Preparing for the Prescribing Safety Assessment (PSA)

The Prescribing Safety Assessment (PSA) is easily one of the most dreaded final year exams in medical school. You’ve probably heard stories of seniors complaining about the difficulty/ lack of time/ sheer number of questions in the exam; all of which can be true, but only if you lack the practice for the exam.


So what is the PSA? Essentially, it is an exam designed by the British Pharmacological Society and the Medical Schools Council to test final year medical students on their prescribing skills, attention to detail, knowledge of medicine and clinical judgement. It is simply an exam to test your basic prescribing skills to see if you have reached the bare minimum expected from a Foundation doctor. Therefore, it is not important if you score very highly for the exam - you simply need to demonstrate that you have the minimum skills to practise as a safe doctor.



Structure of the exam

During the PSA, you have a total of 60 questions (with a combined total of 200 marks) which you have to answer in 2 hours. Time is a key factor in this assessment, so you have to work through the exam as quickly and efficiently as you can. The exam is taken online, so you will have access to the PSA website where the exam will be made available to you on the decided date.


There are 8 main sections and 7 key specialties that are covered in the assessment:



This is important, because this means that any of the 7 specialties can be covered within any of the sections, e.g. a paediatrics-focused question can appear in the drug monitoring section. As such, a good knowledge of the management for common conditions in these specialties would be highly beneficial when taking the exam as you would be more fluent in approaching and identifying the answers.


The breakdown of the exam is also shown below:


Understanding this breakdown is integral to how you approach the exam - this will guide your strategy in studying and doing the questions for the PSA. For instance, you will notice that Section 1 holds nearly half of the marks for the whole exam; this may be where you dedicate most of your time and brainpower to answer the questions instead of focusing too much on smaller sections like Section 4 or 8.


*A key change to note for PSA 2021 onwards: marks are no longer awarded for signing your name and date - all of which would be automatically filled in for you in the exam.


During the PSA, you will also have access to the online BNF (British National Formulary) and cBNF (the paediatric version of the BNF). You won’t have access to the NICE guidelines, but honestly, you can make do with the guidance from the BNF as it correlates quite closely to the NICE guidelines (or better yet, actually know the management by heart!). You can also bring along physical copies of the BNF and cBNF, blank pieces of paper, some stationery and a calculator.


Thankfully, the user interface for the PSA is relatively easy to use as seen below:



You will have access to an online calculator, the BNF, and an overview of all the questions so you can navigate between them faster. Key things to note would be the “mark for review” button (which you should optimise when doing the exam), and being familiar with how the medicine names will appear, the formulations and respective doses for them when doing the questions. There is even a function to increase or decrease the font size of the questions if it's bothering you; so really, this exam was made for you to do well!



Preparing for the exam

Now that you have understood the structure of the PSA, you can think of your strategy in approaching the exam. Here are 5 key tips for doing well:


1. Start early!

You should start thinking seriously about how you would prescribe medications and manage patients early on in your final year because this will be a massive help for you when you come to sit the PSA. The exam is usually undertaken in the second half of your final year, beginning in early February, so if you begin practicing and building up your working knowledge of the ins and outs of prescribing early, it leaves you with plenty of time to become well-versed in the skills needed to ace the PSA.


Since the PSA is such a time-pressured exam, you should optimise your time management and save time wherever you can. One good way of doing that is by familiarising yourself with common conditions - for example, it is so much easier (and faster) to just know the acute management for asthma and COPD than to search it up on the BNF! This also has the added benefit of boosting your knowledge for finals while helping you whiz through the PSA.


In terms of actually practicing past papers and questions, I recommend starting around 1-2 months beforehand so you can take your time for practicing for the exam. If you follow this timeframe, dedicating around 5 hours weekly to go through the material is enough for you to sit for the exam comfortably. Alternatively, you can even start 2 weeks before the exam; however, this does mean longer and more dedicated days needed to practice for the PSA.


2. Be familiar with the BNF

If you are not familiar with the BNF by now, you should! The BNF is a treasure trove of information and you can get nearly all you need to know from it if you know where to look. Just spend 20 minutes of your day flipping through the BNF and know what information exists in the book - this will prove to be invaluable for you during the exam.


It is also worth practicing using the online BNF as you will have access to it during the PSA. Throughout your time in clinical years, you would have no doubt been given opportunities to practice prescribing using the BNF, so treasure these opportunities and utilise the online BNF so you know how to navigate and utilise the search function quickly and accurately.


Other important things to note would be the way the indications, cautions (specifically for renal and hepatic impairment, pregnancy and breastfeeding), side effects, medicinal forms and brands are written for each drug. The BNF is written for medical professionals, so all the information would be written in medical jargon, i.e. the side effect of high sodium would be written up as “hyponatraemia”. This is particularly important when you are searching up the key words - don’t panic if you can’t find them at first, and try to think of the medical term for what you are searching for!


Pro tip: Ctrl + F will be your best friend during the exam


3. Do the PSA mock papers

The official PSA mock papers are probably the closest thing you can get to the exam. You will have access to 3 mock papers (each with 30 questions), and it is highly recommended that you have a go at them so you become familiar with navigating the questions and time pressure. They also come with explanations and markings for each of the answers, so be sure to read through them to gain an understanding of what is expected to obtain the marks.


Key note: don’t be disheartened when you first attempt the questions! Your score will improve quite dramatically over time with practice and working on your weaknesses.


4. Know your weaknesses

Your weaknesses will become more apparent as you practice for the exam - be sure to pay particular focus on them so you become more well-rounded and prepared for the actual PSA! It can be tempting to focus on perfecting your strong areas and avoid revising the things you know you are weak at, but make sure to resist! Your efforts will pay off in the end.


5. Practice under time pressure and recognise which sections take the longest time

Time, time, time - this is the main problem most students face during the PSA, so you get used to practicing under time pressure! Certain sections (i.e. Section 1 and 2) will take more time than others, hence, prioritising finishing shorter sections would be integral to creating more time for answering longer sections.


Pro tip: recognise where to find key pieces of information for adverse drug reactions/ drug monitoring/ key information for the drug in the BNF, be very familiar with conversions and develop number fluency so you can quickly finish Section 4-7 within 30 to 45 minutes! They are easy marks to get and hence, very worth the effort in gaining familiarity and fluency for common drugs here.



Resources and important information

There are loads of resources out there that you can use as part of your preparation for the PSA. You might be pressured to buy a book to help you out - that’s perfectly fine, but the best practice you can get is definitely the mock papers from the official website.


Personally, I’ve gone through a few of the resources and summarised my thoughts on them below:



When practicing for the papers, don’t forget to also revise the management for common conditions in key specialties like obstetrics and gynaecology, paediatrics, psychiatry and old-age medicine. Themes like contraception and end of life care are commonly tested in the PSA, therefore, it is essential that you become comfortable with prescribing them.


At times, the PSA will ask certain questions that you cannot look up in the BNF - this is when you need to have good clinical understanding and judgement of the situation. As such, it is imperative that you still know basic management for common conditions, as you may encounter such questions during the exam (particularly so in Section 3).



Day of the exam

There are a few tips you can utilise to help you go through the exam:


1. Sleep well the night before

Forget being a night owl to stay up studying for the exam; sleep is probably the single best thing you can do that will help you do well for it. The PSA is long, and you need to be fresh and ready to read through long bits of text and perform basic arithmetic to do well.


2. Don’t compare yourself to your friends!

If you are taking your PSA alongside your cohort in an invigilated environment, it can be easy to be pressured by the speed at which everyone goes through the paper. Remember that everyone works differently and has different approaches in completing the paper; stick to your own approach and focus on doing well in the exam!


3. RTFQ

Read the friggin’ question! The devil is in the details and you can easily trip up on questions if you don’t read the question properly. Be careful in identifying keywords and what the question is asking; do not assume the answers at first glance without reading the question carefully.


4. Be wary of the time spent on each question

Having said that, you also need to be wary of the time you spend on each question. Keep an eye for the timer in the box and train yourself to be aware of the time allocation for each section. If you encounter a difficult question, it is often easier to mark it for review and return to it later rather than spend a lot more time trying to figure out the answer for it.



What next?

Well done if you have made it this far! Your university’s PSA lead will usually notify you when the results are available (usually 2-3 weeks after the exam date). You will be able to see a breakdown of your scores according to each section, but unlike the mock test, you cannot receive feedback for questions as the PSA only have a finite number of questions within their exam bank.


If you passed, congrats! You will be able to download your certificate from the website as proof that you have successfully sat for the exam (which you should keep for your records). The pass will usually be valid for 2 years, but it does not expire if you start your F1 year.


If you did not pass, don’t worry just yet. Depending on your university, the PSA may be taken as a formative exam, thus it is still possible to graduate without passing the exam (although this means that you will not be able to prescribe when you start F1). Resits are usually available and can be taken either after graduation or if your institution organises one, so get advice and help early on to do well in your resit.



Last bit of advice for the PSA

The PSA can be challenging, but ultimately it is an exam that anyone can do well in. Passing marks for the exam tend to be quite reasonable (60-65%), and most students will usually pass on their first attempt. With enough time, preparation and practice, you will (almost) definitely do very well in the exam!



Sources:

https://prescribingsafetyassessment.ac.uk/

https://prescribingsafetyassessment.ac.uk/resources/PSA-Blueprint.pdf

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