AKT — Applied Knowledge Test | Bradford VTS

MRCGP Examination

AKT — Applied Knowledge Test

Because knowing things in theory is lovely, but the AKT wants to know if you can actually apply them under time pressure in a GP context. No pressure.

🎯 High-yield tips for AKT & SCA 📚 For Trainees, Trainers & TPDs 💎 Knowledge not found elsewhere

160 Questions (from Oct 2025)

160 Minutes — 2 hrs 40 min total

60s Per question on average

80% Clinical knowledge content

£481 Exam fee (2025/26)

Last updated: 4 April 2026 | Reflects Oct 2025 format: 160 questions / 160 minutes / ~60 seconds per question

📥 Section 1

Downloads

Handouts, summaries, teaching extras, and mock resources — ready when you are. Print them, save them, share them with your study group.

path: THE APPLIED KNOWLEDGE TEST (AKT)

🌐 Section 2

Web Resources

A hand-picked mix of official guidance and real-world AKT preparation resources. Because sometimes the best exam advice isn't hiding in official documents.

📚 Official & Clinical Sources

Official RCGP AKT Overview Page Official exam info, format, marking, reasonable adjustments Official RCGP Exam Dates & Booking Apply via MyRCGP portal — check dates and deadlines here Official RCGP e-Learning (Self Test) InnovAIT, Essential Knowledge Updates, RCGP Self Test Official NICE CKS Your primary clinical reference — use in every consultation Official BNF Online Drug doses, interactions, monitoring — know the first few chapters Official DVLA At-A-Glance Guide Fitness to drive — a favourite AKT topic. Know it cold. Official Notifiable Diseases What to report, and how — a regular AKT admin topic Official Childhood Immunisation Schedule Know the schedule. You will be tested on it. Guaranteed.

🎓 Revision & Exam Resources

Exam Prep Bradford VTS High-Yield AKT Package High-yield notes, question bank, and AKT Notebook Question Bank Bradford VTS AKT Question Bank High-yield notes, question bank, and AKT Notebook — built for GP trainees Official RCGP AKT Preparation Tools Official tips, question examples, and preparation guidance from the RCGP Official RCGP AKT 57 Feedback Report Oct 2025 examiner feedback — the most important free revision tool available Clinical Bradford VTS Clinical Pages All clinical topics — built for GP trainees with exam tips Wellbeing Exam Stress & Nerves (BVTS) Managing exam anxiety — don't skip this one Stats Bradford VTS Statistics NNT, NNH, sensitivity, specificity — explained simply Clinical GPNotebook Quick clinical summaries in GP context — very revision-friendly

💡

Insider Resource Tip

The RCGP publishes detailed feedback reports after every AKT sitting. These are gold. Examiners highlight where candidates struggled — and those areas are repeatedly tested. Find them in the Downloads section above and on the RCGP website. Read at least the last 3 sittings.

⚡ Section 3

Quick Summary — If You Only Read One Thing

Scanning before clinic? Night before the exam? Here's everything you absolutely must hold in your head.

⚡ AKT At a Glance — The Non-Negotiables

160 questions, 160 minutes (2 hrs 40 min) from Oct 2025
60 seconds per question (160 Qs / 160 min) — only slightly more than before
80% clinical / 10% evidence-based / 10% admin-org
No negative marking — always guess if stuck
Pass mark ~60–70%, adjusted per sitting difficulty
Max 4 attempts to pass
Sit from ST2 onwards — sweet spot: late ST2 / early ST3 GP post
4 sittings/year: Jan, Apr, Jul (from 2026), Oct
Book via MyRCGP — booking window opens ~7–8 weeks before
Stats and admin = easiest marks — don't neglect them
NICE CKS > BNF when in doubt
Read examiner feedback — same areas come up again and again
Start preparation 4–6 months before — not 4–6 weeks
Flag difficult questions, guess, move on — never get stuck

🚨

The Single Biggest Reason People Fail

Neglecting the stats and admin sections. These 20 questions are the most "learnable" part of the exam — finite, teachable, and repeatable. Yet trainees consistently score only 2–5% in stats, then fail overall by 1–3%. Study stats and admin properly. It can be the difference between a fail and a comfortable pass.

📊 Section 3b — Direct from Examiners

RCGP Examiner Feedback — What Actually Gets Tested

The RCGP publishes a detailed feedback report after every AKT sitting. This is the closest thing to an official revision guide you will find — and most trainees never read it properly.

🎯

Why This Section Matters

The 5-year cumulative feedback summary (AKT 40–57) identifies the areas that have been flagged as poorly-answered most consistently. These areas are re-tested repeatedly. Revising these is not just good preparation — it is the highest-return revision you can do.

📋 Most Frequently Flagged Weak Areas — 5-Year Cumulative Summary

Curriculum Area	Times Flagged (out of ~17 sittings)	Specifically Weak Points Identified	Priority
🧠 Neurology	11	Acute presentations, MND/MS/MG pattern recognition, rare but important conditions, cord compression signs	Highest
💊 Improving Quality, Safety & Prescribing	10	DMARD monitoring, drug interactions, dose calculations, side effects of long-term medications	Highest
👶 Children & Young People	9	Safeguarding/NAI, developmental assessment, consent/capacity, paediatric cancer recognition	Highest
🫁 Respiratory Health	7	Asthma management (adults and children), spirometry and peak flow interpretation, updated guidelines	High
🏛 Leadership & Management	5	Confidentiality, medical records access, capacity, GDPR rules	High
🩸 Metabolic & Endocrine	5	Diabetes management, insulin regimes, oral antidiabetics, T1 vs T2 differentiation	High
❤️ Cardiovascular Health	4	ECG interpretation, BP management targets and step therapy	Moderate
💊 Sexual Health	4	Contraception — serious adverse effects, teratogenic drug contraception protocols, LARC rules	Moderate

🔍 AKT 57 (October 2025) — Specific Weak Areas Named by Examiners

💊 Side Effects of Long-Term Medication

Common and important side effects of frequently prescribed drugs. This is tested every year. Know the high-yield drug side effects table (see Clinical section below).

🔒 Confidentiality

GMC confidentiality guidance is detailed and must be actively revised — not skimmed. When you can and cannot disclose, duty of care vs privacy, GDPR/DPA 2018 rules.

👶 Paediatrics

Cancer presentations (common + rare), acute illness recognition, safeguarding. Variable performance across candidates — those who prepare this specifically score well.

🧠 Neurology

Flagged in 3 of last 4 sittings. Significant neurological conditions — pattern recognition is key. MND, MS, MG, GBS, peripheral neuropathy — know the distinguishing features.

📊 Data Interpretation

Study design terminology, data collection concepts, graph interpretation. Consistently the lowest-scoring domain for all candidates — especially IMGs.

💉 Immunisation

Examiners now test indications, contraindications, side effects, and occupational vaccine requirements — rather than detailed infant schedule specifics. Know why vaccines are given and when they cannot be given.

📣 RCGP Examiner Key Messages — Internalise These

These principles are extracted directly from RCGP feedback reports. They describe the mindset examiners expect candidates to bring into the exam room.

1️⃣

"The AKT tests appropriate and cost-effective management — sometimes the correct answer is NOT to investigate, prescribe, or refer."

This is a deliberate trap. Trainees default to action. The correct answer is frequently watchful waiting, reassurance, or a safety-net appointment — not a battery of tests.

2️⃣

"According to current national guidance" means NICE or SIGN — not NICE CKS alone.

Where NICE/SIGN guidance and NICE CKS differ, the full NICE guideline or SIGN guideline takes precedence. CKS is a summary tool — the AKT tests the underlying source guidance.

3️⃣

"If it's not stated, it isn't there." — UK SBA convention.

Only information in the question stem is relevant. Do not infer unstated findings. If the question doesn't mention a chest finding — there is no chest finding. Do not import assumptions from clinical experience into the exam.

4️⃣

No negative marking. Always answer every question.

An unanswered question is a guaranteed zero. A guess is a 20% chance. Fill in every answer before leaving the exam. If time is short — scroll through and click something for every question.

5️⃣

"Drug dose calculations will be included. Reality-check your answer."

Errors by dangerously large amounts are submitted in real exams. If your calculation gives a dose that would fill a swimming pool — recalculate. Drug dose questions appear every sitting.

6️⃣

Photographs of skin conditions will include diverse ethnic backgrounds.

Rashes, lesions, and skin findings may be shown on a range of skin tones. Prepare for this by ensuring your revision includes images on darker skin tones — many textbooks historically did not. Resources like DermNet NZ and Skin Deep provide good diversity.

💡 How to Use Examiner Feedback Reports — The Right Way

Don't just skim the list. For every topic flagged: (1) Look it up in NICE CKS and read the full management section. (2) Do 10–15 targeted questions on that topic in your question bank. (3) Note what you got wrong and why. Repeat for the last 3–4 feedback reports. This process alone can add 5–10% to your overall score.

🔢 Quick Reference

Must-Know Numbers — AKT Quick Reference Dashboard

The AKT is threshold-heavy. These are the numbers that appear most often as the pivot between wrong and right answers. Know them cold — they come up every sitting.

🩸 Diabetes — Diagnostic Thresholds

HbA1c

Normal

<42

mmol/mol

Pre-diabetes

42–47

mmol/mol

Diabetes

≥48

mmol/mol

⚠️

AKT Trap — HbA1c 47

HbA1c of 47 mmol/mol = pre-diabetes. The correct next step is lifestyle advice + repeat in 6–12 months — NOT a diagnosis of diabetes, NOT starting metformin. This trap catches trainees every sitting.

Fasting Plasma Glucose

Pre-diabetes: 6.1–6.9 mmol/L

Diabetes: ≥7.0 mmol/L

Random (+ symptoms): ≥11.1 mmol/L

2hr GTT (diabetes): ≥11.1 mmol/L

❤️ Blood Pressure — Targets by Age & Condition

Clinic Targets

Under 80 years (standard)	<140/90
80 years and over	<150/90
CKD with proteinuria (ACR >70)	<130/80
Diabetes (NICE NG28)	<140/80
ABPM / Home daytime target (standard)	<135/85

⚠️

AKT Trap — Mild hypertension, no red flags

New BP 148/92 in a 52-year-old: the correct first step is lifestyle advice + confirm with ABPM or home monitoring — NOT starting an ACE inhibitor. NICE requires confirmation before treatment in Stage 1 hypertension.

🫘 CKD — Staging & Referral Thresholds

Stage	eGFR (mL/min/1.73m²)	ACR Category	Action
G1	≥90	A1 <3 (normal) A2 3–30 (moderate) A3 >30 (severe)	Monitor + manage CVD risk
G2	60–89	A1 <3 (normal) A2 3–30 (moderate) A3 >30 (severe)	Monitor
G3a	45–59	Consider referral if ACR >70 or rapid decline	Review medications; monitor 6-monthly
G3b	30–44	Consider referral if ACR >70 or rapid decline	More frequent review
G4	15–29	Refer nephrology	Prepare for RRT
G5	<15	Refer nephrology	RRT / palliative

💡 AKT Trap — eGFR 58

eGFR 58 = Stage G3a CKD. The correct answer is monitor (6-monthly; manage CV risk; avoid nephrotoxics) — NOT immediate nephrology referral. Referral is triggered by eGFR <30, ACR >70, rapid decline (>25% or >15 mL/min fall in 12 months), or uncontrolled hypertension despite 4 agents.

❤️ Cardiovascular Risk Thresholds

QRISK3 — Statin Decision Threshold

<10%

Lifestyle advice only

≥10%

Offer statin (discuss)

⚠️ AKT trap: QRISK 8% → lifestyle advice only. Not yet at threshold. Choice of statin: atorvastatin 20mg for primary prevention.

AF — Anticoagulation (CHA₂DS₂-VASc)

Male: score ≥2

Female: score ≥3

→ DOAC (not aspirin)

Never aspirin

Aspirin is NOT recommended for AF stroke prevention (NICE NG196)

PE Investigation Pathway

Wells Score

→

D-dimer (if low probability)

→

CTPA (if high prob or D-dimer +ve)

AKT trap: jumping straight to CTPA without Wells score + D-dimer = wrong. This is the hospital shortcut, not the NICE pathway.

🚨 2-Week Wait (2WW) Referral Triggers — Key Ones

Cancer	2WW Trigger
Lung	Unexplained haemoptysis in any adult; OR ≥40 yrs with ≥2 unexplained symptoms (cough, fatigue, dyspnoea, chest pain, weight loss, anorexia)
Colorectal	≥40 yrs: rectal bleeding + change in bowel habit. ≥50 yrs: unexplained rectal bleeding. ≥60 yrs: change in bowel habit or iron deficiency anaemia alone.
Upper GI	Any age: dysphagia. ≥55 yrs with weight loss + upper abdo pain, reflux, or dyspepsia.
Bladder/renal	Any age: unexplained visible haematuria. ≥60 yrs: unexplained non-visible haematuria + dysuria or raised WCC.
Breast	Unexplained breast lump (any age); ≥30 yrs with unilateral nipple changes or skin changes.
Endometrial	Post-menopausal bleeding (no HRT); or on HRT with unexplained bleeding.
Prostate	PSA above age-specific threshold + urinary symptoms. Note: raise PSA → repeat first if no red flags, then consider 2WW.
Skin (melanoma)	Weighted 7-point checklist score ≥3; or dermoscopy suspicion.

⚠️

AKT Trap — "Persistent Cough"

A cough for 3 weeks alone in an otherwise well adult does NOT automatically trigger a 2WW referral. Per NICE NG12, lung cancer 2WW requires either unexplained haemoptysis OR ≥40 years with ≥2 unexplained symptoms. Trainees who refer on cough alone are marking incorrectly.

🧪 The Investigation Ladder — "Test Before You Request"

No test

History + examination → clinical diagnosis. Many presentations do not need investigation.

Basic tests

Bloods (FBC, U&E, TFTs, HbA1c, ferritin, etc). Urine dipstick. BP. These are cheap, fast, GP-available.

Simple imaging

Plain X-ray, USS. When clinically indicated — not as a default for every presentation.

Specialist tests / imaging

CT, MRI, endoscopy, specialist bloods. Requires red flags or clear clinical indication — not for routine presentations.

💡 AKT Examples of Getting the Level Right

Tired 28-year-old, Hb 114 → Ferritin (Level 2), NOT colonoscopy or iron infusion
Suspected PE, low probability → Wells score + D-dimer (Level 2/3), NOT immediate CTPA
2 weeks acute back pain, no red flags → Conservative management (Level 1), NOT MRI
10-day cough, no red flags → Reassure + safety-net (Level 1), NOT CXR + antibiotics

🔁 "Repeat Before Refer" — When This Applies

Finding	First Action	Why
PSA mildly raised, asymptomatic	Repeat PSA in 1–3 months	Single elevated PSA unreliable; confirm before 2WW
HbA1c 47–48 (borderline)	Repeat in 3 months	Diagnosis requires confirmation on repeat (unless symptoms)
BP 148/92 (Stage 1, no red flags)	ABPM/home monitoring	Clinic BP overestimates — NICE requires ABPM before treating Stage 1
Mildly raised LFTs	Repeat + lifestyle review in 3–6 months	Transient elevations common; confirm before onward referral
eGFR mildly reduced (G3a, stable)	Repeat at 3 months	CKD requires 2 readings ≥3 months apart for diagnosis

📊 Additional High-Yield Numbers — AKT Specific

These specific thresholds and targets are regularly tested as the pivot point between wrong and correct answers. Know them to the decimal.

🩸 HbA1c — Management Targets (Not Just Diagnosis)

Lifestyle modification only

or single non-hypoglycaemic drug

Two or more antidiabetic drugs

or any drug with hypo risk

Diagnostic threshold (T2DM)

Two readings, or one if symptomatic

≥48

AKT trap: The question describes a patient already on metformin whose HbA1c is now 56. Their target should be 53 mmol/mol (on medication), not 48. Distinguish diagnosis from management targets.

🔬 FIT Test — Colorectal Cancer Threshold

≥10

μg Hb / g faeces

→ 2WW colorectal cancer referral

Below 10 μg Hb/g → does not meet 2WW threshold. Manage according to symptoms and re-test if clinically indicated.

💡 AKT Context

FIT replaces FOB (faecal occult blood) in the NHS bowel cancer screening programme and in 2WW decisions. The 10 μg/g threshold is the specific number the AKT uses — not "elevated" or "positive."

🚨 Cancer 2WW — Key Triggers at a Glance

Cancer Site	Trigger	Age
Colorectal	FIT ≥10 μg Hb/g; rectal bleeding + bowel change; unexplained anaemia	≥40/50/60 by scenario
Lung	Unexplained haemoptysis; ≥2 symptoms (cough, fatigue, dyspnoea, chest pain, weight loss)	Any; ≥40 for symptoms
Upper GI	Dysphagia; weight loss + upper abdo symptoms	Any; ≥55 for symptoms
Endometrial	Post-menopausal bleeding	Post-menopausal
Prostate	PSA above threshold — but repeat before referring unless red flags	≥50

🔬 Clinical High-Yield

Clinical Areas Frequently Tested in the AKT (High-Yield)

These clinical areas appear repeatedly across AKT sittings, drawn directly from RCGP examiner feedback reports. Accordions and tables cover the specific facts, thresholds, and traps that score marks.

🔥

The AKT Hot List — Direct from Examiner Feedback

The RCGP examiner feedback consistently identifies the same areas where candidates lose marks. The topics below are repeatedly highlighted. Treat this as your revision checklist.

🩺 Clinical High-Yield Areas (80% of your exam)

❤️ Cardiovascular

AF — rate vs rhythm, anticoagulation, CHA₂DS₂-VASc
Heart failure — LVEF, GDMT, fluid management
IHD — NICE pathways, secondary prevention targets
Hypertension — step therapy, target BP, special groups
Stroke / TIA — FAST, risk stratification, DAPT timing

🫁 Respiratory

Asthma — NICE 2024 step therapy, SABA vs ICS-formoterol
COPD — GOLD staging, exacerbation management, rescue pack
Pneumonia — CAP severity scoring (CRB-65), who to admit
OSA — screening, CPAP referral criteria

🩸 Metabolic

Type 2 Diabetes — HbA1c targets, SGLT2i benefits, GLP-1
Hypothyroidism — targets for TSH, when to refer
CKD — staging, eGFR thresholds, referral criteria
Gout — acute management, allopurinol timing rules

🧠 Mental Health

Depression — PHQ-9, first-line, when to refer urgently
Anxiety — GAD-7, treatment ladder, NICE guidance
Psychosis — early recognition, risk assessment in GP
Self-harm and suicide — safe messaging, risk factors

👶 Paediatrics

Developmental milestones — by age, in detail
Immunisation schedule — UK childhood programme
Febrile illness — traffic light system (NICE CG160)
Child safeguarding — recognition, referral, documentation

👩 Women's Health

Contraception — all methods, which is safest in which scenario
Menopause — HRT types, indications, contraindications
Cervical screening — intervals, HPV triage
Antenatal care — schedule, referral timings

🦴 Musculoskeletal

Back pain — red flags, management, when to image
Rheumatoid arthritis — DMARD targets, monitoring
Osteoporosis — FRAX scoring, bisphosphonates, T-score thresholds
Gout — as above

💊 Prescribing

Drug interactions — warfarin, metformin, lithium, methotrexate
Monitoring requirements — which drugs need what checks
Renal and hepatic dose adjustments
Pregnancy — safe vs contraindicated medications

🏥 Urgent / Acute

Sepsis — NEWS2, 6-hour bundle, GP role
Chest pain — ACS differentiation in primary care
Anaphylaxis — adrenaline dose, when to call 999
Meningitis — rash features, immediate actions

📊 Statistics — The "Easy Marks" Section

This section is finite and teachable. Every formula below can be learned in a focused afternoon. Trainees who master this gain 5–8% extra overall — often the difference between fail and pass.

Concept	What It Means	AKT Exam Tip
Sensitivity	True positive rate — how well a test identifies disease	High sensitivity = good for RULING OUT (SnNOut)
Specificity	True negative rate — how well a test excludes disease	High specificity = good for RULING IN (SpPIn)
PPV / NPV	Probability of disease given test result	Affected by prevalence — watch for questions changing the prevalence
NNT	Number needed to treat = 1/ARR	Lower NNT = more effective treatment
NNH	Number needed to harm = 1/ARI	Higher NNH = safer drug
ARR	Absolute Risk Reduction = control rate − treatment rate	This is what actually matters clinically
RRR	Relative Risk Reduction = ARR/control rate	Can look impressive but inflated if baseline risk is low
Likelihood Ratio	How much a test result shifts probability of disease	LR+>10 = strong evidence of disease; LR−<0.1 = strong evidence against
Forest plot	Displays results of multiple studies in a meta-analysis	Left of 1 = favours treatment. Line crossing 1 = not significant.
Funnel plot	Tests for publication bias in a meta-analysis	Asymmetric funnel = publication bias likely

📊 Statistics Deep-Dive — Complete EBP Domain Revision

The EBP domain consistently scores the lowest of all three domains. In January 2025 the mean score was 65.2% for EBP vs 75.1% for org/management. This is learnable. Every concept below has a formula, a mnemonic, and a clinical application. Spend 2–3 focused sessions on this and the marks will follow.

The 2×2 Contingency Table — Build This First

	Disease PRESENT (+)	Disease ABSENT (−)	Row Total
Test POSITIVE (+)	TP True Positive	FP False Positive	TP+FP
Test NEGATIVE (−)	FN False Negative	TN True Negative	FN+TN
Column Total	TP+FN All with disease	FP+TN All without disease	Grand total

Key Formulas + Mnemonics

Term	Formula (from 2×2)	Mnemonic / Rule	Clinical Meaning
Sensitivity	TP ÷ (TP + FN)	SnNOut — High Snsitivity: if Negative → rules OUT	How many with disease does the test correctly identify? A sensitive test misses few cases.
Specificity	TN ÷ (TN + FP)	SpPIn — High Specificity: if Positive → rules IN	How many without disease does the test correctly exclude? A specific test has few false positives.
PPV	TP ÷ (TP + FP)	Increases with higher prevalence	If positive, what is the probability of disease? Depends heavily on prevalence — same test has different PPV in different populations.
NPV	TN ÷ (TN + FN)	Increases when prevalence is low	If negative, what is the probability of no disease? Most useful when disease is rare.
ARR	CER − EER	Absolute Risk Reduction = the real clinical effect	Control event rate minus experimental event rate. This is the number that matters clinically — not RRR.
RRR	ARR ÷ CER	Always looks more impressive than ARR — it's relative	Always calculate from raw data. RRR of 50% on a 1% baseline = ARR of 0.5% = NNT of 200. Not impressive.
NNT	1 ÷ ARR	Lower NNT = more effective treatment	Number of patients who need treatment for one to benefit. Calculate from ARR — never from RRR.
NNH	1 ÷ ARI	Higher NNH = safer drug	Number who need treatment for one to be harmed. Compare NNT vs NNH to weigh benefit vs risk.
Odds Ratio	(TP × TN) ÷ (FP × FN)	Used in case-control studies	OR >1 = increased odds of outcome with exposure. OR approximates RR when disease is rare.
Relative Risk	EER ÷ CER	Used in RCTs and cohort studies	RR >1 = exposure increases risk. RR <1 = exposure reduces risk. RR = 1 = no association.
LR+ (Positive Likelihood Ratio)	Sensitivity ÷ (1 − Specificity)	LR+ >10 = large, clinically significant increase in probability	How much more likely is a positive result in disease vs no-disease? LR+ >10 strongly raises post-test probability.
LR− (Negative Likelihood Ratio)	(1 − Sensitivity) ÷ Specificity	LR− <0.1 = large, clinically significant decrease in probability	How much less likely is a negative result in disease vs no-disease? LR− <0.1 strongly lowers post-test probability.

Study Design Hierarchy — Evidence Pyramid

Level	Study Type	Best For	Key Weakness
1 (Top)	Systematic review / Meta-analysis	Top of hierarchy — pooled analysis of multiple studies	Heterogeneity between studies; publication bias (shown by funnel plot asymmetry)
2	Randomised Controlled Trial (RCT)	Causation — best for evaluating interventions	Ethical constraints; cost; exclusion criteria limit generalisability
3	Cohort study	Incidence, relative risk, longitudinal outcomes	Confounding; attrition bias; time and cost
4	Case-control study	Rare diseases; odds ratios; efficient for uncommon outcomes	Recall bias (cases remember exposures better than controls)
5	Cross-sectional survey	Prevalence; point-in-time snapshot	Cannot establish causation; prevalence-incidence bias
6 (Base)	Case report / case series	Hypothesis generation; rare events; adverse drug reactions	No comparison group; no statistical significance possible

P Values, Confidence Intervals & Errors

P Values & CIs

P < 0.05 = statistically significant (5% chance result is by chance)
95% CI not crossing 1.0 (for RR/OR) = statistically significant
Wide CI = small study, high variability, low precision
Narrow CI = large study, high precision, more reliable
Statistical significance ≠ clinical significance — a tiny effect can be highly significant in a huge trial

Type I & Type II Errors

Type I error (α error) — False positive: rejected the null hypothesis when it was actually true. The P value threshold (0.05) sets this risk.
Type II error (β error) — False negative: failed to reject the null when it was false. Related to the power of the study (power = 1 − β).
Increasing sample size reduces BOTH error types
Memory aid: "Type I = seeing something that isn't there; Type II = missing something that is"

Bias Types — AKT Definitions

Bias Type	Definition	Which Study Design
Selection bias	Sample is not representative of the target population — skews results	All study types
Recall bias	Cases remember past exposures better than controls — overestimates association	Case-control studies
Measurement / observer bias	Systematic error in how data is collected or recorded	All study types
Confounding	A third variable linked to both the exposure and the outcome distorts the apparent relationship (e.g. smoking confounds alcohol–cancer studies)	Observational studies
Attrition bias	Participants who drop out differ systematically from those who complete the study	RCTs and cohort studies
Lead-time bias	Screening appears to improve survival simply by detecting disease earlier — not because treatment is more effective. Survival is measured from diagnosis, so earlier diagnosis artificially extends apparent survival time.	Screening studies; cancer survival statistics
Hawthorne effect	Participants change their behaviour because they know they are being observed	Observational studies, RCTs
Publication bias	Positive results are more likely to be published than negative results — inflates apparent treatment effects in meta-analyses. Detected by funnel plot asymmetry.	Systematic reviews / meta-analyses

Forest & Funnel Plots — Reading Them Quickly

🌲 Forest Plot

Each horizontal line = one study; box = point estimate; line width = confidence interval
Diamond at bottom = pooled result; diamond width = confidence interval of pooled result
Line of no effect = 1.0 (for RR/OR); if a study's CI crosses 1.0 → not statistically significant
If the pooled diamond crosses 1.0 → overall result not significant
Left of 1.0 = favours treatment (reduces risk); right of 1.0 = favours control

🔻 Funnel Plot

Each point = one study; x-axis = effect size; y-axis = study size/precision
Symmetrical funnel = no publication bias
Asymmetrical funnel = publication bias likely — small negative studies are missing (not published)
AKT will show you a funnel and ask whether publication bias is present — look for asymmetry

📋 Wilson & Jungner Screening Criteria — The AKT Asks About These

A good screening programme should: (1) Target an important condition with significant burden; (2) Have an acceptable and effective treatment; (3) Be acceptable to the population; (4) Use a test with high sensitivity (to capture most cases) and acceptable specificity (to avoid excessive false positives); (5) Be cost-effective; (6) Have a well-understood natural history. The AKT may present a scenario and ask whether it meets screening criteria — apply these principles.

🏛 Admin & Regulatory — The Other "Easy Marks" Section

Topic	Key Points to Know
DVLA / Fitness to Drive	Know the common conditions and their reporting rules — epilepsy, diabetes on insulin, MI, sleep apnoea, visual acuity requirements. Use the DVLA at-a-glance guide. Very popular AKT topic.
Mental Health Act Sections	Section 2 (28-day assessment), Section 3 (6-month treatment), Section 4 (emergency 72h), Section 5(2) (inpatient holding). Who can sign what.
Sick Notes / Fit Notes	Self-certification up to 7 days. GP issues Med3 from day 8. Med3 can be back-dated. GP can issue prospectively. No 'sick note' for A&E or hospital consultants from GP.
Notifiable Diseases	Know which are notifiable and to whom (local Health Protection Team / UKHSA). Notify by phone for urgent diseases, written form for others.
Death Certification	GP can certify if they attended the deceased within 28 days (was 14 days pre-2024). Certain causes must be referred to HMCD (formerly coroner).
Prescribing Law	Controlled drug regulations — schedules, requisitions, safe custody, destruction. Who can prescribe what.
Child Protection	Section 47 vs Section 17 enquiries. Fraser Guidelines for under-16 contraception. Capacity vs Gillick competence.
GP Certificates	Cremation Form 5 (Attending Doctor), MatB1 (Maternity), DS1500/SR1 (Benefits), SC1 (Self-cert form). Know who completes which form.

📐 Study Design Hierarchy — Know These Definitions

The AKT expects you to name the study type, know its strengths/weaknesses, and identify which question it answers best. The hierarchy matters — examiners test this directly.

Study Type	Key Features	Best For	Hierarchy
Systematic Review / Meta-analysis	Synthesises multiple studies; uses statistical pooling; forest + funnel plots	Strongest overall evidence when well-conducted	1 ⭐
RCT (Randomised Controlled Trial)	Random allocation; controls; blinding (single/double); reduces confounding	Gold standard for causation and treatment efficacy	2
Cohort Study	Follows exposed vs unexposed groups over time; prospective or retrospective	Incidence, risk factors, prognosis	3
Case-Control Study	Looks back from outcome to exposure; matches cases with controls; calculates odds ratio	Rare diseases — efficient when outcome is uncommon	4
Cross-Sectional Study	Snapshot at one point in time; surveys; prevalence data	Prevalence; planning services	5
Case Series / Case Report	Descriptive; no comparison group; no control	Signal-generating only — hypothesis generation, not testing	6 (lowest)

🌲 Forest Plot — How to Read It

Each study = one horizontal line with a box (box size = study weight/sample size)
The line = 95% confidence interval for that study
The diamond at the bottom = pooled estimate across all studies
If the diamond (or CI line) crosses 1.0 (for RR/OR) or 0 (for difference) → NOT statistically significant
Wide diamond = heterogeneous studies; narrow = consistent

🔺 Funnel Plot — Publication Bias

Each dot = one study; x-axis = effect size; y-axis = study size/precision
Symmetrical funnel = no publication bias — studies of all sizes distributed evenly
Asymmetrical funnel = publication bias likely — small negative studies are missing (not published)
AKT shows you a funnel plot image and asks: is publication bias present? → Look for asymmetry

🏛 Admin Deep-Dives — Examiner-Flagged Regulatory Content

The admin/organisational domain is the highest-scoring domain on average (mean 78.8% in Oct 2025). These accordions cover the topics most likely to be tested — including recent updates that many trainees miss.

🚗 DVLA Fitness to Drive — Group 1 vs Group 2 Full Table

Group 1 = cars and motorcycles. Group 2 = buses, lorries, HGVs — much stricter rules. The AKT frequently presents a clinical scenario and asks whether the patient must notify the DVLA and when they may resume driving.

Condition	Group 1 (cars/motorcycles)	Group 2 (HGV/bus)
First unprovoked seizure	Must not drive; reapply after 6 months seizure-free	Must not drive; reapply after 5 years seizure-free (off medication)
Epilepsy (established)	1 year seizure-free before driving	10 years seizure-free off medication
ACS / STEMI (no PCI)	Must not drive for 4 weeks	Must not drive for 6 weeks + functional test + LVEF >40%
ACS post-PCI	Must not drive for 1 week	Must not drive for 6 weeks + functional test + LVEF >40%
Stroke / TIA	Must not drive for 1 month (stroke); 1 month (TIA)	Must not drive for 1 year (stroke); 3 months (TIA)
Insulin-treated diabetes	Must notify DVLA; restricted licence (renewable 1–3 years); check BG ≥2 hours on long journeys	Must notify DVLA; must test BG ≥2× daily including before driving; no severe hypo in last 12 months
Sulphonylurea (hypo risk)	Notify only if ≥2 severe hypos awake in last 12 months	Notify if 1 severe hypo — stricter threshold
Dementia	Report if affecting driving ability; DVLA assesses individually	Must inform DVLA if diagnosis confirmed; generally cannot hold Group 2
Psychosis (acute)	Must not drive during acute episode; DVLA notified; review once stable	Stricter — specialist involvement required; usually barred during active illness
Arrhythmia (incapacitating)	Must not drive for 4 weeks from last symptomatic event; may resume if no recurrence	Must notify; off until ≥3 months symptom-free
Angina (at rest or at the wheel)	Must not drive while symptomatic at rest or while driving; may resume when controlled	Must notify DVLA; assessed individually
Sulphonylureas (hypo risk)	Need not notify DVLA; self-monitor; avoid driving if symptoms suggest hypoglycaemia	Must notify DVLA; stricter threshold than Group 1
Simple syncope (single episode, identified cause)	No driving restriction if cause identified and treated — but must be clear the event was simple vasovagal	Detailed assessment required; usually cannot hold Group 2 licence during investigation
New pacemaker implantation	Must not drive for 1 week	Must not drive for 6 weeks
CABG (coronary artery bypass graft)	Must not drive for 4 weeks	Must not drive for 3 months + functional test
Vision: binocular	Acuity ≥6/12 in better eye with both eyes open; visual field >120°; no significant diplopia	Acuity ≥6/9 in better eye, ≥6/12 in worse; stricter visual field requirements

⚠️

Doctor's Duty — What to Do When a Patient Refuses to Notify DVLA

Advise the patient of their legal obligation to notify DVLA. Document this advice clearly. If the patient refuses and you believe continued driving poses a serious risk to others, GMC guidance supports breaching confidentiality and notifying DVLA directly. This must be a last resort after all other steps. Always inform the patient before disclosing.

🧠 DVLA Epilepsy Mnemonic — "The 1-10 Rule"

Group 1: 1 year after last seizure. Group 2: 10 years seizure-free off medication (established epilepsy). First unprovoked seizure is different: Group 1 = 6 months; Group 2 = 5 years. Know these four numbers and you will answer most DVLA epilepsy questions correctly.

📋 Death Certification — September 2024 Reforms (New — High AKT Relevance)

🆕

Major Reform from 9 September 2024 — Now AKT-Testable

From 9 September 2024, all non-coronial deaths in England and Wales must be reviewed by a Medical Examiner (ME) before registration. This changes the certification process significantly. Candidates who revised from pre-2024 resources will have outdated knowledge on this topic.

📋 MCCD Structure — Part 1 and Part 2

The Medical Certificate of Cause of Death (MCCD) follows a structured format. Knowing the Part 1/Part 2 distinction is specifically tested in AKT organisational questions.

Part 1 — Direct Causal Sequence

1a — The direct/immediate cause of death (e.g. pneumonia)

↑ caused by

1b — Condition leading to 1a (e.g. lung cancer)

↑ caused by

1c — Condition leading to 1b (if applicable)

Part 2 — Contributing Conditions

Conditions that contributed to the death but were not part of the direct causal sequence.

Example: A patient dies of pneumonia (1a) caused by COPD (1b). They also had heart failure and type 2 diabetes. These go in Part 2 as contributing conditions.

🏥 Medical Examiner (ME) System — England & Wales from September 2024

Independent doctor who scrutinises all non-coronial deaths before registration
Reviews the MCCD, speaks to the attending practitioner and bereaved family
MEs can refer to coroner if concerns arise — they are the gateway, not the GP directly
Designed to improve accuracy of cause of death data and identify unnatural deaths

What Changed (September 2024)

Medical Examiner review is now mandatory for all deaths not investigated by the coroner
The MCCD is completed by the "attending practitioner" — this is now a broader definition (any GP who attended the patient, not just within a fixed recent period)
Concerns are raised with the ME — not directly to the coroner — for clarification first
Deaths must be registered within 5 days of receipt of the MCCD by the registrar (unless coroner is involved)

When to Refer to the Coroner

Cause of death is unknown
Death related to industrial disease or poison
Violent, unnatural, or suspicious death
Death within 24 hours of hospital admission
Death during or after an operation or procedure
Death in custody
Death of a child in care

💡 AKT Tip — Old vs New Knowledge

Pre-September 2024, there was a rule about attending the deceased within a certain number of days. This has been removed. The key new facts are: (1) Medical Examiner reviews ALL non-coronial deaths; (2) Registration within 5 days; (3) "Attending practitioner" has a broader definition. If your revision notes predate September 2024 — update them.

🔒 GMC Confidentiality — Flagged 5 Times in 5-Year Summary

Confidentiality is one of the most tested admin topics. The AKT tests whether you know when you MUST disclose, when you MAY disclose, and what the legal and ethical framework is.

MUST Disclose (no discretion)

Court order — legal obligation
Statutory duty: notifiable diseases (Public Health Act); terrorism (Terrorism Act)
Child or vulnerable adult at immediate serious risk of harm — safeguarding duty
FGM (mandatory reporting to police for girls <18 where it has been carried out)

MAY Disclose (professional judgement)

Serious crime — prevent harm to others where benefit outweighs privacy
Patient poses serious risk to others (e.g. DVLA notification)
In the public interest, after careful balancing
Disclosed information that is not personally identifiable (aggregated/anonymised)

Access to Medical Records — GDPR / DPA 2018

Subject Access Request (SAR): Patient has right to access their records. Provider must respond within 1 calendar month.
No charge unless request is "manifestly unfounded or excessive"
Can refuse access if disclosure would cause serious harm to the patient or a third party
Deceased patients: GDPR does NOT apply after death. Access to Health Records Act 1990 applies — relatives with "sufficient interest" may access records.

After Death — Confidentiality Continues

Duty of confidentiality continues after a patient dies
Information may be released to: coroner, research with ethics approval, next of kin (where no objection was made)
GMC guidance: "you still owe a duty of confidence to the deceased"

🔒 Caldicott Principles — 7 + 1

The Caldicott Principles govern how patient information is handled across the NHS. The "7+1" structure is specifically tested in AKT organisational questions.

1. Justify the purpose — every proposed use must be clearly defined and scrutinised

2. Don't use identifiable information unless necessary

3. Use the minimum necessary — access only what is needed

4. Access on need-to-know basis only

5. Everyone must understand their responsibilities to respect confidentiality

6. Comply with the law — GDPR, Data Protection Act, common law

7. The duty to share can be as important as the duty to protect — failure to share can harm patients

+1. Inform patients about how their information is used — unless doing so would undermine the purpose

AKT Trap: The "+1" principle (inform patients) is the most recently added and the most commonly omitted. The "duty to share can be as important as duty to protect" (Principle 7) is also specifically tested — it counters the assumption that confidentiality always means withholding.

⚖️ Ethical Frameworks & Four Pillars — AKT Admin Domain

The Four Pillars of Medical Ethics

🧑

Autonomy

Respect the patient's right to make their own informed decisions. Underpins consent, shared decision-making, and confidentiality.

💚

Beneficence

Act in the patient's best interests. The positive duty to do good and promote wellbeing.

🛡️

Non-maleficence

First, do no harm (primum non nocere). Avoid causing unnecessary harm. Justifies restraint in prescribing and investigation.

⚖️

Justice

Fair distribution of healthcare resources; treat similar patients similarly. Underpins rationing decisions, equitable access, public health.

💡 AKT Application of the Four Pillars

Most AKT ethical scenarios test whether you can balance these principles when they conflict. Classic conflicts: autonomy vs beneficence (patient refuses treatment that would help them); beneficence vs justice (expensive treatment that benefits one patient at cost to many); autonomy vs non-maleficence (patient requests something potentially harmful). The correct answer almost always involves maximising patient involvement while acting proportionately to the risk.

⚖️ Mental Capacity Act 2005 — Five Principles & Capacity Assessment

The Five Statutory Principles — Must Know All Five

Assume capacity unless it is established otherwise. The burden of proof is on those asserting lack of capacity.

All practicable steps must be taken to help the person make a decision before concluding they lack capacity. (Simplify information, use pictures, find an interpreter.)

An unwise decision does NOT equal lack of capacity. People have the right to make decisions others consider unwise — this alone cannot be used to declare incapacity.

Decisions for those lacking capacity must be made in their best interests — considering all relevant factors and involving the person as much as possible.

Decisions must be the least restrictive option — preserve as much freedom and dignity as possible.

Capacity Assessment — Four Functional Elements (All Must Be Met)

🧠

Understand

Understand the information relevant to the decision

🗃

Retain

Retain it long enough to make the decision

⚖️

Weigh

Use and weigh the information in the decision-making process

💬

Communicate

Communicate the decision (by any means)

🧠 MCA Capacity Mnemonic — URWC ("You Are Worth Capacity")

Understand → Retain → Weigh → Communicate. All four must be present for capacity. Capacity is decision-specific (capacity for one decision does not imply capacity for another) and time-specific (may fluctuate — reassess).

📄 Fit Notes (Med3), Certificates & GP Contracts — Organisational Domain

Fit Notes (Med3) — AKT Facts

Any registered doctor, nurse practitioner, pharmacist, physiotherapist, or occupational therapist with relevant training can now issue a fit note
Self-certification covers the first 7 days of sickness — no Med3 needed
Med3 can be issued as "may be fit for work" with conditions: phased return, amended duties, adjusted hours, workplace adaptations
Med3 can be issued before seeing the patient (e.g. phone assessment) and can be backdated
Cannot be post-dated — a fit note must cover from a date that has already passed or from today; it cannot be written to start in the future
Hospital team issues their own fit notes during inpatient admissions — the GP does not issue fit notes covering a hospital admission
GP cannot be compelled to issue a fit note they believe is not clinically appropriate

AKT Trap — Post-dating: A question may describe a patient requesting a fit note backdated to before the illness started, or post-dated to a future date. Cannot be post-dated; can be backdated.

GP Contracts — Key Organisational Knowledge

Contract / Structure	Key Points for AKT
GMS (General Medical Services)	Standard NHS GP contract. GP as contractor, not NHS employee. Includes essential, additional, and enhanced services.
PMS (Personal Medical Services)	Alternative contract, locally negotiated with ICB. Allows more flexibility than GMS.
QOF (Quality & Outcomes Framework)	Points-based system rewarding evidence-based care and organisational targets. Annual review. Indicators change each year — don't memorise specific targets, understand the framework.
PCN (Primary Care Network)	Groups of practices covering ~30,000–50,000 patients. Receive DES (Directed Enhanced Service) funding. Responsible for additional services including care home visits, enhanced access, early cancer diagnosis.
ICB (Integrated Care Board)	Replaced CCGs (Clinical Commissioning Groups). Responsible for commissioning most NHS services in a geographic area.
CQC (Care Quality Commission)	Independent regulator of health and social care in England. Inspects and rates services (Outstanding / Good / Requires Improvement / Inadequate).

⚖️ Consent in Minors, Controlled Drugs, Complaints & Capacity — Expanded Admin Guide

🧒 Consent in Minors — Parental Responsibility & Gillick

Scenario	Key Rule
Gillick competence	Under-16 who fully understands the nature, purpose, and consequences of treatment can consent to it. Gillick applies to all medical treatments — not just contraception.
Fraser guidelines	Specific to contraception for under-16s. GP must be satisfied: young person understands the advice; cannot be persuaded to involve parents; will likely have sex with or without contraception; best interests require treatment.
Age 16–17	Can consent to treatment by statute (Family Law Reform Act 1969). Their refusal can be overridden by a court, but not by a clinician acting alone.
Parental responsibility — mother	Mother always has parental responsibility automatically.
Parental responsibility — father	Automatic if: (1) married to the mother, OR (2) named on birth certificate after 1 December 2003. Otherwise requires a court order or parental responsibility agreement.

🧠 Mental Capacity Act — LPA, ADRT & DoLS

LPA — Lasting Power of Attorney

Two types: Property and financial affairs (can be used while the person has capacity); Health and welfare (can only be used once capacity is lost). Must be registered with the Office of the Public Guardian before use.

ADRT — Advance Decision to Refuse Treatment

Legally binding refusal of specific treatments made in advance. For life-sustaining treatment it must be written, signed, and witnessed. Must be specific — "no hospital treatment" is not valid.

DoLS — Deprivation of Liberty Safeguards

Applies in care homes and hospitals only (not community settings). Authorises deprivation of liberty for people lacking capacity. Being replaced by the Liberty Protection Safeguards (LPS) — implementation pending. AKT currently tests DoLS.

Court of Protection

Makes decisions about property, finances, and welfare for those lacking capacity. Can appoint a Deputy where no LPA exists. Used when there is disagreement about best interests that cannot be resolved clinically.

🧠 Mental Capacity Act — 2-Stage Capacity Test & 5 Principles

5 Key Principles

Presumption of capacity — assume the person has capacity unless assessed otherwise
Support decision-making — all practicable steps must be taken first
Unwise decision ≠ lack of capacity — people may make decisions others disagree with
Best interests — any act for someone lacking capacity must serve their best interests
Least restrictive option — interfere minimally with rights and freedoms

2-Stage Capacity Test

Stage 1: Is there an impairment of, or disturbance in, the functioning of the mind or brain?

Stage 2: Does this mean the person CANNOT:

Understand the information?

Retain it long enough?

Weigh / use it?

Communicate the decision?

Mnemonic: URWC — Understand, Retain, Weigh, Communicate

Critical AKT rule: Capacity is decision-specific and time-specific. "Lacks capacity" in general terms is legally meaningless. A patient can lack capacity for one decision but retain it for another. Always document which decision you are assessing.

📋 Fit Notes (Med3) — Key Facts

Self-certification covers the first 7 days of sickness — no Med3 required
Med3 required from day 8 of illness
Can be backdated — no restriction on this
Can be issued after the patient has returned to work
Can be issued as "may be fit for work" with conditions: phased return, amended duties, adjusted hours, or workplace adaptations
Since April 2022: can be issued by nurses, physiotherapists, occupational therapists, and pharmacists — not just doctors

💊 Controlled Drug Prescriptions — Legal Requirements

A valid CD prescription must include all of the following — any omission makes it legally invalid:

Drug name, formulation, and strength
Dose and frequency
Total quantity to be dispensed — in both words and figures
Patient's name and address
Prescriber's name, address, and signature
Date of signing

AKT trap — "words and figures": The total quantity must appear in both words ("twenty-eight") AND figures (28). This is a specific legal requirement tested in the prescribing safety domain.

📋 Controlled Drug Schedules — Key AKT Facts

Schedule	Examples	Key Rules
Schedule 2	Morphine, oxycodone, fentanyl, methylphenidate, diamorphine	Full CD regulations — register, requisition, 7-day prescription limit, safe custody, destruction witnessed. Electronic FP10 now acceptable.
Schedule 3	Buprenorphine, tramadol, temazepam, phenobarbital	Prescription requirements + some require safe custody. No register required (except temazepam).
Schedule 4 Part I	Benzodiazepines (diazepam, lorazepam, clonazepam)	28-day prescription limit. Less strict than Schedules 2–3. No handwriting requirement.
Schedule 4 Part II	Anabolic steroids	Minimal prescription restrictions but subject to import/export controls.
Schedule 5	Low-strength codeine preparations (e.g. codeine linctus)	Minimal controls — retain invoices for 2 years.

📋

FP10MDA — Instalment Prescriptions for Addiction Treatment

FP10MDA is the specific prescription form used for instalment prescriptions — where a controlled drug (typically methadone or buprenorphine) is dispensed in daily or regular instalments rather than all at once. Used in opioid substitution therapy. AKT tests: which form, why it exists, and the difference from a standard FP10 prescription.

🦠 Notifiable Diseases — Urgency Tiers

🚨 Notify Within 24 Hours — Urgent (by phone first)

Meningococcal disease / meningitis
Measles, mumps, rubella
Whooping cough (pertussis)
Diphtheria, tetanus, poliomyelitis
Typhoid and paratyphoid fever
Cholera, plague, anthrax
Rabies, viral haemorrhagic fever

📋 Notify Within 3 Days — Non-Urgent (written form)

TB (pulmonary and non-pulmonary)
Hepatitis A, B, and E
Scarlet fever
Enteric fever (typhoid counted separately)
Lyme disease
Legionnaire's disease

💡 Who to Notify and How

Notify the proper officer at the local authority (usually via the local Health Protection Team / UKHSA). For urgent diseases: phone first, then written notification within 3 days. The AKT tests the recipient (local proper officer / HPT — not PHE, which no longer exists) and the urgency tier.

🟡 Yellow Card Reporting & Off-Label Prescribing

🟡 Yellow Card Scheme (MHRA)

Report suspected adverse drug reactions (ADRs) to the MHRA. Report:

ALL suspected ADRs for: new drugs, vaccines, and biologics (Black Triangle ▼ products)
Serious suspected ADRs for established drugs
Give extra attention to: children, elderly, and pregnant/breastfeeding patients

AKT Trap: Not all ADRs need reporting — only suspected ADRs, and only serious ones for established drugs (all for new/Black Triangle drugs).

📋 Off-Label Prescribing

Permitted in UK practice when clinically justified
Requires informed consent — patient must be told the drug is being used outside its licensed indication
Must be documented clearly in the records
Prescriber takes on greater professional responsibility

Common GP examples: topical ivermectin for scabies, low-dose amitriptyline for neuropathic pain, intranasal steroids for Eustachian tube dysfunction.

📝 Complaints Process (England)

Stage	Timeframe	Detail
Acknowledge	Within 3 working days	Written or verbal acknowledgement. Name a lead for the investigation.
Full response	Within 40 working days	Written response addressing all issues raised. Apologise if appropriate — apology is not an admission of liability.
Escalation	If unresolved after local resolution	Parliamentary and Health Service Ombudsman (PHSO) for NHS complaints. CQC for service regulation concerns.

⚠️

AKT Trap — Complaints Timeframes

The acknowledgement is 3 working days (not 3 calendar days, not 5 days). The full response is 40 working days (not 28 days, not 6 weeks). These specific numbers are regularly tested.

🔬 Clinical Deep-Dives — Examiner-Flagged Content

These accordion sections cover the specific clinical topics most frequently flagged as poorly-answered in RCGP examiner feedback. Expand each one to revise the high-yield content.

🧠 Neurology — Highest Frequency Topic (Flagged 11 of ~17 Sittings)

Pattern recognition is the key skill in AKT neurology. The exam rarely asks for management details — it asks you to identify the condition from a brief clinical description. Learn the hallmark features of each condition cold.

The AKT Neurology Trinity — Pattern Recognition Table

Condition	Key Pattern	Hallmark Finding	What Is Absent
Motor Neurone Disease (MND)	Mixed UMN + LMN signs simultaneously	Wasting + fasciculation (LMN) AND brisk reflexes + spasticity (UMN) — in the same limb	No sensory loss — this distinguishes MND from other motor disorders
Multiple Sclerosis (MS)	Dissemination in time AND space	Two distinct episodes affecting two distinct anatomical regions. Optic neuritis, internuclear ophthalmoplegia, bladder dysfunction, Lhermitte's sign	Single episode = clinically isolated syndrome — NOT MS yet
Myasthenia Gravis (MG)	Fatigable weakness — worse with activity, better with rest	Ptosis that worsens through the day. Diplopia. Bulbar symptoms (dysarthria, dysphagia). Ocular involvement in most first.	No sensory loss. Reflexes normal. Crisis = respiratory compromise.
Guillain-Barré Syndrome (GBS)	Ascending flaccid paralysis 2–4 weeks after infection	Areflexia. Previous respiratory or GI infection (Campylobacter classic). Can progress to respiratory compromise — monitor closely.	Fever usually absent. Sensation may be mildly impaired but motor symptoms dominate.
Peripheral Neuropathy	Glove-and-stocking sensory loss + distal weakness	Symmetrical, distal. Loss of vibration and proprioception early in large-fibre. Pain and temperature in small-fibre.	Check for: diabetes, B12 deficiency, alcohol, drugs (metronidazole, isoniazid, amiodarone)

Acute Neurology Red Flags — Must-Know in Primary Care

⚡

Thunderclap headache → subarachnoid haemorrhage until proven otherwise. Urgent CT head; LP at 12 hours if CT negative.

👁

New headache >50 + systemic symptoms → temporal arteritis (GCA). Urgent ESR, CRP; temporal artery biopsy; start steroids without waiting.

🦴

Progressive limb weakness + back pain → cord compression. Urgent MRI spine — do not delay.

🌡

Focal neurology + fever → encephalitis/meningitis until proven otherwise. Emergency admission.

Migraine — AKT-Relevant Facts

Acute treatment: triptans (5-HT1B/1D agonists) are first-line if simple analgesia fails
Prophylaxis options: topiramate, propranolol, amitriptyline, candesartan — note topiramate is teratogenic (warn women of childbearing age)
Combined oral contraceptive (COC/CHC) is CONTRAINDICATED in migraine with aura — stroke risk. This is a UKMEC Category 4 absolute contraindication.

🧠 Neurology Quick-Recall — Mnemonics & Key Thresholds

🚨 SNOOP4 — Headache Red Flags

S — Systemic symptoms / disease

N — Neurological deficit

O — Onset sudden / thunderclap

O — Older age (new onset >50)

P4 — Previous headache change; Precipitated by Valsalva; Postural; Progressive

🔴 SAH — Key AKT Facts

Presentation: Thunderclap headache ("worst headache of life"), neck stiffness, photophobia, vomiting. May have brief loss of consciousness.

If CT negative: LP at ≥12 hours after onset — look for xanthochromia (yellow CSF = breakdown products of haemoglobin). Negative CT does NOT exclude SAH.

AKT Trap: "CT head was normal — SAH excluded." WRONG. CT sensitivity drops after 12h. LP for xanthochromia is the next step.

Raised ICP — Cushing's Triad: Hypertension + Bradycardia + Irregular/slow respiration. This triad is a late sign of critically raised intracranial pressure. Act immediately.

🩸 TIA Management — ABCD2 & Antiplatelet Rule

Antiplatelet after TIA:

Aspirin + clopidogrel (dual) for 21 days
Then single antiplatelet long-term
Start immediately if TIA confirmed

High-risk TIA = same-day specialist assessment:

ABCD2 score ≥4
AF as the likely cause
≥2 TIAs in one week

ABCD2 score: Age ≥60 (1) + BP ≥140/90 (1) + Clinical features: unilateral weakness (2) / speech without weakness (1) + Duration: ≥60min (2) / 10–59min (1) + Diabetes (1) = max 7

😐 Bell's Palsy — Key Facts for AKT

Lower motor neurone facial nerve (CN VII) palsy — forehead involved (distinguishes from UMN lesion)
Start prednisolone within 72 hours of onset — improves recovery
Eye care essential — corneal exposure risk; tape eye shut at night, artificial tears
Add antivirals (e.g. valaciclovir) only if severe presentation

🧠 Parkinson's — TRAP Mnemonic

Tremor

Resting; "pill-rolling"

Rigidity

Cogwheel / lead-pipe

Akinesia

Bradykinesia; freezing

Postural instability

Late feature; falls

First-line for motor symptoms: Co-careldopa or co-beneldopa (levodopa + dopa-decarboxylase inhibitor). In younger patients, dopamine agonists (ropinirole, pramipexole) may be preferred to delay motor complications. Referral to neurology for initiation and specialist review.

🧠 Motor Neurone Disease (MND) — AKT Key Facts

Classic features:

UMN AND LMN signs together
No sensory loss — key distinguishing feature
Bulbar symptoms (dysarthria, dysphagia)
Progressive — no remission

GP Management:

Riluzole — only licensed disease-modifying drug; modest survival benefit (~3 months)
MDT approach: neurology, SALT, physio, OT, palliative
Advance care planning early

AKT Trap: UMN + LMN signs without sensory loss = MND. Adding sensory symptoms points away from MND to cord compression or demyelination.

💊 Drug Side Effects — Examiner-Flagged Every Sitting

Side effects of long-term medications are flagged in almost every AKT feedback report. The table below covers the highest-yield drugs. Know the serious and the common side effects for each.

Drug / Class	Key Side Effects to Know	Monitoring / Action
Metformin	Lactic acidosis (rare but serious — especially in AKI, iodinated contrast, sepsis); GI upset; long-term B12 deficiency	Hold in AKI, before contrast if eGFR <60, and during serious illness. Monitor B12 annually in long-term use.
Sulphonylureas	Hypoglycaemia (most important); weight gain	Educate patient on hypo symptoms. Avoid in frailty/impaired awareness of hypoglycaemia.
SGLT-2 inhibitors	UTI and genital thrush; DKA (including euglycaemic DKA — glucose may be normal!); Fournier's gangrene (rare but serious)	Stop perioperatively, in AKI, and in serious illness. Educate about euglycaemic DKA symptoms.
GLP-1 agonists	Nausea/vomiting (usually resolves); pancreatitis; weight loss (often therapeutic)	Stop if pancreatitis suspected. Check renal function — some not recommended if eGFR <15.
Pioglitazone	Fluid retention/heart failure exacerbation; increased bladder cancer risk; fracture risk in women	Contraindicated in heart failure. Monitor for oedema. Avoid in patients with haematuria.
Statins	Myopathy/rhabdomyolysis (check CK if symptomatic); hepatotoxicity (rare)	Check LFTs at baseline and if symptomatic. Stop if CK >5× upper limit of normal.
ACE inhibitors	Dry persistent cough (bradykinin — switch to ARB); hyperkalaemia; renal impairment; angioedema (rare — emergency)	Check renal function and electrolytes 1–2 weeks after starting or dose increase.
Amiodarone	Thyroid dysfunction (both hypo AND hyper); pulmonary toxicity; photosensitivity; peripheral neuropathy; corneal microdeposits; hepatotoxicity	Monitor: TFTs, LFTs, CXR — annually. Very long half-life — side effects can persist months after stopping.
Lithium	Narrow therapeutic index. Toxicity: tremor, ataxia, confusion, vomiting — can be life-threatening	Monitor serum lithium levels (target 0.4–1.0 mmol/L), renal function, TFTs — every 6 months when stable. Caution with NSAIDs and diuretics (raise lithium levels).
Methotrexate (MTX)	Hepatotoxicity; bone marrow suppression; teratogenicity (requires pregnancy prevention)	FBC + LFTs every 2 weeks until stable 6 weeks, then monthly. Folate supplementation required. Avoid in pregnancy — use effective contraception (+ 3 months after stopping).
SSRIs	Serotonin syndrome (with MAOIs, tramadol); hyponatraemia (especially in elderly); increased bleeding risk; sexual dysfunction	Review at 2 weeks in under-30s (increased suicidality risk initially). SSRI + NSAIDs = significantly increased GI bleed risk — consider PPI cover.
Clozapine	Agranulocytosis (mandatory FBC monitoring via CPMS); constipation (can be fatal — ileus/perforation); myocarditis; metabolic syndrome	Mandatory FBC monitoring programme. Never prescribe without monitoring enrolment. Constipation prevention is essential clinical management.
Digoxin	Narrow therapeutic index. Toxicity: nausea/vomiting, xanthopsia (yellow-green visual disturbance), bradyarrhythmias, heart block. Hypokalaemia significantly increases toxicity risk.	Monitor digoxin levels, U&E (especially K⁺). Amiodarone and verapamil raise digoxin levels — halve digoxin dose if adding amiodarone.
Warfarin	Bleeding risk — intracranial, GI. Extensive interactions: cranberry juice, grapefruit, antibiotics, NSAIDs, St John's Wort.	INR monitoring. Reversal: vitamin K (non-urgent); PCC + vitamin K for major/life-threatening bleeding. FFP alone is not first-line for emergency reversal.
Azathioprine	Bone marrow suppression, hepatotoxicity. Severe interaction with allopurinol — can cause fatal toxicity.	Check TPMT activity before starting. FBC + LFTs every 2 weeks for 3 months then 3-monthly when stable.
Sodium valproate	Neural tube defects, cognitive impairment, polycystic ovaries, hepatotoxicity. Highly teratogenic — Pregnancy Prevention Programme (PPP) mandatory for women of childbearing potential.	Must NOT be prescribed to women of childbearing potential unless on PPP with annual specialist review and documented counselling.
Corticosteroids (long-term)	Adrenal suppression (risk of Addisonian crisis if stopped abruptly), osteoporosis, DM, cataracts, GI ulceration, immunosuppression, weight gain, skin fragility, avascular necrosis of hip.	Never stop abruptly if on >3 weeks. Steroid card. Sick day rules: double dose during illness/surgery. DEXA if >3 months. PPI cover if GI risk. Consider osteoporosis prophylaxis.

🎯 AKT Tip — "Which drug causes which side effect?"

Questions often present a patient with a new symptom and ask "which of their current medications is most likely responsible?" Build a mental map: dry cough = ACEi, tremor/confusion = lithium, euglycaemic DKA = SGLT2i, photosensitivity = amiodarone, hepatotoxicity + bone marrow = methotrexate.

🔬 DMARD Monitoring — Tested in Prescribing Safety Domain Repeatedly

DMARD monitoring requirements appear regularly in the AKT prescribing safety domain. Know which drug requires which tests and at what frequency.

Drug	Monitoring Required	Frequency	Key Additional Point
Methotrexate	FBC, LFTs, U&E	Every 2 weeks until stable 6 weeks, then monthly	Folate supplement required throughout. Teratogenic — contraception mandatory. Never give folic acid on the same day as MTX.
Azathioprine	FBC, LFTs	Every 2 weeks for 3 months, then 3-monthly	Check TPMT enzyme level before starting — low activity = high toxicity risk.
Sulfasalazine	FBC, LFTs	Every 2 weeks for 3 months, then 3-monthly	Can cause oligospermia — warn men. Yellow discolouration of urine/tears is harmless.
Hydroxychloroquine	Annual eye check	Annual (after first 5 years of use)	Retinopathy is the main concern — risk is low but must be screened. Refer to ophthalmology annually once on long-term use.
Leflunomide	FBC, LFTs, BP	Monthly for 6 months, then 3-monthly	Very long half-life — washout procedure (cholestyramine) needed before pregnancy or switching. Effective contraception required + 2 years after stopping.
Ciclosporin	Renal function, LFTs, BP	Every 2 weeks initially, then 3-monthly when stable	Nephrotoxic — monitor eGFR closely. Avoid NSAIDs. Gingival hyperplasia and hirsutism are common side effects.

⚠️

AKT Trap — DMARD Monitoring Intervals

Questions often ask: "A patient on methotrexate has not had monitoring blood tests for 4 months. What is the MOST appropriate action?" The answer is: stop the drug pending blood tests and refer back to the prescribing team — not "continue and order bloods." Unmonitored DMARDs must be stopped, not just caught up with.

👶 Paediatric Cancer Recognition — Flagged 2 of Last 4 Sittings

Paediatric cancer recognition is specifically flagged in recent AKT feedback. The AKT tests whether you would recognise features warranting urgent referral — not the detailed oncological management.

Cancer Type	Presenting Features	Action
Leukaemia / Lymphoma	Pallor, easy bruising, lymphadenopathy, bone/joint pain, recurrent infections, fatigue, hepatosplenomegaly	Urgent FBC and blood film. Urgent paediatric referral if concern.
Brain Tumour	Morning headache that wakes from sleep, headache + vomiting, personality change, new seizures, visual symptoms, squint (new), papilloedema	Urgent 2WW referral (paediatric). Urgent CT if very unwell.
Wilms Tumour (nephroblastoma)	Abdominal mass in a child usually under 5 years — often painless, discovered incidentally or by parent	Do not palpate repeatedly. Urgent paediatric referral.
Osteosarcoma	Bone pain and swelling in an adolescent — especially around the knee or shoulder. Often misattributed to "growing pains" or sports injury.	Do NOT reassure as growing pains without imaging. Urgent X-ray + 2WW bone tumour referral if suspected.
Retinoblastoma	Absent red reflex (leukocoria — white reflex in photo), squint in a young child	Urgent ophthalmology referral. Red reflex check is part of neonatal and 6-week check — know this.

🚨

AKT Pearl — "Osteosarcoma Trap"

A teenager with knee pain and swelling, worse after sport, presents twice. The temptation is to diagnose musculoskeletal injury or growing pains. The AKT will test this. Any persistent, unexplained bone pain or swelling in an adolescent — especially if it is not resolving — requires X-ray and consideration of 2WW bone tumour referral. Do not dismiss it.

👶 Paediatric Extras — Febrile Convulsions & Paediatric Urology

🌡 Febrile Convulsions — Simple vs Complex

✅ Simple Febrile Convulsion

Generalised (no focal features)
Duration <15 minutes
Only one episode in 24 hours
Age 6 months–5 years
Full recovery within 1 hour

Action: Reassure, safety-net, no anticonvulsants needed. Manage the fever.

⚠️ Complex Febrile Convulsion

Focal features OR
Duration ≥15 minutes OR
More than one episode in 24 hours OR
Age outside 6 months–5 years OR
Todd's paresis after event

Action: Paediatric assessment needed. Consider EEG, neuroimaging.

AKT Trap: Anticonvulsants are NOT recommended routinely for simple febrile convulsions. The question may offer diazepam or phenobarbitone — the correct answer for a simple febrile convulsion is reassurance + safety-netting.

🩺 Paediatric Urology — Three AKT-Tested Conditions

Undescended Testis

If not descended by 6 months — refer
Orchidopexy should be performed before age 1
Risk of infertility and testicular cancer if untreated

AKT Trap: "Refer at 1 year" is wrong — refer before age 1.

Hypospadias

Urethral meatus on ventral surface of penis
Do NOT circumcise — the foreskin is needed for surgical repair
Refer to paediatric surgery

AKT Trap: A parent requests circumcision — hypospadias means circumcision is contraindicated.

Nocturnal Enuresis (Bedwetting)

Normal up to age 5–6; common up to age 7
Consider referral / active management if age >7
First-line: enuresis alarm (better long-term outcomes than medication)
Second-line: desmopressin (short-term use)

💊 Contraception — Teratogenic Drugs, Emergency Contraception & CHC Contraindications

Drugs Requiring Highly Effective Contraception (LARC Recommended)

Drug	Indication	Contraception Requirement
Methotrexate	RA, psoriasis, IBD	Effective contraception throughout treatment AND 3 months after stopping — for both males and females
Sodium Valproate	Epilepsy, bipolar	Compulsory Pregnancy Prevention Programme (PREVENT). Annual risk acknowledgement form + specialist letter required for each prescription. Highest teratogenic risk of any commonly prescribed drug.
Isotretinoin	Severe acne	PPP (Pregnancy Prevention Programme). Monthly pregnancy test. LARC or two methods simultaneously required throughout + 1 month after stopping.
Leflunomide	RA	Effective contraception during treatment + 2 years after stopping (or 3 days after washout procedure with cholestyramine)
Mycophenolate	Transplant, autoimmune	Effective contraception throughout + 6 weeks after stopping. Teratogenic — associated with miscarriage and fetal abnormalities.

Emergency Contraception — Know the Timeframes Cold

Method	Window	Key Points
Levonorgestrel 1.5mg (Levonelle)	Up to 72 hours after UPSI	Efficacy decreases with time — most effective if taken immediately. OTC available.
Ulipristal acetate (ellaOne)	Up to 120 hours after UPSI	More effective than levonorgestrel if >72 hours have passed. Prescription required. Must wait 5 days before starting hormonal contraception.
Copper IUD	Up to 120 hours (or 5 days after earliest expected ovulation)	Most effective EC method overall. Can be kept as ongoing contraception. Offers no protection from STIs.

⚠️

AKT Trap — Starting Hormonal Contraception After Emergency Contraception

After ulipristal acetate: must wait 5 days before starting any hormonal contraception (they interact — ulipristal works by inhibiting progesterone, so progestogens reduce its efficacy). After levonorgestrel: hormonal contraception can be quick-started immediately (with barrier method for 7 days).

CHC (Combined Hormonal Contraception) — Absolute Contraindications (UKMEC Category 4)

Migraine with aura (any age)
Personal history of VTE
Breastfeeding <6 weeks postpartum
Smoker aged ≥35 years AND >15 cigarettes per day
BP ≥160/100 mmHg
Active liver disease / hepatocellular carcinoma
Current breast cancer
Known thrombogenic mutations (e.g. Factor V Leiden)

❤️ Hypertension — NICE NG136 Complete Guide (Diagnostic Thresholds, Treatment Steps, AKT Traps)

Diagnostic Thresholds

Clinic BP	Action
<140/90 mmHg	Check BP at least every 5 years
140/90 – 179/119 mmHg	Offer ABPM/HBPM; investigate for target organ damage (TOD); assess 10-year CVD risk
≥180/120 mmHg	Assess for TOD urgently. If TOD present → consider immediate treatment. If no TOD → repeat clinic BP in 7 days.

ABPM/HBPM Staging

Stage 1

Daytime average 135/85 – 149/94 mmHg

Treat only if: age <80 AND has TOD, CVD, renal disease, diabetes, or 10-year CVD risk ≥10%. Otherwise: lifestyle + monitor.

Stage 2

Daytime average ≥150/95 mmHg

Offer drug treatment regardless of age (if age ≥80: clinic target <150/90).

Treatment Steps — ABCD Rule

Step	Age <55, non-Black	Age ≥55 OR Black African/Caribbean
Step 1	ACEi or ARB	CCB
Step 2	ACEi/ARB + CCB
Step 3	ACEi/ARB + CCB + thiazide-like diuretic (indapamide preferred)
Step 4 (resistant)	K⁺ ≤4.5 → add spironolactone \| K⁺ >4.5 → add alpha-blocker or beta-blocker

Treatment targets: Age <80: clinic <140/90 / ABPM <135/85 | Age ≥80: clinic <150/90 / ABPM <145/85

Diabetes + Hypertension: Target <130/80 mmHg (clinic). First-line: ACEi or ARB (especially if proteinuria present). More aggressive target than general population.

CKD + ACR ≥70 mg/mmol: Target <130/80 mmHg. First-line: ACEi or ARB — renoprotective and reduces proteinuria progression.

🧠 Memory Aid — ACTS & CATS

The four drug classes added in steps spell a word that tells you the order. Use ACTS for most patients, CATS for Black African/Caribbean patients (CCB comes first in this group).

Most patients — age <55, non-Black

ACTS

Step 1

ACEi or ARB

Step 2

+ Calcium channel blocker

Step 3

+ Thiazide-like diuretic (indapamide)

Step 4

+ Spironolactone (or alpha/beta-blocker)

Black African/Caribbean — CCB first

CATS

Step 1

Calcium channel blocker

Step 2

+ ACEi or ARB

Step 3

+ Thiazide-like diuretic

Step 4

+ Spironolactone (or alpha/beta-blocker)

Steps 3 and 4 are the same in both pathways. The only difference is whether you start with the A (ACEi/ARB) or the C (CCB) at Step 1. ACTS and CATS share the same final two letters — T and S — because the drugs at Steps 3 and 4 are identical regardless of ethnicity.

🎯 AKT Traps — Hypertension

Never combine ACEi with ARB. NICE NG136 explicitly prohibits dual renin-angiotensin blockade — a classic distractor in single-best-answer questions.

Prefer indapamide over bendroflumethiazide. Guideline specifies a "thiazide-like diuretic" — indapamide, not a conventional thiazide.

Accelerated hypertension = BP ≥180/120 + retinal haemorrhage or papilloedema → same-day specialist review. Not "arrange follow-up."

Beta-blockers are NOT first-line for hypertension — only use with compelling indication (post-MI, HFrEF, angina, or AF).

🩸 Type 2 Diabetes — NICE NG28 Drug Treatment, SGLT2i Rules & eGFR Thresholds

Drug Treatment Steps (NICE NG28)

#	Treatment	Key Note
1	Metformin + lifestyle modification	First-line for all patients (unless contraindicated). Review dose if eGFR <45; stop if eGFR <30.
2 ★	Add SGLT2 inhibitor — at any point, including alongside metformin as first intensification	If: established ASCVD, QRISK2 ≥10%, CKD, or heart failure. Do NOT wait for metformin failure before adding SGLT2i in these patients.
3	SGLT2i, DPP-4i, pioglitazone, or sulphonylurea	No CVD/CKD — patient preference and tolerability guide choice
4	GLP-1 receptor agonist	Fourth-line for glycaemia under NG28; earlier use for weight or CVD benefit via separate NICE TA

🎯 AKT Traps — T2DM

Metformin eGFR rules — tested every sitting: Review dose at eGFR <45 ml/min; stop metformin if eGFR <30 ml/min. This is not "stop at eGFR <45" — that is the threshold for dose review only.

SGLT2i are not just second-line. In patients with ASCVD, high CVD risk, CKD, or heart failure — add an SGLT2 inhibitor at any point. Do not wait for metformin failure. This is a major NICE NG28 update that the AKT tests directly.

HbA1c is unreliable in haemolytic anaemia, haemoglobinopathies, and pregnancy. Use fasting plasma glucose or 2-hour OGTT in these patients instead.

🫘 CKD — NICE NG203 Updated Referral Threshold (KFRE >5% Replaces eGFR <30)

🫘 CKD Staging — Quick Recall

The six eGFR stages from normal to failure — in a single glance. Colours match severity: green → amber → red → failure.

≥90

Requires
damage marker

60–89

Requires
damage marker

G3a

45–59

Mild–
moderate

G3b

30–44

Moderate–
severe

15–29

Severe

<15

Kidney
failure

⚠️

CKD Diagnosis Requires BOTH Duration AND Cause

CKD = eGFR <60 OR a kidney damage marker (proteinuria, haematuria of renal origin, structural/genetic abnormality) — for ≥3 months. A single eGFR reading alone does NOT diagnose CKD. G1 and G2 require a damage marker — eGFR alone at 60–89+ cannot diagnose CKD without one.

🆕

Major Update — AKT Specifically Tests This

The referral threshold has shifted from eGFR <30 (old) to 5-year KFRE >5% (current NICE NG203 recommendation). eGFR <30 is still practically associated with referral, but is no longer the correct guideline answer. If the AKT asks about referral threshold — answer KFRE >5%.

Referral Criteria — NICE NG203

Criterion	Detail
5-year KFRE >5% ⭐	Primary referral trigger — replaces eGFR <30 as the guideline threshold
ACR ≥70 mg/mmol	Regardless of eGFR
ACR >30 mg/mmol + haematuria	Investigate and refer if persistent
eGFR decrease ≥25% AND category change in 12 months	Rapid decline — investigate and refer
eGFR decrease ≥15 ml/min per year	Rapid progression
HTN uncontrolled on ≥4 antihypertensives	Resistant hypertension with CKD — refer

CKD Diagnosis — Duration Requirement

⏱

≥3 Months Required

CKD is defined as eGFR <60 ml/min/1.73m² OR evidence of kidney damage (proteinuria, haematuria of renal origin, structural abnormality) for ≥3 months. A single abnormal eGFR reading does not diagnose CKD — it must be confirmed on a repeat test ≥3 months later.

💊 Contraception — UKMEC 2025 Complete (Categories, 2025 Updates, CHC Contraindications, Emergency Contraception)

UKMEC Categories

Category	Meaning	Clinical Action
1	No restriction — use freely	Prescribe without restriction
2	Advantages generally outweigh risks	Use, but monitor
3	Risks usually outweigh advantages	Expert judgement needed; prefer alternatives
4	Unacceptable health risk	Do NOT use — contraindicated

💡 Cumulative Risk Rule

Multiple UKMEC 2 conditions = cumulative risk — review overall safety. Multiple UKMEC 3 conditions together may constitute unacceptable risk. Consider this when prescribing CHC to patients with several moderate risk factors.

🆕 Key 2025 UKMEC Updates

CKD (all severities) — elevated VTE risk; CHC not suitable. This is a 2025 update — CKD now explicitly listed as a reason to avoid CHC regardless of severity.

Sickle cell trait — modestly elevated VTE risk; alternatives to CHC preferred. Distinct from sickle cell disease — trait is UKMEC 2/3, not 4.

Anxiety / mood disorders — CHC not consistently shown to worsen mental health. Offer personalised counselling rather than blanket avoidance.

Absolute CHC Contraindications — UKMEC 4

Current breast cancer
Migraine with aura (any age)
Systolic BP ≥160 mmHg or diastolic ≥100 mmHg
VTE (current, unanticoagulated)

Stroke / TIA or ischaemic heart disease
Severe liver disease / hepatoma
SLE with antiphospholipid antibodies
Major surgery with prolonged immobility

Emergency Contraception — Quick Reference

Method	Window	Key Notes
🥇 Cu-IUD (copper coil)	Up to 120 hours (5 days) post-UPSI	Most effective method overall. Can be kept as ongoing contraception.
Levonorgestrel (LNG)	Up to 72 hours	Efficacy decreases with time. Available OTC.
Ulipristal acetate (UPA)	Up to 120 hours	More effective than LNG after 72h. Avoid breastfeeding for 1 week after. Avoid if enzyme-inducing drugs. Must wait 5 days before starting hormonal contraception.

🚨

Don't Leave Admin and Stats Until the End

These 32 questions (20% of your exam) are more finite than clinical knowledge. They can be specifically studied. Many trainees who fail do so by ~2–3% — almost entirely because they scored less than 50% in stats and admin. Study these domains early and properly. You will thank yourself.

🏥 Using Hospital Posts for AKT Revision

Your Hospital Posts Are Live AKT Revision

Most trainees plan to revise for the AKT during their GP post. The smart ones realise that every hospital rotation is already an AKT question bank — they just need to unlock it.

🔥

The Key Insight Most Trainees Miss

A significant proportion of AKT questions draw on conditions managed in secondary care. Every ward round, every clinic, every case presentation is revision — if you ask the right questions. Clinical memory (memory tied to a real patient) is far more durable than memory from books alone. The trainee who learns COPD exacerbation management on the respiratory ward will remember it for years. The one who reads it from a textbook at 11pm will remember it until the exam — maybe.

🧠 The "Hospital = AKT Goldmine" Framework

Train yourself to ask these four questions for every patient you encounter in hospital. Do it in your head as you walk out of the bay. It takes 30 seconds and is one of the most efficient AKT revision habits you can build.

🔍

1 — Diagnosis

What is the most likely diagnosis? What are the two key differentials? How would a GP recognise this?

🧪

2 — Investigation

What is the single best investigation? What would the AKT ask? What finding confirms or excludes the diagnosis?

💊

3 — First vs Second Line

What does NICE say? What is first-line? What comes next if that fails? The AKT loves the "already on treatment X, what now?" scenario.

⚠️

4 — Complications & Cautions

What must not be missed? What drug interactions exist? What monitoring is required? What would a NICE guideline specify?

🔥 High-Yield AKT Content by Hospital Rotation

Click a specialty tab to see the most important AKT learning points from that rotation. These are the facts most likely to appear as exam questions — drawn directly from examiner feedback.

Medicine rotations are one of the most AKT-dense placements. Chest pain, breathlessness, ACS, heart failure, arrhythmias, metabolic emergencies — every ward round is a question bank. Ask your senior to explain the NICE guidelines as they apply clinically.

Condition	High-Yield AKT Fact	Classic Trap to Avoid
ACS / STEMI	Aspirin 300mg immediately (chewed/dispersed). Add second antiplatelet (ticagrelor or clopidogrel). PPCI within 120 minutes if STEMI and available.	Not giving dual antiplatelet early. Confusing STEMI vs NSTEMI management pathways.
Atrial Fibrillation	Rate control is first-line in most stable patients. CHA₂DS₂-VASc: men ≥2, women ≥3 → anticoagulate. DOACs preferred over warfarin. Use ORBIT score to assess bleeding risk when reviewing anticoagulation — not to withhold it.	Knowing the score names but not applying them: questions give a patient — you must know what the score means for the decision. ORBIT assesses bleeding risk; CHA₂DS₂-VASc assesses stroke risk. Both needed together.
Heart Failure (HFrEF)	First-line triad: ACE inhibitor (or ARB if intolerant) + beta-blocker + MRA (spironolactone/eplerenone). SGLT2 inhibitors now added per updated guidance.	Missing MRA as part of the triad. Confusing HFrEF (reduced EF) and HFpEF management — they differ.
Hyponatraemia	Categorise first: hypovolaemic / euvolaemic / hypervolaemic. Chronic hyponatraemia: correct slowly (risk of osmotic demyelination if too fast). SIADH: fluid restrict first.	Giving rapid saline in SIADH — wrong. Correcting too rapidly in chronic hyponatraemia — dangerous.
DKA	IV fluids first (before insulin). Fixed-rate insulin infusion 0.1 units/kg/hr. Target: ketone clearance >0.5 mmol/L/hr. Continue long-acting insulin throughout.	Stopping long-acting insulin in DKA. Delaying fluids while preparing insulin. Not adding dextrose when glucose falls below 14 mmol/L.
Acute Kidney Injury (AKI)	NICE defines AKI as any of: (1) serum creatinine rise ≥26 micromol/L within 48 hours, (2) creatinine ≥1.5× baseline within 7 days, or (3) urine output <0.5 mL/kg/hour for >6 hours. Manage by treating the cause, reviewing fluid balance, and stopping nephrotoxic drugs.	Missing drug causes — ACEi, ARBs, NSAIDs, aminoglycosides, diuretics. The question describes a patient on these drugs who develops AKI. Answer: hold the offending drug(s) and review.

💡 AKT Traps Specific to Medicine Rotation

First vs second vs third line: AKT often describes a patient already on first-line treatment and asks "what next?" Know management ladders for hypertension, T2DM, heart failure, and depression well enough to name the third-line option.
Thresholds and timescales: NICE sets specific numbers. 2-week-wait cancer referrals, 48-hour UTI review, 3-month HbA1c recheck — the wrong-number distractor is a classic AKT trap.
Distractor "hospital" answers: Questions about a recently discharged patient may present a management option that is correct for inpatients but wrong in the community. Always think "What would a GP do?" not "What would a ward doctor do?"

COPD staging, asthma management, spirometry interpretation, ABGs, when to refer for CT — these are direct AKT fodder. Ask your senior to explain the guidelines as they apply to each patient you see.

Condition	High-Yield AKT Fact	Classic Trap to Avoid
COPD Exacerbation	Oxygen target: 88–92% (not 94–98% as in other patients). Controlled O₂ therapy. Nebulised bronchodilators, prednisolone 30mg for 5 days, antibiotic if purulent sputum.	Over-oxygenating → CO₂ retention → type 2 respiratory failure. The O₂ target (88–92%) is one of the most-tested AKT facts in respiratory medicine.
Acute Severe Asthma	SABA nebuliser + prednisolone 40–50mg early. Life-threatening features: SpO₂ <92%, silent chest, bradycardia, peak flow <33% predicted. IV magnesium sulphate for life-threatening.	Confusing moderate / severe / life-threatening asthma criteria. Not recognising when IV magnesium is indicated vs when to escalate to ITU.
Community-Acquired Pneumonia	CURB-65 guides severity. Score ≥3 = high severity → consider hospital admission. Each point: Confusion, Urea >7, RR ≥30, BP systolic <90, age ≥65.	CURB-65 applies to CAP only — not hospital-acquired pneumonia. Confusing the letters or cut-offs.
Spirometry interpretation	Obstructive: FEV₁/FVC <0.7. Restrictive: FEV₁/FVC normal or elevated, but FVC reduced. Both reduced = mixed. Post-bronchodilator FEV₁ used for GOLD staging of COPD.	Diagnosing COPD before a post-bronchodilator spirometry. Not recognising a mixed pattern.
Asthma — NICE 2024 Update	ICS-formoterol (MART) is now preferred over SABA alone at all steps from Step 2 onwards. SABA-only prescribing is no longer recommended for most patients. Know the step therapy clearly.	Prescribing SABA alone as first-line rescue for mild-moderate asthma — this has changed. An outdated answer here will cost marks.

⚠️

The O₂ Target Is Tested Every Year

The 88–92% oxygen target in COPD is one of the most-tested facts in the AKT. It is the opposite of what trainees reflexively do in most clinical situations. Learn it and remember it — and know that the reason is hypoxic drive in CO₂ retainers.

Risk assessment, the Mental Health Act, antipsychotic side effects, depression in complex patients — psychiatry is extremely high-yield for the AKT. Make structured notes during this post. This is not a rotation to let wash over you.

Topic	High-Yield AKT Fact	Classic Trap
Mental Health Act Sections	Section 2 = 28-day assessment. Section 3 = 6-month treatment. Section 4 = 72h emergency (GP + AMHP). Section 5(2) = 72h doctor's holding power (inpatient). Section 136 = police hold, public place.	Confusing Section 2 (assessment) with Section 3 (treatment). Forgetting that Section 4 requires an AMHP — not just a GP alone. Misapplying which section applies in which setting.
Mental Capacity Act	MCA applies to adults lacking capacity. Presume capacity unless assessed otherwise. Capacity is decision-specific and time-specific. Best interests decision when capacity is lacking.	Applying the MCA when MHA is appropriate (the person has capacity but refuses). These overlap — knowing when each applies is tested directly.
Antipsychotic Side Effects	EPS: akathisia (restlessness), dystonia (muscle spasm), Parkinsonism, tardive dyskinesia (late, may be irreversible). Clozapine: agranulocytosis — mandatory CPMS monitoring. Metabolic syndrome with all antipsychotics.	Confusing acute dystonia (needs anticholinergics acutely) with tardive dyskinesia (stopping the drug may be needed). Not knowing clozapine's monitoring requirements.
Depression — NICE step therapy	Step 1: Watchful waiting. Step 2: Guided self-help, CBT. Step 3: Antidepressants (SSRIs first-line) ± CBT. Step 4: Complex depression — specialist referral, combination treatment.	Starting antidepressants at Step 1. Not reviewing within 2 weeks of starting an antidepressant (suicide risk increases initially in some patients, especially under 30).

⚖️ MHA vs MCA — The Framework That Trips Trainees

Mental Capacity Act (MCA)

For adults who lack capacity
Decision-specific and time-specific
Best interests principle
Applies to all medical decisions

Mental Health Act (MHA)

For patients with mental disorder
Can override capacity and consent
Compulsory assessment or treatment
Applies specifically to mental disorder

Key rule: A patient may have capacity to refuse treatment but still be detained under the MHA. The MHA can override a capacitous refusal for treatment of mental disorder. The MCA cannot.

💊 Psychiatry AKT Tips — High-Yield Drug & Clinical Facts

🤰 SSRI in Pregnancy

Sertraline — preferred (most safety data in pregnancy)
Avoid paroxetine — associated with fetal cardiac defects
All SSRIs: neonatal adaptation syndrome risk in third trimester

⚡ ECT Indications

Severe depression with psychotic features
Treatment-resistant depression (failed adequate trials)
Catatonia
Life-threatening situation requiring rapid response

⚠️ Dangerous Drug Interactions

SSRIs + triptans → serotonin syndrome (hyperthermia, clonus, agitation, autonomic instability)
MAOIs + tyramine-rich foods (cheese, red wine, cured meat) → hypertensive crisis
MAOIs + SSRIs → fatal serotonin syndrome — washout period mandatory when switching

⚖️ Mental Health Act Sections — Quick Recall

Section 2
Assessment
Up to 28 days

Section 3
Treatment
Up to 6 months (renewable)

Section 4
Emergency assessment
Up to 72 hours (GP + AMHP)

Section 5(2)
Doctor's holding power
Up to 72 hours (inpatient)

Section 5(4)
Nurse's holding power
Up to 6 hours

Section 136
Police power (public place)
Up to 24 hours

Paediatric posts are revision gold. Growth and development, common childhood presentations, immunisation schedules, recognising serious illness — all AKT regulars. They are also some of the most memorisable if you learn them properly now.

📅 Key Developmental Milestones

Age	Gross Motor	Fine Motor / Speech
6 weeks	Head lag; fixes and follows	Social smile
6 months	Sits with support; rolls	Monosyllables; grasps
9 months	Pulls to stand; crawls	Pincer grip emerging
12 months	Cruises; stands unaided	2–3 words; pincer grip
18 months	Walks alone	6–10 words; points
2 years	Runs; kicks ball	2-word phrases; 50+ words
3 years	Up stairs (one per step)	Sentences; strangers understand
4–5 years	Hops; skips	Full sentences; counts to 10

🚦 Febrile Child — NICE Traffic Light System

🟢 GREEN — Low Risk

Normal colour, responds normally, moist mucous membranes, no tachycardia. Manage at home with safety-net advice.

🟡 AMBER — Intermediate Risk

Pallor, not responding normally, tachycardia, reduced urine output, fever >5 days, rigors, swollen joint. Urgent review / refer.

🔴 RED — High Risk

Non-blanching rash, stiff neck, bulging fontanelle, Kernig's/Brudzinski's sign, SpO₂ <92%, decreased consciousness. Emergency admission — call 999.

🛡️ Child Safeguarding — AKT High-Yield Points

Gillick competence: Under-16s can consent to treatment if they have sufficient maturity to understand the nature and implications. Not the same as Fraser guidelines (which apply specifically to contraception).
Fraser guidelines: Apply specifically when prescribing contraception to under-16s. The GP must be satisfied the young person understands the advice, cannot be persuaded to involve parents, will likely have sex with or without contraception, and that providing contraception is in their best interests.
Section 47 enquiry: Initiated when there is reasonable cause to suspect a child is suffering or likely to suffer significant harm. Led by social services ± police.
Section 17 enquiry: For a child in need (not necessarily in danger of harm). May still refer to social services but lower threshold than Section 47.
If in doubt, refer: The threshold for making a safeguarding referral is "reasonable cause to suspect" — not certainty. Always document your decision, even if you don't refer.

🫀 Kawasaki Disease — AKT Recognition Criteria

Kawasaki disease is a vasculitis of childhood that can cause coronary artery aneurysms if untreated. It is specifically tested in AKT paediatric questions.

🔴 Diagnostic Criteria

Fever >5 days PLUS ≥4 of the following:

Non-purulent conjunctivitis (bilateral)
Rash (polymorphic, trunk)
Cracked lips / strawberry tongue / oral erythema
Cervical lymphadenopathy (usually unilateral, >1.5cm)
Oedema / desquamation of hands and feet

⚕️ Management & Risk

Refer urgently to paediatrics
Treatment: IVIG + aspirin
Main risk: coronary artery aneurysms (up to 25% if untreated)
Echocardiography needed

AKT Trap: Kawasaki can present with incomplete criteria. Prolonged fever in a child without clear source = consider Kawasaki.

🌡️ HRT — NICE 2024 Guidance (NG23 Updated)

✅ When to Offer HRT

Offer to women with menopausal symptoms affecting quality of life
Low risk in most healthy women under 60 within 10 years of menopause
Benefits generally outweigh risks in this group
Do not withhold HRT solely based on age if within 10 years of menopause

🩺 Route & VTE Risk

Transdermal preferred (patch/gel) — does not increase VTE risk unlike oral
Oral oestrogen → modest increase in VTE risk
Women with uterus: add progestogen (combined HRT) to prevent endometrial cancer
Hysterectomised women: oestrogen-only HRT

AKT Tip: The 2024 update specifically changed guidance to support offering HRT more proactively. The old "never HRT after 60" position is outdated. The updated message: assess individually, prefer transdermal, discuss risks and benefits. Expect questions testing the updated route preference and the <10-year postmenopause window.

Falls, polypharmacy, frailty, dementia, capacity assessment — geriatric medicine posts are more relevant to GP practice than almost any other hospital specialty. And they are increasingly tested in the AKT. Don't underestimate this rotation.

Topic	Key AKT Points
Falls in the Elderly	Multifactorial assessment required (NICE). Check: visual acuity, vestibular, medications (especially antihypertensives, sedatives, diuretics), postural hypotension, gait/balance. FRAT (Falls Risk Assessment Tool) used in care homes. Offer Tai Chi or strength/balance exercises as intervention.
Polypharmacy	Review all medications in patients over 75 or on 5+ drugs. STOPP/START criteria guide deprescribing. Look for: anticholinergics (high fall and cognitive risk), NSAIDs (GI bleed, renal, CV risk), hypnotics, and duplicate drug classes.
Dementia	Alzheimer's (most common) = AChEI first-line (donepezil, rivastigmine, galantamine). Vascular dementia: no specific drug — manage cardiovascular risk. Lewy body dementia: never use antipsychotics (severe sensitivity reaction). Frontotemporal: no drug evidence.
Capacity Assessment	4-stage test: (1) Understand information, (2) Retain it, (3) Weigh it up, (4) Communicate decision. Must be applied for every decision where capacity is in question. Document your assessment explicitly.
Delirium	Acute onset + fluctuating course + altered consciousness ± cognitive impairment. Predisposing: dementia, sensory impairment, dehydration. Precipitating: infection, drugs, constipation, urinary retention, pain. Non-pharmacological first; only haloperidol if distressed/unsafe (short-term).

💡 AKT Trap — Lewy Body Dementia

Antipsychotics are contraindicated in Lewy body dementia — they cause severe neuroleptic sensitivity reactions, including rigidity, immobility, and death. This is a classic "which drug must you avoid?" AKT question. The answer is always: do not give antipsychotics to a patient with Lewy body dementia.

Contraception, pre-eclampsia, ectopic pregnancy, common gynaecological presentations — O&G provides specific, numerical, high-yield AKT material. Learn the NICE guidelines for each condition you encounter.

Topic	High-Yield AKT Facts	Trap
Ectopic Pregnancy	Risk factors: previous ectopic, PID, IUD in situ, previous pelvic surgery, IVF. Classic: amenorrhoea + unilateral pain + bleeding. Always exclude if positive pregnancy test + pain. Emergency if haemodynamically unstable.	Missing ectopic in a patient presenting with "light periods and shoulder tip pain" — haemorrhage causing diaphragmatic irritation is classical and testable.
Pre-eclampsia	BP ≥140/90 + proteinuria after 20 weeks. Severe: BP ≥160/110, headache, visual disturbance, RUQ pain, oedema. Risk factors: nulliparity, previous PET, BMI >35, multiple pregnancy. Treatment: labetalol (first-line in UK). Definitive: delivery.	Labelling as essential hypertension without checking for proteinuria. Not recognising severe features requiring emergency admission.
Contraception	Combined OCP: avoid if migraine with aura, age >35 + smokes ≥15 cigs/day, VTE history, BP >160/95. POP: suitable if breastfeeding, migraine with aura, age >35 smokers. LARC (IUS/IUD/implant/injection): most effective methods.	Prescribing COCP to a patient with migraine with aura — this is a contraindication. Forgetting that the implant is the most effective reversible method.
Antenatal Schedule	Booking ~8–10 weeks. Anomaly scan 18–20 weeks. GTT at 24–28 weeks if risk factors. OGTT 24–28 weeks for gestational diabetes. GBS screening: not routine in UK. Anti-D for Rh-negative mothers: 28 weeks and after sensitising events.	Stating that GBS screening is routine in the UK — it is not (unlike in some other countries). Anti-D timing and indications are frequently tested.

📋 Screening Programme Specifics — All Ages & Intervals

Screening ages and recall intervals are specifically tested in the AKT. Memorise each one — wrong numbers are a favourite distractor.

Programme	Who	Interval	Method
Cervical screening	Women 25–49	Every 3 years	HPV primary screening → cytology if HPV +ve
	Women 50–64	Every 5 years	As above
Breast screening	Women 50–70	Every 3 years	Mammography
Bowel cancer screening	Ages 50–74 (England)	Every 2 years	FIT (faecal immunochemical test)
AAA screening	All men aged 65	One-off	Ultrasound
Diabetic retinopathy	All known diabetics	Annual	Dilated fundus photography
NHS Health Check	40–74 (no CVD/DM)	Every 5 years	CVD risk assessment

🧠 SAD MANS — Drugs to Withhold in AKI

AKI is extremely high-yield in the AKT. The most commonly tested questions focus on which drugs to stop and which are most nephrotoxic. Learn this mnemonic once — it will serve you in the exam and in real practice for your entire career.

💊 SAD MANS — Drugs to Withhold or Review in AKI

Sulfonylureas

Accumulate in renal impairment → hypoglycaemia. Withhold and switch to safer agents during AKI.

ACE Inhibitors

Reduce efferent arteriolar tone → worsen renal perfusion in AKI. Stop and restart once recovered.

Diuretics

Volume depletion worsens AKI if pre-renal cause. Stop loop and thiazide diuretics during AKI.

Metformin

Accumulates in AKI → lactic acidosis (Metformin-Associated Lactic Acidosis, MALA). Stop immediately. The AKT specifically tests this interaction — know it cold.

ARBs (Angiotensin Receptor Blockers)

Same mechanism as ACE inhibitors — impair renal autoregulation. Stop alongside ACEi during AKI.

NSAIDs

Inhibit prostaglandin-mediated afferent arteriolar dilation → reduce GFR. Contraindicated in CKD and AKI. One of the most commonly prescribed nephrotoxic drugs in primary care.

SGLT2 Inhibitors

Reduce renal glucose reabsorption — ineffective and potentially harmful when GFR falls. Stop during AKI. Also associated with euglycaemic DKA — hold perioperatively.

Important: These drugs are withheld during AKI — not permanently stopped. Restart only once renal function is recovering and the patient is haemodynamically stable. Restart ACEi/ARBs at low dose with renal function check at 1–2 weeks.

⚠️ AKI — Prescribing Traps the AKT Loves

AKT Trap	Why It Trips Trainees	What to Do Instead
Metformin + AKI	Metformin accumulates in AKI → lactic acidosis. Commonly prescribed, so very commonly tested.	Stop metformin. Resume only when eGFR >45 and patient is clinically well.
NSAIDs in CKD/AKI	NSAIDs reduce renal perfusion — contraindicated in CKD and during AKI. Frequently appear in "what would you advise this patient to avoid?" questions.	Avoid NSAIDs in anyone with CKD or AKI. Use paracetamol or weak opioids if pain relief is needed.
DOAC dosing in renal impairment	Dose reduction required for DOACs (apixaban, rivaroxaban, edoxaban) when eGFR is impaired. Thresholds differ between drugs and between indications. Always check BNF.	Never rely on memory for DOAC dose adjustments — always verify against BNF based on specific drug, indication, and renal function.
ACEi/ARB in bilateral renal artery stenosis	ACEi/ARBs can cause severe AKI in bilateral renal artery stenosis — this is an absolute contraindication. A classic AKT "what must you never prescribe?" question.	Avoid ACEi and ARBs entirely. Alternative antihypertensives required. Refer to nephrology.

🚨 Sepsis — The AKT Version

The Sepsis 6 bundle must be initiated within 1 hour of suspected sepsis. Know the bundle and its GP-specific implications — including when to call 999 from primary care.

🚨 Sepsis 6 — Within 1 Hour

GIVE — 3 treatments

→ High-flow oxygen
→ IV fluid bolus (crystalloid 500ml)
→ IV antibiotics (broad-spectrum, immediately)

TAKE — 3 measurements

→ Blood cultures (before antibiotics)
→ Serum lactate
→ Urine output (catheterise + monitor hourly)

Lactate >2

mmol/L = significant concern even without hypotension

Never delay

antibiotics waiting for blood cultures to come back

NEWS ≥5

→ escalate immediately. In GP → call 999

⚠️

AKT Trap — Sepsis in the Community

If sepsis is suspected in a GP setting, the appropriate action is a 999 call — not observation, not starting IV fluids in the practice, not deferring for further workup. The AKT tests this: candidates who choose "start IV antibiotics in practice" are marked wrong unless there is a specific scenario supporting it. The safe GP answer is prompt transfer by emergency ambulance.

🎯 Cross-Rotation AKT Traps — Know These Before You Sit

📈 Management Ladders

The AKT commonly describes a patient already on first-line treatment and asks what to do next. Know management escalation for hypertension, T2DM, asthma, COPD, depression and heart failure well enough to name the third-line option confidently.

🔢 Thresholds & Timescales

NICE sets specific numbers — 2-week wait cancer referrals, 48-hour UTI review, 3-month HbA1c recheck, 6-week postnatal review, anti-D at 28 weeks. Wrong numbers are a favourite distractor. Memorise these.

🏥 Hospital vs GP Logic

Questions about recently discharged patients may offer a management option that is correct for inpatients but wrong in the community. Always ask: "What would a GP do first?" — not "What would a ward doctor order?"

⚖️ Legal Framework Overlaps

MHA, MCA, and Children Act have overlapping powers. Classic mistake: applying the MCA (for adults lacking capacity) when the MHA (detention for mental disorder) is correct. Know which applies in which scenario — and why.

🎯 The Hospital-to-AKT Rule — After Every Useful Case

The bridge between working hard on the ward and passing the AKT. After each clinically interesting case, ask yourself these five questions. They take 2 minutes and convert service work into revision.

Working Diagnosis

Most likely diagnosis — write it down

Three Differentials

What else could it be? Rank them.

Relevant Guideline

What does NICE / BNF say? Look it up.

Red Flag

What would make this more serious or urgent?

GP Prescribing Issue

Drug choice, dose, interaction, or safety point a GP needs to know?

🗓 The Weekly AKT Conversion Exercise

Once a week, pick one hospital case and run it through this five-step filter. It takes 10 minutes and converts service work into structured revision. Do this consistently and it adds up to hundreds of high-quality revision points across a hospital placement.

Working diagnosis — write it down

Not just the label — what features pointed to it? What made you settle on this rather than the alternatives?

Three differentials — ranked

Force yourself to name three. What investigation or clinical feature would distinguish them?

Relevant guideline — look it up

Open NICE CKS. What does the guideline say about management? What threshold matters? Write one key fact down.

Red flag — name it specifically

What one feature would change this from "manage here" to "admit now"? Be specific — not just "deterioration."

GP prescribing or safety issue

Is there a drug choice, dose, interaction, renal adjustment, or monitoring issue that a GP would need to know and that NICE tests?

💡

Bonus Step — Write One SBA-Style Question

After running through the five steps, write one single-best-answer question about the case. It takes 3 minutes. The act of writing forces you to identify the actual exam-relevant point — not just "know about" the condition. Bring it to your next HDR session: your peers will thank you.

⚠️ The Most Expensive Revision Mistake in GP Training

Many trainees plan to do all their AKT revision in their ST2 GP post. This creates enormous pressure and means they miss the most effective revision period: their hospital placements. Every time you see a patient with a condition, NICE will test you on it. Learn it while you are seeing it — when motivation and context are both highest. Your clinical memory is your most powerful revision tool. Use it.

🚨 Urgent & Unscheduled Care

Urgent & Unscheduled Care — AKT High-Yield

One of the most commonly tested domains in the AKT. Every question follows the same pattern: a reassuring clinical picture with one red flag buried in the vignette. Act on the red flag. Every time.

📊 NEWS2 — National Early Warning Score 2

NEWS2 is the primary risk stratification tool recommended by NICE NG253 (2024) for adults in ambulance and acute hospital settings. It is supported — but not yet mandated — in routine primary care. The AKT tests whether you know this distinction.

Parameter	Score 3	Score 2	Score 1	Score 0 (Normal)	Score 1	Score 2	Score 3
RR (/min)	≤8	—	9–11	12–20	—	21–24	≥25
SpO₂ — Scale 1 (most patients)	≤91	92–93	94–95	≥96	—	—	—
HR (bpm)	≤40	—	41–50	51–90	91–110	111–130	≥131
Systolic BP (mmHg)	≤90	91–100	101–110	111–219	—	—	≥220
Temperature (°C)	≤35.0	—	35.1–36.0	36.1–38.0	38.1–39.0	≥39.1	—
AVPU / GCS	—	—	—	A (alert)	—	—	V, P, or U

🚦 NEWS2 Action Thresholds

Score

Risk Level

Action

Very Low

Review; safety-net; monitor

1–4

Low

Review within 1 hour; consider bloods

5–6

Moderate

Assess; consider urgent transfer

≥7

HIGH

999 + pre-alert hospital

⚠️ AKT Traps — NEWS2

COPD patients: Use O₂ Sats Scale 2 (target 88–92%). Scale 1 is for all other adults. Using the wrong scale in COPD = wrong answer.

New confusion / AVPU change always scores 3 — regardless of all other scores being normal. Any AVPU change = NEWS2 score ≥3 + clinical concern = 999.

NEWS2 is NOT yet mandated for routine primary care use by RCGP — it is supported but not compulsory in GP surgeries. AKT questions may test this distinction specifically.

Single parameter scoring 3 + clinical concern → treat as high risk even if total score is <7.

🔴 Sepsis — NICE NG253 (January 2024 Update)

🆕

Important 2024 Update — NICE NG51 is now NICE NG253

NICE updated sepsis guidance in January 2024. NEWS2 is now the primary risk stratification tool for adults (≥16, non-pregnant) in ambulance and acute hospital settings. AKT questions may test whether you know the updated guideline number and the primacy of NEWS2 over SIRS criteria.

📋 Definition (Sepsis-3)

Life-threatening organ dysfunction caused by a dysregulated host response to infection
NOT "infection + SIRS criteria" — Sepsis-3 (2016) moved away from SIRS criteria
Organ dysfunction defined as SOFA score change ≥2
In community / GP: qSOFA is a useful screening tool

qSOFA (quick SOFA) — 3 items, 1 point each:

RR ≥22/min
Altered mentation
SBP ≤100 mmHg

Score ≥2 = high risk of poor outcome. Use in community settings where SOFA is impractical.

🚨 Red Flag Sepsis Features (NG253)

Any ONE of these = 999 immediately — not "urgent GP review," not "attend A&E independently," not "review in 2 hours"

New altered mental state
Respiratory rate ≥25/min
New need for supplemental O₂ to maintain sats >92%
Heart rate >130/min
Systolic BP <90 mmHg (or >40 drop from baseline)
Non-blanching rash, mottled / ashen / cyanotic skin
Not passed urine in 18 hours (oliguria)

👥 Populations That Mask Sepsis — High AKT Risk

These groups may not mount the expected fever or tachycardia. Maintain clinical suspicion even with "reassuring" vital signs — this is a classic AKT trap.

👴 Elderly

May not mount fever. Confusion may be the only presenting sign — often misattributed to dementia or "going off legs."

💊 Immunosuppressed

Steroids, chemotherapy, anti-TNF — blunted inflammatory response. Lower threshold for suspicion and action.

🤰 Pregnant women

Physiological tachycardia and leukocytosis at baseline — sepsis may appear masked by normal pregnancy physiology.

👶 Infants

May present only with poor feeding, irritability, reduced tone. Classic vital sign changes may be absent or subtle.

💊 Beta-blocked / dehydrated

May not develop tachycardia despite haemodynamic compromise. HR is unreliable as sole indicator.

⚠️ AKT Trap — Nitrofurantoin and Sepsis

Nitrofurantoin has poor systemic bioavailability — it does NOT treat bacteraemia. An elderly patient with a "treated UTI" who becomes confused may have sepsis, not simply a slow antibiotic response. The AKT tests this distinction specifically: if the patient is systemically unwell, nitrofurantoin is never the right answer.

📞 Telephone Triage — The 3-Part Decision Framework

Every telephone triage decision sits in one of three categories. Know the examples cold — the AKT tests the category, not just the diagnosis.

999 Immediately

Life-threatening

Collapse / unresponsive
Chest pain + diaphoresis
Anaphylaxis
Stroke symptoms (FAST+)
Seizure not resolving
Severe difficulty breathing
Non-blanching rash + fever

See Within Hours

Potentially serious, stable

Febrile child under 3 months
Suspected UTI in diabetic
Possible fracture
Headache + fever (no rash)
SOB + pleuritic pain
"Funny turn" in elderly

Routine / Self-Care

Safe for home management

URTI in well adult
Mild musculoskeletal pain
Minor skin complaints
Early UTI in well adult
Simple viral illness

🎯 AKT Triage Traps — High-Yield Pitfalls

Scenario	AKT Trap	Correct Action
Infant <3 months, fever >38°C	Telephone management / safety-net	Must be seen face-to-face — cannot telephone manage this group
Headache + fever + photophobia / rash	See in hours / prescribe antibiotics	999 — suspected meningitis
SOB + pleuritic chest pain	Routine GP review	Urgent same-day / A&E — PE until proven otherwise
"Funny turn" in elderly	Routine follow-up	Same day review — possible TIA
Testicular pain, young male	Analgesia, routine review	A&E immediately — testicular torsion until proven otherwise
Back pain + bilateral leg weakness / bowel-bladder	Urgent GP review	999 / A&E — cauda equina emergency

❤️ Acute Coronary Syndrome — AKT High-Yield

🚨 ACS Red Flags

Chest pain lasting >20 minutes
Radiation to arm, jaw, or back
Diaphoresis (sweating) or vomiting
Cardiovascular risk factors (DM, HTN, smoking, family history)
Pain at rest or on minimal exertion

AKT Trap: A normal ECG does NOT rule out ACS. Always admit for troponin and serial ECGs when clinical suspicion is present — even with a normal initial ECG.

⏱ ACS Decision by Time Since Pain (NICE CG95)

Current acute chest pain (ACS suspected)

→ 999 ambulance immediately; aspirin 300mg chewed; do NOT delay transfer for ECG

Pain-free now, but pain within last 12 hours

→ ECG immediately; if normal → same-day urgent hospital referral; if suggests ACS → manage as above

Pain 12–72 hours ago

→ Clinical assessment + ECG; refer urgently same day

⚠️ AKT Trap — Emergency vs Urgent

Pain-free + normal ECG within last 12h = still requires same-day urgent hospital referral. "Normal ECG, safe to discharge" is the wrong answer. Always.

👥 Atypical ACS Presentations — Must Not Miss

AKT questions specifically target atypical presentations — always maintain ACS in the differential for these groups.

Group	Typical Presentation	How They Actually Present
Diabetic patients	Classic crushing central chest pain	Autonomic neuropathy masks pain — may present with weakness, syncope, or confusion
Elderly patients	Chest pain, diaphoresis	May present as breathlessness, nausea, or syncope only — no chest pain
Women	Classic crushing chest pain	Less likely to describe classic crushing pain — more often fatigue, jaw pain, back pain, or nausea

🧠 Head Injury — CT Criteria (NICE)

NICE specifies CT head within 1 hour if any of the following are present in adults:

CT Within 1 Hour — Indications

GCS <13 at any point since injury
GCS <15 at 2 hours after injury
Suspected open or depressed skull fracture
Any sign of basal skull fracture (haemotympanum, "panda eyes," CSF leakage, Battle's sign)
Post-traumatic seizure
Focal neurological deficit
More than 1 episode of vomiting
Age ≥65 + any loss of consciousness or amnesia
Coagulopathy + loss of consciousness or amnesia

⚠️

AKT Trap — Vomiting

ONE episode of vomiting in an adult does NOT meet CT criteria on its own — it requires more than 1 episode, or the presence of other criteria. However, one episode in children is taken more seriously. Read the vignette carefully — this distinction is regularly tested.

GP Action

In primary care: if any CT criteria are met → send to A&E immediately. Document the specific criterion that triggered the decision clearly in the notes.

🩸 Suspected PE — Wells Score in Detail

Wells Score Components

Clinical Feature	Points
Clinical signs of DVT (swelling, tenderness)	3
PE more likely than alternative diagnosis	3
Heart rate >100 bpm	1.5
Immobilisation ≥3 days or surgery in past 4 weeks	1.5
Previous DVT / PE	1.5
Haemoptysis	1
Active malignancy	1

Wells Score Interpretation

Score ≤4 — PE unlikely

→ D-dimer: if negative = PE excluded; if positive = imaging (CTPA)

Score >4 — PE likely

→ Immediate imaging (CTPA) — do NOT do D-dimer. It is clinically useless at high pre-test probability and will delay life-saving treatment.

AKT Trap: The "obvious" answer is "D-dimer" for chest pain + SOB. But if Wells >4 → go straight to imaging. Always calculate Wells before ordering D-dimer.

🚨 Must-Not-Miss Presentations — The Complete AKT Table

AKT questions present a "reassuring" clinical scenario with one red flag buried in the vignette. Read every detail. The AKT tests whether you recognise the one item that changes "safe to manage at home" to "refer immediately."

Presentation	Must-Not-Miss Diagnosis	Red Flag Features + Action
Headache	SAH, meningitis, temporal arteritis	Thunderclap onset ("worst ever"), neck stiffness, fever + rash, visual symptoms in over-50s. CT negative in first 12h → lumbar puncture needed for SAH.
Chest pain	ACS, PE, aortic dissection, tension pneumothorax	ACS: diaphoresis, radiation. PE: pleuritic, haemoptysis, Wells >4. Dissection: tearing/ripping chest/back pain, differential arm BPs, aortic regurgitation murmur.
Abdominal pain ± collapse	Ectopic pregnancy, AAA, appendicitis, mesenteric ischaemia	Ectopic: any woman of reproductive age + abdominal pain + collapse — do NOT wait for positive pregnancy test. Pulsatile abdominal mass = AAA until proven otherwise.
Back pain + neurological symptoms	Spinal cord compression, cauda equina, aortic aneurysm	Back pain + bilateral leg weakness + urinary retention / saddle anaesthesia = emergency MRI immediately. Do not send home.
Limb pain/swelling	DVT, compartment syndrome, necrotising fasciitis	Calf warmth/swelling → Wells DVT score. Severe pain out of proportion to injury, pale/pulseless → compartment syndrome. Woody swelling + fever + rapid skin spread → necrotising fasciitis (surgical emergency).
Fever + rash + meningism	Meningococcal meningitis / sepsis	Non-blanching petechiae or purpura = 999 immediately. Give benzylpenicillin 1.2g IM/IV before transfer (unless confirmed penicillin allergy).
Acute mental state change	Hypoglycaemia, sepsis, stroke, subdural haematoma, delirium	Any acute confusion → check BM immediately. Fluctuating course = delirium until proven otherwise. Do not assume dementia exacerbation without excluding treatable causes.
Arm/leg weakness, slurred speech	Stroke / TIA	FAST+ (Balance, Eyes, Face, Arms, Speech, Time). TIA: aspirin 300mg immediately, urgent TIA clinic same day, DVLA notification (stop driving), ABCD2 score guides urgency.
Fever in oncology patient	Neutropenic sepsis	Temp ≥38°C in patient receiving chemotherapy = oncological emergency. Call oncology team immediately — do not treat as routine infection.
Young woman + collapse + haemodynamic compromise	Ectopic pregnancy, anaphylaxis, arrhythmia, DKA	Do not anchor on one diagnosis. LMP, pregnancy test, BM, ECG, anaphylaxis trigger — all needed. Ectopic: do NOT wait for positive test if haemodynamically compromised.

🔥 The Single Best Answer Pattern

AKT questions always give you a reassuring picture with one red flag buried in the vignette.

A patient who "looks well," "seems stable," or "has had this before" — but has BP 85, or a non-blanching rash, or a thunderclap headache onset. Always act on the red flag. The distractor answers are designed to capitalise on your relief at the reassuring details. Don't let them.

The Four Most Common UUC AKT Traps

Scenario	❌ The Trap Answer	✅ The Correct Answer	Why
Chest pain — possible ACS	"Try GTN first and see if it helps"	Admit immediately, aspirin 300mg, 999	Response to GTN does not rule in or rule out ACS. Normal ECG also doesn't rule it out.
Suspected PE	"D-dimer immediately"	Calculate Wells first. If >4 → direct to imaging, not D-dimer	D-dimer is useless at high pre-test probability and doesn't exclude PE when Wells is high.
Sepsis features present	"Start oral antibiotics"	Admit for IV antibiotics, fluids, monitoring. Call 999 if red flag sepsis.	Oral antibiotics are inadequate in sepsis. Delay = preventable deaths.
Sudden severe headache	"Most likely tension headache or migraine"	Rule out SAH — thunderclap onset = CT head urgently	"Worst headache of their life" / thunderclap = SAH until proven otherwise. Never assume migraine without excluding SAH.

🩸 Hypertensive Emergency vs Urgency

🚨 Hypertensive Emergency (BP ≥180/120 + End-Organ Damage)

Signs of end-organ damage include any of:

Chest pain / breathlessness (cardiac)
Visual disturbance or papilloedema
Neurological deficit / altered consciousness
Haematuria / oliguria (renal)

→ 999 / A&E immediately. Do not attempt oral antihypertensive treatment in primary care.

⚠️ Hypertensive Urgency (BP ≥180/120, No End-Organ Damage)

No signs of end-organ damage:

Headache alone (without papilloedema / neurological signs)
Asymptomatic very high BP reading

→ Same-day urgent review. Oral antihypertensive. Do NOT lower rapidly — cerebral hypoperfusion risk. Confirm with repeat readings.

AKT Trap: "Hypertensive emergency" requires end-organ damage — not just a very high BP. A patient with BP 195/118 and a headache but no papilloedema / neurological signs is a hypertensive urgency, not an emergency. The distinction changes the correct answer.

💉 Anaphylaxis — Diagnosis & Emergency Management

Diagnosis — Clinical, Not Lab-Based

Sudden onset, rapid progression
Involving airway AND/OR breathing AND/OR circulation
Usually with skin/mucosal changes: urticaria, flushing, angioedema

AKT Trap: Urticaria and angioedema alone do not constitute anaphylaxis. You need airway / breathing / circulation involvement. This distinction is regularly tested in the AKT.

Discharge — Must Provide All 5

Information on signs/symptoms of anaphylaxis
Explanation of biphasic reaction risk (can recur 1–72h later)
Auto-injector training — demonstrate use
Trigger avoidance advice
Referral to allergy clinic

First-Line Treatment — Immediate

🚨 FIRST — IM Adrenaline

500 micrograms IM (0.5ml of 1:1000) — outer mid-thigh

Repeat every 5 minutes if no improvement in ABC parameters

999 immediately — call simultaneously with giving adrenaline

Position: Lying flat, legs raised — OR sitting up if breathing compromised. High-flow oxygen. IV access + fluids if available.

Second-line adjuncts (after adrenaline, not instead of):

Chlorphenamine 10mg IM/slow IV
Hydrocortisone 200mg IM/slow IV

These do NOT replace adrenaline — they supplement it. Giving antihistamine instead of adrenaline = wrong answer.

AKT Trap — Auto-injector dose: Adult auto-injectors (e.g. EpiPen) typically deliver 300 micrograms — this is LESS than the recommended 500 micrograms. This difference is a specific AKT question. IV adrenaline is for experienced clinicians in specialist settings only.

🧠 Delirium — A Medical Emergency, Not a Psychiatric Diagnosis

⚡

Key concept: Delirium is a medical emergency — not a psychiatric condition. It is explicitly listed as an AKT testing area. The AKT tests whether you can distinguish delirium from dementia and whether you know the screening tools.

Clinical Features

Acute onset (hours to days) with fluctuating course — the hallmark that distinguishes delirium from dementia
Impaired attention and consciousness
Hyperactive: agitated, restless, aggressive — more visible
Hypoactive: withdrawn, quiet, sleepy — most commonly missed
Mixed: fluctuates between both subtypes
Dementia is the biggest single risk factor — but delirium can occur without it

AKT Trap: Hypoactive delirium is the most commonly missed subtype — the quiet, withdrawn patient is easier to overlook. When chronic vs. acute confusion is unclear: treat as delirium first.

Screening Tools

4AT

Quick, validated for primary care. Score ≥4 = probable delirium. Covers alertness, AMT-4, attention, and acute change / fluctuation.

CAM (Confusion Assessment Method)

Requires: Feature 1 (acute onset/fluctuating course) + Feature 2 (inattention) + either Feature 3 (disorganised thinking) OR Feature 4 (altered consciousness).

Investigations in Acute Confusion

Blood glucose (immediately) → FBC, U&E, LFTs, TFTs, CRP, bone profile → MSU → Blood cultures if sepsis suspected → 12-lead ECG → CXR. Do not wait for results before referring if clinically unstable.

📋 Delirium — Differential Diagnosis (AEIOU TIPS Framework)

Category	Key Examples
A — Alcohol / drugs	Alcohol withdrawal (seizure risk), opioids, benzodiazepines, anticholinergics
E — Epilepsy (post-ictal)	Post-ictal confusion, non-convulsive status epilepticus
I — Infection	UTI, pneumonia, meningitis, sepsis — most common cause in elderly
O — Oxygen / metabolic	Hypoxia, hypo/hyperglycaemia, hypo/hypernatraemia, uraemia, liver failure
U — Uraemia / endocrine	Hypothyroidism, Addisonian crisis, hypercalcaemia, hepatic encephalopathy
T — Trauma / structural	Stroke, SAH, subdural haematoma
I — Ischaemia / cardiac	MI, arrhythmia, cardiac failure with poor cardiac output
P — Pain / retention	Unrecognised pain, urinary retention, constipation (especially in elderly)
S — Stroke / space-occupying	Intracranial lesion, meningitis, post-ictal state

⚡ First Fit in Adults — GP Action Pathway

History ± eyewitness account

Examine: neurological, cardiac, mental state, check for tongue biting. Full post-ictal assessment. Rule out syncope, hypoglycaemia, TIA.

Investigations

Blood glucose immediately, FBC, U&E, LFTs, calcium, ECG (to rule out arrhythmia as a mimic of seizure). Do not delay referral waiting for results.

Urgent neurology referral — seen within 2 weeks

Do not wait for investigation results before making the referral. Refer and investigate in parallel.

DVLA — advise and document

Cars (Group 1): stop driving immediately — 6 months seizure-free required. HGV/Bus (Group 2): 5 years seizure-free. The GP's responsibility is to advise, document the advice, and notify DVLA if the patient refuses to stop driving.

Safety advice

No swimming alone, shower rather than bath, avoid heights and heavy machinery. Document advice given.

💊 AED Choice — NICE NG217 (2022)

Seizure Type	First-Line AED
Generalised tonic-clonic	Lamotrigine, levetiracetam, or sodium valproate
Focal seizures	Lamotrigine or levetiracetam

Sodium valproate — MHRA restriction: Must NOT be prescribed to women of childbearing potential unless enrolled on the Pregnancy Prevention Programme (PPP) with annual review. This is a mandatory safety requirement — not optional.

🚨 Status Epilepticus — OOH Management

Drug	Dose	Route
Buccal midazolam (first-line pre-hospital)	10mg adults; 5mg if ≥10 years	Buccal
Rectal diazepam (alternative)	10–20mg adults	Rectal

Maximum 2 pre-hospital doses (including any given before arrival)
Call 999 immediately — do not wait
IV lorazepam is hospital first-line

💊 Emergency Drugs — Doses You Must Know

The AKT tests specific drug doses in emergency scenarios. These are the drugs that appear most frequently — know the dose, route, and indication for each.

Drug	Dose	Indication	Route	Key Note
Adrenaline 1:1000	500 micrograms (0.5ml)	Anaphylaxis	IM (outer mid-thigh)	Repeat every 5 min if no improvement. EpiPen delivers 300mcg — less than recommended dose.
Aspirin	300mg	ACS	Oral (chewed)	Give immediately in all suspected ACS. NOT used to "test" if chest pain is cardiac.
Benzylpenicillin	1.2g	Meningococcal meningitis/sepsis — give BEFORE transfer	IV or IM	Give before transfer unless confirmed penicillin allergy. Time-critical — do not wait for hospital.
Hydrocortisone	100–200mg	Anaphylaxis (adjunct); acute asthma; adrenal crisis	IV or IM	Second-line in anaphylaxis — after adrenaline, not instead of. 100mg IV in acute asthma.
Chlorphenamine	10mg	Anaphylaxis — antihistamine adjunct	IV or IM	Adjunct only — not a substitute for adrenaline. Never give antihistamine as sole treatment.
Buccal midazolam	10mg (adult); 5mg (≥10 yrs)	Status epilepticus (pre-hospital / OOH)	Buccal	Maximum 2 pre-hospital doses. Call 999 immediately. IV lorazepam = hospital first-line.
Glucagon / GlucoGel	1mg glucagon; GlucoGel buccal	Hypoglycaemia — patient unable to swallow	IM / buccal	IV glucose (10% or 20%) is preferred in hospital. Glucagon less effective in alcohol-related hypoglycaemia.
GTN spray	1–2 puffs sublingually	Angina	Sublingual	For symptom relief in known angina — NOT to "test" whether chest pain is cardiac. Response to GTN does not exclude ACS.
Salbutamol	2.5–5mg nebulised	Acute asthma / acute COPD exacerbation	Inhaled / nebulised	Back-to-back nebs in acute severe asthma. Drive with O₂ (not air) in asthma; use air in COPD.
Naloxone	400 micrograms; repeat every 2–3 min PRN	Opioid overdose — respiratory depression	IM or IV	Short half-life — effect wears off before opioid. Repeated dosing required. 999 always.

⚠️

AKT Trap — Benzylpenicillin Timing

In suspected meningococcal disease (fever + non-blanching rash + meningism), give benzylpenicillin 1.2g IV/IM before transfer — not on arrival at hospital, not after blood cultures. Unless there is a confirmed penicillin allergy. Time is critical.

🌙 Out-of-Hours (OOH) — Definition & Contractual Requirements

📋 OOH — What Counts

Item	Detail
GMS Contract definition	18:30–08:00 on weekdays + all weekends + all public holidays
Extended hours (<08:00 or >18:30)	Does NOT count as OOH if part of your usual contracted hours
RCGP requirement	Capability-based — no mandated specific number of sessions
Common trust expectation	~6 sessions per 6-month GP post (paid as salary uplift)
Contractual vs capability	Meeting the session count ≠ capability sign-off. Quality ePortfolio evidence is still required.

⏰ Working Time Directive — Key Rules

Maximum 40 hours/week average (over 6-month rolling period)
11 hours rest minimum between consecutive shifts
20-minute break in shifts of more than 6 hours

💡 AKT Context

OOH requirements appear in the organisational and management domain. The AKT may test the GMS Contract definition, RCGP capability requirements vs contractual expectations, and Working Time Directive rules. Know the distinction between contractual compliance and capability evidence.

📋 Section 4

The Exam Format — What You're Actually Facing

Know the battlefield before you arrive on it.

160

Total questions (from October 2025 onwards)

160

Minutes total — 2 hrs 40 min (= 60s per question)

109

Pass mark Oct 2025 (68.1% of 160)

70.6%

All-candidate pass rate (Oct 2025)

88.8%

UK-graduate first-time pass rate (Oct 2025)

⚠️

The UK Graduate vs All-Candidate Pass Gap — Why It Matters

In October 2025, UK-trained first-time candidates passed at 88.8% — yet the overall rate was only 70.6%. This 18-point gap is almost entirely explained by preparation differences, not ability. IMGs who prepare specifically for UK GP format, NICE guidelines, and admin/stats content close this gap substantially. There is a dedicated IMG section later in this page.

Question Types

Single Best Answer (SBA) — one stem, five options, one best answer. The "trap" is often an option that is correct but not the BEST in this specific GP scenario.
Extended Matching Questions (EMQ) — a list of options, multiple scenarios. Match each scenario to the correct option. Often used for diagnosis, drug choice, or management.
No trick questions — the RCGP is clear on this. But they do write careful distractors. Read every stem slowly.
Graphs and images — may appear, especially in the stats section. Practice interpreting flow diagrams, forest plots, funnel plots, and number-needed-to-treat tables.

Practical Logistics

Computer-based at a Pearson VUE test centre (150+ UK locations)
Photo ID required — name must match your registration exactly
No personal items in the exam room — everything in a locker
Questions can be flagged for review — use this feature
Timer visible throughout — monitor your progress
Morning and afternoon sessions available — including for candidates with reasonable adjustments from Oct 2025
Reasonable adjustments available — extra time up to 25% for dyslexia, separate room options. Apply well in advance via RCGP.

📊 The 80 / 10 / 10 Content Split — Explained

Domain	Weight	Questions	What's Tested	Key Tip
Clinical Knowledge	80%	~128	Diagnosis, management, prescribing, referral across all GP specialties	Focus on common presentations — what you see every day
Evidence-Based Practice	10%	~16	Critical appraisal, stats (NNT, NNH, sensitivity, specificity, likelihood ratios, forest plots)	These are learnable — spend focused time on them, score reliably
Organisation & Administration	10%	~16	DVLA, sick notes, MHA sections, child protection, death certificates, prescribing law, GDPR	More defined than clinical — study it properly, it's free marks

💡

The New Format (Oct 2025 onwards) — What Changed

The RCGP reduced the exam from 200 questions / 190 minutes to 160 questions / 160 minutes (2 hours 40 minutes). This gives slightly more time per question (~60 seconds vs ~57 seconds previously), allows both morning and afternoon sessions for candidates with reasonable adjustments, and reduces overall fatigue. The standard, content, and 80/10/10 split are unchanged.

Key implication of 40 fewer questions: Each item carries proportionally more weight — there is less room to "make up" marks in easier sections. Accuracy matters more than speed. Do not rush through questions you feel confident about; read every stem twice. The pass mark is adjusted per sitting — 109/160 (68.1%) in October 2025.

📅 Exam Dates & Key Deadlines (2025–2026)

Sitting	Adjustment Deadline	Booking Window	Exam Date	Results
October 2025	19 Aug 2025	10–12 Sep 2025	28 Oct 2025	27 Nov 2025
January 2026	12 Nov 2025	3–5 Dec 2025	26 Jan 2026	26 Feb 2026
April 2026	18 Feb 2026	9–11 Mar 2026	27 Apr 2026	28 May 2026
July 2026 🆕	5 May 2026	25–27 May 2026	7 Jul 2026	6 Aug 2026

🆕 A fourth sitting (July) is now available from 2026. Book via the MyRCGP portal. No reservation needed (from December 2025). Staged payments are compulsory from April 2026. Always check the RCGP website for the latest dates — they occasionally shift.

⏱ Section 5

Time Management — The Updated Guide

The new format gives you ~60 seconds per question — slightly more than before. Here's exactly how to pace yourself and finish with time to review flagged questions.

⚠️

Important: This reflects the NEW format (Oct 2025 onwards)

The old format was 200 questions in 190 minutes (~57 seconds each). The new format from October 2025 is 160 questions in 160 minutes (~60 seconds each). Any resource quoting 240 minutes or 90 seconds is incorrect. Use the figures below.

⏱ Your Pacing Guide (New Format: 240 min / 160 Qs)

40 min Q40

80 min Q80

120 min Q120

~140 min Q160 ✓

140–160 min Review

Aim to finish your first pass through all 160 questions by 140 minutes — leaving 20 minutes to review flagged questions. Check the clock every 40 questions (which should take 40 minutes at pace). With only 60 seconds per question, the time pressure is real — flag and move on quickly.

🎯 Question-by-Question Strategy

Read the stem carefully — once, but slowly

The answer is nearly always in the stem. Look for the key clinical feature that separates the right answer from the distractors. Is it the most APPROPRIATE option in a PRIMARY CARE context?

Answer before reading the options if you can

Form your answer in your head first. Then look for it in the options. This stops the distractors pulling you in the wrong direction — they are designed to look plausible.

If you don't know it within 45 seconds — flag and move on

Pick the best guess, flag it, and move. Never spend more than 60 seconds on any question on the first pass. Time is extremely tight in this exam. Easy marks later are worth exactly the same as hard marks now — and there is genuinely no time to spare.

Always answer — there is no negative marking

Every unanswered question is a guaranteed zero. A guess is at least a 20% chance. Never leave a question blank. Even in the last minute — scroll through and click something for every remaining question.

Use your review time strategically

Return first to questions you flagged with high confidence of getting right with a second look. Avoid second-guessing questions you felt certain about — your first instinct is usually correct.

💡 Examiner Insight — The "Most Appropriate" Trap

Many SBA questions in the AKT don't ask what is CORRECT — they ask what is MOST APPROPRIATE for a GP in this specific scenario. This means all five options may be technically correct, but only one fits the primary care context perfectly. Think: what would the best, safe, UK GP do as their FIRST or NEXT step?

📅 Section 6

When Should I Take the AKT?

The timing question that everyone agonises over — here's a clear, honest answer.

✅ Eligibility

Can sit from ST2 onwards (not in ST1)
Active MRCGP membership required
Training records up to date in your ePortfolio
Maximum 4 attempts to pass
Discuss timing with your Educational Supervisor (ES) first

🎯 The Sweet Spot

Most experienced trainers suggest:

Best timing: First GP post in ST3, OR the final few months of a non-GP ST2 placement. You'll have clinical context without the additional pressure of SCA preparation running simultaneously.

Sitting too early (early ST2) means limited GP context for clinical questions. Too late (late ST3) means competing with SCA stress.

🔑 The ST2 vs ST3 Decision

Factor	Sitting in ST2	Sitting in ST3
Clinical context	Limited GP experience — harder for scenario-based questions	Richer GP exposure — clinical reasoning feels more natural
Stress level	Lower — no SCA prep running simultaneously	Higher — SCA, portfolio, and AKT can overlap
Academic freshness	Closer to foundation/medical school — stats knowledge fresher	May need to re-learn stats from scratch
Preparation time	Needs to be planned around busy rotations	More GP placements = more patient-based learning
Verdict	✅ Good if in a GP post or quieter rotation	✅ Good if disciplined about not leaving it too late

4 months might be enough if...

You're in a lighter rotation
Few caring or family commitments
Comfortable with stats already
Planning to do focused, structured daily revision

6 months is safer if...

Working full time in a busy rotation
Family, childcare, or health commitments
It has been a while since exams
Statistics genuinely frighten you

💡 Insider Tip — From Trainee Experience

Trainees consistently report underestimating preparation time. The actual effective preparation needed is 16–18 weeks of consistent effort — not the 8–12 weeks you might hear informally. "I started 6 weeks before and it nearly broke me" is a very common story. Start earlier than feels necessary.

📖 Section 7

Study Strategy — How to Prepare Without Losing Your Mind

There is a more effective way to study than reading a textbook from page one. Here's what actually works.

🎯

The Single Most Important Principle

The AKT tests the working knowledge of a competent GP — not encyclopaedic medical school memory. Common things are common. What you see in GP clinics every day is exactly what's tested. Focus on breadth across primary care, not depth in any single specialty.

Your Step-by-Step Preparation Plan

Start with a self-assessment — find your weak spots

Use the RCGP curriculum or Bradford VTS AKT self-assessment tool to map the curriculum. Identify where your gaps are now, at the start. Targeted study at weaknesses beats re-reading what you already know.

Read the last 3 AKT examiner feedback reports

These are published on the RCGP website after every sitting. Examiners flag where candidates consistently struggled. Those areas are re-tested repeatedly. This is the closest thing to an exam preview you'll get.

Create a study schedule — and protect it

Plan which clinical areas you'll cover each week. Build in stats and admin blocks early — don't leave them for the end. Aim for short, consistent daily sessions rather than long weekend marathons. "Little and often" genuinely works better for retention.

Choose one good question bank — and use it properly

Don't collect five question banks and use each one superficially. Choose one reputable bank, work through it topic by topic, and read every explanation carefully — even for questions you got right. That's where the real learning happens. Good options include Bradford VTS, GP Self-Test, and the RCGP e-Learning platform.

Learn from every patient in clinic

AKT questions are written by practising GPs using real clinical scenarios. Every patient you see is a potential exam question. After each surgery, write down one topic you weren't sure about and look it up. Clinical exposure is irreplaceable for building context that sticks.

Ask your trainer to do Random Case Analysis (RCA)

Take a case from your own clinic list. Your trainer questions you on the clinical reasoning, management options, and relevant guidelines. Gaps emerge naturally — and you learn in context. Ten minutes of RCA per week is more effective than a monthly two-hour tutorial.

Do timed mock exams in the final 4 weeks

Sitting under timed conditions is a skill of its own. Do at least 2–3 full timed mocks. Your score will improve simply from developing familiarity with the time pressure and question style — separate from knowledge gain.

📚 Essential Resources — The Short List

🥇 Must-Have

NICE CKS — use in every consultation
One question bank (see above) — used thoroughly
BNF — especially prescribing chapters
RCGP Examiner Feedback Reports
InnovAIT journal (comes with AiT membership)

📘 Highly Recommended

Oxford Handbook of General Practice
Medical Statistics Made Easy (Harris & Taylor)
Bradford VTS clinical topic pages
GPNotebook for quick clinical summaries
Video courses on statistics — RCGP free stats videos (Prof Harris) are excellent for this

🎙 Apps & Podcasts

Mobile flashcard apps — search your app store for "MRCGP AKT" for current options
RCGP Essential Knowledge Updates podcasts
BBC Radio 4 Inside Health — topical NHS relevance
BMJ OnExamination YouTube channel

🧠 Study Environment Matters

Study at a desk — not on your sofa, not in bed. Your brain needs spatial cues that separate "study mode" from "rest mode." Avoid high-sugar snacks during study (they cause energy spikes then crashes). Protein-rich snacks (nuts, yoghurt, boiled eggs) keep your brain fuelled without the fog. And yes, this actually matters — exam fatigue is real, especially in a 4-hour sitting.

📚 Study Methods — Evidence-Based Comparison

Not all revision methods are equal. This table ranks the main approaches by evidence strength — with a practical tip for each. Trainees who pass early do more of the top rows.

Method	Evidence	Practical Tip
🔁 Spaced repetition	Strong	Use Anki or a question bank daily — short daily sessions beat weekly marathons. 30 minutes every day beats 4 hours once a week.
❓ Question banks	Strong	Use well-regarded question banks. After each wrong answer, look it up in NICE CKS or BNF — not more questions.
📖 Guideline reading	Essential	Read NICE CKS after every clinical case — this directly links ward work to exam preparation. The bridge between doing and revising.
📊 Statistics revision	Often neglected	How to Read a Paper — Trisha Greenhalgh. The definitive guide for primary care. Start this in ST2 — do not leave it to the last month.
👥 Study group	Helpful	Peer quizzing cements retention far better than passive re-reading. Explaining a concept to a colleague is one of the most powerful learning tools available.
⏱ Last 3 weeks — timed mocks only	Strongly recommended	Consolidation only — no new topics in the final 3 weeks. Book 3 weeks of study leave before the exam. Exam pace is a learnable skill. Timed mocks are the only way to train it.

📅 Phased Revision Plan — What Actually Works

Based on successful candidate experiences. The single most valuable first step is reading the last 3–4 RCGP AKT Feedback Reports. Candidates who do this and focus on flagged weak areas consistently outperform those who revise by topic alone.

Months 1–2

Build Clinical Knowledge

NICE CKS for every clinical area
GPNotebook for quick primary care summaries
BNF for drug knowledge
Structured question banks (RCGP e-learning and well-regarded primary care question banks)
Focus on breadth — one weak topic per day

Month 3

Stats, Admin & Deep Revision

Stats + admin: work through the admin/stats section of your question bank 3× (spaced repetition)
RCGP Self-Test (free for registrar members)
DocSupport YouTube — AKT feedback deep-dives
Build Anki cards for high-yield thresholds
Stats are "free marks once learned" — prioritise these

Final 2–4 Weeks

Consolidation Only

Timed full mock exams — practice exam pace
Review weak areas from mocks only
No new topics — reinforce, don't overload
Anki daily for high-yield thresholds
Book 3 weeks study leave; protect it

❓ Using Question Banks Effectively — What High-Yield Performers Do

Question banks alone are not enough. High-performing candidates consistently describe the same four habits that separate strong from average performance.

🔁 Do Banks More Than Once

Repeat the same questions after an interval. The second pass reveals what has actually been retained vs what was surface recognition. Spaced repetition across multiple rounds beats one thorough pass.

🎯 Deliberately Revisit Weak Topics

Use performance data from the question bank to identify low-scoring topic areas. Dedicate specific sessions to those areas — do not avoid them because they feel hard. Every weak topic is a mark to reclaim.

📚 Don't Neglect Guidelines + Stats

Always check the NICE CKS or BNF explanation after a wrong answer — not just the question bank rationale. Stats and admin questions reward dedicated structured revision, not last-minute cramming.

📋 Use Structured Topic Tracking

Keep a simple log of topics covered, weak areas, and re-test dates. Random revision feels productive but leaves unpredictable gaps. A structured tracker converts a question bank into a genuine curriculum.

💡 What Trainees Wish They'd Started Earlier

Starting AKT preparation earlier than feels necessary — especially if English is not your first language or you read more slowly
Not ignoring stats and admin — they are ~20% of the paper and highly learnable
Using NICE CKS to fill gaps after wrong answers — not just doing more questions

⏱ The Final 3 Weeks Rule

Book 3 weeks of study leave before your exam. Use this period for consolidation only — timed full mocks, reviewing wrong answers, reinforcing weak areas. No new topics. The most common mistake is trying to cram new material in this window instead of cementing what you already know.

🎯 Section 7b — Exam Technique

SBA Exam Technique — How to Answer Like an Examiner Expects

Many candidates fail not from lack of knowledge, but from misapplying UK exam conventions. This is where IMGs in particular lose marks — and where a focused session can add 5–8% to your score.

The Most Important Insight in This Entire Section

🔥 The AKT Is NOT a Knowledge Exam — It Is a Decision Exam

Every question is asking one thing: "What would a safe UK GP do NEXT?" Candidates who fail the AKT usually know the clinical facts. They fail because they think like a hospital specialist, not a GP. The answer is almost always the safest, most conservative, most primary-care-appropriate option — not the most impressive one.

Think GP

Not hospital specialist

Think Conservative

Not impressive

Think Safe

Not clever

Think First-Line

Not step 3 or 4

📋 Five-Step Approach to Every SBA

Apply this to every single question — especially when stuck. It takes 10 seconds and prevents the most common errors.

Read the Last Line FIRST

"Most appropriate next step?" vs "Most likely diagnosis?" vs "Investigation that confirms?" — each demands a completely different answer.

Identify the Clinical Context

GP surgery vs A&E. GP trainee vs consultant. The setting changes the decision threshold significantly.

Note Qualifying Words

"Most appropriate," "most likely," "according to current guidelines," "NEXT step," "BEST initial." These words determine the answer.

Apply UK Convention

Only what is stated exists. No chest pain = no chest pain. Do not add clinical findings that aren't written in the stem.

Eliminate, Then Choose

Cross out definite wrongs first. Then choose between the remaining options. Reduces 5-choice to 2-choice for most candidates.

🎯 The Three Core SBA Question Patterns — Recognise Which One You're Facing

Every AKT SBA question falls into one of three patterns. Identifying the pattern in the first 5 seconds changes how you read the options. Train yourself to name the pattern before reading the choices.

Pattern 1

"Most Appropriate Next Step"

What it tests: Whether you know when NOT to act — and when to gather more information before committing.

🔦 Worked example

52-year-old, BP 148/92 at clinic — single reading, no symptoms.
❌ Start ACE inhibitor | ✅ Lifestyle + confirm with ABPM/HBPM

🧠 The Rule: Start conservative → stay primary care → confirm before committing. Specialist referral is almost never step 1.

Pattern 2

"Best Initial Investigation"

What it tests: Whether you choose the cheapest, simplest, most accessible primary care test — not the gold standard.

🔦 Worked example

28-year-old, tired, Hb 114 g/L.
❌ Colonoscopy / coeliac screen | ✅ Serum ferritin first

🧠 The Rule: Think in the investigation ladder. No test → basic bloods → simple imaging → specialist tests. Pick the lowest rung that answers the question.

Pattern 3

"Gold Standard vs GP Reality"

What it tests: Whether you know the practical stepwise GP pathway — not just the definitive investigation or gold standard.

🔦 Worked example

Suspected PE — pleuritic pain, tachycardia.
❌ CTPA (gold standard) | ✅ Wells score → D-dimer → CTPA only if needed

🧠 The Rule: Jumping straight to the hospital-level test = wrong. The AKT tests the full pathway — not just the final destination.

🔑 Keywords That Change the Answer — Read These Before the Options

Train yourself to identify these qualifying words in the last line of the question stem before reading the five options. Each word shifts what the correct answer actually is. Trainees who misread these lose marks on questions they fundamentally understood.

Keyword	What It's Actually Asking	The Common Trap	Marker of Right Answer
"Initial" / "First"	The very first action — before anything else has been done	Picking step 3 or 4 of the pathway because you know it's the right treatment — but not the first step	Cheapest, most available, least invasive first action
"Most appropriate"	The best overall option in the full GP context given — not the most thorough	Picking the most thorough or aggressive option rather than the proportionate one	Conservative, primary-care-level, proportionate to the scenario
"Next step"	What comes immediately after what has already been described in the stem	Jumping ahead in the pathway — treating before diagnosing, or diagnosing before confirming	Follows logically from where the scenario has been left
"Best investigation"	Usually the simplest, cheapest, most available primary care test — not the definitive one	Picking the gold standard or hospital-level test (CT, MRI, specialist biopsy) when basic bloods or USS would do	Lowest rung of investigation ladder that answers the clinical question
"According to current guidelines"	The NICE/SIGN/BNF answer — not your trainer's preference, not local protocol, not common practice	Answering based on what you do in your practice — which may differ from national guidance	What NICE says, not what your trainer does
"If two look right — pick the less aggressive"	A deliberate distractor pair — both options may be clinically reasonable but only one is the GP-appropriate first step	Picking the more impressive-sounding, more aggressive, or more specialist-level option	The more conservative option is almost always correct

💡 Trainee Insight — Reported Across Multiple Sittings

"I didn't read 'initial' properly. I knew the guideline but picked the wrong point in the pathway." | "I kept picking the most advanced answer. I knew it worked — but it wasn't the FIRST step." | "Two options both looked right. I picked the more aggressive one and got it wrong every time."

The fix: Read the last line of every question stem twice. Underline the qualifying word. Form your answer in your head. Then read the options — don't let them pull you before you've committed to a direction.

🎭 MCQ Trap Patterns — Recognise These Before You Read the Options

Candidates who recognise the trap type in the first sentence of the stem score significantly better. These are the five most common trap patterns in the AKT — each with a specific counter-strategy.

Trap Type	Example	✅ Correct Approach
"Most likely" vs "Next step"	Chest pain in 50-year-old smoker — "What is the most likely diagnosis?" vs "What is the most appropriate next step?"	Read the last line of the stem carefully before reading options. Asking for diagnosis vs investigation vs management changes the answer entirely — even for the same clinical scenario.
First-line vs second-line	Hypertension treatment — age 48, not Black African/Caribbean	Know first-line by age and ethnicity per NICE NG136. The correct first-line differs by patient group. ACEi/ARB for <55, CCB for ≥55 or Black African/Caribbean.
NICE vs BNF dose discrepancy	Antibiotic dosing in children — NICE CKS vs BNF give different weights/doses	NICE CKS is the primary reference for the AKT. If NICE and BNF conflict, the NICE CKS answer is correct. Never rely on personal prescribing habits or local formulary.
Rare but serious vs common but benign	Red flags for cancer in children alongside common viral presentations	The AKT is testing whether you will act on the serious possibility. Safety beats probability — if a red flag is present in the stem, the correct answer always addresses it first, regardless of how reassuring the rest of the picture looks.
Statistics word problems	"A screening test has sensitivity 80%, specificity 90%. In a population with 5% prevalence, what is the PPV?"	Apply the formula — never rely on intuition. PPV is affected by prevalence; the same test has very different PPV in high- vs low-prevalence populations. Build the 2×2 table if unsure.

🔥 The Meta-Rule That Covers All Five Traps

Every AKT trap exploits one of two reading failures: (1) misreading the question type (diagnosis vs investigation vs management vs referral) or (2) answering what you expect rather than what is asked. The fix is mechanical: read the final sentence of the stem twice, identify the question type, form your own answer before looking at the options, then choose. This single discipline eliminates most trap responses.

⚠️ Common SBA Traps — and How to Beat Them

Trap	What It Looks Like	How to Avoid It
"Not acting" is the answer	Tempting to investigate, prescribe, or refer — but the correct GP response is watchful waiting, reassurance, or a safety-net appointment	Always ask: "Is the cost-effective, appropriate answer here to do something — or to monitor carefully?" The AKT rewards restraint.
Jumping to Step 2 when Step 1 is asked	Question asks for "initial management" — but candidate selects a second-line option because they know it works	Look for the word "initial," "first-line," or "NEXT step" — then think: what does NICE say is step 1?
National vs local guidance	Answering based on local formulary or what your trainer does — which may differ from NICE	All AKT answers are based on NICE/SIGN/BNF. When local and national differ — national wins every time.
Extrapolating unstated findings	"The chest sounds clear, so there's no heart failure" — the exam never stated the chest was clear	If it is not written in the stem, it does not exist. Apply ONLY what is given.
Drug interaction blindness	Choosing a medication that has a red-flag interaction with a drug already listed in the patient's history	Always scan the full drug list in the stem. Check: would my choice interact with anything already listed?
RRR vs ARR confusion	Question gives RRR (which sounds impressive) — candidate calculates NNT from RRR instead of ARR	Always calculate ARR = CER − EER from the raw numbers given. NNT = 1/ARR. Never calculate NNT from RRR.
Over-investigating mildly abnormal results	Choosing a battery of tests for a slightly out-of-range result when the correct answer is "repeat in 3 months"	NICE often recommends a repeat test or observation before further investigation. "Recheck in 3 months" is a valid and frequently correct answer.
The hospital answer in a GP question	Choosing what a hospital doctor or specialist would do — when the question asks what a GP should do first	This is a primary care exam. Ask: "What would a safe, competent, NICE-following GP do as their FIRST step?" Not a specialist, not a registrar.

🔍 Anatomy of a Well-Read SBA Question

📍 Step 1 — Read this first

The question itself (last line): "What is the MOST APPROPRIATE initial management?"

Key word: "initial" = Step 1 only. Key word: "appropriate" = GP context, not hospital.

📋 Step 2 — Read the stem

Extract: age, sex, setting, key symptoms, current medications, any red flags stated. Write nothing in — only what is there.

💡 Step 3 — Form your answer BEFORE looking at options

What would you do? What does NICE say? Form this in your head before the options distract you.

✂️ Step 4 — Eliminate

Remove definite wrongs. Look for your pre-formed answer in the remaining options. If it is there — choose it with confidence. If not — choose the closest.

💡 The "Appropriate GP Answer" Principle

The AKT is not testing whether you know everything. It is testing whether you would behave like a safe, competent, cost-conscious, NICE-following GP. Sometimes the most clinically thorough answer is wrong because it is not what a GP would do first.

💡 The "One Mark for One Answer" Principle

Every question is worth one mark. Do not agonise. If you are stuck after 45 seconds — flag, make your best guess, move on. A difficult question is worth exactly the same as an easy question you might miss if you run out of time.

🎭 Worked SBA Examples — Wrong vs Correct Thinking

These are the specific clinical scenarios that trainees consistently get wrong — drawn from repeated patterns in exam feedback, trainee accounts, and AKT preparation communities. Study the reasoning, not just the answer.

Scenario 1 New mild hypertension — 52-year-old, BP 148/92, no red flags

❌ What Trainees Pick (Wrong)

Start ACE inhibitor immediately
Order ambulatory BP the same day
Refer to cardiology

✅ Correct Answer

Lifestyle advice + confirm with ABPM or home monitoring. Stage 1 hypertension (clinic 140–159/90–99) requires confirmation before treatment.

💡 Trainee insight: "I jumped to treatment too early. The AKT is testing whether I know I need to confirm Stage 1 before prescribing."

Scenario 2 Tired 28-year-old woman, Hb 114 g/L

❌ Trap Answers

Colonoscopy
Immediate coeliac screen + colon investigation
Refer for IV iron infusion

✅ Correct

Ferritin — the single best first test to confirm iron deficiency before investigation or treatment.

💡 Pattern: "AKT always wants the simplest, cheapest, most informative first test. Then you build. Not the other way round."

Scenario 3 Suspected PE — low clinical probability

❌ Common Wrong Answer

CTPA (CT Pulmonary Angiography) — jumping straight to the "gold standard" investigation

✅ Correct

Wells score → if low probability, D-dimer. CTPA only if high probability OR D-dimer positive.

💡 Key insight: "Gold standard ≠ correct GP answer. If you jump to the hospital-level investigation without going through the pathway — it's wrong."

Scenario 4 62-year-old man, PSA 5.2 ng/mL, asymptomatic, no red flags

❌ Trainees Pick

Immediate 2WW urgent prostate cancer referral

✅ Correct

Repeat PSA in 1–3 months (exclude prostatitis, UTI, recent ejaculation first). A single elevated PSA requires confirmation.

💡 Rule: "PSA almost always repeat first — unless red flags (bone pain, hard irregular prostate, haematuria) are present."

Scenario 5 45-year-old, 2 weeks of back pain, no neurological symptoms, no red flags

❌ Wrong

MRI lumbar spine — first-line imaging

✅ Correct

Conservative management: analgesia, keep active, reassurance. No imaging in non-specific low back pain without red flags.

💡 Red flag reminder: MRI IS indicated if: bladder/bowel dysfunction, bilateral leg weakness, saddle anaesthesia (cauda equina), or suspected malignancy/infection.

Scenario 6 QRISK3 = 8%, 55-year-old, no significant comorbidities

❌ Wrong

Prescribe atorvastatin 20mg — QRISK is elevated

✅ Correct

Lifestyle advice only. Statin offer threshold is QRISK ≥10%. Below this threshold, lifestyle modification is first.

💡 Threshold rule: <10% = lifestyle. ≥10% = discuss statin (atorvastatin 20mg for primary prevention). The AKT is precise about this boundary.

Scenario 7 AF, CHA₂DS₂-VASc score = 2 (male patient)

❌ Classic Wrong Answer

Prescribe aspirin 75mg for stroke prevention in AF

✅ Correct

DOAC (e.g. apixaban, rivaroxaban, edoxaban or dabigatran). Score ≥2 in males → anticoagulate. Aspirin is NOT recommended for AF stroke prevention per NICE NG196.

💡 Important: "Aspirin in AF" is probably the single most-tested wrong answer in the cardiovascular domain. It comes up every few sittings.

Scenario 8 HbA1c 47 mmol/mol in an acutely unwell patient

❌ Two Wrong Answers

Act on the result immediately — diagnose pre-diabetes and commence lifestyle programme
Repeat HbA1c in 3 months while the patient is still unwell

✅ Correct

Repeat HbA1c when clinically well. Acute illness — including infection, surgery, and physiological stress — falsely elevates HbA1c and makes the result unreliable.

💡 Teaching point: HbA1c is unreliable in: acute illness, recent blood transfusion, haemolytic anaemia, haemoglobinopathies (sickle cell, thalassaemia), iron deficiency, and chronic kidney disease. In these situations, use fasting plasma glucose or 2-hour oral GTT instead for diabetes diagnosis.

Scenario 9 Patient with known sickle cell trait, incidental HbA1c 51 mmol/mol

❌ Wrong

Diagnose diabetes — HbA1c ≥48 mmol/mol on a single test is sufficient

✅ Correct

Do NOT use HbA1c for diabetes diagnosis. Use fasting plasma glucose or 2-hour OGTT. Haemoglobinopathies (sickle cell, thalassaemia) make HbA1c unreliable — it can be falsely low OR falsely high.

💡 Conditions that invalidate HbA1c: Haemoglobinopathies (sickle cell, thalassaemia), haemolytic anaemia, recent blood transfusion, iron deficiency anaemia, CKD stage 4–5, acute illness. This is a recurrently tested AKT clinical nuance.

🔥 The Hidden Rule — "Safe, Boring, GP-level, Stepwise"

After failing, trainees repeatedly say the same things: "I knew the knowledge but picked wrong answers," "I overthought simple questions," and "I didn't think like a GP." The AKT correct answer is almost always the safest, least aggressive, most appropriate first step at primary care level. If two answers look equally good — pick the less aggressive one.

⚠️ Section 9

Common Pitfalls — Trainee Traps

Mistakes that cost real marks in real exams. Read each one and ask: "Could this be me?"

❌ Preparation Mistakes

Starting too late. Eight weeks is not enough. Eighteen weeks of consistent effort is the realistic target.
Reading textbooks cover to cover. Ineffective for this exam. Targeted study at weak areas is far more productive.
Doing the same question bank superficially. It's not about volume — it's about reading every explanation carefully, even for correct answers.
Ignoring stats and admin until the last two weeks. By then, panic sets in and they're not retained properly.
Not doing timed practice. Knowing the answers is different from knowing them under exam conditions in 90 seconds.
Trying to learn everything about every condition. You don't need to know everything about cardiac sarcoidosis. You need to know everything about AF, heart failure, and hypertension.

❌ Exam-Day Mistakes

Getting stuck on hard questions. Every question is one mark. A difficult question is worth exactly the same as an easy one. Move on.
Not flagging questions for review. Use the flag feature — return to uncertainties if time allows.
Leaving questions blank. No negative marking. A guess is a 20% chance. Blank is 0%.
Not reading the stem carefully. "Most appropriate NEXT step" is different from "most appropriate management." The word "next" matters enormously.
Choosing the hospital answer in a GP context. The AKT is set in primary care. When in doubt, ask what a safe, reasonable GP would do first — not a specialist.
Changing correct first answers. Your first instinct is usually right. Only change if you have a specific reason, not just doubt.

🔍 Content Traps — Where the Marks Quietly Disappear

The "Plausible Wrong Answer" Trap

SBA distractors are carefully designed to be tempting. Often all five options are correct in some context — only one is best in this GP setting. If you're choosing from instinct rather than logic, you're vulnerable to this.

The "Hospital Logic" Trap

Some trainees default to hospital-based thinking — order everything, refer everyone. The AKT rewards the GP mindset: safety-net, manage conservatively where safe, know your referral thresholds, don't over-investigate.

The "I Know This From Clinic" Trap

Local practice sometimes differs from national guidelines. The AKT tests NICE / BNF / national guidance — not your trainer's personal preference or your surgery's local protocol. When they differ, go with NICE.

The "Stats Guessing" Trap

Trainees who haven't studied stats often guess randomly. This is predictable and avoidable. The stats section is learnable — every concept is finite and logical. Don't guess when you could have learned it.

The "Outdated Guideline" Trap

Guidelines are updated regularly. The AKT is updated to reflect current NICE guidance. Check whether your resources are current — especially for asthma (2024 changes), diabetes (SGLT2i / GLP-1 guidance), and cardiovascular prevention.

The "NICE vs BNF" Confusion

When NICE CKS and BNF disagree (which is rare), NICE takes precedence in the AKT. When a book or old resource conflicts with NICE — NICE wins every time.

⚖️ Medico-Legal Traps — The AKT Tests These Too

These are not just clinical errors — they are documentation and professional duty failures that the AKT specifically tests. They appear in the organisational and prescribing safety domains.

📝

No Documentation of Advice Given

Advising a patient not to drive after a seizure, warning about drug side effects, or safety-netting — and then failing to document it.

AKT pattern: "The GP told the patient verbally but did not document it. Which of the following is the most appropriate action?" → Document all safety-critical advice. If it's not written, it didn't happen.

📋

No Follow-Up Plan for Abnormal Result

An abnormal blood result is received but no action is taken and no follow-up is arranged. The patient assumes they would have been contacted if something was wrong.

AKT pattern: Leaving an abnormal result without a documented plan to act on it. Every significant result must have a documented management response — even if it's "repeat in 3 months."

🚨

Ignoring a Flagged Abnormal Result

A result marked "abnormal" by the lab is actioned as normal, or filed without review. The system flags it but the clinician fails to act.

AKT pattern: "The GP received the result but did not action it. The patient presents 3 months later..." → Results must be actively reviewed and actioned. Passive receipt is not sufficient.

⚖️

The Medico-Legal Rule That Underlies All Three

In UK general practice, the duty of care does not end when advice is given verbally or when a result is received. It ends when appropriate action is documented, the patient is informed, and a follow-up plan exists. The AKT tests this principle repeatedly in prescribing safety and organisational domain questions. If no documentation = no defence.

⚖️ Unsafe Assumptions — Medico-Legal Risk Points

These clinical assumptions have featured in NHS Resolution claims analysis as common causes of missed diagnoses. The AKT specifically tests whether you know when not to take the easy option.

🔴 Rectal Bleeding = Haemorrhoids

Assuming rectal bleeding is haemorrhoids without excluding sinister cause in patients over 50. PR bleeding + age ≥50 → 2WW referral, not reassurance.

🔴 Back Pain = Musculoskeletal

Treating back pain in patients over 50 without considering malignancy or infection. Night pain, weight loss, or age >50 = consider cancer or cord compression.

🟠 Falls in Elderly = Just a Trip

Discharging elderly patients with "falls" without assessing for syncope, cardiac cause, or performing a medication review.

🟠 CHC Without Aura Check

Prescribing the combined oral contraceptive without checking for migraine with aura (absolute contraindication — UKMEC 4) or thrombophilia history.

🟠 Breathlessness = Deconditioning

Assuming breathlessness in an obese patient is deconditioning without excluding PE, LVF, or malignancy. Obesity increases — not decreases — VTE risk.

🔴 Sudden Headache = Tension/Migraine

Missing SAH by assuming a sudden-onset severe headache is tension or migraine. Thunderclap onset = SAH until proven otherwise. Always ask: sudden-onset? First or worst ever?

🔴 Teratogenic Drugs Without Counselling

Prescribing methotrexate or sodium valproate in women of childbearing age without adequate counselling, PPP enrolment, and explicit documentation. Both are NHS Resolution risk points.

🔑 The Common Thread in All These Cases

The path of least resistance — "most likely it's fine" — is the one that generates clinical negligence claims. The AKT specifically rewards the ability to recognise when the comfortable default answer is the wrong one. When you see a familiar presentation in a higher-risk patient (older, comorbid, on teratogenic drugs), the threshold for action lowers. Know when conservative is right, and when it is just easy.

💡 Section 10

Insider Pearls — What Nobody Tells You at First

The things trainees consistently wish they had known earlier. Drawn from the real experiences of those who've passed and those who've had to retry.

🎯 Targeted Study Beats Scattergun Every Time

Reading a textbook from front to back is the least efficient way to prepare for the AKT. Work from your weaknesses. Use the RCGP curriculum as a map, not a reading list. The biggest score gains come from finding and fixing your weak spots — not from re-reading what you already know well.

📖 Read the Explanations, Not Just the Questions

The real learning in question banks is in the explanations — not the questions themselves. A trainee who does 1,000 questions carefully and reads every explanation will outperform one who races through 3,000 and skips the learning. Quality beats quantity every time.

📋 The Examiner's Mindset is "Safe GP, Not Hospital Doctor"

Question setters are practising GPs. They write scenarios from their own clinics. The correct answer reflects what a safe, competent, NICE-following GP would do — not a specialist. When stuck between two options, ask: "What would a cautious, thoughtful GP do first?" — that's your answer.

🏥 Use Your Clinic as Your Revision Session

Every patient with an interesting or uncertain presentation is a learning opportunity. Look it up that evening. Keep a running list of topics to revisit. One targeted look-up per clinic session compounds into hundreds of revision points over 6 months — and they stick because they're attached to a real person you met.

📊 Stats Will Save You or Sink You

The stats section has the highest score variance between candidates — some score 90–100%, others score 20–30%. It is the most learnable section in the whole exam. Trainees who pass first time nearly always score well in stats. Those who fail often scored poorly. Spend a focused 2–3 weeks on stats alone — it's worth it.

🧠 Study Groups Work — But Only If They're Structured

A good study group is valuable: sharing insights, testing each other, splitting difficult topics. But unstructured chats that feel productive but aren't don't help. A structured session with a clinical scenario, timed questions, and a debrief is worth three hours of solo passive reading.

💻 Use AI Tools — But Don't Trust Them Blindly

AI tools like ChatGPT or Perplexity can be valuable for quizzing yourself: "What are the NICE first-line options for X?" or "Explain NNT with an example." Use them as an interactive revision partner. But always cross-check clinical facts against NICE CKS — AI can hallucinate guidelines. Useful as a teacher; not reliable as a reference.

😴 Sleep, Food, and Breaks Are Revision

Cognitive performance during a 4-hour exam depends directly on sleep quality in the preceding week. Cramming the night before erases more than it adds. A rested brain with moderate preparation will outperform an exhausted brain with excellent preparation. Protect your sleep. Eat properly. Take breaks. This is not indulgence — it's strategy.

🌟

The Examiner's Own Advice — and It's Still the Best

One AKT examiner who sat the first-ever exam and scored 82.5% — with no revision — put it plainly: "Read widely and learn from the patients you see and you will have no problem passing the AKT." The exam tests what good GPs actually know from doing the job well. Be a good GP. The exam follows naturally.

🧠 The AKT Decision Filter — Ask These 4 Questions

When stuck between two options — or when an answer feels right but you can't be sure — run this filter. The correct AKT answer satisfies all four.

🛡

Is it safe?

Does it protect the patient? Could harm come from choosing this option or delaying action?

1️⃣

Is it first-line?

Does this reflect step 1 of the NICE pathway? Not step 3. Not what a specialist would do.

🏥

Is it GP-level?

Would a GP do this — or is it a hospital-level intervention? The AKT is primary care only.

↩️

Is it reversible?

Does it avoid irreversible harm? Conservative + reversible beats aggressive + irreversible in primary care.

🧠 GP SAFE — A Consultation Memory Framework

Use this for both the AKT (management questions) and the SCA (consultation structure). It captures what every GP response should include.

Serious causes ruled out

Red flags checked and addressed first. Never skip this step.

Appropriate first step

First-line, GP-level, proportionate. Not over-treating or under-treating.

Follow-up plan

Clear timeframe for review. Escalation pathway if not improving.

Explain to patient

Patient understands the diagnosis, the plan, and when to act. Check understanding.

💡 How to Apply GP SAFE in the Exam — Step by Step

When stuck on a management question, work through S → A → F → E in order. The correct answer will address the most critical missing element — starting from S and working down.

S first — Serious causes ruled out?

Red flags present = rule out the serious diagnosis before treating the likely benign cause. If a red flag is mentioned in the stem and the options include an investigation to exclude danger — that comes first.

A — Appropriate first step?

What does NICE recommend as step 1? Not what you know works — what NICE says is first. Conservative management / lifestyle / basic investigation first. Never specialist referral as a first step without indication.

F — Follow-up plan?

AKT penalises "treat and leave" responses. If the scenario ends without a safety-net, review, or repeat test — options that include a follow-up plan are more correct than those that don't.

E — Explained to patient?

In SCA and some AKT organisational questions — has the patient been informed and involved? Options that include patient communication, consent, or shared decision-making often score higher than those that don't.

🎯 AKT Decision Filter — Applied in Practice

When two answers look equally plausible, apply these three questions in order. Stop at the first question that gives a clear answer. This is faster than the 4-question version under exam pressure.

The Three Filter Questions

Is this primary care appropriate?

Can a GP manage this independently, or does it require specialist input?

Is it first-line?

Is this NICE step 1 — not step 2 or 3?

Is it safe?

Does it avoid irreversible harm or unnecessary risk at this stage?

Applied Example — Low Back Pain

45-year-old, acute back pain, 10 days, no red flags. Options: MRI, physiotherapy referral, conservative management with analgesia.

Primary care appropriate? ✅ All three could be — no clear answer yet.

First-line per NICE? ✅ Conservative management only. MRI and physio are not first-line steps 1 in acute back pain without red flags.

→

Answer: Conservative management with analgesia and reassurance. Q2 gave a clear answer — stop there.

🔥 The Hidden Examiner Rule

The correct AKT answer is almost always: safe, boring, GP-level, and stepwise.

If you are choosing between an answer that feels impressive and one that feels pedestrian — pick the pedestrian one. The AKT is not testing how impressive you are. It is testing whether you are safe.

😴 Safe

🚶 Boring

🏥 GP-level

📶 Stepwise

🎯 The 5-from-Every-Patient AKT Method

The AKT is not a memorisation exam — it is a pattern recognition + threshold exam. The trainees who pass earliest build it from real patients, not textbooks. After each clinic, spend 5 minutes with NICE CKS on one condition. This beats 2 hours of passive reading every time.

After Every Clinic — Pick ONE Patient

Extract These 5 Things:

Diagnosis

The most likely diagnosis in this scenario

Key Differential

The one diagnosis you must not miss

Red Flag

The feature that would change your management

First-Line Treatment

+ dose if a drug is involved

Referral Threshold

The specific number or feature that triggers action

⚠️ Three More AKT Traps That Catch Trainees Out

⚠️ Trap 1 — Knowing Conditions, Not Thresholds

Knowing "iron deficiency anaemia → refer" is not enough. The AKT expects who and when with precision:

❌ "Refer to GI" — no specificity

✅ Male or postmenopausal → 2WW GI referral

✅ Premenopausal → consider cause first (menorrhagia, coeliac)

The rule: Learn thresholds, not just diagnoses. For every condition, know who gets referred, when, and at what specific threshold.

⚠️ Trap 2 — Guidelines ≠ What Your Trainer Does

The AKT marks to NICE — not to local practice or trainer habit. Common divergences:

Depression → SSRI first-line if moderate/severe — not counselling alone
UTI → nitrofurantoin vs trimethoprim depends on local resistance AND eGFR
Hypertension Step 1 → age/ethnicity dependent — not one-size-fits-all

The rule: If your trainer does it differently — learn both. But always answer to NICE in the exam.

⚠️ Trap 3 — The Over-Investigating Trap

The AKT frequently rewards restraint. When stuck between options, ask three questions in order:

What is the safest next step?

What is most cost-effective?

What prevents the worst-case outcome?

The rule: Often the answer is watchful waiting + safety-netting — not "do every test possible." GPs tolerate uncertainty. The AKT tests this tolerance.

🩺 Practical GP Shortcuts — From Experienced Trainees

These insights come from trainees who've sat through hundreds of GP consultations and reflected carefully on what actually works. They're not in the guidelines — but they make a real difference.

🤫 Silence Is Diagnostic Data

What a patient does NOT say is as important as what they do say. Silence, avoidance, or a quick change of subject can reveal the real reason for attendance — often more clearly than direct questioning. The AKT tests ICE precisely because of this.

📋 The 30-Second Pre-Consult Rule

30 seconds reading the notes before the patient enters shapes the whole consultation more efficiently than any single question. Know the problem list, the medications, the last contact. Walk in prepared, not reactive.

📖 When In Doubt — NICE CKS First

NICE CKS is written specifically for primary care and covers 370+ topics. It is the fastest route from uncertainty to guideline-aligned confidence. It's also what the AKT is based on. One CKS page per clinical uncertainty beats 10 random revision questions.

⚠️ The Forgotten 6-Week Review

Many AKT clinical scenarios require follow-up. The absence of a planned review is often the wrong answer. When a new drug is started, a diagnosis is made, or a result is borderline — the correct answer almost always includes a specific follow-up plan. "Treat and leave" fails.

💡 Practical Shortcuts That Actually Work

🔁 "Repeat Before Refer"

Applies to: PSA, HbA1c (borderline), BP, LFTs, mildly reduced eGFR. A single abnormal result almost never warrants immediate referral — confirm it first. This is one of the most reliable rules in the entire exam.

🚫 "No Red Flags = No Imaging"

For back pain, headache, and most musculoskeletal presentations without neurological signs or serious features — the AKT does not want early imaging. Conservative management is correct. MRI is not routine first-line.

👶 "Young + No Red Flags = Conservative"

Young patients with common presentations and no red flags almost always get conservative management as the first answer. Reserve investigation and referral for those with atypical features, red flags, or failure to respond to first-line treatment.

🚨 "AKT Hates Over-Treatment"

When stuck between two options — choose the less aggressive one. The AKT consistently rewards restraint, step-wise management, and "wait and see" with appropriate safety-netting over proactive intervention without indication.

🥇 "Choose the Safest, Not the Cleverest"

After failing, trainees say: "I knew the knowledge but picked the wrong answers" and "I didn't think like a GP." The correct answer is safe, boring, GP-level, and stepwise — not the answer that shows off the most knowledge.

📖 "If Two Options Look Good..."

Pick the less aggressive one. This applies across clinical scenarios, investigations, referral decisions, and prescribing questions. The AKT rewards restraint and proportionality.

🗣 SCA — Consultation Skills in Practice

SCA Worked Case Examples — Weak vs High-Scoring

The SCA tests the same knowledge as the AKT — but asks you to demonstrate it in a consultation. Here are two common presentation types with weak and strong candidate approaches side by side.

🎯

What Examiners Are Actually Assessing

Examiners are not just checking clinical knowledge. They are looking for three things: safe, structured data-gathering (not fishing, not exhaustive); clear, patient-appropriate explanation (chunk-and-check, jargon-free); and meaningful shared decision-making — including safety-netting that the patient can actually act on.

🎭 Case 1 — Mechanical Low Back Pain

❌ Weak Candidate

Jumps straight to examination without exploring the patient's concerns
Orders MRI "to be safe" — no red flags present
Gives no explanation of the likely cause
No reassurance given
No safety-net — patient leaves without knowing what to look out for
No follow-up plan

Result: Patient leaves confused, possibly anxious, without meaningful management.

✅ High-Scoring Candidate

Opens broadly: "Tell me what's been going on with your back"
Explores ICE: "Were you worried it might be something serious?"
Rules out red flags explicitly: bladder/bowel, bilateral weakness, saddle anaesthesia
Explains clearly: "This sounds like mechanical back pain — very common, usually improves with movement"
Validates concern: "It makes sense this has been worrying you"
Gives a management plan: analgesia, keep active, avoid bed rest
Safety-nets specifically: "If you develop any weakness in your legs, difficulty going to the toilet, or numbness in the groin — come back urgently"
Offers follow-up: "If it hasn't improved in 4–6 weeks, come back and we'll review"

Result: Patient is reassured, informed, has a clear plan and clear red flags to act on.

🗣 High-scoring phrase for this case:

"The good news is this doesn't sound like anything serious — this pattern of back pain is very common and usually gets better with gentle movement and appropriate pain relief. What I do want you to watch out for is..."

🎭 Case 2 — Viral URTI / Cough, Patient Expecting Antibiotics

❌ Weak Candidate

Prescribes antibiotics to avoid conflict — "just in case"
Gives no explanation of why antibiotics are not appropriate
Doesn't address the patient's expectations
No red flags checked or mentioned
No safety-netting at all

Why this fails: Antibiotic stewardship is a core GP competency. Avoiding conflict by prescribing inappropriately is a patient safety issue the SCA specifically tests.

✅ High-Scoring Candidate

Acknowledges expectation without capitulating: "I can completely understand why you thought antibiotics might help — a lot of people feel that way"
Explains viral nature clearly: "The good news is, from what you've described, this looks like a viral infection. Antibiotics only work on bacteria, so they wouldn't help here"
Addresses harms honestly: "And they can actually cause side effects without giving you any benefit"
Offers positive alternatives: symptomatic management, fluids, rest
Safety-nets explicitly: "If you develop breathlessness, chest pain, a high fever that doesn't settle, or this goes on beyond 3 weeks — please come back or contact us urgently"

What scores marks: Handling expectations, explaining reasoning, offering alternatives, and specific safety-netting with timeframe.

🗣 High-scoring phrases for this case:

"I can see why you'd think antibiotics might help — a lot of people feel that way. Let me explain what I'm seeing..."
"Antibiotics wouldn't help here because this is a viral infection, and they could actually cause harm without benefit."
"If you develop breathlessness, a high fever that doesn't settle, or the cough persists beyond 3 weeks — please come back or contact us urgently."

📋 Consultation Structure Templates

Template 1 — Standard GP Consultation

Open — broad opening, invite the patient's story

ICE — ideas, concerns, expectations before examining

Focused history — hypothesis-driven, targeted

Explain — chunk-and-check, patient's language

Shared plan — "What are your thoughts on that?"

Safety-net — specific symptoms + timeframe + action

Template 2 — Complex / Multi-Issue Case

Acknowledge emotion first — before clinical content

Clarify expectations — "What's the most important thing for you today?"

Prioritise issues — agree agenda, tackle in order

Shared decision — involve patient in each decision

Follow-up plan — what happens next, who does what

Close clearly — "Does that all make sense? Anything else?"

🗣 High-Yield SCA Phrases — Trainee-Verified

Handling Expectations

"I can see why you'd think [X] might help — a lot of people feel that way. Let me explain what I'm seeing and why I'm suggesting something a bit different..."

Interpretive Empathy (not just "oh dear")

"It sounds like this has been [exhausting / frightening / frustrating] more than anything else."

Name the specific emotion — generic "that must be hard" scores less than a reflection that shows you actually listened.

Safety-Netting (Specific = High-scoring)

"If you develop [specific symptom], [specific symptom], or [specific symptom] — please come back urgently or call 111. Otherwise, if things haven't improved in [X days / weeks], come back and we'll review."

Generic safety-netting ("come back if you're worried") scores lower than specific triggers with a timeframe and action.

Managing Uncertainty

"At this stage, we don't need urgent tests — but I don't want to miss anything, so let's keep a close eye on this. If anything changes before we meet again, please don't hesitate."

⚠️ The Biggest SCA Failure Mode — No Safety-Netting

Safety-netting is one of the most common reasons candidates lose marks in the SCA. It must include three elements: specific symptoms to watch for, a timeframe, and a clear action. "Come back if you're worried" has no timeframe, no specific trigger, and no clear action — it scores poorly. Practise safety-netting for every case type until it is automatic.

🧠 SCA Consultation Frameworks — Two Essential Mnemonics

SCA Mindset — Every Case

CARE

Connect — warm opening, let them speak first, name a verbal cue early

Acknowledge — ICE and empathy, interpretive not generic ("that sounds exhausting" not "I understand")

Reason — verbalise your working diagnosis and logic aloud at ~6 minutes (if you don't say it, it can't be marked)

Engage — shared decision-making, management together, specific safety-net

ICE Alternative — More Natural

IDEA

Impact — "How has this been affecting your day-to-day life?"

Diagnosis — "What do you think might be going on?"

Emotions — "What worries you most about this?"

Aims — "What would feel like a good outcome for you today?"

These 4 questions, woven naturally through the early history, replace the robotic "What are your ideas, concerns, and expectations?" block. Use whichever flows naturally.

⏱ SCA 12-Minute Timing Structure

The 6:6 split is the single most important structural insight for the SCA. Trainees who spend 9–10 minutes on history consistently fail because Clinical Management (the most heavily weighted domain) is underdeveloped. Commit to the switchover at 6 minutes.

Time	Focus	Target
0:00 – 1:00	Opening, open question, initial ICE/IDEA	Patient's agenda and hidden concern established
1:00 – 6:00	Focused history, red flags (named aloud), psychosocial context	Key data gathered; relevant red flags covered and stated
~6:00 ★	State working diagnosis aloud	"Based on what you've told me, I think what's most likely is X, because of Y and Z."
6:00 – 11:00	Management + shared decisions; address ICE; prescribing safety; guideline reference	Options discussed; patient involved; NICE referenced where relevant
11:00 – 12:00	Safety-net (named symptoms + timeframe + action); summarise; check understanding	Plan confirmed; teach-back where appropriate

🔍 Murtagh's Diagnostic Strategy

A structured approach to clinical reasoning in any consultation — particularly valuable for undifferentiated presentations. Ask all four questions before concluding your assessment.

Probable diagnosis

What is the most likely explanation for this presentation?

Must-not-miss diagnosis

What serious condition could this be, even if unlikely? This must be excluded.

Masquerade diagnosis

What commonly-missed condition could be presenting atypically? (e.g. depression as fatigue; hypothyroidism as low mood)

Psychosocial dimension

Is there a contributing psychosocial factor being missed? (relationship, work, financial, bereavement, abuse)

⚖️ Safety-Netting — Medico-Legal Requirements

Legally defensible safety-netting is one of the most underrated clinical skills. Vague safety-netting is both an SCA fail point and a medico-legal vulnerability. NHS Resolution claims frequently involve inadequate safety-netting documentation.

✅ Legally Defensible Safety-Netting Requires ALL THREE:

1. Specific red flags named

"If you develop a high fever, difficulty breathing, or blood in your urine" — NOT "if it gets worse"

2. Clear timeframe

"within 24–48 hours" / "same day" / "immediately" — not "soon" or "shortly"

3. Explicit action required

"call us that day" / "attend A&E" / "call 999" — the patient must know exactly what to do

+ Teach-back (checked for understanding)

"Just to make sure I've explained that clearly — can you tell me what you'd do if your symptoms changed overnight?"

Document that the patient understood. In the SCA, state this aloud. In real practice, add to the record: "Patient safety-netted re [symptom]: advised to attend A&E immediately if develops [X]."

Over-netting risk: Creating disproportionate anxiety leads to unnecessary attendance and erodes trust. Safety-netting must be proportionate to the actual risk — calibrate the urgency language to the clinical probability.

🧠 Section 11

The PASS AKT Framework

A memorable framework that captures the seven principles of effective AKT preparation.

🏆 PASS AKT — Dr Ram's Proven Preparation Framework

Prepare Early

Start 4–6 months before your exam — 16–18 weeks of consistent effort. Little and often beats two-week panic every single time. Create a schedule and stick to it.

Ask For Help

Talk to your trainer, peers, and TPD. Struggling with stats? Ask someone to explain it. Doctors love teaching, and asking is not a weakness — it's smart resource use.

Study Groups

Join or form a structured study group. Explaining a concept to a colleague is the single best test of whether you actually understand it yourself. Teaching = learning.

Sit After Experience

GP exposure makes theoretical guidelines stick. Real-world clinical context is irreplaceable for AKT scenario questions. See patients, learn from them, then sit the exam.

Apply Knowledge

Don't just read — do question banks. Practice applying what you know to AKT-style scenarios. The skill of answering SBAs under time pressure is separate from raw knowledge.

Know Guidelines

NICE CKS is your best friend. When books and guidelines disagree — NICE wins. Focus on the "Management" sections and learn thresholds, not just concepts.

Take When Ready

Your mental health and wellbeing come first. If life is genuinely too hectic, it is okay to defer. Walk into the exam feeling confident and rested — not depleted and frantic.

🧠 Section 11b — Memory Aids

Clinical Mnemonics & Memory Frameworks

High-yield memory tools for the topics most commonly tested. Learn these once — recall them under time pressure.

📊 SnNOut / SpPIn — Statistics

SnNOut

High Snsitivity:
if Negative → rules Out

SpPIn

High Specificity:
if Positive → rules In

A sensitive test is good for screening (you don't want to miss cases). A specific test is good for confirming diagnosis (you want few false positives).

❤️ CHA₂DS₂-VASc — Stroke Risk in AF

CCongestive heart failure1 HHypertension1 A₂Age ≥752 DDiabetes mellitus1 S₂Stroke / TIA history2 VVascular disease (MI, PVD)1 AAge 65–741 ScSex category (female)1

Anticoagulate if: ≥2 in males; ≥3 in females (the female sex point means women need a higher score before anticoagulation is triggered). Use DOACs in preference to warfarin for most patients.

💊 ABCD Rule — Hypertension Step Therapy

ACE inhibitor or ARB — Step 1 if <55 or with diabetes. ARB preferred in African/Caribbean origin.

Calcium channel blocker — Step 1 if ≥55 or African/Caribbean (any age). Added at Step 2 alongside A.

Diuretic (thiazide-like — indapamide) — Step 3. Add to A+C at optimal doses.

Beta-blocker — Step 4 only (resistant hypertension) OR specific indications (AF, post-MI, heart failure). NOT routine step therapy for uncomplicated hypertension.

Step 4 (resistant): add spironolactone if K⁺ ≤4.5 mmol/L; add alpha-blocker or beta-blocker if K⁺ >4.5 mmol/L.

🗣 SPIKES — Breaking Bad News (SCA Relevant)

Setting up — Private room, sit down, minimise interruptions

Perception — "What have you been told so far?" / What do they already know?

Invitation — "How much do you want to know?" / Check how much detail they want

Knowledge — Give the information clearly, in plain language, in small chunks

Emotions / Empathy — Respond to the emotional response before continuing

Strategy / Summary — Clear plan, follow-up, written information if appropriate

🚗 The DVLA 1-10 Rule — Epilepsy

Year seizure-free
Group 1 (cars)

Years seizure-free off meds
Group 2 (HGV/bus)

First unprovoked seizure: Group 1 = 6 months; Group 2 = 5 years. These are different from established epilepsy — know both sets.

🚨 Must-Not-Miss Red Flags — Quick Reference

Thunderclap headache → SAH (CT head; LP at 12h if CT negative)

Ascending paralysis after infection → GBS (admit urgently)

Central crushing chest pain + diaphoresis → ACS (999, aspirin 300mg)

Severe tearing chest/back pain → Aortic dissection (do NOT give thrombolytics)

Non-blanching purpuric rash + fever in child → Meningococcal septicaemia (IM benzylpenicillin if not allergic; 999)

Bilious vomiting in neonate → Malrotation/volvulus until proven otherwise

Post-menopausal bleeding → 2WW referral (endometrial/cervical cancer)

🧠 More Essential Mnemonics

Pain History

SOCRATES

Site

Onset

Character

Radiation

Associations

Timing

Exacerbating / relieving factors

Severity (0–10 scale)

Frailty & Falls Assessment

THREADS

Thinking — cognition assessment

Hearing and vision

Remedies — polypharmacy and deprescribing

Equilibrium — balance and gait

Anatomy — feet, joints, footwear

Dying / depression

Systems — cardiovascular, neurological

🗣 Consultation Models — Summary Table

The AKT tests consultation frameworks in the organisational domain. Each model has a specific SCA relevance. Know what each one contributes — not just the name.

Model	Core Concept	SCA Relevance
Calgary-Cambridge	Task-based; 73 skills mapped to 5 stages: Initiating, Gathering, Examination, Explaining/Planning, Closing	Most commonly taught in UK training; RCGP SCA toolkit is based on this framework
Roger Neighbour	5 checkpoints: Connecting, Summarising, Handover, Safety-netting, Housekeeping	Safety-netting as a formal checkpoint originates here — directly tested in SCA closing
Pendleton	Presenting problem → cause → predisposition → action → understanding → resources → involvement	Systematic and patient-centred; less flexible but useful for structured debrief after cases
Balint	"The doctor as a drug" — the therapeutic relationship itself has healing potential	Relevant for complex/chronic consultations; explains why the "how" matters as much as the "what"
SPIKES	Setting → Perception → Invitation → Knowledge → Emotion → Summarise/Strategy	Breaking bad news — use for serious diagnoses in SCA; widely expected in palliative/cancer scenarios

🔢 Key Thresholds — Quick Reference

These thresholds appear as the pivot point between wrong and correct answers across multiple AKT sittings. Memorise them cold.

Scenario	Threshold / Action
ABCD2 score ≥4 (TIA)	Same-day specialist review (high-risk TIA)
CHA₂DS₂-VASc ≥2 (men) / ≥3 (women) — AF	Anticoagulate (DOAC first-line)
AUDIT-C ≥5 (alcohol)	Brief intervention indicated
PHQ-9 ≥10	Consider antidepressant; ≥20 = severe
eGFR <30 — metformin	Stop metformin
Serum lithium target	0.4–1.0 mmol/L (check 12h post-dose)
TSH suppressed on levothyroxine	Risk of atrial fibrillation and osteoporosis — reduce dose
ACEi — U&E monitoring	1–2 weeks after starting and after each dose change
Cervical screening — start age (England)	Age 25; then 3-yearly until 49; 5-yearly 50–64
AAA screening	One-off USS at age 65 in men
Bowel cancer screening	qFIT every 2 years, ages 50–74 (England)
Breast screening	Mammogram every 3 years, ages 50–70 (NHS programme)

📅 Section 12

Exam Day — What To Do

The practical stuff. Because arriving flustered is an entirely avoidable own goal.

72 Hours Before — Last Revision Pass

Focus only on the high-yield definable topics — not clinical knowledge cramming. Go through:

DVLA fitness to drive rules (review the at-a-glance guide)
UK childhood immunisation schedule
Child developmental milestones (by age)
Maternity schedule and antenatal appointments
Contraception — summary of each method's key features
Mental Health Act sections (2, 3, 4, 5(2), 136)
Notifiable diseases — the list
Stats formulae — NNT, NNH, ARR, sensitivity/specificity
GP certificates — which form, who completes it
Prescribing law — controlled drug schedules

Day of the Exam

Arrive 30 minutes early — test centre admin takes time and rushing is catastrophic for composure
Bring two forms of ID — photographic primary, name-bearing secondary. Names must match your registration exactly.
Nothing in the exam room — all personal items go in your locker, phone off
Use the onscreen timer — check it every 40 questions (roughly once per hour in the new format)
Flag, guess, and move on for any question taking more than 90 seconds
Eat well beforehand — protein-rich, not sugar-loaded. Your brain needs fuel for 4 hours.
Rest before the exam, not just that night — the week before matters too

✅

The Night Before — What To Do (and Not Do)

Do: Light review of your highest-yield summary notes. A short walk. A proper meal. An early bedtime. Don't: Start a new topic, attempt a full mock, drink heavily, or stay up late studying. The night before is consolidation, not acquisition. What you don't know at 11pm you won't learn by midnight.

💪 Section 13

If You Don't Pass First Time

A message written with genuine warmth — because this happens to excellent doctors, and it doesn't define you.

First: please don't panic. Many outstanding GPs didn't pass the AKT on their first attempt. It is not a reflection of your clinical ability, your intelligence, or your future as a doctor. It is a test that requires specific, targeted preparation — and sometimes that preparation needs a different approach. You have up to 4 attempts. Use them wisely.

Get your feedback — it's detailed and it's valuable

The RCGP sends domain-level performance data after every sitting. This shows exactly where you scored well and where you lost marks. This is not just polite — it's essential. It tells you exactly where to focus your revision next time.

Analyse the patterns honestly

Was it clinical knowledge? Stats? Admin? Time management? Each requires a different solution. Don't just "do more questions" — understand why you lost marks and change your approach accordingly.

Change your study method — not just your effort level

Doing more of the same thing that didn't work is unlikely to produce different results. Try a different question bank, a structured course, video learning, a study group, or targeted clinical reading. Something needs to change, not just increase.

Consider a neurodiversity assessment if timing was an issue

If time management, reading speed, or processing under pressure were significant factors, consider a formal dyslexia or ADHD assessment. With appropriate documentation, the RCGP can grant up to 25% extra time. This can genuinely change outcomes. Your deanery may be able to help arrange an assessment.

Book your next attempt promptly

Don't wait until motivation fades. Give yourself adequate preparation time (3–4 months minimum) but book soon after receiving your results. Having a clear next date creates structure and prevents the failure from becoming demoralising drift.

🩺 Reasonable Adjustments — Know Your Rights

Extra time (up to 25%) — available for dyslexia, ADHD, and certain other conditions with appropriate documentation
Separate room — for concentration difficulties, anxiety, or medical conditions
Modified screen settings — font size, colour overlays
Rest breaks — for certain physical health conditions
Medical evidence required — formal educational psychologist assessment for dyslexia. Contact RCGP exams team early — before the booking window.

Needing adjustments is not a weakness. It is knowing yourself and advocating for a fair assessment. Do it early — the process takes time.

🔗

Neurodiversity Screening

If you're wondering whether neurodiversity might be affecting your exam performance, an online screening tool is available at geniusscreening.com. This is a screening — not a diagnosis — but it can be a useful first step.

🌍 Section 13b — For International Medical Graduates

IMG-Specific AKT Guide

In October 2025, UK-trained first-time candidates passed at 88.8% — all candidates at 70.6%. This 18-point gap is largely addressable. Here is exactly where it comes from and how to close it.

🎯

The Gap Is About Preparation, Not Intelligence

IMGs are not less capable doctors — they are often more experienced clinically. The performance gap is almost entirely explained by four factors: unfamiliarity with UK-specific regulations, differences in clinical approach conventions, lower EBP/stats preparation, and unfamiliarity with UK SBA exam technique. All four are fixable.

📋 Content Gaps Most Common in IMGs

🚗 Administrative & Legal

DVLA rules, Mental Health Act sections, death certification (including 2024 ME reform), notifiable diseases, GMC confidentiality guidance, GDPR/DPA 2018 — all UK-specific. Study each one explicitly; they do not transfer from other countries.

📊 Statistics & EBP

If your undergraduate training did not include UK-style statistics teaching, this entire domain needs specific targeted revision. The RCGP provides free video tutorials on statistics (with Prof Michael Harris). These are excellent — use them.

💊 Women's Health & Contraception

UKMEC contraindication categories, LARC options, emergency contraception timeframes, teratogenic drug protocols — frequently tested and a consistent gap for IMGs from countries with different contraception frameworks.

🏛 NHS Structure

PCN, ICB, CQC, NHSE — know what each does. QOF and GP contract knowledge is tested in the org/management domain. These concepts have no direct equivalent in most international healthcare systems.

🩺 Clinical Approach Differences to Internalise

✓

Conservative investigation threshold

UK primary care does not investigate everything. Treat common things commonly. The AKT rewards restraint and safety-netting over exhaustive investigation.

✓

Antibiotics for viral URTI = wrong answer

Watchful waiting with safety-netting advice is the correct first-line management for most viral URTIs in adults. This is tested directly and repeatedly.

✓

Symptom-led diagnosis is expected

Making a working diagnosis and managing it without exhaustive investigation is often the correct answer. UK GPs are expected to tolerate diagnostic uncertainty while safety-netting.

✓

NICE wins over all other sources

NICE guidance supersedes local protocols, hospital practice, and international guidelines. If your home country does it differently — apply NICE for the AKT.

🧠 UK Exam Mindset — Thinking Like an Examiner Expects

The "Best GP Answer" Principle

UK SBAs test the best answer from the UK GP perspective — not the most thorough, not the most defensive, not what a specialist would do. The answer that a careful, cost-conscious, NICE-following GP would do first is almost always correct.

Only What Is Written Exists

Do not add clinical findings or assumptions not stated in the stem. Many IMGs lose marks by inferring findings from context ("the patient probably has X too"). The UK SBA convention is explicit: if it isn't written, it isn't there.

Less Action Is Often Correct

The AKT tests appropriate, cost-effective management. Sometimes the correct answer is watchful waiting, safety-net advice, or no investigation at all. IMGs often lose marks by defaulting to intervention when observation is the right answer.

Learn from UK GP Community

Read UK GP trainee perspectives: r/GPUK, GP trainee blogs, Bradford VTS, and Red Whale — these reflect the mindset examiners reward. Colleagues who have already passed are often willing to share their experience — ask them.

📅 IMG-Specific Revision Priority Guide

Priority	Topic Area	Why IMGs Need Extra Time Here	Best Resource
Critical	DVLA fitness to drive	UK-specific rules with no international equivalent — must be learned from scratch	DVLA At-a-Glance guide (GOV.UK)
Critical	Statistics & EBP domain	Lowest-scoring domain for IMGs — often not covered in international medical training	RCGP free stats videos; Bradford VTS stats page
Critical	Mental Health Act	UK-specific legal framework — sections, who can apply, detention criteria all unique to UK	NICE CKS Mental Health Act; Mind.org.uk
High	GMC confidentiality & GDPR	UK regulatory framework — MUST vs MAY disclose scenarios	GMC Confidentiality guidance (2024)
High	Contraception (UKMEC)	UKMEC category 3/4 contraindications are UK-specific — frequently tested	FSRH UKMEC 2016 (updated)
High	Death certification	September 2024 Medical Examiner reform — entirely new to all candidates	GOV.UK MCCD guidance (Sept 2024)
Standard	Clinical knowledge (NICE)	Good clinical training travels — but apply NICE, not your home country's guidance	NICE CKS; Bradford VTS clinical pages
Standard	SBA exam technique	UK SBA conventions may differ from home country exam formats	SBA Technique section above; RCGP Self-Test and question banks

💡 The Single Most Impactful Thing an IMG Can Do

Sit with a UK GP trainee or trainer who has passed the AKT and go through 20–30 questions together — discussing the reasoning behind each answer. The UK SBA mindset is difficult to internalise from a textbook. Hearing how a UK-trained doctor approaches the stem, applies NICE, and rejects tempting distractors is worth hours of solo study. Most colleagues are glad to help when asked.

🧠 Neurodiversity & Reasonable Adjustments — Worth Knowing

Some trainees who repeatedly struggle with the AKT — particularly with timing, reading speed, or working under pressure — have unrecognised neurodiversity (dyslexia, ADHD, processing differences). This is not a rare situation, and it is not a reason for concern — it is a reason to seek support.

What support is available:

Extra time or other reasonable adjustments in the AKT
Modified conditions for the SCA
Deanery/NHSE learning support plans
Occupational health assessment referral

How to access it:

Speak to your TPD or Educational Supervisor — this is the first step
The RCGP has a formal reasonable adjustments application process
Apply well in advance — adjustments cannot be applied retrospectively
An assessment by an educational psychologist may be needed

The message: Repeated AKT failure despite good preparation is worth discussing openly with your TPD. It may reflect an unmet support need — not a knowledge deficit. Asking the question costs nothing. Missing the opportunity to apply for adjustments could mean sitting the exam at a significant disadvantage.

📋 Professional Development

PDP, ARCP & Your Training — AKT-Linked Development

The PDP is not just a portfolio box to tick — it is the mechanism that connects what you learn in clinical practice to what the AKT tests. Trainees who write strong PDPs perform better in the AKT because they develop habits of targeted, evidence-linked learning.

AKT Insider Tip

💡 Turn Every Wrong Practice Question Into a PDP Entry

Every wrong answer in a question bank is a signal — not a failure. Apply this three-step process: (1) Identify the specific guideline tested. (2) Read that section of NICE CKS or BNF. (3) Write a specific PDP entry if the gap is large enough. This is the most AKT-efficient use of your question bank performance data.

📋 PDP Mandatory Minimums

Requirement	Detail
Minimum per training year	2 PDPs with progress demonstrated in at least one at each ESR
Good practice (per placement)	3 per placement — aim for this, not the minimum. Retrospective PDPs are flagged at ARCP.
Who agrees them?	Trainee and Educational Supervisor jointly at the ESR. Both sign off the plan and the evidence of progress.
What must each entry contain?	Learning need + action plan + target date + how success will be demonstrated
❌ NOT acceptable as PDP entries	"Pass the AKT" / "Pass the SCA" / "Add more log entries" — these are national requirements, not personal learning needs

🧠 Applying AKT Thinking to Your PDP Writing

❌ Trap 1 — Reflection Without Action

"I need to revise diabetes." — This is not a PDP entry. It names a topic area without specifying the gap, the guideline, or the outcome.

✅ How to Fix It

"Review NICE NG28 — HbA1c targets (48/53/58 mmol/mol), SGLT-2 indications, insulin initiation criteria in primary care. Demonstrate via a CbD on a diabetes patient."

❌ Trap 2 — Vague Learning Goals

"Improve dermatology knowledge." — The AKT tests a specific rash, a specific threshold, a specific step in treatment. Vague goals produce vague learning.

✅ How to Fix It

"Review NICE CKS eczema — step-up therapy (steps 1–4), topical steroid potency classification, when to refer for patch testing or phototherapy."

🗂️ Linking PDPs to the 13 Core Capabilities

Every PDP entry should be tagged to one or more of the RCGP's 13 core capabilities. PDPs heavily weighted in Area B (clinical knowledge) alone will be flagged at ARCP — see the Capability B Trap below.

Area	Theme	Core Capabilities
A	Knowing yourself & relating to others	Communicating and consulting (updated name from Aug 2025) \| Ethical approach \| Fitness to practise
B	Applying clinical knowledge	Data gathering and sense-making (incl. examination & procedural skills) \| Making decisions and diagnoses \| Clinical management
C	Managing complex & long-term care	Managing medical complexity \| Working with colleagues and in teams
D	Working in organisations	Performance, learning and teaching \| Organisation, management and leadership
E	Caring for the whole person	Holistic practice, health promotion and safeguarding \| Community health and environmental sustainability (updated Aug 2025) \| Co-production of care

🚨

ARCP Pitfall — The Capability B Trap

Ensure at least one PDP per review period falls outside Area B (clinical knowledge). Trainees who write all their PDPs on clinical topics neglect communication and consulting, ethical practice, leadership, and community health — all of which are assessed at ARCP. The AKT also tests capabilities from Areas A, D, and E (confidentiality, prescribing law, public health, patient safety systems). Align your PDP to the whole curriculum.

🔬 Learning Needs Identification Tools

📊 RCGP GP Self-Test

Free for registrar members. 2,950+ AKT-style questions across the curriculum. Gives peer comparison data so you can see your performance against other trainees nationally. Use at the start of each placement to identify your weakest curriculum areas — then write PDPs based on those gaps rather than guessing. Around 15% of AKT content is directly similar to GP Self-Test questions per trainee reports.

📋 Placement Planning Meeting

Complete the specialty self-assessment handbook tool before meeting your Clinical Supervisor. This prevents retrospective PDPs — you identify gaps before the placement starts, not after it ends. Retrospective PDPs are specifically flagged at ARCP as evidence of poor reflective practice.

💬 WPBAs — COTs, CbDs, Mini-CEX, MSF

Review feedback from every workplace-based assessment. Recurring themes across multiple different assessments are strong candidates for PDP goals — because they represent genuine patterns rather than isolated incidents. A single assessor's comment may reflect their preference; three assessors flagging the same thing is a real gap.

🔍 PUNs and DENs

Patient Unmet Needs (PUNs) and Doctor's Educational Needs (DENs) — the most authentic sources for PDP goals, grounded in real patient encounters. When you see a patient and realise you didn't know something that would have helped them — that is a DEN. That is the most powerful PDP generator in primary care training.

📅 RCGP Curriculum Update — August 2025

🆕

What Has Changed (August 2025)

Assessment, exams (AKT and SCA), and ePortfolio requirements are unchanged. New PDP priority themes and capability name updates:

New PDP Priority Themes

Virtual and remote consulting competence
Planetary health — prescribing choices including inhaler selection
Health equity and accessibility
Co-produced care plans

⚠️ Capability Name Changes

"Communication and consultation"
→ "Communicating and consulting"
"Community orientation"
→ "Community health and environmental sustainability"

Use the updated names in your ePortfolio from August 2025. Old names may be flagged in automated systems.

🩺 Post-CCT & Regulatory Requirements

Becoming a GP — What the AKT Tests About Regulation & Registration

The organisation and management domain (10% of AKT marks) includes regulatory requirements for GP practice. These are consistently underrevised and often caught trainees out in recent sittings. The GPPID-C framework covers everything you need to know before first independent GP work.

Memory Aid — Before First Independent GP Work

🧠 GPPID-C — The Six-Step GP Readiness Checklist

GP Register

Post-CCT with GMC

Performers List

Apply 3–6 months before CCT

Protection / Indemnity

MDO + state-backed cover

ID + Document Pack

Right to work, certificates

Designated Body

Know your RO; update GMC Online

Checks

DBS / OH / contracts / pension

📋 GPPID-C — Detailed Reference

Area	Key Facts	AKT Trap / Common Mistake
GP Register	Separate from GMC general registration. Required post-CCT to work as an independent GP. Apply via GMC. Joining the GP Register and joining the Performers List are two separate requirements.	Trap: "GMC registration = ready to work as a GP." Wrong — you also need GP Register entry AND Performers List. These are three distinct requirements.
Performers List	Apply to NHS England Medical Performers List no earlier than 6 months before CCT; ideally no later than 3 months before CCT. Since September 2023 regulatory change, ST1/ST2 trainees no longer need to apply early just for GP placements.	Trap: Old teaching implied all trainees must be on the list throughout training — that is no longer the position in England after 2023. Also: must apply as GP Registrar before CCT, not as GP Performer.
State-backed Indemnity (CNSGP/GMPI)	Covers clinical negligence from NHS GP work — trainees, salaried GPs, locums providing NHS services. Does NOT cover: private work, GMC proceedings, coroner's inquests, complaints support, disciplinary processes, or criminal matters.	Trap: "State-backed indemnity means I can cancel my MDO." Wrong — clinical negligence is not the whole medicolegal picture. MDO membership is still required for GMC, complaints, disciplinary, and non-negligence matters.
Indemnity — changes in practice	Must inform your MDO/indemnity provider when you: change role, change sessions/commitment, or start locum work. Cover can be invalidated by undisclosed changes.	Trap: "Doctor starts locum work without updating indemnity." Answer: Unsafe — not fully covered.
DBS Update Service	Enhanced DBS required for GP work. DBS Update Service annual fee: £16/year. Must join within 30 days of certificate issue. Makes certificate portable between employers where check level and workforce type match.	Trap: "Doctor repeatedly asked for DBS by different agencies — best solution?" Answer: Join the DBS Update Service. Also: not all employers are obliged to use it — they may still request a fresh check.
Occupational Health	Pre-placement OH assessment is a patient safety requirement — not a formality. Covers fitness for role, infection risk, exposure-prone procedures (EPPs), and reasonable adjustments under equality law. Hepatitis B status is critical — must be confirmed before clinical work starts.	Trap: "Practice refuses start without OH clearance." Answer: Correct — this is a patient safety requirement, not unreasonable.
Designated Body & Revalidation	Post-CCT: move from ARCP to annual appraisal/revalidation cycle. Must know your responsible officer (RO) and designated body. Update GMC Online when moving region or role. First appraisal generally expected within the appraisal year following your ARCP revalidation.	Trap: "Appraisal starts much later once settled." Wrong — newly qualified GPs need early clarity on designated body, RO, and first appraisal timing.
Locum Pension	GP locums can pension NHS locum work, but Locum A and B forms must be submitted within 10 weeks or the work is lost to pensioning (unless exceptional circumstances apply).	Trap: Assuming pension admin sorts itself out. It doesn't — missed 10-week windows result in permanent loss of pensioning for those sessions.

🎯 Classic SBA Traps — Regulatory Domain

⚠️ SBA Trap 1

Q: "ST3 applies to the Medical Performers List 8 months before CCT. What happens?"

→ Application invalid — too early. Apply no earlier than 6 months before CCT.

⚠️ SBA Trap 2

Q: "Doctor applies as a GP Performer before CCT."

→ Incorrect — must apply as a GP Registrar before CCT. GP Performer status is post-CCT.

⚠️ SBA Trap 3

Q: "Doctor starts locum without updating indemnity."

→ Unsafe — not fully covered. Any change in role/sessions requires informing MDO.

⚠️ SBA Trap 4

Q: "Doctor repeatedly asked for DBS by agencies. Best solution?"

→ Join the DBS Update Service (£16/year). Certificate becomes portable where check level matches.

⚠️ SBA Trap 5

Q: "Practice refuses to let doctor start without OH clearance. Is this reasonable?"

→ Yes — patient safety requirement. OH clearance (including Hep B status) is mandatory before clinical work.

⚠️ SBA Trap 6

Q: "GMC registration means I'm automatically on the GP Register."

→ Wrong. GMC Register, GP Register, and Performers List are three separate requirements.

👨‍🏫 Section 14

For GP Trainers & Supervisors

Your role in AKT preparation is more powerful than you might think. Here's how to use your time with trainees effectively.

🎯 Your Most Powerful Tool: Random Case Analysis

RCA is one of the most effective teaching methods for AKT preparation — and it takes only 10 minutes per session.

Pick a random case from the trainee's recent clinic list — any case

Ask them to present it briefly (2 minutes max)

Probe their clinical reasoning: "Why did you choose that? What were the alternatives? What does NICE say?"

Identify knowledge gaps — and give the trainee a specific learning task

Follow up next session — did they look it up? What did they find?

💡 Trainer Insight

10 minutes of RCA per week is more effective than a monthly 60-minute tutorial. Frequency and context beat duration every time.

🧠 Common Trainee Blind Spots on the AKT

Where trainees consistently struggle — and where your teaching input has the highest impact:

Statistics — most trainees are genuinely frightened of this. A focused tutorial on NNT, sensitivity/specificity and forest plots can add 5–8% to their overall score
Admin and regulatory topics — DVLA, MHA sections, death certification, prescribing law. These feel unglamorous but score well if studied
NICE guideline adherence — trainees often apply local practice rather than national guidance. Reinforce: "In the exam, NICE wins"
Primary care context — trainees from hospital backgrounds default to hospital-based management. Correct gently and consistently
Examination technique — many trainees don't practice under time pressure until too late

💬 Discussion Questions for AKT-Focused Tutorials

Clinical Reasoning

"Walk me through how you'd manage a patient with newly diagnosed AF in clinic today. What does NICE say? What does your practice currently do? Where do they differ?"

Stats & Evidence

"This trial shows an RRR of 35%. The control event rate is 4%. What's the NNT? Would you use this treatment? Why or why not?"

Admin & Regulatory

"A patient with newly diagnosed epilepsy asks if they can still drive. Walk me through your discussion with them. What DVLA rules apply? How would you document this?"

Exam Technique

"Do this 10-question timed SBA set in 15 minutes. Then let's go through your thinking — not just whether you got it right, but HOW you answered each question."

Weak Area Targeting

"Look at your question bank scores by topic. Which areas are below 60%? Let's pick one right now and go through a focused 20-minute review of just that topic."

Reflective Practice

"Since our last tutorial, what three things have you looked up because you weren't sure in clinic? What did you find? How has that changed how you'd manage it next time?"

🎓

For TPDs — Supporting Struggling Trainees

If a trainee has failed the AKT, the most helpful early steps are: (1) access and review their domain feedback together, (2) identify whether the issue is knowledge, technique, or time management, (3) consider referring for neurodiversity screening if timing is a significant factor, and (4) create a specific, supervised revision plan — not just "try harder." Many trainees pass comfortably on their second attempt with the right structured support.

✅ Section 15

Final Take-Home Points

The bits to remember tomorrow — and the day of the exam.

📋 Format (the new one)

✓160 questions / 160 minutes from October 2025
✓~60 seconds per question — check clock every 40 questions (every ~40 min)
✓No negative marking — always guess
✓4 sittings/year: Jan, Apr, Jul, Oct
✓A calculator is available on screen — use it for dose calculations, NNT, ARR. Always reality-check drug dose answers: if the number looks implausible, recheck the decimal point before moving on.

📚 Preparation

✓Start 4–6 months out — 16–18 weeks of real effort
✓Targeted study > scattergun reading
✓One question bank, used thoroughly
✓Read the RCGP examiner feedback reports

📊 The 20% That Saves People

✓Study stats properly — NNT, sensitivity, forest plots
✓Study admin / regulatory topics — DVLA, MHA, certificates
✓These 32 questions are more finite than clinical
✓Pass or fail often happens right here

🧠 In the Exam Room

✓Think GP, not hospital specialist
✓NICE beats everything when guidelines conflict
✓Flag, guess, move on — never spend more than 90 seconds
✓Never leave a question blank

You've got this. 💪

The AKT is not a test of how clever you are. It's a test of whether you've prepared intelligently for the knowledge needed to be a safe, effective GP. You have access to excellent resources. You have time. You have a trainer. Use all of them.

Bradford VTS is rooting for you. 🩺

DOWNLOADS

path: AKT RESOURCES/mockpapers

CLINICAL FOLDERS (scroll to bottom section)
COPING WITH NERVES

QUICK-LINKS

AKT examination dates
RCGP AKT examiners’ feedback
RCGP Learning (including RCGP Self Test, RCGP Knowledge Updates, InnoVAIT, Knowledge Libraries)
Fourteen Fish AKT package
Exam stress, nerves & pressure (BVTS)
Bradford VTS pages on MCQs in general (studying for & tips)

NEW “AKT FLASH” APP

WEBLINKS – common AKT areas at a glance

Latest AKT books

Top Tips for AKT preparation

Remember, targeted study at areas you are weak at is far better than a scattergun approach. Reading a book from front to end is also no where near as effective as targeted study.
Do lots and lots of MCQs.
- Yes – go through as many books and online mcq’s as you can.
- And especially go for resources that provide a good level of detail in their answers for each question.
- Try and do the practice MCQs (both online and books) at a desk rather than on your sofa. The desk will help improve your focus and concentration. It also helps to keep your ‘place of study’ and your ‘place of rest’ separate (and that in itself will give you some sense of sanity).
- Make a note of the clinical areas you keep falling down on – and read around that subject. (=targeted study)
In your surgeries, treat each patient as a wealth of potential knowledge. Clinically, what did they come in with? If you’re struggling with that clinical area – look it up there and then with the patient or alternatively write it down and read up about it at the end of surgery. Keep doing this and you will acquire clinical knowledge in no time. (=targeted study)
Ask your trainer if they can do something called Random Case Analysis with you. This is a method of reviewing the patients you have seen in surgery and they can test your knowledge in various areas, using the patient you saw as a springboard to explore other areas. Make a note of your weak areas. Then read around those subject areas. (=targeted study)
Make sure you attend all post-surgery debrief sessions and ask the doctor debriefing you to test your clinical knowledge as you go through the cases. And ask your clinical teachers where they think your weaknesses are. Make a note of your weak areas. Again, read around those subject areas. (=targeted study)
Know your common areas – Asthma, COPD, CHF, Angina, Hypertension, Diabetes, Renal Failure, DVT pathway, Cellulitis.
Read the Examiners feedback on the last 2-3 years of AKT exams. They’re on here in the downloads section about BUT they’re also on the RCGP’s website. They often give you clues about what previous trainees have struggled with. Questions from these areas of difficulty are often repeatedly tested.
This is important: if you think about it, the clinical domain is actually limitless BUT critical appraisal, evidence-based medicine, health informatics and organisational topics are more contained. Therefore, don’t neglect these areas as the questions relating to them are pretty easy to pick up.
Quite a lot of questions will be based on recent literature. So, get to grips with the evidence for common conditions. Images such as algorithms, ECG traces and photographs may also be shown.
Did you remember our suggestion about targeted study? One trainee wrote: “I also looked at myself and my weakness and challenged myself to adapt, focusing on those weaknesses that could be improved relatively easily (like organisational domains and statistics).”

Top Tips for the few days before and the day of the AKT exam

72 hours before the exam, go over key topics which consistently come up – like
- driving and flying rules, (DVLA website) Click here for ‘at a glance view’ by MIMS
- vaccinations,
- child developmental milestones
- common drug doses for children
- maternity schedules,
- contraception guidelines
- mental health acts
- notifiable diseases
- certificates and reports in General Practice (sick notes, ES113, MatB1 etc)
Get a good night’s sleep the day before.
Read each question very carefully. Look for clues in the wording.
Keep checking that you are filling in the lozenges in the right places on the answer sheet.
Remember, you have about 57 seconds for each question. Keep an eye on the time otherwise you will run out and then you will risk missing out on answering some potentially easy questions that you do know the answers for. Check the clock every half hour and remember in each half hour block you are aiming to complete 33 questions. (more on this below).
A lot of the single best answer questions will have the correct answer but other plausible options. The differentiation will be that for the specific question, one of the options will be the ‘best’ or ‘most likely’. If you can answer the question with the option list covered, you’re likely to be correct.

Time Management in the AKT

Timing is really important in the AKT. A lot of trainees run out of time because they were thinking too long and too hard about several other questions. The problem with this is that in spending that extra time on these difficult questions, you will run out of time and wont finish the exam. And the remaining questions that you missed might have been lots easier than the ones you were spending extra time struggling on. Hence you lose easy marks, and then you risk failing!

It is a 3 hour 10 minute computerised machine marked test consisting of 200 questions.
That’s about 57 seconds per question!
You should aim to complete 33 questions every half hour. So checek the clock every half an hour and see how you are doing.
- Half hour = 33 questions.
- One hour = 66 questions. 1.5h = 99 questions
- 2 hours – 132 questions. 2.5h = 165 questions.
- 3h = 198 questions. last 10 minutes = 2 questions left which should take 2 minutes leaving 8 minutes spare.
So, don’t look at the clock every 5 minutes. Just every half an hour. And speed up if you are not getting through 33 questions in that time.
The exam itself is not negatively marked so if unsure of a question, after 50 seconds, have a guess and move on.
Or alternatively, Questions can be flagged for later review – but move on in a timely way.

Top Tips from an Examiner

How to revise for the AKT – by James Heathcote, GP Trainer and Examiner, Bromley, Kent

In planning how best to help you, I have tried to guess your ideas, concerns and expectations for this article and I hope I’ve got it wrong, because my guess is that you probably think that revision is the best way to pass an exam and that what you really need now is a short reading list. This idea is based on the assumption that the best way to pass an exam is to go on the right course, read the right books and practice lots of MCQ questions. But that’s not going to be my advice to you, because that’s not how I see the exam and not how I would recommend you should study.

So, if the very idea of applying ideas, concerns and expectations to the AKT is already making you uncomfortable – why is that?

Well, firstly, don’t worry – I’m not going to completely overturn your expectations. I would however strongly advise you to reflect on an alternative view of this exam, which is based on the idea that the AKT is an exam designed to test the working knowledge of a competent GP, the concern that what you cram today stays in your brain for a couple of weeks at most and the expectation that if I can persuade you to consider lifelong learning, it really will set you up for life!

Although I have only the accounts of others to tell me how today’s GP trainees study, I do have 13 years of experience of examining for the old MRCGP and was briefly involved in writing AKT questions. I therefore know a lot about how examiners think and have witnessed the process whereby questions are chosen and refined for inclusion in the AKT question bank. I also sat the first ever AKT, when examiners were invited to try out the paper in advance of the candidates, and passed it with a score of 82.5% having done no revision whatsoever. So my advice on studying for the exam is not just a collection of random thoughts.

So – what does lifelong learning look like? Well, there are two ways of looking at what you need to know to be a GP. The current favourite is to define a ‘curriculum’ and then structure an exam around that curriculum using a ‘blueprint’ (www.rcgp.org.uk/gp-training-and-exams/gp-curriculum-overview.aspx ).

This feels reasonably scientific and the exam is very carefully planned to sample different areas of the curriculum in due proportion. But there is another view of what you need to know for real life general practice, which I suggest provides a much better way of preparing both for the exam and for your future career – i.e. consider that common things are common and, as you already know, after just a few weeks you have seen all of the most common conditions (URTIs, headache, back pain, UTIs, feverish children, hypertension etc.), after three or four months, you will have seen the majority of important GP problems and after a year you will have seen almost everything you need to know.

You may not have seen a case of Churg Strauss syndrome or pseudo-hyperparathyroidism, but that doesn’t matter. You will have seen all the common and reasonably common conditions and refined your ability to recognise what you don’t know and how to find the information you need to manage uncertainty. That is what GPs do and if throughout your trainee years you keep your eyes open and research your gaps and your learning needs (your PUNs and DENs) you will easily cover all that you need to pass the exam.

But because you may think it’s better to take the exam early in the year (which I understand, but don’t really recommend), you should also get reading now!

Buy a good general practice textbook (eg Practical General Practice by Khot and Polmear)
Use online resources such as GPnotebook, Patient UK and CKS both during and after your consultations, so that you link your learning to live cases.
Make revision notes if you are a note taker and include the patient ID number, so that you can refresh your memory later.
Read the BMJ – because it is a reliable source of information and follows the mood of the day, but concentrate on the bits that are relevant to general practice – clinical reviews, the Ten-Minute Consultation articles and papers written by ‘ordinary’ GPs.
Read also the assorted bits of paper that come to the practice on a daily basis from various sources. In the past few days, I have seen some useful information on HIV and the Chief Medical Officer’s newsletter which included updates on HPV vaccination, carbon monoxide poisoning and changes to the law on cremation – the sort of information that the AKT question setters are reading but that you won’t find elsewhere!
And when you go to meetings in the practice or elsewhere, keep your ears and eyes open for essential information that might make a good AKT question – i.e. information that is relevant to general practice, clear cut and not so detailed or obscure that you would expect to have to look it up.
And read a GP magazine (online if you wish to) like Pulse or GP or InnovAIT. InnovAIT is written for you and comes as part of your AiT package.
Practitioner (see links below) because they focus on subjects of relevance to ordinary GPs and their production values are very high and

“But what about the cramming?” you ask. Well before you hit the NICE guidelines, first make yourself really familiar with the bible of general practice therapeutics (the BNF) and study the chapter headings for all common conditions. Then register for eGuidelines, which is a good web resource and has a mobile app and only then (if you must) order some NICE guidelines – but be selective. The AKT is not a test of NICE guidance – just ask your trainer when s/he last referred to a NICE guideline during a consultation! By all means know about the guidelines that exist, but focus on when and how to apply them in real life situations.

General practice is a very broad subject and quite different to the hospital medicine that you are used to. It does have clear cut content, but there is no definitive study guide, the MCQ books on the market are not written by AKT question setters and the real examiners approach general practice and the AKT from many different angles.