Decoding the KFP

Consider the Context

Be Specific

Don’t Overcode

Show Breadth

Quiz

Here is an unofficial guide to the Key Feature Problems (KFP) exam technique for FRACGP candidates.

The KFP is a notoriously tricky exam for FRACGP candidates. Thanks to the public Exam Reports, we know that this exam requires a very specific exam technique in order to score well. Recent results suggest that our technique is improving, but on many questions we still consistently lose marks due to technique rather than from medical knowledge. This guide was developed in the interests of transparency and fairness for candidates. There are no courses or prep materials for sale here.

The information in this study guide is based on the RACGP Exam reports from 2016.1, 2016.2 and 2017.1. The tips in this study guide have been grouped into the following 4 main techniques:

  1. Carefully consider the context
  2. Be specific
  3. Don’t overcode
  4. Show breadth across your answers

1. Consider the Context

The KFP is a test of clinical reasoning, not just medical knowledge, so context is essential.

The KFP examiners want to know if you can prioritise the most likely diagnoses and the most important signs / tests / treatments in a particular scenario, not whether you can recite a textbook. Here is an example of the difference between medical knowledge and clinical reasoning:

Medical knowledge

Q: List 12 causes of Dyspnoea.

  1. Upper respiratory tract infection
  2. Asthma
  3. Emphysema
  4. Bronchiolitis
  5. Epiglottitis
  6. Pulmonary embolism
  7. Lung cancer
  8. Congestive heart failure
  9. Pneumonia
  10. Inhaled foreign body
  11. Anaemia
  12. Anxiety

= 12 / 12 marks correct. These are all causes of dyspnoea.

Clinical reasoning

Q: George is a 4 month old boy who has gradually developed low fevers, increased work of breathing, cough and poor feeding over the past 2 days. He has no medical comorbidities and there is no family history of atopy. On examination there is tachypnoea and diffuse wheeze. There are fine creps bilaterally with moderate subcostal recessions. What is the most likely diagnosis?

  1. Bronchiolitis
  2. Asthma (At this age, bronchiolitis is more likely.)
  3. Pneumonia (Also possible, but the low fever, time course and chest examination points more to bronchiolitis).
  4. Inhaled foreign body (Possible and often missed, but the bilateral symptoms and gradual onset point more to infection).
  5. Congestive heart failure (More likely in an infant with previous medical comorbidities).
  6. Upper respiratory tract infection (The chest examination points to a more serious infection than a simple cold).
  7. Emphysema (Not likely in this age group with no medical comorbidities).
  8. Epiglottitis (Not likely with this presentation of wheeze and fine creps, as opposed to a toxic child with drooling and stridor).
  9. Pulmonary embolism (Not likely without any risk factors and at this age).
  10. Lung cancer (Not likely at this age).
  11. Anaemia (Not likely with these examination findings and infective symptoms).
  12. Anxiety (Not likely at this age).

If you listed all of these 12 diagnoses in a KFP, it would look like you had poor clinical reasoning as most of the diagnoses do not fit the context of the scenario. As there is no negative marking, you wouldn’t lose points on the individual question, but you would lose a percentage of the overall mark due to overcoding.

Demo Select an element below to see how it could affect the correct answers in a KFP.
Age

George is a 12 month old boy with a wheeze… List the 4 most likely causes of his wheeze.
(Wheeze)

  • Asthma
  • COPD
  • Allergy
  • Heart failure
(Wheeze in an infant)

  • Bronchiolitis
  • Inhaled foreign body
  • Reactive airways disease
  • Bronchomalacia
Gender

Julie is a 17 year old female with left iliac fossa pain… List the 4 most likely diagnoses.
(LIF pain)

  • Diverticulitis
  • Constipation
  • Irritable bowel syndrome
  • Ulcerative colitis
(LIF pain in a young woman)

  • Ectopic pregnancy
  • Pelvic inflammatory disease
  • Constipation
  • Irritable bowel syndrome
Onset

Fred, age 50, presents with a sudden onset, severe headache… What are the most likely causes of his headache?
(Headache)

  • Tension headache
  • Migraine headache
  • Cluster headache
  • Sinus headache
(Thunderclap headache)

  • Subarachnoid haemorrhage
  • Cerebral venous sinus thrombosis
  • Hypertensive emergency
  • Migraine
Duration

Bob, age 65, has had a persistent cough for the past 6 months… List the 4 most likely diagnoses.
(Cough)

  • Viral upper respiratory tract infection
  • Acute bronchitis
  • Pneumonia
  • Pertussis
(Chronic cough)

  • Chronic obstructive pulmonary disease
  • Gastro oesophageal reflux
  • Chronic sinusitis
  • Lung cancer
Practical Tips

Every Detail Matters. Patient age, gender and ethnicity can all have a large impact on the most likely diagnoses. For example, don’t fall into the trap of requesting a PSA on a woman, or considering an ectopic pregnancy in a man! Also, don’t waste answers requesting details of the history or examination that have already been given in the case stem.

Location, Location! Some cases are specifically located in a rural or remote area, where access to hospital / tests / specialists may be limited.

Same patient, new presentation. Parts of the KFP can address different points in time. Patients may present with worsening of their disease, complications of the disease or treatment, or with a new condition entirely. Do not assume that the subsequent presentation is related to the initial presentation.

You can’t invent or change the context. For example, in a patient with depression, you might consider that patients often also have problems with alcohol / weight / smoking / domestic violence etc., but you won’t score marks for including management of these problems unless the case states that that related problem is actually present. Otherwise, just manage the depression.

2. Be Specific

To maximise your marks in the KFP, be as specific as possible.

There are several general rules that can help you to avoid losing marks from KFP answers that are too vague or too brief:

Medications may need a dose, route, frequency and duration to score well. For example, a single dose of azithromycin 1 g orally can score better than azithromycin, and antibiotics is unlikely to score at all. If you don’t know the dose, put as much detail as you can remember!

Imaging should specify the exact body site and test requested, just as you would do on an imaging request form. For example, an arterial doppler ultrasound of the left leg can score where doppler or ultrasound is unlikely to. Even now that many imaging questions are multiple choice,
you may have to type an answer where they are looking for a single most important investigation.

Pathology tests should also have as much detail as you would need to order them on a request form. For example, Nasopharyngeal swab for pertussis polymerase chain reaction is better than swab or PCR.

Nonpharmacological management is an easy area to lose marks for not being specific enough. For example, diet, exercise, school exclusion, referral, review, education and reassurance are all too nonspecific to score marks. For any advice or education, specify what exactly you would tell the patient. For referrals, specify why you are referring, e.g. referral to gynaecologist for colposcopy, and the degree of urgency if relevant, e.g. immediate transfer to the emergency department via ambulance.

GPMP and MHCP are not considered to be management components by the college, so don’t waste an answer on writing these things.

Abbreviations can be misinterpreted, so they should be avoided as much as possible.


Don’t be vague…


Be specific!!!

Demo Each of the answers listed below could lose you marks in the KFP. Select one of these answers to see how it could be made better:
AAA
analgesia
antidepressants
contraceptive advice
counselling
diet
doppler
education
excise
exclude from school
exercise
family history
fracture
GPMP
inhaled steroids
medication review
medications
MHCP
ongoing prevention
optimise medication
paracetamol
pathology
PCR
provide handout
reassure
refer to emergency
refer to nurse
referral
regular review
review
serology
side effects
smear
support
swab
therapy
topical steroids
ultrasound
vital signs
xray
Also, Answer the Specific Question!

Every KFP report mentions at least one question where candidates didn’t read the question properly. If they ask for history features, don’t give diagnoses. If they want non-pharmacological management, don’t give drugs. If they ask for non-hearing related causes, don’t mention ears! One trick is to beware the difference between being asked for the diagnosis of a rash (i.e. dermatitis herpetiformis), and the underlying cause of the rash (i.e. Coeliac disease).

3. Overcoding = More than ONE item in ONE answer

Overcoding is perhaps the most widely discussed reason for losing marks in the KFP.

Overcoding is where one of your answers includes more than one item. This can occur when you purposefully or inadvertently mention multiple symptoms, signs, tests, diagnoses, medications or other management items within a single answer. Overcoding is penalised significantly because it can prevent the KFP examiner from assessing your clinical reasoning and clinical priorities. In short, overcoding means you can’t just hedge your bets and hope the examiners find what they’re looking for in amongst a long list of your possible answers. You need to construct a targeted set of answers so that the examiners can see that your priorities match their priorities.

Practical Tips

Avoid AND, OR, or PLUS because these will tend to make your answer into a list of things that really should be separate answers.

Avoid examples because they risk you inadvertently introducing a second answer without realising it. For example, LABA e.g. tiotropium is really two answers (LABA and tiotropium) as tiotropium is an anticholinergic not a long acting beta agonist. Instead, just write the single medication with dose, route and frequency.

Avoid bonus answers, even if you are sure they are all correct. For example, there may be 9 possible correct answers you can think of and they may only ask for 4 of these to get full marks. There is no point in listing extra answers – even if you get all 9 correct, you will lose marks from overcoding.

Don’t avoid detail. Overcoding is not about too much detail, just too many answers. You can still include drug doses / frequency / route / duration, and test details such as xray site / side, without losing marks. You shouldn’t usually need to explain or justify your answer though, so because should not be required.

Demo: Which of these answers has avoided overcoding?

  • Simple analgesia, i.e. paracetamol or ibuprofen
    This is two answers and can lose marks due to overcoding. Instead, write paracetamol 1g orally, 4-6 hourly as required.
  • LABA, i.e. Spiriva.
    Examples are not recommended. By adding an example here that is not actually a LABA,
    there are now two answers and marks will be lost due to overcoding.
  • Weight loss, anorexia or sweats.
    Each of these symptoms could be listed individually as key features of the history. Putting them together on the same line is overcoding and could lose marks.
  • Increase exercise and lose weight.
    This is two different answers that should be listed separately.
  • Referral to gynaecologist for colposcopy.
    This answer is ok and will not count as overcoding.
  • Headache that is severe / sudden onset.
    This is two different answers. They should be listed separately.
  • Photophobia / neck stiffness or petechial rash.
    This is three different answers. They should be listed separately.
  • Gastrointestinal disturbance such as diarrhoea.
    Yes, this is not overcoding, but in general it is simpler to avoid using examples and just say diarrhoea.
  • Infection, e.g. pneumonia, UTI or skin infection.
    This is at least 3 different answers.

4. Show breadth across lists of answers

Lists of answers need to avoid being repetitive or narrow.

In KFP questions, there may be many more possible answers than you are allowed to give. To score the maximum marks, your answers need to address as many different key areas of the marking criteria as possible. One known pitfall is to give multiple answers that are too narrow or similar. For example, listing multiple different infections as a cause for delirium in an elderly patient. This will take up space that could be used to unlock points for non-infective causes. Likewise, listing only various eating disorders ignores many other causes of amenorrhoea.

Practical Tips

Group your answers when brainstorming. Grouping your answers can be useful for diagnoses, history, examination signs and management. You do not need to name the group in your answer, because this could risk overcoding.

Choose only the best answer from each group. For example, there might be several medications that could cause a particular rash, but maybe amoxycillin is the most important.

Consider a surgical sieve to broaden your range of differential diagnosis groups. VITAMIN C is a well known surgical sieve (Vascular, Infective, Trauma / Toxins, Autoimmune, Metabolic, Iatrogenic / Idiopathic, Neoplasia, Congenital). This can avoid you listing only infections if there is a wider range of possible causes.

Be holistic in your patient management. If they ask for long term management, in addition to medications think of specific referrals, self management strategies (i.e. action plans), targeted immunisations, specific points of patient education and lifestyle measures.

Target the differentials. In some cases, you need to consider aspects of history that would rule in or out the important differentials, rather than just confirming the most likely diagnosis.

Re-read the question. You should think broadly, but not more broadly than the original question. There are no marks for including history when they have asked for investigations, drugs when they want non-pharmacological management (or vice versa), or infective causes when they have asked for non-infective causes…

Demo Select an example to compare narrow and broad lists of answers in a KFP.
Diagnosis

Betty, age 89, has become acutely confused… List 4 likely causes of her delirium.
  • Urinary tract infection
  • Pneumonia
  • Cellulitis
  • Encephalitis
  • Pneumonia
  • Subdural haematoma
  • Opioid side effects
  • Hyponatremia
Management

Billie is diagnosed with bipolar I disorder… List the most important aspects of your long term management.
  • Monitor lithium levels every 6 months
  • Educate the patient on the importance of taking the lithium long term
  • Monitor calcium 6 monthly
  • Advise patient on common side effects of lithium
  • Monitor lithium levels every 6 months
  • Referral to clinical psychologist for cognitive behavioural therapy
  • With the patient’s consent, involve family in identifying early warning signs of relapse.
  • Arrange regular review every 3 months

Quiz

Here are some KFP cases written by Raja Devanathan. After you have a go at answering a question, you will also be asked to analyse someone else’s answer. This exercise is designed to give you more experience in identifying what makes a good KFP response.

You can read Raja’s disclaimer here.
KFP Cases (Developed by Raja Devanathan – for free use by anyone, anywhere).

These cases are written for the benefit of our members, and should be used as an learning opportunity (but should not be the only source of learning!). The cases may not resemble those in the KFP exam. These cases are samples only. The commentary is accurate to the best of my ability, however it may not be always reliable and its advisable to check with your supervisor or medical educator for more information. These are samples only and have not been intensely scrutinized by any examining body, and is not in any way associated with any training providers, nor RACGP. I design such cases because I like teaching, and will aim to help as many people as possible. At the very least, these cases may help trigger some learning gaps in your preparation. Try to complete each case within 7.5 minutes (2.5minutes per question), just like the real KFP. Please avoid contacting me about these cases, as it is unlikely I would be able to provide individualized feedback. The cases come with no warranties or guarantees. I hope you enjoy the cases as much as I enjoyed creating them.

Further Reading

As always, this study guide is a work in progress. If you have suggestions to share or something isn’t working on your device, please use the feedback box below. Please note that the included topic / question / answer examples are either based on the public exam reports or are entirely made up. Recalls of past exam questions will not be used.

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