Entry into GP Vocational Training Scheme (GPVTS)
GPST Selection Stage 2 - Computer-Based Test

Candidates who meet the eligibility criteria assessed in Stage 1 of the GPST Entry / Selection process will be invited to attend a computer-based assessment. Notification is traditionally made by email (so check your inboxes and your spam folders!). The test takes place on a day of your choice during a week mid January at a centre run by Pearson Vue (who also run computer based tests for entry to medical school and for driving licenses). You will need to book a date for your test yourself. There are many centres around the UK (nearly 150), but if you want to take the test in a venue which is popular, it is very much a case of first-come, first served, so we would advise you to plan this step early. That might save you having to travel hundred of miles to attend a centre where are still places left.

The GPST Entry Stage 2 test consists of 2 papers:

Paper 1: Professional Dilemmas (also called Situational Judgement Tests or SJTs)
Paper 2: Clinical Problem Solving

Both papers must be sat together in one sitting on a day of you choice within one week mid-January.

GPST Stage 2 Paper 1: Professional dilemmas (110 minutes)

This GPST Professional Dilemmas paper consists of approximately 50 scenarios which you must deal with within 110 minutes (so, approximately 2 minutes per scenario). The paper is designed to test a range of skills featuring in the National Person Specification for entry into General Practice, including:

Professional integrity (i.e. your ability to according to professional expectations even in difficult situations)
Ability to cope with pressure
Empathy
Sensitivity

For each scenario, you are asked to determine the most suitable course of action. Questions for the GPST Stage Professional Dilemmas paper come in two different formats:

Format 1: Ranking options

You are given a scenario which highlights a specific problem or dilemma. You are also given 5 or 6 possible actions that you can take. Your task is to rank the options from the most suitable to the least suitable.

Example:

Your best friend is on holiday abroad. During that period, her father is admitted in the hospital where you work, but in a different service. Your friend calls you, asking for information about her father as the hospital is refusing to give her any indication as to the nature of the illness or whether she needs to return from her holiday early.

Rank the following options from the most suitable to the least suitable:

A - Decline politely, telling your friend that her request would be in breach of regulations
B - Ask your friend to give you written confirmation that you are permitted to request the information on her behalf
C - Ask your consultant for advice on what you should do
D - Tell your friend that you will ask her father to get in touch with you
E - Tell your friend that you will raise the matter with her father's consultant.

Answer:
Best answer: C, E, B, D, A. Other possible answer: C, E, D, B, A
(see further down how the exam is marked)

Explanation:
This question deals with several dilemmas.

First of all, there is a clear issue of confidentiality; there must be a reason why the hospital is refusing to divulge the information to your friends. Since you are not a doctor in the team which deals with the father, you have no right to interfere with the work of that team on what amounts in effect to personal grounds.

Secondly, you are not aware of the full picture, and you do not know either the extent to which the father is aware of the full picture. Interfering with the process may result in incorrect or incomplete information being passed on. Asking the father to get in touch sounds on principle like a good idea, but you do not know what his emotional state is, or the reasons why the information is being withheld from the daughter. As such, you may make things worse by getting involved with the patient. He may also start quizzing you on his condition, which you will not be best equipped to handle.

The ultimate principle will be that the matter should be handled by the admitting team whcih is why Option E must rank towards the top. Before you do so, it may be advisable to check with your own seniors whether that would be appropriate; hence why C would rank higher than E.

Option B would essentially mean that you are acting on behalf of your friend. It is worth a try and at worst the hospital can refuse to give you the information too. Provided you do not "steal" information from the notes and breach confidentiality, then that option would be better than Option A, which is essentially doing nothing.

Option D would also be acceptable if you kept the relationship at a personal level and did not interfere with the clinical side. It would also be better than Option A.

In terms of ranking, A would need to be last because all options are sensible to a degree and therefore are better than doing nothing. Option C (asking your consultant) is better than ask the father's consultant. If you have any doubt you should always consult one of your own seniors first. He may then direct you to approach the father's consultant or take some other approach.

There is not much between Options B and D and as such the marking scheme may allow for both options to be interchangeable.

Format 2: Multiple Best Answers

You are given a scenario which highlights a specific problem or dilemma. You are also given 6 or 7 possible actions that you can take. Your task is to choose the three most appropriate options (no need to rank them).

Example 1:

During a very busy shift, the relatives of a recently deceased patient wants to see you to discuss "things". What do you do? Choose the 3 most suitable actions to take in this situation:

A - Ask a nurse to talk to the relatives to get an understanding of the type of "things" that they want to discuss so that you can be fully prepared when you see them.

B - Tell the nurse to let the relatives know that you are aware they are waiting, that you are busy right now but that if they go home you will call them as soon as you are free.

C - Ask one of your juniors to talk to the relatives, to let them know what yoi cannot see them because you are busy and to deal with any queries.

D - Tell the nurse that you will grant the relatives 5 minutes only as you are busy.

E - Inform your Registrar that you need to need to see the relatives and ask him whether he can cover for you.

F - Tell the nurse to send the relatives to PALS as your involvement with the patient is over.

G - Tell the nurse to find an excuse to send the relatives home as the patient is dead and the matter is therefore less important than the patients that you are currently dealing with.

Answer:
Best answer: A, B, E

Explanation:
Option A – You are using another team member appropriately; the nurse is already with the relatives and it makes sense that you may want to know more about the relatives’ request in order to ensure that you can have the relevant information ready when you do meet with them eventually.

Option B – This may be a little inconvenient for the relatives as they would obviously prefer to get answers straight away. But you are being honest with them and there is a feeling that you want to get their queries resolved even if it is only on the phone.

Option C – This is potentially placing your junior in a difficult situation and it also looks a little like you are trying to pass the buck. But this is a possibility.

Option D – This places the nurse in a difficult position. It is also a fairly aggressive stance.

Option E – Talking to your Registrar may help you identify a good way around the problem. Also, if you need to go and see the relatives, then this option will make the Registrar aware of the situation and the team will be able to deal with your temporary absence.

Option F – PALS won’t be able to deal with the relatives’ queries. They will only encourage the relatives to contact you so it will defer the problem. It may sound like a good tactic in the short term but it is really unhelpful. In any case, you should consider it part of your duty to deal with the relatives, particularly if you have been dealing with the patient before his death.

Option G – This is rude both to the relatives and to the nurse, whom you will place in a difficult position.

There are therefore four possible candidates for the most appropriate actions: A, B, C and E. We need to eliminate one: it will be C because of the potential difficulty to which you will be exposing your junior colleague.The answer is therefore A, B and E. (Note that these do not need to be ranked.)

Example 2:

A nurse asks you to assess a patient who wants to self-discharge from the ward. The patient is still on the ward and has undertaken onpy part of the investigations he was meant to undertake for lung cancer. He is very agitated and anxious, and borders on aggressive, which is making the nursing staff feel threatened.

Choose the 3 most appropriate actions to take in this situation.

A - Spend some time listening to the patient's concerns.

B - Tell the patient that you are sorry that he is upset.

C - Tell the patient that you understand how he feels.

D - Explain to the patient that it is perfectly normal to be anxious about a possible diagnosis of lung cancer.

E - Explain to the patient that it is important that he completes all the tests.

F - Explain to the patient that if he leaves he could be putting himself at risk.

G - Offer the patient help for his anxiety.

Answer:
Best answer: A, B, E

Explanation:
You will probably have found that more than 3 of the options appear reasonable; and it is indeed the case. However the aim is to determine which options are the MOST appropriate. the easiest way to henadle the problem is therefore to eliminate those which you feel are unreasonable and, once you are left with 4 or 5 options, to compare them in order to determine which ones may be the most appropriate.

Option A – Listening to the patient is a sensible thing to do. He is clearly anxious and it would help if you could determine what worries him so much. The tests are also not so urgent as to stop you spending time with the patient (in an emergency situation you may not have so much time to spend listening).

Option B – Saying that you are sorry he is upset will help demonstrate empathy without sounding condescending and patronising. This is therefore also a viable option.

Option C – On the surface, telling the patient you understand how he feels may sound like a good idea, and one which also helps demonstrate empathy; but the truth is that you don't really understand how he feels and it may come across as far more patronising that Option B. The patient may well come back with "No, you don't." So, Option C is a possible option but Option would be more appropriate.

Option D – Telling the patient that it is normal to be anxious is a sensible thing to do, but the mention of a possible diagnosis of lung cancer may well make things worse.

Option E – Explaining the importance of completing the tests would be a very constructive approach and would also help steer the conversation away from the emotions. Your aim should be to focus on the end result (i.e. getting the patient to complete the tests) without being coercive. Option E achieves that.

Option F – Telling the patient that he could be putting himself at risk if he leaves is only remotely true. There is no major emergency here and it would be perfectly possible to let the patient go home and then invite him back a few days later once he has had time to consider the situation in a calmer environment. Making such statement would be considered slightly coercive, verging slightly on emotional blackmail.

Option G – The situation is what is causing the anxiety. Sorting out the immediate issue is therefore likely to resolve the anxiety. This may be appropriate if the patient suffers from anxiety generally speaking, but this would not be an immediate priority in this instance.

Note: you may get partial marks for listing A, C, E instead of A, B, E.

Example 3:

You are very upset after your clinical supervisor was rude and undermined you in front of a patient during a mini CEX performance assessment.

Choose the 3 most appropriate actions to take in this situation.

A - Speak to your clinical seupervisor about the way you feel.

B - Apologise to the patient for your supervisor's behaviour.

C - Wait until you are calmer to take any action.

D - Speak to yur programme director as soon as possible.

E - Reflect on whether you can learn from the feedback.

F - Discuss your supervisor's behaviour with your colleagues.

G - Behave as normally as you can so that you supervisor does not see that you are upset.

Answer:
Best answer: A, C, E

Explanation:
Here, you are dealing with a non-urgent situation, which seems to be a one-off event (otherwise the question would tell you that this has happened before).

Option A – Since the supervisor caused an issue which upset you it would make sense to address it directly with him first. So this option is one of the most appropriate.

Option B – On the surface, it would seem sensible to apologise to the patient; however, though the supervisor behaved inappropriately, it may be that this was because you performed poorly. No harm has been done to the patient; at worst they may be a little confused, and if you apologise to them, they may well side with the supervisor. It is also possible that your apology would be interpreted as seeking to undermine the supervisor in the eyes of the patient with the sole purpose to make you look good, and may acutally make the situation more confusing. If anything, it should be the supervisor's responsibility to apologise to the patient rather than yours.

Option C – Waiting until you are calmer is always a good option if there is no emergency, particularly when dealing with emotions. It will stop you having a knee jerk reaction that you may regret later.

Option D – Speaking to the programme director might be needed further down the line if the problem persists; but after one event, you should consider addressing the issue directly with the supervisor first. The fact that the option contains the wording "as soon as possible" makes it far less appropriate.

Option E – As mentioned earlier, despite the lack of tact shown by the supervisor, that behaviour may have been prompted by failures on your part. The behaviour does not take away your need to learn and improve and therefore reflecting on the feedback, however badly it was delivered, will be a valuable and appropriate thing to do.

Option F – Discussing you supervisor's behaviour with your colleagues may help you put things in perspective, but this is not as immediately appropriate as some of the other actions, mainly because you would also undermine the supervisor in doing so.

Option G – Ignoring the problem will not help..

Because the paper deals with dilemma there may sometimes be more than one right way of acting upon the given scenario. Because of that, a consensus is reached amongst the examiners as to what the "ideal" answer, for which the maximum mark is allocated. In some scenarios, alternative answers may be acceptable and are also allocated marks.

GPST Stage 2 Paper 2 - Clinical Problem Solving (75 minutes)

The GPST Stage 2 Clinical Problem Solving paper consists of 80 to 100 clinical questions or scenarios which you must answer within 75 minutes. Officially, the questions come in a variety of formats, but since 2007, only two formats have been used:

Single Best Answer (MCQ / Best of Five): you are given a scenario and 5 options, from which you must select the correct answer.
Extended Match Questions (EMQ): You are given a list of 8-10 options and then a number of scenarios. You must select from the options available the answer to each of the individual scenarios. Though the format is slightly different, it boils down to multiple choice between 10 possible answers.

Questions may be asked on any topic, including:

Cardiology
Dermatology
ENT
Eyes
Endocrinology
Metabolic
Gastoenterology
Nutrition
Infectious Diseases
Haematology

Immunology, Allergies & Genetics
Musculoskeletal
Paediatrics
Pharmacology & Therapeutics
Psychiatry
Neurology
Reproductive (Male & Female)
Nephrology
Urology
Respiratory

Most questions are based on a patient-based scenario and concern:

Diagnosis
Disease factors
Emergency Care
Investigations
Management plans
Prescribing

Example of an Single Best Answer / Best of Five question
Mr Peterson is a 72-year-old retired carpenter. His brother recently died of a heart attack at the age of 75 and Mr Peterson comes to see you to request a check up. He claims to be fit and well, and walks his puppy dog for an hour every day on the Moors. He denies any chest pain or shortness of breath and is on no medication. On examination, he has a good volume pulse at 78 beats per minute and blood pressure is 122/68 mmHg. You hear an ejection systolic murmur at the left sternal edge. There are no murmurs at the carotids. What is the most likely diagnosis?

Aortic stenosis
Aortic sclerosis
Pulmonary valve stenosis
'Flow' murmur
Hypertrophic obstructive cardiomyopathy

Answer: 2
While all the options are associated with an ejection systolic murmur, it is the additional clinical features that aid diagnosis. This is a fit 72-year-old man with no angina or dyspnoea; therefore functional valve disease or left ventricular outflow obstruction is unlikely. This rules out options 1, 3 and 5. Aortic sclerosis is a thickening of the aortic valve - very common with advancing age - and can be differentiated from stenosis by the absence of radiation to the carotid arteries. While flow murmurs are also benign and commonly detected on examination, they are a result of turbulent flow associated with a hyperdynamic state e.g. anxiety, sepsis or pregnancy. Since the pulse rate and blood pressure are not elevated, a flow murmur is unlikely.

Example of an Extended-Match Question (with 5 stems) Options

Mesenteric adenitis
Inflammatory bowel disease
Acute appendicitis
Henoch-Schonlein purpura
Urinary tract infection
Constipation
Intussusception
Peptic ulcer
Renal stones
Bowel obstruction

Questions
Pick the most likely diagnosis for each of the following scenarios.

a. An 8 year old boy has lost his appetite and had central abdominal pain which has now radiated to the right iliac fossa.
b. A child complains of abdominal pain and has a purpuric rash on the buttocks with some joint pains.
c. A 4-month-old girl has a recent episode of gastroenteritis. Now she has episodic screaming and pallor. There is some passage of blood and mucous in the stool. Ultrasound shows a ‘doughnut sign’.
d. A 15 year old boy has had pains most nights for at least a month. He is afebrile. The pains are eased by drinking milk.
e. The patient has recurrent abdominal pain and malabsorption.

Answers: a = 3 ; b = 4 ; c = 7 ; d = 8 ; e = 2

Tips for GPST Stage 2

Professional dilemmas questions take some getting used to in order to get into the spirit of the questions. Make sure you practise as early as you can.
On the day of the exam, you will be pushed for time. Though you should not attempt to time yourself for every single question, you should have a good idea of where you are aiming to be by half-time and 3/4 time.
All questions are allocated the same weight. Therefore, if a question is difficult, take a guess and come back to it at the end of the exam if you have any time left.
Generally speaking no watches, drinks or other paraphanalia are allowed in the examination room. Make sure you can cope without a watch (there is a timer counting down on the computer screen) and that you have sufficient reserves of water and sugar to last you 2 hours.
Not all centres allow a break between the two parts of the GPST Stage 2 exam. Your only certain chance of getting a break is to finish the first paper early, but that should not be at the expense of your overall performance. If you save time on one paper, you will not be able to carry that time forward to the next paper.