interview questions

Question 1

Why do you want to be a doctor?

Answer 1

• myriad reasons
• suits my natural demeanour and traits. naturally caring person, cared for mum which cemented this.
• fortunate to have an analytical mind which means i’m quite adept at problem solving
• love science, studied at school, university. Interested in becoming an applied scientist in a role that involves a lot of people skills.
• i want to be pushed to the limits of my skill set academically, physically, emotionally, and be forced to make difficult decisions. This will foster growth.
• I want to work in a career that allows me to emotionally invest a little in my patients while also intellectually stimulating me.
• I’m fascinated by the progression that there will be in our lifetimes. So much has happened in the last 50 years, and I want to see what’s going to happen in the next 50. But I want to be doing this as a professional, not as an outsider.
• I’m fascinated with the body and mind and I hope to specialise in psychiatry. However I wasn’t interested in psychology because I want my understanding to come from a base of physiological and pharmacological knowledge.

Question 2

What’s your biggest weakness?

Answer 2

• people are constantly in flux, weaknesses can improve, strengths can diminish, moods, personalities and beliefs can change.
• as a result, i wouldn’t say i have a fixed biggest weakness. I try to spent tiem being introspective on a fairly regular basis. This allows me to recalibrate, identify weaknesses and begin considering how to improve on them.
• over-empathising is a definitely weakness. I realised this was the case while working at a food bank.
• i’ve learned that taking a more utilitarian view helps me with this while allowing me to maintain compassion.
• further to this, considering virtue ethics too, there were some weeks where i was able to provide extra rations because i knew we had food that would expire.
• currently i’m struggling with a lack of spontaneity. owing to lockdown, studying for the GAMSAT and UCAT and having moved back from Canada to a town where i have no social circles, i have become very regimented and routine. Addressing this is more complex than you’d think. I need to organically make friends in my area first.
• i’m currently learning to schedule better.
• although i’ve always been reliable, i have mentally remembered what i need to get done and as i’m becoming busier, this is becoming more stressful. I’m starting to work on keeping a planner and also learning how to integrate this with remaining spontaneous.

Question 3

What’s your biggest strength?

Answer 3

• Humility
• On paper, i know that i’m intelligent, both emotionally and academically and athletically talented.
• i don’t brag about these things or in any way feel that they elevate me above others.
• This is a strength as my natural demeanour comes across as likeable to most people.
• I’ve realised in the last few years how fortunate i am to be intelligent, and how useful having strong emotional intelligence has been as i find it fairly easy to empathise with and develop rapport with people.
• My demeanour.
  I’m intelligent but also a compassionate and empathetic person and I believe I have strong emotional intelligence
  This means I find it fairly easy to connect with others and make them feel at ease.
  Emotionally investing in people around me also means I’m more likely to notice subtle changes in their behaviour or expressions which often leads to me being the the friend that’s turned to for advice.
• This means that I function well within teams, it also means that in my groups of friends I tend to fall into the role of a leader, or the individual that others turn to for emotional support.
  I believe these qualities will also lends themselves well to a career in medicine.

Question 4

why southampton?

Answer 4

-curriculum based around clinical learning and self-directed study. This is how medical career would be.
- i like the similar approach you have to PBL. But as well as providing case information on paper, i like that you provide videos or actual patients as this will developed information extraction and general soft skills.
- i like that year 4 contains a psychiatry module in the form of a placement as i plan to specialise in this.
-

Question 5

does euthanasia have a place in modern medicine?

Answer 5

• this is a complex issue that can’t be summed up with a black and white response
• legality and ethical considerations vary depending on which type of euthanasia. There is voluntary, involuntary, assisted and passive.
• autonomy and beneficence (in terminally ill patients that want to die with dignity) would suggest it does
• however, active euthanasia goes against the hippocratic oath.
• the swiss seem to believe it does, and this causes lots of british patients to travel abroad to undergo the process. if this is going to happen anyway, we should give consideration to allowing case by case decisions on euthanasia in the UK to allow people to die in their home nation.
• Ultimately i think it does, where it allows patients to die with dignity and brings an end to untreatable pain.
• There are so many arguements for and against.
  -Allowing patients to die with dignity is definitely a reason I believe it should be considered.
  however, we have the specialty of palliative care for this reason. And I’ve heard that a lot of healthcare workers in this field report that patients who claimed they wanted to die, later express joy that they continued living for a little longer.
• I would also argue in terms of patient autonomy, that patients should be allowed to have the choice. To further this, there was a case in the past in which a woman argued that able bodied people can commit suicide, and so those who are physically unable should be given the same rights.
  -The reason the courts gave against this however is that it’s not beaureacracy that’s preventing a patient taking their life, but instead their illness.
• There is also the idea of a slippery slope, and that if we allow active euthanasia, then people may end their lives prematurely because of pressures such as feeling like a burden to their families. We could even see pressure for people to end their lives because of organ transplants.
• In terms of beneficence and non-maleficence, I would argue thought that sometimes the best thing to do for a patient is to allow them to die. Especially if they are in constant pain.
• My final thought is about dignities in switzerland. The fact that we have patients who travel to Switzerland to undergo euthanasia means that their family may not be able to be with them at the end, and it may present issues in terms of burial or cremation. It might be more beneficent to allow patients the same options here in the uk.
• In terms of consequentialism, I could also argue that withdrawing life support (which is legal) has the exact same consequences as euthanasia.
• Overall this is very complex. I would say that I agree with passive euthanasia like withdrawing life support. Active I do feel is a bit of a slippery slope and if considered should be something that is decided case by case and has a panel of doctors or court come to a decision.

Question 6

Do you agree with abortion?

Answer 6

I agree under the right conditions.
There are obviously a lot of complex considerations like foetal rights, mothers rights, fathers rights, the sanctity of life.
To me a large part of the decision is sentience. A line has to be drawn between embryo and foetus. This is a very difficult line to draw though. Neuroanatomical apparatus necessary to feel pain or sensation isn’t complete until around week 26 of pregnancy.
I know that in the uk we have 24 week abortion limit. Most reports I’ve read state that babies born before this stage have very low chances of survival and will almost always have disabilities.
I know most women have abortions by the 12 week stage, however it’s important to keep the limit at 24 weeks because reports state that some women struggle to be seen and this is the upper limit for where vulnerable women can be treated.
After this stage, it’s harder to argue that we’re not taking away a life as babies are much more likely to survive a premature birth at this age and are therefore more easy to see as autonomous beings.
Another consideration is beneficence and non-maleficence to the mother. We have a law in the uk that I agree with which states that abortions can only be carried out if they present less risk to the mother than continuing the pregnancy would. We have to consider the long term mental health effects that can arise from a terminated pregnancy.
Bodily rights of woman.
Women are disproportionately affected by pregnancy and gender equality is a consideration here. Not only do pregnant women have to carry baby to birth, they will have to care for it for at least 18 years afterwards. Men don’t ‘have’ to have the same responsibility.
We have to consider cases like rape. Forcing a woman to raise a child of their attacker will likely cause severe psychological issues. They will face cognitive dissonance over the combination of loving their child and it sharing genes with a rapist.
We do have to consider the pressure that partners may put on women to make this decision. As such it’s important that women considering abortion are asked appropriate questions by medical staff and are seen to be making an autonomous decision free from external pressure.
Life may begin at conception, but personhood is different. Fertilised eggs produced for IVF are routinely thrown away and this would consistute mass murder if they were all considered living humans.
Although adoption is available, this isn’t an alternative. The attachment a women develops to her baby is likely to grow over time and by childbirth a women is far less likely to give up a baby for adoption than they would have been to go through with abortion, and yet the same economic and social challenges are likely still present. In fact in countries where healthcare is private, the act of childbirth may have exacerbated a woman’s economic difficulties.

Question 7

A patient refuses treatment for a life-threatening condition. Discuss the ethical issues involved

Answer 7

• It’s important that the patients autonomy be respected here. However, it’s important that the patient’s condition, and full details of the treatments available are provided so that they can make an informed decision.
• Although not an ethical issue, it would also be important to determine whether the patient is competent.
• although respecting the patients autonomy may mean going against the idea of non-maleficence and beneficence. Ultimately if they have been given all the information and are deemed competent, then it’s up to them. forcing them to have the treatment would become a legal issue.
• If they were under 18 things may be different as minors are able to consent to treatment, but aren’t able to refuse it.

Question 8

A 14 year old asks her GP for the pill, discuss the ethical issues

Answer 8

• safeguarding - is the child being manipulated or abused?
• Gillick competency - is the child competent? if so then it’s not necessary to breach confidentiality.
• it would be important to explain the options available and get more information about the teenagers sexual activity to help reduce the likelihood of issues. it will also allow them to make the most informed decision possible.
• not providing this information may be maleficent as the patient may undergo unprotected sex.
• if the patient appears competent, the beneficent thing to do may be to prescribe the contraception.
• Autonomy - if she’s competent then she can make a decision.
• Justice - she can chose to do what she wants and as long as she’s competent shouldn’t be discriminated against.
• In terms of beneficence though, is there a risk that the patient is being taken advantage of? It would be worth suggesting that she either speak to a parent, or to a service if necessary to be sure this isn’t a safeguarding issue.
  Further to this, what effect could being sexually active at this age have on her emotional wellbeing going forwards?
• children under 13 aren’t able to consent to sexual relationships. report to child protection lead.
• will not prescribing lead to significant physical or mental health detriments?

Question 9

A patient diagnosed with HIV reveals to their GP that they haven’t discussed this with their partner

Answer 9

• first: discuss with patient the risks associated with this and try to encourage them to do so.
• considering non-maleficence and justice, it would be permissible for the GP to breach confidentiality in order to inform the partner. Prior to doing so, it would still be necessary to inform the patient that this was going to happen.
• we see patient autonomy at odds with justice, beneficence and non-maleficence here.
• this is a case of beneficence to others versus the impact that this may have on the patient in the future, such as their likelihood of disclosing future issues.

Question 10

you notice a fellow medical student putting equipment in their bag. when you ask them they say they want to practice clinical skills and that you shouldn’t tell anyone. what should you do?

Answer 10

• consider demeanour when approaching the friend. It’s possible they’ve been given permission to do this (although unlikely).
• may be struggling with clinical skills in which case i could offer to help.
• may be struggling with external issue that i could be supportive about.
• talk to your friend and explain the seriousness of their actions. although it may not seem it, this is an ethical violation as it could result in shortages in supplies and as a result potentially could endanger lives - relevant with pandemic.
• Recommend that they come forward about the incident. Be supportive of any emotional issues that may arise.
• If they refuse to come forward, i would explain that unless they are willing to, i would have to report their behaviour.

Question 11

What does patient confidentiality mean? when would it be appropriate to breach this?

Answer 11

• Law whereby doctor’s cannot reveal what patients have told them during consultations.
• Vital for the doctor patient relationship. it fosters trust and encourages patients to be more open about things.
• Without it, patients may hold back or avoid seeking treatment at all.
• In order to maintain confidentiality it’s important to be thorough in work. Don’t leave documents lying around at the end of the day, and if discussing things as part of a multidisciplinary team, be sure to do it in a private space, or, do it quietly and share the minimum amount of information necessary.
• its important to mention confidentiality to patients and ensure that they understand what it means, and that information may be shared within the team if necessary in their care.
• if confidentiality is to be breached, it’s essential that the patient is informed.
• its appropriate to breach in cases where justice is involved, such as when a patient has a transmittable disease and refuses to share information that means others are at risk.
• it’s appropriate to breach in multidisciplinary teams so that members of the team are updated on the case.
• in cases of incompetency both in adults and children, sharing of information may be necessary
• In cases of abuse, or when a childs behaviour is putting them or others at risk, information may be shared without consent.
• in cases where breaching confidentiality is being considered, it’s important to double check GMC guidelines as there are lots of grey areas and it’s important that professional duty, not personal beliefs be the deciding factors in decision making.
• had some practice with eric in foodbank. made sure to speak to Sara privately so that what he told me wasn’t overheard.
• shadowing allowed me to hear from numerous consultants how important they consider support networks and hobbies to be in order to mitigate the stress that comes from maintaining confidentiality..

Question 12

A 13 year old patient reveals to you that they are sexually active and that their parents don’t know, what would you do as a doctor in this situation?

Answer 12

• unless you believe the patient to be incompetent (Gillick), confidentiality must be maintained.
• it would be important to empathise with the patient, to understand what they know about safe sex, whether they’re using protection.
• they could be being taken advantage of, which could be detrimental to their physical and mental health in the future, and so beneficence would suggest that i should encourage them to speak to their parents about being sexually active.
• If it appeared that they were being taken advantage of, non-maleficence may make it acceptable to breach confidentiality in order to follow child protection protocols.
• providing information about safe sex and contraceptive options would also be important.

Question 13

A depressed patient who has mentioned having suicidal thoughts has refused treatment and you’re concerned about his wellbeing, discuss ethical issues.

Answer 13

• In regards to autonomy, it’s the patients right to refuse treatment. Forcing it upon them is unacceptable.
• If the doctor is concerned, then i would assume empathy has already been applied for the concern to have arisen. however, it would be important once again to empathise with the patient, to understand why they are refusing treatment, and to look for any concerning signs.
• It’s important to ensure the patient has had their options fully explained to them. Although they are refusing treatment, this could be due to a lack of understanding of the nature of their depression and what the different treatments will actually entail.
• If i believed the patient presented a real danger to themselves, then it might be necessary to breach confidentiality in a non-maleficence way. However, this is a decision that shouldn’t be taken lightly as breaching confidentiality could cause a different kind of harm such as damaging the patients trust in doctors leading to a reduction in future openness.
• is the patient competent? psychiatric conditions can result in loss of capacity.
• Is the patient concerned about feeling like a burden? In terms of justice of equality, ensure they know that their problems are as valid as anyone else’s and that they are entitled to treatment.
• Does the patient have dependents? this will influence whether overriding the refusal of psychiatric treatment has more grounds.

Question 14

Do you think the NHS should fund treatment for smokers?

Answer 14

• ethical principle of justice would suggest yes as doctors have duty to all patients
• sin tax from cigarettes is more effective as the additional revenue will help support treatment. beneficence may support this as a better option.
• it’s also worth considering socio-economic factors. Whether someone smokes is largely influenced by their environment. studies show that the lower classes have more smokers, by not providing treatment, the class gap will be furthered, which isn’t really the way we want society to be moving.
• non-maleficence/ justice, smokers may suffer injury unrelated to smoking, it wouldn’t be fair for them to have different levels of care.
• we have a single payer healthcare system in the NHS which unfortunately isn’t in a position to fund all treatment for all patients, and so a utilitarian approach to resource management makes this an interesting debate. Lung transplant, maybe not, cast for broken wrist, reasonable.
• patient autonomy also states that patients have the option to make their own choices and shouldn’t be punished for this.
• once precedent is set, where do we draw the line? if smoking is considered a lifestyle choice not worthy of receiving treatment, then what happens to people injured from leisure activities or drinking, or how about road accidents?
• smoking related illnesses account for a lot of budget usage, although tax revenue balances this out for the most part from what i’ve read. beyond this, it’s the governments responsibility to ensure those tax revenues go where they should.

Question 15

What would you do if you saw a colleague making a mistake with a patients medicine?

Answer 15

• approach them empathetically, and in private and suggest that i believe there may have been a mistake with the patients medication.
• hopefully we could determine if this is the case.
• it would be worth checking that everything is ok with my colleague at this point. patient care is vital and this could have been a lapse in concentration, or it may have resulted from distraction due to greater problems. Being supportive will allow this to be determined, and will allow me to offer help if necessary.
• the mistake has to be reported as per GMC guidelines, so it would then be important to encourage my colleague to report the issue, and state that if not, i will have to do it myself. Be clear that this isn’t a personal attack, but is a matter of patient safety and following guidelines.
• we want to foster an environment of teamwork and support, this is why it[s important to be empathetic and give the colleague opportunity to report the mistake themselves.

Question 16

Is it ever ethically acceptable for NHS doctors to go on strike?

Answer 16

• the kantians among us would most likely say no, and that this is a black and white issue.
• consequentialism however, would suggest that in some cases, yes it is.
• as we saw with the junior doctor strikes, sometimes doctors feel that they are being overworked, and if the consequences of this are that they underperform and may cause harm to patients, then removing themselves from the situation in order to address the cause is acceptable in my opinion.
• This falls under non-maleficence. The doctors felt that they were in a position where they may do harm due to external factors and had to take action to change this.
• Now if the situation was that doctors were on strike because they wanted free parking at their hospitals then perhaps not. my point here being that this is a nuanced discussion.
• In terms of autonomy, it is also a doctors choice to practice. We don’t live in a caste system and no one is forced to be a doctor, so again, if they are making decisions in order to prevent harming patients, then it’s their right to do so.

Question 17

You are a GP and a patient confides in you that they are using illicit drugs, what should you do?

Answer 17

• empathise with the patient first and foremost. Understand how regularly they are, if they feel addiction is an issue, if they know of any underlying causes for their substance misuse.
• have a frank but not judgemental discussion with them about the dangers of their behaviour in the short and long term.
• provide information about drug cessation and mental health services, and, if necessary provide a referral.
• in terms of immediate care, ascertain whether the patient is experiencing any adverse health effects, and provide treatment for these.
• confidentiality: breachable if it’s deemed necessary to speak to the police or social services (patient or someone else must be in direct danger because of the drug use).

Question 18

Should vaccination of children be mandatory?

Answer 18

• tough question
• vaccinations are no doubt important, and the more people who are vaccinated, the quicker, or more easily we will reach a state of herd immunity.
• we know from wakefield scandal that when childhood vaccinations drop, there is a rise in infection rates. unfortunately we’ve seen that our ‘measles free’ status has been rescinded as those that would have been children around the time of the wakefield scandal are now university age, and there has been a breakout of cases in universities.
• Unfortunately, there is an abundance of false information surrounding vaccinations online, and group polarisation and confirmation bias only serve to worsen the issues. there are claims that vaccines are toxic.
• Unfortunately we have seen a rise in anti-vax group popularity during the pandemic. Labour have even propose a new law the tackle the spread of fake anti-vax news.
• our best hopes are to promote more vaccine education.
• making them mandatory could create social problems and it’s taking away patient autonomy which could create friction and mistrust in the NHS.
• We have to consider as well that vaccinations efficacy or side effects are likely to come under the shape of a normal distribution. Although most will benefit from their vaccination, some will have side effects, and if someone forced to have a vaccine happens to have an adverse reaction, this could create a scandal.
• lack of evidence that mandatory vaccination actually increases uptake despite reducing public trust.
• Because vaccines reduce prevalence of horrible diseases, they’re no longer seen first hand, therefore parents may be misguided in their understanding of how bad the alternative is compared to the possible side effects of the vaccine.
• research suggests that empathising with concerned parents and allowing them to talk through their concerns with a trusted healthcare professional is one of the best methods.
• Allowing childhood vaccinations to occur at school is important though as research has shown that low uptake is influenced by difficulties in getting to appointments. This also reduces the burden on the NHS as multiple vaccinations can be taken care of in a day rather than many appointments being taken up by people needing vaccines.
• we do know that the WHO declared the UK to be measles free in 2017. Unfortunately by 2019 we lost this status. it appears that the reduction in vaccines that followed the wakefield scandal has now seen a rise in measles cases within universities (those babies are now at that age).
• I know that the NHS plan to improve coordination and support in low uptake areas as well as adding MMR checks for children aged 10-11 as well as attempting to catch-up young adults who missed the vaccinations as children.

Question 19

How much does a mountain weigh?

Answer 19

• can you tell me the radius of the base? and the height? 1/3 pi r squared from these gives volume
• can you tell me what material the mountain is made from? density = mass/ volume. if i know the material, i can find the density and calculate the mass.
• now that i’ve got the mass, can you tell me what planet the mountain is on? or at least, what the value of gravitational acceleration is on that planet?

Question 20

how different would the world be if the wheel wasn’t invented?

Answer 20

• very different.
• transportation would exist, except for things like dog sleds in snow covered areas.
• cogs and gears wouldn’t exist and so we most likely wouldn’t have accurate methods of tracking the time
• gyroscopes wouldn’t exist, these are necessary for most smartphones
• we wouldn’t have CD’s, DVD’s, Vinyl
• hydroelectric power couldn’t be generated
• shopping and manual labour tasks would be a lot harder as we wouldn’t have trollies or wheelbarrows.
• disabled people would be at a major disadvantage as wheelchairs wouldn’t exist .
• culture would be wildly different, we wouldn’t have sporting events like formula 1 or tour de france.
• skiing resorts wouldn’t exist as gondolas require wheels in their mechanisms.

Question 21

How many words are there in an average book?

Answer 21

• depends on what type of book. the average nursery book will have significantly less than the average legal manuscript.
• further to this, the verbosity of the book would be a factor. A book with lots of long words will have less words per page than a book with more rudimentary language, and so i’d need a bit more information from just page length.
• once some of this has been cleared up, let’s say the ‘average book’ type we’re considering is 300 pages long, with 20 lines of text per page. that would be 6000 lines of text.
• if each line has 10 words, we have 60,000 words. However, some pages like the title page, the contents, the dedication, pages at the start and end of chapters, would have less words, and so a conservative estimate would be around 58000.

Question 22

To what extent do you think fear is beneficial?

Answer 22

• it’s an evolutionary response to help us avoid dangerous situations.
• Without fear, people might wander off the edge of buildings.
• It’s also allows us to connect. Empathising with other peoples fears brings us closer as a species.
• unfortunately there are negatives of fear, but by understanding these we can try and turn them into positives. Considering patient care, fear may lead to apprehension. By being empathetic about this, we are able to reassure patients, help them disclose information and foster better relations with them.
• Overcoming fears allows people to grow.
• fear can give us social cues. being afraid of rejection can lead to social cohesion. and feeling apprehensive about saying or doing something can lead people to act more favourably.

Question 23

why do we wear shoes?

Answer 23

• protect our feet against the environment.
• protect our feet against soil living parasites.
• culture
• societal norms - conformity.
• expression of individuality
• to allow us to perform certain activities i.e. ski boots, running shoes have extra cushioning.

Question 24

if you were stranded in a remote rainforest and trying to escape, who is one person you would want to accompany you and why?

Answer 24

• ideally a native of the rainforest.
• if that wasn’t an option, then my friend dan.
• he’s a level 3 certified mountaineer. he’s trained in back country navigation techniques, how to make makeshift repelling equipment, he’s a licensed paramedic, and is exceptionally fit.
• further to this, we are close friends. We first bonded over our mutual appreciation of music (specifically blur), and have taken numerous trips together where for 5 hours drives the conversation doesn’t stop. We can be discussing skiing, music, philosophy.
• He also spent a year working a forest tour guide in Canada.

Question 25

How many atoms are there in a glass of water?

Answer 25

- find weight of glass with and without water. determine weight of water - 1 mole of water weighs 18grams. divide weight of water by 18 to find number of moles - 1 mole is 6.02x10^23 molecules so multiply number of moles by this. - each water molecule contains 3 atoms so multiply this value by 3.

Question 26

What do you think are the advantages of this style of teaching? (Swansea)

Answer 26

- the integrated spiral curriculum is smart. It's well known that spaced repetition is one of the best ways to learn and that's what this system does. - Not only do you allow for spaced repetition, but by adding a little more complexity each time, it will allow the brain to gradually absorb and process novel information while relating it to previous understanding - Early exposure to patient care is essential too. At the end of the day medicine is an applied science, and although many scientific theories are relatively black and white, very few interpersonal interactions are. As such, having more time to practice interacting with patients (especially while learning support will be available) is very helpful. - I think it's great that the clinical placements include a week or nursing practice. It's important to understand the role of other members in a team in order to better function as an empathetic team. - i like that at the end of fourth year shadowing of an f1 doctor occurs too. Taking the step from student to practitioner (although being a student will be a lifelong designation in medicine) will be a big one and it will be an easier transition having had a good amount of time to shadow. - case based learning is also something i appreciate. By having to actively think and apply theoretical knowledge to cases stretches the neurons a little.

Question 27

Do you think cadaveric dissection is important for medical schools?

Answer 27

- I believe it has benefits, although whether i would say it's important for medical schools i'm not so sure. - It is obviously a humbling experience bringing students face to face with a deceased person. it will bring the realities of the field into perspective for those who have possibly been bogged down in the theoretical. - it also provides the most accurate representation of anatomy possible. - Lots of doctors are astonished at the complexity of the body too. It also provides a mental picture of the body. How deep things are, where they are. This will help guide doctors in procedures. - however, the modern techniques we have as alternatives are so good that i believe they are good enough. especially in medical school. perhaps if someone decides to specialise in surgery or radiology then there would be slightly more benefit. - techniques like radiological anatomy, body painting, ultrasound and digital 3D models provide lots of opportunity to learn. - in terms of the loss of humbling experience. one would hope (although i'm sure this isn't always the case), that medical students are aware of the realities of the discipline. - however, I have heard that the embalming substance used and the cooling process means that performing surgery on a living patient feels different to dissection.

Question 28

What would you do if you fell behind on this course?

Answer 28

- my first move would be to have a look at my diary and scheduling and see if i could rectify the issue. If i had assignments due, then i would need to speak to the module convenors as soon as possible. - If i could alter my schedule in a way that would permit me to catch up within a reasonable time frame (without cutting out all leisure activities and risking burnout), then i would go forward with that, but still speak to the course director and or module convenors to explain my situation. - if i fell behind because of personal issues, i would most likely seek out the course director and discuss the situation with him, as well as seeing either the university counselling service, or my GP is the problems called for those actions. - Depending on the situation, i would involve close friend for moral support. - I would speak to friends who may be able to help me with any notes they made during lectures.

Question 29

Have you spoken to any current medical students?

Answer 29

- I spoke with a formed school friend who studied undergrad medicine at UoN and while studying my undergraduate degree there i also dated a medical student and had medic friends in the tennis team. - It was my conversations with these individuals who initially jolted me into considering medicine, and the idea has snowballed from there! - From talking with them, i'm left in no doubt about the intensity of the workload, and these people were all on A100 courses, so i'm sure my workload will be even greater. However, they all managed to remain active in sports teams including playing in matches, and most of them enjoyed their time at university. None of them seemed to be plagued by perpetual stress that was unmanageable. - yes. While I was at university I had friends in the tennis team who were medics, I also have a friend from school who studied medicine at Nottingham and I dated a medic for a year. I’ve also spoken to these friends since they graduated about life as junior doctors. There are a range of perspectives I’ve gained. Some of them found medical school fairly straight forward, they enjoyed their time studying and they are enjoying working as a junior doctor. One of my friends struggled at medical school and was close to dropping out in his third year. He ended up persevering and is loving working as a junior doctor now. My ex girlfriend on the other hand really enjoyed her time as a student, and is struggling with sexism as a junior doctor apparently. The area she’s working in sees a lot of older men requesting a male doctor and she’s struggling with this. The thing that I learned from all my friends is the importance of scheduling. Especially the friends in the tennis team. They were able to train multiple days a week and play in matches by having a consistent schedule. The friend that struggled fell behind and was overwhelmed by the idea of having to catch up, mainly because it meant that he would have to sacrifice his down time. This also brings me on to another idea I learned from my friends which is that balance is important in medicine. Being a demanding subject/ career, it’s important to make time for the things you enjoy in order to destress and give yourself time to return to work with fresh eyes.

Question 30

Talk us through your personal statement

Answer 30

- as you can see from the first paragraph, my realisation that i wanted to study medicine came shortly after graduating. In fact, having medic friends and a medic girlfriend and university are what first got me thinking about returning to study graduate medicine, and then my time in canada allowed me to study a diverse range of topics and spend considerable time being introspective, all culminating in me arriving back at that decision (although from a much more informed perspective) - Early on in to my realisation that this is the career i really want to pursue, i was a little irked that i hadn't realised this sooner as it was one of those 'but of course that's what i'm suited for' moments. Having had more time to learn about medicine, i now believe that i'm in a much better position to succeed with the maturity i possess today that i would have been straight out of school - although it would have been nice to save myself a bit of time haha. - As you can also see from my statement, the other reason for this is that a lot of my adolescence consisted of caring for my mum. In addition to having tennis training for a couple of hours each day, studying for my a levels and trying to have a social life and make time for my girlfriend, i really didn't have much time to be introspective. - Considering this, it does make sense that it would take until i had the time to step back and be introspective for me to realise my aspirations. - In addition to wanting a career that involves the continual care of others, i'm also interested in the academic side. I like how challenging medicine will be intellectually on the theoretical side, and emotionally on the practical side. I've always had a natural balance or empathetic and analytical and a career that will push me in both of those areas is what i want. - my time away in addition to helping me confirm my aspirations, also helped me to start working on skills and improving weak areas. By volunteering at a food bank, i was able to realise my tendency to over-empathise. By speaking to my manager as well as having read lots of philosophy (in this case utilitarianism being helpful), i've been able to improve in this area by taking a broader view of care. Rather than considering that particular patron at that particular instance whose asking for extra rations, but instead considering the foodbank as a whole over the longer term, i was able to maintain compassion while explaining that that wouldn't be possible. - i've also learned the important of clear communication from shadowing. and since writing my personal statement, i have been fortunate to virtually shadow a number of specialties through live video sessions hosted by the university of texas. - Would you like me to talk you through the way I’ve structured it, or the general content of the statement? Or both? In contrast to everything else with my application, I didn’t read any blogs or posts about how to write a medical statement. I wanted the information I put in it to be completely authentic. With the UCAT and GAMSAT I spent hours and hours studying, I worked hard to secure volunteering opportunities, and I read extensively about which courses I wanted to apply for. But this one area, I didn’t want what I conveyed to you on the page to be cliched or externally influenced. I will admit, after submitting my applications I panicked a bit about whether I’d been foolish in doing this, but hopefully not. So I decided I wanted to loosely break my statement down into 3 parts. My first paragraph aimed to express why I want to study medicine, or at least the catalyst to my realisation that this is the career I want to pursue. It also contained information about achievements and accolades of mine that I believe show relevant character traits. As I’m sure you can see, a large part of what has shaped me into an empathetic and compassionate individual is my teenage experience of looking after my mum. This was a fairly tough time while also going through puberty and while lacking a male role model - which was a large part of the reason I am so interested in ethics and morality. I’m very driven to be a good and conscientious person, and when you grow up without an example to base your behaviour on, you have to look at literature for guidance. It was quite easy when I was younger to take things personally because unlike a lot of people, I hadn’t developed social or emotional skills through imitation, they were entirely self taught, and so when someone disagreed with something, it was more personal. however, it also led me to think and constantly be looking to improve. furthermore, during this stressful time is when I achieved a lot of my accolades which I think speaks volumes for my character. I was training hard at tennis after school in order to play at a county standard, working hard at school in order to be elected a prefect and nominated for academic awards, and working hard at home to learn about things I considered important for my development and trying to ensure my mum was ok. My second paragraph was intended to express external life experiences I’d had that I believed to be important in shaping my character further. I believe empathy is incredibly important in life, as well as in medicine. And the way that empathy grows is by interacting with a diverse cohort of people. As such I spoke about my time living in canada as this brought me into contact with people from all corners of the globe and I instructed clients ranging from children to heads of industry and had to adapt my communication and demeanour each day. I also wanted to express how much I enjoyed my scientific ethics module at university. I didn’t realise at the time that medical ethics was as big of a topic as it was, and I hadn’t read all that much philosophy before this module, but I thoroughly enjoyed it and it helped me realise that the breadth of my thinking is a skill I should give more credit to. My final paragraph was aimed at highlighting the experience I’d managed to undertake and what I had learned from this. Since writing my statement I’ve actually undertaken a lot more shadowing and have been able to glean much more.

Question 31

Do you read any publications that are relevant to your interest in medicine? tell us about an interesting article you've read recently.

Answer 31

- i tend to listen to the new scientist podcast as this allows me to balance things better. i like to use my time at my desk to study. and my time walking my dog or driving is for listening to articles. - something i enjoyed recently was hearing about a potent new antifungal that was discovered in the microbiome of a marine animal. - i enjoyed learning about the red queen hypothesis in biology and this is an example of that. The new anti-fungal appears to be resistant to multi-drug resistant fungi. - i was also fascinated to learn that a potential issue that comes from anti-fungal drugs is toxicity to humans. Although i know that both fungi and humans are eukaryotes, i hadn't considered this. - when virtually shadowing an endovascular surgeon from UT southwestern, i was really fascinated by the options we have to treat aneurisms and the progression of these technologies. I thought the wire coil that's built up in vivo was really cool, and then got to hear about the mesh bubble that expands, but doesn't need to be built up in a patient as well as flow directing stents. - I read a couple of interesting articles recently. I was interested in an ethical question I looked into regarding withdrawal of consent in c-section patients. I then read an article regarding the ethical issues surrounding this and was intrigued to see that this is a common problem that obstetric doctors face. It’s not as clear cut as autonomy as there is justice and non-maleficence of the baby to consider. There is also the issue of whether the withdrawal of consent is capacitous or is externally influenced by factors such as stress. There was a case cited where a blood transfusion was necessary and a Jehovah witness family were involved. The daughter (old enough to consent) had given her consent for a transfusion, however, her mother then asked to speak to her, after which she reversed her decision. It was decided that her withdrawal of consent was invalid because she was pressured to make the decision. - also read that recent research is suggesting that stents may not be any more effective at preventing heart disease than lifestyle changes.

Question 32

Have you heard about any public health campaigns recently? what is your opinion of the role of public health campaigns in medicine?

Answer 32

- I believe they're positive. As set out by the ethical pillars (and something i have come to consider naturally), patient autonomy is of great importance in medicine. public health campaigns for things like nutrition are a good way at attempting to improve a problem through spreading of knowledge rather than risking a loss of patient autonomy through forced procedures. - Health campaigns are also important in helping improve detection of medical problems. A pertinent example would be the F.A.S.T. campaign. I believe this helped close to 5000 individuals be prevented from long-term disabilities. - In recent times we've had the 'hands, face, space' campaign. These types of campaigns help to spread simple information that mitigates a little of virus spread, they also come with the benefit of promoting a social contract that leads to feelings of solidarity across communities. - So the obvious one at the moment is ‘hands, face, space’. This is a catchy slogan to help people remember to distance. However, I personally feel that we need more information through tv adverts or otherwise explaining the importance of keeping your nose covered by your mask. From what I understand, the nose is the primary form of attachment by the virus, and the volume of people who keep their nose uncovered is frustrating to say the least. My irritation aside, I believe public health campaigns are important. They help spread knowledge, even if it’s often a watered down version. They may spark the interest of people who can then read into things a little more deeply, or they may cement themselves in peoples minds. The campaign I always remember is the fast campaign for strokes. I remember my friends talking about it at scouts when we were younger, and from what I understand it had a very positive impact. I remember reading at one point that around 5000 individuals were prevented from long term disabilities because of people noticing their signs and symptoms earlier. There will obviously be people who ignore public health campaigns, but the alternative of forcing people to act a certain way isn’t really an option in my opinion so as an easy method of engaging with the majority of the population I think they are a very useful tool.

Question 33

Have you thought about what you would like to specialise in?

Answer 33

- i have been leaning towards psychiatry. I still believe this is the area i want to get into, however, after shadowing and learning about the prevalence of emotional burnout due to perceived lack of progress in patients, i am giving more thought to other specialties too. - i really enjoyed shadowing neurology and endovascular surgery. From what i understand, neurology shares a fair amount of overlap with psychiatry early on which is a bonus. Surgery would obviously be a very different kettle of fish. - ultimately i feel that i can't make a fully informed decision until i try the specialties out for myself.

Question 34

what have you learned about medicine from the doctors you've spoken to?

Answer 34

- Something that i'd already considered in a slightly different way, and was made abundantly clear, is the importance of empathising with patients as a way to prevent burnout and to remain engaged with the work. - almost all of the doctors i shadowed spoke about this. That giving patients a little will often lead to you receiving a little in return. - This was also spoken about as one of the challenges facing psychiatrists - i was informed that because patients may progress slowly, there can be a perceived lack of progression, or in a lot of cases there is a lack of progression. It's absolutely essential to find ways to remain emotionally invested in these patients. - I've also learned a lot about the importance of teamwork. i'd thought about this is the context of doctors working with nurses, pharmacists etc, however i hadn't realised how prevalent multidisciplinary teams are in practice. Fortunately teamwork is an area i believe i shine in. I have played on many competitive sports teams and worked in a number of jobs and have always been adept at working in a team. When i was younger i used to struggle with confrontation, but having read about assertiveness i have improved on this weakness. - I learned about advancements in particular fields like the progress we’ve made in aneurism treatment in endovascular surgery. I also learned about heuristics that doctors use in emergency situations like the XABC approach. - I learned about the many uses we have for ultrasound beyond pregnancy. who\d have thought it could be used for for detecting the speed and direction of blood flow. - I learned about the importance of empathy in terms of emotional resilience. I learned that the ability to differentially diagnose improves with experience. I got a good perspective on death from a clinical paediatrician. She said that it’s important to remember that most patients coming through the doors would have suffered if it wasn’t for our care, and that anything we do should be seen as a positive regardless of the final outcome. I learned that balancing schedules can be hard, but is possible.

Question 35

what do you think is the most exciting recent development in medicine?

Answer 35

- i think virtual and augmented reality provide the potential for huge development. Virtual reality like the microsoft hololens will allow anatomy to be studied in great detail without the need for cadavers. - augmented reality can assist surgeons, and psychiatry patients can benefit from virtual reality helping them overcome phobias through exposure therapy. - a pertinent piece of medical news, although the technology has been around for a few years is obviously mRNA vaccines. - I think technology has been huge in recent times. We’ve seen massive improvements in things like ultrasound over the past 30 years or so and this has had a big impact in our ability to detect abnormalities. - I think the recent push for more mental health services is also very exciting and necessary development. We know from things like the ACE’s study and I know from having read ‘the body keeps the score’ that the nature of emotional scars is far more insidious and enduring that physical ones. As such, without treatment, mental health problems can manifest themselves physically and they can damage many parts of someones psyche. Further to this, we have seen rises in suicide rates and eating disorders with the pandemic and increase in social media respectively. The fact that the importance of promoting mental health has grown is something I’m thankful for and excited by.

Question 36

what do you think has been the most important development in medicine?

Answer 36

- depends who you talk to. - On a local level in terms of patient convenience, the advent of centralised hospitals was huge. - My friend who studies surgery would probably say the development of anaesthesia as it allowed his specialty to flourish given that beforehand patients would often opt for near certain death over the pain of surgery. - on a population level germ theory was huge. without it we probably wouldn't have vaccines, which are hugely important in the current climate. - medical imaging is another important advancement. it allows us to detect pre-natal conditions, tumours, brain damage. It also facilitates. the teaching of anatomy at some medical schools! - All of these developments, with the exception of centralised hospitals came as a result of the scientific method. I would say that has been the most important development in medicine, possibly in the world as it also lead to the enlightenment.

Question 37

How important is evidence based practice in medicine?

Answer 37

- very. medicine is an applied science. - researchers studying certain diseases or conditions will look at many more patients that a doctor may ever treat, never mind treat for that condition. - As a result, consulting the research in an unbiased manner will allow for understanding of recent developments and making the most informed and best decision on treatment is important. - it allows for progression of treatment while avoiding outdated knowledge being prevalent in practice. It used to be believed that resting in bed was beneficial to most conditions, however, research has allowed us to conclude that in patients recovering from heart attacks, they should perform light exercise as soon as they are able as it provides physical and mental health benefits. - I recently discovered that there’s evidence that the amount of cholesterol in ones diet doesn’t have much of an effect on the amount of cholesterol in their blood and that LDL density is far more important. - Another consideration is that doctors may know the best treatment overall for a condition, but the best treatment may vary when you consider the individual needs of a patient, and reviewing evidence can help a doctor determine what this may be.

Question 38

how have you demonstrated your commitment to medicine?

Answer 38

- Volunteered with NHS responders app. - volunteered at a food bank in canada. - Virtually shadowed GP's through the observe GP platform - Virtually shadowed clinical paediatrician, endovascular surgeon, emergency surgeon, emergency doctor, psychiatrist. All through UT southwestern. - Had coffee with a surgeon, spoken to 3 junior doctors who are friends. - academically i have invested many hours into studying for the GAMSAT and UCAT, and since these exams i have continued to read philosophy and revise Biology and chemistry.

Question 39

how would you define empathy to someone who doesn't know what it is?

Answer 39

- it's putting yourself in someone else's shoes. - it's understanding the situation someone may be in, the emotions that may be triggered. - Empathy can be triggered in numerous ways. Works of art can allow people to understand the emotions of the artist, or to understand their own emotions better. - Tolstoy once said a purpose of art is to express emotions that can't be expressed otherwise. - Empathy is similar, it's understanding, relating to, and even feeling the emotions that someone else is feeling, often without them needing to describe them. Although, communicating will allow someone to empathise with you more deeply.

Question 40

Why is it important for medical professionals to be empathetic towards their patients?

Answer 40

- It will allow for better care through greater understanding. By empathising, you are able to understand the reason a patient is saying what they are. - perhaps they have turned down a treatment, and by empathising you're able to understand this is not because they are against the treatment, but because they are afraid. From here you may be able to comfort them and help them decide to go ahead with the treatment. - If not able to understand this simply through empathy, empathetic communication will allow the patient to explain this. Not only will this allow for better care, but it will improve trust therefore improving care over the longer term, and it will also save time by getting to the bottom of a situation sooner. - can reveal new perspectives to a doctor. - It will also help with emotional resilience of the medical professionals. Sometimes patients may be upset or angry, and they may misplace their emotions onto their nurse, physician or other healthcare provider. Empathising with them will allow one to understand that this is likely the case and to avoid taking any emotionally charged comments too personally. - empathising and emotionally investing a little in patients is also important for preventing clinical burnout. I learned from psychiatry that a common issue is when a patient isn't progressing, and their psychiatrist then struggles to remain emotionally invested. This would be a hard situation to deal with, but one that's no doubt important to face head on. - Although evidence based practice will allow a doctor to determine the best treatment from research, in order to choose the right treatment for the individual patient, empathy must also weigh in. - In specialties like psychiatry, patients afflictions may stem from a lack of empathy from parents, in this situation, it's important that the physician provide consistent empathetic care to help the patient to start rewriting things. - what's patient expecting as clinical outcome? beneficence...

Question 41

Is the practice of being an empathetic healthcare professional something that you can learn in a lecture?

Answer 41

- Yes, although i wouldn't say this is the best way to learn it. - the theory of empathy, and some general guidelines can be provided in lectures. - empathy is situational though, it's not a concept that can be memorised and regurgitated, it's a skill that one develops. - spending time in practice will allow one to develop this skill. - it can also be developed in the wider world, i found my empathy grew considerably while working as a ski instructor. - it has even been suggested that reading fiction allows one to improve their empathy.

Question 42

Which is more important in medicine, being empathetic or sympathetic?

Answer 42

- They're both important. - Empathy probably more so for medicine though. My understanding of the difference between the two is that empathy involves actually feeling what another person is, or at least trying to by communicating with them, as such, this requires emotional investment. Sympathy, is a more cognitive process, it's about understanding someone else's feelings, but it can take place from a more distanced position. - i saw a ted talk a while back in which the speaker claimed that empathy fuels connection, while sympathy drives separation. - Sympathy often involves an 'at least' sort of response to someones problem. such as 'my mother is sick', 'at least you still have a father too'. It's attempting to create a silver lining. This is the way in which it can create separation, it can often involve fairly disingenuous sentiments that show little support for, or worse, belittle someones emotional problems. Although well intentioned, sympathetic responses run the risk of appearing flippant or glib. - Empathy on the other hand, drives connection by actually engaging with and attempting to understand another persons feelings. It may lead to responses like 'that's incredibly tough and i just want you to know i'm here for you'. It's not always about giving a quick fix, but is much more about connecting, relating, understanding. - This is incredibly important in medicine. In evidence based practice, it's important that one is considering not only which treatment is best overall, but also which treatment is best for their patient in order to maximise beneficence. - It's also important to foster trust. A patient that is genuinely considered and cared for will more likely develop trust and openness towards their physician. - In specialties like psychiatry, empathy is imperative. In lots of cases patients may have developed their issues due to a lack of empathy and it will be extra important for their physician to provide stable and understanding care. - Empathy will help in situations such as if someone is becoming irritated about their wait in A&E. By understanding why the wait is stressing them out and making it known that they are understood, they are more likely to listen in return. Barking pre programmed responses at them from an emotional distance is likely if anything to escalate the situation. - this being said, sometimes you don't need quite as involved of a process as empathy. in the case of slight apprehension about an injection, sympathising would suffice if you were to say 'this may sting a little but ill do it as quickly and painlessly as i can for you'

Question 43

How would you explain to a patient that they will need to have another blood sample taken if theirs was lost?

Answer 43

- Empathise with them. They may be concerned about the implications of this, they may be frustrated about the fact that they have to go through the procedure again, they may have a fear of needles and have struggled the first time. The results they are waiting for might be important and having to wait may impose particular stress on the patient. - apologise sincerely for the error and explain as fully as possible what has happened - Although not an intentional breach of confidentiality, the patient may perceive it as such, or at least it may represent a breach of trust to them. Due to this it's important that they understand the nature of the mistake. - I’m very sorry Mrs Lindham, we don’t know the whereabouts of the blood sample that was taken from you yesterday. In order to get your results back to you quickly we need to take another one. I completely understand if this frustrates you and I’m deeply sorry for what has happened, but we want to do the best we can for you moving forward. Please let me know if you have any concerns.

Question 44

Why should members of a healthcare team show empathy towards one another as well as towards their patients?

Answer 44

- Support. I learned from my time virtually shadowing a range of doctors from UT southwestern hospital that in order to maintain the emotional resilience of the team, it's important to support one another. Especially given that because of confidentiality, your team members are sometimes the only people who can fully empathise with what has happened. - It helps prevent burnout too. Putting up barriers to protect oneself will eventually lead to physician burnout. By giving and receiving empathy, the team can remain stronger and will have the 'energy' to invest a little emotion into their patients. - this will allow each member of the team to provide better care. - multidisciplinary teams are obviously huge in healthcare settings, and empathising with team members allows for better teamwork. No team functions well if a group of individuals are espousing views at one another without considering the perspective of the other members. In order for a team to function well, it's essential that people are heard and understood. Then if someone disagrees, or believes there is a better approach, they are building on what has been said, not shouting over it. - other members of the team may be emotionally struggling due to issues inside or outside of work.Being empathetic will allow you to be more supportive.

Question 45

As a doctor, how would you deal with a parent who has. brought their child into A&E and is angry about having to wait for them to be seen?

Answer 45

- First and foremost communicate and empathise with the parent. - why are they angry? is their anger a result of stress because of something like needing to pick up a different child? how can the situation be improved? - once their frustration is better understood, it would be important to give them realistic expectations. Apologise sincerely, explain the reason for the wait. Try to help them understand how much longer they will likely have to wait for. - They may have a dead phone and need to make a call, in these sort of situations it may be possible to provide a phone for them to use.

Question 46

What would you say to a female patient who is scared to get the HPV vaccine (protects against cervical cancer)?

Answer 46

- in order to understand her situation better it would be essential to empathise. Using the ICE approach will help with this. - what are her ideas about the vaccine? - what are her concerns about it? - what are her expectations regarding the vaccine? - By understanding these things, it will be possible to engage in a more productive conversation. Her reluctancy can be addressed more directly. - I would explain the pros and cons of the vaccine and why it is believed to be important. - In terms of beneficence it would be important to share as much information with the patient as possible so that she can make the most informed decision. - ultimately, autonomy must be respected, but hopefully despite initial fear, she would make an informed decision after the conversation.

Question 47

as a recently qualified junior doctor, you are given the chance to perform your first unsupervised colonoscopy. During the procedure the colonoscope perforate the colon. This results in the patient becoming acutely unwell and dying 2 days later. The patients family have come to see you. How would you approach this situation?

Answer 47

- I would ensure i speak to them in a private space. I would also make sure this was at a time where i had the time to speak to them without distractions or having to cut things short. - Be sure the room has things like tissues available and possibly also water. - Honesty would be important. I would apologise sincerely for what had happened. - after this i would listen to what the family had to say. - it would be natural for there to be anger directed at me at this stage. - Showing empathy to the family is incredibly important. - it may be possible to reassure them that procedures are being put into place to prevent this happening again in the future, and that i am personally undergoing a period of supervised practice. - It would be important to share information with the family pertaining to counselling services and other similar outlets. - They should also be provided the option to speak with a senior doctor. - present information in small chunks so that the family have time to digest.

Question 48

what thoughts and feelings will go through the head of a patient after having been told that their alcoholism has led to irreversible liver damage?

Answer 48

- disbelief - feelings of guilt - feelings of anger maybe towards themself, maybe towards individuals they consider to be the root cause of their substance abuse - Fear. - Any or all of these emotions and thoughts could be present, so it would be important to communicate and empathise with the patient in order to understand their particular situation. - from here we can move forward. They may be in a state of shock and require information repeating. They will definitely require information to be presented to them in sizeable chunks (this is good clinical practice) - what does this mean going forwards? - am i entitled to a transplant? - will i get one in time? - is this a death sentence?

Question 49

tell us about a time you've displayed empathy?

Answer 49

- i have 3 friends who live together. It's a couple and a single. We all went to uni together and have been friends since first year. - There has been a conflict in the house which both parties (the couple and single) spoke to me about separately. - I empathised with each in order to understand the situation and try to help the group resolve their conflict. - In a nutshell, the couple were interested in having a 'mature' household. they wanted a cleaning and cooking rota. The single works much longer hours than them and commutes into london and feels that the rigidity of these rota's add unnecessary stress to his life. - I learned too that the single believes the couple are just 'tidier people', whereas the couple are of the opinion that it's a choice to become more mature, not an inherent love of cleaning, although the do love cooking. - It was also clear from the opposite end, that the couple were unaware of the stress the single was experiencing from work. - it was unfortunate that it took them coming to me as a mediator to improve a situation that could have been improved by communicating amongst themselves. - In the end, a conclusion was reached in which the couple would cook each evening and simply add more ingredients for the single as they both get home a lot earlier and enjoy cooking. in return he would do the washing up once back. and in terms of keeping their apartment tidy, the single agreed to clean the bathroom once a week, and beyond that any mess made in communal areas should be tended to as it's made. - Ski instructing. Different members of the group have different strengths and weaknesses. Important to empathise to understand what is it people want to achieve. What their energy levels are Any fears they have What type of learner they are After this can structure more efficiently Give explanation of drill and feeling were looking for for the feel based learners, then a visual demo for visual learners. Then sit with analytic members of chair lift so they can ask more detailed questions.

Question 50

What do you think you would find hardest about being a doctor?

Answer 50

I think there are a few things. Although I would hope that as I progress, what I find hard would fluctuate as I develop new skills and realise new weaknesses. During my shadowing I found over-empathising to be a problem, however, having read literature on assertiveness versus being passive or aggressive, and thinking about shifting perspectives such as viewing things in a more utilitarian way in order to remain compassionate without damaging self care, I would now say this is becoming a strength. This being said, I think I would struggle with the death of my first patient. I was fortunate to get a good perspective on this from a paediatrician I shadowed, and assuming I’m fortunate enough to have the opportunity to become a doctor, this will definitely help, however, I still think this will provide a real challenge to overcome. The thing I’m currently working on, that I would struggle the most with if I were graduating right now, is scheduling. I’ve always worked from a mental schedule, and although this has worked well in the past, I learned from my shadowing that there are too many tasks that doctors need to be prioritising to be wasting mental effort remembering a schedule. So I’m working on using an app to schedule. Although this might sound pretty simple, I’m working on prioritisation and scheduling in a way that means I don’t lose my flexibility.

Question 51

How do you cope with failure?

Answer 51

- It depends on the nature of the failure, but i tend to try and breakdown what happened and determine how i can learn from the situation. - I've learned that a good question to ask myself is whether my intentions were good. This allows me to zoom out from the failure and little and get some perspective. If they weren't then there's a serious problem. - I'm fortunate to be a tennis player and skier. These are 2 sports that teach you a lot about mistakes. In tennis, you're going to miss a lot of shots, the important thing is to learn from those mistakes and also to keep playing. If you get into the mindset of playing not to lose instead of playing to win, you've already lost half the battle. - Skiing has taught me about grit and determination. A fail in this sports is quite often painful, and to continue pushing on requires a strength of character than i'm glad to have developed. - Beyond this, in terms of actually dealing with a failure, I like to go on walks in the forest to clear my head, i spend time with friends to experience joy and connection and i play sports as a way to get into a state of flow and destress.

Question 52

If your peers were to describe you in 3 words, what would they be?

Answer 52

-smart, understanding, driven. I’m someone who is naturally authentic. I work well in teams, have been involved in football to a fairly high level and I enjoy being part of social groups. however, I don’t tend to conform due to social pressures. I will conform to things that I agree with, and I have good enough social skills that I don’t ruffle feathers often. But, owing to my adolescence, I had to develop a keenness for morality, and I am genuine in the fact that I won’t agree with things I don’t believe in. Aside from doing well at school and getting in to Mensa when I was younger, being smart isn’t something I think about at all, I just read things I enjoy and I work hard in classes. I have had a number of friends at university tell me how smart they think I am, and I’ve had 2 friends repeatedly tell me they think I’m a genius haha. These were obviously nice things to hear, and although they haven’t really affected my ego or how I go about my life, it is nice to know that I give this impression to my friends without really aiming to do so. I’m the friend who tend to fill the role of a sort of agony aunt for my other friends. I’m a compassionate person and I believe I’m quite open minded and this is why I’ve always believed people tend to come to me for advice or comfort. Maybe I’m really just the only option available hahaa. Owing to this I also often fall into the role of a leader. I think this is because my friends and peers trust me based on my genuineness, and because of my caring nature they also know that I will have the best interests of the group in mind.

Question 53

how do you deal with stress?

Answer 53

- from work experience, speaking with medical students and doctors and reading, i know stress is one of the harder parts of a career in medicine. - I have a few different ways that i deal with stress. First of all, i try not to let it build up. If i have projects to do, i begin working on them as soon as they are set, this really helps prevent me becoming bogged down. - In a broader perspective, i started a morning routine a while back. This consists of 5 minutes of breathing exercises followed by 10 minutes of stretching and posture exercises, finishing in me making my bed. I found setting an alarm for 30 minutes earlier and going through this routine before breakfast allows me to start the day in a calm manner, and returning home to a clean bedroom allows me to have a comforting personal space. - From having worked in some stressful jobs and having been in stressful situations when skiing, i know that for me, one of the best things i can do is to try and remain present and to get into a state of flow. This makes me perform said task more efficiently by focussing on it more, as well as reducing stress created by background thoughts. - In dealing with longer term stress, i like to maintain a fairly balanced life. I make time to phone different friends each week, this allows me to maintain relationships and relax by connecting with those i care about. - i'm also actively involved in sports and enjoy going to the gym, these physical activities allow me to blow off steam. - In some localised stressful situations, i think it's important to ask others for help. Sometimes they help with the task, but sometimes people offer advice about ways to manage situations or stress in the future. This is doubly helpful as it allows me to grow. - Also shifting perspectives can be useful. Viewing the bigger picture and looking for ways that a stressful situation could actually lead to personal growth can make it more enjoyable to engage with.

Question 54

Do you know when to seek help?

Answer 54

- I believe i do, although this is obviously a very situational question. If i am to make a mistake in this area it's usually that i wait slightly too long. Not because of stubbornness or arrogance, but because of getting into a state of flow/ a bit of tunnel vision, although fortunately this is rare. - In my opinion, the tougher part of seeking help is not wanting to burden others with your workload, and as such, i prefer to proactively seek advice in a way that minimises my likelihood of needing help. an example of this comes from my time ski instructing. I noticed early on that lots of clients struggled with the same problem of getting their weight stuck on the inside of their turns. Although i knew drills to fix this, i asked more senior instructors for insights into what drills they use in preparation for having a client with which none of my drills resonated. - obviously there will be times when help is required regardless of knowledge. for example if workload is too large. - In a hospital setting, asking for help is obviously important in instances where i may be unsure about a procedure or the guidelines for a certain situation. It may be necessary to ask nurses for help with a patient, or to ask senior staff members for help with new procedures. - I like to believe I do. This is a situation where it’s important to leave your ego at the door. I think there’s nothing wrong with speaking to friends or colleagues for alternate perspectives early on in projects or situations as this is often a fairly casual chat that doesn’t impact someone else schedule too much and can also allow one to grow. This is also much more productive than trying to work a situation alone for a long time and then pleading for others to help when I will involve them being burdened with the issue. In some situations I think it’s actually beneficial to proactively seek help for hypothetical scenarios so that you’re prepared to deal with them if and when they arise. An example of this would be when I was ski instructing. I had a few different drills for different technical areas in mind after first qualifying. however, early on in the job I began to realise that a lot of people experienced the same issue with having a dominant leg. Although the drills I had were working thus far, I realised there would likely be a time where I had clients who didn’t connect with these drills. As such I spoke to more senior instructors at lunch and after work to ask what drills they like to use to address this issue and what they do if someone can’t get past it. - Emotionally speaking I also think it’s important to seek help early on. It’s better to be honest with a friend that you’ve been having a tough time and possibly have them take you out or watch a film with you than it is to bottle things up and then reveal them at the stage where you need outside help.

Question 55

Why do you deserve a place at this medical school over other candidates?

Answer 55

- i don't know that i would say i 'deserve' a place more than anyone else, i'd like to assume all candidates have their own merits. - i believe i'm a strong candidate because of my drive and intellect. I believe i'm academically and emotionally intelligent and these are both qualities that a doctor needs. Beyond this though, i'm curious and driven to continually grow in these areas. As stated in my personal statement, I read a broad range of topics in order to grow and improve my understanding of the world. I believe this will help me be a better doctor too. I have already reaped the rewards of having read a lot of philosophy when starting to read medical ethics, and my knowledge of psychology has deepened my ability to empathise. - I'm also fairly well aware of my strengths and weaknesses and track them over time. I have actively worked jobs that force me to work on weaknesses over the past couple of years in order to continually strive to be the best version of myself possible. - I put a lot of value on morality in my life. I obviously follow rules, but i also consider things deeply. In my opinion there is a strong distinction between obedience and 'goodness'. The former tends to involve blindly following the rules, whereas the latter involves weighing up situations and determining what you believe to be the best course of action. I'm fortunate that this is how i inherently think, because it's something that is vitally important for Doctors given that lots of cases involve weighing up ethical considerations and don't have clear cut rules. - I'm also a team player. I've shown this over time. As i stated in my personal statement, i was chosen as a prefect in primary and secondary school which shows i'm responsible, i was chosen to be social secretary for my university tennis team which shows that i'm likeable amongst my peers, and my friends would likely describe me as both empathetic and a leader. - My time ski instructing has allowed me to hone my ability to take theoretical knowledge and apply and explain it in simple ways. - I'm confident in my ability to self study. I did this in my undergraduate degree while dealing with suppressed adolescent trauma, and i've done this while studying for the GAMSAT in a new town with no social connections. If i can work effectively in this less than ideal circumstances, then i can definitely thrive in an environment of my peers. - I know from skiing that i can think rationally in stressful situations.

Question 56

Give an example of a time when you were unsatisfied with your performance.

Answer 56

- county cup tennis finals. - I played well all the way through the tournament, when i got to the final i had to play Ed Beak. We had the same home club and were pretty good friends and i knew from training that it could go either way depending on the day. - I just couldn't get a rhythm. I must have lost 15 points from double faults during the 2 sets, and my backhand was consistently landing short. - I tried all sorts of tactical changes as the match progressed, i was hitting top spin first and second serves to improve percentages, i tried serve volleying because of my backhand issues, i tried messing with his rhythm through changing the ball spin by slicing my backhand and attacking my forehand. - Ultimately I just didn't perform to the best of my abilities technically speaking. - I ended up losing the match 6-2, 6-2. After the build up to the match, and the fact that there was a fairly big crowd in the stands, and i had numerous family members that had come to watch i was pretty disappointed. - the solace i had was that i'd thought rationally throughout the match and had done everything i could to try and turn the tides. - Following this, i doubled down on drills. I worked on drills for my backhand where i started under pressure and had to turn the point around. I also spend hours each week working on serve accuracy and i also developed drills that allowed me to simulate the pressure of big matches too. - The next year as a 14 year old i was able to win the title, and i did so for the next 2 years afterwards. - When I was younger I played in the county cup tennis finals. I played well through each round of the tournament and was confident about the final. This was something I’d worked hard for for about 10 years. My parents came to watch, my grandparents and my dad even brought some co-workers with him. When the match actually began I just couldn’t get a rhythm. I was struggling with consistency of my shots, I was making a lot of unforced errors on my serve. I tried varying my tactics, I tried varying my strokes to try and upset my opponents rhythm or at least get some consistency going for myself. Unfortunately I couldn’t seem to manage and I ended up losing the match 6-2,6-2. I was pretty gutted on the way home as you’d expect. I spent a lot of that evening trying to understand what I did wrong. In this particular example I learned that I simply had a bad day. I actually ended up over analysing and trying to change things that didn’t need fixing over the next few weeks. This was obviously a good lesson and it’s something I still carry with me. It’s no doubt important to take a look at situations where you’ve made mistakes, but it’s also important to take a step back and assess the bigger picture. In this example, my serve and groundstrokes had been fine over the past few months and were poor on the day. It wasn’t indicative of a technical problem. I also kept a cool head and tried changing tactics so it wasn’t so much a mental problem. It was a poor performance from which I learned the importance of not being too hard on myself.

Question 57

What would you change about yourself?

Answer 57

- i want to improve at my scheduling abilities. - I am a very routine person in terms of my life. I have a morning and evening routine, I actively work on different things if and when i need to and i make time for fitness and socialising each week. - I don't have issues completing tasks, i get things done on time and i am good at juggling things, however i tend to operate on a mentally imagined schedule. - Although this has worked for me so far in life, i believe i step that would be helpful is for me to start scheduling my time more efficiently. The issues that come with my approach are that i don't have designated relaxing time, and it requires more energy and creates more stress having to remember all the things i've done/ still need to do. - I think in order to mitigate some stress, it would be beneficial for me to actually make a schedule or to do list in order to have a physical means of keeping track of things rather than adding the mental effort.

Question 58

Give an example of a time you worked in a team and it was a success?

Answer 58

when working at starbucks in canada. There was good communication and empathy between all the staff members. We would work hard to ensure fair rotation of tasks so that no one felt undervalued. We also engaged with one another outside of work and were supportive of peoples personal problems when they spoke of them. As a result we had very low employee turnover, even in a transient job in a transient mountain town. We even forged a strong relationship with other local shops. This is something that is obviously very important in medicine. I saw from a video I watched while virtually shadowing an endovascular surgeon, just how large and dynamic a surgical team is, and without strong communication there’s going to a be a lot of stepping on each others toes. I also saw the importance of viewing patients as part of a team during a GP consultation. This was furthered when I spoke with a psychiatrist who explained that no emotionally engaging with patients is a common cause of burnout. As well, given the stress of medical jobs, having a strong team at work is vital for promoting resilience and providing better care.

Question 59

Give an example of a time you worked in a team and it failed?

Answer 59

STARR - link empathy questions back and avoid waffling… situation - d of e. Task - reconcile different perspectives of two team members - one wanted to make it about performance, the other wanted to enjoy a group activity. The performance member would storm ahead and make the other feel excluded. Action - As a group we spoke the first evening, we attempted to come to a compromise by having each member share their opinion. Result - unfortunately the driven member was also fairly brazen and inflexible, this ultimately led to the other member dropping out of the group. Reflection - this wasn’t the result anyone wanted and it showed the importance of empathy and communication. If the brazen individual had communicated better and empathised, he would have been able to understand the other perspective and therefore be a better teammate. This is something that’s hugely important in medicine. Not only within healthcare teams who need to empathise with one another in order to support resilience in a stressful job, but also to work successfully in multidisciplinary teams. It’s also important in patient interactions. Without empathising with patients, we aren’t able to provide the best care as we wuldn’t know if treatment is in line with their expectations, or worse, we may have missed a perspective that empathising with them would allow us to discover.

Question 60

What are the attributes of a good team leader?

Answer 60

- Communication. It's important that a team understand their workload, who is doing what, the timeframe they have, any external pressures. - communication is also a two way street, all the members of a team need to have their opinions be heard. This is something i've personally strived to do in the past. When i worked at a starbucks in canada and at a housekeeping company, i made sure members of the teams i was in saw reasonable rotation between tasks. I also worked hard to ensure there was good rapport between team members. - resilience, leaders often encounter high volumes of stress, whether from organisational or emotional avenues. The president of my university tennis club was great in this regard. He ran a tight ship, but always had a positive energy around training or social events. His demeanour allowed the club to feel more cohesive. - empathy - this goes along with communication. Without empathising with members of your team, you can't fully appreciate what they can bring to the team, what they may be suited for. You also won't get the benefit of different perspectives. This is something i experienced when ski instructing. Group lessons would often involve different types of learners, but empathising and communicating with clients, i was able to determine the best way to teach. - I also think it's important for leaders to take responsibility. If a team fails, they shouldn't chastise individuals, but should look at how their management could have been different.

Question 61

What are the attributes of a good team member?

Answer 61

- Being empathetic and supportive towards other team members. - Being able to accept feedback. It's alright to constructively disagree, but it's important to engage with feedback that's given. - A good team member will understand the bigger picture. They will perform their tasks well, but they should understand what else is required of the team and offer support when and where they can. - The ability to compromise. Group leaders will invariably go in a different direction to what you consider the correct choice at one time or another, a good team member will stand up for what they believe in, but should be willing to compromise, or, back down in trivial circumstances. knowing when one should push for compromise or back down is again linked to empathy. - Dedication, it's important that each member of a team pull their weight. - Positivity. i took this role during my time playing tennis at university. although not a captain each year, i drove the team to away matches and worked to maintain and develop team morale during outings in order to support the captain. i also accepted a change to my playing position from 1 to 2 in order to improve our team success.

Question 62

Are you a leader of a follower?

Answer 62

- Depending on the situation i can be either. - i often fall into a leadership role in groups of friends i have because i'm naturally quite empathetic. This means i often fill the role of confidante. Beyond this i'm productive and place a lot of value on morality which means i'm well suited to naturally leading a group. -I was a good leader for my university tennis team when I worked as social secretary. I noticed a divide within the teams and worked hard to improve cohesiveness. - i've been a follower in situations where i don't have expert knowledge though. i think it's important to have the balance in medicine. especially in multidisciplinary teams where it's important to take lead and to sit back depending on which morbidity is being treated at the time. - In situations where I’m a follower though, I still care about ethical considerations. Although I may not have a huge amount of input from the technical side, I will assert myself if I feel that we are making poor choices as a team.

Question 63

Is teamwork important in medicine?

Answer 63

- Yes. - It greatly improves the quality of care. - Evidence based practice is essentially a massive team working effort, and this is largely recognised as the best way to practice medicine. By improving our collective intelligence, we are able to improve our patient care. - Given the sheer amount of people that visit hospitals, without receptionists, nurses, doctors, cleaners it would be pandemonium. - For patients with multiple morbidities, multidisciplinary teams are essential. If the doctors from each specialty weren't able to work as part of a team the patient would receive subpar care. treatments would clash with one another amongst other issues. - Teamwork is important in shadowing and training. Without these things the profession would struggle to continue. It also allows prospective medical students the opportunity to experience medical work and make an informed decision about whether they want to pursue this career. - You could consider empathising with patients to be a form of teamwork, and this is widely acknowledged as a pillar of good practice. By understanding their thoughts and desires, it's possible to work with them to provide the best possible care. - A review by the royal college of surgeons found that in cases where there are problems in surgery, poor teamwork is one of the major factors.

Question 64

How do you resolve conflict within a group?

Answer 64

- This will vary from situation to situation, the nature of the disconnect will largely determine the best route to take. - some general steps would be quell any active arguing and allow people to take 30 seconds to breathe deeply. - After this, empathise with each member, and ensure they are allowed their time to speak, it's only through allowing them to fully communicate that their perspective can be properly understood. - it's quite possible that the conflict was due to a misunderstanding and that it will be resolved simply by having given each member the time to explain their perspective. - if this isn't the case, in the event of black and white options it would be necessary to allow each member of the group to present their choice and reasoning so that a collective decision could be made (the reasoning means that those on the losing side will at least understand why people went the other way). - if the conflict falls in a grey area then a good option would be to work towards a compromise that the group are happy with.

Question 65

What would you do if you were working on a group project and noticed that one member of the group wasn't contributing?

Answer 65

- I would begin by speaking to the group member privately about the matter. They might have a personal reason for their low work rate. - Depending on the outcome of the discussion, i would either encourage a discussion among the group in order to amend our personal workloads, or i would encourage the individual to speak to the module convenor. It may also be necessary to suggest that they speak to the counselling service. - If the individual has no reason for their low workload then it might be necessary to say that unless they are willing to contribute more and catch up with the schedule i would have to take the matter to the module convenor. - Speak with the group about what people have done so far, and what they are still to do. See what the best way of dealing with the increased work load would be. Or speak to the module convenor and see if a reduction in workload could be accounted for.

Question 66

Why is it important for a team leader to be able to allocate?

Answer 66

- Team leaders should be aware of the bigger picture of a project as well as smaller interval timelines, this is essentially good management. - in order to complete the project on time, it will be important to meet the shorter checkpoints. - A good leader will empathise and communicate with their team. This will allow them to understand the strengths and weaknesses of each member, and it will allow them to communicate what they need to be done by specific times. - Once strengths and weaknesses are understood, the team leader should delegate or allocate tasks to members of the team. - This will share out the workload and also allow people to work to their strengths which should improve the quality of the work. - It's also important because a mistake some leaders make is not trusting their team mates. A leader who believes they will perform each task to the highest quality and therefore takes on too much work not only risks damaging their relationship with each group member, but also risks the quality of the project and their personal health by taking on too much. - Finally, having more time will allow the leader to check the work of each team member to ensure that it is what it should be.

Question 67

You are the team leader for a fundraising project. While totalling up donations you notice that £20 is missing. You suspect that one of your team members has been keeping some money for themselves. What do you do?

Answer 67

- It would depend how 'certain' i was. If i was certain, then i would speak to the individual privately. I would first try to empathise with them to understand whether the money may have been lost. I would then communicate the moral implications and negative consequences that taking fundraising money has. and give the individual the chance to return it, or explain that i would have to report them/ fire them. - if i only had a hunch then i would call a group meeting and explain the situation. I would ask if anyone knows what could have happened, and would also offer the option to talk to me after the meeting in private. - I would also speak to the charity directly to explain what had happened and that we are working hard to rectify the situation so that they don't lose out.

Question 68

What medical experience have you carried out?

Answer 68

- Shadowed GP's through observe GP. fortunate to see GP deal with emotional consultation - this highlighted to me the importance of empathy from the perspective of noticing subtle changes in your patients in primary care. Because the GP has seen this patient before and empathised with her, she was able to notice the patients emotions and body language didn't align with her responses to questions. This led to the GP questioning further and being more supportive, as a result, the lady opened up more and was able to receive better care and support. - Virtually shadowed via UT southwesterns webinars. Was able to shadow an endovascular surgeon, a clinical paediatrician, an emergency paediatrician, a psychiatrist, a neurologist, a radiologist who specialised in ultrasound. - I learned the importance of empathising to prevent physician burnout. This is apparently a particular problem in psychiatry where the slow progress of patients can lead to struggles remaining emotionally invested in them. I also found our advancements in aneurism treatment fascinating! I also learned some practical heuristics like the XABC's for assessing emergency patients. - I have learned some practical skills through the geeky medics youtube channel. - I volunteered with the NHS responders app as a caller. - I worked at a food bank. - I learned that many symptoms don't have a simple diagnosis and that ones ability to differentially diagnose is very important, but i was also reassured that this is a skill that develops with time.

Question 69

What did you learn from your work experience?

Answer 69

- From a video i was shown by an endovascular surgeon, i saw just how large surgical teams can be, there were around 10 people performing different tasks in the operating room and i was really impressed with their fluid teamwork. - I learned from shadowing a psychiatrist, that a good doctor needs to view themselves as their first patient. Because of things like dissonance caused by burnout when you lose emotional involvement in hard patients, it's important to have a good grounding and understanding of oneself to deal with these things. Fortunately this is something i've long considered and i believe i have a good understanding of myself (much to my friends dismay over the past few years as i have be deconstructing and interpreting everything). - In shadowing an emergency doctor i learned a useful heuristic in the XABC model for quickly assessing a patient. - GP shadowing allowed me to glean the importance of empathising in regards to noticing subtle changes in your patients over time. A GP i observed used this skill to pick up on non-verbal cues with a patient. This allowed her to ask pertinent questions and ultimately provide better care. - learned my own weaknesses. - learned how much note taking and paperwork doctors have. - learned about scheduling difficulties.

Question 70

From your work experience can you tell me about a difficult situation you observed/ had to deal with and what you learned from this?

Answer 70

- I would like to tell you about 2 from opposite ends of the spectrum if i may. - I observed a GP in an emotional consultation with a patient whose husband had recently died. She was clearly very upset but appeared to be trying to 'put on a brave face'. From this i learned the importance of empathising with patients from the perspective of it allowing you to notice subtle changes in them or pick up on non-verbal cues. In this way, the GP was able to notice that although the patient purported that she was 'fine' she really wasn't. By empathising and then communicating well, the GP was able to establish the problems the patient was having and help her begin to address them. She also provided literature for support services. - on the other end of the spectrum, I learned about the XABC heuristic approach to emergency medicine. Emergency medicine is a specialty that i've always looked at as slightly to intense, and i still have the impression that it is very much so, but i learned that this approach allows you to quickly and calmly assess each situation. - i saw images of a man who had been stabbed in the side of the head. The physician had run through this heuristic and had found that his airways, breathing and circulation were fine, and that although there was external blood, he wasn't externally bleeding a profuse amount anymore. He also assessed the patients speech and comprehension. From here it was possible to send the patient to a neurologist.

Question 71

What qualities did you learn are important from the doctors and nurses during your work experience?

Answer 71

Empathy. Not only for improving patient care and making patients feel more valued, but also because it helps prevent burnout in doctors. Teamwork, because of the prevalence of multidisciplinary teams and healthcare teams in general. resilience. This was a big one that I heard about from a number of doctors. I’d already considered this from the emotional side given the nature of the work, however, having seen the amount of prioritisation required of doctors, I can see it’s also important from the workload perspective. Communication skills. I saw this in a GP consultation. There GP regulated the cadence and tone of her voice to help the patient feel at ease, as well as picking up on non-verbal cues from the patient. I also observed an asthma review led by a senior nurse. The patient here didn’t understand how to use their inhalers properly due to poor communication when they were prescribed. As a result their condition had worsened, and resources were wasted. finally, the ability to handle stress and remain calm under pressure. Fortunately this is something I’ve developed through my years playing tennis and my time ski instructing. I have a number of methods that help me stay present with the task at hand rather than letting stress lessen my performance, as well as a number of methods of reducing stress outside of work.

Question 72

What aspect of your work experience was most challenging and why?

Answer 72

- One of the hardest parts was actually getting experience haha. While in Canada i emailed and subsequently visited every hospital and GP practice in my town and the neighbouring one and eventually volunteered at a food bank. - My time at the foodbank, and shadowing afterwards allowed me to realise that although i have good abilities to empathise, i had a tendency to over-empathise. In cases such as when patrons of the food bank asked if they could have second helpings, i struggled to say no. Fortunately from reading philosophy and speaking with my manager, i was able to address this issue by taking a more utilitarian viewpoint. By considering the food bank as a whole i was able to explain why i couldn't give second rations, while still remaining compassionate. - In this regard, I found it difficult to observe an emotional GP consultation, however, I was able to see a lot of what I’ve learned from assertiveness literature being put into practice by the GP. I also got to see her personal methods for maintaining emotional resilience after the consultation finished. - One thing i found difficult to observe (although i found it really cool) was the building up of a aneurism blocking coil in vivo. I observed a sped up video of stages of this operation and the self-efficacy endovascular surgeons need to have astounds me. I like to think i'm good under pressure and have good hand-eye coordination, but the idea of performing such a fine procedure was challenging to consider.

Question 73

What did you like most about the work experience you undertook?

Answer 73

- I really enjoyed learning how broad and diverse medicine is. I knew it was a far reaching discipline, but by shadowing a variety of specialties i've learned how many options i will have after graduation. - I found shadowing an endovascular surgeon really cool, i really enjoyed learning about the methods and developments we have for treating aneurisms. - I like the emotional insights i gained. Although i understood the importance of empathising with patients in order to provide better care, I learned about its importance in preventing preventing physician burnout. - i also learned that viewing yourself as your first patient is important as one needs to have a good grounding and understanding of themselves in order to foster emotional resilience in tough situations. - I also enjoyed learning that emergency doctors have heuristics that allow them to work efficiently under stress. This is a specialty i've always thought may be too stressful, but learning about things like the XABC approach has opened my mind to the possibility of going in this direction.

Question 74

Why do you think we ask candidates to undertake work experience?

Answer 74

- for a lot of reasons! - as i undertook more experience, i became more engaged by medicine as a subject. I was able to relate concepts i'd come across in one area to other areas and start understanding no only specialties themselves, but also how the interact in a web like fashion. - It gave me a good grounding of the challenges i may face both in medical school and in practice, and it also allowed me to glean some insights into how i would go about dealing with those challenges (burnout) - it also helped cement the idea of the commitment this career requires. - It also helped me realise some weaknesses i have and begin working on them (over-empathising) - conversely, you may find areas that you are naturally adept at, and these will serve to foster confidence. - It was also humbling. I heard from a number of doctors about the ghosts that haunt them and the perspectives they have on how to deal with this. The best was Dr. Dutton a clinical paediatrician. She said it's important to keep in mind that most patients who are suffering a bad injury or illness would have naturally deteriorated without access to medicine so any care one can provide is already a positive thing, even if ultimately you are essentially providing palliative care. - I also heard the phrase "overwhelmed doesn't equal inadequate". This was reassuring to hear as i've heard from friends who are junior doctors that that period is quite overwhelming.

Question 75

Reflecting on your work experience, what event, if any, changed your views on modern medicine?

Answer 75

- From an academic standpoint, learning about the ways in which we can deal with aneurisms really opened my mind to the rapid advancement of certain specialties. - I was surprised by the number of uses we have for ultrasound too! Somewhat naively i had always associated it with pregnancy, but having shadowed a specialist, i learned about doppler ultrasound which is really cool - this is ultrasound that can detect the speed and direction of blood flow. - I also found it cool to observe an ultrasound of a patient with appendicitis. When looking at the ultrasound, as you may expect i couldn't interpret a whole lot, but with guidance from the physician, it was cool to see that the diagnosis was as simple as the fact that it didn't compress while all the organs around it did. - Further to this, I learned from the ultrasound consultant that a single cat scan provides approximately a lifetimes worth of radiation and so being able to use ultrasound as an alteranative diagnostic tool is good. - Also learning that emotionally engaging with patients will prevent burnout was fascinating. Although important, one would think that this could in some cases contribute to burnout, but since hearing it, it does make sense as investing a little in patients will keep the work engaging. - When shadowing an emergency consultant, I learned that the use of heuristic approaches to quickly assessing patients are important. The consultant relied on the XABC approach to determine if a patient was stable or required immediate intervention. This is something I really enjoyed learning as emergency medicine would be a particularly stressful specialty to go into, and it was nice to learn that there is a quick approach that most doctors use to initially assess.

Question 76

give an example of an interaction between a doctor and a nurse or patient that you observed during your work experience. What skills did you find to be important for this type of communication?

Answer 76

- When observing a GP i saw a particularly emotional consultation with a patient whose husband had recently died. - I was impressed by the cadence and tone of the GP's communication. She spoke in small and clear blocks giving the patient time to digest things. - Empathy was big. Although the patient purported that she was doing 'fine', the GP's ability to understand non-verbal cues allowed her to probe further. The patient then opened up about the struggles she was having. - I was then impressed by the depth of community knowledge the GP had. She provided information on financial services, emotional support groups. - On the topic of communication, i also saw an asthma review appointment run by a nurse. The patient she was with hadn't used their inhalers correctly because they hadn't understood how or why they should be used.

Question 77

During your work experience did you learn about or see anything that did not appeal to you about being a doctor?

Answer 77

- Fortunately i didn't see anything that i found overtly off putting about medicine, although i did have a few times that gave me food for though - which is one of the important aspects of undertaking experience. - I had thoughts about whether or not particular specialties would suit me. In endovascular surgery, although i found it really cool learning about and watching the placement of an aneurism blocking coil. The idea of building these devices up in vivo with such high consequences for mistakes was something i'm not sure i would be best suited for. I'm good at handling myself under pressure and believe i have good hand-eye coordination, but the longer term stress that would come from this is something that would weigh on me. - In psychiatry shadowing i became aware of the prevalence of patients who appear not to be progressing over the long run. I would like to believe i would enjoy the growth that comes from finding ways to remain emotionally invested in these patients, but it's still a less enjoyable challenge of medicine. - work schedule is the other major thing. I've worked shift jobs in canada, and the past year i've worked weekends while studying in the week. This is something i'm fine with, and i accept is part of medicine. I've found productive ways to remain active both physically and socially while being on a contrasting schedule to my peers, but ultimately having. a more 'normal' schedule would come with benefits.

Question 78

During your work experience what 3 skills did you learn and could you rank their importance?

Answer 78

- Empathy (incorporating communication), teamwork and emotional resilience were the 3 stand out skills for me. - I don't think i could definitively rank them because they're all important and depending, and the need for each is situational. If i felt one of these skills was a weak area for me personally, then i would consider it most important in terms of working on it. But medicine is largely about understanding grey areas and weighing things up, and to categorically say 'this is the most important skill' would set someone off on the wrong path in my opinion. - I guess you could say the most important skill is learning to regulate your skills, emotions and schedule to suit different times and needs. - however, emotional resilience, empathy and teamwork. I learned that emotional resilience is huge in medicine. Not only in situations like presenting bad news, but also in ways that I hadn’t thought about as much. For instance, when shadowing a psychiatrist, I learned that it’s common to have patients who aren’t progressing much, and to naturally invest less in them emotionally. This often leads to burnout. Finding creative ways to deal with these situations is important for remaining resilient in your work. Empathy is vital not only for improving care and doctor-patient relations, but it also again links to resilience. It’s important to empathise with patients in order to stay engaged with your work, and it’s also important to empathise with members of the team in order to foster a healthier work environment. communication. This links with empathy, but I saw first hand the effects of poor communication. When I observed an asthma review I saw that the patient hadn’t been using their inhalers because they didn’t understand when to use each of them. As a result resources had been wasted and the patient hadn’t effectively treated themselves.

Question 79

How did your work experience help you confirm your desire to pursue a career in medicine?

Answer 79

- it gave me a much broader perspective of what medical work can and does entail. This has led to me discovering more areas that fascinate me. - for example, i found endovascular surgery really cool especially hearing about methods for treating aneurisms. - weirdly enough i've enjoyed reading medical ethics. As i stated in my personal statement, i really enjoy reading philosophy, and medical ethics is just a continuation or maybe i'd call it more of a lateral move from the ethics i have read in the past. I also really enjoy considering nuanced situations (whether i will feel the same when faced with a real and emotionally challenging dilemma is yet to be seen. It will definitely be more stressful, but in turn it will lead to a lot more character development which is something i strive for). - I found it fascinating. It obviously illuminated the challenges that doctors face both emotionally, in terms of scheduling and in other area. But it also allowed me to understand the depth of areas medicine covers. I was fascinated by endovascular surgery and thought it was cool to hear just how many areas we can specialise in. I was also fascinated to hear about the many uses for ultrasound beyond pregnancy. I also discovered and worked on some weaknesses. Although difficult, I found this really rewarding, and the idea that medicine as a career would continually subject me to this process of growth is something I’m driven by. - Learned that other doctors had same concerns early on. Allowed me to see the difference that can be made to patients and understand the feeling of altruism rather than just romanticising it.

Question 80

After your work experience, how did your view on real life medical professionals compare to that depicted by the media?

Answer 80

- considering the media as in news outlets, i feel like doctors tend to make headlines or stories when they've done something particularly good or bad, they're either put on a pedestal or they're being vilified. - In reality, doctors are people. I did find that across my shadowing, all the doctors came across as intelligent, conscientious and pleasant people, but it was also apparent that they share common struggles and woes. The issue of remaining emotionally engaged with patients who aren't progressing was a common one, as was concerns of making mistakes early on in practice. - there was a noticeable commonality surrounding a push for continual progress amongst the cohort. - I feel like fictional media also leaves out understanding of how much stress doctors may be facing from their schedule. They're more interested in showing the dramatic operations or situations, but in reality, bureaucracy and workload appears to be one of the main struggles.

Question 81

Tell me about the roles of allied health professionals that you met?

Answer 81

- I learned a few things. First of all they're incredibly important for reducing physician workload and provided a balanced and rounded team. - They're also important because they will have specialist knowledge in their areas. - It should also be noted that allied health professionals are subject to the same stresses and pressures as physicians and nurses. - I met a paramedic who had a man die on his first shift and well as then having a cardiac arrest patient within his first week. - Paramedics are obviously important members of a medical team because the are the first port of call. They allow patients to get to hospitals and are able to stabilise them en route. - i've also spent time with a speech and language therapist. They are important members of multidisciplinary teams - they perform initial assessments of swallowing and communication difficulties following the acute stages of strokes. - they also provide longer term rehabilitation as well as coaching and support for family members.

Question 82

Which ethical principle of medicine do you consider to be most important?

Answer 82

- I think they're all equally important. - Beneficence and non-maleficence are obviously important for the patient's wellbeing. - Justice is incredibly important. Not only to help prevent discrimination, but also, given the single payer healthcare system we have, in considering opportunity costs and fair allocation of resources. - However, i think autonomy will most often determine the outcome. The other principles are likely to help a physician determine what they believe to be the best treatment, however, ultimately the route that is taken will be decided by the patient. - This being said, in cases like when decided who would receive a transplant, autonomy is probably going to be the least important as one would assume that each patient would like to receive it. - Owing to this, i'd say they're all equally important, but the weighting of their importance is subject to some situational fluctuation. - They’re all important! From having read philosophical ethical theories and then having read medical ethics and then having learned the four pillars of medical ethics, I can see that they are grounded in extractions from different theories. There’s definitely a balance of kantianism or deontology if you wish, there’s utilitarianism in there too as well as virtue theory. In the same way that the principles are derived from different core theories, I believe their importance derives from the particular situation. They are all as important as each other on paper, but in specific situations, there may be more or less important ones. In the situation of deciding who gets a transplant, autonomy is less likely to be important as it’s fairly likely that each of the patients being considered wants the transplant otherwise they probably wouldn’t be in consideration. However, beneficence would be particularly important here and considering ideas like QALY’s would help determine the outcome if each patient was scoring identically on the transplant lst. On the other hand, in a situation where a patient is refusing a potentially life saving treatment, autonomy would be the pertinent consideration as regardless of the treatment being the most beneficent and non-maleficent thing to do, if the patient doesn’t consent, then it can’t be perfoemd, with the caveat of minors who regardless of whether they are deemed hillock competent, aren’t able to refuse treatment. In a situation like the Charlie Gaard case, or something like when a patient has an infectious disease like HIV and is refusing to inform others of their condition, justice may be the most important consideration in protecting others. Given we have a single payer healthcare system in the NHS, distributive justice is also particularly important in cases of expensive treatments as we have a finite amount of resources with which to provide the best overall care to the population.

Question 83

You have been housesitting for a friend and broke their favourite ornament by mistake. How would you approach them when they got home?

Answer 83

- First of all i would approach them normally. No one wants to return from holiday and be immediately confronted with an upsetting situation. They are my friend and i'd ask them how their holiday was, what they got up to, whether they'd go back there again. - I would then ease into telling them. i would assume they may ask how the house is after telling me about their holiday. i would use a warning shot to indicate that something bad has happened. This could be along the lines of 'yeah not too bad thanks mate, although there is one thing i need to tell you about and you may be upset'. "Do you want to sit down at all before i tell you?" - I would then explain the situation, what had happened and how, and offer a sincere apology. - After letting them process the information and vent if necessary, i would then ask if there was anything i could do the remedy the situation.

Question 84

You are faced with an actor playing a 65 year old who has just been diagnosed with alzheimer's. He has visited a GP for advice on how to cope with the diagnosis as he's heard a lot about the burden dementia can present to his family and the healthcare service.

Answer 84

- It would be worth setting up advanced directives - these are answers you would give to hypothetical scenarios you may face in the future. This will help alleviate caregiver stress as they won't be forced to make these decisions. - Beyond this, you can nominate a lasting power of attorney, this doesn't have to be a family member, if they agree to it, you can list your primary physician as your LPA meaning they will be the person making medical decisions, which again can reduce stress on your family. - in terms of caregiver burden, there are a few major factors. - denial is one. It will be important for you to communicate with your loved ones and try to ensure that they understand and have accepted your diagnosis. - social withdrawal: you should make it abundantly clear that you want your spouse to continue having a life (if this is the case). This may involve working together to find ways that she can have help in your care in the later stages, or you may be able to make use of assistive technologies like home systems which remind you to perform certain tasks.

Question 85

You enter the hospital staff room prior to surgery with Dr. X. As you enter you see her take a swig of a clear drink from a bottle and quickly closer her locker. You suspect the drink to be alcohol and over the course of your conversation she begins to forget things and starts slurring her words, how should you approach this?

Answer 85

- I would begin by making friendly small talk as is normal with a superior. - "Hey Dr. X, how are you today? I'm looking forward to our surgery together later today, i think it'll be a great learning opportunity for me" - this could move into something along the lines of "it is gonna be a long one though isn't it! i'm going to grab a coffee before we get started, do you want one?" - As the conversation progresses, i may be able to gauge her mental state by asking a few technical questions. If this is the point at which she is becoming forgetful or slurring her words, i would ask if she's ok. - This will give her the opportunity to offer up any information voluntarily. - If she doesn't do this but is continuing to present signs that concern me, i would have to be more direct (although not judgemental). "Forgive me for asking Dr. X, but when i came in the room i saw you take a drink of what appeared to be alcohol and since then you've slurred some of your words, is everything ok? you can always talk to me if you need to" - If after this she doesn't want to talk it would be necessary to step in for patient safety. - "Dr. X, i'm really sorry, i can see you don't want to talk about this, but in the interest of patient safety i'm going to have to recommend you take the rest of the day off and go rest, or perhaps do some aerobic exercise to destress a little then watch a film at home?" - "my offer to talk still stands, I'm free from 7pm onwards and would be more than happy to pop round or have a chat on the phone if you change your mind. Just let me know!" - If she refuses to go home, state that you are going to have to speak to a more senior colleague. It would also be important to check if she had discharged any patients over the past few days, as well as arranging for cover. - There is a duty of care to my colleague too, i would arrange for a taxi to take her home. - my duty of care to the hospital would mean it necessary for me to speak to my clinical director too.

Question 86

Can a female colleague refuse to treat a rapist?

Answer 86

- GMC guidelines state that if providing a treatment conflicts with a physicians religious or moral beliefs, and they believe that this will affect the level of care that they provide, then it is important to explain this to the patient and tell them they have the right to see another doctor. - must also be satisfied that the patient has sufficient information available to enable them to exercise that right.

Question 87

What would you do if a patient acted in an abuse manner towards a colleague (physically or verbally)?

Answer 87

- first ensure that the abuse isn't stemming from their underlying medical condition. - if this isn't the case, then inform the patient that their behaviour is unacceptable. If they persist give them a formal warning. - if they continue after this, hospital security may have to remove them from the premises. - Care shouldn't be hampered though and the responsible physician should make arrangements for transfer of care. - the case is the same for racial abuse.

Question 88

one of your peers is constantly late for work in the mornings, what do you do?

Answer 88

- Informal discussion is possible here. - Discuss their performance and why it needs improving. - come to an agreement with them about the steps going forward - Even if an informal discussion is the method used, the decided response should be communicated to the physician in writing and notes kept.

Question 89

your consultant mentions something to a patient that you believe to be wrong, how do you react?

Answer 89

- First of all be empathetic and communicate. Don't do this in front of the patient. - speak to the consultant away from the patient and say that their approach is different to what you would have done in the situation and could they explain why they made that choice? - If you're still not satisfied then it would be worth actually addressing this with the consultant in the interest of providing optimal care. - If they don't appear to listen to you or you aren't happy with the solution, or you struggle to raise this with them, then speaking to a supervisor or clinical director may be necessary.

Question 90

what do you think about presumed consent for organ donation?

Answer 90

- this was adopted in may 2020 to increase the amount of organ donations. - rather than opting-in, patients have to opt-out. - up to 90% of people say they would donate their organs, but only 40% actually opt-in. Is this an issue of laziness or of false testimony. - There is an ethical dilemma. the Human Tissue Authority is very clear about the fact that consent is an active process. it's imperative that people be fully aware of the situation and that they are choosing to donate their organs by not opting out.

Question 91

An actor hands you a card which states that you are playing the role of a GP and that they are a 16 year old girl who has come to ask for information about getting tested for STI's but is worried about her parents finding out.

Answer 91

- "Hi, i'm Dr. Bird, what's your name?" - "what can i help you with today __?" - "ah i see, what leads you to believe this? - signpost before asking more personal questions: "i'm going to ask you some questions now that might seem a bit personal, but they're things i need to know in order to find the best treatment for you so please answer as honestly as you can" - Have you engaged in unprotected sex? are you experiencing any symptoms?" - check for capacitance - do they understand the risks, do they understand what contraceptive options are available to them? are they using contraception? do they understand the difference between using contraception and using protection? - Is she able to understand, retain, weigh up and report back informed decisions or thoughts on the area? - is there reason to be concerned about a safeguarding issue? - Is she at risk for longer term mental health implications from being sexually active? - if the patient appears to be competent, then "i want you to know that everything we've discussed today will remain confidential" - "is there anything else i can help with?" this will prompt the actor to nudge you towards anything you may have forgotten about.

Question 92

there is a graph of plasma glucose levels over the course of a day as well as information about the times of day that meals were consumed. describe the graph.

Answer 92

- following meals, plasma glucose levels will rise. - in response to this, the pancreas will release insulin and plasma insulin levels will rise. - the insulin will have 2 effects, it will cause glucose to be used by cells, and it will lead to the liver storing it as glycogen.

Question 93

An actor hands you a card which states you are playing the role of a surgeon and they are a patient on whom you recently performed a hip replacement. You must inform them that some nerve damage occurred during the surgery and that they may not regain full use of their leg.

Answer 93

- "Hi, how are you feeling today?" - give a warning shot. "Although we've successfully replaced your hip, i'm afraid there has been a problem" "are you prepared to hear the news now or would you like to come back with a family member first?" - give them time to digest, possibly wait for them to speak to you. - "During the replacement you suffered some nerve damage, we don't know the full extent of what this means yet, however, you may not regain full use of your leg. I'm so sorry". - give a little time to digest. - "Are there any questions you want to ask me? or would you like some time to be alone?" - "if you have concerns about future ailments i want to reassure you now that you will receive the support you need and that physiotherapy will also be available should you need it.

Question 94

You have 4 minutes to explain the process/ purpose of vaccination in the way you would to a competent adult. After this, you have 4 minutes to explain it how you would to a child.

Answer 94

- pathogens (virus and bacteria) have markers on their surface known as antigens. Each different pathogen will have a different antigen, but within a particular strain, all the individual pathogens will have a common antigen. - The antigens are what our immune system is able to use to identify pathogens as foreign. We have a whole host of immune cells that perform different functions, but in short, the first thing they need is to identify a pathogens antigen. - our immune cells aren't simply able to scan things for antigens though, our immune cells have structures that are complementary to antigens and are able to identify them by binding with them. - We produce immune cells with many different shapes of these complimentary structures - known as antibodies, and it will take our body as long as it takes for the correct structures to come across and bind with the antigen for us to notice there's a foreign substance in our system. - This could take a little while, and that's why we tend to be ill when first encountering a disease. - Once our body has bound an antigen once though, we ramp up production of immune cells with the complementary antibody. This allows us to fight the illness, and afterwards, it means we have many more copies of those antibodies in circulation. - This means that if we are exposed to the same pathogen again, our body will be much faster in binding the antigen because of the massive increase in antibodies. - This is essentially how vaccines work. - We inject either a dead or attenuated (weakened) version of the pathogen into your system, this allows your body time to recognise the antigen and ramp up production of complementary immune molecules, without you suffering the illness itself. - Then, if and when you are exposed to the living pathogen, you will already have the reserves necessary to fight it. - Most vaccinations are designed to provide lifelong immunity, however some viruses mutate each year meaning a new vaccine is required seasonally - like the flu. Child: - When a germ get into your body, it takes a bit of time for your body to learn how to fight that disease. - all the different diseases have something on the outside of them that helps your body recognise and fight them, but it takes a bit of time for your body to do this. - our body has the tools to fight the different illnesses, but it takes a while to sort through and work out what the best tool is. - it's kind of like, imagine the germ was hiding behind a door and we couldn't fight it until we got the door open. We have the key to open the door, but it's somewhere in a pile of 100 other keys so it will take us a little while to find the right key, and while we're looking, the germ can make us ill. - Once we find the right key though, we can get rid of the germ, and we can make lots and lots of copies of the key so that if that germ comes back, we can quickly get the right key and open the door. - This is what our body does, we have all these tiny fighting cells in floating around that are all built to fight different germs, and it takes a while for us to decide which cells should fight this particular germ. But, once we know which cell is right, we can make lots more copies of it so that if the germ comes back, we can get rid of it really fast! - And this is how vaccines work. We inject a small amount of a germ that is either really weak or is dead so that our body can work out which fighter to use, but without the germ causing us any harm while we work it out. - Then once we do, we'll make lots more copies of the fighter cell meaning that if the living version of the germ gets into our body we can get rid of it before it does us harm to us.

Question 95

4 people all need a liver, all with equal chance of success. one has 2 weeks left to live without it, one is the sole carer for their father, one is a pregnant lady, and one has taken a large paracetamol overdose. Assuming there is nothing to medically differentiate the patients and considering only the ethical aspect, who would you give the liver to?

Answer 95

- although this question says all have equal chance of success, things to consider if it didn't: 1) Are all of the patients a HLA match? 2) Age discrepancy between donor and recipient 3) Mechanical factors - will size and shape of organ match any patient better than any others, and do any of the patients have issues that will make the procedure more difficult/ less likely to be successful (like haemophilia) 4) Are there any circumstantial factors? eg the paracetamol overdose that means there could be a reduction in the beneficence afforded to one individual. 5) Look at QALY's. who stands to gain the most, and in terms of justice, to whom are the resources most valuable? who will have the greatest increase in the number of HEALTHY years to their life. 6) social factors - what change in quality of life to the children/ the old father that is being cared for? looking at ethical pillars - autonomy isn't the most pertinent in this case as one would assume all the patients would like a liver otherwise they wouldn't be being considered for the transplant. Although it would be worth checking. - Non-maleficence - where do each of the patients sit on the transplant list? if there's nothing medically separating them then i would assume they're all sharing the top spot. In this case then, what is the prognosis for the 3 that don't have 2 weeks to live? Do they have rare HLA or other factor that means it's unlikely another match will be found for any of them, or do they have fairly common type. If all the individuals are likely to survive until more livers are available for transplant except for the lady with 2 weeks to live, then the principle of non-maleficence would suggest that by preventing a certain death, she may be the strongest candidate. transplants also only last a finite number of years in many cases so if the others can wait until another transplant becomes available then they will make better use of it at that stage. also the current scoring system gives priority to those that are 'super urgent'. - considering beneficence, we could look at QALY's for the patients, and also QOL changes for their families. Are there any considerations that mean that there is reduced chance of operation success, or reduced quality of life following the operation, considering the paracetamol overdose, is the patient likely to attempt to take their own life again, will they take care of the liver? Age - a younger healthier person is likely to gain more QALY's. how about QoL for family members, what are the psycho-social effects of growing up without a mother? could the person caring for their father provide alternate care, do they have the financial ability to do this if necessary? - considering justice, QALY's would once again be huge.. the NHS is a single payer healthcare system with limited resources, so who is likely likely to benefit the most from the liver? -

Question 96

Mrs. x is a 29 y/o patient in the nephrology clinic with.a GFR of 28ml/min. She has had type 1 diabetes since she was 7. She asks to be transferred to the dialysis clinic (normally done at GFR < 20) in order to be placed on the renal transplant list asap. She hopes to receive a cadaveric transplant quickly in order to be able to try for pregnancy. Normally people are only put on the transplant list when they reach a GFR of 15. How would you approach this situation?

Answer 96

- The threshold is set at 15 because this is when a patient will actually NEED a transplant. Above this, although a patient may be experiencing symptoms, they won't be in dire need. Transplants also only last for a finite number of years in lots of cases, therefore, to maximise resources, we want to give them at the right time. Also in regards to justice, the NHS only has a finite number of resources and so they want to give transplants to those most in need. it can't be based on those that say they want them the most. - Could she have baby without transplant? no. GFR is already reduced and it's unlikely that her body would be able to keep up with the increased stress a baby would put on it. we also know that the patient has type 1 diabetes which is a risk factor for high blood pressure, which is a risk factor for kidney disease. In addition, pregnancy increases risk of high blood pressure through pre-eclampsia. - unfortunately that doesn't impact the transplant list. It's based on clinical evaluation, not social needs or wants. It's based on a points system which considers things like: time since diagnosis, time on list, HLA match, age difference of donor and recipient. - The patient should be educated of these things. - If asked what if she was 10 years older - priority is sometimes given to children and young adults due to the increased QALY's they will gain. But clinical evaluation would still determine if this warranted any effect. - what if they patient knew a living donor who wanted to donate to them? - autonomy and non-maleficence - does the donor understand what this will mean for them? do they have any underlying health issues which mean that they wouldn't be suitable for this? what if she has genes that mean hypertension is likely later in life? she will probably need her kidney... - patient would still need their GFR to drop below 20 before transplant is able to be carried out...

Question 97

what are the consequences of an ageing population?

Answer 97

- older patients tend to have a higher frequency of chronic conditions - these are more timely and costly to deal with and will result in a reduction in available resources. - older patients who suffer physical injuries don't tend to recover as quickly. They may also be less mobile. This means they will require longer stays in hospital and may need things like physiotherapy or wheelchairs which again use up finite resources. - They also suffer delayed discharge and exit blocking which increase A&E wait times due to reduced numbers of beds. - These increased risks in various areas also increases the chance of multiple morbidities or having morbidities alongside injuries. This will increase the stress placed on the NHS due to the need for multidisciplinary teams. it will also, once again mean that longer stays in hospital are necessary and that will take up bed space.

Question 98

what are the pros and cons of privatising the nhs?

Answer 98

- privatisation would allow for more competition - could increase quality and also drive down prices (although compared to current system, prices would rise for public)\ - could reduce waiting times. this could come from increased competition, or it could come from people leading healthier lifestyles because of cost of healthcare, or from people thinking more carefully about whether they need to go to the doctors for a particular ailment. - having the option to pay for your drugs will give more options to patients, however, this may further the class divide, although if a more expensive drugs is available that will benefit a patient and they have the means to afford it, then we should provide the best care possible. - healthcare may become overly commercialised though, medicine should be about treating the patient to the best of a physicians ability. We see this issue in america, where pharmaceutical reps pressure doctors to prescribe their product. - Another con would be the influence of pharmaceutical reps. I read recently that because of the stress and lack of time that a lot of American GP’s have, a lot of their up to date understanding of medications available comes from pharmaceutical reps. This is obviously biased information. As a result, healthcare becomes less about providing the best care, and more a money making industry.

Question 99

Brexit and the NHS?

Answer 99

- economic uncertainty will lower the value of the pound which makes UK wages less competitive compared to other countries and as such will reduce the supply of foreign workers we have. - ideas like the immigrant health surcharge will further this issue. currently those form outside of the EU economic area has to pay an annual charge to receive healthcare in the UK - for potential workers with families, this presents a large overhead and a deterrent. - 5.5% of workers are foreign and studies show that they are net contributors to the NHS, not burdens. - We already have a shortage of around 40,000 nurses as well as issues in other departments. a decline in sterling value, harsher immigration laws will only exacerbate this problem. - It will likely be harder for us to be involved in research programmes, and we will lose out on the funding the EU provide. - Fortunately we are one of the most innovative counties. However, not all the medicine we innovate is produced here, and so we will still suffer issues of shortage while attempting to transport it across the red tape. We had built up a stockpile to help mitigate this, however, our covid response meant that we had to use up most of this. - Further to this, we may be delayed in receiving new drugs. switzerland who have numerous bilateral trade agreements with the EU still receive drugs around 6 months later.

Question 100

Why do you want to go to medical school?

Answer 100

- i want to be a career that will push me academically, and also requires one to have a high level or moral certitude and emotional intelligence. - these are all things that in my opinion are shaped by ones life history. My upbringing developed my emotional intelligence faster than most, and i put a lot of value on ethics in my life. - These are also things i don't consider there to be an endpoint for though. You can always be more empathetic, you can always learn how to respond more appropriately when empathising, you can always learn more about the nuanced topic that is ethics and gain a wider perspective. This is something i'm interested in. i want to work in a field that not only fosters this growth, but requires it. - I feel the same about the academic side of medicine. I've always been fascinated with science, and even in my free time i'm constantly hypothesising about random things, and i want to work in a job that requires this. - I also care a lot about people and want to pursue a career that i believe matters. - Beyond these thoughts, my time preparing for the gamsat and shadowing have both furthered my interest in medicine. I found the gamsat really enjoyable to study for as it required me to engage with a variety of topics i haven't considered much before. It's also improved my ability to extract information from material and apply it to practical situations. - From shadowing, i was able to quell the nerves i had about areas like emergency medicine. Learning that a lot of doctors were nervous at first, and also learning about heuristics like the XABC approach to quickly assessing patients was nice. - I’m obviously not remiss of the realities of medicine though, and although there were some things that stuck out as being less enjoyable when I undertook my shadowing, I saw far more things that motivated me further. I was fascinated by how broad of a subject medicine is, I hadn’t considered some of the nuanced specialties, or how many uses we have for things like ultrasound. Who’d have thought it could be used to detect the speed and direction of blood flow!

Question 101

if you weren't offered a place to study medicine, what would you do?

Answer 101

- I would first try to understand why, given that i'm at the interview stage, i would assume the issue wasn't to do with my personal statement or score in the UCAT/ GAMSAT and is more likely to be because of my performance in the interview, or due to the amount of shadowing i managed to undertake/ the reflections i had on this. - Once i had an understanding of where i need to grow, or what i need to spend more time doing over the next year i would start planning for how to do that and as well as what to do with the rest of my time as i would have considerations like finances. - After that i would continue to prepare and would most likely also be working. Hopefully i would then manage to secure an offer next year. - if i don't manage to get an offer ever, then i've had a few thoughts about what i could do. I think i would do fairly well in accountancy. i'm not as passionate about it and may burnout after 10 years or so, but it once again combines theoretical knowledge with people skills.

Question 102

what aspects of the working life of a doctor appeal to you?

Answer 102

- lots - the fact that you get to be academically stimulated but are also in a role that fosters emotional and ethical growth is something i an hugely engaged by. All of these are areas that are important to me, and to have the triad of them be essential in my career would be perfect. - I'm fascinated by the progression i would get to see over my career. When i virtually shadowed an endovascular surgeon i was fascinated by the progression of aneurism treatments. Compared to this, thinking about what developments are going to come in the next 50 years is amazing! - I really enjoy problem solving. In a similar but lower level way to medicine, this is something i was able to utilise while ski instructing. Out of a group, it would be necessary to 'diagnose' each of their technical issues, then to empathise with the group members in order to understand how they each learn best. After this i would consider which area of the mountain would provide the most suitable terrain, combined with quietest lifts as well as which drill we should perform in order to benefit the group as a whole as much as possible. - After this, i may break things down into individual feedback so that people directly benefited more from the drill they were doing. - In terms of introspective understanding, i like the challenging nature of the field. i'm someone who likes to question their own ideas and beliefs. From shadowing a psychiatrist, i learned that a common problem faced by many different specialities of doctor is burnout due to a reduced amount of emotional involvement in patients over time. This is something that i would most likely experience at some point, and i would need to find a way to overcome it.

Question 103

what aspects of the working life a doctor don't appeal to you?

Answer 103

- the struggle of a work life balance, especially when considering family. I'm interested in being as involved of a parent as i can and this will no doubt present a challenge. it will no doubt lead to growth on my part in terms of scheduling and will also mean i enjoy my time with my family more, but i ultimately think this is still something i consider a negative. - There are things that don't appeal to me, but that i have a choice in, like certain specialties. although i found endovascular surgery fascinating to shadow, i don't know how well i would deal with the enduring stress and unsociable schedule of the specialty. - also the emotional burden of having patients that aren't trying to improve. this would be particularly relevant to psychiatry, but could occur in other specialties too.

Question 104

can non-scientific hobbies add to a persons ability to be a good doctor?

Answer 104

- for sure. - I learned a lot about teamwork from my time playing football. - i learned about remaining calm under pressure from my skiing and tennis. - skiing also taught me not to be afraid to fail. The way you progress in skiing is often by falling multiple times. A good instructor once told me that if you don't fall at least once a day you're not skiing, just cruising. and that great things don't happen in comfort zones. - i learned about communication from playing doubles at tennis. - i learned the effects of steady practice from going to the gym. - beyond the skills gained from these hobbies, i also find them cathartic in times of stress and given the stress that medical careers can present, i think this is also a huge benefit. - If I didn’t have skiing as a hobby I wouldn’t have gone to canada to instruct. This led to me improving my communication skills and empathy. Both necessary for doctors.

Question 105

what do you find interesting about medicine?

Answer 105

- I like that it requires 3 'skills' that i consider to be important. it needs academic excellence, a strong sense of morality, and good emotional intelligence. - I'm intrigued by the developments we will have through my lifetime, i was fascinated to learn about the progress of aneurism treatment in endovascular surgery, and i'm sure the field as a whole will have much more progression still. - i find the problem solving nature of the job interesting, the fact that what is apparent may not be the problem, and that beyond what a patient is purporting, a good doctor needs to empathise and consider their particular situation. - I’m like the fact that what we understand is constantly evolving. I recently read about the fact that the amount of cholesterol one consumes may not be as relevant as once thought, and the amount of LDL’s present in the blood in much more important. I also read that stents may be less effective than they were believed to be in the past. In much the same way that we can look back on medical history and see how much we’ve progressed, we are likely going to be able to see similar progression heading into the future and I’m interested in being at the forefront of that movement. -I like the variety of medicine too. The life of an ultrasound specialist is pretty different to the life of a psychiatrist, which is again quite different to that of a GP. There are so many options of what to specialise in, and yet, one may still learn about other areas when working in multidisciplinary teams.

Question 106

what do you wish to achieve from your medical career?

Answer 106

- I want to make a difference. I had a nice lesson from Dr. Karri Dutton who is a clinical paediatrician, she pointed out that in most cases, without treatment patients would deteriorate, so anything a doctor does is positive, even in the cases where the outcome isn’t good, it’s worth always remembering that our intentions were good and that we likely made a difference compared to no treatment. I also want to satisfy my desire to learn and grow. Obviously medicine is academically challenging, and this is one of the things that drives me. I loved living in canada, I had a fun job and enough income to live comfortably, but I wasn’t academically challenged and after a while this started to bother me. By contrast, exam periods at universtity, which most people hate, I used to really enjoy, they brought out the best side of me, and forced me to grow. I’m also fascinated by biology and disease. I want to have the opportunity to learn about different conditions and the pharmacology of medicine in detail. Beyond the academic side, I want to have my emotional intelligence grow. Medicine will put me in a lot of challenging positions and I’ll have to face these head on, or with the help and support of others. Both of these avenues however will lead to growth. - I want to do as much good as possible. i know this is an airy statement, but i want to help people. i want to give them the best chances possible to live a quality life. - i'm particularly fascinated by the insidious and long lasting nature of emotional scars, and as a result i'm interested in pursuing either psychiatry or neurology as it stands, although as i progress with my degree and subsequent training, this may well change. - ultimately, if i make it to consultant level, i would like to finish my career in canada in order to combine my love of helping people, with my love of the outdoors. This would allow me to live in a much more nature-centric place and own an RV and tour the national parks of america and Canada as well as do a lot of hiking and skiing (if i have no physical problems by then).

Question 107

why a doctor and not a nurse?

Answer 107

- So obviously nurses are an important part of the healthcare team. i've heard from friends who are junior doctors that nursing staff made them feel most comfortable early on in their work and that they have also helped them with decisions due to their greater level of experience. - however, I want the challenge and responsibility that comes with being a doctor. - i'm interested in combining the academic, moral and emotional excellence that is demanded. - All of these things are required of doctors, and although they are also necessary in nurses, the extent of medical training is less which is less appealing to me as i'm interested in the academic side of diseases in addition to the holistic care of patients, and i believe nursing focusses more on the latter. - furthermore, although some nurses can prescribe and may run clinics, doctors get to do this on a much more regular basis and earlier on in a career. I'm interested in the challenge that will come from coordinating the full care of a patient. I also would want to be in a position where if i am making tough choices, i have had the most rigorous training possible, and this comes with medicine. - although this may not sound like a positive, i like that being a doctor would demand more reading of research/ more years of training. Although i enjoy my free time, i've learned in the past few years that too much free time is actually a bad thing for me, i end up just becoming complacent. I have friends who are nurses and friends who are doctors, and from what i understand the doctors have more continual reading to be doing. - I would also have a greater ability to specialise as a doctor - especially earlier on. - Although i don't currently aim to head down this route, working as a doctor would give me the possibility to go into research or to teach too. - I really enjoyed shadowing an endovascular surgeon, and surprisingly, i enjoyed learning organic chemistry for the GAMSAT, and medicine will provide more incorporation of the surgical and pharmacological aspects of patient care.

Question 108

what excites you most about a career in medicine?

Answer 108

- i don't think there is a most. there are lots of things that excite me/ make me want to pursue this career. - i like the idea that it will foster growth and will push me in the areas of life that i consider important and naturally care about which are academia, morality and emotional intelligence. - I'm excited about the progression of medicine and i think it will be really cool to see what new developments come through my career. - i'm excited to know that what i'm doing is of some significance and will make a difference, and that at the times that it doesn't, this will still put me in positions where i have to be introspective and grow as an individual. - I’m also interested in learning about illness and disease in depth. I’m a bit of a biology nerd and having a career that requires me to keep up with research, as well as being surrounded by other doctors that I will learn from is really cool. - I like the problem solving nature, and having spoken to a lot of different consultants, I’ve learned that ones ability to differentially diagnose will grow with time and experience too.

Question 109

what is the sugar tax?

Answer 109

- it was introduced in 2018 - drinks with over 8g of sugar per 100ml have to pay 24p/L tax - 5-8g/100ml have to pay 18p/L - as a sin tax it has been effective at reducing the amount of sugar that industry put in their drinks - 45 million Kg's less sugar used annually since introduction. - public choice doesn't seem to have changed a whole lot though.

Question 110

what are the issues with obesity? and what has been done/ discussed?

Answer 110

- obese children are likely to become obese adults. - increased risk of type 2 diabetes - the government have introduced a plan to ensure that children have more opportunities to do an hour of sport/ physical activity every day. - There was discussion of a fat tax, although this is much more controversial that the sugar tax because of the negative connotations/ judgement. support for this comes because obesity costs more than any other lifestyle factor and is preventable. - price manipulation is also a form of control without educating people on the reasons. - nearly 8% of critically ill covid patients are obese but only 3% of population are. - since covid began, unhealthy food adverts have been banned on tv/ online before 9pm. - BOGOF promos for high fat and sugar foods have been stopped. - expansion of weight management services by NHS.

Question 111

why are there more covid cases iin countries such as brazil and india compared to europe?

Answer 111

- there is clear evidence that inequality leads to worse outcomes and that strong leadership implementing clear policies works best. - Brazil - 9th largest GDP on earth and yet 25% live in poverty. - poorer brazilians are unlikely to have access to healthcare. - bolsonaro refused to enforce a lockdown. instead left the matter to governors and mayors. This has led to a patchwork across the country that hasn't achieved a lot. - India again struggles with being a very fragmented country. lots of the rural areas don't have much access to healthcare. - The country was also hit hard by the lockdown it imposed.

Question 112

Did lockdown work?

Answer 112

- It depends on which perspective your asking from. Economically it definitely didn't and rishi sunak appears incredibly stressed. On the individual level we've obviously worked hard to try and mitigate these issues and systems like furlough and freezing of loan repayments have helped to increase trust in the government and support those who are struggling. - From a social standpoint yes and no. It definitely united the Nation the first time around. Things like the weekly clap for frontline staff united neighbourhoods. And the feeling of solidarity has brought the nation closer together. however, the loss of ability to socialise has had significant negative effects on peoples mental health. We saw suicide rates spike and we have to consider things like domestic abuse, what effect will lockdown have had on those cases? In terms of education, this new lockdown is likely to have negative effects. It also poses an issue for the lower socioeconomic classes as they may work jobs that require them to be out of the house, and they will struggle with childcare. In terms of the medically. It’s hard to tell, it would appear that it did make a difference. Evidence from Scandinavia suggests that lockdowns are effective given that Sweden saw higher case numbers than it’s neighbouring countries. We also didn’t get as overrun as we may have. The nightingale hospitals were largely unused during the first lockdown. - It did help stem rising infection rates and reduced the possible burden on the NHS. - it did also have negative impacts on peoples mental health though, and we need to consider things like how lockdown would have been for domestic abuse sufferers. - The long lasting impacts of the psycho-social effects are yet to be seen. - It also restricted peoples freedom and by some is considered a breach of trust as countries like sweden trusted their citizens to socially distance (they are against masks except for health workers) rather than forcing lockdown on them (although it has seen a higher death rate than its neighbouring countries which did impose such measures). Adding to the feeling of restriction of freedoms, public trust was further declined by events like dominic cummings trip to Barnard castle. - We unfortunately saw a spike in suicides during lockdown. - We also saw 3 million people go hungry in the first 3 weeks of lockdown. - i feel there were benefits of lockdown that are harder to measure such as an increase in the feeling of solidarity amongst our nation.

Question 113

How does herd immunity work?

Answer 113

- Herd immunity describes a population that's resistant to the spread of a contagious disease. - it's achieved when a sufficiently high proportion of individuals within the population are immune to it. This will stop the spread of the virus by disrupting the chain of transmission. - it normally comes about through the introduction of vaccinations, but given no vaccines were available for a while for covid, our chief scientific advisor suggested that it was necessary to infect 60% of the population. This was heavily criticised.

Question 114

How was the approach by most european countries different to that of sweden (herd immunity)?

Answer 114

- Sweden had one of the highest death rates relative to population size in europe. - They generally made suggestions rather than enforcements. They wanted their citizens to work from home, avoid public transport. They also banned gatherings of more than 50 and shifted restaurant service to tables only. - swedish data has shown that leaving schools open had negligible effects on the spread of the virus. - second time around they are planning on introducing stricter measures as the projected herd immunity hasn't been reached with their tactic. - Evidence from neighbouring countries has suggested that the stricter approach was more effective at quelling the virus and that the economic effects of their lockdowns weren't as detrimental as first feared.

Question 115

What are the issues facing BAME staff and patients in the NHS?

Answer 115

- they're under represented amongst board members. 20% of NHS workforce, but only 8% of board members are. - This lack of representation can result in unconscious bias. Although it's important for doctors to work hard to be aware of any unconscious biases they may have, this isn't always the case, and the fact that white applicants are 1.5x more likely to be selected for roles could be evidence of this. - There are issues that stem for political correctness. A GMC report found that doctors from diverse groups didn't always receive effective, timely or honest feedback due to difficult conversations being avoided if the manager is from a different ethnic background. We possibly need more training in order to improve this situation. - Not surprisingly given the last 2 points, there is a higher rate of reported discrimination amongst BAME staff members. - in terms of patients, black women are 5x more likely to die during childbirth and mixed race 3x more likely than white women. - 95% of doctor mortality in first month of pandemic were bame backgrounds. - the NHS has addressed these issues in it's people plan for the year. We will have to see whether this proves effective or if more needs to be done. the plan aims to address the risk faced by BAME staff in the covid response, and also improving representation of BAME staff across all levels of the workforce.

Question 116

What are the problems we're having with A&E?

Answer 116

- we have a 4 hour standard for A&E in the UK. Unfortunately we haven't been able to meet this on a national level any year since 2013/14 due to sustained periods of financial austerity and staffing pressures. - There has been a 17% rise in the number of patients visiting A&E since 2011. - This leads to exit blocking (when admissions are delayed due to lack of beds - this is also an issue with an ageing population due to multiple morbidities). - Ageing population also presents the issue of delayed discharges - patients who no longer need medical treatment but can't be discharged. - Unnecessary attendances are a concern too. This is an argument in favour of privatising the NHS. If people have to consider whether treatment is necessary at risk of paying a large fee or seeing their insurance premiums rise, they are much less likely to seek treatment when it's not necessary.

Question 117

Discuss the issues that surrounded the junior doctor contract?

Answer 117

- Junior doctors felt that the contract suggestions made in 2013 by the department of health presented a risk to patient safety as they would have led to unfair working conditions. - the proposed changes would have seen an increase in basic salary, but a drastic reduction in supplementary pay for working on-call shifts outside of sociable hours. This effectively meant that pay would be reduced. - Concerns that the new contract would increase stress, tiredness and burnout, and as a result would damage patient safety. - 98% of junior doctors voted to reject the contract in November 2015. - It took until may 2019 for negotiations to be settled. - after the 2018 discussions, there are greater restrictions on the hours that can be worked, and required rest periods are in existence. - There has been a fifth pay point added for trainees at ST6 and above.

Question 118

how do you think junior doctors cope with stress in the workplace?

Answer 118

- For lots of reasons. - After years of training, and support, you're now the one making the tough decisions. - you've also left university where you likely had a support network and social life and have entered a new environment where you have to rebuild these things and are quite possibly working long, unsociable hours to boot. - Furthermore, junior doctors will be hard at work considering which specialty they'd like to work in, and after this, this will be working and studying. - i learned from shadowing that emotionally investing a little with your patients really helps you to engage with your work, prevents burnout and reduces stress as they will often give a little bit back. - It's important that a junior doctor isn't too proud to admit that they are struggling. - It's important to learn to delegate. - maintaining hobbies is also important. it allows you to have a life beyond your work, blow off steam and make social connections. - In terms of coping with the stress, it’s important to build these social connections at work. A lot of my friends who are or have been junior doctors told me that they received a lot of support from nursing staff early on. By empathising with your team, they will likely empathise with you and this will provide some support.

Question 119

Why are mental health services important?

Answer 119

- It's becoming a bigger issue. there has been significant increase in mental health problems throughout the pandemic according to lancet - studies show that 1/3 people experience mental health issues throughout their lives. - 1/5 women experience perinatal mental health problems - usually depression and anxiety. This affects their early development of a connection with their child. - in 2018 the NHS pledged an extra £23 million to improve perinatal mental health services. - april 2019, new and expectant mothers are given access to specialist mental health services. - Estimated that £30 million extra goes into funding eating disorders each year. - in 2019 diabulimia patients (diabetics that restrict their insulin in order to lose weight) were given access to therapy for social media and body image problems. - the NHS has a goal of 95% of all children with eating disorders receiving treatment within 1 week (for urgent cases) and 4 weeks for routine ones. - lots of patients can't get a bed in a mental health hospital in their own area. 6000 patients were sent out of their local area to receive care in the past 2 years. - NHS plans to invest a further £15 million to strengthen services available for nurses, therapists, paramedics, pharmacists and support staff.

Question 120

What are our issues with primary care? and what is being done to try and improve the issues?

Answer 120

problems: - shortages - 15% of GP posts are empty. - We have increasing demand due to our ageing and growing population. - practices are closing meaning people have to change GP's and the burden on the remaining ones increases. - unsafe patient levels - 1/10 gp's are seeing over 60 patients a day. Some working 11 hour days. - 1/3 of patients have to wait a week to be seen and people are finding it increasingly difficult to get through to their GP on the phone. - Public satisfaction lower than it has ever been. solutions: - medical school students are being encouraged to think about the specialty by incentives like flexible pay premia. - more promotional videos available to help educate young doctors about the specialty. - one off 'golden hello' payment of £20,000 for GPs. - Remote GP services being made more prevalent - reduces wait times, frees up schedule.

Question 121

What are the rules around medicinal cannabis?

Answer 121

- it has been legalised under very specific conditions, and it can't be imported until after a prescription has been made. This means that there are very few cases in which it is actually prescribed. - our chief medical officer has called for scientific trials of its safety which could take years.

Question 122

If a medication is suggested as a possible treatment but there is very limited evidence base to support it, should we try the treatment?

Answer 122

- The nature of medicine is that at some point, medications and treatments were new. The field has essentially progressed in this way. granted, in the modern day we have lots of stages of clinical trials that take place before treatments are approved. I think we can be guided by the ethical pillars here though. If a patient is in dire need and other options aren’t suitable for them, then beneficence and non-maleficence would suggest that trying to treatment is worthwhile. In addition, patient autonomy is important to consider. If the patient understands the risks, and has come to an informed decision, then they should be able to decide if they want to try the treatment. - It would be imperative to get consent and that the patients was completely autonomous in wanting to try the treatment. - It would also depend on the cost and possible success of the treatment. - In the case of billy caldwell, it had been shown that he benefitted from cannabis oil as it helped prevent his seizures, however because of a lack of testing, the GP received a letter stating that they mustn't renew the prescription. This resulted in the seizures returning and the family having to invest a lot of time and money into travelling around to find the oil. Given the positive effects and the clear autonomy of the patient, in this sort of case the grey areas should be considered, and we could expand what is meant by evidence. - In terms of cost and QALYs, in cases like charlie gard, the treatment that was suggested was from a utilitarian perspective, considered to have too low of a success rate when considering justice of resource allocation, the trauma that charlie would suffer in travelling, and the quality of life he would have if he were to survive.

Question 123

charlie gard case?

Answer 123

- parents noticed after 1 month he was struggling to hold up his head and diagnosed him with MDDS. - There's no real treatment for this mitochondrial disease. - parents felt there wasn't much harm in trying treatment - justice of resources suggests that from utilitarian standpoint, QALY's gained to cost aren't worthwhile compared to the alternatives available. - Dr. Hirano who offered nucleoside bypass therapy has been criticised for offering false hope. - His ability to breathe, open eyelids were affected and he had congenital deafness and epilepsy. was also believed to have severe brain damage. - courts and great ormond street believed his life support should be removed to prevent prolonging his suffering and to allow him to die with dignity. - even aside from justice of resources, when his parents offered to pay for the treatment themselves, the high court ruled that the cost of his QALY's were considered way beyond what is a reasonable sum, his survival hopes from the treatment were too low and his quality of life would also be too low to justify putting him through the torment of the process. - The great ormond street experts believed that Charlie was expressing pain. they believe that every day that passed since this was determined was another day of allow him to suffer. - It can be said that experimental treatments are important for progressing medicine. at one point or another every treatment was considered experimental. However, it's a tougher decision when a child is unable to make an autonomous decision.

Question 124

why is it important to maintain the dignity of a patient?

Answer 124

- it helps with decisions about where to draw the line between continuing and ceasing treatment. This was evidenced by the charlie gard case. The courts decided that his survival chances and quality of life thereafter would be too low to consider it reasonable to put him through the suffering that would be necessary to fly him to america and perform the surgery. Instead they decided to allow him to die with dignity. - dignity and autonomy are firmly related concepts. we can't respect a patients autonomy without respecting their dignity. without these things medicine ceases to be an empathetic practice and becomes a practice of forced obedience. - Respecting the dignity of patients diagnosed with degenerative diseases will reduce the caregiver burden their family experience by allowing these individuals to make decisions to hypothetical situations while they can. - when considering palliative care, patients may want to spend their final days making peace with loved ones, and resolving any emotional or psychological burdens they have rather than being subjected to invasive procedures. - it has been shown from studies that most complaints against healthcare professionals don't come from medical errors, but rather from poor communication and a compromise of patients dignity. - showing empathy (respecting dignity) can help prevent physician burnout. - It’s also important to promote doctor-patient trust. With issues like difficulty getting appointments at GP practices and long waiting times in A&E, the more we respect patients dignity, the more we can foster trust and hopefully have them communicate necessary but hard to reveal information quicker.

Question 125

What are the problems and proposed solutions of antibiotic resistance?

Answer 125

- Bacteria can develop resistance to antibiotics through random mutations. - Bacteria are able to share these mutations to their offspring, and they are also able to share them within their generation through sex pilli, tranduction and plasmid transfer. - worryingly we have seen cases of bacteria that are resistant to colistin which is our last resort antibiotic. problems: - antibiotics are often prescribed in hospitals in developed countries and people don't finish their dose - this means that if a couple of resistant bacteria survive as well as a lot of non-resistant, the resistant bacteria can pass on the resistance. whereas if the full course of antibiotics are finished, then only a few resistant bacteria may survive, and our body should be able to kill these off. - livestock are dosed with antibiotics which increase the amount of resistant bacteria in the population. - pressure to convince patients that they have gained something from their GP visit means that around 20% of antibiotic prescriptions may be unnecessary. solutions: - GP's are being encouraged to prescribe more sparingly. - There is a push to help reduce infections contracted from surgery. - farmers have been restricted in which antibiotics they can give to livestock. - clinical commissioning groups have reduced the use of broad-spectrum antibiotics. - new subscription style payment model for antibiotics is hoped to drive R&D - rather than paying for how much is used, the NHS will pay based on how valuable to drug is to them. - phage therapy is controversial - involved infecting patient with phages that target and kill the resistant bacteria. - combination therapies - it has been shown that using two or more drugs in unison can make each more effective.

Question 126

The medical licensing agreement, what is it?

Answer 126

- it's a new exam that replaces finals. - 2 parts - applied knowledge test and clinical skills assessment. - it incorporates and replaces the prescribing safety assessment. - it's pass/ fail and there will be a maximum number of resits allowed. - must revalidate every 5 years. - supporting information showing that you are continuing to meet principles of good medical practice is required.

Question 127

what things can you consider while thinking about beneficence?

Answer 127

- will this option resolve the patients issue? - is it proportionate to the scale of the medical problem? - is it compatible with the patients individual circumstances? - is this in line with the patients expectations of treatment? - what will the lasting effects be socially, emotionally and physically?

Question 128

How does non-maleficence help distinguish some options that beneficence may allow?

Answer 128

- beneficence allows you to rank all possible treatment options in terms of their net amount of good. - non-maleficence would have you discard those treatments that have their net bad outweighing their net good.

Question 129

When must you obtain consent?

Answer 129

before doing anything!!!! if you don't ask for consent then it's considered battery if you touch a patient and you can be sued or lose your license. - written consent is best from a legal standpoint, oral consent is common for routine procedures (but should be documented in notes) - the bolam test is for legal cases surrounding consent. If a panel of doctors agree with the way a situation was dealt with then it's considered that the doctor gave enough information. think "what would a reasonable patient expect to know?"

Question 130

In terms of distributive justice, what could a utilitarian approach to maximising healthcare consider?

Answer 130

- maximise healthcare with the available resources - cost per QALY should be as low as possible.

Question 131

what are the pros and cons of the QALY system?

Answer 131

- it maximises the healthcare budget. - it discriminates against those with expensive healthcare problems. - it can discriminate against treatment for the same issues depending on other morbidities - eg two patients with community acquired pneumonia - one is fit and healthy, one has co-morbidities, QALY system may favour treatment of patient A alone. - They also favour younger patients.

Question 132

what competency rules are there for different ages? | when can treatment be provided without consent?

Answer 132

- patients over 18 are deemed competent unless proven otherwise. patients can suffer temporary loss of capacitance. - children 16-17 can consent to treatment, however they can't refuse it. (if they are competent) - Children under 16, their capacity must be proven (Gillick competency). they must be able to understand and retain information provided, weigh up the pros and cons and communicate an informed decision with their doctor. If patient isn't competent and doctor believes that parents aren't acting in childs best interests then legal action can be sought. - in emergency situations treatment may be provided without consent. attempts should be made to assess capacity, if not possible, a family member may give consent, if it is life or death then acting in the most beneficent manor is reasonable. -

Question 133

pregnant mother at term comes to hospital with complications and needs caesarian. She initially consents, then withdraws her consent last minute due to a fear of needles. The baby is in danger, how would you deal with this situation?

Answer 133

- although patient autonomy must be respected, it would be important to determine if the patient was suffering a temporary loss of capacity due to the stress and fear of needles. - delayed c-section can lead to severe forms of brain damage that can result in cerebral palsy. - this was seen in a case with a family of jehovas witnesses and a blood transfusion. The daughter consented to a transfusion, then after speaking with her mum retracted her consent. It was determined that she wasn't making a capacitous decision due to pressures from her mum. - In a similar way, because the patient has already consented, but is withdrawing consent due to a fear, it would be important to consider if she is capacitous. Does she understand the situation, is she able to retain information and weigh up the pros and cons of her decision for both herself and her baby, and is she able to communicate this information back to the doctors? - In terms of beneficence, and non-maleficence, the best option is to perform the c-section. - we are also considering two lives here. Although there may be maternal refusal, beneficence, justice and doing no harm to the foetus should be considered and may ethically overrule the refusal of a surgery (and this is heightened by the fact that she has consented). - If she is competent, try to empathise with her situation and understand why she has changed her mind. This will allow a solution to be worked. - if she doesn't have capacity then the healthcare team decide together on what the best course of action is.

Question 134

what are advanced directive and lasting powers of attorney?

Answer 134

- advanced directives - if a patient has a disease that is likely to reduce their capacity in the future, then they can provide responses to possible scenarios while they are competent. - lasting powers of attorney - in addition to advanced directives, patients expecting to lose competency in the future can nominate a health and wellbeing LPA who will make decisions in their best interest in the future.

Question 135

Ethics of euthanasia arguments for and against?

Answer 135

- we have palliative care as a specialty, and good palliative care should mean that euthanasia isn't necessary - palliative care doctors often report that patients who wanted to die some months before report improvements in mood. - allowing someone to live in pain goes against do no harm, and not allowing them to chose to die goes against autonomy. - we do however need to think about protecting vulnerable individuals. Vulnerable people may feel under pressure to end their lives due to feeling like a burden on their families and the NHS. - On the other hand, vulnerable people who are physically incapable are being discriminated against by not being allowed to end their suffering. - However, it's not the doctors who are directly preventing these people the ability to end their own lives, it's the individuals illness. - Consequentialism would suggest that in a lot of cases it should be permissible. Withdrawing someones life support and euthanasia both have the same consequences if they are done to prevent the prolonging of someones suffering. - would we see pressure put on individuals to end their lives because of needs like organ donation? - On the other hand, places like dignitas in Switzerland allow for active euthanasia, and this puts pressure on British citizens concerned about the same things. They may feel pressure to end their lives prematurely because they have to do so while they are well enough to travel.

Question 136

what is justice?

Answer 136

distributing the benefits and burdens of care evenly across society.

Question 137

Personal versus joint account model of confidentiality?

Answer 137

This is something that occurs in cases like genetic conditions. it it personal information and up to the patient whether or not to tell relatives, or, because it may affect them, is it considered joint information and therefore the doctor is able to share it with all who it concerns? The personal model fails to take justice into account as there is an asymmetry of information amongst those involved.

Question 138

medical time management?

Answer 138

- unwell patients should be treated as top priority. - TTOs should also be high priority because of bed blocking. These can often be multitasked with other things like speaking to a colleague. - anything involving patient safety is a high priority. - bloods and routine tests can be lower priority compared to these other tasks.