You will have a total of 10 minutes of interactive time. Prior to the station, you will be provided with a clinical vignette or series of clinical vignettes involving a number of medical emergencies/sick patients +/- general F1 on call jobs +/- ethical or medicolegal dilemmas.
During this section of the interview you will talk through your approach to the situation with the examiner, typically ending up in you talking through an A-E on a medically unwell patient, whilst ensuring all other issues are satisfactorily dealt ensuring patient safety throughout. You will not be expected to manage all patients, but you will be expected to prioritise appropriately and use the resources and team members around you to ensure that patients are kept safe… perfect preparation for FY1 then! Medicine is a team sport, and your examiners will expect you to appreciate this.
It goes without saying that you must comprehensively understand the A-E approach, and how to adapt treatment based on the clinical information provided. We won’t teach you badly what the Resus Council does so excellently here.
A common pitfall seen by candidates is to approach the station like medical finals questions, looking for an immediate and definitive answer. Instead, excellent candidates approach the station like it is the real world. Do the basics well and demonstrate to the examiner that you are going to be safe in the middle of the night as a fresh-faced F1. Similarly, there may be a temptation to seek one definitive diagnosis which is readily treatable, this again is not in keeping with what you will experience most of the time in the real world. You must ensure patient safety and keep your diagnostic sieve wide e.g. verbalising an appropriate approach to a patient with chest pain may be something along the lines of “my top differential, in this case, would be a pulmonary embolism, however, my patient has an increasing oxygen requirement, tachypnoea, and tachycardia on the background of a several day hospital stay, therefore after initiating resuscitative management and seeking senior support I would consider the following life-threatening differentials, in the interim I will implement these measures monitoring their impacts on my patient’s clinical status and observations”.
The amount that examiners interact with you within the station varies, you may get next to no feedback and have to talk through your approach and A-E without interruption, or you may be provided with clinical information to guide you. This is of no reflection of your performance, but more an attempt to evaluate how well you respond to new and dynamic information.
Similarly, you will likely get interrupted at some stage with a competing priority or a number of priorities e.g., cardiac arrest, angry family member, patient wanting to self-discharge, etc. You will be expected to evaluate this information, reassess your priorities, and act accordingly whilst justifying your decision.
We cannot stress this enough – PATIENT SAFETY TRUMPS ALL. If you are with a patient, you are carrying the crash bleep and a patient goes into cardiac arrest in the next bay… you must attend the arrest whilst also ensuring that the patient you are with is safe e.g. is there an experienced nurse nearby that can keep a close eye/deliver immediate management? If there is an urgent discharge summary that needs to be completed and a senior sister is shouting at you but you are with a patient with an increasing oxygen requirement… you must not leave the medically unwell patient. Common sense, but you’d be surprised by how many people this trips up.
At the end of the ten minutes, you may be asked to summarise, provide differentials, be asked a specific ethico-legal question or something similar. Respond accordingly based upon the principles that we are sure you’ve learned throughout medical school and explain your decision-making. Keep in mind that you are not expected to practice independently as an FY1, verbalising this is a quality, not a flaw e.g. “in this acutely unwell patient I would provide life-saving treatment if unable to gain immediate consent, however, whilst doing so I will seek senior support to aid me in both my clinical and ethical decision making”.
It is 4:57 pm, you are due to finish your day-shift in a few minutes time. One of the nurses comes and speaks to you, one of the ward patients in question is complaining loudly about abdominal pain. The same nurse also noticed that one of the patients is very drowsy and is only responding to physical stimulation. You are also aware there is a discharge summary, still to be written for a patient who will be discharged tomorrow.
‘How would you approach this scenario?’
For every single scenario without exception:
- Get more information – ask for SBAR handover and any observations/investigations already taken.
- Prioritise based upon patient safety whilst utilising the resources around you… in this scenario, you have a patient with reduced GCS, a conscious patient who may have a serious underlying pathology, and a relatively urgent discharge summary. We would deal with each of these patients in that order. If you are struggling, think A-E with some caveats… e.g. if a patient has a 2L oxygen requirement and another has just exsanguinated half of their circulating volume then we may have to adapt that systematic approach. However, for the most part, a desaturating patient will trump a hypotensive patient and so on and so forth.
- Think about appropriate holding measures. You will not be managing these patients in isolation, state how you’d manage the competing priorities e.g. “I am concerned about patient A’s ability to protect their airway so I will ask the nurse to put out a peri-arrest call whilst I am on my way, I will communicate with my SHO/registrar to ensure that patient B is also seen imminently whilst asking the nurse to perform regular observations and initiate basic management, I will inform the other staff member that the discharge summary will have to wait for now as I am managing a series of unwell patients who must take priority”
- Think real life and how to make it just a little bit easier – what can be done before you even arrive? In patient A you can ask for a crash trolley to be by the bedside and an up-to-date set of observations to be completed. You can also ask for a member of staff who is aware of the patient’s medical history to be waiting for you in order to help you make key initial decisions.
- Always ask for DNACPR and escalation status of a patient before you initiate management.
- A-E is designed for a reason, you will gain no points from deviating from this approach. For EVERY patient who is even remotely unwell, you should state that this is how you will approach the patient. If you feel like a patient is significantly unwell put out a peri-arrest/cardiac arrest/medical emergency team call early, there is no nobility in managing these patients on your own either in interview or in real life.
As previously discussed, it is likely that you will be interrupted throughout your station. Be flexible but retain these key components and you can’t go far wrong. If you don’t know, don’t guess, say that you are unsure and therefore you’d seek advice from your seniors… just as you will once you start work.
Preparation – our tips and tricks
- If it’s in the medical emergencies section of the Oxford Handbook, you should know it. At the very least the management steps provided there, but preferentially current NICE/royal college/ALS guidance. Many also know common drug dosages, this is preferable but not absolutely essential. If you are to learn dosages, a rule of thumb that we followed was to learn the dosages that you may not have time to look up in real life.
- Understand the legality of common ethical dilemmas faced during clinical practice, e.g. patient not consenting to life-saving treatment, patient lacking capacity, confidentiality, the treatment of patients <18y/o, DNACPR and resuscitation decisions.
- Pick all of the common presenting complaints of patients experienced on ward cover/in A-E e.g. chest pain, breathlessness, and reduced level of consciousness and learn the life-threatening causes of these presentations, how you would identify and manage these causes and the complications associated with them. Learning these will help you during the interview and make life as an FY1 much easier.
- Whilst practising the A-E approach consider situations where variations in practice exist, for example, when might you not give a 500mL bolus to a hypotensive patient? In which medically unwell patients may high flow oxygen therapy be ill-advised?
- Spend some time shadowing an F1 on call/SHO on call and see how they manage/prioritise patients on a busy shift. See how things are done in the NHS system – it will show to examiners that you have an understanding of clinical practice in the real world rather than regurgitating an A-E with limited context. Knowing who in the team you can ask for help and use is also as important as the clinical aspect itself.
Consider being able to smoothly talk through an A-E as a baseline. You will feel stressed in the interview, so freeing up some headspace by being able to verbalise this almost unconsciously will stand you in good stead. Once you are able to do this:
- With other candidates/past candidates/supervisors/colleagues/friends/foes go through multiple scenarios with single patients, multiple patients and priorities, lots of interruptions, no interruptions and etc. You don’t want to become flustered during the interview so practice for all eventualities.
- It is tempting to practice just with your friends… don’t. Practice with others and take useful tips and tricks which they use to apply to your approach. Many current and past AFP doctors will be delighted to help, so reach out!
Written by Dr Jack Barton, Dr Daniel Richardson, Dr Jack Teh, Dr Abigail Whittaker, and Dr Rachel Millar.
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