More Sample Questions

You are the on-call ST3 and have just admitted a young lady with a crush injury to the lower leg which will require an amputation. This is your first on call as a registrar. Whilst you have assisted your consultants with a below knee amputation you have not performed one yourself. The patient is unwell and showing signs of sepsis. What do you do?

Stabilise the patient and prepare for theatre

  • Ensure the ABS’s have been followed
  • Ensure that analgesia and oxygen have been administered
  • Ensure the patient is not hypotensive or hypothermic
  • Ensure ‘special circumstances’ eg tetanus have been dealt with
  • Ensure adequate blood has been crossmatched
  • Ensure that theatres are informed and ready. All appropriate staff muct be informed




Explain the procedure and take appropriate consent

 

  • Even if you are not competent to perform the procedure, you should be competent to consent – it saves time
  • Explain the procedure to the patient and/or relatives with compassion




Call for senior help as soon as possible

 

  • Phone your supervising consultant at the earliest convenience. On further questioning the examiner might say that his phone has gone through to answerphone. In this instance the second option is to phone another consultant, a senior registrar colleague, or a consultant from another hospital. If still not available then the next line of attack is senior nurse, hospital manager and then finally defence union
  • If you are essentially on your own then the decision has to be taken as to whether an operation by you is better than no operation at all
  • The answer to this is usually yes and you could even take phone advice to help. It is important to remember that this however is only as the last resort – the least unsafe option




Further Points

The interviewer is asking ‘how do you know when you are out of your depth and how do you deal with this?’ Many similar scenarios could be described. The key to your answer is not so much the medical treatment/consent aspect although these obviously play a part but to demonstrate that you recognise the seriousness of the situation and will deal with it safely and appropriately given your experience. Remember that heroics only have a place in the final stages of this case, there are many things you can do to temporise the situation whilst waiting for help. Only if the interviewer removes all your options should you say you would perform the operation on the grounds that it was ‘the least unsafe option’

 

What are your principles of breaking bad news?

 

Introductions and background

  • Setting the scene with introductions and establishing position within the team
  • Establishing whether patient has someone with them
  • Establishing their level of current knowledge and what they expect from the consultation
  • Making sure that they know they will have the opportunity to ask questions and will be given more information at the end

Consider how you will close the meeting

  • Give the patient the opportunity to ask questions again
  • Make sure the patient has adequate follow up afterwards
  • Make sure the patient has the number of the specialist nurse or similar support
  • Make sure you have offered written/web based information

You are driving to work and witness a serious car accident two cars ahead of you. You are unsure of the level of casualty. What would you do?

 

Ensure the safety of yourself and your passengers

  • Ensure that you can park in a safe place so as to not endanger anyone else
  • Make sure that your passengers, especially children, are also safe

Duties of a doctor in good medical practice

  • ‘In an emergency, wherever it arises, you must offer assistance taking account of your own safety, your competence, and the availability of other options for care’
  • Assess whether you are technically competent and up-to-date enough to help without doing further harm
  • Weigh up the options available for the patient and do what you feel will be the best eventual outcome for the patient

Legal standpoint

  • There is no requirement in Law for you to help the injured party unless you have caused the initial injury
  • You are within your rights to walk away and will not be sued but may be in breach of your ‘duties of a doctor’ as stipulated by the GMC
  • If you choose to get involved you have a duty of care. If your intervention leaves the patient in a worse position then you may be legally liable

In the interview circumstance, it would be inadvisable to say that you would do nothing but explaining the legal standpoint is also useful

 

You notice a FY2 drinking from a bottle of whisky in the doctors’ office at 13.30. How would you deal with this?

 

Use the SCAPE structure

  • Situation
  • Clinical Problem
  • Action Plan
  • Progression of Events
  • Empathise




Situation

  • Your colleague clearly has a drink problem as you have found him drinking alcohol at work
  • This contravenes both GMC ‘duties of a doctor’ and trust policy




Clinical Problem

 

  • Your colleague clearly poses a threat to clinical care as he is not capable of reasoned decisions
  • You should attempt to convince him to go home and try to ensure that he does this in a safe way (taxi rather than car)
  • If you cannot convince him then you will need to escalate this to a senior member of your team
  • Before he goes you should make it clear that you will have to escalate the matter further
  • After he has left, ensure that the notes are reviewed and all patients who have come into contact with your colleague are checked




Action plan

 

  • Inform the ward that your colleague will be absent for the day
  • Offer to help out to cover your colleague’s duties if appropriate
  • Make sure your colleague has got home safely and also offer to talk to him/her about it as appropriate
  • If you know friends/family try to ensure he has adequate short term support




Progression of events

 

  • ‘If you have concerns that a colleague may not be fit to practice, you must take appropriate steps without delay, so that the concerns are investigated and patients protected where necessary’ – GMC Good medical practice
  • A drunk colleague has clearly breached these guidelines
  • Inform your supervising consultant and also the consultant responsible for the FY2
  • Avoid informing too many people to avoid rumour mongering
  • Monitor the response from your senior colleagues to ensure it has been dealt with adequately




Empathise

 

  • Support your team in taking up the excess work that your colleague’s absence may have left
  • Support your colleague as much as is appropriate
  • Explore the reasons for the change of behaviour
  • Offer support groups eg alcoholics anonymous




Further Points

Your Answer:

submit

When walking into clinic you notice an elderly lady remarking that she refuses to see a ‘black doctor’. What would you do?

 

Model Answer:
Use the SCAPE structure

  • Situation
  • Clinical Situation
  • Action Plan
  • Progression of events
  • Empathise




Situation

  • Assess why this lady does not want to see a ‘black doctor’ – has she been the recent victim of a mugging by a black person for example? Do this yourself if appropriate or via one of the nurses
  • Try not to be confrontational without the full information
  • What are your trust’s policies on exclusionist behaviour?




Clinical Situation

  • This depends on the trust policy. Some trusts will not treat these patients even as an emergency
  • It may be appropriate in some scenarios to offer a different doctor if available but all effort should be made to ensure the patient understands that it is not because the replacement doctor is in any way better
  • If racism is the reason, many trusts will refuse to treat the patient as the patient has essentially refused treatment




Action Plan

  • If you feel comfortable, and it is appropriate, attempt to broach the situation with the patient yourself
  • Explain that her behaviour has a deleterious effect on both the doctor and the team
  • Make sure that copious accurate notes are taken detailing events
  • Ensure that any ‘black’ colleagues feel supported as much as possible




Progression of Events

  • If you do not feel able to broach the situation ensure that this is escalated to your consultant
  • If this is a recurrent problem, it may be necessary to bar the patient from care. This will need to be decided at a senior level
  • Make sure that your senior deals with the problem to your satisfaction
  • You may need to call security if necessary




Empathise

  • Show support to your ‘black’ colleague who may feel insulted and ostracised
  • Try to remember that the elderly lady may be a victim of a previous incident and may be behaving irrationally because of this. She may also benefit from advice or support




Further Points

Tell me about your CV

 

Model Answer:Can you give an example of when you have helped an underperforming junior colleague?

Use the CRATE structure

  • Clinical
  • Research
  • Admin and management
  • Teaching
  • Extras




Clinical

  • Brief details of your training posts so far
  • Mention rotations rather than individual jobs
  • Concentrate on jobs which make you stand out if needed
  • Describe skills and clinical experience which are either index for this position in the person specification or which are advanced for your level




Research

  • Papers written and submitted
  • Audits written up and published
  • Relevant postgraduate courses
  • Postgraduate degrees and their subjects
  • Prizes/awards/grants




Admin and Management

  • Any relevant experience both inside and outside medicine
  • Hospital committees
  • Organising rotas
  • Organising training/teaching/appraisal
  • Supporting colleagues both formally and informally




Teaching

  • Detail courses undertaken to prepare you for a teaching role
  • Who you have taught and when
  • In what setting this teaching took place and what techniques you used
  • How your feedback was collected and what it was
  • What you have gained from your teaching experience




Extras

  • Information on life outside medicine
  • Concentrate on hobbies with transferable skills if possible and also those where you have had particular distinction
  • Why you want to pursue this speciality and where you see yourself eventually




Model Answer:
Use the STAR structure

  • Situation
  • Task
  • Action
  • Result




Situation

  • Choose an example where your colleague needed support which you could give to good effect
  • If possible have the problem brought to you by the junior
  • An example would be a colleague who feels that they are not on top of their work or are always disorganised




Task

  • May already be covered by the situation section but usually for specific tasks
  • An example may be a colleague who is not able to take arterial blood gas samples




Action

  • Support your colleague, educating without being patronising
  • Offer to observe the task to see whether you can give any pointers
  • Ensure you make it clear that the patients’ welfare is your highest priority
  • For organisational problems, you could offer to work with your colleague for a day if possible to see if there are simple steps which would improve the situation
  • For practical skills, you could start by visiting a clinical lab together and then organise supervised mentoring on the wards to reinforce the skills learnt
  • You could offer to cover some of their routine work to free up time for them to obtain focused training
  • Offering a tutorial and written support may also be useful




Result

  • Outline how your efforts lead to a positive result eg an increased accuracy of ABG taking, a more efficient doctor who makes it home on time etc
  • If asked, offer ways in which you could have done this better

What features about you make you a suitable trainee for this speciality (or what are your good points)?

Model Answer:
Focus your answer to cover the person specification and try to pick out 3-4 salient points to cover in detail
  • Each point should be framed effectively and divided into constituent grouped skills if possible
  • An example would be ‘I am a confident operative surgeon and am happy to make decisions in this environment but am also ready to learn from others, be adaptable and ask for help when I feel out of my depth’
  • Try and expand all points to give the answer originality and substance




Ensure that your answers are speciality linked, using examples if possible
Manual dexterity and ability to learn new skills may be more relevant to surgical specialities than medical ones

  • Dexterity and hand eye coordination
  • Working under pressure and adapting to changing scenarios
  • Being willing to seek help when needed
  • Engaging and establishing rapid rapport and trust with patients
  • Good team working abilities being able to liaise with theatre and secretarial staff as well as other members of the surgical team
  • Hard working and ready to learn new techniques and skills




Communication Skills are important for all specialties but are probably especially relevant for Paediatrics, Obstetrics and Gynaecology and Psychiatry

  • Ability to effectively communicate is essential
  • Ability to deal with vulnerable adults/children/parents where appropriate in a non judgemental manner
  • Ability to deal with situations when under pressure
  • Appreciate that there are often additional issues to deal with around these patient groups
  • Ability to involve various members of multidisciplinary teams




Problem solving skills are paramount for medical specialities

  • Lateral thinking and problem solving
  • Excellent communication skills with a broad patient base
  • Ability to multitask and use members of the team effectively
  • Ability to deal with stress, calling for help when necessary
  • Ability to empathise and relate with both patients and their relatives




Further Points

You are not aiming to give exhaustive examples, more to give the interviewer a broad brush idea of your relevant skills

Your Answer:

submit


25055



Average


What particularly attracts you to this speciality?

Model Answer:

Use the SCAPE structure

  • Situation
  • Clinical Situation
  • Action
  • Progression of Events
  • Empathise




Situation

  • Establish the situation and reasons for your colleagues behaviour
  • Are they based on prejudice
  • Are they based on a previous exposure to sexual assault either on your colleague or on people she knows
  • Are they based on comments from the patient




Clinical Situation

  • Safeguard the patients interests
  • He has a right to healthcare independent of his conviction or your colleague’s beliefs
  • Ensure that the patient gets the treatment he is entitled to from yourself or another colleague




Action Plan

  • Organise an informal meeting with your colleague to try and address the situation
  • Investigate the reasons for your colleague’s behaviour to the best of your ability
  • If they are due to personal experiences of abuse then if appropriate you could try to listen
  • If they are due to prejudice then this is in direct breach of duties of a doctor and you should make you should make your colleague aware of this in a tactful way




Progression of Events

  • If due to prejudice then it may be appropriate to ask your colleague to discuss it with your seniors
  • If she won’t comply you should inform them yourself if only to pre-empt a complaint
  • If due to personal traumatic circumstances then encourage your colleague to discuss the matter with either your seniors or a trained counsellor




Empathise
Depending on the reasons, empathy is vital



Further Points

 

What regulates research ethics within the UK?

 

Model Answer:

Use the CRATE structure

  • Clinical reasons; Research reasons; Administration and Management reasons; Teaching reasons; Extra reasons
  • Ensure that you answer the question using personal experience if possible as it makes your answer much more interesting and believable
  • Try to show that you have come to this speciality by a process of excluding other specialities which are not appropriate for specific reasons and also that you have tried to get the most basic exposure to this speciality before they give you further commitment
  • Try to offer a range of diverse reasons rather than just one. With each reason real enthusiasm is the key




Clinical reasons

  • These will differ according to the particular speciality
  • Developing practical skills (eg surgery, radiology, pathology)
  • Holistic care (cancer based specialities, elderly care, psychiatry)
  • Rapid results (surgery, radiology, A and E)
  • Broad patient mix (most specialities)
  • A community-based slant to work (paediatrics, GUM, pre-hospital care)
  • Mixture of clinical settings (most medical and surgical specialities)
  • Mix of medicine and surgery (O and G, gastroenterology)
  • Investigative speciality (most medical specialities but particularly neurology and rheumatology)




Research reasons

  • Rapidly evolving speciality with a broad research base
  • Technological advances (eg robotic surgery/laparoscopic surgery)
  • Excellent research opportunities (eg oncology)




Administration and Management reasons

  • Multidisciplinary team working (most specialities)
  • Working with-out of hospital services (A and E, psychiatry)
  • Enjoy the ability to change and develop the idea of service provision (public health)




Teaching reasons

  • Practical teaching (surgery, radiology, anaesthetics)
  • Encourage analytical mind in juniors




Extra reasons

  • Some specialities are more conducive to a family life (eg pathology)
  • Some specialities cross over (ITU/anaesthetics)
  • Some specialities fit in with existing hobbies (sports medicine/expedition medicine)
  • Some specialities work in large teams (eg A and E/ITU) which suit particular personalities
  • Some specialities offer communication skills challenges (Oncology)




Further Points

Model Answer:

You are just about to submit a research paper when your colleague asks you to put his name on it also and that your Consultant on the paper has said it was ok. You are aware that they meet socially outside the hospital and they play rugby together. How would you deal with this?

 

Be able to talk about the local and national regulation of research ethics

  • Research ethics committees (REC’s) were first established on a local level in 1991 following the DOH publication ‘the Red Book’ . Their role was to regulate and test the validity and integrity of NHS research carried out at local levels
  • In 2000 the ‘Central Office for Research Ethics Committees’ (COREC) was established to oversee the local ethics committees and required submission of a rigorous on-line internet based form for every new piece of research carried out in the NHS
  • COREC also approved the paperwork which was to act as information and consent to the patient participants and also the information that would go to the GP
  • Following submission to COREC the local ethics committee would then assess the proposal before making judgement
  • In 2007, the ‘National Research and Ethics Service’ (NRES) was established to oversee COREC and the Local REC’s
  • Without passing through NRES original research cannot be submitted towards higher degrees and should not be submitted for publication




Be able to talk briefly about research strategy planning in the UK

  • The ‘UK Clinical Research Collaboration’ (UKCRC), the ‘UK Clinical Research Network’ (UKCRN) and the ‘Office for Strategic Coordination of Health Research’ (OSCHR) play the main role in planning research strategy in the UK
  • The UKCRC aims to “Reengineer the environment in which clinical research in conducted in the UK” by promoting research infrastructure, clearer research channels without the red tape and a unified mechanism of governmental funding
  • UKCRN is part of the UKCRC and aims to “support the conduct of high quality trials and other well designed studies”
  • The OSCHR oversees both the other bodies and should “take the lead in developing a translational research strategy to maximise the economic and health benefits of innovation”. It plays a role in bidding for money for medical research from the treasury




You have been helping your professor with a paper performing the literature review. The paper has been accepted by a prestigious journal. You have now realised that he has excluded some of his data to produce the desired significant result. How would you deal with this?

Model Answer:

Use a modified SCAPE structure – SAP

  • Situation
  • Action Plan
  • Progression of Events




Situation

  • Establish whether the Consultant has actually agreed to this course of action
  • Clarify with the Consultant and the Trainee why he should be put as a named author on the paper
  • Establish that the Trainee has not had a significant input into the paper




Clinical Situation – probably not relevant


Action Plan

  • Explain to the trainee that it is a serious breach of research ethics and actually a GMC reportable offence if he continues to have his name on the paper
  • Try to persuade him to withdraw his name voluntarily
  • If there is no justification explain to your fellow Consultant that you cannot put his name on the paper, because you as first author would be committing research fraud which is a serious offence
  • You could send the paper off without telling your Consultant but this would probably not do you any favours




Progression of Events

  • If your Consultant still insists you put the other name on the paper you should raise your concerns with a senior member of your team, with another consultant, the clinical director or in a University Trust the academic head of the unit
  • If you get no support you should escalate the problem within your hospital to Chief Executive level if necessary and if needed to the GMC following this as it breaches Good Medical Practice




Empathise – Not relevant in this case


Further Points

Your Answer:Enter Answer Here: (free text)
Model Answer:

Use the SCAPE structure

  • Situation
  • Clinical Situation
  • Action Plan
  • Progression of Events
  • Empathise




Situation

  • Review the paper in detail with all the raw data you have to check whether the excluded data should have been included or not according to the exclusion criteria
  • Re-do the statistics with all the data included to see whether the results would have been different or not
  • Bring your concerns up with your Professor in a non-confrontational way in the first instance ‘I was just going through the paper again and noticed that this subset if data hasn’t been included’




Clinical Situation

  • Maybe of relevance depending on the clinical nature of the paper, the exposure of the journal and the widescale clinical significance
  • If you come from a good unit and the paper is clinically relevant, many readers of the journal may change their clinical practice based on its results – this is potentially clinically disastrous
  • In addition, other papers published from this unit may have serious flaws and may have misdirected changes in clinical practice putting patient care in danger
  • A senior clinician who shows such errors in judgement may have other flaws in his/her clinical practice




Action Plan

  • Confront your professor with your concerns regarding research ethics and invite him to withdraw the paper
  • This may be very difficult as he is an extremely senior member of the team
  • Discuss the matter with the other co-authors to ascertain whether they knew about the problem or whether they were also in the dark – this may give you support when you do confront your boss




Progression of Events

  • Contact the journal’s editor yourself to explain the matter
  • Discuss the matter with your clinical consultant or the senior research lead in your hospital
  • If your Professor cannot give a good reason as to why the statistics don’t add up, this will eventually have to go to the University Research and Ethics Board and potentially to the GMC




Empathise

  • This may not be immediately relevant but you may be able to empathise in that research departments rely on publications to secure funding and this pressure may have made your professor overlook his results
  • When someone believes in a hypothesis and is convinced that it will improve patient care then they may overlook the wood for the trees




Further Points

Your Answer:Enter Answer Here: (free text)

What do you understand by clinical networks? What are their advantages and disadvantages?

Model Answer:When was the last time you felt out of your depth and how did you deal with it?

Define clinical networks

  • Clinical networks link clinicians dealing with the same pathology into groups across separate trusts for a variety of functions




What are the advantages of clinical networks?

  • These groups act to facilitate setting standards across the network to ensure that patients are being treated in the same way irrespective of the hospital attended ie reduces the postcode lottery
  • Provide a mechanism by which clinical groups can meet in a formal setting to discuss issues which affect them all eg implementing new NICE guidelines, trying new technical equipment etc
  • Provide mechanisms by which research collaborations can be forged and resulting data disseminated
  • Centralise certain rare treatments within a group to one centre with the most experience (eg sarcoma services or gynaecological malignancy)




What are the disadvantages of clinical networks?

  • They reduce the autonomy of individual clinicians as network guidelines should be followed
  • They may de-skill the centres who are not chosen to perform the rare procedures even though the clinicians may be perfectly competent to carry them out
  • By forcing patients to travel to the preferred hospital for treatment of the rare conditions this may cause inconvenience




 

How would you deal with bullying at work?

Model Answer:

Use the STAR structure

  • Situation; Task; Action; R esult
  • Not limited to a clinical situation which although relatively straightforward may lack originality
  • Could use a situation where your revision was getting on top of you and you had trouble juggling this and work
  • Could be dealing with a new baby, being up at night and having to be functional at work also
  • We will illustrate the answer with the scenario of an SHO in general surgery who is dealing with a multi-trauma whilst his registrar is busy in theatre




Situation

  • Describe the scenario in some detail
  • I was on call on a busy Friday night when a trauma call was put out. My registrar was busy in theatre. When I went to A and E, I was told that 3 traumas were expected from an RTA. As I still had relatively little trauma experience although ATLS qualified I initially felt quite out of depth……




Task

  • When the ambulances arrived we were told that the trauma patients were of varying degrees of severity
  • I had several junior A & E senior house officers working with me and a helpful A & E registrar who asked me to prioritise the patients and coordinate my colleagues as it would be good experience….




Action

  • I informed my registrar in theatre of the situation and asked him to join me in A and E when he finished
  • I also informed the general surgical consultant on call in case he would be needed
  • I triaged the patients in order of severity and divided up the clinical teams to ensure that they were best suited to the injuries ie asked the anaesthetist to lead on the patient with a possible compromised airway
  • I called the orthopaedic registrar to help as one patient had a probable fractured femur
  • I tried to act in a calm coordinated way involving all members of the team and sharing responsibility as appropriate
  • I asked for help where appropriate and remained open to questions from the team at all times




Result

  • All three trauma patients made an excellent clinical recovery
  • The casualty registrar commended me on my management skills




Further Points

Need to choose an event sufficiently recent to be plausible without compromising your current ability and with a positive outcome

Your Answer:Enter Answer Here: (free text)
Model Answer:
Use the SCAPE structure

  • Situation; Clinical Situation; Action Plan, Progression of Events; Empathise
  • If possible illustrate this answer with an example either from personal experience of from observation of the way a colleague has been treated




Situation

  • Describe the situation in which the bullying occurred if possible
  • IF you don’t have a situation in mind then you could describe a theoretical situation of a consultant who persistently makes you feel stupid by undermining you on ward rounds or in educational meetings
  • Explain how it made you feel or whould have msde hyou feel to make it more personal




Clinical Situation

  • This may not be directly relevant
  • If you are bullied in front of a patient this may undermine your standing in the team and if the bullying is about clinical matters this could undermine the trust the patient has in you
  • If you are bullied in a meeting then it may affect how others perceive you and therefore they may not ask for your opinion in future and the patients may suffer as a result
  • If the bullying causes you to lose confidence in yourself then you may doubt your abilities, make mistakes because of over checking or avoid tasks to prevent being criticised




Action Plan

  • Discuss the matter with the consultant in the first instance. Preferably on your own in a quiet room at a booked appointment
  • Find out what the problem is, whether he has genuine concerns regarding your performance or whether he is usually fine but is having a bad day
  • Take notes and if there are issues to address, ask him how he feels you could address these
  • Reschedule another meeting saying you will attempt to address the problems in the meantime
  • You should be able to tell your consultant how his behaviour affects you and that it is not acceptable




Progression of Events

  • If you don’t feel you can talk to your consultant due to his aggressive personality you should attempt to escalate the situation to your educational supervisor, clinical director or another senior clinician
  • If you are still having no joy then you should consult you induction pack which will have a formal process to deal with bullying




Empathise

  • Only empathise if you feel that your Consultant may have personal problems that he tells you about




Further Points

Remember bullying is extremely serious and you should know how you would deal with this situation

It is important to attempt to deal with the issue on a local level before escalating

When was the last significant error you made and how did you deal with it?

Model Answer:
Use the STAR structure
  • Situation or Task; Action; Result
  • Choose an error which is significant for the patient, for you or hopefully both
  • Choose an error which could have happened to anyone
  • Choose an error which did not have a long lasting significance eg a near miss
  • Choose an example which can be learned from and can have changes made which would prevent it happening again

We will illustrate the answer with an example of a prescription of flucloxacillin which you prescribed and was given to a penicillin allergic patient




Situation or Task

  • Describe the situation in which the error occurred
  • I was on a busy ward round and was asked to prescribe some antibiotics for a patient with cellulitis of the lower leg
  • We had a large number of patients to see and my registrar was in a hurry to get to clinic. It was suggested flucloxacillin would be appropriate, the nurse asked me to prescribe it then so that it could be started by iv infusion
  • I prescribed the medication but 20 minutes later was fast bleeped back to the ward and told that my prescription had been given but the patient was penicillin allergic




Action

  • I immediately attempted to safeguard the patients welfare
  • I ensured a large bore intravenous cannula was in place, the patient had fluids and oxygen and that adrenaline was to hand
  • I moved the patient to a monitored bed
  • I informed my registrar and said that I would ask for help when required
  • I explained the situation to the patient, apologising for the error made
  • Following stabilisation of the patient at a later date I reflected on the event
    • Should not rush on ward rounds
    • Shouldn’t prescribe in a hurry without thinking about allergies and when prescribing antibiotics should triple check with the patient verbally, the allergy band and the notes
    • Discussed the event with the nurse who started the infusion encouraging her to be part of the checking process
    • Discussed the case with my registrar to see whether we could start the ward round slightly earlier or arrange to write and prescribe later in the day to avoid mistakes




Result

  • The patient did not suffer any significant injury
  • The Clinical Team and I implemented new methods for checking for allergies prior to antibiotic prescribing
  • Ward rounds were smoother and safer




Further Points

Your Answer:

Enter Answer Here: (free text)

Can you give me an example of your effective time management?

Model Answer:
Use the STAR framework
  • Situation, Task, Action, R esult
  • Juggling several balls at the same time is an integral skill to medical practice and as such is something that we all do every day
  • It is important that you choose an example which is personal to you and do not be afraid to admit that you found it hard to deal with
  • We will illustrate this example with an SHO who has his MRCS examinations in 2 weeks, an abstract to submit and a busy colorectal firm to organise




SITUATION/TASK

 

  • I was a general surgical SHO working in a busy colorectal firm with 40 inpatients. I was due to sit my MRCS clinical examinations in 2 weeks and had a deadline for submission of an abstract for a meeting in one week
  • I felt very stressed and was worried that my work would suffer as a consequence of this




Action

  • I recognised that I was stressed and struggling with the work I had to deal with
  • I took a step back from the situation and prioritised the jobs I had to do
  • I asked my registrar who was a co-author of the abstract whether she would be able to help prepare it with me as I was struggling with time. She said that she would be happy to and suggested that we do it over 3 evenings and then have a teaching session following this for my exam and then unwind in the pub afterwards
  • I asked my SHO colleagues whether they would be able to help me with some of my ward work over the next fortnight until the exams and by doing this I managed to free up some of my time in the afternoon to revise
  • In return, following the exams I agreed to reciprocate the favour
  • I swopped 2 on-calls over the 2 week period which also enabled me to spend time revising
  • I let my consultant know that I had a lot on my plate and that my colleagues had agreed to help me out over the next 2 weeks. I also asked whether I would be able to sit in on his clinics to prepare for my exams




Results

  • By organising my time effectively, I managed to cope with a fairly stressful situation without dropping too many balls. The abstract was submitted and the presentation was awarded a prize. I passed my MRCS and patient care didn’t appear to have suffered.




Further Points

Have you had a clinical complaint? How did you deal with it?

Model Answer:
If you have not had a complaint then say this and move on

Alternatively if you have had a complaint, use the STAR structure

  • Situation; Task; Action; Results
  • Try to paint yourself in a favourable light
  • If the complaint has substance which is indefendable it is probably best not to admit to it
  • If the complaint has substance which is defendable and you have learnt then this is ideal
  • Ideally the complaint should be about a system error in which you played a part rather than actually directed against you
  • The interviewer will understand that we are all fallible and wants to ascertain how you deal with potential error




Situation

  • Detail the scenario in which the complaint occurred
  • Be careful not to dismiss the complaint in any way. Even if you don’t agree with the content or don’t think it is a fair criticism in the context of the interview it is valid and needs to be addressed




Task

  • The task in question here is to address the criticism openly and honestly whilst learning from the points made




Action

  • Read the complaint carefully and try to see it from the patient’s point of view
  • Review the notes which are the only legally admissible evidence of your patient contact
  • Reflect on the part you played in this patient’s care and also on how your clinical team behaved
  • Is the complaint based on reasonable points or does it arise from another reason (blaming the trust for a death could be bourne out of grief, is there a financial motivation)
  • Be aware that most complaints are multifactorial and usually represent system failure at many levels
  • Discuss the complaint with your clinical supervisor to see how he/she feels your part could have been improved
  • If appropriate arrange a team meeting with those involved and discuss the case highlighting areas for improvement and if necessary discuss it at a M and M meeting
  • Try to put systems in place to ensure similar problems don’t occur
  • If requested make a written response to the letter but if appropriate contact the patient advocacy and liaison service at your trust to offer a meeting with the patient or relatives to answer questions they may have




Result

  • The complaint was dealt with quickly and effectively
  • The clinical team learnt important lessons regarding communication and delivery of care which were then implemented
  • The patient appeared happy with the results of the complaints procedure




Further Points

Your Answer:

Enter Answer Here: (free text)

What do you understand by the term ‘levels of evidence’?

Model Answer:
Define in general terms
  • Levels of evidence are used to classify research
  • They do not themselves give any information regarding the relevance of research, it’s accuracy, clinical importance or the data generated
  • They give information regarding the methodology of research and therefore the importance of the research on a wider scale if believed to be clinically relevant




The levels of evidence

 

  • 1A Systematic review or meta-analysis of randomised, controlled trials
  • 1B At least one randomised, controlled trial
  • IIA At least one well-designed, controlled study without randomisation
  • IIB At least one well-designed, quasi-experimental study, such as a cohort study
  • III Well-designed, non-experimental, descriptive studies, such as comparative studies, correlation studies, case-control studies and case series
  • IV Expert committee reports, opinions and/or clinical experience of respected authorities




What is your opinion of the ever extending role of nurses in clinical practice?

Model Answer:
What is meant by the extended nursing role?
  • Increasingly , the nursing and medical role are becoming blurred
  • The reasons for this are multifactorial but include
    • Reduced cost to the NHS of nursing time
    • May free up medical staff to deal with other duties
  • Potentially a politically difficult question as your interviewer probably has a clear answer in their mind
  • In the answer give a reasoned argument with clear Pro’s and Con’s but avoid sitting on the fence




Pro Points

  • Potentially cheaper to provide the same service with the same HRG code
  • Takes work pressure off junior doctors (eg phlebotomy) or senior doctors (eg nurse consultants, nurse endoscopists)
  • Give a valuable source of information and experience to junior and senior doctors alike
  • Often stay in a department for a long period of time and therefore offer constancy to the patients and can train new starters




Con Points

  • May take longer to perform the same tasks
  • Not trained in the same analytical way as doctors and lack the basic medical training, therefore good with protocols but may be less able to think outside the box
  • Associated with more complications potentially as still in learning curve
  • Take training opportunities away from medical staff in eg endoscopy, catheterisation and phlebotomy




Further Points

What do you understand by National Service Frameworks?

Model Answer:
What are National Service Frameworks?
  • DOH published documents which aim to set clear quality guidelines for a variety of key health areas
  • Based on the best available evidence and research for which treatments and services are most effective for patients in these fields
  • Have the advantage of being inclusive, asking opinion from health professionals, carers, patients, managers, voluntary agencies and other focus groups
  • Aim to set clear quality requirements for basic care and also offer mechanisms to support those agencies through the process
  • There are several NSF’s for a variety of conditions and they are regularly updated to reflect both changing practice and the changing population needs
  • It is not important to know the details of all NSFs but more importantly to know how the NSFs have set targets and standards for your speciality eg the cancer reform strategy




What are the current established NSFs?

 

  • Cancer
  • Blood pressure
  • Children, young people and Maternity
  • COPD
  • CHD
  • Diabetes
  • Long term conditions
  • Long term neurological conditions (stroke)
  • Mental Health
  • Older People
  • Renal




For example: Cancer

Has sections on:

  • Preventing cancer
  • Diagnosing cancer earlier
  • Ensuring better treatment
  • Living with and beyond cancer
  • Reducing cancer inequalities
  • Delivering care in the appropriate setting

Has specific guidance which extends the NHS Cancer Plan:

  • 31 day standard extended to all cancer treatments
  • 62 day standard will be extended to include screened cancers

All patients with breast symptoms if referred to a specialist should be seen with 31 days whether they have cancer symptoms or not



NSF’s are important because … (2 main reasons)

 

  • They define practice which should become the national gold standard therefore driving standards up and also reducing healthcare inequality
  • They contain information together with NHS targets and priorities and NICE guidance, which is used to define quality by the Healthcare Commission (now Care Quality Commission). This then determines the star ratings




Further Points

Have you had any experience of NHS targets within your clinical practice? What is your opinion of them as a working practice?

Model Answer:
What are NHS targets?
  • NHS targets are closely related to NHS priorities
  • The targets are clearly set out in “The operating framework for the NHS:2010-2011” and represent key features within the NHS which all trusts should strive to achieve and have to report on to the CQC
  • There are also 5 NHS priorities
    • Improving Cleanliness and Healthcare associated infections
    • Improving access through achievement of the 18 wk referral to treatment pledge
    • Keeping children and adults well, improving health and reducing inequalities
    • Improving patient experience and staff satisfaction and engagement
    • Responding to states of emergency
  • These priorities have various points within them, which are divided into 3 tiers
    • Tier 1 are mandatory and are treated as such by the CQC
    • Tier 2 contains priorities for local delivery in which effort is needed across the board. They are not however all mandatory
    • Tier 3 are optional features which can be worked on at a local level
  • The CQC judges trust performance based on adherence to NICE guidelines, targets (which are also found in appropriate NSFs) and priorities (tier 1 and 2), and importantly a series of patient and staff reported outcomes




Choose a target to discuss

 

  • These can be found in full on ‘The operating framework for the NHS:2010-2011’
  • 4 hour A and E waiting time
  • Guaranteed access to a primary care professional within 24 hours and a primary care physician within 48 hours
  • Chlamydia screening service to be rolled out nationally
  • Cancer waiting times (31 days from referral to diagnosis and 62 days from diagnosis to treatment)
  • 18 week target for routine hospital appointments




Good points of NHS targets

 

  • Drives improvements in waiting times for patients therefore patients benefit
  • Promotes efficiency of working practices
  • Tends to improve timekeeping and data entry ie ‘if it hasn’t been recorded it hasn’t been done’
  • Targets improvements in areas which are clinically important
  • Prevents health inequality




Bad points of NHS targets

 

  • Results in ‘political practice’ eg keeping patients in ambulances to prevent breech times or cancelling elective operations to house A and E patients
  • Compromises patient care
  • Puts staff under huge pressure




What is appraisal?

  • A structured detailed discussion with a senior colleague (in the case of junior doctors) and peers (in the case of consultants)
  • Reflection on personal practice concentrating on aspects of ‘Duties of a doctor’ and also on features which are speciality and grade specific




How is appraisal undertaken?

  • The framework for appraisal should be based on 2 main themes
    • The 4 domains and 12 attributes contained within ‘Duties of a Doctor’ as a framework for good medical practice
    • The ongoing appraisal folder detailing details of the job plan, details of a PDP, ( including courses, teaching, audit and research), clinical practice and outcomes, evidence of research and other miscellaneous data (eg patient letters etc)
      • In reality it deals more with the actual practice of the individual over the past year rather than a formal appraisal of ‘Good Medical Practice’ which should be formally dealt with at revalidation but ‘Good Medical Practice’ should always be bourne in mind
  • Where deficiencies are found, planning can be undertaken to address them before the next appraisal date
  • In this way appraisal can also be used to set goals for the forthcoming year. and differs from assessment
  • When revalidation comes into effect, the results of annual appraisal will be passed to the trusts ‘responsible officer’ who will use them with the formal revalidation data to recommend revalidation to the GMC or not




How do the RITA/ARCP mechanisms fit into appraisal?

 

  • RITA and ARCP for a mechanism of appraisal for those junior doctors who are on a recognised training programme within the United Kingdom
  • RITA (Record of In Training Assessment) is a 6-12 monthly appraisal for those with a national training number as part of the Calman system
    • Help centrally and organised by the host deanery
    • A panel consisting of the Programme director, Dean (or representative), external assessor, STC chair, regional assessor
    • Aims to evaluate PDP, trainee assessment (by supervisor), placement assessment (by trainee), log book and objectives for the year ahead
    • Aims to identify a plan for progression of training both clinical and academic for the year ahead
  • ARCP (Annual Review of Clinical Practice) is an equivalent system for those trainees who are post MMC
    • Similar to a RITA but more structured
    • Looks at workplace based assessments
    • Compares the trainee against a nationally standardised curriculum and result are held regionally and also at the relevant Royal College which will eventually recommend registration with CCT




Further Points

It is a good idea for a trainee to hold their own appraisal folder as well as their formal RITA/ARCP in preparation for revalidation which will affect everyone

Your Answer:

Enter Answer Here: (free text)

What do you understand by clinical effectiveness? Can you give an example of this from your own practice?

 

Model Answer:
What is clinical effectiveness?
  • ‘The extent to which specific clinical interventions when deployed in the field for a particular patient or population do what they are intended to do, that is, maintain and improve health and secure the greatest possible health gain from the available resources’
  • Relies on the availability of information regarding best practice and evidence based medicine which must be reliable and comprehensive




How in clinical effectiveness implemented?

 

  • OBTAINING EVIDENCE
    • This refers to research based approaches to establishing new standards from predominantly Level 1 or 2 evidence
    • It is obviously important that this evidence has the opportunity to make it’s way into the public sector so that it can then inform changes in clinical practice
  • IMPLEMENTATION
    • The evidence accrued must then be implemented to change practice
    • This is most effectively performed via national guidelines and guidance (NICE) or through established national frameworks (NSFs)
  • EVALUATION
    • Have the changes implemented made a real clinical difference
    • Usually determined by audit




Can you give an example from your clinical practice?

  • Examples may include
    • Implementation of sentinel node biopsy reducing the incidence of unnecessary axillary clearances
    • Implementation of NICE guidance for DVT prophylaxis to reduce symptomatic DVT and PE
  • Must have closed the audit loop




What is clinical risk management?

  • Forms part of the” NHSPlan” (2000)
  • ‘Systematic approach to improving the safety and quality of healthcare (clinical and non-clinical) delivered in the NHS by identifying and assessing, as well as analysing and prioritising, the risk to patients, staff and members of the public and acting to prevent or control them’
  • Can be assessed by critical risk reporting of adverse events or near misses or retrospective audits of the medical records




How would you reduce hospital acquired infections?

 

  • HAI’s are extremely important and topical
  • 9% of inpatients have a healthcare associated infection (HCAI) and the number of MRSA deaths has increased 10 fold over to years to 955 in 2003
  • Try to answer this using examples from your local policy guidelines which will be freely available




Essential to work as part of a team and understand that for improvements to occur there needs to be change in the hospital environment and changes in the behaviour of patients and staff

 

  • ENVIRONMENTAL CHANGES
    • Access to hand washing and alcoholic hand gel
    • Easy clean work surfaces and computers
    • Adequate toilets and bathrooms for staff, patients and relatives
    • Side rooms where possible, and isolation wards for those with proven contagious HCAI
    • Mandatory reporting for HCAIs (MRSA 2001, C.difficile 2004)
    • Reduced total bed occupancy
  • BEHAVIOURAL CHANGES – PATIENT CENTRED
    • Promoting a culture of cleanliness by encouraging reporting of ‘dirty areas’, challenging staff as to whether they have cleaned hands, encouraging visitors to clean hands
    • Promote education of patients and relatives regarding HCAIs
    • Screening for MRSA pre-admission
    • Treating with pre-operative chlorhexidine
  • BEHAVIOUR CHANGES – STAFF CENTRED
    • Use of appropriate barriers to infection eg gloves, visors etc
    • Safe management of spillages and disposal of sharps
    • Education on infection and the importance of hand washing etc
    • Cleaning, disinfection or sterilisation as appropriate
    • Use of antibiotics as a prophylactic measure when appropriate but avoidance of long term use
    • Sensible clothing policy




Further Points

This is one example of the practical application of risk management.

Others may be the prevention of allergic reactions, or the policy around safe surgical site marking etc

What happens when a patient lodges a complaint?

 

Model Answer:
VERBAL COMPLAINT
  • The complaint can be addressed to any member of the team and not necessarily those that were part of the complaint
  • This then needs to be relayed to the complaint lead for the department who will then gather the appropriate people named in the complaint for a management plan to be developed
  • An explanation is then derived together with an apology if an error has been made
  • This is then fed back to the complainant in an expeditious manner




WRITTEN COMPLAINT

 

  • Once a complaint is registered by either the Chief Executive’s office or the Patient Advocacy and Liaison service (PALS) it is forwarded onto the complaint lead/complaint officer
  • Statements are then collected from all persons involved via departmental managers and are then assessed in completeness by a designated assessor (often the medical director)
  • A letter is then drafted to be signed by the Chief Executive which should be in plain English and address all the points with an apology if appropriate
  • This should take no greater than 20 days from receipt




What is the next step if this doesn’t achieve solution?

  • The matter is investigated by an independent review panel (IRP), made up of independent clinicians and lay members. They may recommend further resolution at a local level.
  • If the complainant is still unhappy then referral to the local Ombudsman is the last option. He or she has links to the DOH via the Care Quality Commission (CQC) and their decision is final.




Are there methods for legal redress?

  • If the complainant want to pursue the legal route this is a separate process and is funded by the Clinical Negligence Scheme for Trusts (CNST) which is itself managed by the NHS Litigation Authority (NHSLA)




Further Points

What features in you make a good surgeon?

Model Answer:
Manual dexterity
  • The importance of basic manual dexterity
  • The ability to show improvement and learn new techniques
  • The importance in recognising that improvement comes with practice and reflection on ones deficiencies




Problem solving ability

 

  • The ability to approach a problem in a rational and stepwise fashion
  • The ability to assimilate the information obtained and formulate an action plan
  • The ability to recognise that this plan can be surgical, medical or conservative depending on the problem and that these options may change
  • The ability to disseminate this information to the patient in a way they can understand




Working under pressure

 

  • Should be able to work in pressured environments
  • Be able to prioritise tasks in order of clinical importance
  • Should be able to keep calm when things are not going to plan
  • Should be able to multitask effectively




Team working/management skills/leadership

 

  • Please see generic questions ‘What makes you a good team player/leader etc’ for further suggestions. A good surgeon will need to develop leadership, management and organisational skills in equal measure to the more practical aspects such as manual dexterity




Further Points

  • The answer will be individualised according to your own beliefs
  • That there is more to a surgeon than operating and communication is a very important skill

You are assisting one of your junior ST trainees performing an appendicectomy – it becomes apparent that she is not competent to perform the procedure. What would you do?

Model Answer:
Recognise that patient safety is paramount with tact and diplomacy
  • Make the operation safe as soon as possible
  • Try not to embarrass the junior trainee in front of theatre staff
  • If possible hand the operation back to your junior when it is safe to do so under close supervision




Ensure that informal but structured feedback is given

 

  • Soon after the operation has finished have a feedback session
  • Review what the trainee has feels has gone well and badly
  • Feedback what has gone well and then what could be improved upon
  • Review a verbal/written logbook and assess whether the trainee is appropriate for his/her stage in training
  • If appropriate explore any particular reasons for poor performance on this occasion




Implement a plan for future training

 

  • Plan perhaps a staged operation where the next appendicectomy has a defined part for the trainee to perform and concentrate on
  • Highlight a particular deficiency to improve on eg suturing/knot tying/anatomical knowledge and then test this specifically at the next operation




Further Points

Remember to accentuate the positives before concentrating on the negatives

Remember that patient safety is your chief concern rather than training

What are the advantages and disadvantages of surgical practitioners?

Model Answer:
Define a surgical practitioner
  • Surgical practitioners are non-medically trained health care practitioners from a variety of backgrounds who perform a variety of usually minor surgical procedures without supervision




Advantages

 

  • Ease waiting list pressures which is of benefit to the patient, to the organisation as a whole and also potentially to the trainee who can then focus on more ‘major cases’
  • Surgical practitioners are generally less costly to employ for a trust
  • Surgical practitioners will usually form part of the department’s regular clinical team as opposed to junior doctors who tend to rotate




Disadvantages

 

  • Issues regarding training. Many of the cases carried out by surgical practitioners would have previously been ‘training’ cases for CT and junior ST level doctors
  • With a finite volume of minor work it may be completely deskilling the junior doctor
  • Without experience at the normal anatomy and straight forward cases, increasingly difficult to deal with complications and re-do cases
  • Issues of patient safety
    • Practitioners would not usually have the breath of surgical knowledge that a junior doctor would have – issues regarding dealing with the unexpected event
    • Independent practitioners with a nominal consultant. Who to call in the event of a serious complication
    • Should patients be given the choice as to who will be performing their operation
    • Issues regarding professional regulation
  • Issues regarding finance
    • Although cheaper to employ in the short term, possibly take longer to perform the procedure – questionable long term savings




Further Points

With all of these questions which probably will have an effect on your training, be careful to give a balanced, reasoned argument. Try to understand it from both sides of the coin

 

What are your views on competency based training. Are we just treating you like children?

Model Answer:
Describe what is meant by competency based training
  • Be able to define the various components of CBT (otherwise known as Workplace Based Assessments – WBA)
    • Mini PAT (peer assessment tool) or 360° assessments. Multi person assessments every 3 years
    • Mini CEX (clinical evaluation exercise). Assesses professional skills
    • DOPS (directly observed procedures). Assesses practical skills. Depends on level and speciality and is trainee led.
    • CBD (Case based discussions). Detailed discussion to assess clinical judgement, decision making, ability to prioritise and application of clinical skills
    • PBA’s (procedure based assessments). Similar to DOPS but for surgeons. Tests technical skills and ability for index procedures at an appropriate level
  • Discuss why they have become an important part of modern training
    • Not only ensure that trainees progress satisfactorily but also provide documented evidence of learning and development
    • Trainee led and directed therefore can be tailored to choice of future career
    • With training becoming shorter the development of a structured practical portfolio is essential




Describe the benefits of competency based training

 

  • Repeated assessments of practical issues
  • Regular appraisal
  • Evidence for portfolio
  • Potential to involve many more trainers, medical professionals and patients




Describe the pitfalls associated with competency based training

 

  • Time consuming filling in of forms
  • Patronising
  • Variable relevance dependant on the quality of the assessor and their feedback
  • However, emphasise the need to engage in the process to try and improve some of the obvious shortcomings




Further Points

WBA/CBT is here to stay. We all appreciate that it can be laborious but in the increasingly litigation led world we live in, it is probably a very worthwhile thing in the long term

 

Have you had experience of teaching a surgical procedure and if so can you tell me about it?

Model Answer:
Choose a procedure and set the scene
  • Procedure that you are competent to perform
  • Trainee who is appropriate level to learn procedure
  • If possible divided into distinct sections which can be learnt independently




Describe how you taught the procedure or part of the procedure

 

  • Teaching experience highlighted beforehand
  • Trainee expected to read up on procedure and you to brush up on relevant anatomy
  • Encourage trainee to take ownership of operation ie pre-op checks, consent if appropriate, positioning, prescription of thromboprophylaxis/antibiotics etc
  • Allow trainee to perform the complete operation or a pre agreed part of operation with encouragement but under supervision
  • Always be available to give support if needed
  • Remember patient welfare paramount




Were there any difficulties encountered?

 

  • Was the trainee out of his/her depth and you had to take over sympathetically
  • Did your trainee encounter a complication you had to deal with
  • Did your trainee encounter a complication which you couldn’t deal with
  • Did the patient not want a trainee operating on them




How did you deliver feedback?

 

  • In a semi formal setting perhaps using a PBA
  • In a constructive manner – good points then points to improve on from both yourself and the junior trainee
  • Defined points for improvement next time and ensure that they are assessed again




How did you collect feedback?

 

  • Ask trainee to complete a feedback form you have designeed
  • Shows dedication to improvement and that you take teaching seriously




What have you enjoyed about the process?

 

  • Personal satisfaction from teaching colleagues
  • Gives you the opportunity to revise the procedure and anatomy
  • Helps the team bond together




Further Points

Remember to highlight that teaching is best received if in a relaxed supportive environment and patient safety is paramount

 

In the world of general and ‘visceral’ surgery do you think that laparoscopic training of your seniors will de-skill you in open surgery?

Model Answer:
Laparoscopic surgery is a major innovation in both upper and lower gastrointestinal surgery
  • Set to be the gold standard
  • Improved patient pathway in the majority of cases
  • Something all ‘visceral’ trainees should aspire to be proficient in




It is important to have exposure to both open and laparoscopic approaches and be proficient in both

 

  • Laparoscopic surgery is not appropriate in all settings. You should recognise the importance of both techniques
  • Emergency surgery or the battlefield abdomen often requires the open approach
  • The open approach is inevitably needed when an operation cannot be completed by the laparoscopic route
  • Emphasise the skill set you have acquired as a ‘specialisation’




Without the UK system of rotational training there would be a real risk of becoming a ‘one trick pony’

 

  • Throughout rotational training the trainee will be exposed to trainers with a variety of clinical skills and interests
  • For a variety of reasons different units will always have a different and varied case mix
  • In the future, all GI surgeons will be competent in laparoscopy to a lesser or greater extent
  • It will be vital for the same surgeons however to remain proficient in open surgery for the points mentioned above
  • To avoid being de-skilled the trainee will have to seek out the training needs which are most appropriate to them as part of rotational training
    • The difference in modern Gi training now is probably that the trainee will be exposed to laparoscopic approaches almost hand in hand with open training
    • Whereas this has obvious advantages, it should also be remembered that the trainee has to act with a large degree of responsibility for his/her own training




Further Points

 

You have been asked to see a 28-year-old man in clinic who has a biopsy proven melanoma on his left arm. He is terrified of surgery and flatly refuses any treatment. How would you deal with this situation?

Model Answer:
Introduce yourself and ascertain level of knowledge
  • Explain your role within the team
  • Discover how much he knows about the diagnosis and prognosis
  • Ascertain whether his beliefs are grounded in fact or fiction
  • Try and establish how much he needs to know vs how much he wants to know




Give facts in an honest and professional manner

 

  • Explain the facts of his condition based on the information you have
  • Give your recommendations regarding treatment
  • Explain the basis for your recommendations
  • Explain that refusal of treatment is his right and doesn’t affect the treatment he will receive, but is associated with a poorer prognosis
  • Explore the pros and cons of alternative methods of treatment




Investigate reasons for not wanting treatment

 

  • Ask what are his reasons for avoiding treatment
  • What aspect of surgery worries him the most
  • Is there anything else which is affecting their decision




Attempt to address the fears in a rational way, offer a second opinion etc.

 

  • Address the issues in a sympathetic and non-judgemental way
  • Offer a second opinion from your consultant
  • Offer written/internet based information sites




Arrange a follow up visit

 

  • Give him time to think about the options
  • Arrange a follow up visit with yourself and the consultant
  • Give the contact details of your specialist nurse in the meantime
  • Give details of melanoma support groups if appropriate




Further Points

Be aware that although you have the patients best interests at heart, what needs to be shown is that you can have a reasoned argument whilst remaining sympathetic to the patients concerns and fears

 

You have asked one of your senior ward sisters to apply a dressing to a wound following inspection. When you come back later in the day, the patient has an uncovered wound and tells you that the nurse told him that in her experience this was best and that she was going to talk to you about it. What would you do?

Model Answer:
Discuss the issue with the ward sister in person
  • Ask the sister why she chose to leave the wound exposed (ie what was her evidence) in a non confrontational way
  • Explain your reasons for asking the wound to be dressed in this particular case
  • Ask the sister if she would be able to contact you before changing the management plan next time
  • State that you are always willing to learn and are there any other points that she feels would be useful
  • Suggest the involvement of a tissue viability nurse or similar professional no as arbitration but as advice
  • Try and come to a conclusion between yourselves
  • Come to a conclusion between yourselves




Discuss the issue with the patient

 

  • Try and approach the patient with the sister as well
  • Explain to the patient that there are many ways to manage a wound which are all equally valid
  • Give the reasons for leaving a wound covered or exposed
  • Stress that the sister has much more experience than you and that any definitive decisions are made by a clinical team
  • Explain why the management is as it is in this particular case




Disseminate the information you have gathered

 

  • Via a teaching session for the nurses
  • Via an educational session at a M & M meeting
  • If possible it should include nursing input either from the ward sister or a tissue viability nurse
    • This is a classic question hinging on effective teamwork
    • You should make it clear that you respect the sister’s opinion and value her as an integral part of the team
    • You should also however make it clear that it your instructions are to be changed it is important that this is discussed with you prior
    • You should be respectful but stick to your guns
    • Multi disciplinary team working is the key




Further Points

Your Answer:

Enter Answer Here: (free text)


26337



Average

This question is essentially ‘how to deal with a complication’

Inform your supervising consultant

  • As early as possible, let you consultant know and the circumstances under which it happened
  • Try and salvage the situation if possible (with urology input)
  • Finish the operation safely and carefully




Document what has happened clearly in the notes

 

  • Document how the complication happened
  • Document who was involved and who you consulted for advice




Inform the patient at the first available opportunity

 

  • Explain the complication to the patient
  • Check whether he was consented for this complication from the consent form
  • Explain the possible side effects that this error may have
  • Organise follow-up semen samples if necessary




Put measures in place to ensure the complication is avoided in the future

 

  • Constructive feedback with your consultant
  • Revision of anatomy
  • Present in an M & M meeting




Further Points

Complications happen, some are avoidable whilst some are not

It is important to recognise potential complications early

In an interview setting it is important to show that you can learn from your mistakes

 

You are working in casualty and have been asked to see an elderly man who has come in with bowel obstruction probably secondary to an obstructing tumour. He is very upset as he was sent home the day before from casualty by your registrar who said it was wind.. How would you tackle this?

Model Answer:
Review the clinical notes from yesterday
  • Ascertain what the mode of presentation was yesterday and how it differs from today
  • Try to explain to yourself why the clinical misdiagnosis was made
  • Try to establish whether you feel any clinical harm has come to the patient by the delay in diagnosis




Make sure that the patient understands that his clinical situation is your priority at the moment

 

  • First ensure that the patient is managed appropriately for his diagnosis
  • Explain carefully what his likely diagnosis is at the present time
  • Explain the likely steps in his management from now on




Explain that it is difficult to second guess a colleague with the benefit of hindsight

 

  • Explain that the clinical presentation of this condition can change day to day
  • Explain that you may have done the same as your colleague the day before when the presentation was different
  • Explain that mistakes happen and that your colleague is experienced and would have been trying his best
  • Explain that the delay is very unlikely to affect his eventual diagnosis or prognosis




Understand that part of his annoyance is probably fear at this unexpected diagnosis

 

  • Explore this avenue and ensure that he understands that there is treatment
  • Make sure that he has access to appropriate information and eg colorectal nurse specialists
  • Ensure that his family understand the diagnosis (with the patient’s consent)




Explain that you will feedback to your colleague

 

  • Give feedback to your registrar whenever it is appropriate to do so
  • Explain that the patient can place a complaint if he still feels the need and give him the contact details




Further Points

This a common communications scenario and you are being tested both on clinical knowledge and effective communication skills

Be careful to support your colleague but equally you are the patient’s advocate

 

You are the casualty SHO and have been asked to see a young boy who has been involved in a high speed RTA. He has a probable splenic laceration and is hypotensive and tachycardic. He needs blood and theatre. His parents are Jehovah’s witnesses and object

Model Answer:
Remember that the child’s welfare is your chief concern
  • This patient is very unwell which needs to be recognised swiftly
  • The patient needs to be managed according to ATLS protocol
  • It is very likely that he has lost a significant amount of blood which needs to be replaced




Explain the diagnosis and proposed treatment plan to the parents

 

  • Explain the likely diagnosis and seriousness of the situation
  • Ascertain the parents beliefs
  • Explain that whilst you understand their beliefs, their child’s welfare is your main concern
  • Explain that you will avoid blood if possible it is likely that you will have to administer it to save the child’s life




Try and be sympathetic to the parents views and beliefs

 

  • Try to understand their reasons and beliefs
  • Make sure that the parents appreciate that you are not dismissing them and that you want them to be a part of the decision making processes
  • Try and involve a Jehovah’s witness advocate/religious go between/elder




Seek legal representation if required and involve your seniors

 

  • Involve consultant surgeon, consultant paediatrician and consultant haematologist
  • Involve legal service/on call Judge
  • May need to involve social services if you believe that administering blood would compromise the care the child receives from its parents post-operatively




Further Points

Your only duty here is to the child under ‘Duties of a doctor’

Whilst it is right to keep the parents views in mind, they should not stop you doing your job

If the child refuses treatment, you also have the right to treat regardless

Involve seniors early in these difficult scenarios

What do you understand by informed consent?

Model Answer:
Definition
  • Agreement granted by the patient to receive a given treatment, or have a specified procedure performed on them, after full consideration of the facts and implications




Assess the patient to tailor the consent process

 

  • Gauge the level of understanding and the level of information both desired and comprehendible
  • Takes into account relevant social and religious views and values




Describes the available options

 

  • Describe the various management options which the patient could pursue including the option to do nothing. The risks and benefits of each should be given and although a preferred option can be stated it should not be used to coerce the patient
  • Details of further investigations, tests and procedures which will be required and their purpose
  • The risks, benefits, side effects and success rates of the proposed treatment. Detail should be given on serious side effects even if rare and of the more common side effects no matter how trivial
  • Is the treatment part of a research project or new innovation – the patient should be given the option not to participate and that this would not compromise their care
  • The right to a second opinion
  • The right to have treatment which is not available in your hospital for whatever reason but would be advantageous to the patient
  • Information regarding prognosis
  • Use words the patient can understand and if necessary visual aids




Takes informed consent

 

  • The patient accepts the treatment having weighed up the evidence
  • If the patient does not accept the treatment this should be explored as long as the patient is comfortable
  • If consent is accepted it should be explained that second opinion is available and that the consent can be withdrawn at any time for any reason
    • Remember that consent should be taken by the operating surgeon or a suitably trained member of the team
    • Written consent demonstrates that the process took place with due care and that both parties understood the process.




Further Points