Ten tips to pass the AKT

The Membership of the Royal Colleges of General Practitioners (MRCGP) Applied Knowledge Test (AKT) is a challenging exam, testing applied knowledge relevant to UK general practice. This article provides some key tips to help you prepare for and pass the exam.

1. Understand the basics

The exam lasts 3 hours and 10 minutes, and consists of 200 questions. Eighty percent of the questions relate to clinical medicine, 10% to evidence-based practice and 10% to the organisational domain. The exam is computerised, and there is now access to a basic on-screen calculator. The majority of questions are single best answer and extended matching questions. Other formats include algorithm questions, short answer (you type the correct answer into a box), video questions and picture-based questions.

2. Fail to prepare, prepare to fail

Allow enough time to revise all the material in the exam; most candidates need 3 or 4 months to be able to cover everything sufficiently well to pass. The curriculum is large and covers a broad range of topics; try to have a systematic approach to allow you to cover all the important topics adequately. The RCGP (RCGP, 2014) has produced an AKT topic review, which details the key areas and subjects covered. The Medical Protection Society (Medical Protection Society, 2011) has produced a more concise checklist of key topics as part of their free MRCGP Study Guide.

3. Cover the clinical domain effectively

Aim to spend the majority of your revision focusing on the clinical domain: this makes up 80% of the questions (160 questions). Someone who scored very poorly in this area (under 60%) would usually fail the exam, even with 100% in the other domains. Overall, a poor score in this domain is the most common cause of failure in the AKT exam. It also takes the longest time to cover, as the bulk of the curriculum is focused on clinical topics. Questions from the clinical domain can include those relating to making a diagnosis, ordering and interpreting tests, disease factors and risks, and management. The Oxford Handbook of General Practice (Simon, Everitt, van Dorp, & Burke 2014) is a useful starting point, although you need to supplement this with other sources to ensure you are up-to-date with newer guidelines. A good knowledge of key guidelines e.g. by the National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network and British Thoracic Society, is essential. The volume of topics can make this domain seem daunting; a good way to cover it effectively is to work through topics from different clinical areas, starting with your known weaker areas. This may include areas you have not been exposed to in clinical practice since medical school, or areas identified with the help of your trainer early on in your rotation. Once your revision is underway, you may identify further gaps in your knowledge by working through sample AKT questions.

4. Revise core statistics and evidence-based practice

Ten percent of the exam is evidence-based medicine, including basic statistics, graphs and charts, and types of study, which offer easy marks if you grasp the basic concepts. Make sure you can calculate averages (mean, mode, median), numbers needed to treat (NNT), sensitivity and specificity, as well as understanding absolute and relative risk, odds ratios, p values, 95% confidence intervals and standard deviation. Questions will test your ability to apply your knowledge, rather than simply recall facts e.g. being able to calculate the NNT from a table of results.

You should be able to interpret scatter, L’Abbe, Forest, funnel and Cates plots. Finally, understand the common study types, including cross-sectional surveys, case-control studies, cohort studies and randomised controlled trials, as well as recognising the difference between qualitative and quantitative studies.

5. Do not forget the organisational domain

This makes up 10% of the exam, and is where most candidates do worst. These areas can be dull to read, but learning about practice management, Quality and Outcomes Framework, certification, Driving and Vehicle Licensing Agency guidelines and legal duties of doctors, will not only get you easy marks, it will be useful when you qualify.

6. Learn from other people’s mistakes

Read through the examiners’ feedback reports to see which topics caused trainees problems, as they are usually retested in the next few exams. Having analysed every feedback report published so far, it is interesting to note that the same subjects are repeatedly featured!

7. Make the most of your revision time

Effective revision should combine reading with practising questions. Try to practise questions to time, as time pressure is a big issue with this exam: you have about 57 seconds for each question! If you get a question wrong, try to read more broadly about the subject to gain a deeper understanding. By relating it to a question you have just answered, you are more likely to retain the information. Concentration drops dramatically after an hour, so try to revise in chunks of no more than an hour at a time. Take a short break, even for 10 minutes, to make a hot drink, or get some fresh air.

8. Learn the subject, not the question

Some candidates approach AKT revision by picking an online revision service and then go through all the questions multiple times. This can lead to a false sense of security and ultimately failure in the exam. Repeating the SAME questions multiple times provides very little additional benefit. Often complex questions, such as data interpretation, are answered the second time by remembering the pattern rather than understanding the subject. A better approach is to read up on the subjects and explanations after doing a set of questions, and then once you complete all the questions, move on to a different set of questions from a different service or book.

9. Read the question carefully

Many candidates that have a good knowledge base still fail by a few marks due to poor exam technique. It is really important to read the question carefully to prevent losing marks for silly mistakes. This can relate to the instructions e.g. some questions ask you to drag the right answer into a certain part of the screen: clicking the right answer instead of dragging it will gain no marks. Understand certain keywords e.g. if the question asks for a ‘characteristic feature’, it means it is there in almost every case (90% or more), whereas if it asks for a feature that is ‘commonly’ seen in a condition, it only needs to be there in around 60% or more of cases. Some questions are negatively framed – “Which of the following is not part of the Rome III criteria for diagnosing irritable bowel syndrome?” – candidates that fail to spot the “not” in this question could easily select the wrong answer despite knowing the Rome III criteria.

10. Keep to time

To complete the entire paper, you have just 57 seconds per question. Try to be disciplined – if you are not entirely sure of the best answer, it is better to put down your best guess after about 55 seconds and move on. You can flag questions for review, so you could try to come back if you finish a little early. By being strict with your time, you will at least pick up all the easy marks for topics that you have covered in your revision. Candidates that spend 2 or 3 minutes struggling with a few really challenging questions often end up unable to complete the paper. They may have missed easy marks from questions at the end of the paper that they did not see. It is useful to have some pace checkpoints – try to finish 33 questions every 30 minutes. At this pace, you will have completed 66 questions after an hour, 99 questions after 90 minutes, and complete the whole paper with just less than 10 minutes left to go over any questions flagged earlier.

Summary

The MRCGP AKT is a challenging exam with a significant failure rate – around a quarter of candidates fail each exam, with the long-term mean pass rate around 73%. It covers a large curriculum, so it is important to allow enough time and to have a plan to enable you to prepare in a systematic way. A lot of the knowledge gained from preparing will help you not only in everyday practice, but also for the MRCGP Clinical Skills Assessment. By mixing reading with practice questions, you should have both the knowledge and the exam technique to allow you to pass well.