Management

Question 1

Presentation:

Reflect on your experience of leadership when working as a team member and how this will be useful as a core trainee

Answer 1

I believe both leadership and teamworking skillsa re essential to being an effective core trainee.

i) Clinical -On a recent stroke night shift i received a thrombolysis call so attended resus. Whilst there the charge nurse informed that there were 3 other calls that had just come in.

Given our target door to needle time is 30 minutes I was well aware that it would not be physically possible for me to provide good care on my own.

I displayed excellent delegation skills, situational awareness and initiative by discussing this with resus registrar and requesting an SHO and an extra resus nurse help me. I quickly briefed both on the minimum that would be required from then as neither had been trained in thrombolysis calls.

I also called the consultant on call early, this is the regular route of escalation, who was happy with the plan. All patients were seen and treated in a timely manner

Delegation - important with junior colleagues and in theatre

Situational awareness - Awareness about multiple unwell patients while on take/ on the ward

management - Previously I organised and lead a national global surgery hackathon aimed at medical students and science students, within a parent innovation conference.

Being organised and able to prioritise effectively was of paramount importance. I had a timeline within which I had to prepare various facets for the event. Furthermore, with a high volume of participants attending, being organised on the day afforded me flexibility when required and ensured the smooth running of events.

Throughout the event i was required to communicate both in a horizontal manner with my team members and a vertical manner for example with judges who I had recruited and the participants themselves.

Organisation - will be important in terms of managing my time between ward work, theatre time and continued professional development.

Communication - versatile + adaptive I will be exposed to patients and colleagues of differing seniority with whom ideally I will have strong working relationships with.

Personal - I created and fulfilled the role of strength & conditioning coach at the imperial college kabaddi club whilst studying.

In this capacity I lead warm ups at practice sessions, organised regular team gym sessions and also provided support to individuals who approached me with specific goal setting.

I demonstrated enthusiasm, commitment and was conscientious in my role. Being enthusiastic and committed in the team setting is important in difficult times which we are likely to face as trainees be it in the context of particularly heavy caseload or during academic work. Being conscientious of the thoughts and feelings of others will be important in promoting a good working environment for the entire team.

Question 2

i) Leadership in 3 words

ii) Examples of good leadership

Answer 2

i) Change, People and Results

ii) It is my belief that a good leader is someone able to inspire those who they lead to want to improve and perhaps change their own practice.

They are also supportive and aware of those who they are leading and able to assist them where possible.

An example that comes to mind is that of an eminent professor of UGI surgery I met through my training who told me the start of his journey was at the UGI department in Dundee:

• Through optomising the workflow and tightening up their practice he was able to improve the outcomes of the specific centre
• He told me that a good team is less about the place and more about the people in the team. This is important in our profession as there is a huge emphasis on the centre you work in for example working in London has a tag of prestige attached.
• I have deduced he meant this in more ways than one as I have seen his interactions with his department. He is confident and firm providing direction to his team whilst also being receptive to the ideas of others with regards to veins of research.

Question 3

Framework for answering questions regarding challenging situations?

Answer 3

SPIES

Seek Information - Gather information before jumping to conclusions

Patient Safety - Assess what the risk to patients are

Initiative - Try to resolve the situation then and there before escalation as this can be more damning

Escalate - Decide if it is important to escalate the situation - maybe its worth anonymously discussing it iwht someone senior first to see what they think

Support - Explore whether there is more than meets the eye - are there personal problems the subject of inquiry is facing? is there a lack of awareness of the wrong they are doing?

Question 4

An example of poor leadership

Answer 4

Remember - Change, People and Results

I attended a cardiac arrest call in my FY1 year where there were two registrars present.

The registrar standing at the end of the bed and assuming the position of leader of the arrest:

• Did not communicate or guide the team effectively
• When receiving results from various investigations or updates about the patients history did not attempt to relay this information to the rest of the team
• There was a lack of resource utilisation/awareness - the ITU team came and there was a delay in updating them on the patients history/current clinical status

I understand that crisis situations can be stressful and there may have been other people factors influencing this senior’s behaviour, however it is important to remain decisive and to utilise the resources to the patients benefit.

I also think in the midst of having two seniors present this is particularly important as having a single authoritative leader is crucial in allowing good cohesive management. When there are too many voices there can be confusion as to what should be done.

Question 5

What to do if other healthcare professionals are being obstructive?

Answer 5

SPIES

Seek Information - attempt to see the source of obstruction. Who is being obstructive? What is leading to their view?

Patient Safety - Is this directly compromising patient safety. Can the task being obstructed wait or must it to be done immediately?

Initiative - Try to discuss the situation with the osbtructors and perhaps recruit people who may be able to hold sway over the situation to resolve it.

Escalate - Discuss with seniors following the chain of command

Support - Reflect on the situation as a group with everyone involved - this should be prevented from happening again.

Question 6

Bed Pressures on an elective list?

Answer 6

SPIES

Seek Information - What cases need to be done? What are the combordities of the patients? Will all patients need a bed?

Patient Safety - Are there any urgent cases? Patients should be informed of cancellations at the earliest possible time

Initiative - See if there are any patients on the ward that can be discharged today and if the bed can be held? If any patients will be going to ITU after discuss with ITU to see if there are beds opening up today? Discuss with the bed management team to see if the patients can temporarily be placed anywhere else? Find out if any patients have management aspects that are more challenging therefore requiring mre urgent treatment - i.e. anticoaglation / sliding scale/ steroid users

Escalate - Inform the consultant of the situation and of the things you have gathered

S - Support the team be ensuring there are no errors in thi situation (patients need to be cancelled, there won’t be a surplus of patients to beds). Communicate with consultant

Question 7

Discussion regarding operation with a mentally incpacitous patient and their family?

Answer 7

Situation - Explain the situation to the family member and the patient allowing time for information assimilation

• use of appropraite language
• multimodal information transfer (pictures, leaflets)

Task - Explain they will need an operation

• gravity of the operation
• things that it will entail
• relevant risks

Action - Explain that we will need to

• discuss with other colleagues (anaeshtetics, geriatrics)
• A consent form of sorts will need to be filled
• given incapacitous - consent form 4 will need to be completed with us acting in her best interests

Result - She will remain an inpatient afterward for a period of time to monitor recovery and to ensure therapy support

Question 8

Post operatively deteriorating patient - how to handle conversation with family

Answer 8

STAR

SItuation - Important to clarify the family’s belief regarding current situation

• Talk through the different facets to the deterioration (pain, concurrent infections)

Action - Important to not attribute blame but explain there are complications

• Be honest about expectations regarding outcomes.
• Reassure that you will continue treatment or explain rationale behind making a patient palliative
• Try not to be absolute about the survival
• See if there are any further investigations that may be useful (X rays of joint replacements contributing to pain, is patient appropraite for ITU?)

Result:

• Continuously update the pateint where possible rather than having a single discussion when things get much worse
• Discuss with seniors and relay any thoughts regarding the clinical situation

Question 9

How to deal with an angry patient or parent. The source of anger being due to an omission.

Answer 9

STAR

Situation - introduce yourself.

• Ask them to voice their concerns and run through everything with them (therapuetic for the patient and allows you to be brough up to speed)
• Apologise for what has happened and avoid laying blame

Task - Explain what you need to do currently (Examine the patient/ Change a pat of the management)
Continue to empathise and reinforce the apology

Action - Make changes as appropraite to the care and contact seniors as required

Result - Do your best to ameliorate the situation

• Point patients towards PALS if they wish to make a formal complaint

Question 10

How to deal with an agressive patient/relative.

Answer 10

SPIES approach

Seek Information - From nursing staff, from the patient, from the agressor. Try to see why there is this commotion

Patient Safety - Is there a danger to the patient ( maybe it is their parent being angry )? Will they try to leae?

Inititiave -

Try to use your conflict resolution training to resolve the situation

• Explain the effect of their agression? Explain the consquences if they don’t de-escalate? Explain the way they’re making you feel?

Escalation -

• If this doesn’t work do you need to call security?
• Does anything need to be done to safeguard other patients?

Support -

• Contact other doctors, nurses, security, family members for help.

Question 11

How to deal with situations where other staff are angry/complaining about a colleague

Answer 11

SPIES

Seek Information - Important to gather all of the information

• Is there a back story
• Has the same concern come from someone else before

Patient Safety - is patient safety compromised by these actions?

Have patients been made uncomfortable>

Initiative - Difficult and action may vary based on yur relationship with colleague.

Consider asking the colleague subtly about the encounter

If you feel comfortable try to give a view point about the situation and see if it can be resolved

Escalation -

If it cannot be solved through you does this need to be escalted to the colleagues ES/CS?

Support -

Support the agrieved - Try to console them or calm them down if upset. Explain that you will do your best to help them in the matter. Don’t diminish their concerns

SUpport the incitor - If accepting of help point them towards the deanery based pastoral support system if relevant.

Suggest ways that you can think of which may be useful

Question 12

Challenges facing surgery in the future

Answer 12

Training - Reduction in working hours, Fewer Jobs at senior positions, More sub-specialised, Longer Training course, The risk of burn-out. Service provision role moreso than training sometimes.

Financial - Pay Cuts. Regarding the service and revenue - Restricted elective procedures, limitations on equipment purchasing

Management - Public Perception, Releasing Outcomes, Reduced consultation time.

Clinical - Antimicrobial resistance, Patient expectation increasing, Expert Patients,

Question 14

How would you know you are making good progress with training?

Answer 14

I think reflection is important to assess how one is progressing - I would do this through keeping my portfolio up to date and keep on top of my work placed assessments.

Asides from this setting regular goals and meeting them is important for progression:

• By doing this personal career related goals can be set and monitored and thus skills can be gained. For example I might want to attend more venous procedures on a vasuclar job and could go about trying to attend some lists which ahve more vein cases on them

I hope to meet regularly with my clinica/educational supervisor and to see what goals they think would be smart for me to pursue.

I would also monitor the person specifications for the next points in my training to make sure I am at par or above this specification to ensure I am not lagging behind

Question 15

What is the most interesting case you have managed?

Answer 15

I have to be honest and say it was a medical case.

A yound philipino nurse presented with recurrent abdominal pain and chest pain and raised CRP/ESR. She had been investigated previously at another hospital and even had a PET scan but nothing had been elucidated. She had been given steroids by a the treating medical team eventually which caused the symptoms to abate and the question was raised whether she had a vasculitic condition of some variety. All autoimmune investigations were negative however.

She represented to us on this occasion with the same sympatamatology and once more only a raised CRP. This time on the CT scan there was notes of splenic hypodensity. This caused concerns regarding whether she in fact had a lymphoma or other haematological condition.

• My consultant was not keen to biopsy the spleen due to the bleeding risk and the rheumatology team was not happy to start steroids in case we were masking a lymphoma

She was dischaged when the pain had abated with plans to be followed up in the rheumatology outpatient clinic.

• I later found she had had a splenic biopsy and it was in fact AFB positive and Lowenstein- Jensen Medium cultured Mycobacterium Tuberculosis.

Learning points for me were:

• The heterogeneity of both lymphoma and TB presentations
• The dangers of blindly prescribing steroids
• And of course reinforced that TB should be somewhere on my differential diagnosis

Question 16

Clinical Situation when you have needed help?

Answer 16

I think its important to appreciate when you are out of your clinical depth. This is primarily in order to maintain patient safety.

Recently:

An inpatient with meningitis of uncertain cause who was being worked up complained to a nurse of blurred vision.

I reviewed her and found that she had what i believed to be a sixth nerve palsy and attempt fundoscopy. Both fundi looked abnormal but I hadn’t seen enough to be conclusive about the severity of the pathology.

I immediately called my registrar expressing concerns about raised intracranial pressure. She came to see the patient and found bilateral papilloedema + haemorrhage on one side. This led to her imaging being expedited and us starting her on acetazolamide.

Question 17

How do you stay upto date>

Answer 17

Currently, I am a subscriber to the BMJ, uptodate and to medscape. I receive email updates from the latter and like to learn both major medical and surgical advancements.

Recently I read an opinion article in the BMJ regarding arguments for and against screening everyone for atrial fibrillation with an ECG over the age of 50.

It highlighted the importance of AF as a condition to prevent more serious pathology such as stroke or mesenteric embolus giving reference to the Wilson’s Criteria for screening.

A recent cohort study involving more than 5000 patients incidentally found to have incidental AF found the stroke risk reduced from 4% to 1% when anticoagulated.

The readers argued that AF can be easily and inexpensively screened for with single lead ECG and argued for its uptake.

Question 18

What is clinical governance

Answer 18

Clinical governance was first cited in 1998 by Sir Donaldson. It encompasses that NHS trusts should strive towards continuous quality improvement and the safeugard of high quality care.

Pillars are:

Patient Involvement

Information Governance

Risk Management

Audit

Training

Effectiveness & research

Staffing

Question 19

Have you had any complaints raised against you or your team?

Answer 19

I haven’t had any complaints raised against myself but while on a surgical attachment a patient’s family expressed that due to the consultant’s expertise not being in Upper GI Malignancy and their father having been found to have an advanced cholangiocarcinoma wanting him to be moved to a specialist unit:

I discussed this with the family at length letting them vent as I felt much of their anger culminated from fear and anguish at the diagnosis.

• I calmly explained that we had referred them to the upper GI team already and they had said no operative management would be given
• I explained we had performed the necessary investigations already
• I explained that if they wanted to formally complain that PALS was avialble to them
• I also reiterated that we were always happy to speak to them and were ready to update them on a regular basis and also to discuss further management.

Result:

• They were happy for him to remain under our care before we discharged him to outpatient management under oncology

Question 20

Who is responsible for your learning?

Answer 20

At a local and regional level - The RCS, the surgical advisor committees and the local programme directors are responsible

Immediately - my educational supervisor and ultimately myself are integral in ensuring my learning is maintained. I think that personal motivation to progress and improve will dictate how much I learn and progress

My complying with work based assessments and ensuring that i make these valuable and fruitful tasks rather than simply tick box exercises is also useful

Question 21

Are work based assessments useful?

Answer 21

Work based assessments are useful as they direct learning. As working hours have declined simply expecting learning to come by osmosis is not realistic. Having some guidance on learning points is useful.

We are expected to complete 42 work based assessments per year which can be time-consuming and viewed as unimportant. However with comprehensive reflection in tandem with these WBAs they can be made to be more meaningful and laced with deeper learning.

Question 22

Have you ever witnessed someone else make a mistake?

Answer 22

Situation: Medical student in theatre with vascular team while they performed a hybrid procedure. I noticed a hair fall in to the wound from the consultant’s head.

Task: Although worried about rebuke I spoke up after a few seconds and told the team what I had seen without mentioning from whose head it had fallen

Action: The team stopped what they were doing and the consultant retrieved their hair from the wound and after looking at it said it was likely to be his own. He washed out the wound further before continuing with the surgery.

Result: I’m not sure whether this was mentioned to the patient or put on the operation report. I believe that this event falls into the near miss category. The duty of candour tells us that:

• the organisation should be informed
• that the patient should be informed if it will be benificial to them

Question 23

Legal guardian not present for a minor who needs a procedure/treatment

Answer 23

Seek information: As the legal guardian is not present you cannot gain consent. but if the procedure is important and you cannot simply wait for the guardians to show up what should you do

Try to talk to the minor:

• Where are guardians?
• What do you they understand about the current scenario?
• Is there any way in which we can contact them?

Patient Safety:

How urgent is the procedure?

Initiative:

If able to contect guardians - then consent can be gained.

If not able to contact guardians - doctors must act in best interest especially if the intervention cannot be delayed

Escalation:

Contact the guardians.

Fill in consent in best interest if guardiasn unavailable and procedure can’t wait.

Contact Seniors

Support:

Trust legal team + seniors for yourself

For the patient try to be supportive and kind.

Question 24

Colleageus arguing over theatre time

Answer 24

Seek Information:

• It is important for trainees to get into theatre?
• Are there added pressures at the moment- Interviews, portfolio, ARCP?
• Are there other things that are causing tension between them?
• Any problems at home?

Approach individually and then collectively to get a good reflection of situation

Patient Safety - Priority is safe ward coverage of patients and that junior/senior staff are not left unsupported

Initiative -

Look through the lists together.

Devise a rota so that everyone is happier whilst ensuring adequate cover.

Try to turn it into a QIP for the team so this is a portfolio enhancing event.

Offer to introduce regular rota meetings to ensure that people continue to be happy

Escalation/ Support -

If this continues to be a problem then discuss with other SHOs to see if they know anymore about hte situation

Then it can be discussed with a registrar.

Ultimately it may need to be discussed with the respective colleagues’ CS/ES

If this is not useful then it may be worth talking to someone higher up the chain like the trainee lead/programme director

Question 25

What would you do if a registrar/SHO undermines a plan you put in place in front of a patient/consultant?

Answer 25

SPIES

Seek Information - You have been undermined by a colleague which is not acceptable.

As the aptient is in the scenario it is best to leave this for later.

Patient - patient safety comes first so I would apologise to them after the ward round if a mistake had been made.

Initiative - I would discuss the incident with the colleague:

• Don’t appreciate being admonished in front of patients/ other colleagues and would prefer the feedback to be in private in the future
• Would appreciate formal teaching on the clinical sitaution so you could improve
• Anything else that needs to be done for the patient in view of mistake?

Escalation -

If the situation doesn’t improve -

More senior SpR

CS/ES

Question 26

You are informed you have received many of the same complication from a recent list

Answer 26

Seek Information -

As operating doctor you are responsible for these complications.

Important to route cause analysis to find out what steps were taken to mitigate for the complication and if anything was omitted that may have caused it.

Have you had similar problems in the past?

Patient Safety -

As patient safety has been compromised this should be reported.

Ensure patients are receiving effective management plans for their complications

Initiative -

Report the issue to CORESS - Confidential reporting system for srugery

Try to reflect on the procedures and see if you can find any places to improve.

Escalation -

Speak to senior colleagues about this (registrars, consultants, ES, CS) - don’t be ashamed and try to learn from it

Formal documentation for complication audit

Question 27

Examples of never events

Answer 27

1. Wrong site surgery
2. Foreign body retained post-op
3. Maladministration of insulin
4. Air embolism
5. Patient misedintification
6. Inappropriate administration of daily methotrexate

Question 28

How are surgeons responsible for patient safety in theatre

Answer 28

Before theatre:

Knowledge of co-morbitidies

Do any drugs need to be stopped/ started

Transfer patient safely

Ensure correct equipment is available and that HDU/ITU bed is avalaible if necessary

Infection measures - Clearn patient carefully, scrub carefully, antibiotics given if indicated

During operation:

Patient correctly identified/ correct site/ correct implants or prosthesis

Operate within limits

Follow instructions from seniors carefully

Communicate with anaesthetics teams if things aren’t going as planned or for general steps to procedure

Careful haemostasis

After operation:

Ensure recovery

Post operative antibiotics/ analgaesia

Ensure any medications that need to be started or prescribed

Question 29

Describe a difficult problem you have faced at work and how you have dealt with it?

Answer 29

Situation - While on call I was bleeped by a nurse:

Gentleman on the ward having had an intentional rivaroxaban overdose was threatening to leave the hospital

Task -

When i arrived the gentleman insisted he be allowed to leave and professed that he would try to take his life once he left.

Given the intentional overdose and that he had not been reviewed by the psychiatry team I did not believe he’d had an appropriate psychiatric assessment so needed to be kept as an inpatient.

The nursing staff explained that no section had been put in place for him so I filled one out. However in the process of doing so he absconded the ward.

Action -

Prioritising patient safety - I asked the senior sister to call security while I called the police believing he was likely to make it out of hte hospital.

I appreciated the legal documentation required for this situation so - In the meantime another team member sent the Section 5(2) Request internally to ensure it was valid.

Result -

Within the hour the patient was found by the police and brought back into the hospital.

I came to see the patient when he was back and practised openness about what had happened and why i did what i did.

Question 30

How did you make a difficult decision recently

Answer 30

Situation - Patient with severe type 1 respiratory failure on stroke ward. On optiflow for the past 48 horus and HDU had recommended not for further escalation.

• He was not known to have any visitors at all

Task - He begun to deteriorate further and I noticed his respiratory rate falling. He was between V/P on AVPU. I was deciding whether he should continue on optiflow and if anything further could be done for him or if active treatment should be ceased and to prioritise comfort

Action -

To make this decision I rationalised the situation:

• He had bilateral pneumonia and had elements of both hypovolaemic and cardiogenic shock.
• After reading the entry from HDU earlier and coming to the conclusion he would need intubation and ventilation + inotrpes to survive I decided that he should be for comfort management

Second opinion- I contact the medical registrar who agreed with my assessment.

• I asked a nurse to call the NOK (a friend who he hadn’t seen in many years) if he would want anyone by his side. She said that he would want his last rites read so she called the on call chaplaincy team who read him his last rites.

Result - The patient passed away within 1-2 hours of me stopping active treatment.

Question 31

Have you ever made a wrong decision - how did it make you feel?

Answer 31

S - On geriatrics I was bleeped by a nurse who handed over that a confused patient who was known to me had been found sat up against the floor. He was known to have prostate cancer but no bony metastases

T - I reviewed the man obtained a collateral history from another patient in the ward. The patient had slid to the floor and against the wall landing on his bottom.

A - After performing an examination on the gentleman including a musculoskeletal examination I only found some mild superficial tenderness on his medial distal thigh with no bruising. Otherwise examination was unremarkable. He managed to walk back to his bed unaided with my supervision and I noticed a mild antalgic gait .

A few days later I was on call once more and handed over to ensure his clotting was done as he would be going for a NOF repair the next morning.

They had picked up the fracture incidentally while performing a CT-Abdomen Pelvis to investigate constipation.

R - I felt guilty initially that I had actively chosen to not perform imaging based on my clinical judgement.

I also felt glad that it had been picked up and was going to be repaired.

I felt resolved to learn from this event and wrote a refelctive piece in my portfolio. I now have a much lower index of suspicion for requesting pelvis x rays.

I sought support from a registrar and informed my consultant of the mistake who had agreed with my management plan and offered advice of having a high index of suspicion for fractures in elderly patients who may have altered pain localisation.

I completed an IR1 against myself

Question 32

Describe a time where I supported a colleageu at work

Answer 32

Situation - Upon starting my first job as an F2 at board round the consultant had said something insulting to an F1 in front of the MDT

Task - I approached the F1 and consoled him.

He admitted that this hadn’t been the first time the consultant had been rude to him.

I empathised with him explaining that it must knock his confidence given he has just started working and wasn’t a good reflection on what consultants as a whole were like.

I encouraged him to speak to one of the other consultants about what was going on as there was no registrar on the team.

I offered to speak to one of the other consultants on his behalf if he didn’t feel empowered to do so himself.

Action - He spoke to one of the other consultants and explained that I had witnessed this occurence.

They were supportive of him and said they would speak to him privately to try and stop this happening in the future.

The consultant spoke to me to verify the story.

Result - The F1 did not mention further episodes from said consultant.

I reflected on the bullying policy at work and ensure I conduct myself in a friendly and approchable manner at all times.

Question 33

What is empathy

Answer 33

Empathy is the ability to recognise what somebody might be feeling and for communication/interactions to reflect that understanding. We may not have personal experience in what our patients/their relatives are going through but to try and understand this is to be empathetic.

For example in my first month as an f1 a 48 year old man on my team was diagnosed with metastatic bladder cancer.

• He had a daughter about my age and his wife was present all the time.
• Pre-sickness he was the major source of income for the family

Besides feeling sympathetic to them regarding this terrible diagnosis. In conversations with the palliative care team we discussed:

• Whether he might want to go back home
• Whether the family were financially stable or if they’d like to apply for a grant
• Whether they wanted him to be cared for at home or in a hospice.

Despite the diagnosis he maintained that he would survive and fight it off.

• I guess i empathised with him in this aspect more than any other. The need for him to feel like there was hope was so important so I personally refrained from mentioning his mortality as did his family.

Question 34

Empathy / Sensitvity towards a colleague

Answer 34

Situation - Recently my CT2 has been short-tempered. She is usually cheery and I have known her for approximately 1 year and a half overall.

I asked her if everything was okay and she confided that she felt our current job was:

• not teaching her anything
• she felt that she was beign treated like a secretary

Task - I discussed this with her at length allowing her to vent her frustrations.

I asked her if everything at home was okay to make sure there was no other people factors invovled here.

Action - We spoke about how she could improve her learning given it is important for her to achieve things for her CMT portfolio

• I suggested that she go to clinic twice a week and that I was happy to hold the fort during those time periods given that neurology is largely outpatient. We agreed that I could go once a week also.

Results - This is an ongoing trial period so its difficult to assess the results but I think some time in clinic which will both:

• improve her portfolio
• help teach more about management of neurological conditions
• give her a break from the jobs on the ward which may make her feel undermines given her seniority.