Working Effectively As Part of A Team Flashcards
1
Q
- A porter tells you that he has seen an HCA take something from a
patient’s personal belongings.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Ask the HCA to open her locker and empty her pockets.
B Establish exactly what the porter has seen, and confi rm with the
patient that they have something missing before informing the Ward
Sister.
C Call the police.
D Ask the porter to fi nd out more by speaking to the patient and HCA.
E Report the incident to your consultant.
A
- B, E, D, A, C
All healthcare professionals are in positions of trust and must act within
the highest standards of integrity. The porter has made a very serious
allegation which could have damaging legal and professional consequences.
For this reason, the initial claim justifi es some preliminary
investigation to broadly establish the facts (B) before informing the
Ward Sister. The Ward Sister is a more practical and appropriate port
of call than your consultant (E), particularly as she is responsible for the
nurses and HCAs on the ward. However, your consultant might have
useful advice and would be more appropriate to contact than delegating
responsibility for investigating further to the porter (D). (A) and (C) are
very incorrect but (C) is marginally worse as it could represent an even
greater over-reaction. Although it may be necessary to call the police
later on, this is likely to be handled by hospital security that will have
more experience of dealing with similar issues.
2
Q
- You are on a renal medicine ward round and notice your consultant
lose his balance but quickly correct himself. You fi nd his behaviour
slightly unusual and can smell alcohol on his breath. Although the decisions
he is making appear appropriate, you wonder if he has been drinking
alcohol earlier in the day.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Ask the consultant whether he has been drinking alcohol.
B Speak to the consultant’s secretary about his behaviour.
C Discuss your concerns with your registrar and ask whether he feels
that the consultant is acting out of character.
D Inform the Clinical Director.
E Speak with the consultant, and share your concerns about what you
think you have seen recently.
A
- E, A, D, C, B
It is essential to ensure the safety of patients. However, you should fi rst
explain your concerns privately (E) in case a good explanation is forthcoming
before asking directly whether your consultant may be under the
infl uence of alcohol (A). If this is admitted or you are not convinced by
his denial, you should ensure that he leaves the clinical area. This should
be done discreetly but involving other staff and/or security if necessary.
Once the situation has been made safe, you have a duty to escalate
the incident to an appropriate person, in this case the Clinical Director
(D). Involving other members of staff would only be justifi able if you
are insuffi ciently certain to approach your consultant directly (C) (B).
However, these answers are not ideal until the other approaches have
been tried unsuccessfully. Escalating to your registrar (who is an immediate
senior and probably better known to you) (C) seems more appropriate
than contacting your consultant’s secretary (B). Even if your concern
is justifi able and genuinely held, you should involve as few colleagues as
possible to minimize professional embarrassment.
3
Q
- You have asked a nurse to administer a heparin infusion. On
returning to the ward three hours later you fi nd that the infusion
has still not been given as the nurse has been busy with other tasks.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Explain the urgency of giving the heparin, and ask her to prepare the
infusion straight away.
B Avoid antagonizing the nurse by leaving her to complete her jobs.
C Speak to the nurse in charge about the delay.
D Confront the nurse on the ward and insist that she prepares the infusion
straight away.
E Go to the preparation room and prepare the heparin infusion yourself.
A
- A, C, E, D, B
Eff ective working relationships require individuals to have some discretion
about planning their workload. However, the nurse may not
appreciate the urgency of the task which should be reiterated in the
fi rst instance. For this reason, the best answer is (A). If a further delay
is anticipated, it may be necessary to escalate the issue as the nurse in
charge (C) might intervene or allocate a nurse from elsewhere to help.
(E) is correct but not as much as (A) and (C) as you are likely to have
other tasks and will not be as familiar with preparing infusions as the nursing staff . It is, however, preferable (if you can do so safely) than
insisting it is done immediately (D) which may be unsuccessful and risks
jeopardizing future working relationships. The worst answer is (B) as you
must advocate for your patient and it is not suffi cient to satisfy yourself
that a drug was prescribed if you know that it has not been administered.
4
Q
- It is your fi rst day on the neurology ward and all junior doctors
are changing jobs. You are asked by the ward clerk to complete a
discharge summary for a patient who was discharged last week, including
arrangements for follow-up.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Refuse and ask the ward clerk to fi nd the foundation doctor who was
looking after the patient.
B Ask the new SHO to try to complete it.
C Attempt to complete the discharge summary and try to fi nd the consultant
and ask them about follow-up arrangements.
D Write a letter to the previous junior doctor for the neurology ward
and ask them to complete the discharge summary for their patient.
E Complete the discharge summary to the best of your ability and
arrange routine clinic follow-up in six weeks.
A
- C, E, B, D, A
Ideally, discharge summaries should be completed by an individual
involved in the patient’s care. However, if the outgoing team neglected
to complete one, it is important that it is completed to the best of
your ability. As you are unfamiliar with the patient and local policy for
follow-up, the best answer is to check with a senior colleague who might
remember the case (C). This is preferable to blindly arranging a routine
appointment in six weeks (E). This would, however, ensure that
the patient was not lost to follow-up and might be preferable to asking
your SHO to complete the task (B), as they have also rotated posts and
are unlikely to add anything further to the discharge summary. Although
courtesy requires completing routine tasks before rotating to a new job,
it would be inappropriate to expect your predecessor to complete the
discharge summary when they are now in a new post and/or hospital.
For this reason, (D) and (A) are both incorrect. However, (A) is slightly
worse as it puts the ward clerk in the diffi cult position of having to inappropriately
pursue your predecessor after they have moved posts.
5
Q
- A patient approaches you to say that she overheard your registrar
swearing repeatedly when he was at the nursing station. She does
not wish to make a formal complaint at the moment, but suggests that
you do something about his language.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Raise the concern privately with your registrar.
B Inform PALS.
C Apologize to the patient and assure her that you will speak to the
doctor involved.
D Establish what exactly was said and when.
E Explain that the registrar is ‘only human’ and that she should not listen
to conversations at the nursing station as they might be confi dential
A
- D, C, A, B, E
Doctors have a duty to act professionally at all times and it would seem
that your registrar might have erred in this respect. The best answer is
(D) as you should fi rst fi nd out what was overheard to best inform your
conversation with the registrar. (C) is also correct as you should assure
the patient that you will raise her concerns, even if she does not wish
to make a formal complaint. It is only a ‘worse’ answer than (D) as you
could only really do so with a little more information. Only after completing
(D) and (C) should you speak privately to the registrar so that he
is aware of the concerns (A). (E) and (B) are incorrect answers. Although
(B) would be inappropriate, it is not as destructive as (E) which would
be unfair and might either precipitate a formal complaint or reduce the
likelihood of her raising concerns in future.
6
Q
- You are working with Dr Green, a GP, about whom you are
concerned because he never seems to examine his patients. He
appears willing to refer some patients and send others home without
as much as a basic physical examination. However, he is well liked by his
patients and colleagues, and he has never been subject to a complaint or
any disciplinary action.
Choose the THREE most appropriate actions to take in this situation
A You have no substantial proof of malpractice and therefore cannot
report your concerns at the moment.
B The collective support of Dr Green at the practice should dissuade
you from making a complaint.
C Telephone the GMC to raise your concerns with them.
D Ask the GP about his decisions not to examine patients.
E Attempt to discuss the issue privately with other colleagues at the
practice.
F Inform the Primary Care Trust.
G Contact your Educational Supervisor.
H Inform the British Medical Association.
A
- D, E, G
If you have concerns with the standard of care given to patients, you
have a duty to report them, particularly if patients are potentially at risk.
You should not be dissuaded from raising concerns because a doctor
is popular (B) or you do not have proof (A). Ideally, concerns of this
nature should be raised with the doctor involved in the fi rst instance
(D). He might explain his decisions and/or modify his practice without
further action being necessary. If advice is needed as to how to proceed,
other senior colleagues (E) and/or your Educational Supervisor (G) are
appropriate contacts. Informing the Primary Care Trust (F) or the British Medical Association
(H) would be inappropriate and, although a GMC referral might be
necessary at some point (C), a concern of this nature might be more
eff ectively dealt with informally.
7
Q
- Your registrar inadvertently prescribes a ten times dose of methotrexate
which you spot before the fi rst dose is given. The registrar
breathes a sigh of relief that the error was spotted and tells you both he
and the patient had a ‘lucky escape’.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Agree that you are lucky as well, as you would have to complete a
long clinical incident form if it had been administered.
B Raise the issue with the nursing staff so that they are aware of common
mistakes to look out for.
C Mention the prescribing error to the lead pharmacist.
D Raise the issue with your consultant at the next ward round.
E Complete a formal incident report.
A
- E, C, D, A, B
Clinical incident reporting is important for identifying local error patterns.
For this reason, a report should be completed for the ‘near miss’
even though the patient came to no harm. A clinical incident report (E) is
the most appropriate method of error reporting as it will be dealt with
through a formal process and creates a paper trail. (C) is unnecessary,
although the lead pharmacist would at least know the correct procedure
and ensure you completed a formal incident report. Your consultant
could be told (D) but is likely to be sent a copy of the incident report, and
you do not wish to cause your registrar unnecessary professional embarrassment
by raising the issue too often. For this reason, it is worse than
(C). Your consultant would, however, correctly direct you to complete
an incident form. (A) is the next worst answer as it implies no attempt to
report ‘near misses’ and hints at covering up a clinical error to protect a
colleague. It is, however, perhaps less important given that the error was
corrected at such an early stage. Informing the nursing staff (B) is probably
the least helpful response as it implies no attempt to report the issue
formally and potentially undermines your registrar. The only exception
might be if this was necessary to stop the dose being administered once
it has been crossed off the drug chart.
8
Q
- At a multi-disciplinary team meeting, a nurse expresses concern
about a patient’s ability to mobilize safely at home. The occupational
therapy team disagrees and an argument ensues. Five minutes later
they are continuing to argue, and no progress has been made.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Move the agenda on to the next patient, and return to the controversial
case at the end.
B Ask the nurse to elaborate on her concerns.
C Ask the occupational therapist to leave the meeting.
D Invite the social worker to share her opinion.
E Do not become involved.
A
- B, A, D, E, C
Multi-disciplinary team meetings are important forums for identifying
and solving medical and social problems in conjunction with allied health
professional colleagues. It is not necessarily the doctor’s responsibility
to lead such meetings, but you do have a shared responsibility to ensure
that the team is working eff ectively. In this case, time is being wasted
and you should help to facilitate the team arrive at a decision. The best
response is (B) as the nurse should be given space to voice her concerns
uninterrupted and it might yet be possible to resolve the disagreement.
An alternative approach would be to revisit the case later on (A) so that
it can be addressed with fresh minds and progress can be made through
the agenda. However, this might simply postpone the disagreement and
risks the case being forgotten or not considered for lack of time. For this
reason, it is not as good an answer as (B).
Although the social worker might have an opinion, she has not contributed
so far and this might suggest that she has nothing specifi c to add
(D). For this reason, it is not as good a strategy as (B) and (A), although
an additional perspective could help. It is probably incorrect to leave the
nurse and occupational therapist to resolve their diff erences (E) as they
have not made any progress alone so far. The worst answer is (C) as it is
not your place to ask anyone to leave the meeting, and this would be the
wrong time to lose the occupational therapist’s expertise.
9
Q
- You are an FY1 doctor in orthopaedics. You have found the
physiotherapist to be particularly challenging to work with. She
frequently ignores the postoperative plan for mobilizing patients and
seems to actively discourage patients being discharged home. Your
registrar says that the physiotherapist is ‘obstructive’.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Speak to the other members of the multi-disciplinary team prior to
weekly meetings to establish the discharge plan.
B Ask for the physiotherapist to be replaced.
C Invite the physiotherapist to join your consultant ward round so that
discharge arrangements can be made face-to-face.
D Ask an impartial senior colleague for advice.
E Follow the physiotherapist’s advice, as she is ultimately responsible
for the patient’s safe mobilization.
A
- D, C, A, B, E
Personality clashes and diff erences in approach are inevitable consequences
of multi-disciplinary team working. However, these must not be allowed
to impact on patient care. Although neither surgeons nor physiotherapists
are necessarily ‘correct’ about optimal mobilization arrangements,
consensus is more likely to follow collaborative working. The best answer
is (D) as a senior colleague might have a better understanding of the
situation and might be able to suggest a way forward. (C) might be a
positive development but might be better suggested by someone other
than the FY1 doctor—your senior colleague might help. For this reason,
(D) is preferable to (C). It is always helpful to involve other members of
the multi-disciplinary team (e.g. nurses and occupational therapists) in discharge
arrangements so that a consensus is established before meetings
take place (A). However, this is worse than (D) and (C) as it risks alienating
the physiotherapist and making her feel as if the outcome of meetings
has been determined without her beforehand.
(B) and (E) are the two wrong answers. Asking for the physiotherapist
to be replaced (B) is likely to damage working relationships, and this
is rarely the place of a junior doctor rotating temporarily through a
post. However, (E) is the worst answer as you cannot blindly accept the
physiotherapist’s advice when this confl icts with that of your consultant.
Mobilization arrangements will depend on operative considerations (e.g.
bone quality, fracture pattern, and choice of metalwork), details to which
the physiotherapist may not have access. The consultant is ultimately
responsible for patient care and should be informed if his instructions
are routinely being disregarded.
10
Q
- You have been working as the FY1 doctor in the Medical
Assessment Unit for two months. On many occasions during the
rushed morning handover, you have found that tasks are not appropriately
transferred from the night doctors to the morning team. The ethos is focused
on handing over quickly so that the night team can get home to sleep.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Ensure that your own handover is eff ective.
B Arrange a meeting with your colleagues to explain your concerns.
C File incident reports for each individual whom you believe to be failing
in their responsibilities.
D Only comment if urgent tasks are not handed over as it is not worth
making a fuss over routine jobs.
E Inform the consultant in charge that handover arrangements are
inadequate.
A
- B, E, A, C, D
Handover between teams must be done correctly to ensure that important
tasks are not missed. This is particularly vital given current employment
regulations which have made shift working more commonplace.
As this issue relates to a group of doctors, the best answer is (B) which
would allow you to assess the degree of support that you have for change
and collect helpful suggestions. Informing a senior consultant might lead
to change more quickly but could alternatively lead to no change at
all, depending on the individual concerned. As a handover meeting is
already scheduled but being used inadequately, it would be preferable
to address the problem with your colleagues if possible (B) before
approaching a senior colleague (E) to suggest changes, for example
starting the handover meeting at an earlier time. Your own handover
should already be eff ective (A), but this might be hindered if there are
adverse structural issues, such as other doctors wanting you to hurry
up. In this case, the culture of accepting poor-quality handovers must be
challenged. For this reason, (A) is a worse answer than (B) and (E) as it
does not address the wider problem. (C) and (D) are wrong answers.
Submitting incident reports for many diff erent doctors (C) will make you
unpopular. Although it might result in change, it risks creating a personal
issue out of a cultural problem and would not be a measured response
to your problem. There is no such thing as a ‘routine’ task—either itneeds to be done or it doesn’t. Even checking a ‘routine’ blood test is
important if the patient is found to be severely hyperkalaemic. Doing
nothing (D) in this case is the worst option.
11
Q
- Frances, an FY1 colleague, confi des in you that she was
recently diagnosed with thyroid cancer. She does not appear
to be symptomatic and is scheduled to undergo a biopsy and surgical
treatment at another hospital in a month’s time. Although she is not as
spritely as usual, you have not noticed any change in her performance.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Suggest that she refers herself for counselling via Occupational Health.
B Advise Frances to inform her Educational Supervisor.
C Inform your consultant immediately.
D Gently explore how she is feeling about the diagnosis.
E Keep an eye on Frances at work but do not say anything to anyone else.
A
- D, B, E, A, C
You should be aware of factors that might cause colleagues to underperform,
including poor health. As Frances has confi ded in you, it would
seem appropriate to ask how she feels (D) and whether she is coping.
This is a fairly uncontroversial answer and is undoubtedly the best
in this case. Ideally, she should let her Educational Supervisor know in
case anything can be done, or must be done in future, to support her
at work (B). (B) is not as good as (D) simply because you are likely to
solicit more information discreetly before proff ering advice. (E) is correct
although not as good as (D) and (B) in isolation, as your immediate
concern should be to acknowledge the information Frances has chosen
to share. The two worst answers are (A) and (C). Although Frances may
benefi t from counselling (A), you cannot presume that this is something
she would want. The worst answer is of course (C) as it would not be
your place to tell other people about Frances’ health unless there is evidence
of her underperforming and putting patients at risk.
12
Q
- Rachel, a fellow FY1 doctor, is a budding surgeon and frequently
abandons the ward so that she can assist in theatre.
Except for the morning ward round, you have not seen Rachel on the
ward for at least fi ve weeks. Your consultant appears content with this
arrangement as long as the tasks are completed, and you do not have a
particular interest in surgery.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Do nothing as you enjoy the ward and Rachel clearly wants to be in
theatre.
B Speak to Rachel and insist that she spends more time on the ward.
C Go to theatre and leave any ward jobs until after hours when both you
and Rachel can attend to them.
D Suggest that FY1 doctors should be prohibited from going to theatre.
E Talk to Rachel and suggest dividing theatre and ward time more
evenly.
A
- E, B, D, A, C
As foundation doctors, both you and Rachel are expected to gain specifi
c competencies. Rachel is at risk of not doing this eff ectively. Similarly,
as an FY1 doctor on a surgical placement, you should assist in theatre if
there is time available, as this is also relevant experience. Although it is
reasonable to divide tasks according to your respective interests, you
should both aim to gain experience of each setting.
The best answer is usually to try to resolve problems locally fi rst, in
this case by speaking to Rachel (E). Trying to alter her behaviour by
achieving consensus is preferable to insisting she spend more time on
the ward (B), which might be unsuccessful and risks souring your relationship.
(D) is also unnecessarily confrontational and additionally risks
limiting both FY1 doctors’ exposure to an important part of their surgical
experience. As usual, doing nothing when presented with a problem
(A) ranks poorly and you should not accept such a stark discrepancy
without challenge. (C) is, however, clearly the worst answer as leaving
tasks until after hours means both FY1 doctors routinely staying late and
risks either inconveniencing patients or exposing them to danger.
13
Q
- You overhear a medical student on the bus who is giving a
rather unfavourable description of your consultant’s clinical
competence. You do not believe that it is his intention to be deliberately
heard, but it is clear that other passengers are listening.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Explain that the student might have misunderstood the reasons for
the consultant’s decision.
B Do nothing as it is a public place and medical students are not Trust
employees.
C Try to catch the medical student another day to explain that his comments
were unhelpful.
D Write a letter to the dean of his medical school.
E Suggest to the student that he exercises caution when talking about
colleagues in public.
A
- E, A, C, D, B
Your fi rst step should be to stop the medical student continuing this
conversation in public as colleagues (like patients) are entitled to a
degree of privacy. The best way to achieve this would be to let the
student know he can be overheard and that this is unacceptable (E). It is
likely that most students would respond to such a warning, even away
from a teaching environment. Although (A) achieves a similar goal of letting the student know he has been overheard, it is a worse option
as it risks entering a debate about your consultant’s ability. (C) is not
as good as (E) and (A) as it does not stop the conversation, although
it might address the student’s long-term behaviour. (D) is incorrect as
it is an overescalation of a situation that could be more appropriately
resolved in other ways. You might contact the medical school dean if
you became aware of more serious concerns regarding a student, e.g.
cheating or criminal activity. However, (D) is not as bad as (B) because
the medical school dean would probably forward your concern to a
more appropriate person (e.g. the student’s personal tutor), which
would lead to the issue being addressed. (B) is the worst answer as it
does not help the medical student (who needs guidance), your consultant
(who needs support in his absence), and other passengers (whose
trust in the medical profession might be damaged).
14
Q
- Your registrar frequently undermines your organizational skills
on the morning ward round. He expects you to take what you
believe is unfair initiative in terms of organizing investigations before the
patients are reviewed by a senior member of the team. He also criticizes
your note writing and you cannot seem to avoid this, whatever changes
you make to your documentation style.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Explain to the registrar privately that you feel that he expects too
much initiative from an FY1 doctor.
B Ask the registrar to show you how he would like notes taken on the
ward round.
C Inform your consultant that the registrar is constantly belittling your
abilities as a doctor.
D Arrange a meeting with Medical Staffi ng and ask that you are
timetabled so as to avoid the registrar as much as possible.
E Ignore your registrar’s interpersonal style but try to accommodate
his whims.
A
- A, B, E, C, D
Mutual respect is essential to any eff ective professional relationship. Your
registrar might not realize how unconstructive his style has become and
he might improve if approached directly. For this reason, (A) is the best
answer. Asking his advice about note taking might help reduce confrontation
(B) and this answer is only less correct as it seems you have already
made considerable eff ort to adapt your style. (E) is similar to (B) but is a
worse answer as it does not demonstrate to your registrar that you are
trying hard to understand how to improve. (C) and (D) are incorrect, at
least initially, as they represent premature escalation of your diffi culties
which are best resolved in other ways. (D) is only worse as it is a more
signifi cant escalation than (C).
15
Q
- Each time you phone radiology, you receive a barrage of criticism
from a particularly discourteous radiology registrar. Your
colleagues now try to make fewer requests whenever this particular registrar
is on duty. He once criticized your ‘incoherent’ radiology requests
and, when you asked how your requests could be improved, he hung up
the phone.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Arrange a meeting between the radiology registrar and the Mess
President.
B Raise the issue with your Clinical Supervisor.
C Ask for a slot at the monthly radiology meeting to discuss communication
between junior doctors and duty registrars.
D Contact the Clinical Director for Radiology to explain your diffi culty.
E Avoid making radiology requests when this registrar is on duty unless
they are absolutely necessary.
A
- B, D, C, A, E
The NHS employs 1.4 million people, some of whom have challenging
personalities. However, if junior doctors are dissuaded from requesting
investigations because of an obstructive radiologist, this has to be
addressed. As you are unlikely to know the registrar and work in a diff erent
department, you should initially escalate the issue up your own hierarchy
fi rst (B). (D) is a worse answer as it represents a bold step and would
be best done with the support of your Clinical or Educational Supervisor.
The remaining answers are incorrect. Although (C) addresses the issue,
opening a dialogue in such a public forum is inappropriate when your
concerns are about a specifi c colleague. It is, however, a better option
than (A) as the Mess President is unlikely to contribute very much. The
worst answer has to be (E) as your clinical judgement should not be
swayed by an impolite colleague who would risk patient safety.
16
Q
- Your SHO discloses to you that she is going through a very diffi
cult separation and occasionally has suicidal thoughts.
Choose the THREE most appropriate actions to take in this situation
A Reassure her and tell her that everything will be OK.
B Do not get involved with her personal aff airs.
C Off er a friendly ear if and when she wishes to talk further.
D Suggest that she attends counselling.
E Suggest that she books an appointment with her GP.
F Suggest that she speaks to her Educational Supervisor.
G Ask the registrar to prescribe antidepressants.
A
- C, E, F
It is important for medical professionals to ensure their own personal
health and well-being. In this scenario, your SHO has revealed a serious
psychological symptom which needs to be addressed (B). This might be
alleviated through some form of counselling (D) or with antidepressants(G), although she initially requires a full medical assessment by an independent
and objective healthcare professional (E). Professionally, she
may benefi t from the advice and support of her Educational Supervisor
who has responsibility for her pastoral care (F). It is also reasonable to
off er your own time and attention if she feels that she can speak freely
to you (C), but you should avoid false reassurances (A).
17
Q
- You are reviewing your patients on the ward round, and Mrs
Egbert asks if you will need to perform another examination
‘down below’ as it was uncomfortable yesterday. You cannot understand
why this was performed during the SHO’s ward round, and the examination
had not been detailed in the medical notes.
Choose the THREE most appropriate actions to take in this situation
A Inform the vulnerable adults’ nurse.
B Inform your consultant.
C Attempt to establish more detail about Mrs Egbert’s complaints and
the nature of the examination.
D Ask your SHO to describe his review of Mrs Egbert yesterday.
E Speak to the SHO in front of the registrar at the evening handover.
F Contact your Medical Director.
G Inform the patient’s family about what has happened.
H Ask the patient not to reveal any information about the incident to
anyone else until her consultant has spoken to her.
A
- B, C, D
All health professionals have a duty to protect their patients, and we
should always be aware of the potential risk to children and vulnerable
adults. Nevertheless, we also have a duty to respect our colleagues, and
in this scenario it would be inappropriate to raise a serious concern in
front of an unnecessary audience (E) without fi rst establishing more
information (C) and speaking to the SHO privately, as there may be a
legitimate explanation (D). It is likely that your concerns will need escalation
to your consultant (B), who might involve more senior colleagues if
necessary, although this would not usually be something an FY1 doctor
would organize themselves (A) (F). Informing the patient’s family before
establishing all the facts is premature and risks unnecessarily compromising
the patient’s trust if unfounded (G). If a serious assault has occurred,
this would be managed by much more senior doctors and the hospital
management. However, no doctor should conspire to silence patients
and therefore should avoid telling patients what they can and cannot
say (H).
18
Q
- Despite your best eff orts, your Educational Supervisor refuses
to see you because he is too busy. Eight weeks into your rotation,
he eventually asks you to attend theatre and tries to complete your
induction meeting between surgical cases but only manages to spend a
few minutes talking to you. He concludes your brief encounter by asking
you to sign an online educational agreement.
Choose the THREE most appropriate actions to take in this situation
A Sign the agreement, and go home and read it in more detail.
B Do not sign the educational agreement.
C Establish whether it will be possible to arrange a more eff ective meeting
in the near future.
D Ask your favourite consultant to act as your Educational Supervisor
instead.
E Ask your Clinical Supervisor to act as your Educational Supervisor
instead.
F Report your Educational Supervisor to the deanery.
G Arrange a meeting with the Foundation Programme Director.
H Persist with future brief meetings
A
- B, C, G
Your Educational Supervisor has responsibility for providing appropriate
supervision. This includes fi nding time for regular meetings. The scenario
suggests that you have made substantial eff orts to make alternative
arrangements, without any meaningful success (H). You might wish to
try again to arrange a more eff ective meeting (C); otherwise it appears
reasonable to initiate the process of fi nding a suitable replacement (G). It
would be irresponsible to sign an educational (or any other) agreement
without being aware of its contents (A) (B). It is not your responsibility
to ask another consultant to take over the role of Educational Supervisor
(D) (E), and involving the deanery would not be a measured response
at this stage (F).
19
Q
- Your registrar asks you to prepare a presentation for the hospital
grand round. You are very keen to present at the grand
round, although eventually you realize that she intends to present the
case in its entirety and merely wants you to do the preparation work.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Ask the registrar if you can present at least part of the case, as it will
be good experience.
B Ask the registrar to make a case presentation for you to present the
following week.
C Inform your consultant about your registrar’s lack of fairness.
D Refuse to hand over the slides for the presentation.
E Do nothing as she is your senior and there has been educational value
in producing the slides.
A
- A, E, B, D, C
As a junior trainee, your control over a project may not always correlate
with your eff orts. This should not preclude you from striving for fairness.
In this instance, your hard work might be compensated with the chance
to present some of your work, and so (A) is the best answer. Although
there is value in preparing a presentation, doing nothing is only an option
if you are somehow acknowledged in the presentation, to avoid the
charge of dishonesty (E). This would still be a more measured response
than those remaining. (B) is incorrect as it is probably unreasonable to expect your registrar
to prepare a presentation for you the following week, although this
might lead to genuine collaboration on further presentations. However,
it would not be as bad as refusing to share your slides (D) or, worse,
escalating unnecessarily to your consultant (C).
20
Q
- Your registrar suff ers from refl ux disease and is experiencing
very bad heartburn after lunch. His symptoms stop him from
carrying out the ward round. He informs a nurse he forgot to take his
usual proton pump inhibitor (PPI) that morning and is given omeprazole
from the drug cabinet.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Report the registrar for taking patient medication.
B Suggest that he obtains the medication from A&E by admitting himself
as a patient and having the medicine formally prescribed.
C Off er to prescribe omeprazole for your registrar on a discharge summary
prescription.
D Reprimand the nurse who has given him the PPI.
E Do nothing.
A
- B, C, D, A, E
Doctors should not treat themselves and taking medication from a drug
cupboard is likely to contravene Trust policy. Ideally, the registrar should
book in to A&E for an objective assessment if necessary to obtain a
prescription drug (B). Although this is the best option, it might not be
practical and you could alternatively prescribe omeprazole if you are
willing to accept responsibility for the prescription (C). However, you
should recall that symptoms of heartburn might indicate more serious
pathology. (D) is a less positive step than suggesting the earlier alternative
approaches, particularly as it is your registrar and not the nurse
who has instigated this dilemma. However, speaking to those involved is
preferable to escalating them prematurely (A). Doing nothing is, as usual,
an unacceptable response (E).
21
Q
- You overhear a conversation between two of your foundation
colleagues, Peter and James. Peter describes receiving a police
caution the previous weekend during a raucous outing that followed a
stressful week of on-call nights. The nature of the off ence sounds fairly
benign, but it does not seem as if your colleague has any intention of
informing anybody else.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Tell Peter that you will be informing the GMC.
B Arrange a meeting with Peter’s Educational Supervisor to discuss what
you heard.
C Speak to Peter about what you have heard, and whether he is aware
of the guidance related to receiving cautions.
D Do nothing as the off ence sounds relatively benign and no harm has
been done.
E Speak to James, and establish more details about the nature of the
events.
A
- C, B, A, E, D
GMC guidance states that all doctors must declare any caution or criminal
conviction received anywhere in the world. Your professional relationship
is most likely to be preserved by speaking to Peter and encouraging
him to inform the GMC himself (C), or (less good) via his Educational
Supervisor (B), before you consider declaring it yourself (A). Speaking to
James will not change the situation as any caution that is received must
be declared irrespective of the nature of the criminal off ence (E). For
this reason, (E) is a worse answer than the three which involve someone
informing the GMC. (D) is last as it contravenes GMC guidance and
misses an opportunity to help your colleague ensure he does not fi nd
himself in additional trouble later on.
22
Q
- You learn that your colleague is struggling to cannulate patients,
despite being in his second FY1 placement.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Help to train your colleague by guiding him through cannulation and
practising in the clinical skills laboratory.
B Ignore the problem unless a serious incident occurs.
C Tell your colleague to ask a senior for help.
D Fast-bleep the consultant in order to share your concerns with him.
E Email his Clinical Supervisor.
A
- A, C, E, B, D
It is not obvious from this scenario that there is any immediate danger to
patients, although cannulation is a fundamental skill for any junior doctor
and your colleague must learn to master it quickly. Hence, if it is possible
to train him to cannulate eff ectively yourself, with minimal disruption to
your duties, this should be attempted in the fi rst instance (A). Although
taking responsibility yourself (A) is preferable, seeking senior guidance
might also be appropriate, in which case it is better to encourage your
colleague to seek help (C) rather than impose it upon him (E). (B) is
incorrect but is unlikely to cause serious harm, as people learn skills at
diff erent rates and others are also in a position to help your colleague.
The worst answer in this case is (D) as the problem is not one that
could be resolved immediately, and it does not warrant fast-bleeping
your consultant.
23
Q
- You are assisting a senior registrar in theatre during an inguinal
hernia repair. You have seen a lot of hernia repairs during your
training, and you are certain that the registrar has inadvertently tied off
the vas deferens during this operation. Your registrar denies this but,
when you ask him to identify the vas, he does not respond convincingly.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Accept that your registrar is much more experienced and probably
correct.
B Ask the anaesthetist to become involved.
C Allow the procedure to be completed before raising the issue with the
consultant in charge.
D Insist that the surgeon stops as you are confi dent that a mistake has
been made.
E Leave the operating table and contact the consultant, asking him to
attend the theatre
A
- D, E, B, C, A
This is a very challenging situation, which depends on a number of factors,
particularly how confi dent you are that a mistake has been made
and whether this can be reversed if correctly identifi ed intraoperatively.
This is an issue of patient safety and you have a duty to raise concerns
immediately to ensure the best possible chance of rectifying the error.
The best person to raise your concern with initially is the operating surgeon,
in this case the registrar (D). (E) addresses the problem intraoperatively
but leaves the surgeon unassisted and could be very embarrassing
if your concerns prove unfounded. For this reason it is worse than (D).
(B) ranks lower because the anaesthesist is unlikely to have seen what
happened or to want to become involved in any disagreement. However,
they are a senior doctor and might contribute, e.g. by insisting that the
consultant surgeon attend the operating theatre. However, waiting until
after the operation (C) is worse if your opinion was strongly held as the
immediate opportunity to rectify the error will have been missed. (A) is
of course unacceptable as you must speak out if you believe a serious
error has occurred.
24
Q
- Jill is a specialist nurse on your renal team. She is very knowledgeable,
but you feel that she can be overbearing in clinical
situations and you frequently feel undermined in your position as a junior
doctor.
Choose the THREE most appropriate actions to take in this situation
A Discuss your feelings with Jill and ask how she thinks you could overcome
this diffi culty.
B Remind Jill of your superior position as a doctor.
C Adopt a more confi dent approach to patient care.
D Try to gain Jill’s respect by fi nding an opportunity to challenge her clinical
judgement and demonstrate your superior knowledge.
E Adopt a more subordinate position as you are less experienced.
F Speak to your senior colleagues for advice.
G Ask the nursing staff whether they fi nd Jill diffi cult to work with.
H Do nothing as long as her behaviour does not impact on clinical care.
A
- A, C, F
Although Jill probably brings a wealth of knowledge and experience to
the team, it is also important to foster a positive environment in which
all members of the team are respected. It may not immediately impact
on patient care, but, indirectly, poor working relationships are likely
to lead to less effi cient care in the long term and so the issue should
be addressed (A) (H). Eff ective work within a multi-disciplinary team
requires mutual respect, rather than trying to establish dominance or
accepting subordination (B) (D) (E). Nevertheless, your position of
equal worth within the team may be reiterated by adopting a more confi
dent approach (C). Asking the nursing staff whether they fi nd Jill diffi cult
to work with is a leading question, implies fault, and is unlikely to gain you
favour with her colleagues (G). In any challenging scenario, it is rarely
incorrect to approach a senior colleague for advice (F).
25
Q
- Annabelle, the Ward Sister, has bleeped you and asks you
to prescribe atenolol to a patient who is hypertensive. After
reviewing the patient, you disagree and feel that antihypertensives are
not clinically indicated. Annabelle is not convinced by your explanation,
saying that in her ‘extensive experience’ they are needed.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Explain how and why you arrived at your decision not to prescribe
antihypertensives.
B Insist on your management plan as you are responsible for signing the
prescription.
C Agree to prescribe antihypertensives, but ask the patient’s GP to stop
them on discharge.
D Inform Annabelle that you will discuss the issue with a senior colleague,
but that she should not give any medication for the time being.
E Agree that she should give the medication but do not sign the
prescription chart.
A
- D, A, B, C, E
Your response to Annabelle’s request must balance exercise of your
clinical judgement with maintaining an eff ective working relationship.
Given Annabelle’s confi dence in her judgement and the fact that she has
not accepted your initial explanation, it may be sensible (and diplomatic)
to discuss her concerns with a senior colleague at a convenient time (D).
(A) is ranked lower only because it seems some attempt has already
been made to explain your decision-making. Nevertheless, (A) is better
than (B) as insisting seems unlikely to nurture a harmonious working
relationship with an important colleague. (C) and (E) are both incorrect
answers as you should never prescribe a drug that you do not believe is
indicated. Prescribing them initially but stopping them later on (C) would
be deceptive and confusing for the patient. However, the worst answer
is (E) as you should never suggest that a drug is administered without a
prescription.
26
Q
- Vera is an elderly patient on the orthogeriatrics ward who is
currently receiving 20 minutes of counselling a week from the
psychologist. After reviewing her, you believe that she might benefi t from
more regular counselling.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Speak to other multi-disciplinary team members before the weekly
meeting to gauge their thoughts.
B Invite Vera and her family to the multi-disciplinary team meeting to
voice their concerns.
C Continue with the psychologist’s current treatment plan.
D Tell the psychologist he should visit Vera at least twice a week.
E Ask the psychologist whether they think Vera might benefi t from
additional input.
A
- E, A, C, B, D
You should respect the ability of colleagues to deliver their own specialist
services and manage their workload. However, this must be balanced
with a duty to advocate for your patient.
In this case, you should speak to the psychologist to determine
whether they are happy with their current input (E). They might agree
or give reasons as to why so little time is being spent with Vera (e.g.
volume of patients requiring attention or staffi ng pressures). (A) is also
an acceptable approach, although (E) is better as the psychologist would
be more likely to have an informed opinion than other members of the
team. You could certainly accept the psychologist’s plan (they are likely
to know best), but you have a duty to speak up if you think care could be
improved, and so (C) is worse than (E) and (A).
(B) and (D) are incorrect. Although patients can sometimes attend
multi-disciplinary team meetings (B), this is unusual and probably inappropriate
as other patients are usually discussed as well. In addition
we are given no indication that Vera wants to attend or has indicated
any concern about the amount of psychologist input she is receiving.
However, the last answer is (D) as it is not your place to instruct the psychologist
and such an intervention would probably not be well received.
27
Q
- There is a cardiac arrest call in the outpatients clinic at the other
side of the hospital. You arrive to fi nd a nurse performing chest
compressions being watched by a domestic assistant and a fi nal-year
medical student.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Instruct the medical student to take over chest compressions.
B Encourage the medical student to lead the crash call to develop his
leadership skills.
C Instruct the domestic assistant to bring the crash trolley.
D Instruct the medical student to bring the crash trolley, while you take
over chest compressions.
E Wait for instructions from the nurse doing compressions.
A
- D, A, C, E, B
The most appropriate person arriving at a cardiac arrest should assume
the role of team leader. In most cases, this will be the most senior doctor
present, even if that person is an FY1 doctor. A cardiac arrest should
be managed according to established protocols. However, whether the
arrest is successful depends in part on how well it is led and whether
each team member’s skills are optimally utilized.
In this case, the best answer is (D) as the nurse is likely to be
exhausted at this point (possibly delivering ineff ective compressions)
and the student should know what a crash trolley looks like. (A) is an
acceptable alternative although there may be insuffi cient time to confi rm
that the student is confi dent giving compressions and has good technique.
(C) unfairly assumes that the domestic assistant would recognize
a crash trolley and does not ensure relief of the nurse delivering chest
compressions. As eff ective chest compressions are one of the most
important components of managing a cardiac arrest, (C) is ranked lower
than (D) and (A). (E) is incorrect as you should usually (unless the nurse
is exceptionally qualifi ed, e.g. critical care outreach or a resuscitation
offi cer) take responsibility for the situation. However, the worst answer
is (B) as it would be inappropriate to encourage a student (particularly
one you do not know) to lead the resuscitation eff ort.
28
Q
- You are planning to review all your patients quickly before the
consultant’s weekly ward round. The pharmacist insists that
you immediately change all your ‘as required’ prescriptions of paracetamol
from ‘1g qds’ to ‘500mg—1g qds’ according to a new Trust guideline.
She says that she will have to call your consultant if you don’t do this
immediately. You have no concerns about your original prescription, and
there are 25 patients for whom this would need to be rewritten.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Tell the pharmacist to call your consultant as you have other tasks to
complete before the ward round.
B Explain to the pharmacist that there is no substantial diff erence
between the prescriptions but that you will speak to your consultant
when he begins the ward round.
C Tell the pharmacist that you will correct your prescription charts
immediately.
D Tell the pharmacist that you will return after the ward round if possible
to complete the task.
E Tell the pharmacist that you will hand this over to the evening team.
A
- B, D, A, C, E
The pharmacist’s request appears unnecessary and at best non-urgent.
Other healthcare professionals should not generally attempt to prioritize
your work as no one else can fully appreciate the pressures on you at any
one time. However, as the pharmacist is concerned, you should off er to raise the issue with a senior colleague at the fi rst convenient opportunity
(B). An alternative approach would be to off er to complete the task later
on (D) and this is only ranked lower because the task is non-urgent and
you cannot guarantee that your priorities will not have changed by the end
of the ward round. The pharmacist is unlikely to call your consultant to
demand completion of a non-urgent task. However, challenging her to do
so (A) would be incorrect as it risks escalating the situation and embroiling
your consultant unnecessarily in the dispute. Nevertheless, this might
be preferable to (C) which could mean neglecting important tasks (e.g.
reviewing your patients so that the consultant can make better plans on
his ward round) to keep the pharmacist happy. The worst answer is (E) as
the on-call team is unlikely to be available for routine tasks, which risk
distracting them from more urgent demands on the team’s time.
29
Q
- You are working on a busy surgical on-call shift when you are
bleeped for a fi fth time by a junior nurse for another ‘trivial’ task
which could wait until the regular team arrives the following day.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Tell her not to phone you again.
B Explain how few doctors are working out of hours and how to decide
which jobs require urgent attention.
C Go to the ward and ask the senior nurse to triage all further bleeps.
D Take the referral and add it to your list of tasks.
E Listen to the referral while asking for appropriate details.
A
- E, B, D, C, A
You must balance your workload against the risk of dissuading the nurse
from bleeping doctors in future. The best answer is (E) as you are obliged
to listen to the nurse so that she can be satisfi ed that you have all the
details and to ensure that this really is another inappropriate bleep. It may,
however, become appropriate to modify her expectations at some point
(B) as she is possibly unaware of the skeleton medical team available out
of hours, and this might be a valuable education point. (B) is worse than
(E) as it is more important to listen and understand the nurse’s concern
than to emphasize her inappropriate bleeping. Agreeing to complete an
inappropriate task (D) risks neglecting other responsibilities and does not
address the misunderstanding of which tasks need escalating to a doctor
out of hours. For this reason, it is a less helpful response than (E) and (B).
Senior nurses sometimes triage bleeps to reduce pressure on the medical
team out of hours. However, if this is not already local policy, you risk
antagonizing the ward staff by suggesting it (C) at this point. The worst
answer is (A) as, next time, it might be a genuine emergency.
30
Q
- You are confi dent that your patient requires an abdominal ultrasound
scan but the radiologist has refused your request twice,
initially because of insuffi cient clinical details, and then for unconvincing
blood results. Your consultant has insisted that the scan is done today.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Speak to another radiologist.
B Explain that your consultant has examined the patient and, unless the
radiologist is willing to do the same, he should accept the request.
C Ask your consultant for advice.
D Take the medical notes and go to speak with the radiologist in person.
E Do not order the ultrasound scan.
A
- C, D, A, B, E
The radiologist must also be satisfi ed that an investigation is indicated
before agreeing that it should take place. This can lead to diffi culties, as
the most junior person on the team (who probably has the least understanding
of why the scan is necessary) is often expected to communicate
with the radiology consultant.
The best answer is (C) as your consultant might clarify his particular
reason for needing an ultrasound scan or think of a diff erent approach
to the same problem. (D) is a less appropriate response and will only
help if you are armed with additional information—simply harassing the
radiologist to accept your request is unlikely to succeed. However, (A) is
incorrect as it is bad form to speak to another consultant as a way of
skirting a decision made by their colleague. (A) is only marginally better
than (B) if only because the latter is unlikely to succeed and may
jeopardize any future working with this radiologist. The worst answer is
(E) as simply accepting the radiologist’s refusal without informing your
team risks your patient’s well-being by depriving them of a potentially
important investigation.
31
Q
- While working as the surgical FY1 doctor over the weekend,
you are asked to complete a discharge letter for a patient
whom you have never met. After searching his medical notes, you are
unable to fi nd any clear plan for follow-up. The Ward Sister is unsure,
and the registrar is in emergency theatre. The patient and his family are
insistent on leaving as they have waited more than four hours for his
discharge letter.
Choose the THREE most appropriate actions to take in this situation
A Keep trying to contact your surgical registrar.
B Apologize for the delay and explain that you have been seeing unwell
patients for the last few hours.
C Ask the patient to telephone the consultant’s secretary in two weeks
if he has not received a follow-up appointment.
D Book a routine postoperative clinic appointment with the consultant
in six weeks.
E Leave a clear note for the attention of the surgical team asking them
to contact the patient to arrange further follow-up.
F Ask the GP to decide the follow-up.
G Ask the medical registrar for advice.
H Ask the patient to sign a disclaimer stating he is leaving against medical
advice.
A
- B, C, E
Although a discharge summary is clinically non-urgent, the patient has
already been put to some inconvenience waiting for it to be completed.
The regular team should have anticipated a weekend discharge and
already completed the paperwork.
You should certainly apologize for the delay so that it is clear that
the wait was necessary (B). You could complete the discharge summary
from the notes to the best of your ability but ask the regular team to
make arrangements for follow-up (E). This will prevent the patient from
having to attend an appointment unnecessarily or being prematurely discharged
from surgical care. Although asking the patient to contact the
team (C) might challenge his faith in the system, it is an honest approach
and adds another layer of reassurance that follow-up will take place.
As the discharge summary is clinically non-urgent, you should not interrupt
the surgical registrar in theatre (A). Neither the medical registrar
(G) nor the GP (F) should be expected to determine the appropriateness
of surgical follow-up. A routine follow-up appointment (D) might
ensure further contact with the surgical team but may unnecessarily
waste everyone’s time.
The patient should not be asked to self-discharge (H) as the only reason
for him to remain in hospital is administrative.
32
Q
- You are trying to arrange two weeks of annual leave in six
months’ time to attend your friend’s wedding abroad. Despite
emailing and telephoning the rota coordinator at the hospital where you
will be working, you have been unable to secure the time off .
Choose the THREE most appropriate actions to take in this situation
A Write a formal letter of complaint to the hospital.
B Try to arrange cover by swapping your annual leave with a colleague
once the rota is published.
C Inform your future Clinical Supervisor that you will be requesting
annual leave.
D Send a further email to the rota coordinator, copying in anyone else
who might be able to help, such as the Human Resources representative
looking after new foundation doctors.
E Contact a locum agency to assess the cost and availability of cover.
F Do not make any further attempts to arrange your leave for fear of
antagonizing the rota coordinator.
G Cancel your plans to attend the wedding.
H Inform your current Clinical Supervisor.
A
- B, C, D
Booking annual leave in advance can be diffi cult as rotas are not published
and you might not be currently based at the hospital concerned.
However, this should not be an impenetrable barrier and you are entitled
to make annual leave requests in advance (F) (G). You should aim to
let all appropriate people at the hospital know your intention so that
workforce arrangements can be made. These people are likely to include
(at a minimum) your new Clinical Supervisor (C) and the rota coordinator
(D). Once the rota is published, you will be responsible for arranging
to swap any on-call shifts (B).
Your current Clinical Supervisor is unlikely to have very much infl uence,
particularly if your leave request involves a diff erent hospital (H).
A formal letter of complaint (A) is unlikely to have much impact, might
antagonize future colleagues, and will not change the annual leave policy.
It is not your responsibility to arrange locum cover for any shifts that you
might miss (E).
33
Q
- After the afternoon surgical ward round, you have amassed a
long list of tasks. These include seven venepunctures and an
outpatient venesection which was scheduled for an hour ago, two cannulas,
and three discharge summaries. You consider how you will complete
these tasks.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Bleep the phlebotomy team to ask for assistance while you approach
the outpatient venesection.
B Attend the outpatient department where you were scheduled to perform
a venesection an hour ago, and then prioritize the other tasks.
C Hand over your list of jobs to the ward nurse and ask her to bleep you
if there are any problems.
D Head to the coff ee shop with FY1 friends to prioritize your tasks and
recruit help if possible.
E Ask another FY1 colleague for help.
A
- A, E, B, C, D
The two most important qualities of an FY1 doctor are eff ective communication
skills and an ability to prioritize. (A) is the best answer as
informing the phlebotomy team about your dilemma early on increases
the likelihood of them being able to help. Similarly, another FY1 doctor
might be willing to help (E) although this is less ideal as they are likely to
have their own tasks to complete. Both answers are, however, better
than (B) as they might save you from falling behind on other tasks later if
others are able to help. (C) and (D) are incorrect. It would be inappropriate, and unlikely to
foster positive working relationships, if you were to hand over your tasks
to the ward team (C). However, you might enlist the help of nurses who
are able to take blood if they are available to do so. Although it is worth
taking a few minutes to prioritize tasks, taking a coff ee break at this point
(D) would waste time and risk leaving a patient waiting unnecessarily in
the outpatient department. For this reason, (D) is ranked last.
34
Q
- As the FY1 doctor in gastroenterology, you are arranging the
discharge of a patient who is dependent on alcohol and was
admitted with symptoms of withdrawal. He has many social problems,
including unemployment and long-term disability. In an eff ort to maintain
abstinence from alcohol, you consider the diff erent healthcare professionals
you will need to involve, as well as outpatient follow-up with your
consultant.
Choose the THREE most appropriate in this situation
A Ward Sister working on the admitting ward.
B General practitioner.
C Drug and alcohol liaison offi cer.
D Housing assistant.
E Social worker.
F Citizen’s Advice Bureau.
G Psychologist.
H Liver transplant services.
A
- B, C, E
Your patient may benefi t from all manner of services but you must balance
this against the appropriateness of each referral.
The patient’s GP (B) will provide long-term follow-up and will be able
to access many diff erent services of potential benefi t to your patient. He
may also require specialist drug and alcohol input which can be provided
by an appropriately qualifi ed person (C). A social worker (E) could also
help assess the patient’s need for additional services.
The Ward Sister is not likely to expect continued involvement with
this man unless he becomes an inpatient again (A). Similarly, there is no
reason to think that he would benefi t substantially from housing services
(D), the Citizen’s Advice Bureau (F), a psychologist (G), or the transplant
service (H). These may become necessary in future, which is all the more
reason to ensure that he remains engaged with key people such as his
GP and social services.
35
Q
- You are coming to the end of your fi rst FY1 rotation in endocrinology.
The job was challenging and you felt inadequately
prepared for many of the responsibilities during induction. You consider
how you might go about helping your successor.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Feed back your thoughts on the induction to your Clinical Supervisor
during your fi nal meeting.
B Write a list of useful tips for your successor.
C Take a week off your next rotation to help support your successor
during their fi rst week.
D Leave your mobile phone number for your successor to contact you
if they encounter diffi culties.
E Leave the induction process to the Foundation Programme
management team.
A
- A, B, D, E, C
Handover is not only important between shifts but it is also necessary
when moving jobs. You should endeavour to leave all routine tasks completed
and a clear set of instructions for your successor.
If there are ways of improving the induction process, you should let an
appropriate person (e.g. your Clinical Supervisor) know (A). They will
provide continuity between trainees and are best placed to ensure the
induction process is improved based on your feedback. (B) is also appropriate
so your successor inherits your hard-won tips, such as schedules
and useful bleep numbers. (B) is ranked lower than (A) only because
an improved induction process will ensure benefi ts for trainees at every
stage, not just your immediate successor. (D) is a great idea but in isolation
cannot be better than (B) or (A).
(E) and (C) are both incorrect. (E) is unhelpful as the Foundation
Programme cannot provide the post-specifi c advice that is likely to be
most useful to your successor. It therefore misses an opportunity to help
your successor and their patients. (C) is the worst answer because it is
excessive, defeats the purpose of annual leave (rest and recuperation!),
and perhaps most importantly would disrupt your new team which
would have to cope without its FY1 doctor in the fi rst week.
36
Q
- Your SHO has a habit of sending text messages on his phone
during the ward round. Your consultant has not noticed, but
you have seen a number of patients and relatives appear less than
impressed with his inattention.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Let the SHO know that others have noticed him sending text messages.
B Ask the SHO whether everything is OK.
C Suggest that the SHO put his phone away immediately.
D Inform the consultant.
E Initiate a ‘politeness code’, including a rule against excessive texting,
which all members of the team should sign.
A
- B, A, C, D, E
Although people will have diff erent priorities, a minimum standard of
professional behaviour is expected of all doctors. It is usually possible to enforce this (largely unwritten) code of behaviour informally. In this
case, the transgression is relatively minor and so calls for a measured
approach. (B) is the best answer as it raises the issue discreetly in a way
that would allow your SHO to modify his behaviour without embarrassment.
There may actually be a problem (e.g. an emergency at home) and
he might elect to leave the ward round. (A) is ranked lower than (B) as
it is more direct and could lead to defensiveness in some colleagues.
(C) ranks lower than (A) for the same reason, i.e. it is excessively direct.
(D) and (E) are incorrect as they are not measured responses to a relatively
minor problem. (E) is particularly excessive and is unlikely to garner
much support from other members of your clinical team.
37
Q
- You are working on a busy medical ward which is famously
understaff ed. Since your new SHO started the rotation two
weeks ago, she has left work 45 minutes early every day to collect her
children from school. You are working until 8 p.m. most days and still feel
that you are not on top of the workload.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Ask her to cover you for the fi rst 45 minutes of your shift.
B Ask her to work during her lunch break to make up the missing time.
C Arrange a meeting with your consultant to discuss her early departure.
D Tell the SHO that you will be informing the consultant unless she is able
to make alternative arrangements for the collection of her children.
E Establish whether the childcare arrangements are temporary.
A
- E, D, C, B, A
In any diffi cult situation involving colleagues, it is important to establish
the facts early on. For this reason, (E) is the best answer. You might be
willing to help out your SHO if there is a temporary problem with childcare,
but she will be working normal hours in the near future. However,
it might become necessary to confront the SHO and make it clear that
you are unwilling to accept the current arrangement (D) which risks
patient safety and your own well-being. (D) is ranked lower as (E) is
more likely to resolve the issue to everyone’s satisfaction without causing
unnecessary ill feeling. (C) may become necessary later on but is a
worse initial response than (D). If the matter cannot be resolved through
discussion, it must be escalated to your consultant. (B) is the fi rst wrong
answer. Although time might be made up elsewhere, working through
lunch is not an optimal long-term strategy and should not be imposed on
the SHO, particularly by the FY1 doctor. The worst answer is (A) as it
leaves only one doctor on site for 1.5 hours every day.
38
Q
- Your registrar is known for his strong opinions. As an aside
from the ward round, he tells the group of juniors that migrants
from Eastern Europe are stretching the NHS to breaking point. You are
aware of a Polish patient nearby who is listening intently and appears to
be taking off ence.
Choose the THREE most appropriate actions to take in this situation
A Apologize to the patient for your registrar’s comments.
B Try to move the ward round on to the next patient.
C Challenge the registrar’s viewpoint by outlining the contribution immigrants
have made to the NHS.
D Agree with the registrar to appease him and move the ward round on.
E Speak to the registrar privately after the ward round about how you
felt that the patient was reacting.
F Leave the round to speak to the consultant.
G Share your concerns with the consultant if your registrar does not
become more sensitive.
H Return to the patient after the ward round to suggest that they make
a formal complaint.
A
- B, E, G
The immediate goal should be to de-escalate what could become an
infl ammatory situation if an argument was to develop. Your best move
would be to steer the ward round back to its original business of reviewing
patients (B). However, you should also let the registrar know afterwards
that his behaviour raised concerns (E). If this is unsuccessful, the
matter should be raised with your consultant (G).
You should avoid becoming embroiled in controversial discussions
when these are likely to cause off ence in the workplace. This includes
agreeing (D) or disagreeing (C) with the registrar.
It would be an overreaction to leave the ward round (F) or apologize
on your registrar’s behalf (A), although he might wish to approach the
patient after you have brought the issue to his attention. Similarly, you
should not usually solicit complaints from patients about colleagues (H).
39
Q
- A fellow FY1 doctor regularly takes home surgical supplies (e.g.
disposable tools and sutures) to practise surgical skills.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate)
A Speak to the theatre manager about equipment being taken
inappropriately.
B Insist that if your colleague continues to take hospital property you
will have to report him.
C Email his Clinical Supervisor with the details.
D Do nothing as it is good that your colleague is practising to become a
better doctor.
E Insist that he returns the hospital property immediately.
A
- E, B, A, C, D
Dishonest removal of hospital equipment constitutes theft with its
attendant legal and professional consequences. The situation would be much diff erent if he had asked an appropriate person (e.g. theatre
coordinator) and been given equipment with which to practise. The
best answer is (E) as you should give your colleague an opportunity to
recognize his actions were incorrect (he might not have thought through
the consequences thoroughly) and return any remaining equipment.
(B) is correct but would be unnecessarily confrontational as an initial
response.
You might wish to let the theatre manager know that property is going
missing (A) so that items can be appropriately secured and warnings
distributed to staff . However, (A) is not as good as (E) or (B) as it does
not directly address the person responsible.
Reporting your colleague outright (C) under these circumstances
seems excessive as it is likely he has not thought through the consequences
and does not view his behaviour as stealing. If he had stolen
something more obvious (e.g. a hospital computer), you would clearly
have to involve the hospital authorities early on.
The worst answer is (D). Although a surgical registrar could perhaps
argue that the Trust should make reasonable allowances for practice,
this argument is rather less convincing for an FY1 doctor. Instead, he
is forcing his employer to subsidize his further professional education
without their agreement.
40
Q
- It is the third consecutive week that your SHO has not covered
your duties in the preoperative assessment clinic for an hour
whilst you attend mandatory teaching. Each time she has arrived 30 minutes
late, despite being given plenty of warning. She always says she has
been busy with the ward patients.
Choose the THREE most appropriate actions to take in this situation
A Leave the preoperative assessment clinic with instructions that the
SHO should be bleeped if she does not arrive.
B Bleep the registrar and ask her to contact the SHO before each teaching
session.
C Inform your Clinical Supervisor that you are not meeting teaching
commitments because there is inadequate cover for your absence.
D Ask a colleague to sign you into the teaching and pick up an extra
handout.
E Speak to your SHO to identify what is stopping her from arriving and
whether her tasks can be reprioritized.
F Email the teaching coordinator to explain your absence.
G Arrange for the nurse specialist to cover your duties for the hour during
teaching.
H Ask the clinical secretaries to shorten the preoperative assessment
clinics by an hour.
A
- C, E, F
Attending a set number of teaching sessions is a mandatory requirement
for completion of FY1. If you identify diffi culties attending sessions,
these must be raised early on so that you do not fi nd yourself in diffi culty
towards the end of the year.
You could certainly speak with the SHO to emphasize the importance
of suffi cient cover so that you can attend teaching (E). However, the
issue should be escalated swiftly if it persists. Your Clinical Supervisor
(C) is a good place to start, followed by your Educational Supervisor if
issues are still not resolved. It would also be polite to inform the teaching
coordinator as well by way of apology for not arriving (F).
You should not leave the clinic without cover, particularly if you doubt
that your SHO will arrive on time (A). Similarly, you should not delegate
to another healthcare professional (G) unless this has been agreed
locally. The secretaries are unlikely to be able to manipulate the clinic
volume without impacting on the elective operating list (H). Involving a
senior doctor for the simple task of reminding your SHO is unlikely to
be received well (B). Asking a colleague to sign you in to teaching casts
doubt on both your own and your colleague’s probity (D).
