SJT Paper 1 Flashcards
Your consultant Dr Jackson has asked you to prescribe a second antibiotic for a patient who has a chest infection which has been slow to respond to initial treatment. Later that day, a pharmacist informs you that the new antibiotic is not in the hospital formulary. She tells you that the new antibiotic should not be used because of the risk of clostridium difficile infection.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate)
A. Prescribe what the pharmacist advises
B. Explain that Dr Jackson requested the antibiotic and he would be the best
person to speak to about the prescription
C. Agree to contact Dr Jackson to discuss the prescription
D. Ask your specialty trainee* to review the patient to enable an informed
decision
E. Do not change the prescription and make a record in the notes of the
pharmacist’s concerns
Answer: CBDAE
Rationale: This question assesses your professionalism and how to manage your working relationships. The most appropriate action to take would be to contact your consultant (C). As Dr Jackson, your consultant, made the decision about the antibiotics, it is courteous and also in the patient’s best interest to inform him of the pharmacist’s advice. It is preferable for you to contact your consultant yourself (C) rather than expect the pharmacist to have to repeat the same information to multiple members of the same team (B). The next most appropriate action would be to ask a registrar/specialty trainee, who has more experience, to review the patient (D) as there may be complexities surrounding the patient of which you and the pharmacist are not aware. A review by a senior doctor may enable a more robust clinical decision. Option A suggests that you do what the pharmacist recommends without further discussion with her, your consultant or any other member of your team. It is Dr Jackson’s team (of which you are part) who are directly responsible for the patient’s care and there needs to be clear communication about changes to the management plan (A). Option E is not addressing the problem (E).
On the morning ward round, your specialty trainee* said that Mrs Anderson is medically fit following her total knee replacement and could be discharged if Occupational Therapy* feel it is appropriate. The occupational therapist has assessed Mrs Anderson and believes it is safe for her to go home with a care package that has been arranged. It is now 4pm and the nurse informs you that Mrs Anderson is demanding to see a doctor as she does not feel that she is ready to go home yet. An elective admission is waiting in the day room for Mrs Anderson’s bed.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Ask Mrs Anderson about her concerns
B. Ask a senior colleague to speak with Mrs Anderson
C. Ask the bed manager if he can find another bed for the elective patient
D. Explain to Mrs Anderson that the bed has already been allocated and she has to go home
E. Ask the occupational therapist to come and speak to Mrs Anderson with you
Answer: AEBCD
Rationale: This question looks at your ability to cope with pressure but also maintain a patient focus Your primary duty is to alleviate the concerns that Mrs Anderson has in relation to her discharge and reassure her that it is safe for her to go home (A). Understanding her concerns will be the first step to reassuring her that it is indeed safe for her to go home. The occupational therapist is likely to have a greater experience in dealing with questions raised by patients who have anxieties over the safety of discharge once it has been clarified that the patient is medically fit for discharge (E), although your senior staff may be able to assist you in dealing with Mrs Anderson’s concerns (B). Keeping her in hospital without addressing her issues may actually increase the risk to Mrs Anderson of suffering a hospital acquired infection and is an inefficient use of hospital resources (C). Whilst not your highest priority, you should always be aware of how patients are being allocated to beds and if it is clear there could be a delay in discharging Mrs Anderson, it would be appropriate to ask the bed manager to find a different bed for the elective patient. Trying to coerce Mrs Anderson to go home by suggesting that she is depriving another patient of a hospital bed is inappropriate as Mrs Anderson’s concerns remain central to the management of this situation (D).
You are working on a busy paediatric ward. Your shift was meant to finish at 7pm, but it is now 9pm on a Friday, and you are still trying to complete some of your routine tasks from the day. This has happened on a number of occasions in the last month and you feel exhausted as a result. Your workload is also having a negative impact on your social life.
Rank in order the importance of the following considerations in the management of this situation (1= Most important; 5= Least important).
A. The impact on your own wellbeing if you are not able to take time to rest
B. The risk to patient safety if working whilst tired
C. Your right to finish at the designated time
D. That your consultant may give you a poor reference if you are not completing your tasks
E. That you are repeatedly disappointing your friends by not attending social events with them
Answer: BACDE
Rationale: This scenario is about maintaining a good work life balance to work effectively and provide good patient care. As a doctor, the care of the patient is your main concern (B). Your own health has to be looked after in order to provide good patient care (A). Finishing on time is suggestive of an appropriate and achievable workload and indicates good work life balance (C). Getting a poor reference may be important personally but it should have no direct or immediate impact on patient care (D). Disappointing your friends will be the least important consideration in these options as it does not affect the level of patient care and should not influence your decisions on the ward (E).
You are working on the Surgical ward and you are about to attend theatre to observe your consultant undertake a complicated procedure. This will be a good learning opportunity for you and you anticipate being in theatre for about two hours. As you are about to leave the ward, one of the nurses tells you that a patient needs to have her medication reviewed prior to receiving her next dose in three hours’ time. He tells you that he believes one of the other FY1 doctors has been making prescription errors. You also notice one of the patients on the ward beckon you over to his bed urgently. You know from experience that the patient often just wants to have someone to talk to as he gets lonely.
Rank the order in which the following tasks should be undertaken (1= Do first; 5= Do last).
A. Review the patient’s dose, as requested by the nurse
B. Respond to the patient’s immediate question or query
C. Attend the theatre to observe the procedure
D. Take steps to investigate the nurse’s allegations about prescription errors further
E. Spend more time with the patient if he wants someone to talk to
Answer: ABCDE
Rationale: Preventing a potential medication error and ensuing patient harm should be the absolute first priority (A). The patient beckoning you may have a very valid and important question and therefore this should be acknowledged as a priority (B). Attending theatre is a good learning opportunity which will help you deliver better patient care (C). Ensuring that the nurse’s concerns about errors are addressed is very important, but not immediate (D). Spending time with a patient is desirable but can be done by others if necessary – you will need to draw it to the attention of another member of staff (E).
It is 6pm and you are clerking a patient who is to undergo an elective splenectomy the next morning. Before he left, your consultant asked you to prescribe the antibiotics and immunisations that need to be given that evening so that surgery can proceed tomorrow. You now cannot find the folder containing the pre-operative protocols and it is not available on the intranet. Your consultant has already gone home.
Rank in order the appropriateness of the following actions in response to this
situation (1= Most appropriate; 5= Least appropriate).
A. Seek advice from the on-call microbiologist
B. Look in the British National Formulary* and prescribe what is suggested
C. Refer to national guidance for pre-operative protocols
D. Ask the nurse in charge of the ward what is normally given
E. Seek advice from the surgical specialty trainee*
Answer: EABDC
Rationale: This question is assessing your ability to safely and responsibly clarify important clinical information and select how and where to get help. In this scenario, the antibiotics and immunisations clearly need to be administered that evening. The most logical person to contact would be a senior member of your own team who is also responsible for the patient and who would be likely to have knowledge and experience of prescribing these antibiotics in that hospital and for that consultant (E). The second most appropriate thing to do would be to contact the on-call microbiologist (A). Whilst they will certainly know which antibiotics are required and also be aware of local hospital policy, they should not be the first point of contact for routine non-emergency queries. The third most appropriate option is to look in the BNF and prescribe what is suggested (B).This is less preferable than Option A as the BNF does not take into account local policy and preferences. This behaviour would however be considered safe and appropriate (A). The next correct option is to consult with the nurse in charge on the ward (D). Whilst the nurse in charge may well be very knowledgeable and experienced, it is not appropriate to prescribe any medication purely on the advice of a nurse without consulting further with a senior medical colleague or confirming the dose etc in the BNF. National guidelines would be the last place to get information in this situation (C). Local guidelines are based on the national ones but they will include information specific to local circumstances. It is always best to use what has been locally agreed first but as a last resort, the national guidelines may be helpful.
You are looking after Mr Kucera who has previously been treated for prostate carcinoma. Preliminary investigations are strongly suggestive of a recurrence. As you finish taking blood from a neighbouring patient, Mr Kucera leans across and says “tell me honestly, is my cancer back?”
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Explain to Mr Kucera that it is likely that his cancer has come back
B. Reassure Mr Kucera that he will be fine
C. Explain to Mr Kucera that you do not have all the test results, but you will speak to him as soon as you do
D. Inform Mr Kucera that you will chase up the results of his tests and ask one of your senior colleagues to discuss them with him
E. Invite Mr Kucera to join you and a senior nurse in a quiet room, get a colleague to hold your ‘bleep’*, then explore his fears
Answer: DCEAB
Rationale: This question places you in a challenging situation and explores your communication skills. It is not an FY1’s responsibility to break bad news to a patient in this context with incomplete information as the full results are not available yet. It would be most appropriate for a senior colleague to speak to Mr Kucera with regards to his diagnosis (D). Informing Mr Kucera that you will speak to him as soon as you get the test results back would still be appropriate as you are giving him some information, although this may not necessarily mean that you would be providing him with the diagnosis (C). It may be appropriate to discuss Mr Kucera’s fears with him, but by doing this you may not be attending to other ill patients and are asking a colleague to take on your responsibility by holding your bleep (E). It may also become a difficult conversation when you do not have full details of the results. It would not necessarily be appropriate to tell Mr Kucera that his cancer is back as this has not been confirmed (A), however it would be inappropriate to provide false hope to a patient when preliminary investigations are strongly suggestive of a recurrence (B).
At your morning handover/briefing you are reminded by Infection Control* that all hospital staff should wear shirts with short sleeves. When wearing long sleeves, they must be rolled up and secured, particularly when having clinical interaction with patients. During your shift, you notice that your FY1 colleague always has her long sleeves down.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Tell Infection Control that your colleague is not complying with their policy
B. Speak directly to your FY1 colleague about your observation
C. Raise your observation with the nurse in charge of the ward
D. Do not say anything immediately but monitor the situation over the course of the next few days
E. Discuss the situation with your specialty trainee*
Answer: BCEDA
Rationale: This question is looking at your communication with team members and patient focus. All doctors have a duty to raise concerns where they believe that patient safety is being compromised by the practice of colleagues. However, doctors strive to provide the best care possible to their patients and this situation may have arisen out of some misunderstanding. It is best therefore to speak directly to your colleague to explore the issue (B). Infection control is not just the responsibility of doctors but the whole team of staff and indeed the organisation. The nurse in charge of the ward although not a direct line manager will have a key role in ensuring standards are met and so would be a sensible person to alert (C). Your specialty trainee may be able to help address this situation, though this option is less likely to explain directly the reason for your colleague keeping her sleeves down (E). Monitoring the situation (D) is less appropriate as it does not immediately address the problem. However, it is more appropriate than involving Infection Control at this stage (A) as this would risk damaging your professional relationship with your colleague and does not explore the cause of the problem.
You recently discharged two patients from your ward with similar names, who had undergone similar procedures. Arrangements have been made for both patients to receive follow up care in the community. When checking the patient records, you realise that you mixed up their discharge letters and sent each letter to the wrong patient. This means that each patient will receive the other patient’s treatment advice.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Inform the consultant of the mix up
B. Seek advice from an FY1 colleague about what you should do
C. Adjust the original letters in the patients’ records
D. Trust that health care professionals providing follow up care in the community will correct the error, apologising to the patients for the mistake
E. Contact both patients to explain that there was a mix up
Answer: EABCD
Rationale: Although the patients have had similar procedures, we can be sure that they are very different individuals. Their subsequent need for information and management may be very different. The mix up with the letters causes two significant problems – the potential for the occurrence of inappropriate clinical management based upon inappropriate information, and a breach of the professional responsibilities regarding patient confidentiality. Management of the former requires some urgency. The latter requires an apology to both patients. Only answers A and E address both of these problems. Choosing Option (E) makes inappropriate clinical intervention less likely to happen. Then the consultant must also be informed of the mix up (A). The other three options fail to address the primary concerns. Seeking advice from a peer is an appropriate thing to do (B), but a more senior team member would be more appropriate. It would be appropriate to enter information that there had been an error into the case notes and indicate that the specified information did not relate to this patient (C). However, alteration of the case notes with the intention or effect of covering up an error, e.g. removing evidence, would be an extremely inappropriate and unprofessional act. Option (D) does not address the situation or put safe patient care foremost and is an inappropriate act.
You are working on a surgical ward and are on your way to check the discharge of a post-operative patient, Joan, who is due to be transferred to a rehabilitation hospital. You have been advised by the ward manager that Joan’s bed is needed urgently for a newly arrived patient. When you arrive at Joan’s cubicle, her daughter, Allie, tells you that her mother has been complaining about her chest and is struggling with a cough. You review the observation chart and listen to Joan’s chest, which does not indicate a problem. Allie insists that her mother has a chest infection and should not be discharged.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Ask the ward nurse to inform the rehabilitation hospital that Joan’s condition needs assessing on arrival
B. Inform Allie that she should insist on a further review of Joan’s condition when she arrives at the rehabilitation hospital
C. Advise Allie that you will delay the transfer in order to consult with a senior member of your team
D. Advise Allie of the urgent need to discharge her mother to create space on the ward
E. Contact the rehabilitation hospital and write detailed notes outlining Joan’s symptoms and possible investigations to send with her
Answer: CEABD
Rationale: This scenario is about understanding roles and responsibility, communication skills and understanding of the wider teams in the NHS. As an FY1 the roles and responsibilities include decision making with assistance. The FY1 should seek an opinion of a senior colleague, if not a consultant, when there is uncertainty whether the patient’s situation has changed and the family is involved. The FY1 should inform the patient/daughter of a possible delay while the team decides on a plan (C). Ensuring that there is good handover and communication to enable the rehabilitation hospital to conduct possible investigations is also appropriate but it defers the responsibility to the rehabilitation hospital (E). Involving the nursing team at both the discharging and admitting hospital is next in being appropriate (A). Counselling the daughter that the hospital will have been informed already and that they could expect an early review of the patient is a fair point (B). Option (D) is the least appropriate as it does not address the patient’s safety and is never an acceptable explanation if an adverse event were to occur.
You joined a new team three months ago, and you work with two specialty trainees*, Anne and Emma, and an FY2 colleague, Malakai. You notice that the team works well when Anne is present, but when Anne is on leave or absent from the workplace, Emma and Malakai become very dominant and often undermine your decisions in front of patients.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Seek advice from a more senior colleague on how to improve team relations
B. Discuss your concerns with all team members
C. Request to be assigned to a new team
D. Document Emma and Malakai’s behaviour towards you
E. Wait another week to see if the situation improves
Answer: BADEC
Rationale: This question is about effective teamwork and how you should communicate in a professional manner with other team members if and when you feel that your contributions, decisions and confidence are being undermined. The most appropriate option is to discuss your feelings with the whole team; some team members may need to be made aware of the effects of their behaviour (B). Seeking advice from a more senior colleague is useful (A), and will give you a sense of support and an opportunity to discuss the most appropriate actions to take, but it does not address the issue with the team members involved. Option A is however preferable to Option D, which can provide useful evidence and self-reflection of your reactions to the behaviour of your team members, but once again will not address the issue directly with the team members involved (D). It is unlikely that waiting another week will improve the situation without your direct action (E), but option E is preferable to option C, because requesting to be assigned to a new team does not address the professional issues of working effectively in a team at all, and is therefore least acceptable (C).
You work on the Breast Surgery unit. Because of recent advances in surgical techniques, inpatient stay has dropped from five days to an overnight stay. This means that you seem to spend all your time clerking in patients and the number of learning opportunities has reduced as a result.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Take on a position of responsibility as part of the junior doctors’ committee
B. Ask the Foundation Programme Director* if you can move to work at another unit
C. Ask your consultant if you can support outpatient clinics and theatre sessions
D. Offer to assist your FY1 colleagues on other busier wards
E. Inform the Foundation Programme Director that the job should be reviewed to include more learning elements
Answer: CDEBA
Rationale: This question is about demonstrating a commitment to professionalism that benefits both yourself and patients. Asking to be scheduled for outpatient clinics and theatre sessions is an active approach to learning which also enables you to contribute and may improve the value of the post for future doctors if that activity becomes part of the culture of the team (C). Whilst offering to assist colleagues on other wards enables you to contribute actively to the hospital in which you are employed, and demonstrates good team working, it doesn’t necessarily contribute to the team to which you have been assigned (D). Option E would enable to the Foundation team to help both you and the clinical team examine whether changes are needed, and is preferable to Option B, which is a less constructive approach (E, B). Taking on additional positions of responsibility, whilst admirable, is something that you should do because you want to, and can fit in around your professional life both in this, and other teams to which you will move (A).
It has come to the end of your shift, but you have agreed to stay on the ward for another hour due to unforeseen circumstances. A patient, Mr Griffin, is admitted to the ward from the Acute Admissions Unit* (AAU). You notice that Mr Griffin does not have a drug chart or management plan, which should have been completed upon admission.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Contact the AAU to discuss Mr Griffin’s management plan and drug chart
B. Ask the nurse in charge to request the management plan and drug chart from the AAU as soon as possible
C. Send a message to the FY1 doctor on the next shift stating that Mr Griffin was unfortunately admitted without a drug chart or management plan
D. Handover to the night shift FY1 doctor to chase the drug chart and management plan
E. Inform a senior doctor (specialty trainee*) that Mr Griffin was admitted without the correct paperwork
Answer: ADBEC
Rationale: This question is about putting the patient first whilst understanding the extent, and boundaries, of your professional responsibilities. Contacting the admitting unit to discuss the patient’s management plan and drug chart allows you to make a clinical judgement as to whether it would be safer for the patient if you stay even later to fill in the paperwork, or whether it would be safe to handover reliably to another doctor (A). Ensuring a proper handover (with documentation) with the night-shift FY1 is acceptable (D). Asking the nurse in charge to contact the admitting unit achieves a similar result, but is less reliable, and since you have not contacted a specific doctor for a medical task, you will have less certainty that it will be acted on (B). A more senior doctor will be in a position to ‘chase up’ the admitting unit to complete the relevant paperwork and drug chart, but they will also have to other duties that require attention from someone at their level (E). There is uncertainty whether the doctor on the next shift will receive and act upon the message, thereby endangering patient safety and patient care, and is therefore the least appropriate (C).
You are working on a respiratory ward. This ward is attached to a nationally acclaimed academic department. There are posters advertising research projects in all patient care areas. You overhear a patient telling a relative that he is concerned that his personal information will be used in research and made available for all to see.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Tell a nurse what you overheard and ask if she can reassure the patient regarding his concerns
B. Ask the ward manager if communication can be provided to patients explaining that patients’ involvement in research is only carried out with their
permission
C. Ask the patient why he has concerns about the confidentiality of his personal information
D. Reassure the patient that research will not be carried out using his personal information without seeking his permission
E. Inform the patient’s relative that his personal information will not be used without his permission
Answer: CDBAE
Rationale: This question is about addressing the concerns of a patient and providing reassurance. By asking the patient what his ideas and concerns are you can provide specific and relevant reassurance (C). Giving reassurance without discussion may result in you not gaining a full understanding of the patient’s concerns leading to ongoing worries (D). Option (B) is a useful action in due course, but does not address the immediate issue. Delegating the responsibility for reassurance to someone else is less reliable, as you cannot be sure the task will be completed in a timely fashion (A). Speaking to the relative and not the patient is least acceptable as you are not directly addressing the concerns of the patient (E).
It is 8am and you have just finished a busy night shift on the Acute Admissions Unit* (AAU). Mr Dean, a patient on your ward with acute renal failure, needs his blood tests to be re-checked in four hours’ time. You approach Gerard, your FY1 colleague, who is starting his shift on your ward. You attempt to hand over the information relating to Mr Dean’s case to ensure that the blood tests are carried out. Gerard says angrily that he has a long list of other patients to see and has just been called to an emergency situation on another ward. He refuses to accept your handover.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Stay on the ward to do Mr Dean’s blood tests yourself
B. Explain to Gerard that he is now responsible for attending to patients on the ward so should accept your handover
C. Find another appropriate colleague to whom to hand over Mr Dean’s case
D. Advise Gerard that you will leave detailed instructions regarding Mr Dean’s case in the patient’s clinical records for him to follow up later
E. Inform a nurse of Mr Dean’s case, asking him or her to find another doctor to conduct the patient’s blood tests
Answer: BCDEA
Rationale: This question is about assertiveness and ensuring the completion of tasks. Clarifying responsibilities with your colleagues enhances communication and demonstrates appropriate assertiveness (B). Handing the task to another doctor ensures the task will be completed in the patient’s best interests but would mean another colleague undertaking the Gerard’s tasks in addition to their own (C). Leaving written information about a patient in their clinical record is acceptable, but does not ensure that the task will be completed (it seems an easy option, but does not clearly handover the responsibility) (D).Similarly with Option (E), informing a nurse is less reliable as you have not handed over the task to a specific doctor, and the nurse does not know which doctor to contact (E).Taking the blood test yourself will ensure it is taken, but you will risk errors due to fatigue and not have the opportunity for adequate rest (A).
You are admitting a patient who does not speak fluent English for an elective operation. He does not have a translator or a relative present. You know from his notes that the patient speaks Urdu. It is apparent that his pain has worsened since his clinic appointment. You ask the patient how long he has been suffering from this pain. The patient appears to understand what you are saying but cannot reply. He is clinically stable.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Ask a doctor who speaks Urdu to attempt to communicate with the patient
B. Continue trying to communicate with the patient to ask about his symptoms
C. Telephone the NHS language services to obtain a translator
D. Ask a senior doctor for advice on how to proceed
E. Telephone the patient’s next of kin to ask about the patient’s medical history and symptoms
Answer: ACDEB
Rationale: There are clear NHS guidelines about communicating with patients whose first language is not English; you should always consult these (e.g. on your hospital’s intranet) as an FY1. If an Urdu-speaking doctor was available, asking for assistance would be most appropriate as she/he would be communicating directly and fluently with the patient (A). The second most appropriate action is to telephone (or arrange in advance where known) to obtain a qualified translator (C) although this can take longer than Option (A). This patient’s clinical care is potentially being compromised because of the communication difficulties, particularly if these cannot be addressed, so consulting a senior doctor is appropriate (D). There are potential concerns about involving a patient’s next of kin including confidentiality and also gender or age differences depending on the nature of the patient’s clinical problem (E). Simply continuing without taking any alternative action would not be good clinical care (B).
The specialty trainee* on your ward, Dr Kitson, is a good friend of yours. She has just sent you a text saying she is running 30 minutes late for work and asks you to cover for her. One of the patients on the ward, Mr Bradley, informs you that Dr Kitson was supposed to be discharging him first thing that morning and it is now 9am. He explains that it is urgent he gets to work by 10am and it is a 45 minute journey to get there.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Sign Mr Bradley’s discharge paperwork yourself
B. Explain to Mr Bradley that Dr Kitson has been delayed so he may want to contact his work and let them know the situation
C. Contact Dr Kitson and find out whether she can give verbal approval to the discharge
D. Find another senior colleague in your team to review and discharge Mr Bradley
E. Offer Mr Bradley the option of signing a self-discharge form
Answer: DCBEA
Rationale: This question is trying to ascertain your decision making as a professional who puts the patient first. An alternative senior colleague in the team who would be familiar with Mr Bradley’s case would be the most appropriate person to authorise discharge (D). If senior supervision is not available on site then it would be acceptable to communicate with a senior colleague who knows the patient well and, if safe, facilitate discharge through supervision by telephone with the process reviewed face to face as soon as possible (C). Good communication with patients and keeping them informed at all times is an important duty, however this does not address the time sensitivity in Mr Bradley’s work situation as it does not attempt to prioritise the discharge (B). If safe supervised discharge cannot be achieved by any of the above methods, then the patient should be advised of their right to self-discharge but must be fully informed of the potential risks (E). FY1 doctors should never discharge patients without close supervision so Option (A) is inappropriate.
A patient, Mrs Mathews, has been admitted for investigation of abdominal pain, which her husband is aware of. You are asked to take a telephone call from him (Mr Mathews), who is asking for an update on his wife’s condition. You have just found out from a urine test that Mrs Mathews is pregnant.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Tell Mr Mathews that he will need to speak to Mrs Mathews directly about her condition
B. Tell Mr Mathews that you would like to obtain Mrs Mathews’ permission to speak to him first
C. Tell Mr Mathews that you would like to discuss Mrs Mathews’ case with a senior colleague before speaking with him
D. Tell Mr Mathews that you are currently investigating Mrs Mathews’ abdominal pain
E. Inform Mr Mathews that Mrs Mathews has had a urine test with a positive result
Answer: BDACE
Rationale: This question is about patient confidentiality and your duty of care towards your patient while preserving their confidentiality and maintaining good communication with the patient’s family. Informing the patient’s family member that you need to seek the patient’s permission before divulging any clinical information (B) is the most preferred option. Sharing only the information that the family member is aware of (abdominal pain) would buy you some time and you will not have divulged any confidential information with her husband hence (D) is the next option. The patient’s husband is likely to be under stress and asking him to speak directly to his wife to get information is likely to add further stress which makes option (A) less preferable. Similarly saying that you need to discuss the case with your senior (C) is evasive and doesn’t establish patient consent to discuss the results. Option (E) breaks patient confidentiality hence that is the least desirable option.
You are on the ward round with your consultant and attend to a patient who is complaining of a severe headache and neck stiffness. Before the consultation has finished, a nurse interrupts to inform the consultant that he is needed urgently to see another patient. The consultant asks you to conduct a lumbar puncture whilst he is away. You have not done or observed this procedure before.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Conduct the procedure to the best of your ability
B. Find another colleague to conduct the procedure whilst you observe
C. Telephone the neurology specialty trainee* for advice on how to conduct the procedure
D. Inform the consultant, away from the patient, that you have not conducted this procedure before
E. Find a senior colleague to supervise you conducting the procedure
Answer: DBECA
Rationale: This question is about realising your limitations, seeking senior advice appropriately and assessing your ability to safely and responsibly manage the patient. The preferred conduct would be to inform the consultant responsible for the patient/supervising consultant and seek advice (D). The next best option is to seek advice from another senior colleague and observe the procedure first before performing one (B). Option (E) is preferable to (C) and (A) as you have a senior colleague directly observing you who can intervene if needed without the patient coming to any harm. Option (C) is preferable to (A) as you are getting some advice regarding how to do the procedure before doing it. Option (A) is the least appropriate because this behaviour is potentially dangerous.
You are checking drugs chart on a general medical ward and you notice that the diabetes specialty trainee* has prescribed double the dose of a tablet for a patient with diabetes. You are aware that sometimes double the dose of this tablet is given to patients. The patient is stable and the specialty trainee is due on the ward in a few hrs.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Assume the dosage is correct as you know that sometimes the dose is doubled
B. Call the specialty trainee to check the dosage with him
C. Change the dose to the normal amount given
D. Check with the ward pharmacist whether she is aware of the double dosage for this patient
E. Check the dosage with the specialty trainee when he comes onto the ward
Answer: BDECA
Rationale: This question is assessing how you manage issues of patient safety and how you maintain working relationships. The preferred conduct would be to contact the diabetes registrar/specialty trainee immediately and clarify the reason for the double dose. This behaviour is likely to result in the safe, simple and rapid resolution of the problem, highlight your own clinical vigilance and maintain an amicable relationship between you and the other team members. This would therefore provide a learning opportunity for you (B). The next best option is to seek advice from the pharmacist. If the pharmacist recommended the lower dose, the prescription should not be given without consulting with a senior medical team member (D). Option (E) is preferable to (C) and (A) as it will determine the correct dose, but with a time delay. Option (C) is preferable to (A) as the double dose could cause harm to the patient and the patient is apparently receiving the normal dose without major immediate problems. Option (A) is the least appropriate action as the double dose could cause more harm to the patient if the patient was not actually intended to have the double dose.
Albert, a 70 year old patient, was admitted mid-morning to the General Medical ward where you are working. Albert was recently diagnosed with a brain tumour and has come back to hospital for further tests. When he was admitted, you advised Albert and his family that an MRI* scan would be arranged within a few hours. The radiology department contacts you to inform you that Albert’s scan will not be performed until tomorrow morning, as a result of urgent cases needing attention this afternoon. You inform Albert’s family of the delay and they react angrily towards you.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Inform Albert and his family that the delay is the responsibility of the radiology department
B. Apologise for the delay, listening to the family’s concerns
C. Explain the clinical need for other scans to be conducted before Albert’s scan
D. Inform Albert’s family about the formal complaint procedure
E. Advise Albert and his family that the information that you gave them earlier was accurate at the time
Answer: BCEDA
Rationale: It is most appropriate to apologise as Albert’s family is worried about him and upset that the scan will not take place as quickly as the family was originally told (B). Explaining the cause of delay may help relatives to understand the rationale behind it, but the first step is to apologise and listen to their concerns (C). Arrangements often change quickly in a hospital environment and it may be helpful to tell relatives that when you gave them this information, it was correct (E). It is their right to complain but this option is less appropriate because they may be satisfied if you take time to listen and explain things to them (D).It is not fair to blame the radiology department as they are responding to clinical need as required and this is therefore the least appropriate thing to do (A).
You and another FY1, Katrina, are working together as part of a surgical team. The ward is very busy and you are taking a blood test from a patient. You notice that Katrina has left the ward without telling you. A nurse tells you that she has gone to assist a surgeon in theatre. Katrina has had her bleeps redirected to you, which has left you with a very heavy workload.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Contact the operating theatre to request that Katrina returns to the ward
B. Ask Katrina, when she returns to the ward, to speak to you in future when she needs to leave the ward
C. Tell the senior doctor on the ward that Katrina has left without informing you
D. Report Katrina to her line manager for leaving the ward
E. Write a list of the jobs that have arisen in Katrina’s absence so that she can complete them when she returns to the ward
Answer: ABCED
Rationale: It is most appropriate to contact Katrina and ask her to return to the ward. She has not discussed this with you and has left you with an unmanageable workload (A). To address the situation in a longer term, it is appropriate to ask that she hands over to you if she is going to leave the ward especially when the ward is pressured. However, she may have been asked by a senior doctor to go to theatre (B). It would be better to speak to Katrina about this directly before informing senior doctor (C). Jobs will need to be prioritised on clinical need and completed as such (E). Referring straight away to Katrina’s line manager for an isolated incident is not appropriate at this stage, as initially you should take the responsibility for finding out why is has happened and take some action before escalation (D).
You are on your way to add a patient to an emergency theatre list urgently when a nurse approaches you and says that he is concerned about one of your patients, Mr Benn. Mr Benn’s catheter is showing a very low urine output following his surgery earlier that morning. You had already checked on Mr Benn during your ward round two hours previously and had seen that his urine output was adequate given his body size.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Reassure the nurse that you reviewed Mr Benn’s urine output on the ward round earlier that morning
B. Go straight to Mr Benn to review his clinical condition
C. Explain that you need to add a patient to an emergency theatre list urgently, asking the nurse to find another member of the team to review Mr Benn
D. Ask the nurse to record vital signs and tell him that you will review Mr Benn once you have added your patient to the emergency theatre list
E. Ask the nurse whether Mr Benn’s urine output has changed since the ward round this morning
Answer: EDBCA
Rationale: This is about prioritisation and delegation. Option (E) is the preferred option as it can provide more detail about recent changes. Option (D) is acceptable as urine output does not change suddenly and you are asking her to gather more data in the interim whilst you deal with the theatre list which could be crucial. Option (B) appears correct but you are automatically assuming that this is more important than completing your current task. Option (C) is less appropriate as you are putting responsibility of your patient on to another doctor via a nurse. Option (A) is least appropriate as false reassurance is then given.
You are working on a medical ward. You notice that one of your FY1 colleagues on the ward, Bashar, is not completing his assigned tasks. You often find him in the staff room on his mobile phone when he should be completing his tasks on the ward.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Accept that it is not your place to intervene
B. Ensure that you cover any tasks Bashar fails to complete
C. Discuss this with your educational supervisor* at the end of the placement
D. Ask Bashar why he is often in the staff room rather than on the ward
E. Inform a senior colleague of your concerns
Answer: DEBCA
Rationale: This is about supporting your colleague in difficulty. Option (D) is most appropriate as you have given Bashar a chance to explain and also you find out the real reason giving you an opportunity to rectify and support your colleague in difficulty. Option (E) is less appropriate than (D) in the first instance but this will be your second step as seniors need to be aware of the problems early to be able to address them in time. Patient safety has to be placed above all and their management should not suffer and hence Option (B) is more appropriate than (C) and (C) is less appropriate as it is almost similar to (A) whereby you have waited for the entire four months to come and inform your own educational supervisor who may not have any dealings with Bashar. Option (A) is least appropriate as it means you are not raising alarm when things are going wrong.
You are an FY1 working on a general medical ward. As you return to the ward from your break you overhear your FY1 colleague, Clare, speaking to one of the healthcare assistants, Melissa, in the corridor. Clare tells Melissa angrily that she needs to improve her skills if she is ever to be any good at her job. Melissa looks visibly upset, apologises to Clare then walks away. You have witnessed Clare talking in a similar way to other colleagues in the past.
Rank in order the extent to which you agree with the following statements in this situation (1= Most agree with; 5= Least agree with).
A. Melissa needs to learn to accept feedback from other members of the team
B. It is not your responsibility to speak to Clare about her behaviour
C. Clare should not be speaking to members of staff in this manner
D. Melissa should inform a senior colleague if she has been upset by Clare
E. Clare needs to be held accountable for her behaviour
Answer: CEDAB
Rationale: This situation is a familiar one to doctors working in teams and busy, stressful clinical areas. The first step is to determine your reaction to this event and it is clear that your colleague should not be speaking to a member of the team in this manner (C). In doing this, you form a judgement on the accountabilities for unacceptable behaviour (E). The Healthcare Assistant also has responsibilities as Clare may (and has been observed doing so) replicate this behaviour with other members of the team so escalation by Melissa is appropriate (D). Learning to accept feedback is important, but this is not central to this scenario (A). It is clearly unacceptable for you to do nothing (B), so this is the statement that you should least agree with.
One of the FY1 doctors working in your team, Haman, had a seizure whilst at a social event that you attended a few days ago. You have known him for some time and are aware that he is on medication for epilepsy. Today another FY1 colleague, who also knows about Haman’s medical condition, tells you that she saw Haman driving to work this morning.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Advise your FY1 colleague to speak to Haman about what she observed
B. Advise your FY1 colleague to seek advice from a senior colleague
C. Ask Haman if he has been driving after he has had a seizure
D. Suggest to your colleague that she reports Haman to his consultant
E. Suggest to your colleague that it is Haman’s decision whether he feels safe to drive
Answer: ABCDE
Rationale: As your colleague saw Haman driving it is the colleague’s duty to act. They have directly witnessed the driving and therefore are in a better position to describe what they saw. In the first instance it is better that Haman is given the opportunity to act and this is why Option (A) is a better answer than (B). Option (C) also gives Haman the opportunity to act and is preferable to (D) escalating to the consultant immediately. Option (E) is incorrect and therefore the least correct answer.
You are on duty at night and see a patient, Mrs Penn. Mrs Penn has developed sudden shortness of breath and signs consistent with acute pulmonary oedema. You have managed this condition successfully before. However, the nurse in charge of the ward wants you to call the specialty trainee* to come to see Mrs Penn. You are aware that the specialty trainee is currently in the Emergency Department caring for a sick patient.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Explain to the nurse that you have managed this condition before and can care for Mrs Penn
B. Make an initial assessment of the patient, administer appropriate treatment and then inform the specialty trainee
C. Telephone the specialty trainee in the Emergency Department, explain the situation and your experience and follow his advice about what to do
D. Tell the nurse that Mrs Penn is your patient and that you will take responsibility for your decisions
E. Go to the Emergency Department to explain the situation to the specialty trainee in person
Answer: BCAED
Rationale: This question is about providing good patient care while working appropriately as a member of a multi-disciplinary team. Initiating treatment and then seeking advice about how to escalate if needed ensures that the patient gets help in a timely fashion (B). Seeking telephone advice from a senior doctor increases the confidence of the nurse in your proposed management and will not cause undue delay (C). Explaining to the nurse the reason you do not need help in initial management may have a similar effect (A). Going to the Emergency Department for advice without initiating treatment may cause a significant delay (E). Appearing arrogant towards the nursing staff is the least appropriate as this hinders multi-disciplinary care (D).
Mr Farmer has been a patient on the ward for six months; he has a tracheostomy and he breathes with the aid of a ventilator following a traumatic brain injury. As you make your rounds, you notice Mr Farmer appears to be experiencing breathing problems. Both the consultant and specialty trainee* are dealing with a patient on the neighbouring ward. This is your first week as an FY1 and you have not yet attended a potentially critically unwell patient by yourself.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Call the crash team to attend to Mr Farmer as a matter of urgency
B. Seek advice from the physiotherapy team who are on the ward and have experience in managing Mr Farmer’s case
C. Contact the specialty trainee to discuss Mr Farmer’s symptoms
D. Ask the ward nurse to fully assess Mr Farmer’s status with you immediately
E. Ask the consultant to return to your ward straight away to attend to Mr Farmer
Answer: DCBEA
Rationale: This question is assessing your ability to make appropriate decisions in a pressurised situation. It is important to assess Mr Farmer’s status immediately. The ward nurse is most likely to be the health professional available to help and have the skills, knowledge and ability to access help if needed. It is important not to ‘go it alone’ if possible as help is likely to be required (D). Assessing the status of the patient should be your immediate priority and discussion with a senior colleague (C) could help reach an outcome for the patient. It can be important to have wider team involvement and informing them of patient progress is important (B). However, this would not be an immediate action and is less direct than Options D and C. Consultant return may not be appropriate until the patient is properly assessed (E). Crash teams should only be called in the case of arrest or emergency, doing otherwise could put other patients’ lives at risk and is therefore the least appropriate option (A).
You are working on an elderly care ward. During the ward round, your consultant asks you to request a CT* scan for Mrs Roberts. You overhear the specialty trainee* saying to another colleague that there is no indication that a CT scan is needed for Mrs Roberts and that it is inappropriate to request one. The consultant does not hear the specialty trainee’s comments.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Request the CT scan, as asked by your consultant
B. Discuss the case and difference of opinion with the consultant radiologist
C. Discuss with your consultant the reasons for the CT scan
D. Tell your consultant that the specialty trainee has said that the CT scan is not needed and that the request is inappropriate
E. Suggest to your specialty trainee that if he thinks the scan is not needed he should raise this with the consultant
Answer: CEABD
Rationale: This question is about ensuring good patient care while dealing with conflict within a team. A discussion about the reasons for the CT scan will mean that the request form can be completed accurately and the most information gained from the scan. It will also allow differing views within the team to be explored (C). A discussion of the different viewpoints initiated by the registrar/ specialty trainee (E) will allow everyone to learn but may be more confrontational than (C). The consultant retains overall responsibility for the patient and so if it is not possible to discuss the reasons for different viewpoints, it is appropriate to follow the consultant’s advice (A). Discussing the case with the radiologist is likely to be beneficial for patient management and your learning but it would be better to understand the reasons for the difference in opinion by discussing with your own team rather than involving another consultant (B). Option (D) is the least appropriate because it gives the appearance of telling tales and may stir up conflict within the team instead of using the disagreement as an opportunity to learn.
