Effective Communication Flashcards
1
Q
- You are covering medical wards at the weekend when you are
asked by a nurse to speak to the relatives of a patient about his
newly diagnosed malignancy. You have not met the patient before but
are told that his relatives are very anxious.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Establish how much the relatives wish to know, and respond to their
requests honestly and with compassion.
B Politely decline to discuss the health of the patient without his explicit
permission.
C Ask the nurse to read the medical notes and speak to the family after
doing so.
D Explain that you do not know the patient and that they should speak
to the regular ward team instead.
E Collectively address both the patient’s and the family’s concerns, and
answer each of their questions in turn.
A
- B, E, D, C, A
(B) is the only correct answer, as you do not know the patient, the relationship
with their family, and what each party already knows about the
condition. In most circumstances it is necessary to gain express consent
before discussing with relatives, and this becomes even more important
in the context of a serious discussion, e.g. a new diagnosis of cancer.
Therefore (A) is the worst answer as it implies that you have not sought
consent from the patient, despite subsequent steps being correct. By talking
to the family in the presence of the patient, you are giving the patient
an opportunity to indicate they are unhappy about further information
being disclosed, and they are present when any information is shared.
Therefore (E) is the next best answer. Although usually it would be more
appropriate for the day team to deal with this as they know the case
much better and can provide continuity, we are told the family is anxious
and it would be inhumane to leave them uninformed if the patient
agreed to a discussion at this time; hence (D) is less appropriate than (E).
(C) is a bad option as this is not the nurse’s primary role and she should
not be expected to take responsibility for informing the family about the
patient’s signifi cant medical developments. However, (A) remains worse,
as you are explicitly disclosing information without patient consent.
2
Q
- You are a respiratory FY1 doctor and have inserted a number of
chest drains before and have been asked to do so for a patient on
your ward. Previous consents have always been obtained by diff erent
doctors. You intend to obtain consent for this patient but recall that this
can be found to be invalid afterwards unless the patient is warned about
important complications.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Obtain verbal consent and document that the patient has been
consented in the notes.
B Obtain legal advice before consenting.
C Obtain verbal consent with a nurse as a witness.
D Complete a formal written consent form.
E Refuse to complete the procedure as only SHO grade or above
should consent.
A
- D, A, C, E, B
This question tests your understanding of the consent requirements
for diff erent types of procedure. In general you should only consent a
patient for a procedure that you are able to perform by yourself or have
suffi cient understanding of the risks and benefi ts to counsel the patient.
In this case a chest drain is an invasive procedure with potentially serious
risks and it would be most appropriate to obtain formal written consent
(D). The other answers are therefore incorrect; however the best of
these is (A). (A) is better than (C) because a written record is less fallible
than human memory, and you may not recall in years to come which
nurse witnessed the conversation.
Thorough documentation of consent is always mandatory and has to be
the correct answer (D). (E) is clearly wrong as you are able to consent the
patient for this procedure; however, (B) is in some ways worse, as it suggests
a complete misunderstanding of what you should do when consenting
patients for a relatively simple procedure that you are able to perform
3
Q
- You are working as an FY1 doctor at night in the surgical assessment
unit, when you are asked to clerk an elderly patient who is
profoundly deaf and unable to write.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Attempt a brief verbal history.
B Skip the history, and focus your management on the examination and
investigations.
C Do not attempt to clerk the patient without an interpreter present.
D Complete your detailed history via handwritten questions.
E Extrapolate a history based on the limited fi ndings of the ambulance
crew on their initial assessment sheet.
A
- D, E, B, A, C
(D) is the best answer as it is important to adapt to individual patients’
disabilities and ensure that they are not disadvantaged simply because a
task might become harder. (E) is largely incorrect, although an attempt
is being made to obtain a history and there may be useful collateralinformation in the handover sheet. (B) is a worse option as no sensible
attempt is made at obtaining a history; however, the examination should
be suffi cient to ensure that the patient is stable, which is your minimum
duty in this case. (A) is unnecessary and will not yield any useful information
with a profoundly deaf patient if you can communicate this way.
(C) is clearly incorrect as it amounts to doing nothing at all, and may
disadvantage the patient unnecessarily.
4
Q
- Your next patient at the gynaecology clinic arrives with her
brother-in-law, who explains that she is unable to speak any English.
As you begin the interview you start to suspect that her brother-in-law
is only communicating some of the information.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Reiterate to the brother-in-law that you need him to translate word for word.
B Try to establish whether the patient is happy with her brother-in-law
acting as interpreter.
C Schedule another appointment with a formal interpreter.
D Invite the clinic receptionist into the consultation as she claims to
speak a similar language to the patient’s.
E Ask the brother-in-law to leave and complete the consultation without
any interpreter.
A
- C, A, B, D, E
The success of this interview relies on accurate translation of information.
For this reason, the best answer which ensures you can communicate
eff ectively with your patient is to arrange an interview with
a professional interpreter present (C). The other options are less than
ideal, but the next best is probably (A), to address the brother-in-law
directly and insist that he translates word-for-word what is said, as this
may achieve the desired outcome. The diffi culty arises because, once
doubt has been raised about your ability to trust the brother-in-law’s
translation, you are then unable to use him as a way of clarifying whether
the patient is happy with him translating. (B) is therefore less eff ective.
The diffi culty with (D) is that the receptionist speaks a similar language
to the patient, which introduces another uncertain variable into this
already complex scenario. Trying to ascertain the patient’s wishes even
through the imperfect conditions of the brother-in-law is preferable to
introducing a third party who may not be able to communicate with
the third party at all or may introduce misunderstandings. The worst
option is (E) as you are unlikely to fi nd that the consultation either fl ows
or becomes more informative as you attempt communication with a
patient who speaks a diff erent language.
5
Q
- You are on a busy orthopaedic ward round with your consultant
when a nurse mentions that one of your patients drinks 60 units of
alcohol per week. He is scheduled for an elective knee replacement in
two days but is otherwise fi t and healthy.
Choose the THREE most appropriate actions to take in this situation
A Ask the consultant to review the issue during the ward round.
B Return to the patient after the ward round to discuss the matter further
with him.
C Prescribe Pabrinex and chlordiazepoxide while the consultant consents
the patient.
D Discuss the matter further with the patient during the ward round.
E Tell the patient to stop drinking alcohol.
F Mention the issue to the registrar after the ward round.
G Ask the nurse to keep superfl uous information until after the ward
round to avoid interruptions.
H Inform the drug and alcohol services representative.
A
- B, F, H
Although alcohol intake my be pertinent to this elective admission, it can
be addressed more eff ectively after the ward round (B). After your initial
assessment, it may be advisable to inform your senior (F) and involve an
alcohol services representative (H) if the patient agrees. You should not
stop a busy ward round to address non-urgent issues (A) (D), blindly prescribe
medication for alcohol withdrawal (C), or give the patient instructions
without a full history (E). It would be unprofessional and unhelpful
to discourage the nurse from sharing important information (G).
6
Q
- A 50-year-old is admitted to hospital with a severe sudden-onset
headache, which you think is probably a migraine. Your registrar
asks you to telephone the on-call radiologist at home to authorize an
urgent CT scan. You become distracted completing other jobs for the
registrar and only remember to telephone the radiologist an hour later.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Inform the registrar about the delay, and phone the radiologist immediately
to request the CT head scan.
B Phone the radiologist and explain that the registrar only just asked you
to arrange the CT scan.
C Phone the radiologist and explain that the registrar wants the CT head
scan but you think that it is likely to be a migraine.
D Ask the registrar to call the consultant radiologist himself.
E Phone your own consultant and ask for advice fi rst.
A
- A, C, D, E, B
The best answer is to be honest to your colleagues at all times (A). (C) is
an unusual but acceptable way to approach radiology. It would be better
to raise objections directly with your team, but you are being honest
as you are not sure what the diagnosis is but are raising the concerns
of your seniors and their request for a CT head scan. (D) is less good
than (C) because, while still ensuring the scan is done, it will burden
your registrar unnecessarily and is unlikely to expedite your scan, as theradiologist will understand the urgency of the indication if you explain
the circumstances. The objective should be to obtain the scan as quickly
as possible and (E) will not assist you with your cause in any way. (B) is
the worst answer because lying to a colleague can never be justifi able.
7
Q
- At the end of your shift, you are told that a new patient has arrived
under the care of your team. The nurse reads a long list of jobs
that need completing and asks if you would address these before leaving.
This is the third consecutive day that you will leave the ward late.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Leave and review the jobs in the morning.
B Review the jobs and perform those that will take less than 15 minutes.
C Review the jobs that appear most urgent and complete these before
handing over to the on-call doctor.
D Ask the nurses to contact the on-call doctor who can then review the
patient.
E Ask the nurses to do what they can and to contact the on-call doctor
if they feel that anything else must be done before the next morning.
A
- C, D, E, B, A
It is important that doctors do not routinely work beyond their
required hours.
This question is about distinguishing urgent hours which merit working
out of hours, and routine tasks which are better delegated to a colleague.
Therefore (C) is the best answer. (D) achieves the same goal
but is less ideal as the on-call doctor may not be available immediately
and urgent tasks may then be delayed. (E) is less ideal for the same reason
as (D) in that urgent tasks may be delayed, but in addition a doctor
must be asked to review this new patient who has arrived on the ward.
(B) is incorrect because jobs are completed based on an arbitrary selfimposed
time period rather than by clinical urgency. The worst option is
to make no eff ort for the patient to be reviewed (A).
8
Q
- You are the surgical FY1 doctor on call and are assessing an acutely
unwell patient. This takes you until the end of your shift and leads
to the accumulation of many ward jobs. The overnight surgical FY2 doctor
to whom you hand over is infuriated with your ‘slow pace’ and threatens
to complain to your consultant in the morning unless you assist her.
Choose the THREE most appropriate actions to take in this situation
A Apologize for your failure to complete the ward jobs.
B Ask for feedback in order to improve your management and handover.
C Off er to continue working up the previously unwell patient who is
now stabilized.
D Off er to assist with the ward jobs until she feels that the list of jobs has
become more manageable.
E Do not hand her any more jobs, in an eff ort to avoid antagonizing her.
F Explain that you are unable to complete any more jobs now that your
shift is over.
G Phone the surgical registrar in order to help resolve the apparent
confl ict.
H Complain to her consultant in the morning.
A
- A, B, F
An apology may help to appease the situation (A) and the opportunity
could be used as a learning exercise to obtain feedback on your
performance (B). However, you should not be coerced into continuing
working in this situation (F), and your only responsibility is to ensure that
a thorough and safe handover is completed (E) so that the FY2 doctor
can fi nish the remaining tasks herself (C) (D). It should not be necessary
to involve the surgical registrar (G) or consultant (H) unless the situation
could not otherwise be resolved.
9
Q
- You are an FY1 doctor in rheumatology looking after a patient who
is about to be discharged this afternoon. During his stay a CTPA
was completed for chest pain which was negative but showed a lung
mass of unknown signifi cance with a suggestion for interval scanning.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Use capital letters in the discharge letter to highlight the incidental
fi nding and requirement for an interval CT scan.
B Phone the GP to inform them of this fi nding.
C Explain the problem to the patient and ensure he sees his GP to
arrange an interval CT scan.
D Inform the ward clerk to relay the report fi ndings to the patient.
E Advise that the patient returns to the rheumatology clinic to see your
consultant for further review of the mass.
A
- B, C, A, E, D
The correct answer is (B) because a doctor-to-doctor handover will be
most likely to ensure that this fi nding is not missed and clarifi es responsibility
for following up the result of the interval CT scan. (C) is a less ideal
option as it is less foolproof and places responsibility (perhaps unfairly)
on the patient to ensure that interval CT scanning is arranged. However,
it is better than (A) which, despite your heroic eff orts at highlighting the
fi nding, is likely to be overlooked and could result in the patient being lost
to follow up. Your rheumatology consultant is unlikely to be able to provide
the required hospital follow up this patient may need, and this would
be better managed by the GP (E). (D) is the worst answer because it is
not the ward clerk’s responsibility and they are not suffi ciently qualifi ed
to undertake this task.
10
Q
- As the FY1 doctor for a medical team, you are seeing a patient
for the fi rst time on the Monday ward round. You realize that
the admitting doctors on Friday did not arrange a review by the weekend
medical team, despite grossly abnormal blood results. What would you
include as part of your written entry in the medical notes?
Choose the THREE most appropriate in this situation
A Your opinion as to whether it was appropriate to be reviewed by the
weekend medical team.
B ‘This patient was not seen by a weekend review team.’
C Medical entries for the weekend by assessing the patient
retrospectively.
D Both Friday’s and Monday’s blood results.
E Today’s blood results only.
F Today’s management plan.
G Avoid writing anything but review the patient.
H Tell the patient that the doctors treating him initially had done so
incorrectly.
A
- B, D, F
As part of your review, you should include the trend in blood results
(D) rather than values from a single day (E), which are less informative.You should also document your current management plan (F). As a junior
member of the team, you should avoid commenting on the perceived
defi cits of colleagues (A) unless limiting yourself to factual statements
(B). It is not possible to assess a patient retrospectively (C), and notes
should only be written retrospectively if this is made very clear. It is never
appropriate to avoid documenting your fi ndings (G) and rarely appropriate
to undermine colleagues when talking to patients in this way (H).
11
Q
- Your consultant asks you to insert a peripheral cannula into
the vein of a large 14-year-old boy with learning diffi culties. His
parents are very anxious about the procedure after the distress caused
during previous attempts at venepuncture. They ask whether a sedative
could be used just before the procedure.
Choose the THREE most appropriate actions to take in this situation
A Trick the boy into having the cannula inserted by hiding the equipment
from him until the last possible moment.
B Use a play therapist to familiarize the patient with the procedure, even
though this might take several hours.
C Explain to the parents that you will insert the cannula in the middle of
the night when the patient is least likely to resist.
D Explain to the parents that it would be safer to physically restrain
the child.
E Explore the anxieties of the parents before pursuing a mutually
agreed plan.
F Off er to use an intramuscular sedative to ‘help him sleep’ during the
procedure.
G Ask to cannulate the parents fi rst in order to demonstrate the procedure
to the patient.
H Talk to the patient to see how he would feel about the procedure.
A
- B, E, H
Play therapists are a particularly eff ective resource as they can invest
appropriate time working with children to facilitate successful procedures
(B). Before implementing any intervention, it is necessary to
explore any concerns of the parents and/or patient and gain their cooperation
(E). It is imperative to establish what the patient can comprehend,
as learning diffi culties span a vast range of cognitive abilities (H).
Tricking the patient into the procedure (A) or attempting it in the middle
of the night (C) could jeopardize the relationship between clinicians and
patient. It would be sensible to attempt options (B), (E), and (H) before
resorting to restraints (D) or sedation (F). Inserting a cannula in parents
is unnecessary, and is unlikely to alleviate the child’s concerns (G).
12
Q
- You are involved in a clinical research project, taking consent
for the collection of an additional oesophageal biopsy during
oesophagogastroduodenoscopy (OGD). A patient with long-standing
gastric refl ux disease arrives for her regular OGD. She is very pleasant
and accommodating but is known to be anxious prior to OGD
procedures.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A As she is anxious and unlikely to want further information, briefl y
explain that she can help with medical research if she signs a
consent form.
B Explain the complications from the OGD, and how one additional
biopsy adds very little to her total risk from the procedure.
C Try to alleviate her future anxiety by explaining that she is participating
in a trial that will eventually lead to the development of less invasive
methods of oesophageal examination.
D Take the extra biopsy, but wait until after the procedure to obtain
consent from the patient and before using any of the samples for
research.
E Do not include the patient in the study, given her level of anxiety.
A
- B, C, E, A, D
A clinician of appropriate experience must consent the patient as usual
for her OGD. However, you might be an appropriate person to consent
the patient for the additional biopsy and participation in the trial. It
is essential that additional consent is obtained, irrespective of her perceived
anxieties; therefore (B) is the correct answer. (C) is a little unclear
but is a fairly neutral statement in that you are not told whether the
biopsy is going to go ahead or whether you are going to continue seeking
consent. It cannot be far wrong to address the patient’s anxieties in this
way, although obviously it does not directly address the current problem
of seeking consent for the biopsy. It is, however, better than (E), which
deprives the patient of participating in the trial and potentially weakens
the study, but if you feel unable to proceed with the consent process and
no one else is available to help then the patient must be excluded from
the study. (A) and (D) are the worst answers; (A) is coercive and seeks
to obtain inadequate consent, but this is marginally better than unlawfully
removing a biopsy from the patient with no legitimate indication
with no permission from the patient (D).
13
Q
- You are looking after several unwell patients as the medical FY1
doctor covering wards at the weekend when a Sister asks you
for an urgent discharge summary to help relieve a bed crisis in the hospital.
She sympathizes with your workload but insists that a discharge letter
must be written immediately.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Acknowledge the severity of the bed crisis, but refer her to your registrar,
explaining that you have more urgent matters to attend to.
B Phone the registrar and ask if there are any spare junior doctors who
can assist with your tasks.
C Off er to write the discharge letter once you have stabilized your
patients.
D Ask the Ward Sister to complete the discharge letter but sign a blank
copy in advance to expedite the discharge.
E Take two minutes to write a brief discharge letter before returning to
the care of your patients.
A
- C, A, B, E, D
Ensuring the prompt and eff ective discharge of patients is an important
part of being an FY1 doctor. (C) is the best answer as you are being helpful
and providing a realistic estimate of the delay before you will be able to
complete the discharge letter and have correctly prioritized your unwell
patients. (A) is slightly less helpful as it needlessly involves your registrar
who is likely to be busy with other duties. (B) is a further attempt to assistbut is a more complex intervention than (C) and (A) and would be more
appropriate if clinically urgent commitments were arising together. (E) is
less than ideal because it implies that a discharge letter has been rushed
and is shorter than it should otherwise be; however, depending on the
case, a brief letter may be suffi cient to summarize the pertinent aspects
of the patient’s care. It is certainly preferable to (D) which requires the
Sister to complete a duty with which she is likely to be unfamiliar and putting
your signature against a document you have not seen.
14
Q
- A patient with newly diagnosed terminal lung cancer asks to
see you on the general medicine ward. He would like to make
a complaint about your registrar, whom he feels has failed to off er him
treatment that might prolong his life.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Empathize with the patient’s traumatic experience and off er to raise
the matter with the registrar and consultant.
B Defend the registrar’s actions, highlighting their knowledge and experience,
and the generally poor prognosis of most lung cancers irrespective
of the treatment modality.
C Explore the patient’s concerns further.
D Inform the patient that you will refer him to the oncologist to consider
chemo/radiotherapy.
E Off er him the services of an appropriate religious leader to address
any spiritual questions he may have.
A
- C, A, B, E, D
The key issues here are keeping an open mind while trying to support
your colleague. (C) is clearly correct as there may well be a simple misunderstanding
which can be clarifi ed, and you cannot proceed much further
without understanding the patient’s concerns in detail. (A) is also clearly
correct, although in itself does not off er you the best chance at resolving
the issue as there has been no attempt to understand the complaint in
any detail. (B) could represent many diff erent actions depending on your
communication skills and approach to your patient. It may well be appropriate
to explain to your patient that the registrar is a very senior doctor
and that lung cancer is diffi cult to tolerate. But this seems unlikely to placate
the patient completely and it is probable that some other intervention
is also required (e.g. (C) and (A)). (E) and (D) are wrong. The patient
has not indicated he has any spiritual questions at the moment or would
like to meet a spiritual leader; however, this is perhaps less incorrect than
(D) as it is not the role of the FY1 doctor to refer for a treatment which
it sounds as if your seniors have deemed to be inappropriate.
15
Q
- You are working in a team of three surgical FY1 doctors. Tim,
one of the surgical FY1 doctors, leaves the ward on time every
day but routinely fails to complete his daily tasks. You decide to address
the matter after leaving another shift more than an hour late in order to
complete Tim’s tasks.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Share any additional workload between yourself and the other surgical
FY1 doctor without involving Tim in the matter.
B Inform Tim of your additional workload and ask him whether he is
experiencing any diffi culties in completing his routine jobs.
C Speak to your other surgical FY1 colleague and encourage her not to
complete Tim’s routine tasks.
D Demand that Tim arranges a meeting with his foundation and clinical
supervisors in order to ‘address his failings’.
E Inform your consultant.
A
- B, E, A, D, C
The correct answer is (B) as it allows you to identify if there are any
problems or diffi culties that might be impacting on Tim’s performance,
as well as ensuring he is aware of the developing situation. This is better
than (E) as it attempts to resolve the problem itself. (A) is the fi rst incorrect
answer as it fails to address the underlying problem, although it does
ensure that the work is completed. (D) and (C) are not constructive suggestions;
(D) is unlikely to yield a positive result because of the approach
taken, but (C) could easily be interpreted as vindictive, working behind
Tim’s back, and could result in important tasks going uncompleted.
16
Q
- Phlebotomy rounds have been cancelled. You delegate venesection
to your ward team. A nurse refuses to take blood from
a patient who is being investigated for HIV.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Explain the ethical responsibility of medical staff to all patients.
B Demand that the nurse attempts to take the blood sample or else she
will be reported.
C Ask about her concerns about the task and what could be done to
improve her confi dence in this situation.
D Take the sample yourself.
E Instruct another nurse to take the sample, but avoid telling them
about the patient’s possible HIV status to avoid frightening them.
A
- C, D, A, B, E
In any scenario where a colleague voices concerns, you should explore
these further to identify ways of alleviating the problem; therefore (C) is
the correct answer. (D) is the next best answer as it achieves an outcome.
The reason that (A) is not better than (D) by itself is that it is a
statement of principle and does not resolve the problem at hand. (B) is
wrong because you are not in a position to demand that your colleague
must perform a particular task, and it is likely to lead to a poor outcome.
(E) is the worst answer because it unnecessarily misleads a colleague and
exposes them to a health risk.
17
Q
- You are preparing to fi nish your ward shift and must leave on
time to catch a fl ight to the test centre, where you are due to
sit an important examination. There are still two patients left to see as
part of your ward round. Both are stable and awaiting input from social
services, but your visit is likely to be prolonged by family members who
are currently visiting.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Perform a quick examination of each patient without speaking to
them or their families.
B See the patients but explain that you cannot spend much time with
their relatives today, and that someone will be available to answer
questions tomorrow.
C Ask the nurses to remove the families before briefl y reviewing each
patient.
D Assess the patients as usual and answer any questions the family
members may have, even if this results in missing your fl ight.
E Explain to the nurses that the patients will be seen on tomorrow’s
ward round, and catch your fl ight.
A
- B, A, D, C, E
Ward duties must be completed to ensure that patients are safe. In
this scenario, you should complete your ward round but postpone any
non-urgent discussions until the following day. For this reason, (B) is correct.
The other answers are incorrect to various degrees. (A) is the best
of these as it at least allows you to exclude any immediate clinical concerns
about the patient, even if it is impolite.
It is diffi cult to decide between missing your own fl ight (D) and asking
the nurses to remove the families (C), which is impolite. Which of these
options is worse will depend on a number of factors. However, it is not
without precedent to ask for a few moments alone with a patient and
this is unlikely to cause much distress if done politely. For this reason, it
might be preferable to do this than stay late for a non-urgent task and be
penalized for doing so by missing your examination.
The worst answer is (E) as by not seeing the patients at all over the
course of a day you could miss their slow deterioration.
18
Q
- You are interested in orthopaedic surgery and have been
asked to ‘scrub in’ and assist with a total knee replacement.
The orthopaedic surgeon is willing to spend longer with you in theatre
provided that you consent the patient. You have not obtained consent
for a surgical procedure before, but understand about some possible
complications.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Admit to the patient that you are unfamiliar with consenting for the
procedure but that he can ask the consultant later on if he has questions
that you cannot answer.
B Attempt to consent the patient, and refer any specifi c questions to the
anaesthetist who will conduct a preoperative assessment later on.
C Refuse to consent the patient.
D Ask the consultant to run through the procedure with you before
consenting the patient.
E Ask the surgical registrar to consent the patient
A
- C, D, E, A, B
GMC guidelines require consent for operations to be taken by someone
competent to perform the procedure or an appropriate delegate.
The latter must be suffi ciently well informed to act as such, and this is
likely to exclude FY1 doctors for complex operations such as total knee
replacement. The best answer is (C), as in similar questions in other
chapters, as you are not suffi ciently well informed to counsel a patient
thoroughly. All of the remaining answers are wrong as they involve you
obtaining consent for the operation which you must not do. (D) would
be the least inappropriate as it involves you essentially translating information
directly from a suitably qualifi ed person. The next ‘best’ option
might be speaking to the general surgical registrar (E), not because they
are able (or likely) to consent the patient but because they are a senior
doctor with experience of the consent process and are likely to set you
on the right track, e.g. reminding you that you must not consent the
patient for this operation. (A) and (B) are most incorrect because they
involve you attempting to directly consent the patient, although (A) is
marginally better as you have at least tried to involve a more senior
doctor.
19
Q
- You are asked to speak to a new patient who is a suspected
intravenous drug user and has been admitted recently following
an opiate overdose. He has repeatedly been asked to stay in bed but
continues to wander and demands to be allowed to leave.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Explain the nature of his admission and the dangers of discharge, and
reiterate the risk of death if he were to self-discharge.
B Explore his reasons for wanting to self-discharge.
C Obtain the details of his family and ask them to get involved.
D Address any concerns or approaches adopted by the nursing staff that
may be antagonizing the patient.
E Do not attempt to engage with a person who has recently used intravenous
drugs, as they are unlikely to be cooperative.
A
- A, B, D, C, E
The best answer is (A). It might be tempting to answer (B) fi rst as this
is naturally the fi rst thing you would do before (A). However, as a single
intervention, (A) is more likely to achieve your aim and at least ensures
you have discharged the most important aspect of your responsibility to
keep the patient informed. (D) seems less likely to solve the problem as
it assumes that the nurses are somehow responsible for his agitation. You
have been given no reason in the question to think this might be true.
(C) and (E) are clearly incorrect. (E) is the worst because you cannot
choose to treat patients less favourably based on their lifestyle
choices.
20
Q
- You have been asked to complete a death certifi cate for a
patient whose care you were briefl y involved in during the last
few days of his life. There were no suspicious circumstances surrounding
his death, but you are unclear about its precise cause. The mortuary
staff suggest that you speak with someone else fi rst if you are not sure.
Choose the THREE most appropriate actions to take in this situation
A Telephone your consultant.
B Telephone your registrar.
C Telephone the duty pathologist.
D Telephone the coroner’s offi cer.
E Contact the ward clerk.
F Contact the nursing staff who looked after the patient.
G Telephone the patient’s next of kin.
H Telephone the local police.
A
- A, B, C
Death certifi cates must be completed accurately as they are a legal
record. Senior members of your team (A) (B) are most likely to have
a clear idea of the precise cause. A pathologist (C) could help separate
multiple complicated circumstances into causes acceptable to the registrar
of deaths. The other people listed might contribute under specifi c
circumstances but would not routinely be contacted to establish cause
of death (D) (E) (F) (G) (H).
21
Q
- You are clerking a young child in A&E who has been admitted
with suspected bronchiolitis. Physical examination is unremarkable
except for a moderate wheeze, although you note that the parents
appear somewhat unkempt, with dirty hands and clothes. You consider
what to document as part of your fi ndings in the medical notes.
Rank in order the following in response to this situation (1 = Most appropriate;
5 = Least appropriate)
A Your opinion of the parents’ treatment of the child, based on their
appearance.
B Detailed physical examination and objective clinical assessment of
the child.
C A brief summary of your clinical assessment.
D Complete your notes after they have been confi rmed by a senior.
E Complete your notes later on after getting through a few more
patients, to keep the clinic moving.
A
- B, C, E, D, A
The minimum you should document in the notes is your fi ndings on
examination, and therefore (B) has to be correct. It is better than (C) as,
by defi nition, it off ers a more detailed account of your fi ndings than a
brief summary. (E) is worse as documentation should ideally be contemporaneous
to ensure maximum accuracy, and you should not usually see
other routine cases before writing in the notes for this child. (D) is wrong
as your assessment does not require input from a senior, and represents
a greater transgression than (E) as your notes should never be modifi ed
by anyone else’s opinion. The worst answer is (A) as it is opinionated and
prejudiced, and you should confi ne yourself to objective statements and
not infer too many details from the parents’ appearance.
22
Q
- You are working as the only junior doctor for the orthogeriatric
team, assessing a patient who has had a fall. You are bleeped
by a nurse on another ward about one of your outliers who has become
febrile. While you are taking this call, your crash bleep starts to sound.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Document your current assessment of the patient who has fallen and
then attend your other commitments.
B Attend the crash call and then return to write in the notes
retrospectively for the fallen patient.
C Attend the crash call and then see the pyrexial patient before documenting
your assessment of the patient who fell.
D Avoid documenting the fallen patient as you are likely to be distracted
by other tasks after attending the crash call and seeing the pyrexial
patient.
E Allow other members of the crash team to attend the arrest while
you complete all your documentation.
A
- C, B, D, A, E
Documentation is important but must be prioritized after emergencies.
You should attend the crash call, even though other doctors will
do so, unless another emergency prevents you from going; therefore
(C) is the best answer. (B) is incorrect because, although the immediate
life-threatening event is attended to correctly (i.e. the crash call), you
return to write in the notes for the fallen patient before attending the
next most unwell patient who is febrile. (D) may be judged as worse as
the implication is a complete failure to document clinical encounters in
the face of urgent tasks. While it is important to attend crash calls immediately,
it would not be prudent to begin deferring or completely avoiding
documentation in the notes as you are asked to see more patients.
The implications for (D) are greater than a slight delay in reviewing the
febrile patient and therefore (D) is a worse answer than (B). (A) and
(E) are both terribly erroneous, with (A) only being marginally better
than (E) as it implies attending to all the other commitments, rather than
ignoring the crash call completely (E).
23
Q
- You are working alone in the afternoon on your colorectal
ward as the FY1 doctor being shadowed by a fi nal-year medical
student. The nurse informs you that a patient is looking increasingly
unwell, a peripheral venous cannula needs siting for a blood transfusion,
and another patient’s family wishes to speak with you in private.
Choose the THREE most appropriate actions to take in this situation
A Assess the unwell patient alone.
B Assess the unwell patient with the medical student.
C Ask the medical student to assess the patient alone, and join him as
soon as possible.
D Ask the student whether he wishes to try to place the peripheral
venous cannula.
E Attempt to insert the peripheral venous cannula yourself.
F Speak to the patient’s family with a nurse present.
G Speak alone to the patient’s family.
H Ask the student whether he would be comfortable speaking to the
family.
A
- B, D, F
You must review the potentially unwell patient as a priority. Doing so
with the medical student will provide an extra pair of hands and a valuable
learning opportunity (B) (A). Responsibility for reviewing the patient
should not be delegated to the student, even if you soon join him (C).
You might then ask the student to place the cannula, which should be
within his range of experience (D). Although you could site the cannula,this would deprive the student of practice and prevent you from attending
to the waiting family (E). You should speak with the patient’s family,
ideally with a nurse present (F) (G). Although you could speak with the
family alone, it is often helpful to have a nursing colleague handy for additional
perspective. The family are anticipating a conversation with the
medical team and are unlikely to be impressed by a medical student (H).
24
Q
- While you are working in A&E, a nurse informs you that a 33-week
pregnant woman is being brought by helicopter into resuscitation
following a road traffi c collision. She asks you to prepare for her arrival in
approximately fi ve minutes. Your registrar has already been informed, and
he asks you to call for assistance while he bleeps the obstetric team.
Choose the THREE most appropriate actions to take in this situation
A Inform the neonatal registrar.
B Call the orthopaedic consultant at home.
C Fast bleep the haematology registrar.
D Summon the cardiac arrest team.
E Request a phototherapy light.
F Call the switchboard and ask them to put out a trauma call.
G Ask a nurse to fi nd a neonatal incubator and bring it to resuscitation.
H Ensure that there are medical students present, to maximize the
learning opportunity.
A
- A, F, G
Eff ective management of trauma requires a rapid multi-disciplinary
approach. This is achieved in most hospitals by putting out a trauma call
through the switchboard (F). The trauma team will include a general
surgeon, an orthopaedic surgeon, an anaesthetist, and emergency
physicians. It will also alert ancillary staff (e.g. the on-call radiographer).
There should be no additional need to contact the orthopaedic
consultant (B). The facts do not suggest major haemorrhage or
haematological complications and so there is not yet a reason to contact
the duty haematologist (C).
The trauma team will not routinely include an obstetrician or a neonatologist.
Your registrar is contacting obstetrics and so you should contact
the neonatology registrar (A). You might also consider sourcing specialist
equipment (G) in case an emergency Caesarean section becomes necessary
in resuscitation.
The cardiac arrest team will be diff erently composed to the trauma
team (D) and there is no obvious benefi t from sourcing a phototherapy
light (E). Medical students might like to observe if they are present, but
given the circumstances this should not be prioritized (H).
25
Q
- While working on call, you are asked to cannulate a large patient
who requires intravenous antibiotics for a suspected diarrhoeal
infection. Your bleep sounds for a third time during your fourth cannulation
attempt when you fi nally believe that you have obtained access.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Stop your attempt immediately and answer your bleep.
B Secure and fl ush the cannula before answering your bleep.
C Try to get the attention of the Ward Sister so that she can answer
your bleep.
D Answer your bleep after securing and fl ushing the cannula, cleaning
the work area, and saying goodbye to the patient.
E Ignore the bleep as they will call again if it is important.
A
- B, C, D, E, A
Other colleagues in the hospital will depend on your answering your
bleep promptly. However, this must be balanced against the need to
complete tasks that you have already started. In this case, it would be
unfair to subject the patient to a further needle attempt so you can
answer the call, especially now that you have gained access, and so (B) is
the correct answer. In attempting (C) you are likely to dislodge the cannula
and/or distract your nursing colleagues, and (B) is a simpler option
which if completed will only lead to a minimal additional delay in answering
the bleep. While it is important to do all of the things in (D), after
securing the cannula they can be postponed until you answer the call to
avoid further unnecessary delay, and taking longer to answer than in (C).
Ignoring the bleep is clearly unacceptable (E) and only marginally better
than subjecting the patient to further unnecessary needles (A).
26
Q
- A patient on your ward is diagnosed with anal cancer. He tells
you that his community would react very negatively if they
knew of his diagnosis. As a result, he is very anxious that no one fi nds
out, including his family.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Promise to remove any mention of anal cancer from his notes.
B Tell the patient that you will remove any mention of his diagnosis from
patient lists.
C Tell the patient that his family are bound to fi nd out at some point and
it would be better if he told them.
D Let the nursing staff know that his family are not aware of the
diagnosis.
E Treat him as any other patient under your care.
A
- B, D, E, C, A
Additional steps should be taken to protect any patient who is particularly
anxious about confi dentiality. The easiest and most eff ective step would
be to remove sensitive details from your patient list (B). While (D) is also
a sensible option, it should already be clear to all healthcare professionals
not to disclose clinical information about patients to any family withoutthe patient’s consent, although reiteration would not harm the patient.
The patient’s confi dentiality should be respected like any other patient,
but following his request it may be appropriate to employ added precautions,
and therefore (B) and (D) might be considered more appropriate
than (E) alone. It is incorrect to coerce the patient into telling his family
(C), although you might choose to explore reasons for the patient wanting
to keep his diagnosis secret. However, the worst answer is doctoring
the medical notes, and this information might be necessary to ensure
that he is managed appropriately in future (A).
27
Q
- You hear Karen, one of the nurses, speaking unpleasantly to a
child on the paediatric ward. The child is known to be particularly
challenging to work with, and has a history of learning diffi culties
and behavioural problems.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Approach the pair, and ask to speak to Karen.
B Speak to a senior nurse before approaching Karen.
C Ask other staff working on the ward whether they have noticed any
inappropriate behaviour recently.
D Do not raise any concerns as the child is not at risk.
E Inform the hospital Trust.
A
- A, B, C, E, D
You have a duty to confront behaviour that threatens patient dignity.
As Karen is currently speaking to the child in a way that you think is
inappropriate, you should raise the issue immediately, and therefore
(A) is the best answer. You may wish to approach the nursing hierarchy
instead of speaking to Karen directly (B), although this would be a more
appropriate fi rst step if the behaviour causing you concern had already
happened (as opposed to currently happening). It is incorrect to attempt
to investigate Karen’s behaviour by talking to other staff (C), which might
be seen as gossip or bullying. However, gaining additional corroboratory
evidence in this way is probably less extreme than informing offi cials in
the Trust at this stage; from the scenario description it would seem fair to
escalate concerns within the ward hierarchy before doing so anywhere
else (E). It is clearly never appropriate to ignore this issue, and once you
have developed a concern, it should always be acted upon in a way that
satisfi es you that the issue will not arise again (D).
28
Q
- A patient who was admitted for an exacerbation of chronic
obstructive pulmonary disorder (COPD) is upset about the
standard of care she has received over the weekend. She would like to
speak with you about the possibility of making a complaint.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Suggest that making a formal complaint is unlikely to resolve the
situation.
B Provide contact details for the Patient Advice and Liaison Service
(PALS) to see what they can off er.
C Discuss what happened over the weekend to upset her.
D Inform your consultant that the patient is considering making a
complaint.
E Inform the patient that weekend medical cover is often inadequate
and that a formal complaint might help to improve staffi ng levels.
A
- C, B, D, A, E
The most sensible immediate course of action is (C). This may allow
you to facilitate immediate improvements, and you might discover that
the patient is more interested in communicating her concerns than
making a formal complaint per se. It may become apparent that the
patient should be directed to PALS (B) which will off er her a formal
route through which to lodge her complain, but this is a less ideal immediate
course of action, and (C) may resolve the concerns with greater
expediency. While the consultant should be informed that the patient
is considering making a complaint (D), in order to facilitate a discussion
between them and the patient, it is a less appropriate response to the
patient than responding to her query and providing her the option of
PALS. The patient should never be discouraged from lodging a complaint
(A), but perhaps marginally worse than dissuading the patient
is inciting them to generate a complaint that you believe is necessary
(E)—instead your own concerns should be raised openly with the
senior team.
29
Q
- You are being shadowed by a medical student during a long
day in A&E. The student is very keen to help with procedures
and you ask him to catheterize Mr Wills. When you enter the room, the
urinary catheter is partly inserted but you realize that you have directed
the student to the wrong patient.
Choose the THREE most appropriate actions to take in this situation
A Ask the student to stop catheterizing the patient immediately.
B Write a clinical incident form.
C Tell the student that he should go home as he should have checked
the patient’s wristband.
D Allow the student to continue inserting the catheter in case it is necessary
anyway.
E Allow the student to insert the catheter, but take it out afterwards
before telling the patient it was to obtain a clean urine sample.
F Ask the student to apologize to Mr Wills.
G Accept full responsibility for the error.
H Obtain an ultrasound kidney–ureter–bladder (KUB).
A
- A, B, F
Patient safety is always your priority and this patient should be saved an
unnecessary catheterization (A) (D).Although you are the responsible clinician in this case, you cannot accept
full responsibility for the error (G). The student is not yet a doctor, but
he must take some responsibility for any procedures he performs. He
should have checked the patient’s identity and indication before proceeding.
For this reason, both you and the student should apologize to
the misidentifi ed patient (F). However, it would be unfair to blame the
student entirely and mistakes are best learned from by helping to rectify
the consequences, not by being sent home (C).
A clinical incident form should then be completed (B) to create a
paper trail and in case lessons can be learned for the future. You should
identify any contributing factors, e.g. a patient in the wrong bed or not
wearing a wristband. You should certainly not mislead the patient (E) and
there is no clinical indication for an ultrasound KUB (H).
30
Q
- Your registrar asks you to consent a patient whom you have
clerked in A&E for a scrotal exploration with possible orchidopexy/
orchidectomy. He is unable to consent the patient as he is in
the emergency theatre with the patient already in the anaesthetic room.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Ask that he consent the patient with an ‘acute scrotum’ as soon as the
emergency case is fi nished.
B Ask the registrar to contact the consultant at home.
C Phone the medical registrar on call.
D Attempt to take consent as well as you are able to.
E Ask a surgical SHO who has performed the operation in the past to
take the consent.
A
- A, E, B, C, D
The patient requiring scrotal exploration needs to be consented
promptly so that he can be taken to theatre. However, GMC guidance
clearly states that the person taking consent should usually be able to
perform the procedure themselves. In this case, your registrar is the
most appropriate person to take consent once they are available (A).
Clearly it is less ideal to involve someone else outside of care of this
patient, but (E) does off er a reasonable solution. The consultant would
have enough experience to consent the patient, but contacting him at
home is unlikely to persuade him to come in for this purpose and is
unlikely to refl ect best on your own abilities to resolve this matter with
more practicable solutions above (B). (C) is in fact useless, as the medical
registrar is unlikely to off er advice beyond telling you not to take the consent
yourself. (D), however, is the worst answer, as an incorrect consent
can amount to negligence if an issue were to arise afterwards.
31
Q
- You are asked to speak to a patient’s relative who appears
angry. He tells you outright that he is recording the conversation
‘for legal purposes’. He has a number of questions, one of which is
why his brother had a CT head scan instead of an MRI scan.
Choose the THREE most appropriate actions to take in this situation
A Say ‘no comment’ and refuse to speak until the tape recorder is
turned off .
B Ignore the tape recorder and act as you would if it was not there.
C Explain that you are unable to answer his questions.
D Tell the relative that the Ward Sister is in a better position to answer
his questions.
E Contact security if you feel threatened or his presence is obstructing
your work.
F Answer his questions politely.
G Tell the man that you are from another team and have never heard of
this particular patient.
H Try to turn off the tape recorder yourself.
A
- B, C, E
Although the man’s tape recorder and aggressive tone apply pressure,
you should remain resilient and adhere to the general principles of
professionalism.
You should try to ignore the tape recorder (B) and explain that you
cannot discuss a patient’s care without their consent (C) (F). If he persists
and/or is threatening, you might like to ask him to leave and contact
security if necessary (E).
Saying ‘no comment’ is unhelpful (A), as is passing the problem on to
a colleague (D) who is unlikely to appreciate the gesture. You should
certainly not lie to the relative (G), despite his aggressive tone, or
exacerbate the situation by attempting to turn off the tape recorder (H).
32
Q
- You have arranged a bedside teaching session using a patient
with known inoperable lung malignancy. The patient has a good
history and clinical signs and so will be a particularly eff ective case with
which to teach your students. He has agreed to help with the session.
However, as you approach the bed with your students, he appears to
be crying.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Do not enter the room as he is unlikely to agree to the teaching.
B Explain to the students that emotional turbulence is a normal part of
terminal disease.
C Continue as planned to take his mind off his condition.
D Talk to the patient about how he is feeling and whether there is anything
you can do to help.
E Ask the patient whether he would be interested in helping you teach
medical students.
A
- D, E, B, A, C
Although you are with medical students, this should not stop you exercising
compassion when one of your patients is visibly upset. You should
leave the students at a distance and ascertain what has happened to
lower his mood, and therefore (D) is the most appropriate action.While (E) implies you are raising the topic of whether he would feel
comfortable with the teaching session, it ignores the patient’s current
emotional state. It seems unfair to trivialize the patient’s emotional state
(B) into a teaching point for the students, and this still does not immediately
address whether he wishes to continue with the teaching session.
However, this is probably still more fair than asking the patient to assist
with student teaching earlier, and then not giving him the opportunity
to choose (A). It is imperative to give the patient a choice, and worse
than not off ering is insisting, ignoring his crying, and continuing with the
teaching session, as this is likely to be awkward for your students and
potentially further upsetting for the patient (C).
33
Q
- The nurse on the ward wants you to speak to Meredith who
has become increasingly anxious about a bilateral mastectomy
planned for the following day.
Choose the THREE most appropriate actions to take in this situation
A Encourage Meredith to express her concerns.
B Ask the nurse to identify any problems and get back to you if they are
surgical.
C Refer to the psychologist.
D Speak to the family to identify any of the patient’s concerns.
E Talk Meredith through the procedure and what will happen afterwards.
F Inform your registrar early on if she appears to show doubt about the
procedure.
G Inform Meredith that other patients will have missed out on the operating
slot if she changes her mind.
H Tell Meredith she shouldn’t worry as breast reconstructions are very
good these days.
A
- A, E, F
You should listen to Meredith and try to understand her perspective
(A) before talking her through the procedure again with reference to
any specifi c concerns she might have expressed (E). If there is a possibility
that she might opt to cancel the procedure, you should speak
with your registrar early (F). She might benefi t from counselling by
a more senior doctor, and cancellations are best anticipated early in
case other patients can fi ll the operating slot. However, you should
not coerce the patient’s decision (G) or make light of the operation
that she is worried about (H). Patient concerns about an operation
fall squarely within your remit, and the nursing staff should not be
discouraged from contacting you about similar problems in future (B).
Speaking to the patient’s family (D) or referring her to a psychologist
(C) would be presumptuous as you do not know whether this is what
she would want.
34
Q
- Stephen has recently been diagnosed with congestive heart
failure. During a ward round he asks the consultant to explain
what this means and the consultant says that you will come back later on
for this purpose.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Tell Stephen that ‘heart failure is an inability of the central pump to
adequately perfuse the peripheral tissues’.
B Ask what Stephen understands so far and what he wants to know.
C Tell Stephen that ‘congestive heart failure’ essentially means that the
heart isn’t working properly.
D Print out a patient information leafl et provided by the Trust.
E Tell Stephen that there are some good websites online and that he
should read around the subject once he is discharged.
A
- B, D, A, C, E
Ideally, any explanation should start by fi nding out what your audience
already knows and therefore (B) is the best answer. This prevents repetition
of knowledge and allows you to clarify any specifi c misunderstandings.
It is also often helpful to provide patient information leafl ets (D) for
patients to read in their own time; however, this is somewhat less sensitive
as a fi rst measure and does not off er any opportunity for a two-way
discussion; they are best used as an adjunct to verbal explanation so that
patients have an opportunity to ask questions. Although heart failure is
inability of the pump to perfuse the tissues (A), this textbook defi nition
might be lost on a patient hearing it for the fi rst time and is probably
less helpful than providing a pamphlet written for patients. However,
this accurate description is probably preferable to an over-simplifi cation
(C) which can sound frightening, and you should beware of letting
patients who present with occasional ankle swelling go home thinking
that you have diagnosed a terminal illness. Although Stephen should read
about heart failure if he wishes, patients can easily become lost in the
masses of information available online, and therefore the least helpful
advice is to recommend this as the fi rst source of information; hence
(E) is the worst answer.
35
Q
- Rachel is being treated for severe renal failure but refuses to
accept that she will need dialysis and/or a transplant in future.
She says that she would prefer not to know about the disease. Your
consultant informs her that it is serious and asks you to reiterate the
treatment options and poor prognosis. When you return to speak to
Rachel, she appears very happy.
Choose the THREE most appropriate actions to take in this situation
A Inform Rachel that it can be helpful to know what to expect, and to
plan treatment, if you are able to discuss the disease with her.
B Encourage her to share how she is feeling about her disease at the
moment.
C Inform her family instead about the things that Rachel does not want
to know about.
D Place detailed written information on the condition at Rachel’s
bedside.
E Ask her why she feels happy as it is clearly not appropriate at this time.
F Agree not to discuss the topic any further if she insists on not
being told.
G Ask the transplant nurse to approach the topic of prognosis and
survival rates.
H Ask one of the nurses who gets on particularly well with Rachel to
raise the issue.
A
- A, B, F
It is important to share information with patients, but only if this is what
they want. We should not force information on them any more than we
should force anything else. However, you do have a duty to make sure that
Rachel understands why it would be helpful to her to talk about her disease
(A). You should try to understand her perspective by listening carefully
(B). If she continues to choose not to know, the issue should not be raised
again unless there is reason to think that she has changed her mind (F).
You should certainly not coerce her to accept information by providing
written leafl ets (D) or asking other team members to approach the
subject (G) (H). If Rachel consents, you could talk to her family, but in
the absence of such an agreement they should not be told anything more
than normal (C). It would be callous to obstruct Rachel’s happiness by
telling her that she should be otherwise (E).
36
Q
- The palliative care nurse asks you to join her for a meeting with
Jenny, whose husband is close to the end of life. You have been
on leave for the last two weeks and are not familiar with the patient.
Your seniors are all in clinic and you are alone on the ward.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Agree to see Jenny with the nurse, after reading through the
medical notes.
B Ask the nurse to familiarize you with the case details before
meeting Jenny.
C Agree to be present during any discussion but not to answer any
medical questions.
D Ask the palliative care nurse if she can wait until your seniors are back
from clinic as they know the patient better.
E Go into the meeting and pick up the story as the nurse talks to Jenny.
A
- D, A, B, E, C
Your seniors are better placed to attend this meeting (D) as they will
know the patient and might already have a rapport with Jenny. They will
also have greater experience with conversations of this nature. The next
best option if you do attend the meeting is to familiarize yourself with
the patient’s notes beforehand (A). Asking the nurse to brief you would
be inadequate preparation for such an important meeting and therefore
(B) is less appropriate. Even less appropriate would be attempting to
identify the issues as the conversation unfolds (E). The worst answer is
(C) as it would be unhelpful and awkward for all parties if you attended
the meeting but declined to contribute.
37
Q
- The registrar asks you to book a foot X-ray for a patient on the
orthopaedic ward. When booking the scan, you are only able
to fi nd an option for ‘CT foot’. He asks you to book a CT scan but call
radiology to amend the request. You are apprehensive about this strategy
as you have previously seen it lead to inappropriate imaging.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Book a CT foot scan and then call radiology to amend your request.
B Voice your concerns and explain that you have seen this strategy fail
before.
C Speak with radiology fi rst, and then book the ‘CT foot’.
D Complete a clinical incident form about the registrar’s willingness to
compromise patient safety.
E Ask the registrar to book the scan under his name.
A
- B, C, E, A, D
You should learn from previous mistakes, whether your own or a
colleague’s. You will want to let your registrar know that errors have
occurred in this way previously and therefore (B) is the best response.
He might then amend his strategy or decide that the investigation is suffi
ciently urgent to proceed with the original plan. (C) represents a less
foolproof mechanism of booking the scan, but should also lead to the
correct imaging being performed. Although it may be preferable for the
registrar to take responsibility for requesting the scan (E) this is unlikely
to foster a good working relationship between you, and you are still failing
to address the issue of mistaken imaging requests being submitted.
It is clearly less preferable to attempt to establish contact with radiology
after making the imaging request, as this increases the likelihood that the
request will be processed incorrectly (A). (D) is the worst response as it
would not be a measured response to complete a clinical incident form.
38
Q
- Your consultant is about to close the abdomen after a very
long emergency laparotomy. He is a formidable personality and
earlier told you to stop talking so that he could concentrate on fi nishing
the operation. Although you have not been paying full attention, you
think that a swab might have been left behind but are far from certain.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Immediately inform the consultant of your suspicion.
B Ask the scrub nurse to recount the swabs.
C Ask another question to ‘break the ice’, before raising the possibility
of a swab being left in the abdomen.
D Remain quiet as you were not really paying attention.
E Ask an indirect question such as: ‘How harmful would it be if a swab
was left in the abdominal cavity?’
A
- A, B, C, E, D
In this unenviable position, you are nevertheless duty bound to raise
your concern and should do so with the operating surgeon (A). Thescrub nurse should certainly recount the swabs, but this instruction might
be better coming from the surgeon himself; therefore (B) is less ideal.
Many studies of human error have found that juniors are too indirect
when questioning more experienced colleagues. If you believe that
a swab might have been left in the abdomen, you should say so, and
asking other questions fi rst is likely to try your consultant’s patience
when a direct question would have been suffi cient (C). (E) is similarly
unfavourable and perhaps more irritating (and therefore may be worse).
However, clearly the worst option would be to remain quiet, as you
might have been the only person with the opportunity to stop the
patient undergoing a second operation to remove an aberrant swab (D).
39
Q
- Your consultant has agreed to complete a work-based assessment
for you on numerous occasions but has not yet done so.
The deadline for completion of all assessments is approaching.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Ask for your consultant’s login details to complete the form yourself.
B Find another consultant to complete a work-based assessment.
C Let the foundation school know that you are having diffi culty fi nding
assessors.
D Remind your consultant that the deadline is approaching.
E Let your Educational Supervisor know you are having diffi culty fi nding
assessors.
A
- D, B, E, C, A
Finding people who are suffi ciently senior to complete work-based
assessments can be diffi cult. However, these are useful learning experiences
and a minimum number are necessary to pass FY1. The Foundation
Programme is ‘trainee led’ which means that you are responsible for
fi nding suffi cient learning opportunities and assessors to complete the
minimum number. For this reason, you should remind the consultant
who promised you a work-based assessment (D). The next option (B) is
less ideal as it also involves you discussing more cases with that individual
who you might not have the time or opportunity for. It would only be
after attempting both these strategies that you might consider informing
your Educational Supervisor (E), but to do so before would be premature
and ineffi cient. The foundation school is unlikely to be interested at
that time and therefore (C) is a less ideal option. Of course, it would be
dishonest to masquerade as your consultant and complete the assessment
yourself and therefore the worst answer is (A).
40
Q
- You have clerked Mr Smith, a 56-year-old man with abdominal
pain, who was also reviewed by Dr Mayer, the duty consultant.
The following day, the new duty consultant reads your clerking and proposes
a completely diff erent management plan. He has no new information
to hand and did not examine the patient, and you are unhappy with
his suggestions.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Politely decline to follow the second consultant’s management plan
until he sees the patient.
B Clarify with the second consultant to whom you are ultimately
responsible.
C Highlight the diff erences in management between the two consultants.
D Accept the plan instigated by the second consultant.
E Ask the registrar to see the patient afterwards for a ‘tie-breaker’
opinion.
A
- C, D, E, B, A
Management plans change with time according to new information,
evolving clinical signs, and the approach of the clinicians involved. It is
important that doctors—and particularly consultants—have discretion
in managing patients.
However, you should point out the discrepancy between the two plans
(C) as this might make the second consultant consider why they diff er. It
would only be if he insists that you should generally implement his plan as
he is now ultimately responsible for the patient, but clearly (D) would be
less preferred to (C). (E) risks undermining the consultant by seeking an
uninvited third opinion. If you have serious concerns about a new management
plan, you should of course raise these and take necessary action
to avoid harm occurring. If you are uncertain, your registrar might be
able to explain the reason for this new approach. Clarifying to whom you
are ultimately responsible might be interpreted as impertinent (B)—you
are clinically accountable to the consultant on duty that day, and therefore
(B) is probably marginally more unprofessional than (E). (A) is likely
to be slightly worse than (E) as the implication here is that the consultant simply needs to see the patient in order for his management plan to
be followed. Although it would be sensible to ask the consultant to see
Mr Smith, you should not coerce him to do so by refusing to implement
his plan otherwise (A). It is pragmatic to accept that senior doctors will
not always review patients before instigating a management plan.
