Commitment to Professionalism

Question 1

1. A junior colleague on your team always takes his copy of the
   patient list home as there is no confi dential waste bin on the ward.
   He says this also helps him prepare for the following day as he can memorize
   details in time for the consultant ward round.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Tell him this is unfair as he is ‘getting ahead’ and making you look
   disorganized by knowing patient details before the ward round.
   B Ask Matron or a Senior Sister about obtaining a confi dential waste bin.
   C Let your colleague know that he should not be taking a patient list
   home each day.
   D Speak to the consultant about your colleague’s behaviour.
   E Take your own list home so that you can be as familiar with the
   patients as your colleague.

Answer 1

1. C, B, D, A, E
   Confi dentiality is important for maintaining patient dignity and trust in
   the medical profession. The security of a patient list cannot be guaranteed
   at home and most Trusts will have policies preventing staff from
   removing details in this form. The best answer is to raise the issue informally
   with your colleague (C): this deals with the issue immediately and
   gives them an opportunity to refl ect on their behaviour. Asking for a confi
   dential waste bin (B) also deals with the problem but less immediately
   and does not guarantee that it will be used by this colleague. Speaking to
   your consultant (D) also addresses the problem indirectly but it is less
   ideal than (B) because it risks jeopardizing your working relationship, and
   may represent premature escalation. (A) is the fi rst incorrect answer
   as this would appear childish, unnecessarily competitive, and misses the
   real concern about breaching patient confi dentiality. The worst answer is
   (E) as duplicating your colleague’s error only doubles the risk of a patient
   list being lost.

Question 2

2. A patient on your ward is HIV positive. He is from a minority
   community which he feels might react negatively if they knew of
   his diagnosis. As a result, he is very anxious that no one (including his
   close family) should be told.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Eliminate all mention of HIV from his notes.
   B Amend your patient list so this detail is missing or obscured (e.g. ‘retroviral
   illness’).
   C Ensure the safety of other doctors and phlebotomists by writing
   ‘HIV+’ on blood requests.
   D Tell the patient that he should talk to his family as you cannot guarantee
   complete confi dentiality.
   E Continue as you would for any other patient under your care.

Answer 2

2. E, B, D, C, A
   This is a diffi cult question. (E) is probably the best answer as you should
   already be doing everything in your power to maintain patient confi dentiality,
   particularly information that is very sensitive. (B) is almost as good
   an answer as you are acting positively to respect your patient’s request.
   It is not as good as (E) only because you should already have been doing
   everything possible to ensure information is secure. (D) is the fi rst wrong
   answer for two reasons. First, you would not usually tell a patient they
   must talk to their family about a sensitive diagnosis outside the unique
   circumstance of there being a sexual partner at risk of infection. Second,
   although you cannot guarantee they will never become aware of his diagnosis,
   you should be able to confi dently state that everything you do
   will protect his confi dentiality. (C) is wrong as it breaches your patient’s
   confi dentiality unnecessarily. Some Trusts will have a system of indicating
   high-risk patients (e.g. coloured stickers) so phlebotomy staff can
   take additional precautions. However, there is an argument that maximal
   precautions should always be undertaken for invasive procedures and
   therefore this information would be unnecessary to share. In this case,
   writing ‘HIV+’ is incorrect as high-risk patients can be identifi ed without
   disclosing their precise diagnosis. The worst answer is (A) because
   obscuring the diagnosis from his notes will mislead others and potentially
   place the patient at risk.

Question 3

3. You are sitting in the pub opposite your hospital after work.
   A group of doctors and nurses from another department is
   talking loudly and joking about patients on their ward. These patients
   could easily be identifi ed from the conversations you are overhearing.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Speak to the person who is speaking loudest so he is aware that his
   behaviour is inappropriate.
   B Call hospital security and ask them to intervene.
   C Challenge the whole group so that they are aware that their behaviour
   is inappropriate.
   D Contact a manager in their department the following day to alert
   them to this breach.
   E Ignore the situation, as they should know better and you do not want
   to cause a scene.

Answer 3

3. A, C, D, E, B
   This group is exposing patient confi dentiality to signifi cant risk. The best
   answers are (A) and (C) as they address the problem contemporaneously
   and stand the best chance of protecting patient confi dentiality. It is
   diffi cult to diff erentiate between the two but you are likely to have more
   success speaking to an individual (A) than approaching the whole group
   (C). (D) would also address the problem but is less ideal because it does
   not stop the problem at the time it was occurring. However, you might
   not feel confi dent reprimanding colleagues on your own out of hours in a
   social environment and, in which case, you should raise the issue formally
   with the Trust (D). (E) is the fi rst wrong answer as you have a professional
   duty to protect patients and challenge inappropriate behaviour.
   Some people might argue that (B) is at least an attempt to address the
   situation; however hospital security would likely be surprised by such a
   call and have no jurisdiction away from the hospital site.

Question 4

4. As you arrive on the ward one morning, you hear a nurse in a
   side room shouting at a patient. The tone and language used are
   unpleasant. You know that the patient is elderly and has severe dementia.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Knock on the door and ask to speak with the nurse.
   B Discuss the issue with a senior nurse (e.g. Matron) in the fi rst instance
   as soon as they arrive.
   C Make preliminary enquiries from other staff working that night to ask
   if they have noticed inappropriate behaviour.
   D Use body language to show your disapproval but do nothing formally
   as patient safety is not at risk.
   E Contact the Care Quality Commission anonymously to avoid raising
   the issue with employees of your Trust.

Answer 4

4. A, B, C, E, D
   You have a duty to take appropriate action following any concerns about
   patient care, dignity, or safety. The question raises the issue of verbal
   abuse by a member of staff against a vulnerable patient. (A) is the best
   answer because it addresses the issue immediately and separates the
   (potentially abusive) staff member from the patient. (B) is the fi rst incorrect
   answer even though a senior nurse is exactly the right person to
   speak to. This is because waiting for such a person introduces delay and
   does not ensure the immediate safety of this patient. (C) is also wrong
   because it introduces delay but, this time, you are speaking to the wrong
   people, and risk prejudicing a disciplinary (or even criminal) investigation
   at a later time. However, (C) does imply that you are planning to
   take further action, even if it is not your role to investigate at this stage.
   (E) is not as good an answer as there is nothing in the question that
   justifi es raising concerns externally when internal procedures are likely
   to be more expedient. (D) is obviously the worst answer as the GMC
   imposes a duty on doctors to raise concerns about patient dignity being
   compromised. You are not at liberty to ignore this event.

Question 5

5. You begin induction at your new Trust and are asked to sign a
   number of agreements. One of these is an agreement never to
   raise concerns with bodies outside of your employing organization. This
   is a condition of taking up your post.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Sign the form and begin work as instructed.
   B Throw the form away and hope that no one notices that it was not
   returned.
   C Explain that you cannot sign as this prohibits you raising concerns
   appropriately about patient welfare.
   D Sign the form but resolve to raise concerns about patient safety in
   whatever way is necessary to ensure their resolution.
   E Contact your medical defence organization or the GMC for advice if
   in doubt.

Answer 5

5. C, E, B, D, A
   The GMC is clear that doctors must not sign contracts that fetter their
   ability to raise concerns. The simplest approach would be to politely
   explain that you are unable to sign such a document (C) as this might
   resolve the issue and could even prompt the Trust to avoid asking doctors
   to do this in future. An alternative but more complicated approach
   would be to contact the GMC or medical defence organization for advice
   (E). The fi rst incorrect answer is (B) as this ignores your new employer’s
   improper attitude to whistleblowing and has a fl avour of dishonesty as
   you are deliberately not returning the form in the hope that no-one will
   notice. (D) is worse than (B) in that it is essentially the same but this
   time you have deliberately agreed to something with which you have no
   intention of fulfi lling. The worst answer is (A) as this is contrary to your
   professional obligation to raise concerns.

Question 6

6. You are on call and asked to prescribe amoxicillin for a patient
   complaining of pain on urination. The nurse has tested his urine
   which shows leucocytes and nitrites characteristic of a urinary tract infection.
   Amoxicillin is the suggested treatment according to local protocol.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Thank the nurse for being proactive and prescribe amoxicillin.
   B Prescribe trimethoprim as this is the antibiotic of choice according to
   your recollections from medical school.
   C Review the patient yourself and then prescribe if necessary.
   D Reprimand the nurse for testing the urine without instruction.
   E Explain that you will only prescribe antibiotics if the patient becomes
   confused or haemodynamically compromised.

Answer 6

6. C, A, B, D, E
   Although the diagnosis might be clear, you are responsible for the appropriateness
   of prescriptions. The best answer is therefore (C) as the patientwill receive the correct treatment and you can ensure (for example) that
   they are not grossly unwell and have no allergies etc. (A) is the second best
   answer as the patient receives the correct treatment and you are working
   positively with your nursing colleague. You will commonly see this scenario
   played out on the wards; however, the responsible doctor should really
   assess their patient before prescribing. (B) is less ideal because, although
   it may be an appropriate treatment, antibiotic policies will refl ect local
   resistance patterns and should be followed unless there are good clinical
   reasons to depart from protocol. (D) is the fi rst obviously wrong answer
   as you are unlikely to provoke a positive reaction, have not treated the
   patient, and there is no reason why a nurse should not proactively identify
   clinical problems. (E) is the worst answer as it exposes the patient to significant
   harm by waiting for them to become compromised by their infection.

Question 7

7. You feel understaff ed and undersupported when on call. Together
   with an FY2 doctor, you are responsible for all new medical
   admissions and the welfare of around 300 ward patients. Attempts to
   raise your concern with managers, your Educational Supervisor, and the
   Clinical Director have been unsuccessful.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Contact the Medical Director and, if necessary, the Trust Chairman.
   B Document each stage of your complaint carefully.
   C Contact a documentary programme and off er to carry a hidden camera
   to capture specifi c problems.
   D Write an article for your local newspaper raising concerns about the
   care of Mrs Baggins in side room 4.
   E Carry on and do your best whenever you are on call.

Answer 7

7. A, B, E, D, C
   (A) is the correct answer as it is the most appropriate way of escalating
   concerns when other appropriate people have been unable to help.
   (B) is vital as it may protect you later and provides a valuable record;
   however, it does not in itself address the issue at hand. The other three
   answers are incorrect. Although carrying on and ignoring the problem is
   wrong (E), your part is at least neutral and others may highlight concerns
   instead. This makes (E) slightly better than (C) and (D) as these answers
   require you to actively breach patient confi dentiality without any attempt
   to raise concerns internally fi rst. (C) is the worst option only because a
   video record feels like a greater breach of privacy and there is an element
   of dishonesty in concealing a camera at work.

Question 8

8. Your consultant knows that you are interested in his specialty and
   suggests that you attend a one-day course in another city the following
   week. You recognize that this would be a good opportunity for
   professional development. Unfortunately you have no remaining annual
   leave days and are not entitled to study leave. The rota administrator says
   that you cannot have time off to attend.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Ask your SHO if she will look after the ward in your absence and go
   if she agrees.
   B Speak to your Educational Supervisor and, with their support, ask the
   service manager for special permission.
   C Accept that you cannot attend the course.
   D Add up the number of days that you worked late the week before and
   attend the course as you are owed enough hours in lieu.
   E Attend the course as you already have your consultant’s permission.

Answer 8

8. B, C, A, D, E
   The two possible correct answers are (B) and (C). (B) is slightly better
   as you are proactively trying to attend a useful educational event while
   following your department’s rules. (A) is the fi rst incorrect answer as
   informal arrangements of this kind can breach departmental procedures
   and problems could arise, for example if that team member is deployed
   elsewhere because of staff shortages or is unwell on the day in question.
   However, you have at least made an eff ort to ensure your patients are
   looked after and that your clinical team (SHO and consultant) agree to
   your absence. (D) and (E) are both wrong as you are not entitled to
   attend and have made no eff ort to arrange clinical cover. However, (E) is
   worse because, on top of everything else, it means taking time away
   when you are being paid to be at work.

Question 9

9. An elderly patient’s daughter tells you that she is concerned about
   the ward care of her mother. She is thinking about writing a formal
   complaint, and asks you if she is over-reacting and how best to complain.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Tell her that you will look into things but that a formal complaint will
   not help.
   B Suggest that she drops into the Patient Advice and Liaison Service
   (PALS) to see what they can off er.
   C Explore her concerns and try to clear up any misunderstandings.
   D Let your consultant and/or the Ward Sister know that the daughter is
   dissatisfi ed and that a formal complaint might follow.
   E Tell the daughter that the ward nurses are particularly bad and that
   she should complain.

Answer 9

9. C, D, B, A, E
   The best answer is clearly to do what you can to clarify misunderstandings
   (C) as this will help you understand the concerns and might facilitate
   a speedy resolution. (D) is the next best answer as making colleagues
   aware might help resolve issues and will keep them informed. (B) is also
   appropriate as PALS can off er advice independently of the clinical team
   and help this relative take her complaint further. However, she might not
   visit PALS after your conversation and (B) is not as good as (D) becausethe Ward Sister might be able to allay concerns or solve problems more
   expediently. (A) is the fi rst wrong answer because you should never
   discourage others from exercising their right to complain about poor care.
   However, (E) is wrong for two reasons as it is unprofessional to complain
   about colleagues to third parties and, as in (A), you are attempting to
   infl uence the relative’s decision about whether to complain.

Question 10

10. You are reviewing the drug chart of Tim, a young male patient
    with a previous anaphylactic reaction to penicillin. Your
    registrar has prescribed Tazocin which you know contains a penicillin
    antibiotic. The patient has not yet received his fi rst dose.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Strike out the prescription and let the nurse know that it should not
    be administered.
    B Complete a clinical incident form.
    C Speak with the registrar to alert him/her to this error.
    D Ensure that the allergy is recorded clearly on the drug chart and in the
    patient’s notes.
    E Amend the prescription, but do not cause a fuss as no harm was done.

Answer 10

10. A, E, D, C, B
    Your fi rst priority is Tim’s safety. (A) is therefore the best answer because
    it ensures the drug is not administered. (E) is partially correct because it
    ensures the patient is safe, but it does not follow through to understand
    the cause of the error or to ensure it doesn’t happen again. (D) is correct
    and should happen although in itself is insuffi cient to ensure the
    drug is not administered. The last two answers (C) and (B) address the
    cause of the mistaken prescription but fail to correct the immediate risk
    of an avoidable anaphylactic reaction. Raising the issue directly with
    the registrar (C) is better as it ensures immediate feedback (while they
    remember the case) and you can be satisfi ed yourself that feedback has
    been delivered. (B) would complete your clinical governance obligation
    to ensure errors are reported centrally to permit root cause analysis and
    identifi cation of structural problems. However, as an isolated intervention,
    it is less important than the others.

Question 11

11. You are concerned that patients on your ward are rarely seen
    by a senior doctor. They are reviewed weekly by a registrar
    but almost never by consultants, who seem to be working at a private
    hospital most of the time. You are uncertain whether to raise the
    issue or how you would do this as both your Clinical and Educational
    Supervisors are consultants within this department. You are deciding
    whom to contact for advice.
    Choose the THREE most appropriate actions to take in this situation
    A The consultant who seems most absent from the department and is
    known to have the biggest private practice.
    B Your partner.
    C Your medical defence organization.
    D A friend from school whose judgement you trust and is now a solicitor.
    E An employer liaison offi cer at the General Medical Council.
    F A consultant in another department who is known for his fi erce opposition
    to private practice.
    G An SHO who spends his weekends at the private hospital assisting in
    theatre.
    H A senior non-clinical colleague (e.g. a manager).

Answer 11

11. C, E, H
    This is a diffi cult question that implies a long-standing, cultural issue
    within your department, which you have interpreted as resulting in a
    lack of senior staff available to patients. It is diffi cult to know under the
    circumstances who best to contact, although, in such cases of uncertainty,
    the GMC suggests getting advice from a senior member of staff
    (H), a GMC employer liaison adviser (E), a medical defence organization
    (C), or Public Concern at Work, which is a charity providing confi dential
    advice in such cases. The absent consultant (A), moonlighting SHO
    (G), and the consultant opposed to private practice (F) seem unlikely
    sources of impartial advice. Your partner (B) and friend from school
    (D) are not recommended as they might not understand the issues and/
    or are not bound by professional duty (e.g. to keep your concerns in
    confi dence).

Question 12

12. A medical student approaches you for advice. He is very concerned
    that your consultant has asked students to perform
    rectal examinations on patients under general anaesthesia without consent.
    You doubt that this is possible and suspect consent must have been
    obtained beforehand.
    Choose the THREE most appropriate actions to take in this situation
    A Warn the student not to say anything as he will upset the consultant
    and/or make him angry.
    B Explain that the consultant is very professional and that consent might
    have been obtained beforehand.
    C Explain that consent was probably obtained beforehand and that the
    student should do as instructed in theatre.
    D Advise the student to ask the consultant if there is doubt about the
    consent process.
    E Warn the student not to say anything as he needs the consultant’s
    support to pass the rotation.
    F Tell the student that specifi c consent for him is not required for some
    procedures (e.g. rectal cancer resection).
    G Advise the student to mention this on the anonymous feedback after
    the rotation ends.
    H Suggest that the student speaks to an appropriate person at his medical
    school if in doubt.

Answer 12

12. B, D, H
    All doctors should encourage a culture in which concerns can be raised
    openly. This is particularly important for medical students who must
    learn early on not to ignore concerns. However, you should seek to
    clarify any misunderstandings and mention that consent might have been
    obtained without the student being present (B). Ultimately, the student
    should raise this issue with the consultant (D) to ensure they are not
    complicit in examining patients inappropriately. If they have concerns,
    their medical school will have its own ‘raising concerns’ policy (H).You should not advise the student to keep quiet about their concerns.
    Specifi c consent for examination by medical students cannot be implied
    by consent to any particular operation (F). Raising the concern anonymously
    (G) may be unhelpful, as misunderstandings cannot be clarifi ed
    and neither can further details be gathered for the concern to be acted
    upon. The student may wish to contact his medical school (H) before
    escalating concerns up the Trust hierarchy.

Question 13

13. You are the surgical FY1 doctor and hear that an unconscious
    patient in the A&E resuscitation area has a ruptured abdominal
    aortic aneurysm (AAA). Your SHO tells you to feel the patient’s abdomen
    as this is a rare opportunity to feel the expansile mass you read about in
    textbooks. You have never felt a ruptured AAA before.
    Choose the THREE most appropriate actions to take in this situation
    A Decline to examine the patient as you do not have consent.
    B Make a note to read about abdominal aortic aneurysms as this is not
    something you have encountered properly before.
    C Find your medical students so that they can examine the patient
    as well.
    D Examine the patient as this is a valuable learning opportunity.
    E Introduce yourself to the most senior doctor present and ask if you
    can examine the patient.
    F Tell your SHO that you are busy on the ward and will go later if you
    have time.
    G Call the patient’s next of kin at home to ask if you can examine her
    father.
    H Tell your SHO that you will only examine the patient if he completes
    a work-based assessment for your e-portfolio.

Answer 13

13. B, D, E
    As a doctor, you have a responsibility to maintain your clinical skills and
    learn from patients. It is important to make allowance for this despite
    routine clinical commitments (F). Educational opportunities should be recognized
    for their intrinsic value and not simply to gain work-based assessments
    (H). This case clearly raises an issue of consent that is impossible to
    obtain under the circumstances. However, you are unlikely to feel a ruptured
    abdominal aortic aneurysm in a well patient and a brief abdominal
    examination may be appropriate (D) (A). As a doctor, you are in a diff erent
    position from medical students who cannot directly infl uence a patient’s
    care (C). If you were to examine the patient, it might be appropriate to
    ask the senior clinician responsible for their care (E). However, calling the
    patient’s relatives at a time when they are probably distraught is likely to be
    unhelpful (G). You should certainly identify this gap in your experience and
    read about aneurysms whether or not you examine the patient (B).

Question 14

14. You are a medical FY1 doctor seeing a new patient in A&E.
    This could be an opportunity to ask your senior to complete a
    work-based assessment for your e-portfolio. The assessment requires a
    senior doctor to observe you examining a patient and then complete an
    electronic form. You ask the medical registrar who says she is too busy
    to help. Your SHO overhears and off ers to complete the assessment
    without seeing you examine the patient.
    Choose the THREE most appropriate actions to take in this situation
    A Thank the registrar and ask if you could present the case to her later
    for your own experience.
    B Tell the registrar that you need senior feedback if you are to develop
    as a doctor.
    C Thank the SHO and forward him an electronic form to complete.
    D Ask the SHO if he will complete two work-based assessments at the
    same time.
    E Ask the SHO to watch you examine the patient and then complete an
    assessment.
    F Examine the patient as formally as possible, even though you are not
    being assessed.
    G Examine the patient a few hours later when someone might be available
    to assess you.
    H Tell your Educational Supervisor how diffi cult it is to get senior colleagues
    to complete formal assessments.

Answer 14

14. A, E, F
    Work-based assessments are only one means of developing your clinical
    skills as a doctor. You may wish to examine every patient formally as if you
    were being observed and assessed (F). You might also gain by presenting
    and/or discussing the case (A). In this instance, the ‘helpful’ SHO might
    agree to watch you examine the patient before completing the assessment
    (E). Delaying the patient’s assessment or care for your benefi t is
    unacceptable (G).
    Nevertheless, it is important to recognize that senior doctors have
    other commitments and cannot always be available to teach. Reminding
    the medical registrar of their teaching responsibilities is unlikely to nurture
    a joyous teacher–student relationship (B). Although assessments
    can be diffi cult to obtain, each trainee is responsible for achieving a
    minimum number (H). You should resist off ers from other doctors to
    complete work-based assessments if the criteria for these have not been
    satisfi ed (C) (D). These off ers jeopardize the probity of senior doctors
    and may deprive you of opportunities for genuine feedback.

Question 15

15. You are an FY1 doctor required to attend mandatory teaching
    on Tuesday afternoon. This is also the time that your consultant
    holds his only ward round of the week. Your registrar is unimpressed
    that you want to ‘slip off ’ when you are needed to update the consultant
    on each patient’s progress. He suggests that you sign the attendance
    register then return to the ward round.
    Choose the THREE most appropriate actions to take in this situation
    A Explain that teaching is mandatory and you are required to attend.
    B Sign the attendance register so that your progression through FY1 is
    not obstructed, and then attend the ward round.
    C Agree that your presence on the ward round is necessary and that
    you will miss teaching.
    D Speak with your consultant and explain that your commitments are
    confl icting.
    E Off er to update your registrar about each patient so that he can facilitate
    the ward round in your place.
    F Explain that teaching is mandatory and then go to the doctors’ mess
    for a long break.
    G Attend the ward round but read up on the teaching you missed
    afterwards.
    H Send a text message asking an FY1 colleague to sign you in to teaching.

Answer 15

15. A, D, E
    It is your responsibility to satisfy all mandatory requirements of the
    Foundation Programme. However, foundation doctors are a key part of
    the clinical team and your absence could impact negatively on patient care.
    Therefore you should take steps to minimize the impact of your absence.You should attend mandatory commitments (A) unless this compromises
    patient safety. However, to resolve a potential confl ict in future,
    you should seek advice from your consultant (D). It should be possible
    for another member of your team (e.g. the SHO or registrar) to lead
    the ward round (E) in your absence and you can update this person
    to facilitate continuity of patient care. Only extraordinary circumstances
    should cause you to miss teaching (C) (F). If you have to miss a mandatory
    training session (e.g. because of a clinical emergency) you should
    ensure that you catch up in other ways, such as private study (G). Signing
    the attendance register dishonestly (B) or asking someone else to do so
    (H) raises signifi cant probity issues.

Question 16

16. Your consultant has two third-year medical students and asks
    you to teach them for a day. You are a new FY1 doctor who
    is not yet confi dent with the role and feel that you are too busy to look
    after students.
    Choose the THREE most appropriate actions to take in this situation
    A Tell your consultant that you are far too busy to look after students.
    B Wait until your consultant has left, and then sign the students’ attendance
    forms and send them away.
    C Wait until your consultant has left and then tell the students that you
    are too busy.
    D Give your bleep to a colleague and deliver a 60-minute tutorial on a
    topic of your choice.
    E Explore the students’ career aspirations and ask what jobs they are
    applying for.
    F Give the students clear tasks that match their learning objectives and
    help you if possible.
    G Ask the students to spend the morning completing discharge summaries
    which you will check and sign afterwards.
    H Ask the students questions about topics with which you are particularly
    comfortable.

Answer 16

16. A, F, H
    Doctors have a duty to promote the education and development of
    junior colleagues. (A) is correct as it ensures you will be able to fulfi l your
    ward obligations and that the students are not under-sold with regards
    the teaching they receive. (F) is ideal because it helps both you and the
    students achieve your goals for the day. (H) is helpful as it will stimulate
    the students to think while ensuring you are in a position to correct any
    gaps in their knowledge.
    Signing students’ attendance forms before sending them away
    (B) deprives them of teaching and casts doubt on your own probity.
    (C) is incorrect because it implies dishonesty and prevents the students
    from being taught. A formal tutorial might be useful, but under these
    circumstances might confl ict with ward commitments (D). Similarly,
    frivolous conversation (E) will not benefi t the students nor ensure you
    complete your work on the ward. You should not exploit students by
    asking them to spend signifi cant amounts of time on routine tasks with
    limited educational value (G).

Question 17

17. You are coming to the end of FY1 and are being shadowed by
    the fi nal-year medical student intended to replace you. You are
    very concerned about his attitude towards other healthcare professionals
    and have received negative feedback from the nursing staff . After fi ve
    weeks, he asks you to complete a feedback form for his medical school.
    Choose the THREE most appropriate actions to take in this situation
    A Tell the student throughout the placement that he should adjust his
    attitude.
    B Wait until the end of the placement and then meet somewhere privately
    to discuss your concerns.
    C Tell the student about your concerns but mark all performance
    domains as ‘satisfactory’.
    D Let your Clinical Supervisor know that the incoming FY1 doctor has a
    bad attitude.
    E Indicate your concerns on the feedback form with specifi c examples.
    F Give the student an opportunity to discuss your feedback.
    G Write to the medical school dean suggesting that formal action be
    considered.
    H Wish the nursing staff ‘good luck’ working with the incoming FY1
    doctor.

Answer 17

17. A, E, F
    You must be open and honest while delivering feedback in a constructive
    and professional manner. Raising your concerns throughout the placement
    (A) (B) will allow the student to explain his behaviour (F) and adjust
    his attitude. It would be dishonest to mark the student as ‘satisfactory’
    in a domain if you actually believe otherwise (C). Instead, you should
    raise your concerns using specifi c examples (E) as when giving any negative
    feedback. However, concerns should only be raised with the Clinical
    Supervisor (D) or medical school (G) if their gravity warrants such interventions.
    Inciting the nursing staff to prejudge the incoming FY1 doctor
    (H) would be unhelpful and make it harder for him to change before
    starting the post.

Question 18

18. Your Trust has introduced mandatory online prescribing training
    for specifi c drugs (e.g. insulin, warfarin, and antibiotics).
    You are confi dent working with these drugs and will probably have to
    complete the training in your own time as your ward commitments are
    excessive.
    Choose the THREE most appropriate actions to take in this situation
    A Decline to complete the online modules because there is no time during
    your working day.
    B Complete the online modules quickly, but pick random answers so
    that you don’t have to read the text.
    C Ask your Clinical Supervisor or an appropriate manager for protected
    time in which to complete the modules.
    D Complete the modules in your own time without complaint.
    E Refuse to complete the modules but satisfy yourself that you can prescribe
    safely.
    F Provide feedback after completing the modules as to whether or not
    you found them helpful.
    G Ask your partner, who is a doctor, to complete the modules for you
    at home while you are on call.
    H Contact the British Medical Association to ask whether you can be
    forced to complete the modules.

Answer 18

18. C, D, F
    Doctors must continue to develop knowledge throughout their careers
    and ensure that they are up to date. You should either ask for time during
    the day to complete the modules (C) or recognize their general benefi tand do so at home (D). Refusing to comply with reasonable requests
    from your Trust (A) (E) (H) may cause employment diffi culties.
    Asking someone else to complete the modules (G) or doing so without
    reading their content (B) deprives them of their educational purpose.
    The former is also dishonest. Whether or not you found the
    modules helpful, you should consider providing feedback (F) so that they
    can be developed and improved for others.

Question 19

19. A group of fi ve medical students is attached to your fi rm. You
    have been spending a lot of time with one of the students and
    feel that a mutual attraction is developing.
    Choose the THREE most appropriate actions to take in this situation
    A Try to avoid the student for the rest of the rotation.
    B Meet with the student socially so that any romance can develop away
    from the workplace.
    C Try to ensure that your attention is equally distributed between all
    students on the fi rm.
    D Avoid any romance developing while the student is attached to
    your fi rm.
    E Tell the student that you are attracted to them but that you should
    remain professional.
    F Ask one of the others whether this particular student is attracted
    to you.
    G Try to avoid unprofessional feelings developing in future.
    H Continue with any developing relationship, as you are not directly
    responsible for supervising medical students.

Answer 19

19. C, D, G
    You should avoid compromising your professional relationship with colleagues,
    including medical students (H). As a doctor on the team, you are
    responsible for their supervision, learning, and continued assessment.
    Attention should not be distributed unfairly (C) and romantic relationships
    should be discouraged (D), ideally at the earliest possible stage (G).
    It would be unhelpful and unfair to avoid one particular student (A) and
    unprofessional to meet socially with ulterior motives (B). Although honesty
    is usually commendable, a frank discussion should be avoided (E) as
    it risks escalating the situation and surprising the student, particularly
    if you have misinterpreted their feelings. Similarly, asking questions of
    other students should be avoided (F).

Question 20

20. You have been looking after Sid, a 90-year-old with end-stage
    heart failure, for a number of months. His condition is worsening.
    You visit one day and he hands you an envelope containing £500.
    Although you protest, he insists, saying that it is a ‘thank you’ and that he
    ‘doesn’t need it any more’.
    Choose the THREE most appropriate actions to take in this situation
    A Tell Sid that the gift is too much and that you will only accept £50.
    B Thank Sid for the gift but explain that you are unable to accept.
    C Accept the gift and then ask an appropriate person within the Trust
    whether this is allowed.
    D Ask Sid to sign a statement so you are not accused of theft later on.
    E Accept the gift but give it to Sid’s daughter, who is his next of kin, at
    her next visit.
    F Ask him to think carefully about his decision.
    G Suggest that he donates the money to your favourite charity instead.
    H Ask an appropriate person in the Trust for advice.

Answer 20

20. B, F, H
    There is no absolute rule preventing doctors from accepting gifts.
    However, the GMC does prohibit doctors from inviting or pressuring
    patients to make gifts, either to themselves or to anyone else. For this
    reason, you should not suggest that Sid donates money to a specifi c charity
    (G) or that he off ers you a diff erent amount (A).
    Many Trusts will have policies on gifts (e.g. a maximum value) with
    which you should be familiar before accepting (H), and not afterwards
    (C). Although rules will vary, explaining that you are unable to accept the
    gift (B) is certainly an acceptable response. At the very least, you should
    not accept a high-value gift immediately without being convinced that it
    is more than a spontaneous gesture (F).
    Transferring money from the patient to his daughter (E) when this was
    not his intention would be inappropriate. Asking Sid to sign a statement
    (D) would overly formalize the situation and not protect you against the
    accusation of having coerced the gift. If you feel that this is necessary
    given the gift’s high value, this is an indicator that the gift is inappropriate.

Question 21

21. As the obstetrics and gynaecology FY1 doctor, you are called
    to see a 30-year-old woman who is four hours postpartum and
    is actively bleeding. The patient is a Jehovah’s Witness and she tells you
    she will not accept any blood products. Despite your attempts at fl uid
    resuscitation, the patient continues to bleed. She remains hypotensive,
    with an Hb of 5.5, although still alert and orientated.
    Choose the THREE most appropriate actions to take in this situation
    A Transfuse her immediately with red blood cells.
    B The woman’s decision can be overruled when a child’s life is at risk.
    C Commence a frank discussion with the patient, highlighting the risks
    and benefi ts of the blood transfusion including the possibility of death
    if she refuses.
    D Continue to give intravenous fl uids if the patient consents, but do not
    transfuse any blood products.
    E Wait until the patient becomes unconscious before attempting to
    transfuse blood products.
    F Seek the advice of the consultant haematologist as soon as possible.
    G Call the Hospital Liaison Committee for Jehovah’s Witnesses.
    H Speak to your consultant to initiate the process of overruling the
    patient’s decision with a court order.

Answer 21

21. C, D, F
    In this dilemma, you must balance the principles of autonomy and
    non-malefi cence. Good Medical Practice reminds us that ‘doctors must
    not discriminate against patients by allowing personal views to adversely
    aff ect the professional relationship with patients or the treatment they
    provide’ (A). The patient has severe postpartum haemorrhage (PPH) and
    a transfusion is indicated, but it cannot be given without consent. There
    is no risk to the life of the child (B). It is essential to confi rm the patient’swishes and clarify with certainty any decision to refuse blood products
    (C) before ruling out a transfusion (D), and it should not be assumed that
    her wishes would be consistent with ‘typical’ Jehovah’s Witness practice.
    It would be unethical to transfuse the patient without frank discussion
    while she remains conscious (E). In complex cases involving Jehovah’s
    Witnesses it is absolutely essential to involve senior colleagues, and a haematologist
    should also be involved early on (F). If the patient agrees to
    their involvement, a Jehovah’s Witness Hospital Liaison Committee can
    serve as a useful source of support for patients (G). There is no suggestion
    that the patient currently lacks the capacity to make a decision (H).

Question 22

22. You are examining a ten-month-old infant in A&E who has been
    brought in by his parents after an episode of bloody diarrhoea.
    On examination you fi nd that he has signifi cant scarring secondary to his
    circumcision. The parents say that the circumcision was performed by an
    experienced religious leader in accordance with their beliefs.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A The scarring does not require treatment on this admission, as it has
    nothing to do with the presenting complaint.
    B Document the fi ndings and discuss the management options with
    your consultant.
    C The examination fi nding constitutes evidence of genital mutilation,
    and Child Protection Services should be informed immediately.
    D Refer the patient to a paediatric surgeon for further assessment.
    E Refer the parents to parenting classes for failing to act in accordance
    with their child’s best interests.

Answer 22

22. B, D, A, E, C
    The correct answer is to perform a detailed physical examination, and
    discuss this diffi cult situation with your senior (B). A less appropriate
    response would be to make the referral to the paediatric surgeon yourself
    without your senior’s involvement (D). However, this would be better
    than ignoring your examination fi ndings completely (A).
    The assessment of a child’s best interests must include the cultural/
    religious values of the child and/or parents. (E) is therefore an inappropriate
    referral, regardless of your own personal beliefs about religious
    circumcision, while (C) represents an even more serious accusation with
    greater implications for the parents. However, female genital circumcision
    (or mutilation) is a criminal off ence and should be dealt with as such.

Question 23

23. You receive your fi rst paycheck as a qualifi ed doctor at the end
    of a very busy month’s work on an understaff ed medical ward.
    You are pleasantly surprised to fi nd that you have received substantial
    payment for locum shifts, despite having never been asked to work outside
    your contracted hours. You calculate that the additional hours you
    have had to work on the medical ward approximate to the additional
    payment you have received in error.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Overall, you are receiving the correct amount of payment and are not
    under any obligation to correct an error made by payroll.
    B Write a cheque amounting to 95% of the total additional income
    that you have been paid for a charity of your choice, retaining a small
    amount as compensation for your eff orts.
    C Keep a work diary of the number of hours that you are working.
    D Involve your Educational Supervisor, as you should not be working
    outside your contracted hours.
    E Alert payroll to the error so that any additional payment can be
    docked from your salary.

Answer 23

23. E, D, C, B, A
    GMC guidance reminds us that probity is at the heart of medical professionalism.
    In this instance, it is important to address the issues of erroneous
    payment for locum shifts and working additional unpaid hours
    separately. The immediate priority should be to return any excess payment
    to your employer (E) before seeking to rectify your own excessive
    working hours, which may benefi t from the input of your Educational
    Supervisor (D). (C) is not as good an answer as completing a work diary
    in itself does not resolve the problem (although it may be necessary at
    some stage). The two wrong answers are (A) and (B), and there is little
    additional virtue to be found for donating your ill-gotten gains to charity.
    Even if it became evident that you had worked a similar number of hours
    unpaid, failure to raise the issue would cast serious doubt on your professional
    judgement. It could also lead to disciplinary or even legal action.

Question 24

24. You are preparing your specialty training application for general
    surgery. You had few opportunities to gain experience in
    theatre as a foundation doctor. However, you have spoken to many people
    about surgical careers and watched video recordings of operations.
    You have booked a Basic Surgical Skills course and read the manual, but
    have yet to attend it. You are considering what statements you can legitimately
    make on your application.
    Choose the THREE most appropriate actions to take in this situation
    A I have enjoyed participating in various operations during my time as a
    foundation doctor.
    B I have enjoyed developing my surgical knowledge through experience
    as a foundation doctor.
    C While I have made every eff ort to learn about a career in surgery,
    my Foundation Programme rotations have not allowed time to attend
    theatre.
    D I have managed to gain indirect experience of theatre through watching
    videos of operations in my spare time.
    E I have developed an enthusiasm for the working environment of the
    operating room through extensive surgical experience.
    F I look forward to developing my surgical experience during this surgical
    specialty training programme.
    G I am fully profi cient in the Basic Surgical Skills course curriculum.
    H My inexperience in the operating room is compensated by a superior
    command of general medicine.

Answer 24

24. B, D, F
    This scenario tests honesty about experiences and qualifi cations when
    applying for posts. The GMC requires that relevant information must
    not be deliberately omitted. While it is possible to mislead the reader
    with sentences that imply particular experiences (e.g. theatre exposure
    (A) (E) and courses attended (G)), it would be more honest to
    describe actual experiences on the ward (B) and alternative means of
    learning about operations (D), and to share your enthusiasm for future
    training (F). Arguments about too few opportunities (C) or unjustifi edclaims of superior clinical competence (H) are unlikely to impress a
    selection panel.

Question 25

25. You are completing an orthopaedics audit during one of
    your FY1 rotations. The consultant surgeon has asked you to
    review the complication rates for total knee replacements performed
    at this hospital and compare them with the average across the Trust.
    Your analysis shows slightly worse postoperative outcomes at this
    hospital, and the average appears to be signifi cantly skewed by the high
    complication rates of your consultant.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Report the consultant surgeon to the Care Quality Commission, as
    this is an issue of patient safety.
    B Ask all the orthopaedic consultants for advice about the data at the
    following week’s departmental meeting.
    C Speak with your consultant orthopaedic surgeon privately about the
    fi ndings.
    D Omit your consultant’s data, and submit a report without further
    discussion.
    E Obtain further data on preoperative parameters for the cases.

Answer 25

25. C, E, B, A, D
    Integrity is an essential foundation for any clinical or scientifi c study, including
    audit, which rests on the honesty and openness of the investigators.
    Conclusions must not be reached hastily from fi ndings which may be misinterpreted.
    In this scenario the best answer would be to discuss your concerns
    as soon as they arise with the consultant in question (C). She might
    be able to give a simple explanation (e.g. atypical case mix) and point you
    in the right direction for further data collection. This also addresses any
    potential issue early in case there is a short-term change that the consultant
    would like to implement. Although (E) raises your concerns from the
    audit and is very likely to show that there is no problem, it does introduce
    an unnecessary delay and is therefore worse than (C). (B) carries the same
    delay and is an inappropriate forum in which to raise this issue, but still
    off ers the opportunity to address the underlying problems. However, raising
    the issue internally with the consultants in your department should be
    favoured in the fi rst instance over contacting an external body (A); there
    is nothing in the question that would suggest this is necessary. The worst
    answer is (D), as you are potentially complicit in a cover-up.

Question 26

26. After leaving your evening shift as the on-call medical FY1 doctor,
    you walk through the town and come across a group of medical
    students who have been attached to your ward. They are behaving quite
    out of character, obviously under the infl uence of alcohol, and are shouting
    profanities at passers-by. The students are eventually confronted by a
    passing police offi cer before being asked to move on.
    Choose the THREE most appropriate actions to take in this situation
    A No further action is necessary, as medical students are not regulated
    by the same code of practice as doctors.
    B Chase the students down the street and demand that they answer for
    their actions.
    C Inform your Educational Supervisor about what has occurred in the
    morning.
    D Email details of what you observed to the medical school dean.
    E Approach the police offi cer and enquire as to whether further action
    is needed.
    F Confront the medical students about their behaviour the following day.
    G Reserve your comments until the end of their medical placement
    when you are asked to give formal written feedback.
    H Withhold any details of the incident from other junior colleagues.

Answer 26

26. D, F, H
    The GMC sets out professional standards which guide undergraduate
    medical students (A). Behaviour outside the clinical environment can
    impact on a student’s fi tness to practise and should always justify public
    trust in the medical profession. The students should be asked to explain
    their actions (A). It is unlikely to be resolved at the time of the incident
    (B) and is not the responsibility of your own supervisors (C). Instead, the
    students should be confronted soon after the incident (F) (G) and their
    supervisors informed of this breach of professional duty (D). Informing
    your colleagues is unlikely to improve the situation (H). The police will
    deal with the students in their own way—your responsibilities as a member
    of the medical profession are diff erent (E).

Question 27

27. During a two-week vacation in Singapore, you became
    embroiled in an altercation at a bar and were subsequently
    given a caution by police. You return to work feeling rather upset and
    ashamed but determined to put the whole incident behind you.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Try to put the issue behind you.
    B Wait until you have settled into your new rotation before raising the issue.
    C Inform your Medical Defence Union and seek legal advice.
    D Contact the GMC immediately to report the caution.
    E Ask your consultant for advice as to how you should proceed.

Answer 27

27. D, E, C, B, A
    According to Good Medical Practice , doctors must inform the GMC without
    delay if they have ‘accepted a caution, been charged or found guilty
    of a criminal off ence, anywhere in the world’. This includes motoring
    off ences unless these are resolved by a fi xed penalty notice. For this
    reason (D) is the best answer. Asking your consultant for advice at the
    earliest opportunity should help signpost you to the correct procedure
    and is at least an attempt to transparency (E). Seeking independent
    advice is always helpful, but does not go any distance towards discharging
    your responsibility as a professional to declare your caution abroad
    (C). (A) and (B) are clearly wrong as it is contrary to guidelines to delay
    informing the GMC. (A) is worse only because it implies indefi nite dishonesty
    rather than inappropriate delay (B).

Question 28

28. You arrive at work before the consultant ward round and
    attempt to print the patient list. You are hindered by slow
    equipment and a broken printer. The ward round is unable to begin until
    you have a current patient list and your consultant is frustrated as he
    needs to begin an all-day endoscopy list.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Express your frustration with the IT equipment and demand that the
    consultant requests replacements.
    B Send the patient list to your personal email address and print it on the
    neighbouring ward.
    C Ask a medical student to print the list while you begin the ward round.
    D Ask the nurses on each of the wards whether there are any new
    patients who are under the care of your consultant.
    E Advise the team to reconvene in 15 minutes while you contact the IT
    helpdesk and attempt to print the list.

Answer 28

28. C, E, D, A, B
    Punctuality is an essential attribute for facilitating expeditious patient care.
    In this instance, a delay in printing the patient list has limited the time available
    to review each patient. None of the options is ideal and the question
    requires you to balance the practicalities of running an effi cient ward
    round with the diffi culties you are currently facing. In this instance, the
    best answer is to ask the medical student (if they are willing) to catch you
    up with the list once it is printed (C). This would allow the round to begin
    without delaying your consultant’s list. (E) ensures that the list is available
    but at the cost of a delayed endoscopy list and/or rushing the end of the
    ward round. (D) is less suitable as it risks missing patients on the ward
    round who might then be deprived of the opportunity to be assessed by
    a senior doctor. The two wrong answers are (A) and (B). (A) is unhelpful
    and is unlikely to endear you to your consultant, though it is otherwise
    a fairly neutral action. (B) by contrast is the worst answer as it is never
    appropriate to use personal email addresses to send patient information.

Question 29

29. You observe an FY1 colleague shouting at a staff nurse in front
    of a patient. Afterwards, the nurse approaches you to discuss
    the FY1 doctor’s behaviour. He explains that the FY1 has had several
    ‘angry outbursts’ since joining the ward two months ago and he is unsure
    how to deal with them.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Advise the nurse to talk to his line manager as it is not your responsibility
    to get involved in nursing-related matters.
    B Bleep the FY1 and ask him to return to the ward and apologize to the
    nurse and patient.
    C Apologize on behalf of the FY1, and ask the nurse not to pursue the
    matter any further at this time as you will speak to the other doctor.
    D Inform the FY1 colleague’s Clinical Supervisor about the episode and
    what the staff nurse has told you.
    E Send an email to your FY1 colleague detailing what the staff nurse has
    told you, to provide a written record of your conversation.

Answer 29

29. D, B, A, E, C
    It is very tempting when answering these questions to latch on to a
    single algorithm for answering similar situations. For example, most
    scenarios are best answered by directly approaching the person about
    whom you are concerned fi rst. This might even be the correct answer
    here depending on your existing relationship with the FY1 doctor.
    However, in this case, the issue that has arisen is between a nurse and
    another doctor, and you are only involved as a by-stander. It might
    then be more appropriate to report the concerning behaviour you
    have witnessed to an appropriate senior colleague and allow them
    to manage the situation from this point forth. For this reason (D) is
    the best answer. The next best option is to contact the FY1 doctor
    directly, and mediate between the two parties (B). Although this might
    resolve the current issue (B) it is not as good as (D) because only
    their Educational Supervisor will have an overall view of whether this
    represents a pattern of concerning behaviour. (A) is half-correct as
    the nurse probably should contact his line manager, but it sounds dismissive,
    unsupportive, and ignores the fact that you are a witness to
    ‘bullying’ behaviour at work. (E) does not really achieve anything as it
    is an impersonal means of communication and does not take the issue
    any further. Although elements of (C) appear correct, it is the worst
    answer only because you should never discourage a colleague from
    expressing their concerns.

Question 30

30. During the return fl ight from your holiday abroad, an announcement
    is made requesting medical assistance for one of the passengers.
    You graduated from medical school three weeks ago and have
    yet to start your fi rst job as an FY1 doctor; you feel particularly apprehensive
    about attending to a possible in-fl ight emergency on your own.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Do nothing since you are not legally bound to provide medical
    assistance as you have not yet signed a contract with your employer.
    B Inform the cabin crew that you are a recently qualifi ed doctor, and
    begin your medical assessment immediately.
    C Approach the unwell passenger and determine if you will be able to
    off er any help before informing the cabin crew of your presence.
    D Wait for ten minutes to see if anyone else on board can assist before
    volunteering to assess the passenger.
    E Review the passenger, but ask the cabin crew to make an announcement
    for more senior medical assistance as you are only recently
    qualifi ed and very inexperienced.

Answer 30

30. B, E, C, D, A
    It might be tempting to choose (E) as a way of recognizing your own
    limitations and seeking help early; however the in-fl ight emergency
    might be something you are able to manage. A further call before
    even a cursory assessment of the patient would be excessive. You
    will often encounter this in the hospital, when you are asked to attend
    an emergency, and it is usually more appropriate to assess a patientyourself (even if briefl y) before seeking further help, as there are
    often simple things you can do fi rst, and assessing the patient helps
    guide the type of help that you ask for. For this reason (B) is narrowly
    a better answer than (E). (C) is inappropriate as it implies a cursory
    examination, and that you might not formally assess the patient in an
    eff ort to remain unidentifi able. However, it at least supposes that you
    are off ering your assistance. (D) and (A) are incorrect answers as the
    GMC requires that ‘in an emergency, wherever it arises, you must
    off er assistance, taking account of your own safety, competence, and
    the availability of other options for care’. (D) risks delaying review or
    treatment of a patient in extremis, whereas (A) supposes not off ering
    your assistance at all. Although you should always work within your
    limits, inexperience is a poor reason for failing to act appropriately
    in an emergency.

Question 31

31. A group of medical students ask if you can help them prepare
    for their forthcoming end-of-module examination on the respiratory
    system. You agree to teach them at the end of the week, provided
    that they stay and assist you with some ward jobs that evening,
    which they agree to do. You are reminded about your teaching commitment
    the day before the students’ examination, but unfortunately you
    have forgotten to prepare a relevant lesson plan.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Inform the students that they should have reminded you earlier in the
    week, and now you are unable to teach them.
    B Defer the teaching until they want to prepare for their next
    end-of-module examination.
    C Attempt to teach the students, even if your knowledge is insuffi cient,
    but fi nish the teaching early if it does not prove helpful.
    D Teach the students about haematology, with which you are more
    comfortable.
    E Adopt a style of teaching that only utilizes questioning the students,
    and refl ect every question asked back towards the group.

Answer 31

31. C, E, D, B, A
    Doctors must be willing to teach and train students and other doctors as
    part of their responsibility for the care of patients now and in the future.
    This necessity requires the appropriate skills and attitudes of an eff ective
    teacher, one of which is eff ective planning.
    Whether it was wise to do so, you have promised teaching these students
    in preparation for their respiratory exam. You will need to be honest
    and upfront that you have not prepared adequately for this (although
    this is not an option). For this reason (C) is the best answer, as you are
    obliged to attempt to provide some value to the students. (E) represents
    an attempt at teaching; even if you are not contributing to their
    knowledge you can at least try to identify gaps and help them revise.
    (D) is clearly not as good, as this is not what the students have identifi ed
    as an imminent learning need. However, some teaching is better than
    none, and the students might still be grateful for an opportunity to learn
    about a subject with which you are comfortable and confi dent teaching.
    (B) is essentially no teaching (for now) which is worse than (E), as above.
    The worst answer is blaming the students who kept their part of the
    bargain (A).

Question 32

32. You are asked by your consultant in paediatric surgery to clerk
    an infant who has been admitted to A&E with bilious vomiting.
    This is the fi rst week of your fi rst FY1 rotation and you have had limited
    experience in paediatrics beyond your fi ve-week rotation in medical
    school two years ago. You are unsure whether you should clerk the
    patient, if you should inform the parents of your inexperience, and who
    would be responsible if you were to assess the infant.
    Choose the THREE most appropriate actions to take in this situation
    A Attempt a rudimentary clerking before calling the consultant to
    review the patient.
    B Refuse to clerk the patient as you do not have suffi cient experience.
    C Conduct a thorough assessment of the patient once you are sure that
    he is stable.
    D Act with the knowledge that the consultant is ultimately responsible
    for your assessment, as his trainee.
    E Act with the knowledge that you are responsible for your assessment
    of the patient.
    F Introduce yourself as a doctor, but do not state your seniority for fear
    of further worrying the infant’s parents.
    G State your position as a junior doctor.
    H Admit that this is your fi rst week as a junior doctor but that you will
    not be responsible for any treatment decisions yourself.

Answer 32

32. C, E, G
    As a foundation doctor, you will experience many practices for the
    fi rst time (B), and the safe management of patients should be paramount
    (A). You should use an ABCDE approach and ensure that all
    patients are stable before completing a more thorough assessment
    (C). You are ultimately responsible for your actions when assessing
    and treating any patient (E), while the consultant takes responsibility
    for your training and supervision (D). In introducing yourself to
    a patient or parents, you are clarifying your position within the team
    of doctors providing their care (G) (F). Your introduction does not
    require a detailed account of your training and experiences as this may
    unduly compromise the trust placed in your advice (H). However, it is
    important to remain honest and transparent if asked about your grade
    or experience by the patient’s family.

Question 33

33. The fi nal-year medical student attached to your ward asks you
    if you could write a reference in support of his application for
    a university-level history course which starts three months before his
    fi nal-year examinations. You are concerned as, despite his enthusiasm,
    the student has a poor clinical knowledge base. You are not convinced
    by his assurances that he will be able to balance this new commitment
    with his medical course.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Write a reference indicating that his knowledge base is poor but that
    he might do much better in another academic subject.
    B Write a supportive reference, as his clinical knowledge base is not
    relevant to his performance on a history course.
    C Suggest that he asks your consultant to write a reference to provide a
    more seasoned perspective on his ability.
    D Tell the student that your position might not qualify you to comment
    on his suitability for the course.
    E Set the student a mock clinical examination, and off er to write his
    reference based on his performance.

Answer 33

33. C, D, E, B, A
    References should be written honestly and objectively, particularly with
    respect to positions in healthcare which may place patients at risk if individuals
    are appointed incorrectly. (C) and (D) are therefore the most
    appropriate answers. (C) appears more constructive as it off ers an alternative
    to yourself as a referee while implying that there are more experienced
    people available to help with this request. Of the three incorrect
    responses (E) is best because it makes an attempt to objectively determine
    whether the student is coping with their current course of study
    to which they should be committed before embarking on a second. The
    last two answers are diffi cult to distinguish between. You should probably
    express your concerns to the student, but write a generally supportive
    reference (B), rather than sabotaging his application with a poor
    reference, particularly without giving him some indication that this would
    happen if you were to do as he asked (A).

Question 34

34. A male FY1 colleague in paediatrics is clerking a frightened
    15-year-old girl who has been brought into A&E by her older
    sister who says that she has been the victim of a violent attack. After
    establishing a good rapport with the patient, the FY1 arranges for a
    physical examination. However, the girl remains adamant that no one
    else be present. In the absence of your registrar, your fellow FY1 asks
    for your advice.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Advise him not to examine the patient and instead wait for the
    registrar.
    B Suggest that he performs a physical examination by inspection alone,
    with a chaperone present if the girl agrees.
    C He should agree to forego the chaperone and complete a thorough
    physical and internal examination to rule out any genital injury.
    D Tell him to insist on the presence of a female nurse as a chaperone,
    and to avoid examining the patient if she insists on no one else being
    present.
    E Ask the older sister to sign in the medical notes agreeing to act as the
    chaperone.

Answer 34

34. D, A, B, E, C
    The most important fact here is that you are not told the patient is in
    extremis, and therefore there is no clinical urgency to perform an examination.
    There are a number of considerations, including the welfare of a
    scared and vulnerable patient, your colleague’s diffi culties as an inexperienced
    male member of the team, and the complications around examining
    a patient who has been the alleged victim of a sexual assault. (D) is
    the best answer, as he should examine the patient only if a chaperone
    can be available, and his initial examination is likely to be limited (i.e.
    no internal examination until senior support is available). If there is any
    doubt, or a chaperone is not available, then (A) would be the correct
    answer, although less ideal as it makes little progress in the management
    of the patient. (B) is less good, and while credit might be given for performing
    any examination of the patient with a chaperone, examination
    by inspection alone off ers little clinical value. Although it is common
    practice to use a female relative as a chaperone, in a particularly sensitive
    case this is not appropriate, and it is not common practice to ask a chaperone
    to sign in the notes (E). (C) is clearly the worst answer because
    an inexperienced male doctor should not perform an intimate examination
    on a minor who has suff ered alleged sexual assault, regardless of
    whether there is a chaperone!

Question 35

35. Your hospital is at the centre of a news story regarding a leaked
    audit which shows a recent rise in mortality following heart
    valve replacements. As an FY1 doctor on the cardiothoracic ward, you
    feel strongly about the negative portrayal of your senior surgical colleagues’
    abilities, believing the results to be due to the use of a new
    prosthesis. A news reporter approaches you as you are leaving the ward
    and asks if you would like to comment.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Share with the reporter your honest opinions of the competence of
    your senior colleagues and the possibility of a fault with the new prosthetic
    valves.
    B Ask for the contact details of the reporter and agree to an interview
    once you have obtained permission from your local Trust.
    C Politely decline to comment.
    D Discuss in general terms the diffi culty that surgical innovators face
    when introducing novel technologies, without going into specifi c
    details about your department.
    E Explain your frustration with the ignorance demonstrated by the
    media and the general public in relation to health matters.

Answer 35

35. C, B, D, E, A
    Even as a more junior doctor, it is essential to realize the impact that your
    comments can have on your own hospital and more widely across the profession
    itself, particularly those made available in the public domain. The best
    answers are clearly the two in which you are not providing any meaningful
    comment for the reporter at this time, as you are unprepared and inexperienced.
    (C) is probably preferable to (B) because the Trust is unlikely to
    agree to an FY1 doctor providing an interview on this subject. Although the
    next three are incorrect, clearly the better two—(D) and (E)—are the ones
    in which general comments are made and you do not refer specifi cally toyour department or your theories about this particular issue (A). (D) is better
    than (E) because you are unlikely to come across well complaining about
    the ignorance of the general public in the public domain.

Question 36

36. You have volunteered to be the deanery’s FY1 representative.
    A recent survey has shown that the greatest frustration of
    90% of FY1 doctors is the limited teaching given during a typical week.
    However, a senior member of the deanery committee has described his
    frustration at your ‘diffi cult predecessor’ who was constantly ‘trying to
    change things’, and you are unsure how receptive the committee will be
    to your suggestions.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Based on the recent survey fi ndings, request approval for a full review
    into the teaching provided for FY1 doctors by each hospital’s postgraduate
    medical education offi ce.
    B Conduct another questionnaire asking more specifi c questions about
    the teaching to the FY1 doctors themselves.
    C Avoid the topic during your initial committee meetings, as you are
    unlikely to gain the favour of your seniors.
    D Predict the response of all of the FY1 doctors to questions on the
    failures of teaching based on your own experiences, and take this evidence
    to the committee as justifi cation for a detailed review by each
    hospital’s education offi ce.
    E Resign as the deanery’s FY1 representative.

Answer 36

36. B, A, C, E, D
    None of the answers is particularly good. (B) is probably the best answer
    because it gives you an opportunity to fi nd out more precisely where
    diffi culties with teaching provision have arisen, without requiring additional
    resources from the postgraduate medical offi ce. As the FY1 representative,
    you carry the (perhaps unenviable) burden of ensuring some
    change is made if necessary. Although a full review into teaching may be
    excessive this is the only other option you are provided with in which
    FY1 doctors’ views are taken into consideration (A). (C) is less good as
    an answer because it introduces unnecessary delay, although there might
    be strategic reasons for wanting to raise the issue later. (D) and (E) are
    both unhelpful; (D) is worse as it appears to mislead the committee by
    suggesting that you have consulted widely amongst FY1 doctors.

Question 37

37. You are left a gift of substantial value from the family of a
    wealthy patient whom you have recently cared for on the ward.
    You are frequently praised for the time and eff ort that you spend with
    patients, but this is the fi rst time that you have personally received a gift.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Inform the GMC of the gift.
    B Inform the Ward Sister in charge of the gift.
    C Seek the advice of your medico-legal defence organization.
    D Accept the gift, but share its monetary value with the rest of your
    medical team.
    E Attempt to obtain the family’s details and return the gift.

Answer 37

37. E, C, B, A, D
    The GMC requires that you never encourage patients or their relatives
    to off er gifts that will directly or indirectly benefi t you, and you should
    make reasonable eff orts to dissuade them from such off ers. For this
    reason (E) is the best answer as it perfectly mirrors this advice. The
    second best answer is to seek impartial professional advice (e.g. from
    a medical defence organization) as you are unlikely to have experience
    of receiving high-value gifts (C). This is probably more appropriate
    than informing the Ward Sister, but doing so (B) is at least an attempt
    to seek advice and may lead you to be directed towards your Trust’s
    policy on acceptance of gifts. Accepting the gift with no attempt to dissuade
    the relatives should be your last option, particularly given that
    it is high value (D). Although there is no role for informing the GMC
    about receiving a gift, regardless of its value (A), this is probably a safer
    answer than (D).

Question 38

38. An FY1 doctor who works with you on the surgical ward is
    asked to complete a death certifi cate and cremation form for a
    patient he has been treating. However, he has a conscientious objection
    to cremation, based on religious beliefs, and would prefer you to complete
    the form even though you have never met the patient.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Agree to complete the cremation form, as your colleague has provided
    a valid reason for refusing.
    B Advise your colleague to claim that he has not been adequately
    trained to complete cremation forms.
    C Inform your colleague that he has a duty to put aside any personal
    beliefs and complete the cremation form.
    D Suggest he takes a few days annual leave which will give the bereavement
    offi ce time to fi nd someone else to complete the form.
    E Refuse to sign the cremation forms on the grounds that you are not
    familiar with the patient.

Answer 38

38. C, E, D, B, A
    All qualifi ed doctors have a legal obligation to sign cremation forms,
    and cannot refuse on personal or religious objections to cremation
    (Cremation Acts 1902 and 1952). (C) is therefore the correct answer.
    You should probably advise your colleague that, if they are the only doctor
    who can sign the form, they should do so to avoid unnecessary delay
    and distress to relatives. (E) is less helpful but still correct as you are not
    giving your colleague the full benefi t of your medico-legal knowledge
    but have done the right thing in declining to sign a cremation form for
    a patient you do not know. (D) would be improper advice, as your colleague
    going away for this reason would be unprofessional and risk delay
    to funeral arrangements and consequent further distress to family members.
    (A) is the worst option as you are not legally entitled to complete
    a cremation document as you have not cared for the patient during their last illness. This means that encouraging your colleague to lie (B) falls
    between simple unprofessional behaviour (D) and illegality (A).

Question 39

39. You are a foundation doctor with an interest in orthopaedic
    surgery. In an eff ort to improve your specialty training application,
    you would like to complete an Advanced Trauma Life Support
    (ATLS) course. Unfortunately, your Trust gives priority to doctors working
    in A&E. One of the A&E doctors has been given a place on this basis
    but off ers it to you in exchange for covering one of his night shifts.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Accept the off er as it appears to be a mutually benefi cial agreement.
    B Tell the other foundation doctor that you will gratefully accept his
    off er but you are not willing to complete the weekend shift.
    C Refuse the off er.
    D Ask the advice of the ATLS coordinator at your hospital.
    E Accept his off er and attend the course, but do not turn up for the
    weekend shift.

Answer 39

39. D, C, A, B, E
    Although you are keen to attend the course, it would be wrong to
    subvert the process for allocating places. If your colleague is unable to
    attend the course, he should explain this to the coordinators. Therefore
    you should ask whether they would agree to transfer the place to you
    from your colleague, which is why (D) is the best answer. The second
    best answer is (C), as refusing the off er would allow the place to be
    reallocated more equitably. (A), (B), and (E) are all incorrect; of these,
    (A) appears to be preferable as everyone is satisfi ed by the arrangement.
    (B) is next, as you are willing to take the place on the course
    without completing your part of the arrangement. The worst option is
    clearly (E) as this risks leaving the A&E department understaff ed as well
    as betraying your colleague’s trust.

Question 40

40. As the FY1 doctor in cardiology, you are responsible for looking
    after your consultant’s NHS patients. One of the patients
    who had been under your care for the last 48 hours is transferred to the
    private ward on the other side of the hospital. At the request of your
    consultant, the nurses on the private ward have bleeped you on several
    occasions to complete various clinical procedures. You feel challenged
    by the additional workload and are uncertain whether you will complete
    your routine tasks.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Ask the consultant for additional reimbursement in return for providing
    more of your time for assisting with his private patients.
    B Explain the situation to one of the other cardiology consultants.
    C Speak to the patient and ask whether he would mind returning to the
    NHS ward.
    D Arrange a meeting with the cardiology consultant, via his secretary, to
    discuss the additional workload.
    E Do not respond to any bleeps from the private ward; if it is genuinely
    a consultant’s request he will contact you.

Answer 40

40. D, B, A, C, E
    Your NHS employer has allocated a set amount of work per employee
    and may not have accounted for additional tasks on the private ward.
    Your primary responsibility is for your own patients, and their care must
    not be compromised by acquiescence to inappropriate requests, even if
    driven by your consultant. The best answer is (D) as you should generally
    approach the person most likely to resolve the situation satisfactorily,
    who is the consultant in this case. Speaking to another consultant
    would be less ideal but may lead to her imparting wise advice for you
    to follow (B). (A), (C), and (E) are the wrong answers. (A) is probably
    the best of these, although you are unlikely to be entitled to additional
    money for work done during additional time, asking your consultant is
    unlikely to cause signifi cant harm to anything except your dignity and
    career! Attempting to coerce the patient would be much worse (C).
    But failing to answer your bleep (even if you think it’s from a ward for
    which you are not responsible) could result in harm to patients if you are
    uncontactable (E).