Interview questions Flashcards
Explain why you would want to do clinical oncology as a career?
Interest in oncology
- MRes
- Clinical attachements
- Work as registrar
Quickly evolving field with many new treatments coming through
Ability to help and impact patients and make meaningful treatments
Follow patients through their treatment and help support them
Team working
Please outline a difficult case you have had to manage
GRI case
50 year old admitted with worsening neuropathic right arm pain
Previous visit to ED which on retrospect showed lesion at apex of right lung - awaiting CT thorax
On Ct thorax reported Friday afternoon - showed probable lung malignancy with erosion into T4 body with probably MSCC
Discussions with neurosurgery and oncology
Discussions with husband and wife and breaking bad news
Starting treatment
Please give an example of an mistake you have made and your actions following this
During receiving shift on a medical assessment ward a woman was referred in with a history of abdominal pain with a family history of AAA rupture from the rheumatology clinic
I was handed over to chase the report of the CT scan which in the conclusion did not show any evidence of acute coronary syndrome. However in the body for eh report it was noted that the Aorta was enlarged at around 6cm
The following day, the report was amended by the radiology consultant regarding this and advised urgent referral to the vascular service
Please describe a weakness of yours
Over critical
Self-confidence
Please give an example showing how you are a team player
While working in radiation oncology in NZ, we had a patient undergoing curative chemoradiotherapy for a HNSCC.
In the centre we treated patients for across a wide geographic area, and so some patients stayed in temporary accommodation while completed longer courses of radiotherapy
This patient did not have much family support with her and struggled through treatment with a number of side effects to be expected. She unfortunately did miss a number of fractions because of this.
We would see her regularly to evaluate her symptoms, and worked closely with the nurse specialists, radiotherapy technicians, nurses on the ward, cultural liaison for Maori people in the hospital as well as involving her family with her consent
Please give an example where you showed team leadership
Undertaking a respiratory QIP in the inhaler management of COPD to ensure up titration of inhaler therapy to triple therapy inhalers for COPD patients admitted to hospital
Working with pharmacists and more junior staff
Delegating jobs
Please give an example where you showed empathy
While covering medical HDU, there were a number of seriously ill patients, often at the ceiling of their care
A 55 year old man, very comorbid with servere LVSD and COPD was admitted from home with necrotising fasciitis, felt that would not be a surgical candidate due to comorbidities and had been having IV antibiotic treatment
Unfortunately was worsening despite this. His wife was with him
Spoke to her of his deterioration with nursing staff present
Offered support and to call his extended family
Offered chaplain
Would check on her throughout the evening
Organised room in the hospital for her to have a bed
Please explain a situation where you had to consent a patient in a vulnerable situation
Schizophrenia patient with fungating tumour
Patient in NZ with history of schizophrenia attended with CPN
Not sought medical treatment earlier, had been encouraged by CPN, but had been mistrustful and did not wish to seek advice
At point of referral had a large fumigating breast tumour, for which he had been prescribed a palliative dose of radiotherapy
Explained process and involved CPN
Invited questions
Tried to build rapport
Tell us what you know of the training programme in clinical oncology
Enter into ST3 oncology common stem year
- Development of CiPs related to areas of overlap between medical and clinical oncology
Requiring to enrol with the Royal College of Radiologists
Clinical oncology specific ST4-7
- Clinical oncology specific CiPs
Four exams to obtain FRCR (oncology):
- FRCR Part 1 - Oncology - investigation and management of cancer patients, tumour biology, mechanism of cytotoxic drugs, statistics and physics - usually done in ST4
- FRCR Part 2A - radiotherapy and drug therapy - Usually done in ST5-6
- FRCR Part 2B - Usually done in ST5-6
Tell us of your teaching experience
During university:
- SSC with university - anatomy demonstrator for medical/Dental and biomedical students, and clinical skills
Teach the teacher course online
Teaching at hospital:
- ICI with case study of triple M syndrome
Teaching medical students in hospital and online e.g. Haematology and oncology SBAs for medical finals - universities throughout the UK
Tell us the qualities of a good teacher
Sets specific and challenging goals
Able to give good quality feedback
Encouraging
Enthusiasm and shows enjoyment in their topic
Adapts the teaching for the students
Involving
Please describe your experiences with QIP/audits
QIP in F2:
- Immunisation in <5 year olds
Audit in radiation oncology:
- Treatment with RAI in thyroid cancer - presented at national meeting
Audit of ophthalmology reviews with hydroxychloroquine in a rheumatology department
QIP in resp:
- COPD
Difference between audit and research
Audit - Process comparing clinical practice against set standards
Research - Aimed to create new knowledge that can be used to develop new standards of car
Please outline your research experience
MRes
Attendance at journal clubs
Please outline why research is important in oncology
Evolving medical field, with many new treatments and technologies becoming available
New treatments help with patient survival and outcomes
Example in the ICIs
Please outline your interest in research
Know that it is important
Outline reasons you wouldn’t necessarily be involved in research
- Prefer to be patient facing
What is research governance
A framework setting out principles of good practice in the management and conduct of health and social care research in the UK
Full guidelines set out in the Health Research Authority document
Principles include safety, competence of the staff undertaking the trial, scientific and ethical conduct, patient, service user and public involvement and integrity quality and transparency
What is evidence based medicine
The use of best evidence in making decisions about the care of individual patients, alongside your own clinical expertise and judgement
This is applied to a specific case, taking into account patient values
What are the different levels of evidence available
1a. Systematic review or meta-analysis of RCTs
1b. At least one RCT
IIa. At least one well-designed controlled study without randomisation
IIb. At least one well designed quasi-experimental study e.g. cohort study
III Well designed non experimental descriptive studies e.g. comparative studies, correlation studies, case-control studies and case series
IV. expert committee reports, opinions and/or clinical experience of respected authorities
Please outline types of clinical trials
Randomised controlled study:
- Two or more study groups followed up over time which differ in interventions. Usually introduction of new therapy in one group with standard of care in other
- Can be blinded with use of placebo and double-blinded in which clinicians do not know where patients have been allocated
Cohort study:
- Follows a group of people over a period of time
- e.g. identifying risk factors over time in a population in who develops cancer
Case-controlled study:
- Looks at people who have a disease and assess against a control group over risk factors developing the disease. Opposite of cohort study
- Quicker and cheaper than cohort studies but often less reliable
Cross-sectional study:
- Carried out at one point in time, or over a short period of time. They find out who has been exposed to a risk factor and who has developed cancer, and see if there is a link.
What is clinical governance
Quality assurance process, in which clinicians should be involved to maintain and improve the quality of care that patients receive and ensure that the NHS is accountable to the public
Outline the ethical principles
Beneficence - act in patient’s best interest
Non-maleficence - do no harm to patients
Justice
Autonomy
Outline the different stages of clinical trials
Pre-clincial trials:
- animal models/ex-vivo/in-vivo/AI assisted
Phase I;
- Tests small number of people with trial drug to ensure safety and identify side effects, and identify dose
Phase II:
- Given to medium size group to identify effectiveness an for safety profiles
Phase III:
- Large groups comparing to gold standard treatment to identify effectiveness
Phase IV:
- Following approval of medication, long term study of side effects
How can you assess capacity
Understand
Weigh up risks
Retain
Communicate
What are the seven pillars of clinical governance
Clinical effectiveness and research
- Evidence based approach
- adopting new guidelines
Audit
Risk management
- Complying with protocols e.g. hand washing
- Learning from mistakes M&M
- Reporting significant adverse events e.g. Datix
Education and training
- CPD
- Exams
- Appraisal
Patient and public involvement
Using information and IT
Staffing and staff management
CARE mnemonic for the top four
PIRATES for all
Difference between competence and capacity
Competence is a legal judgement
Capacity is a medical judgement
Five principles of the Medical Capacity Act
- Presumption of capacity
- Individuals should be supported to make their own decisions
- Patients have the right to make what may be deemed as ‘unwise decisions’
- Anything done for a patin lacking capacity should be done in their best interests
- The less restrictive option should also be used in a patient lacking capacity
What is your biggest achievement
Presenting at the RANZCR conference in Queenstown NZ
Tell me of a recent research article you have read
ARANOTE trial - Darolutamide in combination with androgen deprivation in patients with metastatic hormone sensitive prostate cancer
Phase III trial
Darolutamide plus ADT significantly improved rPFS, reducing risk of progression or death by 46% versus placebo
What makes you a good team player?
Conscientious
Will catch up with team mates regularly
Diligent
What makes you a good leader?
Able to delegate
Try to take account of team members strengths
Supportive
Describe a situation where you showed professional integrity
Death certificate on ward 10
Came back from leave and death certificate had not been completed as had to be reported to the procurator fiscal
Cleared in the afternoon prior.
The morning in question family rang up multiple times asking for death certificate to be completed, had to deal with a number of sick patients
During phone call, patients family showing quite a lot of pent up emotion and dissatisfaction with patients care
Apologised for wait, explained wait, and directed towards PALS
Discussed with consultant and completed death certificate
how do you handle stress
At the time I organise with list and try to prioritise and delegate where possible
Try to plan ahead such as exams or with deadlines
Support from friends
What do you like least about this specialty
Can be emotionally difficult, following many patients for a long time, and unfortunately some will relapse
There are also some very unlucky patients e.g. 31 fire-fighter with lung cancer with two young children
Please explain the clinical oncology curriculum
Number of generic and oncology Capabilities in Practise (CIPS)
Generic CIPS can be covered in OCS
Specific oncology in St4-7 years such as brachytherapy, radiotherapy planning, SACT
The scientific basis of cancer and its treatments
Acute oncology presentations
Tumour types - rotation through these in St4-7 years
Emerging technologies e.g. genomics and AI
What have you done to demonstrate commitment to specialty
Placements throughout the years
Audits in RAI in Palmy
Year as work as a radiation oncology reg
- experience of the department and clinics
Take me through your CV
Oncology experience:
- F2 experience
- SHO and registrar experience in radiation oncology in NZ - working on oncology wards and in outpatient settings, treatment reviews with radiotherapy patients, consenting to radiotherapy, radiotherapy planning
Academic achievements:
- Distinction in MRes in oncology - research project looking at radioresistance in medulloblastoma
Audits and QIPs:
- RAI audit in NZ, presented at national conference
- Immunisation QIP - two full PDSA cycles, led audit, worked with CSWs, clinical support staff, RNs, GPs, updated practice guidelines, presented locally
- Audit in retinopathy screening in rheumatology - presented locally
Achieved MRCP
Teaching:
- Teaching experience in Uni with SSC in anatomy
- Teaching session - grand round teaching on ICI and with medical students
- teaching the teacher course
What have you done to prepare for clinical oncology
Oncology experience
- IP and OP
- Experience with oncology clinics - with consenting patients
- Talking to oncology MDT staff e.g. RTs and nursing staff
- Radiotherapy experience including planning
Discussing with local registrars and consultants
Attended local MDTs and clinics
Audits in thyroid cancer
Looking at the curriculum and exams needed
What is involved in clinical oncology training
First year in OCS - same training with medical oncology ST3s
4 month rotations in first two years and then repeat in next 2 years
Talk me through some part of your CV that you are proud of
RAI audit in PN
Audit for patients receiving radioactive iodine for thyroid cancer - comparing to standard set out in the ATA guidelines, identifying that patients have been correctly stratified, received correct dose for RAI, and have been correctly rest ratified following treatment with appropriate post treatment investigations
Identified opportunities to improve on post stratification of patients with investigations as laid out in the ATA guidelines
This was presented at a local multidisciplinary meetings as well as an oral presentation at a national conference in New Zealand to an audience of radiation oncology consultants, registrars and associated specialties
Associated skills:
- Teamwork - working with specialist nursing staff, ward staff, consultant and registrars
- Presentation skills
- Analytical skills
A woman with history of breast cancer with recent chemotherapy calls from home through the cancer specialist nurses presenting generally unwell with a temperature
Ask for her to come to hospital unit or assessment unit for urgent bloods and assessment
Let staff know that she has had recent chemotherapy and at risk of neutropenia
A-E assessment
Bloods inc FBC and lactate
Blood cultures
CXR
Urine culture
Sputum culture
Flu swab
Start treatment for neutropenic sepsis while awaiting blood results
Escalation status
Alert parent team
Discuss and highlight to senior
Patient in chemo unit receiving 5U infusion for a colon cancer has been alerted to you due to SOB, what would you do?
Assess in person, abs to check stable
Review notes, PMHx, oncological history, medications, allergies, is this first cycle?, recent oncology clinic letter
Assess A-E
Differentials:
- Allergic reaction
- Infection
- Chemo reaction - coronary vasospasm
- Anaemia
- Progression of disease
Bloods inc FBC and CRP, trop if concerns with chest pain
Blood cultures if pyrexic
Urgent treatment if anaphylaxis as per ALS
Chemo reaction - can slow rates/antihistamine
Alert parent team
ON call first week - consent to radical treatment to prostate
Seek more information - clarify with nursing/RT staff
Find more information - recent clinic letters, or if staff from the parent team are still present
Discuss with patient and family, find understanding of situation, check not confused
As not able to consent patient to a treatment that I yet do not know, apologise to patient
Notify parent team
Try to arrange appropriate consenting
Postpone start to treatment prior to consenting
What do you understand by informed consent
Consent given by a patient or proxy for a treatment, for which the intended outcomes, alternatives and potential side effects, especially common or serious side effects have been relayed to the patient
Asked to speak to the family of an advanced met HNSCC patient, concerned that he is not getting nutrition and ask about alternative feeding such as PEG
Seek more information - read patient notes and recent clinic letters
Discuss with nursing staff and other staff that may know patient e.g. MDT
Check patient’s capacity e.g. check if AWI is in place
Check if ok to discuss with family with patient - whether they would like to discuss in private or together
Check understanding of situation and discuss what they know of alternative feeding methods and what benefits this may gain
Discuss whether this is appropriate - may cause patient harm or distress
If not moving forward - discuss with senior/treating consultant
You have been asked to ask patient if they would wish to be consented for a clinical trial
Check patient meets the specified basic requirements for the trial
Check patents understanding fo the trial
Information on the trial - what this may involve e.g. treatment, follow up, investigations
If RCT - explain that patient may either receive the trial treatment or placebo, explain that they will also get standard of care so will have some cancer treatment. Clinicians may not know if the patient receives this treatment if double blinded
Explain this is absolutely up to the patient, and if patient does not wish to enter trial will still get cancer treatment. Explain that they can drop out of the trial at any time
Involve trial nurses and give trial patient information
You are approached by a family of the patient in the corridor, they have asked you not to give bad news if there shows signs of progression on a recent CT
Question of autonomy
Explain to family in general terms that for any scan results if the patient wishes to know and has capacity then they have the right to know but ask if there were any specific reasons that they did not want the patient to know e.g. low mood
Read patient notes and overview of history and acquaint myself with scan results
Have patient in consultation, and ask whether they would prefer for this to be by themselves or with family present
Go over understanding of treatment so far
Ask whether patient would like to know results of scans - warning shot if wishes to know and negative results
Ideally have specialist nurse present - identify how patient feels and discuss next options in treatment
Call from 17.30 with signs of cord compression
Gain patient information, read notes scans
Contact patient and arrange urgent assessment
Identify if having any pain
Discuss with neurosurgery if surgical route an option - particularly if new diagnosis, no prior biopsy sample, good PS
If any signs of instability ensure log rolling patient
Start high dose steroids and PPI
QDS BMs
May need titration of diabetic meds if has underlying DM
Discuss with on call consultant re urgent radiotherapy
Alert parent team - may need discussion on current treatments and discuss next line treatments
You are called to review a patient that has arrived at chemotherapy treatment and is very confused
Get information from nurses
Information on patient - clinic notes, previous admissions, GP summary and recent medications
History and A-E assessment:
- May need collateral
- Assess for baseline
- PMHx
- Meds and allergies
- Recent oncological history
Bloods:
- Na, Ca, CRP, FBC
- Urine dip
- Blood cultures if spiking
Explain will need to delay chemotherapy as cannot give consent and may be unwell
Dx:
- Hyponatraemia
- Hypercalcaemia
- Drugs e.g. opioids
- Delirium
- Infection
- Disease progression e.g. brain mets
Tell me about the curriculum and exams
New curriculum implemented in 2021, updated 2023
ST4-5 will do 4 month rotations in a number of different tumour types, will then repeat these in ST6-7
Within the Royal College of Radiologists
Competency based
Generic CiPs - develop in OCS in ST3 year
Then further 4 years of training with ST4-7 years - will focus on development of clinical oncology specific CiPs
3 exams:
- Part one, needed to progress to St5 level - usually sat in St4
- - Comprised of 4 parts, clinical pharmacology, cancer biology and radiobiology, medical statistics and physics
- Part 2A and B - written paper and practical exams respectively
- Usually sat in St5-6 year
What is needed for curriculum
Number of different methods to show competency
CBD, Mini-CEx, DORPS, ACAT, MCR, MSF, Teaching observation
2x QIPATs expected to be done within ST4-7
Tell me about developments in clinical oncology
Exciting research driven specialty
- Many new treatment in oncology
- Immunotherapy
- Mutation based treatment e.g. TKI
Arc based models - complex 3D treatment +/- nodes with various doses of radiotherapy
VMAT (volume modulated arc therapy) and IMRT
SABR - Gamma knife
Proton beam radiotherapy
Can you tell me of any trials that have made a difference in the treatment of clinical oncology patients
FAST-Forward trial
Published in the Lancet
Showed non-inferiority with hypo-fractionation in adjuvant radiotherapy for breast cancer with 26Gy in 5# vs 40Gy in 15# in early breast cancer with similar side effect profile
Benefit for patients - not needing extensive longer treatments, which they may have to traveller or spend time away from family
Reduced time for machines and so allows increased slots for other patients
Underperforming colleague
Chemo prescribing error
Patient with brain mets that are still driving
