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Whether you’re gearing up to run the RACGP written exam races soon, or pacing your study for next year, it’s worth considering your training approach. No-one wants a false-step or start’ (which is a synonym for fail) which I explored in a previous blog.

Repeated false starts can result in disqualification so it’s important to act early to identify any reasons for the false-start that can be rectified.

Sometimes the reason for the false-start can affect your performance in the entire race, and the longer the distance, the more likely it is for small issues to become large ones.  The anxiety that caused you to break the start, that tiny blister on your heal, missing breakfast that morning, or skipping that training session a few weeks ago, could stop you from completing the race.

So how do you work out what caused the false-start?

This brief video by Dr Atul Gawande gives a great insight into Why Doctor’s Fail.

Make sure you know what the race entails.

Do you know all there is to know about the race that you’re entering?  It’s interesting that the feedback in exam reports is pretty much the same each time.  That means that those in the exam race are continuing to make the same mistakes.

It’s not good enough to identify the common errors, you need to make sure that you have a strategy to address them.    Let’s look at the common errors made in the RACGP Assessments and some strategies to help avoid them.

These are also the common oversights and errors that are made in real clinical practice! 

Applied Knowledge Test (AKT)

ISSUE STRATEGY

·     Read the question carefully – does you answer fit the most appropriate option versus the most likely?

·       Read the question twice, annotate the prominent key features, generate differential, then look at the other key features and narrow it down.
·     Take note of context and setting. ·       Identify cultural and location factors.
·     Use clinical reasoning based on the information given – don’t make assumptions based on information that is not presented (availability bias comes in here). ·       Only work from your list of identified key features.  Past experience and practice question answers can lead you down the wrong path.
·     Look at the timing of the presentation and the time course of illness. ·       Does the presentation history fit the time course of the differentials you are considering?
·     Consider disease frequency and population health when answering questions.

·       Are there clues to disease prevalence and incidence.   This is called the Base Rate of a condition and can be open to bias.

Key Features Paper (KFP)

ISSUE STRATEGY

·       It is not just a short-answer paper – if you haven’t had to analyse to produce your answer, it may be incorrect.

·       If you have put down an answer without thinking, justify how you arrived at that conclusion.
·       Often the answers are focused incorrectly on past medical history rather than the presenting complaint. ·       Initial differentials should be made on the presenting complaint, and then the history used to re-frame.   Generate a differential list on the prominent key features, not all of them.
·       Answer the question provided and only give the number of responses require. ·       Succinct and specific is the key.
·       Don’t use generic terms. ·       If your answer could be provided by a medical student, you are not demonstrating the required level of knowledge.
·       Check guidelines. ·       These change all the time – make sure you are up to date.
·       Do the practice exam. ·       Practice exams are for identifying knowledge gaps and familiarising yourself with technique.   Everyone needs a warm-up race.
·       Your answers should exemplify your reasoning and that you are safe to manage the case.

·       Ask yourself if your history, examination and investigation steps help you to rule in or out your original differentials.

OSCE

ISSUE STRATEGY

·       Ensure a systematic approach

·     Use an OSCE Reading Time Proforma to ensure you have structure.
·       Ensure your responses are empathic and appropriate. ·       “I’m so sorry to hear that” is not always appropriate.   There are other words to express empathy.  Doctors Speak Up is a great resource.
·       Use Open-ended questions. ·     Allow the patient an opportunity to freely provide information.
·       Check the patient’s understanding of problem and plan. ·     Reflect the history and management back to the patient and ask for their interpretation and clarification.
·       Enunciate confidentiality. ·     Particularly with sensitive issues, child and adolescent health, mental health, and medico-legal presentations.
·       Cover all tasks. ·     Write a task list in reading time, check intermittently what you have covered.
·       Listen to cues, especially if repeated. ·     Only certain prompts are allowed.  If they’re repeated it’s for a reason.
·       Avoid jargon. ·     Consider the jargon words you use often – and then of course avoid.
·       Read handouts carefully so information is not misinterpreted. ·     Take time to read carefully.   Run your finger down the list of tests to ensure that you don’t miss a thing.
·       Checking for obstacles to management. ·     Location and cultural context are important here.
·       Make sure you have time for safety-netting, summarising and follow-up. ·     Do this at the start of management so it’s not forgotten or time restricted.
·       Prioritise information that should be shared (e.g.  know now, know later).

·     Summarise your management plan at the start of management and then work through in order of priority.

Once you know what the race entails, it’s time to review your training.

There’s no point knowing how to run the race, unless you have the skills and the attitudes to put that knowledge into practice.

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Knowledge

  • Check your fitness level: This may be an individual race, but others have run it before and are running it with you.   Calibrate your knowledge against peers to identify areas that could be improved.
  • Use a Study Plan: Moving from topic to topic using a ‘one size fits all’ model will not necessarily work.   The MAP App can create an individualised, research and curriculum-based 20 week study plan for the RACGP Exams.   If you are siting in 2020.2, now is the perfect time to use the MAP App as you have time for 20 weeks of planned study and 20 weeks of revision (and a little extra).  Use the MAP App conjunction with the GP Study System  to focus your study and access the appropriate resources.
  • Learning Styles: Consider if how you are learning is actually how you like to learn.  A learning styles questionnaire can help you to define how you learn.
  • Reinforcing your learning: Regurgitation of a list won’t gain you a pass.  Think about how you can contextualise your learning.  Sit in with a colleague or allied health professional who sees a different patient demographic to yourself.

Skills

  • Clinical Reasoning:   The Clinical Reasoning Compass Course can improve your diagnostic and therapeutic accuracy and your clinical reasoning.   There are also ebooks available on the subjects of clinical reasoning and exam preparation.
  • Direct observation of practice: This activity has been found to be the best way to review a GPs performance in the ‘real world’.  You can also learn a lot by sitting in with another GP in the practice for some ‘peer calibration’ or having them sit in with you and provide feedback.
  • English as a Second Language (ESL) Tutoring: This specific tutoring can ensure you are interpreting questions correctly.
  • Typing courses: Increase your typing speed to allow for longer time to think in exams.

Attitudes

  • Career Counselling: Be sure of where you are headed in your medical career and in particular if continuing your current plan of study will get you there.
  • Confidence Coaching: Lack of confidence can severely impair your exam approach and performance on the day.  The Professional Enrichment Program can help with this.
  • Dealing with uncertainty: Fail safeing your practice – knowing the masquerades, PROMPTs (Probability diagnosis, red flags, Often Missed, and is the Patient Telling me something) – learning these from Murtagh is one thing but entwining them in your practice is the key and will give you confidence.
  • Interpersonal skills: Gain an insight into your interpersonal skills by completion of either Multisource Feedback (MSF) or CARE Measure.

More Training Tips

If you are having difficulties with the AKT rather than the KFP, you may like to consider arranging an Adult Learning Assessment with a Psychologist.    The AKT contains many more words than the KFP and if you have adult learning difficulties such as dyslexia this can be important and can help you understand techniques to improve your approach.  Another indicator that this assessment might be useful is difficulty with AKT/MCQ questions when you were studying medicine at University.

Self-care is also important.   Working too much and not having enough time to study is often the fundamental problem, along with being too mentally fatigued to study when the time comes.  Studying for repeated exam cycles results in ‘study fatigue’ and whilst there are often other factors that contribute to time pressure to ‘re-sit’, sometimes a break from study will improve outcomes.  

If an injured athlete returns to training before their form returns, then it is unlikely that their performance will be optimal.  Why not make the time to have a chat with your GP to check your physical and emotional fitness?

Your Coach

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We all approach learning in different ways – it depends somewhat on how much intrinsic and extrinsic drive you have.  If you can successfully combine learning and training, then you are likely to achieve your goal.

If you have a Coach to help define your learning and training initially, and travel with you on the journey, you are much more likely to stay on track and reach your objectives more easily.

The Coach may be in the form of a Training Pathway, Medical Educator or Mentor.  Make sure that your Coach has the appropriate experience and credentials to provide advice. An Assessment in Medicine (AIM) Consultation is a great place to start.

You are taking part in a high-stakes and high cost (financially and personally) race, but you already have great knowledge, skills and attitudes imparted by your medical training.

Why not take the opportunity to reassess your approach to ensure you get over the line?

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Please feel free to comment.