negative predictive value)?
19: 100/ ( )
20: prevalence
21: 175/ ( )
22: reliable