Coping with Pressure Flashcards
1
Q
- You are a new FY1 doctor on an orthopaedic team. The morning
ward round is running late and both your consultant and registrar
need to go to theatre. One patient has yet to be consented for a hemiarthroplasty
after fracturing her hip. Your registrar tells you to make sure
that she is consented in time to be second on the morning list.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Consent the patient before doing any other jobs.
B Complete all urgent jobs arising from the ward round, and then consent
the patient.
C Explain that you are not suffi ciently experienced to consent patients
for this operation.
D Ask an SHO from another team who can perform hip hemiarthroplasties
to take consent.
E Agree to consent the patient and then ask experienced nurses to
show you how to do this correctly.
A
- C, D, E, A, B
GMC guidance states that the doctor providing treatment (i.e. the
operation in this example) is responsible for obtaining informed consent.
He can delegate this responsibility to someone who is suitably trained
and has suffi cient knowledge about the operation and its risks. As an
FY1 doctor, you are unlikely to satisfy these criteria. Therefore the best
option is to explain your position to the registrar (C). He should then
consent the patient himself or delegate the responsibility to someone
else. The next best option would be to ask an appropriately qualifi ed
doctor from another team to help (D). This is not the preferred option,
as such a person will have other duties, may not know the patient, and
is unlikely to be part of the operating team. If ever in doubt, it is advisable
to ask colleagues for advice. (E) is the fi rst clearly wrong answer;
however, it is redeemed to some extent by the fact that you are seeking
advice, and an experienced nurse will probably point out that you should
not consent patients for complicated procedures in FY1. The fi nal two
options—(B) and (A)—are the most unsafe. (A) is very narrowly better,
as addressing the issue urgently might ensure there is time for consent
taken in error to be rectifi ed.
2
Q
- You are the FY1 doctor on call for medicine. After seeing a patient
with pancreatitis, you recall the need to take an arterial blood gas
(ABG). Unfortunately your only experience of this procedure was on a
model two years previously. You have never attempted to perform an
ABG on a patient before and are not feeling confi dent about success.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Call the duty medical registrar and ask them to supervise your
fi rst ABG.
B Ask another FY1 doctor who is available and more confi dent with
procedures to help.
C Attempt the procedure but without warning the patient about your
inexperience.
D Wait until the end of your shift and then hand the job over to the
night team.
E Attempt the procedure twice after talking to the patient, and then ask
for help if unsuccessful.
A
- C, D, E, A, B
GMC guidance states that the doctor providing treatment (i.e. the
operation in this example) is responsible for obtaining informed consent.
He can delegate this responsibility to someone who is suitably trained
and has suffi cient knowledge about the operation and its risks. As an
FY1 doctor, you are unlikely to satisfy these criteria. Therefore the best
option is to explain your position to the registrar (C). He should then
consent the patient himself or delegate the responsibility to someone
else. The next best option would be to ask an appropriately qualifi ed
doctor from another team to help (D). This is not the preferred option,
as such a person will have other duties, may not know the patient, and
is unlikely to be part of the operating team. If ever in doubt, it is advisable
to ask colleagues for advice. (E) is the fi rst clearly wrong answer;
however, it is redeemed to some extent by the fact that you are seeking
advice, and an experienced nurse will probably point out that you should
not consent patients for complicated procedures in FY1. The fi nal two
options—(B) and (A)—are the most unsafe. (A) is very narrowly better,
as addressing the issue urgently might ensure there is time for consent
taken in error to be rectifi ed.
3
Q
- As the FY1 doctor on call you are bleeped by the pathology laboratory
about an abnormal blood result. They give you a value representing
severe hypernatraemia. You do not recall very much about hypernatraemia
and have never managed a patient with this problem before.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Call the duty medical registrar and ask what to do.
B See the patient to check that they are well, and then call the duty
medical registrar.
C Find a computer terminal and Google ‘hypernatraemia’ for inspiration.
D Consult hospital guidelines, either in paper form or online.
E Prescribe a loop diuretic such as furosemide.
A
- B, D, A, C, E
Your fi rst priority in any patient about whom you are worried is to
familiarize yourself with their details and ensure that they are stable
(e.g. Airway, Breathing, Circulation). (B) is therefore the correct
answer. The next best answer is (D) because hospital guidelines may
ensure you manage the situation correctly and are a way of solving the
problem yourself without unnecessarily overly burdening the medical
registrar (A).
The two wrong answers are (C) and (E). (C) is marginally better as it
is at least an attempt to identify the correct course of action. However,
using unregulated online resources is commonplace but should be discouraged
(C)—hospital guidelines, senior colleagues, and potentially
authoritative books (e.g., Oxford Handbook for the Foundation Programme )
are better sources of information.
The worst answer is (E) as loop diuretics are not used to manage
hypernatraemia—you would have known this had you consulted hospital
guidelines or discussed with the medical registrar.
4
Q
- You are on a busy surgical ward round. Your consultant tells you to
order an urgent CT scan and make sure that it happens that morning.
Although you make a note on your jobs list to do this, you do not
think that there is a good reason for doing the scan.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Ask the consultant what the scan is for.
B Tell the duty radiologist that you disagree with doing the scan but have
been told that it is urgent.
C Explain to your consultant you cannot order the scan as you disagree
that it is appropriate.
D Ask a colleague in your team whether they can explain why the CT
scan is necessary.
E Book an ultrasound instead and then reconsider the CT scan later
depending on its results.
A
- A, D, C, B, E
Doctors should understand (and be able to defend) any investigation
or procedure they request. You should avoid taking responsibility
for requests you do not understand, and it is particularly
difficult to persuade a radiologist to accept a scan request that you
do not understand yourself. Your best option is to ask the consultant
(A) or, not quite as good, another member of the team
(D) what the scan is for.
The other answers are incorrect. Your consultant is unlikely to appreciate
you declining to request the scan (C). However, this is probably
better than taking a similar approach with the radiologist (B). Although
the radiologist might understand why the scan is necessary, she cannot
always be expected to know what your consultant was thinking. You
should aim to be better informed than this before approaching a senior
doctor outside of your team.
The worst answer is clearly (E). If you have been asked to request
a CT scan, you should generally not do something else simply based
on your own initiative. Given that your consultant is considerably more
experienced, ordering an ultrasound scan instead may both delay the
defi nitive investigation and waste a valuable ultrasound scanning slot that
could be used by someone else.
5
Q
- Matron has raised an issue about a drug that you prescribed incorrectly.
You prescribed a times overdose which fortunately was spotted by a
vigilant pharmacist and never administered. Nevertheless, a clinical incident
form has been completed and Matron is going to contact your Educational
Supervisor. You feel that this error was caused by being overly tired.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Tell Matron that the error was not your fault because the Trust made
you work unsafe hours.
B Accept personal responsibility but explain the factors that you believe
contributed to the error.
C Ask Matron not to contact your Educational Supervisor as this was an
isolated error.
D Use your e-portfolio to record the error and refl ect on its reasons so
as to avoid this happening again.
E Ask to meet your Educational Supervisor to discuss the error and
your concerns about the night rota.
A
- B, E, D, A, C
Thankfully, no harm came to this patient as the error was spotted by
the pharmacist. The most important thing now is that both you and the
organization learn from this incident.
The best answer is (B) as you must always take responsibility for your
actions, although you should take steps to communicate the factors that
you think contributed to the error in whatever way is necessary to eff ect
appropriate organizational change.(E) is the next best answer because it raises concerns about the underlying
reasons for your error. It is important to take personal responsibility
but explaining your reasons to Matron in the correct way could lead
to positive changes in the rota. Although (D) is a positive option, it does
not raise the issue beyond your own personal refl ection area and so has
limited practical benefi t.
(A) is not a positive option because it appears defensive and raises
your concern in a forum that is unlikely to result in a constructive outcome.
The worst answer is (C) because you should never seek to cover
up your mistakes or ask colleagues to do so for you. If Matron feels that
the error is suffi ciently serious to raise with your Educational Supervisor,
you should not interfere with this decision.
6
Q
- You are enjoying an evening meal with your friends when you
remember ordering a blood test for an unwell patient, the result of
which you forgot to check or hand over.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Make a note to check the result fi rst thing in the morning before the
ward round.
B Call the duty FY1 doctor through the switchboard and ask them to
check the result.
C Put the issue out of your mind—it’s important to ‘turn off ’ after work.
D Refl ect on how this test was missed and resolve to develop a system
to ensure that such an error does not occur in the future.
E Drive back to the hospital to check the result yourself.
A
- B, E, D, A, C
Patient safety is your priority and someone should follow up this test
result immediately. The duty FY1 doctor is the most appropriate person
to do so (B). The next best option is to visit the hospital yourself and
check the test (E). Although this is of great practical inconvenience and
should not be something you do frequently, it is better than the remaining
options as the patient’s safety can then be guaranteed.
(D) is the fi rst wrong answer as it fails to address the immediate
patient safety issue. It is, however, the best of the incorrect answers as it
might stop similar problems arising in future. (A) is more incorrect as it
introduces unnecessary delay and there is no guarantee that an abnormal
result would have been recognized in time to treat the patient appropriately.
The most incorrect answer is obviously (C).
7
Q
- An FY1 doctor with whom you work closely says she is concerned
that you seem ‘down’ and have been so for a few weeks. You have
noticed that your mood is lower than normal but put this down to stress
and tiredness. You do not think that you are clinically depressed and are
embarrassed by your colleague raising the possibility.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Clarify the nature and reasons for your colleague’s concern.
B See your Educational Supervisor at the next possible opportunity to
discuss your mental health.
C Make a routine appointment with your GP.
D Ask other FY1 colleagues whether they think you are depressed.
E Use a depression screening tool to determine whether you require
drug treatment.
A
- A, C, B, D, E
You should fi rst seek to clarify what has prompted your colleague’s
concerns. There may be good explanations or she might have noticed
something that you have yet to pick up on yourself. For this reason,
(A) is the best answer, and (C) would be the next most appropriate step
if you acknowledged your colleague’s concerns. However, it could still
be an appropriate response, as you are not necessarily best placed to
assess your own health and an independent assessment could be useful
if others are worried. GMC guidance states that all doctors should
be registered with a GP so that objective advice can be sought if necessary.
You should avoid ‘corridor consultations’ with colleagues, but
could discuss this with your Educational Supervisor (B) even though
they might not be qualifi ed to assess you formally. However, it would
be less appropriate to canvass the opinion of your FY1 colleagues (D).
The worst answer is (E) because you should never attempt to formally
assess or treat yourself.
8
Q
- After an emergency operation, a patient is left with a colostomy.
You are the fi rst doctor to see the patient once he becomes conversant,
and he asks whether the bag is permanent. You are certain that
colostomies can be reversed but do not remember very much else.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Tell the patient that his colostomy will be reversed.
B Explain that you are an FY1 doctor and cannot answer complicated
surgical questions.
C Explain that colostomies can sometimes be reversed and that you will
help fi nd out the plan in his case.
D Off er to ask your registrar to drop by later on to answer specifi c
questions.
E Put time aside to read about stomas so you can answer questions
more fully next time.
A
- C, D, E, B, A
GMC guidance states that you must always be honest and recognize the
limitations of your knowledge. Your best option here is to tell the patient
what you know and explain that it is the limit of your knowledge (C).(D) is the next best alternative, as it involves a suitable senior, although
you may have been able to allay the patient’s concerns yourself before
deferring to someone else for further information. (E) suggests refl ective
practice and will improve your care for future patients but does not
address this patient’s concerns at all. Refusing to answer the patient’s
questions without providing a suitable alternative (e.g. speaking with a
senior, fi nding out the answer) is even less appropriate (B). The worst
answer is (A) as you do not know this for certain.
9
Q
- You are seeing a very unwell patient on your ward. He is complaining
of chest pain and is also becoming increasingly hypotensive,
despite fl uid resuscitation. Over the previous few minutes, he has started
to become drowsy. Although you are an FY1 doctor, you recently completed
an Advanced Life Support (ALS) course and feel confi dent in managing
acutely unwell patients.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Summon the resuscitation team.
B Continue to manage the patient regardless of their clinical condition.
C Call the consultant on his mobile phone.
D Call the SHO on her mobile phone for advice.
E Continue managing the patient unless he continues to deteriorate.
A
- A, D, C, E, B
The best answer for managing acutely unwell patients always begins with
‘ABCDE’ and calling for help at your earliest opportunity. A patient who
is clearly deteriorating quickly and whose consciousness level is falling in
front of you warrants urgent assistance as you are unlikely to be able to
manage a threatened airway independently on your ward. For this reason
(A) is the best answer. It is much less appropriate in the acute setting
described to make a telephone call for advice when you should be busy
resuscitating a patient while you are waiting for the resuscitation team to
arrive (D). However, the SHO is more likely to be readily available to
attend the ward and assist you than the consultant (C). (B) and (E) are
the worst options only because neither recognizes that you require help
in this situation. (E) is better than (B) because in the former you have
at least set parameters for which you will summon help, even if you
are likely to reach this point quickly given the patient’s current rate of
deterioration.
10
Q
- Your consultant asks you to meet her in her offi ce. She tells
you that she is concerned about your performance; specifi cally
that you sometimes arrive late for her ward rounds and that your level
of clinical knowledge is below her expectations of a doctor at your level.
You disagree with this assessment, as you have only been late twice and
do not think that there are any particular gaps in your knowledge.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Explain why you feel that her assessment is unfair, and ask her to
provide specifi c examples to illustrate her concerns.
B Ask the foundation school about the possibility of changing consultants
as there has been a relationship breakdown.
C Ask the consultant for advice about how you can act on her concerns
and improve your performance.
D Using your e-portfolio, conduct a Team Assessment of Behaviour
(TAB) round looking for evidence of concern about your performance
from other colleagues.
E Tell the consultant that you believe your knowledge to be no worse
than that of other FY1 doctors, and that you won several prizes at
medical school.
A
- C, A, D, E, B
The key here is to strike a balance between defending yourself against
an assessment that you believe is unfair and adopting a conciliatory
approach so that you can learn from the perception others may have
of you. To ensure a constructive meeting you should start by asking
for advice and listening to your consultant’s concerns; for this reason,
(C) is a better answer than (A). Part of refl ecting on this experience,
particularly as there is an apparent disagreement, would be to canvass
the opinion of others, e.g. using the Team Assessment of Behaviour tool
(D). This alone is not as good an option as (C) and (A) which are part of
the necessary dialogue with your consultant about her concerns. (B) and
(E) are both incorrect; (E) is less incorrect as although your consultant
is unlikely to be less than impressed about your assertion, this does not
involve any other parties. The worst answer is (B) as nothing in the question
indicates that there has been an irreparable breakdown in working
relationships.
11
Q
- You have always enjoyed alcohol but recently have been drinking
more than usual. There is no reason for you to think that this
has aff ected your performance and you have never been drunk at work.
However, a number of junior colleagues have commented on your alcohol
intake, and one has told you that she is concerned that you are developing a
dependency. As a result, you have begun to worry about your intake.
Choose the THREE most appropriate actions to take in this situation
A Ask a friend with whom you socialize whether he/she thinks that you
are drinking too much.
B Ask other FY1 doctors not to joke about your drinking, as you feel
that this undermines your professional reputation.
C Use a validated assessment tool (e.g. CAGE) to determine whether
you have developed an alcohol problem.
D Make an appointment with your GP to discuss your concerns about
your alcohol intake.
E Discuss the issue with your Educational Supervisor at your next
meeting.
F Stop drinking for a week to see if you develop withdrawal symptoms.
G Think carefully about your reasons for drinking more than usual
recently, and consider modifying your drinking pattern.
H Stop going out with colleagues and drink secretly instead to avoid
damage to your reputation.
A
- D, E, G
All doctors should be registered with a GP whom they should approach
with concerns about their health (D). There is no obligation to speak
with your Educational Supervisor if work is unaff ected, although theymay be better placed to support you if they are kept informed (E).
(E) is not necessarily an incorrect answer and may be something you
consider later on; however, the three correct answers listed are better.
It could certainly be helpful to gain the perspective of a friend regarding
your drinking habits (A). Note that in previous scenarios, wider discussions
with other FY1 colleagues has been considered less ideal—in
this case the distinction has been drawn, because a friend is likely to
support you and off er honest advice and be intimately aware of your
drinking pattern. If your alcohol consumption has increased recently,
you might wish to try reducing it for health and social reasons (G). You
should not threaten your physical health by attempting to provoke withdrawal
symptoms (F). You are already concerned about your drinking
and should seek advice from an independent professional rather than
attempting to manage the problem further yourself (C). Although you
might be concerned about acquiring an unhelpful reputation, asking
your colleagues to stop gossiping (B) may be ineff ective and will not
solve any underlying drinking problem. Drinking secretly will certainly
not resolve any such alcohol dependency (H).
12
Q
- You have been working as an FY1 doctor for six weeks but struggle
with intravenous cannulation; in fact, you have yet to site one
successfully despite several attempts. You are concerned about the distress
caused to patients by your unsuccessful attempts and your inability to
cannulate is starting to have an impact on the length of your working day.
Choose the THREE most appropriate actions to take in this situation
A Ask colleagues to site intravenous cannulas as often as possible until
your ability improves.
B Using your e-portfolio, refl ect on what it is that you are fi nding diffi cult
about intravenous cannulation and how you can overcome this.
C Ask a senior colleague to supervise a series of cannulation attempts.
D Avoid trying to cannulate patients with ‘diffi cult veins’, and ask colleagues
to see them instead.
E Consider modifying career aspirations to specialties that are less
procedural.
F Continue to practise, recognizing that the procedure will become
easier as you do.
G Attempt to cannulate each patient no more than once; if unsuccessful,
bleep the duty anaesthetist for assistance.
H Tell every patient that they have ‘diffi cult veins’ so that their expectations
of success are set low from the outset.
A
- B, C, F
Competence in intravenous cannulation is a fundamental skill for doctors
and mandatory for successful completion of FY1.
You should identify what exactly it is you fi nd diffi cult about cannulation
(B), ask for supervision and feedback (C), and then seek opportunities
to improve your ability (F).
Strategies to avoid cannulating patients, such as asking colleagues to
do it (A), avoiding ‘diffi cult’ cases (D), or calling a specialist after a token
attempt (G), will burden others and will not help you to improve your
ability. Covering your own defi ciencies by blaming patients (H) is not
encouraged, although it might be fair to warn patients if you genuinely
anticipate that multiple attempts may be necessary.
Career aspirations could be modifi ed if you fi nd yourself struggling
(and/or not enjoying) practical procedures (E). However, it would be
premature to make such decisions based on experiencing diffi culties with
one skill over such a short space of time.
13
Q
- You are a lone FY1 doctor seeing an elderly patient on the ward
who is hypotensive despite being given intravenous fl uids. You
are concerned that the only intervention you know for managing hypotension
has not worked in this case.
Choose the THREE most appropriate actions to take in this situation
A Ensure that the patient has a valid Not For Resuscitation order in case
they suff er cardiac arrest.
B Accept that the patient is normally hypotensive and avoid further
intravenous fl uids.
C Call your SHO or other senior doctor for advice and assistance.
D Ask the nursing staff to put out a peri-arrest call.
E Begin administering inotropes if further fl uid challenges fail to increase
the blood pressure.
F Ask the patient’s family to attend as their relative is probably dying.
G Ensure that you have good intravenous access and give another fl uid
challenge.
H Monitor the patient carefully for signs of deterioration.
A
- C, G, H
GMC guidelines require all doctors to recognize the limits of their
knowledge and experience. In this case, you have attempted to fl uid
resuscitate the patient without success. The next step is to seek advice
and/or assistance from a senior colleague (C).
As a foundation doctor, you must be able to manage patients
who are potentially deteriorating until help arrives. In this case, you
should ensure that there is good intravenous access (G) and that
the patient is being observed carefully (H) while you are waiting for
support.
Although the patient’s blood pressure may be acceptable for them,
this should not be assumed without further information (B). Similarly, itis far from clear that the patient is peri-arrest (D), dying (F), or appropriate
for a ‘Not For Resuscitation’ decision (A). Inotropes would not be an
appropriate next step in this case (E).
14
Q
- You are feeling stressed as the on-call FY1 doctor and have
just found yourself becoming angry with two sets of relatives
in quick succession.
Choose the THREE most appropriate actions to take in this situation
A Take a short break to regain perspective.
B Ask a colleague to help share your workload if they are able.
C Resolve not to speak with any more relatives on this shift as your
priority must be unwell patients.
D Apologize to the relatives so that they are unlikely to complain.
E Consider what factors led to the altercations and address these as far
as possible.
F Ask security or a nursing sister to remove the relatives so that you are
not interrupted again.
G Manage your frustration by berating a medical student because he is
unable to cannulate a patient.
H Check the time—it may nearly be time to go home.
A
- A, B, E
It is important to remain professional at all times and to take necessary
steps to avoid your own feelings aff ecting how you behave towards
others. In this case, you should recognize early on that you are behaving
unprofessionally and take remedial action. It may be helpful to
take a short break (A), ask a colleague for assistance (B), and address
any specifi c factors that you think may have contributed to your
behaviour (E).
Although patients should always be your priority, dealing with relatives
is an important job for junior doctors, even when on call (C). Apologizing
to these particular relatives (D) may well be appropriate, but the motivation
for doing so should not be to avoid complaints, and it is likely that
an insincere apology could infl ame the situation. Clock watching is not a
strong solution to the problem (H).
Action to remove relatives (F) should only be initiated if staff ,
patients, or other visitors are at risk. You should have suffi cient insight
to wonder whether two ‘clashes’ with relatives in quick succession
may refl ect your behaviour as much as theirs. The medical student
(G) is not to blame!
15
Q
- Your manager emails to say that a written complaint has been
received about your management of a patient seen in A&E.
This concerns a patient whom you saw after a fall but you did not document
a proper examination. A fractured hip was missed for 72 hours.
Choose the THREE most appropriate actions to take in this situation
A Edit the notes to include features that you honestly recall at the time
persuaded you that the patient did not have a broken hip.
B Edit the notes to include features that were not present but might
make your mistake easier to forgive.
C Submit a factual description of events within the deadline imposed.
D Think honestly about the case and what you would do diff erently in
future.
E Ignore the email as you are rotating to a new hospital next week.
F Explain that you were very busy that day and could not thoroughly
examine every patient.
G Document your formal response and ask to be informed of the outcome
of this complaint.
H Submit a response whenever you are able—the clinical care of your
current patients comes fi rst.
A
- C, D, G
You must comply as far as possible with any complaints procedure. In
this case, you should cooperate with your line manager by providing factual
details in a timely manner (C).
Regardless of the complaints process (and outcome), you must
endeavour to improve your own practice. You may identify areas of
clinical practice or communication that could be improved from this
experience (D). As well as documenting carefully, you should ask for the
complaint outcome (G) so as to aid the learning process.
At all times you must be honest and trustworthy. GMC and local disciplinary
procedures will expect this from all clinical staff . You must not
edit the notes retrospectively to protect yourself (A) (B) or obstruct the
process by not replying (E) or delaying your response (H).
Although you may need to explain your actions, being ‘busy’ is not an
excuse for failing to examine a patient thoroughly (F). Doctors must take
personal responsibility for their actions, even if other factors contribute.
16
Q
- Your consultant calls to ask you to relocate a dislocated total
hip replacement for a patient on the orthopaedic ward. He
mentions that you should give intravenous sedation fi rst. When you tell
him that you have never sedated a patient before, he tells you to use
propofol and ketamine, and then hangs up the phone.
Choose the THREE most appropriate actions to take in this situation
A Call the consultant back to clarify what doses you should use and what
movements are necessary to replace the dislocated limb.
B Call the consultant back to say that you are unwilling to do as he asks.
C Use the British National Formulary to determine doses.
D Sedate the patient and then fi nd the duty orthopaedic registrar if you
are unable to relocate the dislocated hip.
E Contact your Educational Supervisor at the fi rst possible opportunity
to discuss this request.
F Contact another senior orthopaedic colleague if your consultant does
not answer or off ers no further advice.
G Attempt to relocate the hip without using sedation.
H Sedate the patient and attempt to relocate the hip.
A
- B, E, F
As a junior doctor, you must recognize your own limitations at all times.
In this case, you are uncomfortable with the request and must ensure
patient safety even at the expense of upsetting your consultant.
You should be honest and communicate to the consultant that you
are unhappy with his request (B). It may have been miscommunicatedand/or your response may prompt the consultant to change his mind.
If you feel pressured to work beyond your limitations, this should be
raised with your Educational Supervisor at the fi rst available opportunity
(E). If you cannot recontact the consultant, you should get in touch with
another senior colleague (F) to discuss your concerns.
In this case, sedating a patient on a regular ward is likely to be unacceptable,
even for a senior doctor (D). You must always prioritize patient
safety over other considerations and should not comply with a request
that you believe might be dangerous (A) (C) (H). Attempting to relocate
the hip without sedation (G) would be very painful and may cause more
harm if you are unfamiliar with the procedure.
17
Q
- A patient asks you why you are ordering a CT scan to eliminate
stroke as a possible cause of her symptoms. She is worried
about radiation risk and wants an MRI scan instead. You do not recall
precisely why CT is used as the fi rst-line investigation for stroke.
Choose the THREE most appropriate actions to take in this situation
A Tell her that CT is probably cheaper than MRI.
B Explain that you are a junior doctor and cannot answer questions
about complex investigations.
C Call the duty radiologist and hand the phone to the patient so that
they can have an informed discussion.
D Explain that you do not know the answer but will speak with someone
to fi nd out the reason.
E Carefully explain the risks and benefi ts of having a CT scan, looking up
information fi rst if you are uncertain.
F Tell her that she cannot have an MRI scan and clearly document that
she refused the CT scan.
G Ask your consultant to visit on his ward round the following week to
discuss management options.
H Use this question to identify a gap in your knowledge and read around
the subject during a spare moment.
A
- D, E, H
You must always be open and honest about your knowledge. In this case,
you should explain to the patient that you do not know the answer but
will endeavour to fi nd out (D). This will also support your development.
Once you have closed any gaps in your own knowledge (H), you should
carefully explain the advantages and disadvantages of CT (E). Good
Medical Practice states that this process is a necessary part of obtaining
consent for any procedure or investigation.
You should not overburden senior colleagues (C) or delay an investigation
(G) if you are able to answer a question adequately after looking
up the answer. This risks distracting them from their own responsibilities.
You can answer any question as long as it is within your knowledge and
experience to do so adequately (B).
Making up an answer (A) is dishonest unless you know it to be true.
Risks, benefi ts, and likely consequences should be explained before a
competent patient is deemed to have refused a procedure (F).
18
Q
- Your registrar suggests one morning before the ward round
that your appearance is inappropriate. In particular, he says that
you are showing too much of your chest and are wearing a watch.
Choose the THREE most appropriate actions to take in this situation
A Remove the watch immediately as it confl icts with Trust policy.
B Explain that you had not realized that your dress was inappropriate
and will consider this before coming to work the next day.
C Point out that your consultant also wears a watch.
D Wear more revealing clothes the following day to show you are free
to interpret the Trust dress code yourself.
E Tell your registrar that he should be more interested in your clinical
ability than your choice of clothes.
F Decline to participate in the ward round because you have been
insulted by the registrar.
G Tell your consultant that your registrar was insulting and bullying
before the ward round.
H Seek feedback from other colleagues if you are uncertain whether
your clothes really are inappropriate.
A
- A, B, H
Wearing a watch confl icts with Department of Health policy on staff
dress in clinical areas. Its removal is likely to be a reasonable request
(A). You should try to accept negative feedback and use it to refl ect on
changes you might make in future (B). If you disagree with negative feedback,
you may wish to seek other views in a genuine attempt to improve
your professional appearance (H).
You may wish to raise your consultant’s compliance with policy at
another time (C). However, this is not an adequate defence of your own
behaviour and should not be raised with another colleague in this forum.
You should not provoke your registrar or act in any way that makes him
feel less able to give you feedback in future (D) (E) (F).
Although bullying is an important issue for doctors, this should be distinguished
from a single episode of negative feedback (G).
19
Q
- You are on call at night and have not eaten since coming to
work. You are very tired and can feel yourself nodding off to
sleep within a few seconds of sitting down. You are about to break away
for a sandwich when a Ward Sister asks you to write two drug charts for
patients who have just been admitted.
Choose the THREE most appropriate actions to take in this situation
A Explain that you were planning to go for a break.
B Off er to write the drug charts later on.
C Explain that writing drug charts is not a job for the on-call doctor and
is best left to the ordinary ward team instead.
D Have a quick look, prescribe any urgent drugs, and then go for your
sandwich.
E Ask the nurse to complete the drug chart for you to sign when you
get back.
F Ask how urgent the drugs are and use this information to prioritize
the task.
G Tell the nurse that she should not bother you for such a routine task.
H Complete the drug charts as requested.
A
- A, B, F
Once again, patient safety must be your fi rst consideration. Prescribing
whilst stressed, hungry, and tired is more likely to lead to errors. Youmust balance the risk of a prescribing error against the risk of the drug
chart being delayed (F).
A single task could be done quickly before getting rest. Two drug
charts may take some time and therefore you could explain your position
(A) and say that you will write them later on (B).
Drug charts must sometimes be written by the on-call medical team
(C) (G) as drugs cannot be given without them. However, they are a
source of prescribing errors as the on-call doctor is tired, balancing
multiple tasks, and may not know the patient. Prescribing should be
taken seriously and not done ‘quickly’ before going for a break (D).
Ideally, drug charts should not be written by someone who is so tired
that they are nodding off to sleep (H) or who is not an authorized
prescriber (E).
20
Q
- You know that you do not always communicate well when feeling
stressed and want to avoid this impacting on your relationship
with colleagues.
Choose the THREE most appropriate actions to take in this situation
A Use Team Assessment of Behaviour (TAB) rounds and informal feedback
from colleagues to gauge your success at managing stress.
B Tell other team members early on that they should avoid making you
stressed.
C Ask other FY1 doctors on your team to be responsible for shared
tasks to minimize your workload.
D Make sure that you always go home at fi ve o’clock.
E Try to streamline your work eff ectively so that you are not left with
lots of tasks to complete at the end of the day.
F Talk to senior colleagues early if you think that the workload is getting
on top of you.
G Drink alcohol in the evenings to ‘loosen up’.
H Ask Human Resources (HR) for time each week to attend yoga and
relaxation classes.
A
- A, E, F
Doctors must be familiar with their own strengths and weaknesses.
The Foundation Programme e-portfolio has a number of tools (e.g.
Team Assessment of Behaviour (TAB)) for refl ecting on and so mitigating
potential weaknesses (A). Eff ective time management can reduce
stress levels (E), as can involving senior colleagues if work levels become
unmanageable (F). Although you should always aim to leave on time,
this will not always be possible and doctors must be prepared to show
some fl exibility (D) to ensure that patients and colleagues do not come
to harm.
Increasing the burden on other junior colleagues (B) (C) is unlikely
to be a successful long-term strategy. Although outside interests are
important, drinking excessively (G) is unhelpful and HR is unlikely to
agree to time away for yoga classes. (H).
21
Q
- As the on-call FY1 doctor, you should fi nish at 10 p.m. and then
hand over to the night SHO. However, one particular SHO
refuses to accept jobs that he feels should have been completed during
your shift. As a result, you fi nd yourself leaving at 1 a.m. whenever he is
scheduled to work nights.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Document that the SHO refused to accept a handover and then
go home.
B Stay late if necessary to ensure that patient safety is not compromised.
C Raise the issue with an appropriate person (e.g. your Educational
Supervisor or line manager) as a priority on the following day.
D Report the night SHO to the GMC.
E Explain that you have completed as many tasks as you were able and
that he should assume responsibility for them at the end of your shift.
A
- B, E, C, D, A
You are entitled to go home at the end of a shift. Your rota is designed
to create suffi cient rest so that it is within the law and guarantees patient
safety. It could be convincingly argued that either (E) or (B) should
fi rst, and a fully correct answer would require you to do both of these.
However, (E) implies that you are passing responsibility to the night SHO
even though he has stated that he will not accept that responsibility. It
may be unfair, but to ensure patient safety that night it may be necessary
to complete urgent tasks if you have reasons to doubt that they would
be completed by your colleagues (B). It is clearly correct to address
the wider problem of this doctor who fails to accept this responsibility;
however, in isolation this does not address the immediate problem of
tasks not being completed (C). (A) and (D) are both probably incorrect.
(D) is inappropriate because there will be Trust processes that should be
exhausted fi rst, and you would always wish to take senior advice before
referring a colleague to the GMC, and this should not be considered in
haste when angry at 10 p.m. However, (A) must be the worst answer
because it achieves nothing except for protecting yourself with careful
documentation whilst potentially leaving an important role within the
hospital unfi lled.
22
Q
- You are a surgical FY1 doctor expected to be prepared in
advance of the morning ward round at 7.30 a.m. Your Clinical
Supervisor tells you from the outset that you must also attend the 8 p.m.
evening ward round. These hours confl ict with the 9 a.m. to 5 p.m. working
pattern indicated by your contract.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Remind your consultant that you are contracted to work between
9 a.m. and 5 p.m.
B Slip off home for a few hours each day to remain compliant with the
European Working Time Directive.
C Ignore your consultant’s instructions and work from 9 a.m. to 5 p.m.
as you are required to do.
D Accept that long hours are an inevitable part of any surgical post.
E Seek advice from your Educational Supervisor.
A
- A, E, D, C, B
Doctors must sometimes work fl exibly because of the unpredictable
nature of their profession. However, your regular work pattern is a
contractual right. Working outside these hours might confl ict with the
European Working Time Directive and should potentially increase your
banding supplement. This issue would be best resolved with your Clinical
Supervisor and therefore (A) is the best answer. (E) is not unreasonable;
however, it is likely to result in your Educational Supervisor suggesting
that you speak to your Clinical Supervisor, which takes you back to (A).
(D) is the fi rst wrong answer, although you may see this played out many
times as you start work, as there are expectations in some specialties
that trainees will adopt a particular approach within their specialty. It is,
however, strictly wrong, for the legal reasons described. (B) and (C) are
clearly the worst answers. (C) is unprofessional if your consultant
believes you will be working the hours he thinks that you are working.
(B) has to be the worst answer because it suggests that your contracted
duties during the day are neglected and it does not make it clear that
anyone is taking care of your patients during this time.
23
Q
- Your registrar calls you during the day and tells you that a
patient’s suprapubic catheter has fallen out and needs to be
reinserted. You explain that you have never done this before, but he says
that it is simple and that no one else is free to help until the operating list
fi nishes eight hours later. He is insistent.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Politely explain that you cannot perform the procedure safely and will
need supervision.
B Ask another doctor with relevant experience to assist.
C Read about the procedure before having a go.
D Do as you are told but document carefully that you were acting under
your registrar’s instructions.
E Refuse to help as you are inundated with other ward jobs.
A
- B, A, E, C, D
There is a narrow margin between (A) and (B) as the correct answer.
Many candidates will feel that (A) is correct as it is up-front, honest,
and may provoke your registrar to think of another solution. It is also
likely to be the fi rst thing you would do in this situation. When answering
the SJT questions it is important to remember that you are being
asked for the most appropriate actions and not the order of actions that
you would perform. As a single intervention, it would probably be more
helpful if you would take responsibility for ensuring that this task happened
and then identifi ed a way to ensure that it occurred safely. In this
case, asking another suitably qualifi ed doctor to help may be appropriate
(B). There is a distinction between this sequence and a similar question
( Question 1 , Chapter 10 ) in that here the registrar is calling from theatre
and has already explained that he is unable to assist; in the other question
the registrar is on the ward and is in a much better position to consent
the patient and off er guidance as to how to resolve the issue. The fi rst
wrong answer is (E) as this fails to address the clinical problem. Worse
still is attempting to complete the task independently, which risks compromising
the patient’s safety—(C) is only marginally better than (D) as
it implies there is a degree of preparation before you embark upon this
unfamiliar task. Documenting your registrar’s request does not absolve
you of your responsibility to the patient if you perform it inappropriately
and the patient comes to harm as a consequence.
24
Q
- An elderly patient with pneumonia is deteriorating despite antibiotic
treatment. As the on-call medical FY1 doctor, you plan
to discuss changing antibiotics with the duty consultant microbiologist.
However, the nursing staff and patient’s family are united in wanting
treatment to be withdrawn to stop the patient from suff ering. You seem
to be alone in wanting to continue treating the patient aggressively.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Familiarize yourself carefully with the case and try to understand why
the family and nursing staff want to withdraw treatment.
B Insist on continuing with your plan as you are ultimately responsible
for the patient.
C Stop all active treatment to hasten the patient’s death and so end her
discomfort.
D Contact a senior doctor to ask for their decision.
E Tell the patient’s family to think carefully about the options and that
you will do as they want if all members agree.
A
- A, D, B, E, C
Ideally, grave decisions of this nature should be based on a broad consensus
including doctors, members of the multi-disciplinary team, relatives,
and the patient herself if possible. The best answer requires you
to understand the case and try to identify the reasons for your current disagreement with the family and nursing staff . It may be that an answer
becomes immediately apparent, e.g. a decision to withdraw treatment
has already been documented (or there may be a consensus position
to be found). For this reason, (A) is the best answer. The other correct
answer is to involve a senior doctor early on (D), although this will
necessarily require you to understand the case before doing so, which is
why it is not as good an answer as (A). The other answers are incorrect
to varying degrees. (B) is probably the best because at the current time
you are responsible for directing this patient’s management. If they do
not have capacity (which is implied in the question) then you are obliged
to make decisions in the best interests of the patient. In the absence of a
more senior doctor the arbiter of these best interests (after taking into
consideration views of relatives, pre-existing wishes, etc.) could even fall
to the FY1 doctor. However, it would be necessary to carefully articulate
this principle and insisting may be the wrong approach. For the reasons
stated here, (E) is worse than (B) because best interests is an objective
clinical assessment and you have no discretion to delegate this responsibility
to family members. Finally, the worst answer (C) is taking actions to
actively hasten death, which is illegal (murder!), although inappropriate
interventions can be discontinued under the doctrine of double eff ect.
25
Q
- You are on call and bleeped by a ward nurse about a bag of
blood that was mistakenly taken out of the fridge. As it cannot
now be returned, she asks you to prescribe it for the patient so that it is
not ‘wasted’. You are not intending to visit the ward for some time and
the nurse sounds frustrated as the blood will be lost 30 minutes after
removal from the refrigerator.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Go to the ward immediately to prescribe the blood.
B Tell her that you will not authorize a transfusion simply to avoid waste.
C Tell her that she should not have removed the bag unnecessarily and
complete a clinical incident form after your shift.
D Encourage her to put the bag back in the refrigerator so that it can be
returned to the blood bank for other patients.
E Explain that transfusion carries signifi cant risks and there is no benefi t
in transfusing a non-anaemic patient.
A
- E, B, C, A, D
Blood transfusion carries signifi cant risks (including death) and should
not be considered without good reason. The best answer is therefore
(E) as there is no indication for transfusion, and this answer ensures you
explain the reasons for your decision to the nurse which will hopefully
ensure she is happier with the outcome. (B) is correct but not as good
an answer as (E) as there is no attempt to share your reasoning with the
concerned nurse. Reprimanding the nurse is probably unnecessary as
she will likely be aware of the seriousness of wasting blood; you could
complete the incident form, but it would probably be more appropriate
if the ward team did so instead, as you have not been actively involved
(C). (A) is clearly the wrong answer as it exposes the patient to the risks
of an unnecessary transfusion. (D) is worst because it exposes another
patient to greater harm, as you have been told in the question that the
blood cannot now be returned for further use.
26
Q
- An experienced staff nurse asks you to sign a prescription for a
sleeping tablet that she administered an hour ago. You decline
as this does not seem to be correct, but the Ward Sister says you have
to sign as this is how things have always worked in their unit.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Sign the prescription retrospectively.
B Tell both nurses that only doctors have the required training to decide
which drugs to prescribe.
C Check the drug details to ensure that there were no contraindications
and that an appropriate dose was administered.
D Advise that a note should be made on the prescription chart and hospital
notes to indicate the drug was administered.
E Explain that an authorized prescriber must agree before drugs are
given in future.
A
- C, D, E, B, A
Patient safety must be your fi rst priority. The best options are therefore
(C) and (D). (C) is the better of these two because you should ensure
that administration of the drug has not had a detrimental eff ect on the
patient. (D) comes a close second as it would also be important to
ensure a record is made in case a similar or incompatible drug was to be
prescribed later on. (E) is less important only because it does not guarantee
your patient’s immediate safety, although it goes some way towards
addressing the problem. (A) and (B) are the two incorrect answers. (B) is
antagonistic and factually incorrect because there are nurse prescribers.
(A) is the worst answer, although you might see this happen on some
units where doctors have tacitly accepted retrospective prescriptions. However, they should generally be discouraged at least in part because
signing retrospectively (in cases where you have not verbally requested
the drug be given) implies dishonestly that you asked for the drug and
that it was administered as a consequence. Ideally, the nurse should sign
to indicate that it was administered, no prescription was signed, and a
description of this event was documented in the notes.
27
Q
- You are an FY1 doctor and part of the cardiac arrest team.
On arriving at an arrest, you fi nd that no one is managing the
patient’s airway despite a number of senior doctors being present.
Other appropriate activities are taking place.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Stand back so that you do not distract the arrest team leader.
B Ask the team leader why no one is managing the airway.
C Move to the patient’s head and use airway adjuncts as appropriate.
D Ask whether an anaesthetist is present and, if not, whether they are
on their way.
E Help with chest compressions because these are easily within your
comfort zone.
A
- C, B, D, E, A
This question requires you to take some responsibility for patient welfare
in an emergency even in the presence of senior doctors if you are
not confi dent that they are acting correctly. You know that the correct
management of a cardiac arrest begins by securing the airway. If no-one
else is actively managing this problem the responsibility will fall to you
(C). (B) is second best answer because, if you were not to choose managing
the airway yourself, you should draw the team leader’s attention to
the problem in the most direct way possible. (D) is less good than (B) as
it indirectly raises your concern about the airway. (E) and (A) are incorrect
as both appear to ignore the threatened airway. (E) is somewhat
better than (A) as you are at least off ering your support.
28
Q
- The on-call bleep is constantly going off and you have a number
of jobs to prioritize. You need to determine which to attend to
fi rst and then in order of priority.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A A 55-year-old man with central chest pain.
B An angry daughter who wants to discuss why her mother is developing
bed sores and is threatening a formal complaint.
C A 40-year-old woman with metastatic cancer with bony pain needing
analgesia review.
D A 24-year-old man after an elective orthopaedic operation who wants
to go home but fi rst needs a discharge summary and prescription.
E A 90-year-old woman with a pneumonia who is hypotensive and
became unresponsive a few moments ago.
A
- E, A, C, B, D
The correct answer is (E) because a critically ill patient who is
deteriorating and may be peri-arrest should be your priority regardless
of her age. (A) is less concerning because at present he is stable;
however, given his presentation, you have good reason to believe he
may become unstable very soon. (C) is not a life-saving emergency,
but severe pain should be accorded high priority for compassionate
reasons—patients should not be left in pain when relief is available.
(B) and (D) are less important because they are not clinically urgent.
The angry relative’s demand must be secondary to the immediate
requirements of other patients. However, bed sores are a serious
concern and you should try to discuss this situation to improve her
mother’s care and avert a complaint if possible. Therefore this situation
should be prioritized above the young patient awaiting discharge (D),
however keen he is to go home.
29
Q
- You are clerking patients in the Emergency Department. Your
current patient is in police custody and, at the point of discharge,
the accompanying offi cers ask you for a copy of the discharge
summary. The patient asks you not to provide them with any details but
the offi cers insist that you must cooperate with their request.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Politely explain to the police offi cers that you cannot provide information
without your patient’s consent.
B Discuss with a consultant if the offi cers insist.
C Give a discharge summary to the patient, knowing that it might be
confi scated later on.
D Give the offi cers a discharge summary, as helping the police is in the
public interest.
E Tell the offi cers that there are no circumstances under which you
would betray your patient’s confi dence.
A
- A, B, E, C, D
The key principle at stake is that you require a patient’s consent before
breaching confi dentiality in most circumstances. (A) is the best answer
because it explains the limitations on what it is appropriate for you to do.
(B) and (E) both correctly withhold the information, although (E) is less
good because it is factually incorrect—there are circumstances under
which you must disclose information to the police (e.g. to avert serious
crime and in fi rearms off ences).
(C) and (D) are the worst options as the outcome is passing on the
discharge letter to the police against your patient’s wishes. However,
(C) is marginally better as this gives the patient some opportunity to
protect his own information.
30
Q
- You are called from the private wing of your hospital. The
receptionist there asks for a cannula to continue a blood transfusion
that is half completed. She called the responsible consultant at
home who told her to bleep the on-call FY1 doctor to resite the cannula.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Decline to resite the cannula regardless of the clinical situation and
suggest that the consultant comes in from home to do so as it is his
private patient.
B Assess the urgency of the transfusion and prioritize according to your
other tasks.
C Help if you are able, but let the receptionist know that they should
have someone capable of cannulating patients on site.
D Cannulate the patient but leave an invoice with the receptionist
for £80.
E Contact a responsible person (e.g. the duty manager) to ask about the
appropriateness of attending to tasks in the private wing.
A
- B, C, E, D, A
Covering the private wing might not be one of your usual responsibilities.
However, you may have a duty to help a patient in extremis (e.g. Hb
5.0 and mid-way through a transfusion). For this reason, (B) is the best
answer as you would fi rst need to assess the situation carefully. (C) is less
good because you are still intending to help; however, there has been
no attempt to prioritize other routine tasks. (E) is less helpful but might
determine whether attending to tasks in the private wing is acceptable as
there may be local rules.
(A) and (D) are both incorrect as you have a moral duty to help in an
emergency, regardless of local arrangements or your personal feelings.
Although charging the private wing for work on NHS time (D) would be
improper, (A) is more incorrect as it suggests you would refuse to help
regardless of the clinical situation.
31
Q
- You are on call and are approached by a staff nurse who admits
to giving an unfamiliar drug stat instead of as an infusion over
12 hours. She asks you to see the patient but not to tell anyone about
the error.
Choose the THREE most appropriate actions to take in this situation
A Review the patient as a priority.
B Call the duty manager immediately to request that the nurse be
removed from work.
C Explain that you cannot cover up the error but that you will let her
speak with the Ward Sister fi rst.
D See the patient but do not write in the notes, to avoid causing the
nurse career diffi culties.
E Complete a formal incident form as soon as possible after the event.
F Call the intensive care registrar to discuss urgent transfer as the
patient has been overdosed.
G Encourage the patient to vomit and prescribe intravenous fl uids to
fl ush out the drug.
H Tell the nurse that you cannot help but to bleep you if the patient
deteriorates.
A
- A, C, E
This patient has had an accidental overdose and needs to be reviewed
as a priority (A). You must not wait until the patient shows signs of
deterioration (H). Although you must not cover up clinical errors
(D), the nurse may prefer to inform the Ward Sister herself (C). As
this is a serious error, a formal incident report must be completed
contemporaneously (E) so that a paper trail is created and lessons can
be learned. There is no need to think that this nurse is an immediate
danger to other patients (B). It would be inappropriate to discuss with
intensive care (F) until you have assessed the patient and have decided
that higher-level care is necessary. Intravenous fl uids and vomiting are
not standard interventions (G) and would only be indicated on senior
advice or if directed by a reliable resource (e.g. Toxbase).
32
Q
- The daughter of an elderly patient asks you for an update about
her mother’s condition. A recent CT scan was suspicious of
lung cancer and your patient has asked you not to tell anyone else to
keep them from worrying. The daughter says she ‘knows something is
wrong’ and it is unfair to keep the family ‘in the dark’.
Choose the THREE most appropriate actions to take in this situation
A Empathize with the daughter but explain that you cannot disclose this
information without her mother’s consent.
B Advise her you will call security if she persists in bothering you for
information.
C Tell her that the CT scan was normal and that her mother will be
discharged soon.
D Explain that her mother has asked you not to discuss certain aspects
of her care with anyone.
E Tell her the results of the CT scan but ask her not to tell the patient
that you have done so.
F Discuss with your patient at the next opportunity to ensure that she
understands the eff ect that withholding information might have on
close family members.
G Talk openly with the daughter, as her mother is elderly and probably
lacks capacity.
H Give her your consultant’s mobile number so that she can discuss
directly with your senior.
A
- A, D, F
You should be sensitive to the daughter’s concern but fi rm that you cannot
breach confi dentiality in this case (A). You may indicate that you
have not been given permission to give details to anyone (D). It might be
helpful to let your patient know that close family members are anxious
for details (F) in case she changes her mind and agrees to involve them.
Calling security (B) is an overreaction and likely to infl ame the situation.
You must not lie (C) or breach your patient’s confi dentiality (E), even if
you feel coerced by her family. Capacity is not age-dependent (G) and
cannot be assumed to be lacking in an elderly patient. Your consultant is
unlikely to approve of his contact details being given out (H)—colleagues
are also entitled to a degree of confi dentiality.
33
Q
- You are on call for medicine but are making no progress with
your tasks because you are fi elding so many bleeps. There are a
number of acutely unwell patients on the wards awaiting assessment and
the Emergency Department is now calling to inform you that patients
are breaching.
Choose the THREE most appropriate actions to take in this situation
A Remove the batteries from your bleep and begin your existing tasks.
B Call your senior to let them know that you are not coping with the
workload.
C Make a clear list of tasks in order of clinical priority.
D Explain to the Emergency Department that you have yet to assess
potentially unwell patients and cannot assist for some time.
E Go to the Emergency Department but document that this distracted
you from other tasks in case anything goes wrong.
F Have a coff ee break now as you work better when rested and are
unlikely to get lunch later.
G Draft a letter to the Chief Executive complaining about the eff ect of
your workload on patient care.
H Tell the Emergency Department that the Trust should appoint more
doctors if it wants to avoid patient breaches.
A
- B, C, D
You have a duty to speak out whenever you feel that patient care is
being compromised. In this case you should let a senior know (B) if you
are unable to cope—they might be able to help or redirect resources
accordingly. A clear jobs list will help you prioritize tasks so that the mosturgent are completed fi rst (C). You must not neglect potentially unwell
patients to meet other commitments (e.g. hospital targets) (D), even if
you document the reason (E). However, you should not be discourteous
or facetious when declining to help the Emergency Department (H), in
order to maintain good working relations. Time spent on a coff ee break
(F) or drafting a letter (G) could be better used to assess your potentially
unwell patients. You should never render yourself uncontactable (A) in
case emergencies require your immediate attention.
34
Q
- You are experiencing relationship diffi culties at home and this
is aff ecting your ability to cope at work. The radiologist has just
refused a CT request which your consultant said is very urgent and you
burst into tears after leaving the radiology department.
Choose the THREE most appropriate actions to take in this situation
A Take a few minutes to compose yourself, and then alert your consultant
to the radiology decision.
B Send an email to your team explaining that you are very stressed and
should be spared diffi cult tasks for the foreseeable future.
C Take a break and speak to a supportive colleague if possible.
D Go back and plead with the radiologist to accept your request.
E Contact the Medical Director to complain that the radiologist was
obstructive.
F Tell Medical Staffi ng that you are unwell and have to go home to manage
your domestic aff airs.
G Ask another FY1 colleague to speak to the radiologist about your
urgent CT request.
H Seek advice from your Educational Supervisor and/or Occupational
Health if you continue to struggle at work.
A
- A, C, H
If the CT request is very urgent, you should alert your consultant (A) if
there is any reason why it cannot go ahead. You might have miscommunicated
its urgency and/or he might want to intervene. You should take
some time to compose yourself and speak to a supportive colleague
if one is available (C). If you are fi nding things particularly diffi cult, you
should seek independent advice from your GP, Educational Supervisor,
and/or Occupational Health (H). Talking again to the radiologist (D) or
asking a colleague to do so (G) is unlikely to be helpful unless the situation
has changed or more facts are available.
The radiologist may have good reason to decline your request and is
not necessarily being obstructive (E). In any event, the Medical Director
would not be your fi rst port of call. You should only ask to go home
(F) if you cannot continue working, as this may disrupt patient care and
is unlikely to resolve your diffi culties. A generic email asking others to
shoulder your work (B) might be misinterpreted and/or unfairly burden
colleagues.
35
Q
- You are a surgical house offi cer. The other FY1 doctor on your
fi rm has called in sick and you feel that the workload is unmanageable
for a single person. Your SHO apologizes for leaving you with
so much to do but says that he ‘has to go to theatre’ or his logbook will
suff er.
Choose the THREE most appropriate actions to take in this situation
A Tell the SHO that patient care should come before his logbook.
B Explain to the SHO that you cannot cope and need some help.
C Explain to the senior nurse on each ward that they should not bleep
you unless patients are ‘really sick’.
D Tell the SHO that you would like to go to theatre instead as he will be
more effi cient on the ward anyway.
E Ensure that your consultant or another senior doctor on the team
knows that you are working alone.
F Call in sick tomorrow in case your colleague is away again and you are
left alone for a second day.
G Carefully prioritize jobs and explain to the senior nurse on each
ward that you are working alone and might be slower to respond
than usual.
H Delay all patient discharges until the following day when your colleague
might have returned.
A
- B, E, G
You should not accept a situation that compromises patient care and
your fi rst action should be to reason with the SHO (B). This should be
done in a non-confrontational manner; however, speaking directly to
the SHO (A) is likely to result in a swifter resolution or compromise
than involving the consultant (E). You should let nursing colleagues
know in advance that you might be slower to respond than usual (G).
However, you should never discourage staff from calling you about
deteriorating patients (C)—more can be done for unwell patients who
are identifi ed early.
If the ward team is short-staff ed, you should not seek to leave your
SHO alone to cope (D). The SHO might be a surgical trainee who will
learn more (and be more useful) in theatre than an FY1 doctor. You must
not fake illness (F) as this is dishonest and unfair to colleagues who will be
even more stretched the following day. Patient discharges should not be
delayed unnecessarily (H) but might be lower priority than some tasks.
36
Q
- You are ambushed leaving the ward by a group of relatives who
are angry about the care of one of your patients who is now on
ITU. They are asking lots of questions and one is videoing the interaction
using a smart phone.
Choose the THREE most appropriate actions to take in this situation
A Say ‘no comment’ and block the camera with your hand.
B Try to ignore the camera and act as you would if it were not there.
C Explain that you are unable to talk about a patient’s care without their
permission.
D Tell the relatives that the Ward Sister is in a better position to answer
their questions.
E Contact security if you feel threatened or their presence is obstructing
your work.
F Answer questions to defuse the situation.
G Tell the group that you are from another team and have never heard
of this particular patient.
H Try to confi scate the camera as you do not wish to be videoed.
A
- B, C, E
FY1 doctors must remain resilient under pressure. In this case, you
should try to ignore the camera (B) and act normally by explainingpolitely that you cannot discuss a patient’s case without their permission
(C). Do not breach confi dentiality simply because the situation is pressurized
(F). You have a right not to feel threatened at work and should
call security for assistance if you feel out of your depth (E). Trying to
obscure (A) or confi scate (H) the camera will aggravate the situation
and look very bad on tape afterwards! You should not lie under any
circumstances (G) but politely decline to answer questions. Although
directing relatives to the correct member of staff (D) might be helpful,
the result in this case would simply be to shift an uncomfortable situation
onto a nursing colleague.
37
Q
- You did not complete any alcohol screening questionnaires for
patients admitted the previous week. A senior doctor tells you
that this means that the Trust will lose a lot of money and that you should
‘make up’ answers to the questions retrospectively. You seek support
from your consultant who tells you to do it to keep the Trust happy.
Choose the THREE most appropriate actions to take in this situation
A Decline to complete screening questionnaires dishonestly.
B Complete the questionnaires, as you have been told to do so by two
senior colleagues.
C Contact a tabloid newspaper to report that Trusts are submitting false
data for fi nancial reward.
D Don’t complete the questionnaires but tell the senior doctor that you
did so.
E Explain that you will make a particular eff ort to complete screening
questionnaires the following week if these are important for the Trust.
F Refuse to complete the questionnaires, as they are unhelpful and
interfere with patient care.
G Put the afternoon aside to call all discharged patients and complete
the questionnaires by telephone interview.
H Explain that you realize the importance of the questionnaires to the
Trust but that you do not think it is correct to complete the forms
retrospectively.
A
- A, E, H
There are very few circumstances that justify dishonesty and this is
not one of them. You should not complete the questionnaires with
false data (A) (B). However, you should recognize your omission and
let your senior doctor know your plan to improve the following week
(E). Empathizing with the senior doctor and demonstrating that you
understand their importance (H) will help defuse any potential confl ict.
Refusing outright to participate (F) is likely to result in confl ict and is at
odds with your status as a Trust employee. However, the questionnaires
need to be prioritized alongside other tasks and an afternoon calling
patients for this purpose is poor use of clinical time (G). Lying to a senior
doctor, even if this might appear to solve the problem, is unjustifi able
and could result in professional diffi culties (D). Raising concerns with a
newspaper in the fi rst instance would be likely to result in employment
and/or professional disciplinary action (C).
38
Q
- A young patient with a pericardial eff usion wants to leave hospital
to attend his brother’s wedding. Both the patient and his
family plead with you to discharge him earlier than your consultant had
initially planned, albeit without knowing his social circumstances. The
patient appears to be very well and has normal observations.
Choose the THREE most appropriate actions to take in this situation
A Explain the risks of premature discharge, looking these up or seeking
senior advice if you are uncertain.
B Tell the patient that your consultant’s word is fi nal and that he cannot
leave earlier.
C Explain that the patient can self-discharge at any point if he wishes
to do so.
D As the patient is haemodynamically stable, agree to discharge him
earlier than planned.
E As the patient is haemodynamically stable, let him leave hospital for
24 hours to attend the wedding.
F Tell the patient that you won’t stop him if he wants to go and that he
can fi nd the risks of pericardial eff usion easily enough online.
G Tell the patient that his health should always come ahead of family
engagements.
H Contact a senior doctor for advice.
A
- C, A, H
You cannot prevent a patient with capacity from leaving hospital and
the patient should be aware that he is free to leave at any time (C) (B).
However, you have a duty to ensure that he understands the associated
risks and you should fi nd these out if you are unsure (A) (F). If you
are concerned about the patient’s decision, you might consult a senior
doctor (H) who could potentially counsel the patient more convincingly.
It is clearly wrong to place the burden of looking up risks on to the
patient (F).
If your consultant has made a clinical plan, you should not contradict
this without very good reason (D) (E). FY1 doctors must be open to
patients having diff erent values and life priorities. It is acceptable for a
patient to prioritize a family engagement (G) as long as he understands
the potential consequences of doing so.
39
Q
- You have fi nished a night shift and are exhausted. As you are
preparing to go home, you receive a call from the day FY1 doctor
to say they are suff ering from diarrhoea and vomiting and cannot
work as a consequence. You are due to work the following night as well.
Choose the THREE most appropriate actions to take in this situation
A Tell the FY1 doctor to pull himself together and come into work.
B Leave your bleep in a designated place.
C Let the site manager know that the day FY1 doctor is unable to come
to the hospital.
D Head home as you have already worked a full night shift and are
unsafe to continue working.
E Work as much of the day shift as you can before you cannot continue
and need to alert the responsible manager.
F Continue working to the best of your ability.
G Keep holding the bleep but decline to review patients, as you are tired
and unsafe.
H Ask the responsible manager to arrange appropriate cover so you
have time for suffi cient sleep before returning to work.
A
- C, F, H
Although, ideally, you should not work when exhausted, it would be
more dangerous for you to leave without a replacement (D) or to
become uncontactable (B). You should continue working (F) but let a
manager know at the earliest opportunity so that relief can be sought(C) (E). As you are due to work the following night, the manager should
arrange suffi cient cover so that you are not still exhausted on returning
to the hospital (H). You must continue to review patients who are
potentially unwell, even if you are tired (G).
Your FY1 colleague should not come to work with diarrhoea and vomiting
as there is a risk of spreading Norovirus to vulnerable patients (A).
40
Q
- An elderly patient with known dementia is attempting to leave
the ward. He has punched a healthcare assistant who tried to
encourage him back to his bay. You do not believe that he has capacity
to leave the ward.
Choose the THREE most appropriate actions to take in this situation
A Try to talk to the patient from a safe distance.
B Tackle the patient’s legs and try to break his fall.
C Contact security urgently.
D Try to conduct an Abbreviated Mental State Examination (AMTS)
from a safe distance.
E Attend to the healthcare assistant’s injuries as soon as it is appropriate
to do so.
F Shout and wave at the patient to encourage him back into the ward.
G Sedate the patient with propofol for his own safety and the safety of
others.
H Continue with your work, as agitated patients are a problem for the
nursing team.
A
- A, C, E
Although the patient has dementia, you should fi rst try to communicate
with him as with any patient (A). As he has already hit a healthcare
assistant, he may continue to be violent and need to be restrained.
Security offi cers are the most appropriate people for this task (C). Once
the situation is controlled, you should attend to any injuries arising,
including to staff (E). You should not do anything likely to scare the
patient (F) or cause harm (B) and should treat him with as much dignity
as the situation permits. An AMTS assessment is unlikely to be successful
or add very much to his immediate management (D). FY1 doctors
should not give anaesthetic drugs (G), let alone in an unmonitored ward
environment—propofol is not a solution in this case.
An agitated patient risks harming themselves or others and therefore
is the responsibility of all staff (H).
