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In the Hot Seat:
Dr Mahibur Rahman

Mahibur RahmanDr Mahibur Rahman, Medical Director of Emedica, shares with Charlotte Hudson insider knowledge on how to pass the MRCGP exams

In March the GMC announced it had set up an independent review into the MRCGP exam result pass rates, following concerns about failure rates for doctors who qualified outside the UK or Europe, as well as among UK-trained black and minority ethnic doctors.

At the LMC’s conference in May, a motion was passed calling on the BMA, RCGP and GMC to investigate reasons for the disparity in pass rates, and to improve feedback from the exam.

Figures from the RCGP show that 65.3% of international graduates failed at their first attempt of the CSA component of the MRCGP exam in 2011/12, compared with 9.9% of UK graduates.

Dr Mahibur Rahman is a Portfolio GP in Birmingham as well as a trainer of doctors at all stages of their careers, including Foundation trainees, GP trainees, GP registrars, and GP trainers. He has taught more than 17,500 delegates including courses to help GP trainees prepare for the MRCGP AKT and CSA exams, and GP careers related courses.

He also leads MRCGP CSA for Trainers courses, helping GP trainers prepare their registrars for the CSA exams. “There are multiple factors that may contribute to the difference in pass rates in the MRCGP CSA exam. Some have been identified, and others are still not clear. It is important that the CSA maintains high standards in general practice, but it is also essential that confidence in the exam is restored by looking into and tackling the reasons behind the differences in pass rates.

"I hope the independent review and further research will help identify any factors that could be addressed earlier on in training to ensure doctors can get the extra support that they need in a timely manner. Improving the feedback from the CSA exam will help both registrars and trainers identify more clearly which areas to work on to help them improve before a resit.”

Why graduates fail the CSA

Dr Rahman says: “One of the common reasons why trainees fail the CSA is poor preparation. There are a lot of myths about the CSA and sometimes candidates don’t do their own research of the facts and so act on some of these myths. This can lead them to worry about the wrong things instead of preparing more appropriately.

"For example, a common myth is that it’s all about communication – of course, communication is an important part of the exam, but most of the marks in the CSA are clinical. Two thirds of the marks for every case relate to taking a good history, recognising relevant examinations, working out the diagnosis and appropriate management. Most candidates fail because of low marks in the clinical management domain of the case.”

Of course, communication is an important part of the exam, but most of the marks in the CSA are clinical
Dr Rahman explains that some candidates try to act a certain way and learn set phrases instead of consulting in a natural manner: “Some candidates are very formulaic in how they approach the consultation; they learn set phrases which they use at certain points of the consultation – for example relating to a patient’s ideas, concerns and expectations. In some cases asking about some or all of these can be very helpful but in others there is no need as the patient may volunteer them early on.

"If a candidate still asks set questions about ideas, concerns and expectations when they have already been volunteered, it comes across as formulaic and seems awkward – the patient will think you’re not listening and it appears to the examiner that you are just box-ticking.

"The really good candidates listen well, and then decide what to explore next depending on the patient. They are comfortable changing the order and style of question depending on what happens – it flows naturally like a real conversation, while at the same time ensuring that all important clinical areas are covered.” 

Another reason is poor questioning skills. Some candidates are disorganised in how they take the history and gather data; they will start by taking a history of pain but then will jump to lifestyle issues and then back again, missing important information. Some have a questioning style that seems almost like an interrogation, or a test of the patient’s knowledge. Poor time management is another reason why a lot of candidates struggle to get things done in the ten minutes that they have to see each patient.

Instead of taking a focused history of what is clinically relevant they will ask a lot of general questions, some that might not be relevant to that patient. This means that they may know how to manage a condition but will not get any marks for this domain as they don’t leave enough time to discuss it. For example, some candidates are still taking a history eight minutes in and by the time they have finished the examination the buzzer sounds so they don’t get any marks for diagnosis or management.

“Getting used to taking focused histories and managing time is something that comes with experience,” says Dr Rahman. “The more patients they deal with in real life, the easier it’s going to be for them to manage their time in the exam.”
Some have a questioning style that seems almost like an interrogation, or a test of the patient’s knowledge

Another common reason, Dr Rahman explains, is poor knowledge. “Two thirds of the marks in every case are clinical, so you need to know your stuff; what the red flags are to exclude if someone comes in with a headache, what the red flags are to exclude if someone comes in with dyspepsia, etc.

"With good knowledge you will know what symptoms to watch out for if someone has a problem, which questions you can safely omit for which presentation to make a history more focused. It will also allow you to make a diagnosis and explain the correct management more confidently. Some candidates underestimate the knowledge required and neglect their reading – to do well in the CSA, you need the same level of knowledge needed to do well in the clinical part of the AKT.”

Passing the AKT assessment

The second examined element to the MRCGP is the Applied Knowledge Test (AKT). Trainees who pass this assessment will have demonstrated their competence in applying knowledge at a level which is sufficiently high for independent practice. Mahibur’s top five tips for passing the AKT exams:

  1. Start revising early. It is a large curriculum and there’s a lot to go through. Most doctors will need at least two to three months to cover the material. 
  2. Understand the exam. It is 80% clinical medicine, 10% statistics and 10% organisational. It is important that the bulk of your time should be focused on revising the clinical area as that’s what most of the questions cover. 
  3. Try to make your learning active. Rather than just reading a text book cover to cover, mix reading with making notes and practising questions. Make sure you have a good understanding of the subjects rather than just specific questions. 
  4. Cover your weakest areas first. Candidates often practise questions on the topics they are most confident in – it is nice to do well and feel good about yourself. However, it is more effective to revise the areas that you are least confident in first, as they are the areas where you will be able to improve the most.
  5. Manage your time on the day of the exam. You have 180 minutes and 200 questions, giving you just over 50 seconds per question. Be disciplined – if you don’t know the answer after 50 seconds, have a guess, mark the question for review and move on. You can always come back to the difficult questions if you have time later.
Trainees who pass this assessment will have demonstrated their competence in applying knowledge at a level which is sufficiently high for independent practice

Challenges of meeting CPD

GPs in the UK now have to provide evidence of their learning for revalidation. To assist with this the RCGP developed a CPD credits system whereby one hour of education equates to one learning credit – each GP is expected to collect a minimum of 50 credits in a year.

It is important that doctors fit in time to go on courses because medicine is always changing, and it is a good way of identifying the skills that you need to improve

“I think most doctors are comfortably doing more than 50 hours of CPD anyway and it’s just that we now have to make sure that we record it and identify what it is we have learnt,” says Dr Rahman. “The challenge is that once you are a qualified GP you are going to have to fund your own CPD in most cases, and because money is tight for a lot of people, one of the easy things to do once you’re qualified is to put CPD quite low down on your list.”

Dr Rahman explains how it is important that doctors fit in time to go on courses because medicine is always changing, and it is a good way of identifying the skills that you need to improve. Learning a new skill is also a good way of helping you stay motivated and preventing you from getting burnt out. The restructuring of the NHS has resulted in a larger workload for GPs, along with less funding.

Dr Rahman anticipates some older GPs retiring early because of revalidation. “Some very experienced GPs who have been keeping up to date with their CPD and doing more than the required amount might feel like they don’t want to jump through the hoops, and might retire early. If this happens it will have a knock-on effect on the workload of the GPs that remain and newly-qualified GPs.”

Importance of taking extra courses during training

Dr Rahman says that taking part in extra courses and revision is an important part of the training process; once you’re qualified it’s much more difficult to get time off. Taking study leave now will help develop skills and knowledge that will help you in your current job as well as in your career later on. Many registrars also benefit from attending a course to help them focus when preparing for their exams.

“A lot of trainees find attending a revision course helpful for their MRCGP exams; they can cover a lot in the day and it’s helpful to meet other trainees who are preparing to get a different perspective. Sometimes candidates fail an exam by a few marks, and gaining a better understanding of the exam, and improving technique can help them get through.

“For the CSA, it can make a huge difference – attending a course with professional simulated patients and individual feedback can give trainees a realistic idea of how ready they are for the exam, identify their weaknesses and show them what they need to work on.”

For more information on Dr Mahibur Rahman and the courses that Emedica offer, visit www.emedica.co.uk
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