After reading this chapter you should understand:
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the structure and format of the AKP examination
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the range of topics covered by the syllabus
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the style of questions presented in the examination
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how each question is produced and reviewed
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advice on some aspects of examination preparation
The Applied Knowledge in Practice (AKP) examination is one of the three theory exams that must be passed before a candidate is allowed to present themselves for the clinical examination—Foundation of Practice (FoP) and Theory and Science (TaS) being the other two. Passing all four examinations leads to the award of Membership of the Royal College of Paediatrics and Child Health.
This chapter will describe the exam format and so allow the candidate to prepare in an appropriate manner. Some details of the exam may change over time and it is therefore imperative that the candidate consults the RCPCH exam website at an early stage to identify possible updates and new advice.
This book is not a comprehensive paediatric textbook. It does, however, aim to cover practically all of the topics outlined in the RCPCH Examination Syllabus and therefore forms the basis of questions in the examination. Although the syllabus and examination aim to cover the main topics of clinical paediatric practice that a Specialist Trainee with 18 months of experience might encounter, it should also be expected that some less-common conditions will appear. A paediatrician should be able to identify uncommon conditions within common presentations, which is a point illustrated by the phrase “all that wheezes isn’t asthma.”
Preparation
Candidates can sit the RCPCH theory examinations in any order although most progress from FoP though TaS to the AKP exam. After six attempts, further attempts are only permitted if evidence of further study is provided. The AKP exam is usually first attempted by trainees who have accrued at least 12 months of paediatric training. However, for those in UK training schemes, there is a pressure to complete the theory exams during 3 years of full-time training as failure to do so will usually require an extension of training time. The AKP exam assesses clinical knowledge and decision-making skills, and an exposure to a broad range of general and specialty clinical paediatrics is therefore needed.
This is a UK examination and assesses understanding of UK laws, expectations and clinical practice. Question writers aim to produce questions that can be supported by published evidence, national guidelines of accepted practice and information in established and respected textbooks and journals.
It is important to remember that much of the AKP exam is aimed at assessing clinical understanding of paediatric medical practice encountered by candidates during their normal daily duties. Questions will ask about the presentation of clinical problems, possible differential diagnoses, appropriate common investigations and the interpretation of results. Answers to other questions will require a knowledge of management and long-term consequences of a broad range of conditions. The examination will also test the ability of candidates to establish clinical priorities and ensure that time-critical decisions are recognised and acted upon. All paediatricians will recognise that care occurs within the context of the family, and therefore an understanding of professional and legal obligations is necessary and assessed in the examination. Candidates will obviously need to build their knowledge base by further background reading.
Examination structure
The examination is a curriculum-driven, computer-based assessment that takes place three times each year. There are two separate papers sat on the same day with each paper lasting 2.5 hours. In total there are 120 questions across the two papers. The exam does not use negative marking—a wrong answer scores zero. The allocation of topics across the various syllabus headings is set by the “Theory Examination Blueprint” that allows specific mapping of questions to the syllabus and aims to provide a balanced selection of questions across the entire syllabus in each exam.
Question journey
The development of questions used and the building of each exam involves many separate steps to ensure that the questions are relevant and current and that the exam is well balanced. Before appearing in an exam, each and every question will have been individually scrutinised by at least nine separate, experienced paediatricians and will be reviewed again by a panel of another six to eight paediatricians after the exam has taken place.
The questions are generated at Question Setting Group meetings that occur throughout the year at various locations in the UK and abroad. The meetings are organised by RCPCH staff and are open to all paediatricians who already hold the MRCPCH diploma. Senior exam facilitators are part of the meeting and guide small groups to create the questions. Each question is then assessed by the Senior Theory Examiner for AKP and is reviewed again by two senior clinicians at RCPCH Examination Board. Following this review, the approved question is placed in the question bank for future use.
Following every exam, and before the results are finalised, a panel of paediatricians meet with the RCPCH psychometrician at the “post examination Angoff meeting” and review the performance of every question. This meeting scores the level of difficulty for each question and reviews any possible discrepancies or problem questions identified in the exam. If, for example, most candidates choose an answer different from the allocated correct answer, this suggests that the phrasing of the question is ambiguous and points to more than one acceptable valid answer. The panel would review that question in detail and, if it is agreed that phrasing of any part of the question is ambiguous and therefore unfair, then the question is removed from that examination. The question is sent for review rather than returned to the question bank.
Question types
There are different question types used in the examination. Examples of these can be seen on the RCPCH website and in Chapter 35 of this book. Some information on each question type is offered here.
Single best answer (SBA)
Most of the questions in the exam follow this format. The stem may include a clinical history, examination, results and images and the question is posed. There are then five answers offered with only one being correct. The most important point for a candidate to understand is that all answers shown will be plausible but only one is the most appropriate for the question asked. If the candidate reads a question and concludes that all answers are correct then the question is a good example of the single best answer format. In this situation, the candidate is advised to re-read the question and clarify the exact phrase of the question posed. Examples of the different types of phrasing are:
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the next most appropriate step in management
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the most appropriate initial management
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the treatment to be given immediately
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the test which will provide a diagnosis
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the most likely diagnosis
For example, a question may describe a child presenting in extremis to the emergency department and, in real life, multiple interventions will be undertaken. Each of these interventions will be appropriate and necessary and therefore will be listed in the answer list. The question may then ask which one intervention from this list must be undertaken as a priority.
Multiple best answer (MBA)
Some questions will ask for more than one answer such as needing two investigations to support a diagnosis. The questions do not ask for more than three answers and the list of options provided will be up to a maximum of 10 answers available.
Multipart question (MPQ)
This question structure follows the format of the single best answer but there are usually two questions joined to the initial scenario and each question is independent of the other. The answer to part one does not give a clue to the answer of part two.
Extended matching questions (EMQ)
This format provides an introductory statement that explains the general topic for the question. Examples would include cardiac diagnoses, drugs for epilepsy or investigations for hypernatraemia.
The question then presents the first statement or clinical scenarios followed by a list of 10 potential answers. The second scenario is then presented followed by the same list of 10 answers and finally the third question with the same 10. It is possible that one of the answers may be chosen for more than one of the questions—each question is independent of the other two.
Detailed advice
Some questions may seem to have one or two obvious answers and the candidate needs to look for further clues in the question stem to support one or the other. For questions where there is no obvious answer, one approach would be to ask the ‘reverse question’ and identify those answers which clearly do not fit the clinical scenario in the question stem. Having removed these answers, the candidate can then work on those remaining to identify the appropriate and correct answer.
All questions in the examination that include results of laboratory investigations will also show the normal ranges for each of the listed test. These ranges may be slightly different from those used at the candidate’s institution but these are the ones agreed for examination. In practice, this is not a problem as the provided results, where appropriate, are obviously abnormal or obviously normal.
The candidate should read the stem very carefully as it often contains specific details to guide the candidate towards particular conditions that may occur more commonly in certain ethnic groups or in certain geographical locations.
An awareness of the indications, contraindications and long-term consequences of some of the drugs administered to children is important. Candidates are advised to use the BNFc during their normal working day as part of their revision and to look at contraindications and common side effects.
Many questions will contain images such as clinical photos, radiographs and ECGs.
Clinical photographs will cover a range of features including specific syndromes and disease-related abnormalities. The ability to identify a series of clinical features in a child and recognise the underlying syndrome is a skill that many geneticists and paediatricians take many years to develop. However, recognising the features of a small group of syndromes is required for the AKP exam and these are presented in this book. Trainees are advised to review as many images as possible of these syndromes to ensure they can identify the major features. Similarly, wherever a condition which has recognised clinical features is described in the text, the candidate should seek out example images or descriptions.
There are questions that require the ability to interpret radiographs although it is accepted practice that it is the radiologist who will provide the definitive opinion and final report. Trainees, however, do need to identify common radiological abnormalities that require an immediate response and management such as the presence of a pneumothorax, a pneumonia, or necrotising enterocolitis. MRI and CT scans must be reported by radiology staff but an AKP candidate must have an understanding of the common abnormalities to allow explanation of the findings to patients, carers and colleagues usually following a discussion with the radiologist. Trainees should attend as many radiology meetings as possible and be prepared to ask radiologists to explain important features.
Evidence-based paediatrics
The AKP examination will contain two questions about evidence-based practice in each paper. The questions usually present information from a published paper but with the methodology and results summarised. The data can be complex and each answer should be compared in turn with the given results to determine whether the answer statement can be supported.
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