General Interview - Anaesthetics COPY Flashcards
Why anaesthetics?
- Since 1st student placement. (SSC, taster weeks, ITU + comp specialties)
1. Challenging + varied
2. Hands-on, enjoy practical skills + good feedback in taster week
– trainees find rewarding, particularly 1:1 time with consultant
3. Academic - in depth physics, physiology, pharmacology. Loved weekly teaching in ITU on this + course (BASICs). Challenge - Most interesting parts of medicine: variety, hands-on immediate interventions; using scientific knowledge. Periop physician. Good experience to start. Think I’ll be a great fit.
Talk me through your training?
- Thoroughly enjoyable
CLINICAL - >20 months experience in complimentary specialties: EM & acute med, trauma. 4 months f2 job in ICM/Anaesthesia - including 2 taster weeks of anaesthetics. Practical skills, log book proud - A-lines, CVC, LP, FIB - satisfying
ACADEMIC - courses + achievement at med school (Top 10% in final year). Improve as clinician - teaching the teacher, BASIC & EM USS. I know anaesthetics hard, think i have brains, determination, work ethich for it
OUT OF HOSPITAL - developed non-technical skills, leadership + education. Elite sport - rugby, england. CrossFit (top 5% in the world in recent Open competition + coach at local gym)
Speaking to anaesthetists - calm + confident leadership are working in MDT - look forward to this
CONCLUSION
- lots of experience working directly with anaesthetists and alongside as part of wider MDT. my experiences leave me in great positoin
Your biggest weakness?
- Difficult question to answer, well rounded and, received good excellent on WBAs & multi-source feedback
- F3 EoY appraisal: high standards, ambitious, aspirational - often disheartened if not achieving goals.
- e.g. pdp - regional analgesia for rib fractures
- no need to rush to achieve things, reflect on how much ive improved in the time working as doctor
- However +ve in steep-learning curve towards IACs.
Worst thing about anaesthetics?
-No career is without its negatives. Pros>cons
- Tricky exams - recent change in curriculum from RCoA giving more time - big fan
- Not run through, bottleneck at ST4. But chance for a break, without looming exams/ARCP. Fellowship in area of interest. PHEM/ US/ ITU /pre-op
- CONCLUSION. though long and hard. speaking to trainees / consultants - generally happy and enjoy their job. way more positives
Courses you’ve been on? How has this changed your practice?
ALS - MDT training, great course, given me a lot more confidence in management of acutely unwell pts. Non-technical skills.
- Particularly useful was the teaching on SBAR handovers; as F1 i’d often found it difficult to handover and escalate patients to seniors quickly & efficiently. But since using and practicing this framework I have had much more success.
– Recent example, deteriorating gentleman with poor oxygenation despite high-flow. Able to concisely refer to ITU who quickly came down to review him.
- Conflicts & complaints framed conflict as a positive + necessary part of teamwork / human interaction.
Teaching experience?
- Really enjoy teaching; huge part of being a doctor.
- Variety of styles: didactic lectures, group discussions, simulation, practical, bedside.
- Variety of audiences: medical students, other junior doctors, MDT
- Peer teaching society, medical student sim teaching. Attended teaching the teacher - learnt about theory of learning - helped my practice - clear learning objectives
- Most proud of: during psych placement developed + delivered regional simulation teaching programme for med students - 6-week course
- Excellent feedback : but wanted less didactic, larger focus on simluation -> changed it and improved for ongoing cohorts
What makes a good teacher?
From teaching I’ve attended, the qualities most important
- Enthusiastic/engaging
- Clear learning objectives + achieve them!
- Receptive to feedback and flexible
- I try to use this as whenever I teach. Lots of experience; PTS, med-student teaching, peers and MDT colleagues. Variety of styles: lecture, seminar, bedside.
- 1 Eg is Med Student Psych teaching - D&D 6/52 course. Objectives of patient encounter, focused Hx + MSE.
– Good feedback but asked for more focus on patient –> changed for next cohort and excellent feedback
Research, audit, QI?
- Research = novel
- Audit = comparing current practice to set standards
- QIP = making changes to current practice and reviewing - PDSA cycles
– Experience in all 3. Recruiting to trials. Auditing sedation holds on ITU. Most enjoy QIPs - Successful audit/QIP in early pregnancy attendance in ED, completed 3rd PDSA cycle, shown a reduction in time waiting in ED by 31%
- Poster to be presented at conference
- Also, leading project in anaesthetics: peri-op monitoring of NOF patients
Tell us about your role in clinical governance?
Part and parcel of daily role. Improving patient care & service quality.
7 pillars. A few good examples are:
- Teaching - educating med students + colleagues. Attending courses + training
- QIPs - EPAU. NOF
- Patient safety through critical incident reporting & DATIX
7 pillars of clinical governance?
- Audit/QIP
- Education/training
- Clinical effectiveness
- Risk management
- Data & info
- Staffing
- Patient involvement
What skills would make you a good anaesthetist?
I think I have many strengths that lend themselves well to anaesthetics and have had good feedback during taster weeks, foundation jobs and current role. Comms, calm, quick learner.
- Communication - with MDT team/leading (TAB feedback) & put patient’s at ease during stressful time -> pt with ischaemic limb palliated -> family were complimentary with my explanations
- Calm under pressure - enjoy acuity. Logical and systematic / thorough - helps me keep cool head in stressful situations -> JCF in ED / ITU placements
- Quick learner (notoriously steep learning curve passing IACs + FRCA); organised + keen- logbook of practical skills (CVC, A-lines, USS, LPs, intubations), manual dexterity for tricky & challenging procedures
CONCLUSION - many skills required to be a good anaesthetist, i have a good baseline to start training
Failed to manage a patient’s pain?
- Young lady, regular attender with non-specific abdo pain. 2nd in 2 days. Normal obs, bloods, examination, reassured + sent home. But she represented the next day.
Reflected on this… - Pain can be a complicated symptom. Multifactoral. Concerns, worries & expectations can play a large part. Going forward i take this into account more -
S- E.g. 56yo lower abdo pain, 2/12 GP / Gynae 2WW. a/w further tests including a hysteroscopy
T- Thorough assessment, hx + examination.
A- No change. No new issue. Not surgical abdomen. - Long discussion, reassurance about no change, advise to optimising analgesia, safetynetting, shared decision
R - Ultimately, no improvement in pain. However, patient’s understanding, decreased worry about urgency of treatment, helped her to manage symptoms
Dysfunctional team you’ve been a part of?
** STICKERS QIP ** better opportunity, recognised negatives and improved it
S- Resus, x4 patients I+V.
- 1 patient was young man, trauma, jumped from building. Head + pelvic injuries.
- BP dropping, anaes bolus metaraminol & ivi. Not feeding back to team leader. Appropriate in theatre, if vasodilation/sepsis but not in trauma ?bleeding
T- Crashed BP, required MTP. Eventually stabilised
A -
R - flash team, unfamiliar people / place / patient group. Independent working rather than collaborative via team leader.
- in future, acknowledge limits of practice; escalate all to team leader (oversee + big picture) better placed to make decisions
How have you made a change in the working of a team? Leadership / Management?
Acute Med stickers QIP.
S - big hospital, 2 arrest teams. Many on-call bleeps and baton bleeps - list explaining on piece of paper in doctors office. Several arrests without full team
T - improve knowledge + arrest care
A - surveyed docs, uncertain. Intervention = stickers on all bleeps (1, 2 or none).
R - led to huge improvement in knowledge, attendance at arrests and subsequently patient care.
Particularly proud of this, recognised + implemented independently. Improved patient outcomes in arrest, care of acute patients is something i am passionate about -> anaesthetics
Reflect on a time you’ve communicated badly.
- Resus: patient with pneumonia, verbally asked nurse to give abx + ivi
- later realised, they were on a nebuliser which i’d not px.
- patient no harm
- ensured treatments were given as intended
– Reflect on importance of clear closed loop communication + the importance of a written prescription - DATIX + discussed at meeting
– Now must be a written/electronic prescription before medication administration -> safer as a department - Change my comms, take more time + closed loop
Main issues facing anaesthesia ?
- ST4 bottleneck
- Proposed expansion of anaesthetic associates in NHS workforce plan
- Rotational training vs regional
- Interested to see the Extraordinary General Meeting discussing these and other issues at the end of the month
–> Big positive for anaesthetics, dynamic and adapting
What is a normal day for a core trainee look like?
Cycle to work
- Arrive at 7:45, check in with supervising consultant. See patients on SAC/TAU - take anaesthetic history [previous GAs; comorbidities]; check airways for any potential difficulties
- Team brief with surgeons, ODPs, scrub nurses, rest of team
- Check equipment - ventilator, suction, oxygen, airway management; draw up drugs
- First patient for induction - Take into theatre. Hopefully given a break by consultant for a coffee before discussing what the ideal volatile would be
- Analgesia, antiemetic, fluids while patient undergoing operation
- Reversal agents for NMB. Time emergence for shortly after end of surgery.
- Wheel patient to recovery. Prepare for the next case
National audits in anaesthesia? What are they?
Huge national research projects - look into rare outcomes:
- NAPs (national audit projects - look at rare outcomes)
– NAP7 into peri-op arrest
- SNAPs (sprint national audit projects - over a few days of data collection)
- NELA (national emergency laparotomy audits)
- ASAP (anaesthesia sprint audit of practice - hip fractures)
What makes a good anaesthetic department?
Good department is a happy cohesive department where all members are valued, respected and working to a common goal - patient care. From my experience in work as well as discussions with anaesthetic trainees, the
key thing as trainee is to feel supported:
- Clinically - opportunity to learn and develop scope of practice
- Educationally - teaching and help with exams
- Wellbeing - non-clinical stuff: parking, rotas; AL/SL; etc
Bad eg GenSurg - very hierarchical; minimal teaching; bad rota + difficult to take AL.
Good eg ED/ITU - 1st name terms; approachable seniors; regular teaching; self-rostered; secure bike lock
When have you worked well in a team?
- Work well - received excellent feedback on MSF - hard worker + reliable
- Collaborate / independent depending on what task requires
(S) Incarc umbilical hernia
(T) Many treatments, investigations, urgent surgery
(A) Led team; asked CSW access + bloods; nurse to give meds; phoned for urgent NELA CT + referred to GenSurg. Flagged up to seniors. Checking in with other team members throughout + updating Surg SpR with results.
(R) Worked well as a team; leading those around me and escalating to seniors with information. Rapid treatment of patient.
Clinical example of leadership?
- Stickers QIP
Professional integrity?
- Patients expecting prescriptions or imaging inappropriately
Problem solving made a difference to patient care?
(S) Young man presented with head injury. He was brought by his friend did not want to come, very dismissive
(T) Assessment of head injury
(A) thorough history, he had collapsed on walking with no prodromal symptoms. Had happened several times. Further tests - LSBP, ECG -> showed Brugada syndrome
(R) Interesting case, keeping broad open mind in assessment.
Would have been easy to pigeonhole patient into minor head injury not requiring CT.
But problem solving skills meant I recognised abnormality, investigated and diagnosed with rare cardiac condition - patient admitted, further tests, was d/c with ICD
Worked well under pressure? Managed competing interests?
- (S) AMU; arrest bleep + deteriorating patient; take shift
- (T) blood tests and imaging to chase; reviewed a deteriorating septic patient; arrest bleep went off
- (A) patient safety priority. Lady i’d just reviewed needed fluids & escalation of abx; arrest to attend
- (R) Ensured treatments prescribed for deteriorating pt; nurse aware; had my bleep no.
– Went to arrest, day team + medical SpR present, explained situation and was allowed to return to my unwell lady - Patient safety is priority. Organise tasks in order of clinical need. Sick patient/arrest clearly top of list. Utilising MDT around me; CSWs, nursing staff; other junior doctors; peers.
How do you deal with stress?
- Being a doctor carries with it a deal of stress - different types (busyness/overworked, emotional, cumulative fatigue). Each dealt with differently
- High workload, deal with by being organised, efficient and working as a team. Recognise own limitations. Take breaks
- Emotional stress - challenging patients, seeing death etc. I am calm, levelheaded - received good feedback on this from seniors
- Cumulative - hobbies outside of work; music, reading, seeing friends; sports - rugby / CF; used to juggling competing pressures and organising my time. Helps me switch off. Also recently started meditating which I’ve noticed a real benefit
- Conclusion: many ways to deal with stress. Find I am often able to remain calm in challenging situations
Worried about a patient who had gone home?
(S) 26yo. Victim of domestic abuse + subsequent overdose of diazepam.
(T) wanting to self discharge
(A) Medically fit, with capacity. A/W psych/DV support.
(R) Tried to stress importance of staying + further support. She did not want. So signposted, gave numbers for crisis team, women’s shelter etc. Escalated to NIC so referral made to DV support (she met threshold)
Patient who self discharged?
(S) IVDU, septic emboli in leg + chest. Septic, haemodynamic unstable, O2 req
(T) Patient self discharged
(A) Really challenging patient, clearly needed significant medical input
(R) He ran away from hospital,
*Ended up returning 2 days later
Differing clinical opinion from colleague? How did you deal with it?
