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At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

The Situational Judgement Test at a Glance

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

This title is also available as an e-book. For more details, please see www. wiley. com/buy/9781118490983 or scan this QR code:

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

The Situational Judgement Test at a Glance Frances Varian Frances Varian is a final year medical student at Warwick University and was seconded by Warwick Medical School to help develop situational judgement educational material and practice questions designed to enhance students' non-technical skills. Lara Cartwright Lara Cartwright is Senior Careers Consultant at Warwick Medical School and a member of the Association of Graduate Careers Advisory Services (AGCAS) and the Medical Careers Advisor's Network (MCAN). A John Wiley & Sons, Ltd., Publication

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

This edition first published 2013 © 2013 John Wiley & Sons, Ltd Wiley-Blackwell is an imprint of John Wiley & Sons, formed by the merger of Wiley's global Scientific, Technical and Medical business with Blackwell Publishing. Registered office: John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 111 River Street, Hoboken, NJ 07030-5774, USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www. wiley. com/wiley-blackwell. The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Library of Congress Cataloging-in-Publication Data Varian, Frances. The situational judgement test at a glance / Frances Varian, Lara Cartwright. p. ; cm. Includes bibliographical references and index. ISBN 978-1-118-49098-3 (pbk. : alk. paper) I. Cartwright, Lara. II. Title. [DNLM: 1. Decision Making-Great Britain-Case Reports. 2. Decision Making-Great Britain-Examination Questions. 3. Professional Practice-Great Britain-Case Reports. 4. Professional Practice-Great Britain-Examination Questions. 5. Behavior-Great Britain- Case Reports. 6. Behavior-Great Britain-Examination Questions. 7. Judgment-Great Britain-Case Reports. 8. Judgment-Great Britain-Examination Questions. 9. Psychological Tests-Great Britain. 10. Test Taking Skills-Great Britain. W 18. 2] 150. 28'7-dc23 2012031981 A catalogue record for this book is available from the British Library. Wiley also publishes its books in a variety of electronic formats. Some content that appears in printmay not be available in electronic books. Cover image: Bigstock © Michael Jung Cover design by Meaden Creative Set in 10/12. 5 pt Times by Toppan Best-set Premedia Limited 1 2013

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

Contents   5Contents Preface  6 Acknowledgements  7 List of contributors  8 List of abbreviations  9 1  Introduction  11 Personality  11 Professionalism  11 Pressures  and prioritisation  12 Effective  communication  and patient  focus  12 Teamwork  13 2  Professionalism  14 What  is integrity?  14 Social  networking  14 Understanding  confidentiality  15 The DVLA  15 Patients  involved  in serious  crime  16 Confidentiality  and the under  eighteens  18 Questioning  professionalism  20 3  Pressures  and  prioritising  22 Probity  22 Ward  rounds  22 Patient  discharge  23 Prescribing  25 Consent  26 Learning  and career  development  28 Informal  opportunities  28 Procedural  29 Prioritisation  29 Bleeps  31 4 Effective  communication  33 Five  principles  for good  communication  33 Written  communication  34 Record-keeping  34 Blood  forms  35 Clinical  coding  35 Death  certificates  35 Cremation  forms  36Verbal  communication  36 Working  with  interpreters  36 Working  with  disability  37 Communicating  personal  views  39 Communicating  with  relatives  39 Breaking  bad news  40 5  Patient  focus  42 Being  the best for your  patients  42 Patient  advocacy  42 Respecting  personal  beliefs    44 Tricky  decisions  involving  treatment:  consent  without  capacity  45 End of Life  care  45 Difficult  patients  46 6 Effective  teamwork  48 Understanding  teamwork  48 Understanding  your  role  49 Effective  handovers  50 Understanding  your  colleagues'  roles  51 The nursing  team  51 The consultant  52 The radiology  department  52 SBAR  53 Professional  conflicts  53 Seeking  support  54 The foundation  school  54 7 SJT  practice  material  56 How  do I approach  the SJT questions?  56 SJT example  questions  56 8 Answers  66 Beyond  this book    86 9  References  88 Index  90

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

6 Preface Preface What are Situational Judgement Tests? Exactly what they say on the tin! A way of assessing how you judge a situation encountered within the workplace. They are not designed to test your clinical knowledge and skills; they are designed to test your attitudes and ethical values. With this in mind, the ISFP (Improving Selection to Foundation Pro-gramme) developed nine domains of assessment for UKFPO (United Kingdom Foundation Programme Office) application: Commitment to Professionalism Learning and Professional Development Working Effectively as Part of a Team Patient Focus Problem Solving and Decision-Making Self-Awareness and Insight Coping with Pressure Organisation and Planning Effective Communication These are assessed in two ways: either by ranking five re-sponses from most appropriate to least appropriate, or by selecting the three most appropriate responses to the situation in question. The response is then evaluated against a prede-termined scoring key decided by the subject-matter experts. Download the SJT Monograph on the UKFPO website www. foundationprogramme. nhs. uk for more information. All sce-narios are evaluated by doctors in terms of their applicability to real life. The SJT scenarios in this book have also been scrutinised and cover similar issues to those offered in the 2010 pilot (AMRC 2010) as well as real situations submitted by foundation year interviewees. The following chapters deal with the nine areas above and detail juniors' experiences from their time on the wards: 1. Introduction: this chapter includes how best to prepare for the SJT, some handy ways of handling the scenarios, as well as some things to look out for on the wards. It also evaluates the importance of self-awareness and insight with respect to conducting yourself day to day in clinical practice. 2. Professionalism : this chapter covers the behaviours expected of a junior doctor together with codes of conduct, including issues of confidentiality. 3. Pressures and prioritisation : this chapter focuses on the common pressures of an FY1: probity, ward rounds, discharges, prescribing and consenting. It also addresses learning and pro-fessional development, managing career progression as well as what to do if your job requires considerable juggling. Finally, this chapter considers prioritisation-including bleep etiquette -in which organisation and planning are integral. 4. Communication : this chapter engages with common pit-falls connected with record-keeping and tips for successful documentation. Also covered are communication difficulties involving translators, disabilities and relatives. 5. Patient focus : this chapter deals with how to be the best doctor for your patients, detailing responsibility for patient advocacy, capacity, end of life care and problem-solving with respect to handling difficult patients. 6. Effective teamwork : this chapter outlines effective hando-vers, handling professional-and personal-conflicts and understanding others' roles so you can most effectively work as a team-player. These include the roles of nursing, radiology and laboratory staff as well as those more involved in your social support such as educational supervisors and foundation directors. 7. SJT practice material : this chapter covers a method of approaching an SJT question and contains 50 practice SJT questions. It concludes with a way of creating your own exam-ples and gives tips on how to develop your own learning on the wards. The aim here is to get you thinking of ways to approach the SJT under exam conditions, as well as to enhance your under-standing of the role expected of you as an FY1. The approach to this text replicated that of the ISFP; interviewing doctors, patients and healthcare professionals about the expected quali-ties of a junior doctor. This material was then integrated into the FY1 job analysis specifications outlined by the ISFP (Pat-terson et al 2010) to provide you with a comprehensive guide to tackling the SJTs. Finally, this material has been reviewed by students who sat the 2011 pilot. They have approved its utility as a preparation for the SJT exam. Please note that, whilst the information closely adheres to GMC guidance, you should refer back to the original documentation for advice in any potentially difficult situation. The information here is designed to assist your learn-ing process in thinking about what you should do in a situation, and not what you necessarily would do in practice. All the examples are from doctors' real-life experiences working on the wards; from which the SJT practice questions have been adapted. The names have been changed in some cases to protect identities. For accuracy, these questions and explanations have been reviewed by an independent writer for the UKFPO SJT selection paper, senior clinicians and foundation trainees. These questions cannot guarantee success in the SJT, but have been developed and designed to replicate as far as possible the types of scenarios encountered in the formal assessment paper (AMRC 2010). Frances Varian Lara Cartwright

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

Acknowledgements   7Acknowledgements We would like to thank all those people who gave their time and expertise to advise us in writing this book. We would par-ticularly like to thank the medical students who reviewed the material-especially James Coe, James Webster, Ayrton Goddard, Jennifer Goddard, Graeme Mattison, James Haddock, Adrian Hayes and David Andrews-as well as all the patients who kindly gave their time-and their stories-to help create an interesting read. Special thanks are due to Katherine Mundy-author of the children's book Thomas Young and the Go To Tunnel -for her artistic talent in creating the original illustrations, and to Graeme Chambers for his work in translating them into the Figures in this book.

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

8 List of Contributors List of Contributors Maggie  Allen Consultant Rheumatologist, Associate Medical Director of Education and Foundation Programme Clinical Tutor University Hospital Coventry and Warwickshire, Coventry Nicholas  Ashley Foundation Year 1 West Midlands Michael  Baker General Practitioner and Educational Supervisor Solihull Anthony  Blacker Consultant Urologist University Hospital Coventry and Warwickshire, Coventry Lara  Cartwright Senior Careers Consultant Warwick Medical School University of Warwick, Coventry Samyami  S.  Chowdhury Foundation Year 2 West Midlands Linda  Crinigan Clinical Skills Practitioner University Hospital Coventry and Warwickshire, Coventry Daniel  Higman Consultant V ascular Surgeon and Foundation Programme Director Coventry Warwickshire Foundation School University Hospital Coventry and Warwickshire, Coventry Carl  Hammond Foundation Year 2 West Midlands Fraz  Hussain Foundation Year 2 West Midlands Colette  Marshall Consultant Vascular Surgeon University Hospital Coventry and Warwickshire, Coventry Sarah  Sharp Foundation Year 2 West Midlands Edward  Simmonds Consultant Paediatrician and Foundation Programme Year 1 Clinical Tutor University Hospital Coventry and Warwickshire, Coventry Anne-Marie  Slowther Associate Professor of Clinical Ethics Warwick Medical School University of Warwick, Coventry Jacqueline  Timeyin Specialist Trainee, Year 1, Paediatrics Manchester Desmond  Varian Psychiatric Nurse Cumbria Frances  Varian Final year Medical Student, Graduate-Entry Programme Warwick Medical School University of Warwick, Coventry Marakatham  Venkataraman Consultant Paediatrician and Foundation Programme Clinical Lead George Eliot Hospital, Nuneaton Ayman  Zaghloul Consultant Psychiatrist Caludon Centre, Walsgrave, Coventry

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

List of Abbreviations   9List of Abbreviations ABG Arterial Blood Gas BMA British Medical Association BNF British National Formulary BSL British Sign Language CAB Citizens Advice Bureau CAE Clinically Adverse Event CRP C-Reactive Protein CS Caesarean Section CT Computerised Tomography DDA Disability Discrimination Act DH Department of Health DKA Diabetic Ketoacidosis DNAR Do Not Attempt Resuscitation DVLA Driver and Vehicle Licensing Agency EHRC Equality Human Rights Commission EOL End of Life ESR Erythrocyte Sedimentation Rate FTP Fitness to Practise FY1 Foundation Year 1 FY2 Foundation Year 2 GMC General Medical Council GP General Practitioner GUM Genito-Urinary Medicine HLC Hospital Liaison Committee ICE Ideas Concerns and Expectations IMCA Independent Mental Capacity Advocate INR International Normalised Ratio ISFP Improving Selection to the Foundation Programme ITU Intensive Treatment Unit KMR Kohner Medical Record MCA Mental Capacity Act MEWS Modified Early Warning Score MHA Mental Health Act MHRA Medicine and Healthcare products Regulatory Agency MPS Medical Protection Society MST Morphine Sulphate Tablets NKDA No Known Drug Allergies OT Occupational Therapist OTC Over-The-Counter PALS Patient Advice and Liaison Service PRN Pro Re Nata QOL Quality of Life RCP Royal College of Physicians SBAR Situation Background Assessment Recommendation SHO Senior House Officer SJT Situational Judgement Tests ST1 Specialist Training Year 1 STAT Statim (immediately) STI Sexually Transmitted Infection UKFPO United Kingdom Foundation Programme Office

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

The Situational Judgement Test at a Glance, First Edition. Frances Varian and Lara Cartwright. © 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.   111Introduction Mike, GP “Recognise where your personality is and try to understand what you are like and how you get job satisfaction; in the end work in that area... you'll feel like you're under far less pressure if you do that” This book lends insight into the kinds of scenario that a founda-tion doctor encounters. However, before we dive in to discuss life on the wards, let's take some time to consider your unique approach to the role of an FY1. SJT questions require you to think about what you should do, i. e. how to handle a situation most appropriately. First though, consider what you most likely would do. Gaining insight into this discrepancy will be helpful in approaching the SJT and, more importantly, in continuing your professional development. Considering what you most likely would do requires an understanding of your own characteristics and behaviour. This helps you to: Work with colleagues who might behave differently to you. Communicate effectively with team members, patients and their families. Evaluate your response to working under pressure. Work out how to best define your priorities. Interpret feedback in relation to your performance. Monitor your well-being at work. Perform your best in selection processes: from the SJT through to specialty training. Personality People behave in different ways, depending on the circumstances or the people they are with. However, it is widely accepted that some aspects of personality stay stable and, over the years, per-sonality testing has evolved to measure these domains. You do not have to take a formal personality test, but understanding a little about personality theory can help you to understand your-self in relation to the role of an FY1. There are five widely recognised domains along which personality is measured, known as “the Big Five”. These are shown in Figure 1. 1. It is helpful to see each of the “big five” as a continuum, with most people coming out somewhere in the middle rather than being able to be labelled as one thing or another. Research has shown that domains are relevant across cultural boundaries (Mc Crae et al. 2005). Openness and neuroticism can be used as examples to show how people respond differently to taking a test like the SJT. If you think you are on the high side of the neurotic scale, and the thought of the SJT stresses you out, you may find the wealth of practice material in this book invaluable in calming your nerves. If you are more of a conformist on the openness scale, you might find the checklists of good practice and procedures to your liking. Different personality types can do the same job equally well. They just bring their own unique stamp to the way they do it. However, different personality traits can result in different indi-vidual experiences and challenges in relation to the same job. Here are some examples with respect to the domains covered by the SJT. Professionalism If you are high on the extraversion scale, you might find it more difficult to rein yourself in on social networking sites and resist talking in an unguarded way. Conversely, if you are low on this scale, you might find it harder to challenge the actions of others and speak out when you see bad practice. If you are highly conscientious, you might find it easier to maintain punctuality. If you are highly neurotic, you might find it particularly hard to switch off from stressful days. Figure  1. 1  The “Big Five”Yes = High Scale Yes = Low Outgoing Gregarious Sociable Warm and supportive in relationships Prefers order and method Prone to worry Overemotional Inventive Imaginative Insightful Reticent Shy Go-it-alone Reserved Cool Detached Adopts spontaneous or casual approach Unflappable Laid-back Conformist Down-to-earth Sensible Extraversion Agreeableness Conscientiousness Neuroticism Openness to experience

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

12  Introduction Pressures  and  prioritisation Being highly conscientious and only mildly neurotic will make it easier to work under pressure and remain calm and in control. If you are highly open to new experiences, you will have an advantage when it comes to managing rapidly changing situations. Conversely, when following protocols, being low on open-ness may stand you in good stead. If you are high in agreeableness you may tend to seek help from others naturally; a key factor in some of the SJT questions. Figure  1. 2  Understanding yourself Yes = High Yes = Low Scale Do you find yourself at the centre of a group of friends or colleagues? After a busy shift, do you relax best in the company of others? Are you affected by patients' stories of hardship? Are you adept at putting patients at their ease? Do you remember to replace equipment in its proper place? Do you keep to your revision timetable? Do you easily get irritated when things don't go your way? Are you prone to worry about things you cannot control? Do you find yourself making reams of notes? Do you find it easy to reflect on your learning? Agreeableness Conscientiousness Neuroticism Openness to experience Do you sometimes need encouragement to give your opinion on a ward round? After a busy shift, do you prefer chilling out on your own? Do you sometimes upset colleagues or friends without knowing why? Are you generally interested in the symptoms more than the patient? Do you often find yourself looking for a pen? Do you go round in circles when you have multiple deadlines to meet? Does it take a lot before you get stressed out? Do you find you are cool in a crisis? Do your colleagues regard you as a 'do-er' rather than a 'thinker' When presenting your findings, do you find it easy to stick to the facts?Extraversion Effective  communication  and  patient  focus Introverts may find relating to patients' concerns a more dif-ficult aspect of the FY1 role. If you are highly neurotic you must remember not to relay your anxieties to the patient; having confidence in your skills as a doctor is an important aspect of the doctor-patient relationship. Being highly agreeable lends itself to good communication with relatives; if you are at the other end of the scale, you may have to work harder to empathise with others.

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

Introduction   13Teamwork If you tend to “think outside the box” when problems occur, your openness to experience may puzzle or even frustrate your more cautious colleagues. If you are high in agreeableness, you may find your priority is to promote harmony within your team. This may also mean that you find it more difficult to challenge colleagues who do not pull their weight. Being high in conscientiousness will be appreciated by your colleagues Teamwork is so fundamental to the FY1 role; it is examined in more depth in Chapter 6. How is this relevant? Bear in mind the different personality traits when you test yourself during the course of this book, especially when you compare what you would do to what you should do (i. e. the right answer). When there are discrepancies, ask yourself why they exist. Is it, for example, because you don't like asking for help? Reflect on your personality and behaviour and consider how you could improve your performance. This is an important skill which will prove fruitful to your future development as a doctor. Finally, it is important that you seek out feedback on your non-technical skills in addition to your clinical competen-cies throughout your clinical attachments. This is part and parcel of continuing professional growth. The questions in Figure 1. 2 will help to guide you towards one side of a particular trait or the other. Although Figure 1. 2 does not constitute a formal personality test, if you answer “yes” easily to one set of prompts, it will give you an indication of which end of the scale you gravitate towards. If you wish for a more formal assessment, most commercially available personality tests include some measurement of these domains. Consequently, you may find it useful to complete an online personality questionnaire such as the Myers-Briggs Type Inven-tory (Myers and Briggs Foundation n. d. ).

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

14 The Situational Judgement Test at a Glance, First Edition. Frances Varian and Lara Cartwright. © 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd. 2Professionalism Mithun, Consultant Psychiatrist “Take pride in being a professional... there are only a few professions which carry such a lot of trust and responsibility. People come to you at times of their weakness, not at their strength: you have to be trustworthy. Medical knowledge is only part of treatment: people skills, the instillation of hope, your smile, bedside manners... all those skills are so important. At the end of the day doctors are tools-we have knowledge and apply solutions scientifically-it' s how we relay those to the patient that is of the greatest importance. ” Always consider whether the information you present online could challenge public confidence in the medical profession. Moreover, consider whether it could change your reputation with colleagues at work. Chris, Consultant “I don't mind Facebook, I am friends with my colleagues and aware of that fact.... I never post anything other than the mundane to protect myself as a professional. Sometimes people forget who they are friends with. I experienced a situation where two secretaries were publically bullying another online and being extremely deroga-tory. I had to discipline them for it as that kind of behaviour wouldn't be acceptable in the office and certainly not online”. In terms of professionalism, foundation doctors are ex­ pected to: Display integrity, honesty and trustworthiness. Understand the role of being a doctor, including ethical responsibilities and respect for confidentiality. Be punctual and reliable. Own up to mistakes. Challenge actions and knowledge which may put others at risk. What is integrity? Integrity is mentioned in connection with the healthcare profes ­ sion in many situations, but few people consider why. Integrity is about being honest and upholding moral principles-always. This is important to realise, because you cannot simply put on your professional face at work and let loose as soon as you exit the hospital doors. As a doctor, you must have integrity woven into every aspect of your life. You are a public figure and must therefore meet public expectations for the security of the profession. Ultimately, you have to be honest, trustworthy and respect ­ able in both your work and your personal life. This leads onto the next discussion: social networking. Social networking is a common area where doctors and medical students can get caught out. Social networking As highlighted, professionalism as a doctor should extend through every aspect of your life. Doctors are expected to behave like doctors. Say, for example, your friend decides to upload a photo of you looking drunk and dishevelled on a Friday night; this might not appear so hilarious to a patient who decides to Google you. Unprofessional behaviour online will impact on your integrity, because social media has increasingly blurred the distinction between our personal and professional lives. The Department of Health (DH 2010) devised six princi­ ples by which patient­identifiable information should be utilised: 1. Justified -what is the purpose of sharing the information? 2. Necessary -how will sharing this information benefit the patient? 3. Minimum -only share what needs to be shared. For example, if you are referring a patient with a broken wrist for physiotherapy, you don't need to tell the physio that they also are being treated for chlamydia. Be responsible and think about what you share. 4. Need-to-know basis -as above, make sure you tell them what they need to know and nothing more. 5. Be aware of your role -you are their doctor, respect the fact that patients trust you and be aware that you have a duty to uphold that confidence in the public eye. Doctors without trust are like buckets with a hole in: not very good at all! 6. Legal -if you are unsure of a boundary, always check it with a senior before you share anything. THE BMA (2011) RECOMMENDS THE FOLLOWING: Be conscious that your online image will impact on your professionalism. Posting about patients or colleagues however informal and “confidential” is inappropriate - think about how that will reflect on you as a person. Sort out your privacy settings to protect personal information. Politely refuse friend requests from current or former patients and explain to the patient the reasons why it would be inappropriate for you to accept. Your ethical and legal duty to protect patient confidentiality is the same on the internet as anywhere else.

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

Professionalism   15Understanding confidentiality There is a wealth of information regarding confidentiality and generally it is very well taught at medical school. Basically, you need to understand the principles of information­sharing, and, if you know those, you should know what to do regardless of the scenario. If you are unsure, always seek advice from a senior colleague in the first instance. Any scenario where confidentiality could potentially be compromised should not be rushed. Beyond this, there are assigned figures within the NHS known as Caldicott guardians. These are typically board ­level clinicians who resolve local issues regarding information ­sharing that go beyond the level of a senior colleague. Typical situations in which Caldicott guardians become involved include (DH 2010): police requesting information a patient requesting for their records to be deleted serious confidentiality breaches It is enough simply to know about the existence of these figures. You should get in touch with your foundation pro ­ gramme clinical lead or foundation programme co­ordinator for all concerns involving the legal department. FY1s are not in a position to handle such matters, nor are they expected to do so. What should you do if confidentiality is breached? A breach of confidentiality is not something that can be 'undone' and puts a serious question mark over your professional conduct. If a patient feels confidentiality has been breached, they can action a disciplinary via the GMC which has serious consequences for your career (Ministry of Ethics 2010). However, rarely does a patient decide to prosecute for a confi ­ dentiality breach. If something does happen, the Medical Pro ­ tection Society (MPS 2010) argues you can best handle this by: 1. Establishing what happened and what went wrong. 2. Offering the patient an explanation and an apology. 3. Giving assurance that lessons have been learned. 4. Identifying how mistakes can be avoided in the future. Common situations where confidentiality is breached are (MPS 2011): In a lift or canteen. In A&E departments and on wards where parents and rela ­ tives are in close proximity. Through patient's notes: commonly left in places where they are easily accessed by the public. Through computers, faxes and printers: information becomes easily visible. In pubs and restaurants (see Figure 2. 1). Information ­sharing and confidentiality can be a bit of a mine ­ field, especially at first when everything is so new. Described below are a few scenarios to be familiar with. Remember, though, that every trust should have local policy guidelines on these matters, and, if you are ever unsure, always seek senior advice. The DVLA What should you do if you think a patient is not fit to drive? The Driver and Vehicle Licensing Agency (DVLA) are respon ­ sible for road safety and have strict guidance on health condi ­ tions and fitness to drive. Three things to note are: 1. It is the driver's legal responsibility to notify the DVLA. 2. You are responsible for telling the patient that their condi ­ tion may affect their driving (see Figure 2. 2). 3. Document in the notes what you have told them. Some common conditions that patients will need to notify to the DVLA are: Epilepsy or a seizure. Diabetes mellitus on any treatment that can cause hypoglycaemia. Acute psychosis. Severe mood disorders or neuroses: especially if they may attempt suicide at the wheel. These two examples illustrate accidental breaches of confi ­ dentiality. Key learning points from these involve taking particular care with relatives and being sensitive, but recog ­ nising that your responsibilities are to the patient first and foremost. Ashleigh, FY1 “I have a really loud carrying voice. One incident that stays with me involved a lady on the respiratory ward who was dying. Her relatives were down the corridor. I was discussing the patient with the consultant behind the curtain on the ward round and we were saying how she was going to die soon. Afterwards the family approached me-they didn't complain or anything-but repeated what was said behind the curtain: 'so you think that she is going to die soon, do you?' It was obvious they had heard us.... I apologised profusely, as I didn't mean for them to hear what we were saying. Whilst our conversa-tion wasn't insensitive, it' s not nice to hear your relatives are going to die in such frank terms. It was pretty horri-ble.... I always dial down the volume now!” Jack, ST1 “There was an 80-year-old gentleman who had a haemorrhagic stroke secondary to brain metasta-sis. He wasn' t known to have cancer. The family came to speak to the registrar who then made the mistake of telling the family about it before the patient knew. The family then said they didn' t want the patient to know. So the registrar listened to this and didn' t tell him! When the consultant found out, he was very angry and went straight to tell the patient what had happened. His theory was-quite rightly-if the patient found out and didn' t want the family to know then that ship had sailed. The patient has the right not to let the family know: not the other way round. In the end it was all OK, the patient was fine with the family knowing, but it shouldn' t have happened. ”

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

16  Professionalism Figure  2. 1  Always think about patient confidentiality... wherever you are You should have seen it! Alcohol and drug abuse: especially if you suspect they may drive whilst intoxicated. Some common conditions where you would advise a period of time off from driving, but they don't need to formally notify the DVLA are: Stroke/TIA Acute Coronary Syndromes (ACS) The criteria for those with “group 2 entitlement”, i. e. lorry drivers, differ from this. Make sure you enquire about occupa ­ tion so that the patient has the correct information. If you are unsure what to do, your options are to (GMC 2009b): 1. Seek advice from a senior colleague. 2. Consult your local policy document or the DVLA (2011) “At a glance guide to the current medical standards of fitness to drive”. Here you should get the information you require about a variety of disorders and conditions that can impair a patient's fitness to drive. 3. Seek advice from the DVLA or their medical advisor; prob ­ ably not your first port of call as this will take time. What happens if your patient disagrees with you? Advise them to seek a second medical opinion but not to drive in the meantime. What happens if they ignore you and carry on driving anyway? Educate them about the consequences of driving against medical advice to try and stop them; but be reasonable-you cannot use force. Use persuasion of friends and relatives if appropriate. What happens if that fails? THEN you are advised to notify the DVLA-but tell the patient that you are going to do this first. Patients involved in serious crime You are in A&E and you are notified that a patient is coming in with a stabbing injury, what should you do? Obviously your A to E approach and acute medical assessment come first, but you need to take account of the following:

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Professionalism   17Figure  2. 2  Tell your patient when their condition may affect their ability to drive Mr Th ompson WAIT!!! 1. The history-you need to find out if this was self­harm or an attack. The police need not be informed for the former. 2. In the case of the latter, inform a senior colleague. Advise them you think the police should be informed in the interests of the safety of both patients and staff. 3. If you are responsible for informing the police, DO NOT disclose the patient's information at this stage, it is unnecessary. All the police need to be aware of is the incident. The police arrive and wish to see the patient, but you feel the patient is not up to it. What next? Your duty of care is to the patient and you should explain this to the police. When you feel the patient is ready, you can then ask them whether they wish to speak to the police. A crime has been committed, but the patient is unconscious so you can't gain consent to reveal their details to the police. What should you do? You can disclose confidential information as required by law and in the public's best interests. This is because others may be at risk of injury and/or it may aid prosecution for the crime (GMC 2009c). With any matters concerning confidentiality you should be seeking advice from the consultant in charge. Disclosing confidential information should never be rushed. Finally, if you are required to disclose anything, you must protect yourself by recording all the reasons for information disclosure in the patient's notes. You find out that this is a domestic dispute and the victim does not want to press charges. What should you do? Whilst it is appropriate to ask patients to disclose information necessary for their protection, you should abide by a competent adult's refusal if the risk of harm is only to themselves and not to others. However, you should warn them of the risks if they do not consent to disclose. You should also give them ways to seek help themselves, e. g. by informing them about domestic violence support groups. If children were involved in this case of domestic violence, however, you would be obliged to dis ­ close the information to social services (GMC 2009d: Paras

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18  Professionalism51-56). Again, it is important to reiterate that, whilst you should be aware of what to do in difficult situations concerning confidentiality, you should always seek senior advice. Confidentiality and the under eighteens If a child is having an operation, it is best practice to have consent from both parents, but legally you only need one person with authority to give permission to treat. In an emergency, you don't need permission at all, as you can operate in the child's best interests. If there is a conflict that cannot be resolved informally, consult a senior as they may need to inform the legal department. Your trust will have a local policy on this, so it is advisable to familiarise yourself with it early on-or at least know where to access the information. Any decision made to act in a patient's best interests must be able to stand up if challenged. Can a young person be seen without a parent? Ideally a young person should have someone with them. However, you would never want to give them the impression that they could not get medical help-especially if it is some ­ thing important that they do not feel comfortable telling their parents about (see Figure 2. 3). You may also want to see them on their own if you suspect there is something odd about the family dynamics. Always offer a chaperone for any physical examination if they are on their own and record whether they accept or decline. Note: divorce or separation does not make any one parent less responsible for their child. Figure  2. 3  Recognise when teenagers may be holding back Dr says, Is ther e anything else she should know ? Erm..... no... no What about a young person under sixteen years who wants contraception, an abortion or an STI check without their parents knowing? This scenario is more likely to present working as a foundation doctor either on a GP or GUM rotation. It is recommended that you treat a young person in their best interests, provided that you cannot persuade them to talk to their parents and that they fully understand both the advice and the consequences. You may be recognising a pattern here, but always seek advice from a more experienced colleague; your job is to flag up situations like this to them so they can be handled in the most appropri ­ ate manner. This does not make your role any less important however as you do not recognise where issues can arise, then problems may occur. Your job as an FY1 includes gathering as much information as possible to pass onto your seniors. How do you recognise potentially abusive or seriously harmful sexual activity in a young person? This is an important distinction to make as often you will see teenagers under sixteen in relationships with an older partner (see Figure 2. 4). Examples of when you should consider sharing information are where (GMC 2011a: 28): The young person is too immature to understand. A big difference in age is ringing alarm bells! The partner is in a position of trust-e. g. the young per ­ son's teacher. There is a force/threat suggesting emotional, psychologi ­ cal or physical pressure. Drugs and/or alcohol are involved. The child is under 13 years (under 12 years in Scotland). Generally speaking, a young person may feel more relaxed about confiding personal information to you, as someone who has been involved early in their treatment. Respect this and try to get as much information as possible, as it may be the only opportunity. If you suspect something untoward, it is often best to get the parents involved-with the young person's permis ­ sion of course. Beyond this, you may have to notify social services. Remember to record your concerns and justify any decisions made by your senior about the disclosure. You also need to be honest with the patient about the information you are disclosing. You have concerns about a parent's ability to cope with their child, what should you do? This scenario is more likely to present itself in A&E. For any patient who comes in with a serious domestic injury, mental health issue or a history of drug or alcohol abuse, you must check whether they have any children. It may be that you need to put in a referral for social services as these children could well be at risk and have fallen completely under the radar.

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Professionalism   19Figure  2. 4  Be wary of inappropriate age differences No! My boyfrien d This must be your father? It is preferable that you gain consent from the parent when disclosing information to social services. Agree with the parent the information that you will share with social services. The information you will need is all on the proforma but will include: Patient details. Details of all the individuals in the household. What the problem is. Other agencies involved e. g. the school they go to, any health visitors. It is not always necessary to get consent to contact social services. If you feel more harm would be caused to the child by not disclosing the information-for example if the parents would harm the child in some way-then you should not get consent and inform a senior straight away. In this instance, social services may be approached by telephone prior to sending the report in writing. This assessment is made on a case­by­case basis dependent upon the sense of urgency. Again, you would flag this up to a senior as this decision should be made by a more experienced colleague. Jackie, ST1 “A&E is the place you are safeguarding children... try to get as much information for social services as possible. It' s a pain in the middle of the night on a busy shift, but it' s important. You should also tell the parents about the referral. There is a box on the form asking whether you have told the parents. I wouldn't be happy submitting the form without the box ticked on my own judgement.... If I think getting consent is going to cause more harm than good, I get senior advice. ” For your reference, the GMC (2011b: para 60) advise the following order of preference for seeking advice: 1. An experienced colleague. 2. A named practitioner for child protection-your foundation clinical lead would help you with this. 3. A Caldicott guardian. 4. The GMC or another professional body (e. g. BMA, RCP) or defence body (non­EU). Only the first two points are applicable to the FY1 as the founda ­ tion school would liaise with three and four on your behalf. If social services call and ask for the medical records of carers of the child, what should you do? You should consider any specific requests for information very carefully. Only very rarely would you disclose whole records

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20  Professionalismand this would not be your decision to make. It is most appro ­ priate to get your consultant to review any records, for which you would need the permission of the individual concerned. With any case, you should be aware that information can be disclosed if it is in the public interest. Although this is not your duty, it is important to be aware of it so that best practice is adhered to. If you see something wrong that could potentially breach confidentiality, you are expected to speak up: this is an aspect of 'integrity' that is often mentioned. A young girl is diagnosed with cancer and her parents do not want you to tell her, what should you do? Although breaking bad news is not the responsibility of an FY1, you should explore with the parents their reasons for not telling their daughter. You should explain to them that you should assess the capacity of the child and deliver information in a way they can understand. This is because children and young people usually want to know about their illnesses. Exceptions to this are when: The information would cause “serious harm”. The child specifically requests that someone else makes the decisions for them. You should not withhold information unless the patient refuses knowledge of that information. The exception to this is if the information would cause “serious harm”, which is more than making the patient upset or meaning that they might refuse treatment (GMC 2010). For example, if a child was particularly unwell, and the parents felt that giving the diagnosis would cause the child more harm and distress, you should get a senior to review the situation. However, you should also go and see the patient yourself and make your own judgement about the situation. If you agree that it would cause further harm, record this in the notes. The decision to withhold the information should be regularly reviewed and the information shared at the earliest possible opportunity. As a junior doctor, you should be aware of the patient's prefer ­ ences at all times even though it will not be your sole respon ­ sibility to make these decisions. You are expected to advocate for your patients, and get as much information as possible to inform your colleagues. Questioning professionalism Samyami, FY2 “Professionalism can quickly be lost.... I had a colleague in a bad mood who-rather than saying 'these bloods have been incorrectly labelled'- threw them at me, shouted on the ward in front of patients, rela-tives and everyone, before storming off. That' s a massive question mark over their professionalism and it' s moments like that where you completely lose credibility. ” If you realise that you have made a mistake and your integrity has been compromised, remind yourself that you are human and these things happen. There are however a few steps that you should take: Apologise to the person it affects: patient, colleague, relative. If it concerns a patient, document the apology in the notes and explain what problem was. The majority of mistakes that happen will be minor things; you can simply fill in a Clinically Adverse Event (CAE) form, learn from the mistake and move on. If the mistake is significant, inform your seniors. Complete a reflection piece within your eportfolio. Tom, FY2 “If you have made a mistake you always need to be honest with the patient. I made a mistake prescribing Warfarin. After I told my consultant, she said I needed to tell the patient. I went to tell the patient that we had accidently overco-agulated her and potentially put her at harm, but that we had corrected it and she was now within range. The patient hadn't come to any harm but I wanted to let her know .... She was fine with it. The next day her daughter came up to me, clearly very angry. She told me that she had lost all faith in doctors because of this incident. That was pretty hard to hear. I still think it was the right thing to tell the patient-not because the consult-ant told me to-but because it showed me that there was a consequence of my mistake, even though I hadn't harmed her. ” How should I learn from mistakes? Charlotte, FY2 “If you make a mistake you do need to reflect on it-and I know that' s a cliché but you really have to. You have to be honest with yourself. Everyone makes mistakes; some are worse than others, but it' s about how you deal with them. If you look into them seriously then you are unlikely to repeat them.... If you make a mistake once, you shouldn't really make the same mistake again. ” Expect to make mistakes; what's important is how you learn from them. Everyone groans at medical school at the mention of the word “reflection”. Unfortunately, however, this is a crucial aspect of professionalism that is vital for your learning and personal development. HERE ARE SOME TIPS FOR GOOD REFLECTION: If something has happened that affected you - write it down! Self-regulation is an implicit aspect of reflection; evaluate what you could have done better. Most of the time it is only you who will question your decisions. If you find a gap in your knowledge, address it; no one else will do it for you. Know the personal state you were in and the circumstances under which the mistake happened. How can you flag these up in the future? Talk to your peers about it; chances are they will have been through a similar experience. Less is sometimes more. Don't reflect because you feel you have to, reflect at times where you know you will learn from it and it will make a difference. It's not about ticking a box.

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Professionalism   21Mithun, Consultant Psychiatrist “As a doctor, you have to be proud of being a professional, and part of being a professional is being good at what you do-that is of the utmost importance. As a junior doctor, learn the importance of not taking short cuts... taking an extensive history... having an inquisitive mind. Be self-critical, want to better yourself and be the best there is. Ask yourself constantly: what can I do to improve my weaknesses?” TOP 5 TIPS ON PROFESSIONALISM: 1. Be conscious of your image as a professional within your personal life. 2. Stop and think before you share information. 3. If you are unsure at any point, consult a senior for advice. 4. If something goes wrong, find out what happened, then apologise to all those concerned. 5. Reflect on the important things that you know you can learn something from.

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22 The Situational Judgement Test at a Glance, First Edition. Frances Varian and Lara Cartwright. © 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd. 3Pressures and prioritising Carl, FY2 “I really cannot stress the importance of organisation enough. You may think a lot of what you do goes unnoticed, but it is well appreciated. As soon as you have a house officer that is not organised it really becomes appar-ent... especially on surgical ward rounds... they have to run very quickly. If you are not on top of it they will notice. ” As far as coping with pressure is concerned, a foundation doctor is expected to: Work under pressure and remain calm and in control. Have effective coping mechanisms for stress. Demonstrate good judgement under pressure. Remain resilient and not give up easily. Deal with difficult situations and manage the unexpected. Know where to seek support. Deliver good time-management. The common pressures which present themselves in foundation placements include: Probity Ward rounds Discharges Prescribing Consenting patients Learning and career development Probity Like integrity, probity is a word frequently bandied around the healthcare profession with assumed understanding. To be explicit, probity is about being honest and trustworthy and acting with integrity at all times, especially when under pres-sure. The following examples are experiences where probity has been challenged: Mike, FY2 “The patient' s family did not want alcohol as the cause of death to be written on the death certifi-cate. They became quite irate as they did not feel this was relevant. After speaking to the registrar-who confirmed it must be recorded-I went to explain to the family that I could not omit the information because that would be falsifying a docu-ment that I had a professional and legal obligation to fill out truthfully. They appreciated I took the time to find out all the information before discussing the death certificate with them and accepted my explanation. ” This is an example of external pressures being put on you by people asking you to falsify information. Another point on probity is being honest and trustworthy with respect to your colleagues: Jeff, Consultant “It was around Christmas time and one of the registrars asked to swap his New Year' s Eve shift for Christmas Eve. Ordinarily this is quite a good switch. The registrar swapping had to rearrange a few family things but did it as a favour to his colleague. Two days before New Year' s Eve the registrar who swapped rings and says 'you have to do New Year' s Eve now because I have family coming that I forgot about'. This was rude and so unbelievably out of order. Ordi-narily we wouldn't hear about such matters but this was so inappropriate, we were all appalled-suffice to say he would not be getting a reference from anyone in our department! Nobody trusted this person and it wasn't long before he moved on. After all there' s nothing that should stop you from being on call, even if you had a holiday booked-we would expect you to get a later flight. ” SOME KEY THINGS TO REMEMBER ABOUT PROBITY WHEN UNDER PRESSURE: Document EVERYTHING: legally speaking if it's not written down, it didn't happen! Always read BEFORE you sign. Always be honest - that extends to being honest with your colleagues (see Figure 3. 1). Remember that being trustworthy is integral to gaining respect. Ward rounds Sarah, FY1 “There' s always pressure, particularly on surgical ward rounds. They can be really rushed, but you have to remember that the consultant and specialist regis-trars have lots of other things to do. If you mess up the ward round in the morning, it messes up their whole day and can leave them in a really bad mood.... Being organised is really the key. ” Understand that as an FY1 you effectively run the team from the bottom up; you are the eyes on the floor. A large part of your role is clerical and, as the ward junior, you need to ensure the ward round runs smoothly. You will be expected to fill in the relevant gaps of each clinical case for the consultant as their commitments may mean they are unable to see the patient every day.

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Pressures and prioritising   23 TIPS FOR A SUCCESSFUL WARD ROUND: Get to the ward at least 30 minutes before the round starts to prepare the notes. Know where your patients are. Ask the nurses whether there were any problems overnight. Have a system for writing the notes: date, time, ward, area and those present are the basic essentials. Summarise patient information before the round starts: the patient's observations now and when they came in, background, presenting complaint and results of any investigations. Know how to access bloods and images quickly. Remember to write your jobs in two places - in the notes and on your list - otherwise you might forget to do them. If you are unsure of the plan made, repeat it back to check. There is nothing more irritating for the consultant than having their management plan messed up, or you calling them later in the day to say “what did you actually mean by that?” Always clarify at the outset. Patient discharge There is huge pressure from the nurses and ward clerks to discharge patients. However, your priorities as a doctor are different from those of your colleagues who are expected to prioritise patient flow. Whilst you should support your Charlotte, FY2 “Discharges can take a long time- often because you are multi-tasking (see Figure 3. 2). Nurses will be asking you questions, physios asking you questions, OTs asking questions... your attention is con-stantly divided so what should take five minutes ends up taking thirty. ”Erm, no... hav en't seen them Have you seen Mr Philips' charts? Figure  3. 1  Be honest with your colleagues colleagues and respect their roles, you must have an appropriate plan that completes the clinical journey such that patients are neither lost in the system, nor return to hospital (hopefully!). Discharge letters may be dull but they are highly important. If they are not done properly, mistakes can lead to the patient getting lost in the system and not being followed-up, the GP not receiving the right information, the patient not getting the right medication.... The list goes on. Here's an example: Priya, FY2 “I had just joined a different hospital and I didn't know their policy on prescribing Warfarin on dis-charge was different. I prescribed it on the system, but didn't realise Warfarin had to be prescribed in the little yellow book for it to be dispensed. It wasn't until the nursing home rang me that I realised my mistake. I apologised and someone came to collect the prescription in the yellow book. From now on I always check the simple things when I move to a new hospital. ”

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24  Pressures and prioritising What if a patient wants to self-discharge? This would typically be against medical advice. In that case you should contact the patient's GP in person as the patient is at high risk of further illness. The GP can also set about trying to get in touch with the patient. If the patient is a child, the situation is different. You can always stop them, or their parents, from trying to self-discharge provided you feel it is in the child's best interests to remain in hospital. You can do this by calling security in hospital, or the police if the patient is outside the hospital (in which case social services should also be notified). Jackie, ST1 “Although parents have the right to self-discharge; they don't have that same right concerning their child. One child was referred in from their GP with an exacerbation of asthma as his sats were 90%. I gave him an inhaler and his sats had improved, but I wanted to keep an eye on him as I wasn't completely happy for him to go home. His mum wasn't concerned and his sats were back up so she took that to mean he was fine. She said she had been waiting long GENERAL TIPS FOR A SUCCESSFUL DISCHARGE SUMMARY: Fill it in as you go along, from admission. That way you have less to do at the end and you won't forget things. Be comprehensive: the more detail you give, the better the follow-up. Don't forget the GP! They will need to know WHY drugs have been started or stopped, what investigations need to be followed up and WHY to continue management. Know the procedure for each hospital as this can catch you out. Figure  3. 2  Try to avoid distractions when writing discharge summaries Has Miss Br own had her cup of tea? Where is Mr F azi for his physio?Have you cannulated Mrs Jones? FOR ACCURATE PRESCRIPTION AT DISCHARGE: Review medications on the patient's drug chart. Ensure they are correctly transcribed - dose, duration, frequency, prn (when required). Ensure you sign and write down your bleep number and ward so the pharmacy can dispense them to the right place.

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Pressures and prioritising   25enough and wanted to leave. I still wanted the registrar to review him though so I asked her to sign a self-discharge as I wasn't happy. I then pleaded that she at least wait for a new inhaler, but she left before even getting the medicine. If I was concerned about the child' s asthma status I would have got the police to bring them back, but I wasn't overly concerned. I spoke to the registrar who suggested I contact the GP to get the medicine to them-which I did. ” Prescribing Prescribing mistakes cost the NHS £500 million annually in England and Wales (DH, 2001). Nationwide, 5-7 % of acute medical admissions are due to prescribing errors, 50% of which are attributed to just four drugs: antiplatelets (16%), diuretics (16%), non-steroidal anti-inflammatories (11%) and anticoagu-lants (8%) (Howard et al. 2007). Prescribing should be consid-ered as the most hazardous area for a junior doctor. Whilst you would never attempt a high-risk practical procedure without supervision, prescribing can be equally harmful-and you carry this out unsupervised from day one (Maxwell and Walley 2003). Strikingly, 90% of the prescribing done in any one hos-pital is by junior doctors; typically for paracetamol, morphine or metoclopramide (DH 2000). Learn the common mistakes now, so you don't make them. The British Pharmacological Society (BPS 2010) lists ten principles of good prescribing: 1. Know WHY you are prescribing the drug. What is it for? How will it benefit your patient? 2. Know the patient's drug history (including OTC medica-tions) and allergies. 3. Consider individual factors, e. g. age, pregnancy, kidney failure. 4. Elicit ideas, concerns and expectations (ICE)! Yes, that all important aspect of establishing a doctor-patient partnership is crucial for compliance. 5. Choose the best medicine for the patient considering: formulation, dose, frequency, route, duration and of course ... cost. 6. Adhere to national, and local, guidance. Put into practice the textbook answer you use when your consultant asks you about antibiotic choice: “ I would use the one given in local hospital guidelines. ” 7. Be aware of the common prescribing errors so you can avoid them e. g. write units, not U. 8. Monitor the medication and know how to report adverse drug reactions. Each BNF has a yellow card in the back which can be filled out and sent to the Medicine and Healthcare Prod-ucts Regulatory Agency (MHRA). Alternatively you can access the MHRA online (MHRA 2012) and report side effects directly. 9. Document your reasons for prescribing and communicate these to patients, their carers and colleagues. 10. Only prescribe within your limitations, seek help early and get calculations double-checked. Lorraine, ITU sister “The two-person check is so important. We are all human and anyone can make a mistake.... You can listen without hearing and see without looking as well. The two-person check means you look at it, think about it and see it properly. ” Learn to be meticulous about prescribing and double-check. Names, doses and frequency should be legible. DO NOT DO ANYTHING BEYOND YOUR COMPETENCE even if you feel pressured to do so. Never guess when prescribing; if you are unsure, ask a senior. Remember not to PANIC (see Figure 3. 3) and you should avoid the common pitfalls: Prescription Allergies Notes Interactions Clear Right Drug Right Dose Right Route Right Patient PRESCRIPTIONS should always include the identity of the patient, the drug name, dose, frequency and start/finish dates. Eighty-five per cent of the errors that occur happen at the prescribing stage (Lesar et al. 1997) so check the British National Formulary (BNF) or ask someone for advice. Always ask about ALLERGIES and record any informa-tion on the chart properly. Do not write NKDA, use 'nil' or 'unknown'. Some consultants interpret NKDA as a sign that you simply haven't bothered to ask the question. Only in rare situations (i. e. an emergency) would you order a verbal prescription; hence, always write them up in the NOTES and on the drug chart beforehand to avoid mistakes. When prescribing multiple medications, be aware of INTERACTIONS and potential side effects. Furthermore, always take a full drug history. If the patient is unable to give you one, ask whether the ambulance brought anything in, or contact their GP. Finally, be CLEAR and write in CAPITALS when writing prescriptions, use the generic drug name-e. g. Ibuprofen instead of Nurofen-and write units correctly-i. e. micro-gram not mcg. Have a clear signature and remember the date, month and year. Be clear in communicating “your instructions to colleagues” rather than vice versa and, most importantly, be clear about your limitations. Always seek help early where patient safety is concerned. Sally, FY1 “I prescribed the wrong medication once. I was supposed to prescribe Metronidazole for bacterial vaginosis, but instead I prescribed Metformin!! The dosage,

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26  Pressures and prioritisingfrequency and patient details were all correct, and I entered the correct drug name in the patient records, but I just wrote the wrong drug name on the prescription. Thankfully I had written “No Alcohol”, and this alerted the pharmacist to the error so the patient received the correct medication in the end. Although this seems like one small error, its ramifications are huge. What if I had written Morphine instead of Metformin and the phar-macist had not realised? Then the patient would have been instructed to take 200mg of MST twice a day, with horrific consequences! It' s likely the mistake occurred because I was chatting to the nurse as I wrote the prescription. Now I always take great care when prescribing, and double check what I've written. ” If you make a mistake when prescribing, the Medical Protec-tion Society (MPS, 2011) recommends the following actions for righting the wrong: 1. Explain what has happened to the patient and apologise. 2. Analyse the potential effects of the mistake and correct accordingly. 3. Apologise to any colleagues involved. 4. Fill in a CAE form so that lessons can be learned. Paul, FY2 “There was a lady on the medical ward who was diagnosed with a pulmonary embolus and was being Warfarinised. She had been given loading doses and was slow to get into range. Her INR hadn't been checked for 3 days and I had been asked to dose the Warfarin. It was 4. 30 p. m. and I knew that if I took the bloods, I would have to hand it over for somebody else to dose. Her last INR was 1. 3 and she'd had 3 doses since so I figured it would be OK. I dosed her and put a request out for the phlebotomist to take some bloods so that it would be ready for the next morning to accurately dose it. The INR came back as 10. 7! We had to give her Vitamin K to reverse it. The patient didn't come to any harm and I explained to her what happened, but I am much more rigorous about prescribing Warfarin now and I don't take shortcuts. ” Consent As consent is such a huge topic, this book breaks it into more manageable chunks. Capacity and not being able to consent are considered in Chapter 4. This section covers consent from the perspective of patients with capacity and the different pressures they may create. For the most part, as a junior, the consent you gain will be implied or verbal. For example, gaining consent for venepunc-ture is easy; most of the time the patient will stick their arm out without you having to say anything. At other times, you would simply give a brief explanation of the ins and outs of the process. Tying together issues of confidentiality and implied consent, Figure  3. 3  Try not to PANIC when faced with a difficult prescription???? ???

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Pressures and prioritising   27however, complicates the matter-particularly regarding the disclosure of information to relatives. The informal nature of a phone call or a family member approaching you at the ward desk can be challenging. Take stock of the situation first, and then make your judgement call. Carl, FY2 “As a house officer you are on the ward all the time and the patients and family will see you as their doctor because of that. The family will often come to you at the desk whilst doing discharges to ask how their family member is. If you know that they have a good relationship with your patient and have been involved in their care from the outset, then you can disclose some information. You have to be sure it' s OK, though, as anyone could just walk in without even seeing the patient and ask how they are. You can' t disclose in that instance, so don' t feel pressured to do so. However, if disclosure includes important information such as diagnosis or sensitive investigations then you must always check if the patient is happy for you to disclose. ” What if I am asked to gain written consent for something I'm unsure of? Being asked to gain written consent for a procedure that you are not so comfortable with may be something you are faced with as a junior. The way you manage this is important. The GMC (2008a) recommends that the responsibility for consent lies with the person doing the procedure. If someone delegates gaining consent to you, they are still responsible. Thus, whoever delegates the responsibility to you should make sure you are familiar with and understand the procedure and the benefits and risks involved. In this case you have two options: 1. Explain you don't yet have the experience but that you would like the opportunity to learn. 2. Begin the consent process and do what you can, leaving the formal signing to a more experienced colleague. Judgement in this situation has to be made on the basis of your own knowledge, recognising where your limitations are. If you feel comfortable explaining some aspects of the proce-dure, then the second option is preferable. This assists the consent process but leaves the formalities to your more expe-rienced colleague. In this situation you need to have a good relationship with your senior and to be sure that they will meticulously go over the information with the patient before signing the form. In reality, there are only a few surgical pro-cedures for which you yourself will obtain consent and these will vary from locality to locality. What should I do if a patient doesn't want to know? Sharing information and knowing how much to share is central to good decision-making, but difficult to gauge. This can be daunting at first. The GMC (2008a) recommends tailoring all discussions to the patient without assuming the information they want. Ultimately you should:1. Find out why they don't want the information. 2. Respect their decision not to have the information, BUT 3. Give them enough to gain consent: e. g. why you are doing it, a brief description of the procedure, any serious risks involved and whether they will have any pain afterwards. 4. If they won't have even the basic information, write down that this is what has happened and explain to them what that means. For example, this may mean that their consent is not valid. What if a patient with capacity wants someone else to decide? If the patient has capacity, the bottom line is that no one else can make the decision for them. The GMC (2008a) recom-mends that you: 1. Explain that it is important that they understand the options and the implications of any treatment. 2. Find out why they don't want the information. 3. Iterate that their consent won't be valid if they do not have this information. What about consent in an emergency? The GMC (2008a) recommends that you should gain oral consent in these circumstances but the patient should still have all the information they need. Record this in their notes. If the patient is unable to consent then you can act in their best inter-ests (see Chapter 4). Ultimately you should recognise that, as a junior, you have only been qualified for a short time. Issues of consent are highly complex and the consequences of one decision over another are largely beyond what you can see. You must share this responsibility and find someone with more experience to give you advice. If something such as a breach of confidential-ity happens because you have not gained consent, it cannot be taken back. Nevertheless, the right actions can be sought afterwards. Amit, FY2 “I was looking after an elderly gentleman with hypercalcaemia who was intermittently confused. His daughter was heavily involved in his care. She asked one of the nursing staff about his CT results. And the nurse- without checking with anyone-said 'Yes, we're doing some further investigations to confirm whether the mass is cancer'. I looked up and thought what have you done?! We hadn't told the patient yet because he was intermittently confused, but between episodes he seemed to have capacity. We then had the situation where the relative had been told and the patient didn't know. The daughter then spoke to me and asked me to keep it from him because she thought he wouldn't take it very well and he had been quite down recently. To be asked by a relative not to tell the patient is completely wrong. I spoke to my consultant and we had a team meeting with the nursing staff to discuss the breach ... in the end the patient was OK with it. ”

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28  Pressures and prioritising Learning and career development Samyami, FY2 “Never forget you are there to learn- not just to complete jobs and discharge patients-that way, you'll really enjoy your foundation training. ” Training whilst doing a job means that pressures in terms of learn-ing and career development are constant. With some tips and good time-management however this can be something to enjoy. A foundation doctor is expected to: Have a desire and enthusiasm for continued learning. Take responsibility for their own development. Learn from others and from others' experiences. Be open and accepting of feedback-appraisals are a key time for this. Have a desire and willingness to teach others-medical stu-dents are usually there for you to impart your wisdom to them. There are plenty of opportunities for learning beyond your protected teaching time. These can be considered within three broad areas: Informal Procedural Teaching Figure  3. 4  Have a desire and willingness to teach medical students Umm....Errr....So, who can tell me what' s wrong with this patient?Mohammed, Consultant Surgeon “Know what you want from your career so you can target the areas of interest and make the most of experiences you know you won't have again in the future.... I made the most of medicine because I knew I wasn't going to do it again. ” Informal  opportunities Remember to learn on the job (see Figure 3. 4). Go down to theatre and practice your suturing; the surgeons will be more than happy to have you. Engage in meetings by presenting cases or clinically adverse events. Get involved with an audit, and do it early! You will have to complete them throughout your career. The trick is to pick something simple; this will lessen the time pressure and make it easier to repeat. When you start a job, let your consultant and/or educational supervisor know what you want from the rotation and-if you know-from your career. This way they can offer you extra experience or direct you towards another team who can help.

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Pressures and prioritising   29Procedural Take every opportunity to learn new skills. Get as much practical experience as you can: go and see lumbar punctures, chest drains etc. If you have a quiet job and a lull in the day, remember that you are a trainee, so try to develop your skills in that time. Don't just chill out and have a coffee as you may not get another chance. Carl, FY2 “Your Registrar or SHO will always want to teach you, as they don't want to be the only person that can do something. Most jobs come with one or two specialist procedures that you should take the opportunity to learn. Once out of that job, you may never get that opportunity to gain that skill. I did a gastro job and I did 30 ascitic drains in four months. I feel confident now that I can do them on my own. If you can get one or two good transferable skills from every job, then you John, FY2 “Ward teaching happens all the time. I pick up something new every day: new drugs and new indications, or changes to guidelines. I find that I learn things that I would never get from a book or even remember in a lecture-but the fact that I was told about it and then asked to prescribe it makes me remember it. ” Alice, FY2 “Know that these two years are probably going to be the best two training years as you get to do a bit of everything. You should go into each of your rotations with an open mind and not think 'well I'm going to do surgery so I don' t care about elderly medicine'. Every speciality you do is going to be important in terms of what you go on to do. If you pick up lots of little skills then you won' t feel daunted about doing a different specialty; in that respect you should already have developed the practical skills to do the job. ”Teaching medical students Nick, FY2 “FY1s and FY2s give some of the best teaching as they still remember what it' s like to be a medical student. Having been through finals, they know the level that you need to know. As a medical student you can overestimate what you really need to know and much of it you will never be asked in finals. Formally teaching students also forces you to brush up on knowledge that you haven't looked at over the past few months-though you would never admit this-so you learn as well!”have done well in terms of learning opportunities-any more than that is perhaps unrealistic. ” Figure  3. 5  Important/urgent grid (adapted from Covey 2004)Important Not important'Critical activities' Sick patient Answering your bleep Meeting deadlines e. g. appraisal, eportfolio 'Interruptions' Answering the ward telephone Responding to colleagues interrupting you'Important goals' Patient safety Helping out colleagues Discharge Death certificates Clinical audits Taking a break 'Distractions' Checking email Social networking Jobs you could delegate to others e. g. bloods, drawing up drugs Urgent Non-urgent Prioritisation Fraz, FY2 “If you are organised it allows you to be more efficient and prioritise more effectively. Prioritisation isn't easy at first, but it comes easier if everything else is organ-ised in a timely fashion. ” For effective organisation and planning, as a foundation doctor you should: Manage and plan workload effectively. Display efficient time-management. Deliver tasks on time. Prioritise effectively and reprioritise where appropriate. Assimilate a range of information and identify key issues. Think creatively to solve problems. Be proactive and take initiative. Attend to detail. Learning to prioritise your workload can be the hardest part of adapting to your foundation job. One particularly useful time-management tool-the Important/Urgent Grid-is described by Covey (2004) see Figure 3. 5.

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30  Pressures and prioritising Excuse me Doct or, I've been waiting hours!Look out fo r that water!!Aaagh! cough... cough... cough... Doct or, doctor Figure  3. 6  Try to prioritise your workload to avoid overload Covey (2004) describes a grid formation of tasks divided with respect to urgency and importance. This system allows you to prioritise tasks more efficiently and use your time more effectively, leading to a more successful and less stressful working day. It's easy to prioritise tasks that are both urgent and important (top left quadrant). These “critical activities” include the “quick wins” and general buzz of “getting the job done”. However, this can lead to a feeling of being constantly busy, but unproductive overall (Figure 3. 6). Covey (2004) highlights how you must focus on the impor-tant and non-urgent tasks as well as the urgent. Prioritisation will therefore be more successful if you concentrate your time in the “important goals” area of the grid (top right quadrant). A few examples of these tasks are included in Figure 3. 5 but the list is by no means definitive. While on your clinical placements, consider arranging tasks in this format to aid your prioritisation; starting early means you can hit the ground running when you qualify. Sarah, FY1 “After a ward round I sit down with all the notes and the list of jobs and put them in order of priority of urgency: urgent, important and those that can wait. Radiol-ogy requests are usually the first thing I do, then discharges, as I know nurses are under pressure to discharge patients. ” If at any stage you feel “critical” tasks are overloaded, consider the reasons why. Some will be “crisis” items which could not have been foreseen; however, some might have been prevented from becoming urgent if they had been tackled at an earlier stage. For example, if your appraisal is imminent

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Pressures and prioritising   31Bleeps At any one time on the wards you could potentially have two bleeps: Your personal bleep An on-call bleep This should NOT be SOMEONE ELSE'S bleep! On-call bleeps are notoriously difficult to prioritise-espe-cially in medicine where, in smaller localities, you may be the only doctor covering all the medical wards in the hospital. At the same time as prioritising your patients, you also have to find time to attend to your own bodily functions: peeing, eating, etc. Ideally, you should not hand over your bleep to another colleague as this is effectively handing over responsibility for your patients to them. Sarah, FY1 “On call in medicine you get bleeped con-tinuously. My colleague handed his bleep to a nurse whilst he had a very quick pee on call last Saturday and during this short time his bleep went off 13 times! The nurses bleeping you will want to get whatever they are asking for done imme-diately, and often will be quite insistent that you need to do this cannula NOW, despite the fact you are currently singlehandedly juggling a septic patient, a pulmonary embolism and an acute exacerbation of asthma-as I was 2 weeks ago. In this situation you will be stressed, hungry and tired. Trying to be firm about the priority of a cannula but simultaneously remaining polite is really, really hard. And it is a daily example for junior doctors on the importance of professionalism. ” There are a few situations in which it is acceptable to hando-ver or 'silence' your bleep, these include: During handover (see Chapter 6). When breaking bad news (see Chapter 4). During protected teaching time. An important point to note about breaking bad news is that patients can see you ignoring your bleep if it goes off HERE ARE SOME TIPS FOR PRIORITISATION: Sick patients come first - without exception. Try to predict your workload over the course of the day and plan accordingly. Scans can take a few hours to arrange, so it's best to discuss them with the radiologist early. Bloods need to be done early, otherwise you end up handing over the results to the ward cover rather than acting on them yourself. Discharges are a careful balancing act as patient flow is important, especially considering the nurses are under real pressure. Getting these done will make things easier for the nursing staff. Ask your immediate seniors for help. They have done the job recently and can tell you what the priorities are. and you haven't completed your self-reflection, ask yourself if you could not, realistically, have done this earlier to avoid the additional stress? Generally speaking, if you spend a high percentage of your working day tackling tasks in this quad-rant, stress levels will be high. At this point you should con-sider asking for help, as you will either need to find another way to manage your workload or to raise the issue that the workload is simply too much for one person to handle. “Distractions” should be considered as time-stealers which prevent you from achieving your goals. Question whether such tasks can be delegated, rescheduled or simply avoided: should you really be checking your email for the tenth time that morning? These could also be things that others want you to do for them, rather than things which contribute to your own goals. Saying no politely but firmly at an early stage is one strategy, but you must also remember that teamwork is about give and take. See Chapter 6 for considering other team members' roles. Finally, interruptions are difficult to avoid, especially when working on the wards. If you find that this is causing particular delay, consider whether you need to find a different place to do your paperwork, or to redirect some of it elsewhere. Part of being a good team-player, however, is being open to interrup-tions. In this respect, the most important thing to remember is to make sure your priorities are flexible: Fraz, FY1 “If you're working on call on a surgical rota-tion and you're the only FY1 available, you have to quickly prioritise. For example, if you have cannulas and a patient crashing; just because the cannula is number one on your list doesn't mean you do it, you have to switch around and swap your priorities. ” With respect to prioritising patients, every patient should be assessed in terms of their CLINICAL needs as this determines their investigations and treatment. On a side note, the GMC (2009a) stresses how these priorities should never be affected by your personal views of the patient; hence even if they are a repeat attender or behaving badly, you prioritise their clinical needs regardless. See Chapter 5 for additional information on patients. As a medical student, you are well schooled in recognising the sick patient; it is the more day-to-day tasks that can be initially hard to prioritise. Nick, FY1 “Prioritisation is key: for patient safety more than anything. It' s hard initially as you're unsure which jobs to do first and how fast to do them. I remember my first week as an FY1, I clerked a patient in with hemiplegia and I had bloods, an ABG... a whole list of jobs were just piling up with no idea where to start. I sought advice from the FY2 and she knew straight away which ones to put at the top of the pile. ”

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32  Pressures and prioritising-demonstrating that you are giving them your undivided atten-tion. Hence, not silencing your bleep can be a positive thing and should be judged specific to the situation. Your personal bleep should be with you at all times and answered in a timely manner. The exception to this is during protected teaching time. Here you are usually asked to hand in your bleep before enter-ing the lecture theatre to ensure your learning is uninterrupted. Ignoring a bleep without very good reason is not acceptable, as this could seriously compromise patient care. TOP 5 TIPS ON PRESSURES AND PRIORITISING: 1. Be honest, clear and up to date with all information. 2. Take responsibility for - and pride in - your job role. 3. Be systematic with your jobs list and prioritise according to urgency and importance. 4. Adapt quickly to situations. 5. Remember you are learning: so seek every opportunity to do so.

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The Situational Judgement Test at a Glance, First Edition. Frances Varian and Lara Cartwright. © 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.   334Effective communication Mary, patient “A good doctor is able to communicate well: be comprehensible, direct, and sensitive to my responses and my needs as the patient. Having patience is also key... for example, when presented with oedema around the ankles, saying 'it' s not exactly life-threatening is it?' isn't par-ticularly helpful!” (see Figure 4. 1)skills. But what constitutes “good” communication skills? Kurtz (1989) outlines five principles for success: 1. Interaction rather than dictation: in other words, a two-way conversation. 2. Reduce uncertainty by allowing the patient to ask questions. 3. Plan and think about the outcomes. Know beforehand what you want to achieve from the conversation or what you want to convey to others in writing. 4. Dynamic: be flexible from one patient to another and be responsive to individual needs. You will encounter a wide variety of patients for which you must adapt your approach. 5. Helical: what one person says influences another and so on and so forth, so that the conversation evolves. This can be challenging, as it requires you to adapt your thoughts to the patient's response. Whilst you may enter the conversation having a set number of points to cover, you may leave having taken a very different tangent. The BMA (2004a) also list barriers to communication which are summarised below in order to help you evaluate your own communication skills. Do you find yourself falling into any of these traps? Lack of understanding of conversational interaction: see Kurtz's principles above. Inadequate recognition of non-verbal skills, including body language and the setting. Figure  4. 1  Don't belittle patients' concerns What?!You'll be okay to swim over, won't y ou? With respect to effective communication, a foundation doctor is expected to: Communicate with patients, relatives and colleagues effectively and sensitively. Adapt their style of communication to individual needs and context. Ensure they have all the relevant information before communicating. Ensure the surroundings are appropriate when communicating. Seek clarification to gain and check understanding. Readily answer questions and keep patients, relatives and colleagues updated. Five principles for good communication The British Medical Association (BMA 2004a) recognises that a doctor must have competent written and oral communication

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34  Effective communication Regarding communication as a low priority. Often all patients need is to feel listened to, and they will feel well cared for. Not having the confidence to communicate effectively. Lack of clinical knowledge about a condition. If you find yourself in this position, be honest with the patient and say that you don't know. It is not appropriate to deliver inaccurate information. Human factors : know yourself well enough to recognise fatigue and stress. Act on this accordingly: for example, all you may need is a 10-minute break. Personality differences : understanding your personality will help you communicate better. Moreover, you also need to rec-ognise the personality of others, i. e. patients, colleagues and relatives, to better communicate with them. Sophie, FY1 “Lack of communication can be a big issue-there are different types of doctors and differ-ent bedside manners (See Figure 4. 2). Sometimes there can be paternalistic styles which are out of keeping with patient expectations and medical practice, and sometimes compas-sion is not shown. This can leave the patient quite upset. It' s not that they are bad doctors, they just haven't communi-cated in the right way for that individual patient. ”The common complaints involving communication arise from three areas (BMA 2004a): patients not being involved in changes to their care; patients given conflicting information by different people (especially doctors and nurses); and clinical notes not being clear or not referred to appropriately. Good communication with colleagues and accurate record-keeping can resolve the latter two areas. Written communication It is essential that your writing is legible so that others can read it and follow up on patient care. If you have spent any time on the wards, you will have seen how difficult it can be to read some of the patient notes. Please think about your colleagues and try to write as clear as possible. Rajen, ST4 “We do audit notes for legibility. All entries should be signed including the GMC number. We will have words with doctors who fail to meet such standards.... Have you seen the nursing notes? They are always fantastic! We should be keeping the same standards. ” Record-keeping Mithun, Consultant Psychiatrist “A key skill is good documentation. I expect everyone to write everything down-almost verbatim-not just to sit down and try to Figure  4. 2  Good communication requires interaction... often all a patient needs is to be listened to Hmmm... Inter esting??!... ??! Erm... doctor?

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Effective communication   35summarise things from perception. Verbatim is more powerful in psychiatry and carries more weight than summarising find-ings. Writing should be legible, and each entry dated with the patient' s name and date of birth on every page. If it' s not, and the continuation sheet is lost, you don't know where it' s come from. ” Good writing in the notes is part of communication. For the majority of the time, the purpose of writing is so that somebody else can read a summary of the patient's problems. If your writing is illegible, this may result in a patient's plan not being actioned. Carl, FY2 “I always fill in everything on the blood form. There' s nothing worse than having to re-bleed a patient ... especially if they're difficult. ” TIPS FOR SUCCESSFUL DOCUMENTATION: (See Chapter 3 for tips on ward rounds and discharges): Always write in BLACK ink in the margin: date, time, ward and area. Always sign your name, print it and put your bleep and/or GMC number. Use only accepted, well-known and unambiguous abbreviations e. g. BP, HR, MEWS. Be thorough: Write LEFT not L. and RIGHT not R.-this is critical in surgery, taking off the wrong limb or removing the wrong organ is a 'should never happen' event. Be contemporaneous and NEVER retrospectively change notes. Tony,  Consultant  Surgeon “A peer of mine who worked in a dysfunctional department told me this story. A patient came in over the weekend and was seen by the locum registrar. The patient was a young lady with pyelonephritis who sadly died on the Monday. This registrar then went and wrote in the notes over the weekend AFTER the event.... He never worked in that hospital again. ” What else should you document? Sam, FY2 “My first few months I forgot to document things half the time. Anything beyond routine jobs you should really document so try to get into this habit early. All discussions with relatives and other professionals... even informal discussions with OTs and physios. Put it down even if it seems obvious, especially if you are not around the next day to impart that information, as it may not be obvious to the ward cover or on-call doctor. ” There is a multitude of certificate and form-filling as an FY1. Routine elements considered here are: blood forms, clinical coding, death certificates and cremation forms. Blood  forms Sarah, FY1 “Taking bloods is a great opportunity to sit down and have a chat with the patient; you get to develop your relationship with them and that means they get better quicker. ”THE FOLLOWING TIPS APPLY TO BLOOD REQUESTS: All requests should be clinically indicated. Don't just tick boxes because you can. Think: is the information you have put on your form enough for the laboratory staff to be able to call you about an abnormal result? Blood tests mean little without the clinical context (Patel and Morrissey 2011). Fill in ALL the required information on the blood bottle and the form, otherwise it won't get processed and patient care will be compromised. Follow up the results: your test, your responsibility. Clinical  coding This is something you may have heard described at medical school. You should have a good induction on coding at your trust when you start working, but here are some basics. Throughout the UK, the system is called the Kohner Medical Record (KMR). Coding involves putting every patient admitted -their diagnosis, co-morbidities and any procedures/treatments -into the computer (or on a written form in the front of their notes). This is an important form of communication because, if you miss something vital in the diagnosis (e. g. hypertension), then it may be missed at handover and so on throughout their care. The KMR is also important for population statistics and the allocation of resources, as the more patients the hospital treats with co-morbidities, the bigger the budget they are assigned. Finally, you should consider utilising this data as a valid selection method for a clinical audit (Patel and Morrissey 2011). Death  certificates Ahmed, FY1 “I made a mistake certifying early on. It was for one of my patients who came in with a fall and died two weeks later from something unrelated. I didn't realise that, because she'd had a fall, she had to go to the coroner. The process was delayed as a result, so it' s worth getting it checked. ” Examine the patient thoroughly to confirm death. It has- very rarely-happened that a patient has woken up in the morgue! Remember to check for a pacemaker: this is important if they are being cremated. Understand there may be specific religious wishes that you need to be sensitive towards. To sign the death certificate you must have seen the patient alive at least 14 days prior to their death (ONS 2010).

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36  Effective communication Know the circumstances in which a death needs to be dis-cussed with the coroner (procurator fiscal in Scotland). Their duty is to decide whether to issue the certificate, order a post-mortem or start an inquest into the cause of death (Patel and Morrissey 2011). Be accurate about the cause of death. Ask advice from someone more senior as, if not done accurately, this can delay the whole process and the family cannot grieve in a timely manner. Cremation  forms This is a paid professional duty and should be done in a timely manner to avoid delay for the family. Two people independ-ently certify for cremation. The first person fills in part one and the second person-with 5 years' experience-fills in the second part. These forms need to match the death certificate, and it makes things smoother if you contact the person who signs part two to let them know that you have completed your section (Patel and Morrissey 2011). You should have identified the deceased; you should have seen them recently, and after death to confirm they do not have a pacemaker or radioactive device which could cause an explosion! Finally, you need to speak to the named nurse who was caring for the patient and was with them when they died as this information is required on the form. Common errors in completing this form, which result in a delay for cremation and funeral for the family are (Ministry of Justice 2012): Not completing the questions in full. Missing out questions. Filling the form in incorrectly. Illegible handwriting. Discrepancies between the two parts on date and time of death. Your local trust will have policy documents for you to view on death certificates and cremation forms which you should famil-iarise yourself with. If you want to look at the forms in the meantime, you can search for the Ministry of Justice website online or follow this link: http://www. justice. gov. uk/coroners-burial-cremation/cremation. Verbal communication Whilst oral communication skills require practice and self-reflection, there are some key points to consider regarding situ-ations where communication can be difficult: Working with interpreters. Communicating with patients with a disability. Communicating your personal views. Communicating with difficult relatives. Breaking bad news. Working  with  interpreters Carl, FY2 “It is difficult to refuse an offer from the family to translate, but if you feel uncomfortable about it, then you have to. I was working in a haematology clinic and had to disclose diagnoses such as lymphoma. With this, it was hospital policy to routinely test for HIV and Hepatitis B/C. Disclosing that information via a translator is hard enough, but if you are using a family member, then there is too great a potential for conflict. Because there is an emotional tie, there are a lot of potential for problems, and you can cause a lot of damage if you don't disclose in the right way. Also, if you are disclosing things like that in clinic, it is always better to have a chaperone. ” When you encounter a language barrier, try to arrange an inter-preter. It is rarely appropriate to use a family member-except perhaps in an emergency where they can give you a history and medications. The problems with using a friend or relative are (Phelan 1995): Their views produce inaccuracies. They try to protect patients from bad news. They don't reveal side effects as they think compliance will be better. The patient may not want to disclose 'embarrassing' informa-tion to them. Tony, Consultant Surgeon “I remember a case 5 years ago of a chap who spoke Urdu and his daughter was translating for him. It was really important that he understood that he had a staghorn calculus in his left kidney that would eventually stop it working, as I wanted to take out his right kidney with the tumour in it. He wasn't that keen on treatment and said 'No I'll leave it'. The medical student then said-once they'd gone out: 'she just said “you've got a stone on the left and stone on the right, you need surgery” and didn't tell him what the matter was. ' He therefore left with no idea of the importance of getting treatment so couldn't make an informed decision. It just shows how families can find it difficult to be objective and relay your issues straight across. ” The best options for interpretation are professional services such as the in-hospital translation service or telephone transla-tion service. You should check what services are available at each trust. SOME KEY TIPS FOR WORKING WITH INTERPRETERS: (As suggested by Phelan [1995]): Debrief the interpreter before and after the consultation. Direct questions to the patient and maintain eye contact with them and not the interpreter. Speak simply and pause to allow for translation. Respond to non-verbal cues. Check the patient's understanding. Try to use the same interpreter for future interviews where possible.

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Effective communication   37Figure  4. 3  You should seek a professional interpreter where possible to avoid miscommunication Mr P etrucci, you'r e going to be okay, but y ou will need to change y our diet and start exer cising I'm sorry Mrs P atel, ther e's nothing mor e we can do f or you They're exploring other angles, mum You'r e /f_ine! Another situation in which you may consider using an inter-preter is when patients have a communication disability. Com-munication support includes: lip readers, British Sign Language (BSL) interpreters, deafblind interpreters, note takers, etc.. If communication support is needed, notice should ideally be given up to six weeks in advance (Directgov 2011). Working  with  disability Depending on the focus of the teaching, the distinction between impairment and disability may have already been drummed into you at medical school: so one more time is probably not going to hurt! Impairment is considered the actual physical or mental 'effect'. For example, someone who is obese may be

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38  Effective communicationunable to walk for more than fifty metres without resting, resulting in mobility restrictions. This impairment would extend to a disability if the effects meant the individual was unable to work or carry out their daily functions as usual for at least 12 months (ODI 2010). Disability is therefore determined by the effect of the impairment; defined by the Disability Discrimi-nation Act (1995) as “a physical or mental impairment which has a substantial and long-term adverse effect on a person's ability to carry out normal day-to-day activities”. This is why you must ask every patient how their condition (i. e. impair-ment) affects their day-to-day life. The social implications of an illness significantly affects your management of it. Without knowing about them, you cannot truly empathise with your patients. Mental impairment can pose the greatest challenge to com-munication. The EHRC (2010) outline has some useful tips for communicating with patients with a disability to help avoid non-attendance and missed appointments: 1. Avoid “diagnostic-overshadowing” and seeing patients only in terms of their impairment. For example, a patient with autism may be behaving inappropriately because they are in pain rather than as a result of their impairment. BUT ALSO 2. Recognise that impairment can lead to health inequalities that require special attention. A patient with a learning difficulty should have the same access to healthcare services as everyone else. However, they should also receive full annual physical health assessments as research suggests they have a shorter life expectancy due to the higher risk of health inequalities. More time should be allowed for these assessments (and thorough physical examination) as impaired communication can impede history-taking (EHRC, 2010). Nick, FY1 “I had difficulties with a 35-year-old patient who-since birth-had no verbal communication. He was self-mobile and could care for himself, and his carer said he had an excellent quality of life (QOL) and was quite active. He came in with a severe pneumonia and, after maximum medical therapy, was still unwell. We called for an ITU opinion and they came down. After a short assessment they said 'no we won't take him'; deciding he had a poor QOL due to severe learning difficulties. I had to arrange for an Independent Mental Capacity Advocate (IMCA) to assess the situation. They laid out all the facts in order to make a decision and were bril-liant. The patient recovered in the meantime thankfully. ” Some key learning points from this example are (EHRC 2010): Never make assumptions about a patient's experience of their disability. For example, not every deafblind patient will have a learning disability. Also, you should avoid attributing physical complaints to a psychological cause in a patient with known mental health problems. Never make assumptions about the personal life of a patient with a disability-they have the same potential for a sex life as everyone else. Find out and remember their preferred means of communica-tion, e. g. writing everything down if they are deaf. Note any access requirements for future appointments: e. g., on discharge, are they able to find their way to their follow-up appointment in two weeks? Note any mobility requirements and make sure the nurses and healthcare assistants are also aware of them. Every effort should be made to understand patients' wishes whether or not they have capacity. As an FY1, you will have first contact with patients and therefore the time to find out from them their individual needs. If communication is difficult, simply ask them how they wish to be communicated with and make sure this is relayed to all the staff so that the patient does not have to keep repeating their requirements. Some patients may have a “passport” for health-care which has all the relevant information on their condition -take note of this. Michael, GP “Not speaking slowly and shouting are two key things you should never do! It' s about under-standing how the disability affects them.... As doctors, we are too often scared to talk about a disability but most people living with a disability are more than happy to talk about what that means. ” What about those patients who are newly diagnosed with a disability? This is very important as patients get stigmatised and margin-alised when labelled with a disability. The more you can support patients on wider social issues, the greater benefit you will be. Also note that time of diagnosis is crucial for every patient and must be handled with empathy, sensitivity and practicality to avoid any potential complaints. As a doctor you will likely be asked about (EHRC 2010): Fit notes-you will probably be expected to write these for patients for discharge, and it is necessary to know how much time the patient will need for recuperation at home. Benefits and statements for home adaptations. Disabled parking badges. If you are unsure, inform the patient about the EHRC (Equal-ity Human Rights Commission). They give telephone advice and guidance on many issues ranging from reasonable adjust-ments employers are expected to make, to expectant parents and social housing providers. There are also other sites you can go to, such as Directgov, which has a wealth of information as well as applications for disability grants and blue badges (Directgov 2012). Knowing where to direct patients is equally as helpful as having all the answers yourself. In the interim, you can also ask for senior input, advice from the nursing staff or, if activities of daily living are concerned, advice from an occupational therapist.

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Effective communication   39Communicating  personal  views Communicating  with  relatives Alice, FY2 “Patients will have no idea where you are in the cycle of being a doctor. They won't be interested if it' s your first day or tenth year as a doctor, they still expect a certain standard of you. Talking to patients and their relatives is one of the biggest challenges. ” In difficult, evocative and emotional situations you have to be really careful about the language you use and the clarity with which you provide explanations. Samyami, FY2 “I understand that this is your mum and you are very concerned and you have every right to be, but from our point of view you have to appreciate that this stroke is so extensive that she doesn't have the potential for rehabilita-tion. If she does arrest, she is going to suffer more injury and we could revive her but her quality of life would be zero. ” Always try to take a chaperone with you when you know a conversation is going to be difficult and you might run into trouble. Nurses are fantastic for this and, more often than not, have great relationships with relatives. Katie, FY2 “I had a high output family a couple of weeks ago. They had just lost their dad a few days before and then their mum had a massive stroke. She was only young, 62. She was in a really bad way and the consultant made the deci-sion to DNAR. The family didn't want it, they didn't even want us to take bloods, yet they weren't willing for us to start on the end of life pathway either. They got angry and quite aggressive, so I said ' OK I think we need to stop', but they didn't listen. The senior nurse intervened and said 'Sorry but we can't have you shouting on the ward, there are other patients'. If you know you have a challenging family, you should have a chaperone. ” Speak out if you see bad practice. Colette, Consultant Surgeon “Safety is very impor-tant. You must raise concerns as soon as possi-ble... The consultant will not get annoyed about asking questions. They may get annoyed if you do not ask and something goes wrong. ” Be careful about the language you use-is it suitable for your audience? Bill, Patient “I had polymyalgia rheumatica and was on steroids for it. At the time I was seeing a young GP at the practice who I generally got on well with, but my ESR and CRP had been fluctuating. He admitted he had been 'bollocked' by the consultant rheumatologist at the hospi-tal.... 'Bollocked' was his comment! As if I would ever use such a word... ” Don't forget, no matter how well you know the patient, you are still their doctor. Tony, Consultant Surgeon “I once referred to the hospital as 'a hotel whilst recuperating' as you're without any need for intervention. That was taken as grossly offensive by the patient. This was a misjudgement of my rapport with the patient. I don't think I've got it as wrong as that since. The patient was very angry so I apologised and took a step back. I had been slightly too familiar... it had been a less formal doctor-patient con-versation, but my description of using the hospital as a hotel didn't work for him and he took it as offensive rather than descriptive. ” Know your limitations, when to seek help, and when to have confidence in your skill set. Carl, FY2 “You need to decide how far you can manage something before you escalate it up .... That' s the skill ... working out the point at which you decide you are out of your depth, but not letting it get to that point before you make that decision. There is a fine balance between not shooting it straight up to the registrar without doing anything for that patient, and leaving it too late before you ask. You need to cut a balance to stabilise the patient and do all the necessary investigations. If you speak to the registrar and they say they don't need something, you can simply cancel the request. But if you ring them and say 'the patient is septic', and they ask what you have done and you haven't done even the initial investigations, they won't be very happy with you. That' s your bread and butter really-doing the initial work-up. When you reach the point where you don't know where to go ... then you should escalate it up. ”HERE ARE SOME TIPS FOR HANDLING DIFFICULT SITUATIONS: Explain the facts and be empathetic the whole way through. Try to explore the bigger picture. Check their understanding. If relatives start getting too angry or confrontational simply excuse yourself and give them a minute to calm down. This can be a natural grief reaction. How should I manage angry relatives? Recognise that relatives may be angry because they are worried, frustrated, scared, anxious .... The list goes on. Y ou should handle these situations by being Safe, Slow, Low and Sympathetico! Safe: bring a chaperone and make sure you know where the exit is. Slow : take everything slowly, let them vent before you speak, and slow down your speech as well as your body language to try and calm the situation. Low : keep the tone and pitch of your voice low.

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40  Effective communication Sympathetico : state empathy obviously “ I can see that you are very angry ”, offer an apology but don't impart blame “ I'm very sorry that this has happened ”. Whatever you do DO NOT TELL THEM TO CALM DOWN, it will blow up in your face. These situations are precisely the ones you should reflect on as it is highly likely you will have experienced such emotions yourself. Speak to a colleague about the events that unfolded. Most people find an angry person intimidating and may leave feeling a little 'shaken up'. Look after yourself so you can look after your patients; drifting around the ward an emotional wreck is no good to anyone (see Figure 4. 4). What if relatives want information about a patient you don't know? This situation is tricky and could well happen if you are working in a small hospital where you are the only doctor on call. Often the nurses will bleep you because the family want to discuss their relative's care with a doctor. In this situation you might not know the patient and not be involved in their care. You then have to consider whether you are comfortable discussing the case in this manner with the relatives. If you do not feel it is appropriate-especially if bad news is involved-you must explain your reasons to the nurse as to why you cannot have that particular conversation. Also get the nurse to suggest to the family that they book an appointment with the patient's consultant the following day. It is better not to communicate at all than to communicate when you know little about the situa-tion and may handle it badly. In this respect communication is all about the TPP : the appropriate Time, People and Place. Breaking  bad  news Breaking bad news is something that you should get practice doing with actors at medical school. You should be familiar with the process as you may be required to deliver bad news sooner than you think. That is not to say that you jump at the opportunity if presented. You must think carefully whether you have enough information about the patient before you decide to do it. Most importantly, take an experienced nurse with you. There are various mnemonics you can use for breaking bad news, SPIKES is particularly popular (Baille et al 2000). Setting up the interview: right place, bleep on silent to reduce interruptions etc. Perception: assess what the patient knows e. g. “what were our reasons for doing the colonoscopy?” Invitation: find out how much they want to know e. g. “how would you like the results?” Knowledge: this is where you fire a warning shot “unfortu-nately I have some bad news... ” avoid using jargon and don't be blunt-patients will not appreciate you blurting out “I'm afraid you're going to die. ” Also, avoid using the phrase “there Figure  4. 4  Seek out support if you 've had a difficult conversation

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Effective communication   41is nothing more we can do for you”, as there is always some-thing you can do: the whole palliative care pathway is designed to facilitate this. Emotions and empathy: this is the hardest part as it is often difficult to predict a patient's emotional reaction to bad news. There could be silence, crying, anger, denial.... Give them time to experience their emotions. Afterwards, address that emotion with empathy “I can see that... ”. Strategy and summary: Having a clear plan reduces anxiety but make sure that the patient is ready to hear that plan. Close by checking understanding of what has been said. This makes it sound simple, but, in reality, there are many personal barriers to breaking bad news. Rosen and Tesser (1970) described this charmingly as the MUM effect. The MUM (keeping Mum about Undesirable Messages) effect describes why it is so difficult to break bad news: the person delivering the bad news may feel anxious, burdened with the responsibility for delivering it, and fearful of a negative reac-tion. Unsurprisingly, this makes delivering bad news much harder, to the point where you become reluctant to deliver it. This effect intensifies when you perceive the patient to be dis-tressed (Baille et al 2000). Whilst you should understand that breaking bad news is not something typically done by an FY1, you may be the most appropriate person to break it if you have the best rapport with the patient. Each situation must be judged on its own merits, balancing the need for the patient to have the information in a timely manner against finding the best person to deliver it. Ultimately, the person delivering the bad news should always be certain of the information. Under no circumstances should you be delivering bad news on a 'suspected' or 'highly likely' premise. You MUST have all the accurate information and, if there are any doubts, wait for senior input. Conversely, you must NEVER deliver false hope; be honest and say you are unsure rather than reassuring the patient. Carl, FY2 “Although you may not be expected to do this, in reality, a lot of breaking bad news gets done on medical wards. You may be asked a direct question by a patient and you have to make a decision whether you are going to tell them that information or go and get help. If you feel comfortable and think it' s the right thing for them to know, you can tell them. If it' s not, then you need to find someone who will tell them in a timely manner. If they have asked for that information, they have a right to know but you have to balance this with the right person; there is nothing worse than a botched job of breaking bad news. Being quite personable and having a good rapport with patients will help. Make sure you get feedback afterwards though... ask a nurse to accompany you both as a witness and for support. ”Always consider whether you are the best person to break bad news. If it is not done properly, it can be disastrous and the patient and/or relatives will never forget. Here are a couple examples of breaking bad news badly, demonstrating how wrongly you can misinterpret the patient's views: Daniel, Patient “I was on the ward for kidney stones. I'd had a horrendous experience myself, so wasn't best pleased with the staff. The patient across from me had been very sick and, unfortunately, passed away during the night. They just drew the curtains around him and left the body in the bed! As if that wasn't bad enough, I heard the daughter come in the following morning and she walked straight past the reception into the ward. She was about to open the curtains when a nurse stopped her and said 'you can't go in there ... he' s dead!' I was shocked; I couldn't believe what had happened. That poor woman, she broke down in tears. I don't know whether they realised it was a relative of the patient but it was just horrific. ” Lorraine, ITU sister “I use this as an example in train-ing; it' s one of the most horrendous things I've ever heard. The patient had sustained a massive head injury and had partial lobectomies. I went in with the consultant to speak to the wife and two sons, daughter, and in-laws. The consultant said 'your husband' s operation was very successful. However, he will never be able to do anything for himself, never know who you are, never have a memory, or a personality... but his life will be normal longevity.... Can I make a suggestion'. The wife said 'Yes, please', and he said 'go home and make your family a lovely meal' and then he left! That was it. And I had to pick up the pieces.... ” And a brilliant one to finish: Lorraine, ITU sister “There was one doctor particu-larly good at explaining it, he said: 'we have machines on ITU that can prolong life indefinitely.... But we are not prolonging your wife' s life anymore; we are simply prolonging her inevitable death. ' That worked very well. ” TOP 5 COMMUNICATION TIPS: 1. Be sensitive towards patients, regardless of your mood. 2. Be meticulous about documentation, it is your legal lifeline. 3. Don't ignore disability, address it. 4. Dealing with relatives is an important part of patient care. Remember to be Safe, Slow, Low and Sympathetico!, and you'll handle difficult situations with ease. 5. Remember successful communication is all about TPP : the appropriate Time, with the appropriate People, in the appropriate Place.

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42 The Situational Judgement Test at a Glance, First Edition. Frances Varian and Lara Cartwright. © 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd. 5Patient focus Sarah, FY1 “Part of patients getting better is them knowing and feeling they are are being well cared for and looked after. ” Patient focus is all about making the care of your patient your first concern (GMC 2010). Foundation doctors are expected to: Gain trust from patients. Be empathetic, polite and courteous towards patients. Respect patient's wishes and work jointly towards their care. Build a relationship with both patients and their relatives. Consider patient safety at all times. This means you will inevitably be required to deal with a wide range of problems concerning your patients. In this respect, foundation doctors are expected to: Demonstrate an ability to assimilate a range of informa-tion and identify key issues. Engage with wider issues and think creatively to solve problems and reach appropriate decisions. Be proactive, demonstrate initiative and attend to detail. Being the best for your patients TOP TIPS ON BEING THE BEST FOR YOUR PATIENTS: Talk to your  patients,  not about  them Julia,  ST2 “When on a ward round, try not to talk about patients in front of them-address them. If you hear your consultant saying for example 'this patient is two days post lap-choli . . . ' try to steer them away from doing it. Ask the patient how they are doing and always go back and talk to them after-wards if you feel they've been left in the dark. ” Look  after  yourself  so you can best  care  for your  patients (see Figure 5. 1) Bill, Patient “Look after your own health-sometimes I am looking at the doctor and they're so ill I'm thinking 'Should they really be here? . . . They look worse than I do'. It does make you question whether they can do their job properly. ” Realise  that  patients  are your  customers .  .  .  they  are  always  right! Be mindful that patients are people with lives outside the hospital. Your job is to get them out of that bed and back to the real world as soon as you can. Charlotte,  Consultant  Surgeon “Really good doctors don't care about the boundaries of care and see patients as human beings rather than 'that's not my speciality so I'm not doing it'. I was seeing a patient transferred from dermatology with really bad leg ulcers who required urgent investigations. The junior said 'eugh... why do we have to look after that patient from dermatology?' That attitude of 'someone else's patient not mine' is simply not tolerated. I was really not impressed. ” Be empathetic. This means understanding where the patient is coming from and that means working out what they are thinking. Without empathy you may fall into a trap: adopting a defensive position, or simply missing the mark altogether. Tony,  Consultant  Surgeon “Sometimes it can take an hour of conversation to develop a rapport with a patient so they trust you enough to let you treat them. I remember one chap seeming very angry with us, but in fact I had read it all wrong-he was just very anxious and fighting his feelings. I handled it fine but I would read that differently again. ” ALWAYS  examine  your  patient. A clinical error such as this is inexcusable. Shan,  Consultant  Surgeon “I know plenty of law suits because the clinician has failed to examine. A colleague of mine came to see me about a breast lump... she said, 'of all the surgeons in this hospital, you're the first one to treat me like a patient and actually examine me. ' I thought this was remarkable, and wholly unacceptable. ” Know  your  responsibility  for social  care  as much  as  medical  care. This is because social factors have a huge effect on the patient's physical and mental health and will determine whether they return to hospital or not. Although the nursing staff will largely liaise with OTs, physios and social services, you need to appreciate social discharge from the point of view of: Which patients require social input. How their social requirements are assessed. The support they will receive at home. Being able to report back to the patient information about their social placement. Don't  forget  about  families  and  relatives  and  be  conscious  that  you are always  being  critiqued. Most complaints come from how you present yourself to others rather than the patient. Be meticulous  about  your  clinical  style and never underestimate the need to be conscientious and diligent. This may require occasionally going the extra mile to facilitate the best patient care. Patient advocacy Sunita, FY1 “If the patient thinks that your consultant is doing a bad job then you have to relay that informa-tion.... You have to just stand back from the fact it' s your senior and be the patient' s advocate. ” Advocacy is again something that is often discussed, but, in reality, it is difficult to perceive its relationship with everyday

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Patient focus   43Erm..... So, what seems to be the problem?... cough... cough... splu/t_ter... Figure  5. 1  As a doctor you have a responsibility to look after your own health practice. Basically, it means fighting someone else's corner using your own unique knowledge base and skill set. Whilst there are external services for this such as the Patient Advice and Liaison Service (PALS 2009)-you must also remember that you are an advocate for your patient when it comes to their care. As the junior member on your team, you will have the largest proportion of contact with your patients, aside from the nurses. This means you have to understand where the patient is coming from and stand back from any difficult behaviour or negative opinions about your colleagues. Samyami, FY2 “I was working on a surgical ward with a patient in hospital for appendicitis. He also had long-standing hyperkalaemia and when he came in his potassium was 7. 0. I was working nights when he became symptomatic; I treated him and he was fine by the morning, but his potassium remained high. My team didn't think this was a priority, and, given his surgical problem was fixed, felt he should be allowed to go home. I spoke up as I didn't feel he was fit for discharge. The nurse specialist was adamant nothing was wrong, so the consultant heard us both out. The consultant agreed that I could investigate because I wasn't happy with it. My team didn't like it as it delayed his discharge for two days whilst I went on a detective hunt to find out what was wrong. In the end it turned out he was taking steroids and needed sodium replacement. I don't regret it, and I would do the same again if my patient needed it. ” This case highlights the fact that the appropriate action for medical professionals-regardless of position-is to raise concerns about patient safety. The GMC (2012) recently adapted such guidance to ensure that a culture of openness is more fruitfully embraced. As a doctor, you are expected to speak up if you think care is being compromised by anything: staff, procedures or policies. You should not hesitate to report a concern and the GMC (2012) explain why: Your duty to put patients first overrides everything else. You are protected by law against being victimised or dis-missed for exposing malpractice. Reasonable belief is enough justification, not hard proof. You are not in the position to put it right yourself. However, you must do this by following the appropriate pro-cedure and going through the proper channels. The correct reporting procedures are detailed below. However, it is advis-able to consult your local trust policy when you start your job. For adverse events or near misses: Fill in a CAE or critical incident form to prevent future recurrence. Usually these are not escalated beyond your team. Jackie, ST1 “The nurses won't think twice about doing a CAE form; they are clued up on good practice. They did one for me when I was working on a post-natal ward at the weekend. There were loads of baby checks to be done, and I kept getting called to deliveries. I couldn't get through all the checks by the time I left at 9 p. m. and the poor night SHO was discharging until 2 a. m. ! You can't avoid going to an emergency C-section though. This was a staffing issue... if you don't fill in a form, nothing will change. ”

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44  Patient focus For serious incidents or repeated adverse events that are not being adequately addressed: Raise the issue with your consultant. Then raise it with your educational supervisor or foundation director. Keep a record of your concerns and the steps taken to deal with the situation. Make sure the patient receives both an explanation and an apology. If you have no joy internally, or feel the matter has been dealt with unsatisfactorily, then you can: Raise the issue with the GMC. Make your concern public-providing that you do not breach confidentiality. It is highly likely that you will have to report bad practice at some point in your career. The irony is that you are more likely to notice it as a foundation doctor as, new to the system-there is less propensity for adopting the “this is how we do it here” mentality. Charlotte, FY2 “I had an experience of being constantly undermined by a senior nurse. All my colleagues felt the same way ... it wasn't an isolated thing. It went so far that she was making me prescribe a drug that I wasn't familiar with-I was unsure of the dose and she wouldn't allow me to check it. That was the last straw. I realised then that it wasn't safe for me or the patient. When you have serious concerns like that it needs to be raised to the supervisor and if not them, your foundation director or FY1 mentor. I raised my concerns with my supervisor rather than the nurse in this instance. They were very supportive but this person was a stable member of the team and very little could be done. Consequently I raised it externally on a deanery visit and they dealt with it, so whistle-blowing is not a bad thing -you need to protect yourself and your patients. ” If you are ever unsure of what to do GMC guidance (2012) suggests: Asking a senior or impartial colleague for advice. Contacting your medical defence body or professional asso-ciation such as the BMA. Contacting the GMC for confidential advice. Contacting 'Public Concern at Work': a charity which pro-vides free, confidential legal advice. When does crossing the line become a 'Fitness to Practise' (FTP) issue? By definition FTP involves “ serious or persistent failures ” and therefore gross misconduct. This includes situations such as those involving (GMC 2006): Risk of harm that cannot be dealt with locally. Deliberate or reckless misconduct. A health problem where the doctor refuses to follow medical advice and poses a continued risk to patients. A doctor abusing patients' trust or violating their autonomy. This may be something that you flag up, but will never be a matter that you yourself should deal with. You should report such concerns to your educational supervisor, foundation clini-cal lead or foundation programme director. They will escalate the matter to the deanery board for 'Doctors in Difficulty' and then to the GMC if necessary (see Chapter 6). Tim, Foundation Programme Director “The only inci-dent I've heard of-on the grapevine-of an FY1 being struck off was a heroin addict who was being abusive towards patients. Drink driving for example would be a 'Doctors in Difficulty' issue. Most of these can be resolved with support- and maybe an extra year' s training if necessary. Many go on to be fantastic doctors, even if they do have a rough start. ” Respecting personal beliefs Under no circumstances should you impose your personal beliefs on patients unless they are directly relevant to their care. However, this can be tricky as you may not realise you have an issue with something until it suddenly hits you square in the face. For that reason you need to stay alert to how your own personal beliefs could interfere with care. If this happens, you must explain this to the patient as well as their right to seek treatment elsewhere (GMC 2008b). Two situations to be aware of involving strong personal beliefs include the refusal of blood products by a Jehovah's Witness and the circumcision of male children for non-medical purposes. Jehovah's Witnesses are discussed below. HERE ARE A FEW TIPS FOR SITUATIONS INVOLVING PATIENTS WHO ARE JEHOVAH'S WITNESSES: If you have a patient who is a Jehovah's Witness, don't assume they will automatically refuse blood products. Enquire about their views and answer questions with honesty and respect. Seek senior advice and consult the local hospital guidelines about the options available. Some patients may not be aware of the different blood products and which are deemed acceptable or not. If you need further advice, then, with the patient's consent, you can contact the local Hospital Liaison Committee (HLC). They should have a helpline set up by the Watchtower Society (Jehovah's Witness society), which is available via the 24-hour Hospital Information Service. “Bloodless medical procedures” are available in some hospitals. Again, you can get these details from the HLC (GMC 2008b). Jackie,  ST1 “We had a patient in his late teens admitted under surgery with a splenic rupture. He initially went to one hospital and was then transferred to ours because we had cell salvage facilities. He didn't have any problems in theatre but there was a fairly high risk he would need transfusion. You always try to accommodate patient's wishes as best as possible. ”

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Patient focus   45Tricky decisions involving treatment: consent without capacity All patients with capacity are assumed able to consent to treat-ment. Patients also have the right to refuse medical care (if over 18 years), even if it means they may die. This premise is compli-cated whenever a patient lacks the ability to consent. Broadly speaking, you will encounter three different types of situations where you may be required to treat a patient without their consent: Psychiatric : e. g. a patient with acute onset psychosis could be treated under the Mental Health Act (MHA). Organic: e. g. a patient with delirium tremens could be treated under the Mental Capacity Act (MCA) 2005. Emergencies: e. g. a patient with diabetic ketoacidosis (DKA) could be treated under the doctrine of necessity. The MHA, MCA and doctrine of necessity are generally very well covered in medical school. Moreover, the MHA should be fairly self-explanatory for a given psychiatric case and not something that you would be involved in as a junior. What is most relevant to FY1 practice is how to approach organic con-cerns of impaired capacity. If a patient lacks the capacity to decide you should firstly (GMC 2010): Know what decisions about care are to be made. Check through all the notes for any legal documentation concerning care, e. g. advanced directives. Next you should enquire about a legal proxy e. g. lasting power of attorney or court-appointed-deputy (England and Wales). This is because, if there is no legal proxy, your consult-ant-as the patient's doctor-would be responsible for the decisions made about treatment for that patient. This means deciding on the “overall benefit” of treatment. In this situation you must involve those close to the patient as well as other members of the healthcare team to help inform your decision. Do not despair if there are no close family or friends available. In this instance, you can contact an IMCA-as Nick did for the patient who couldn't communicate (see Chapter 4, p. 38). An IMCA can be consulted in most difficult decision-making processes; including where there may be a conflict of interest. They act as an independent person outside of the healthcare system to represent the patient's views. Their service may also be required where relatives or friends are available but one of the following circumstances applies (Lee 2007): The friends and relatives are unwilling to be consulted about the patient's best interests. They are too frail to be consulted. They are too far away to logistically be consulted. They refuse. You suspect abuse in the relationship. Places you can look to contact this service include the Depart-ment of Health (DH) website, PALS or the Citizens Advice Bureau (CAB). This however does not apply when an urgent decision needs to be made, as in an emergency. In a life or death situation you treat under the doctrine of necessity. Here, if the consultant “reasonably believes” a treatment is necessary to save the patient's life and the patient lacks capacity, then the treatment can be given without a formal assessment. This is because in an emergency-for example, when a patient is having a cardiac arrest-it is not really appro-priate to be filling in paperwork. You would, of course, do your best to keep the patient informed and consulted where possible (DCA 2005). Most importantly, wherever your job is, your trust will have local policy documents on capacity and consent. Familiarise yourself with them when you start; or at least know how and where to access them. What about confidentiality and information-sharing? You will often find that those close to the patient will want information about the patient's diagnosis and the likely pro-gression of the course of the illness. If the patient has capacity, you must get their permission before sharing this information. If they lack capacity, it is reasonable to assume that (unless otherwise indicated) they would want those closest to them informed about such information (GMC 2010). Remember that if the patient expressly wishes their relatives not to be involved -you must respect this-even after death. Matthew, GP “We had an interesting case recently of a patient who didn't want her information divulged to her mum even after death. This patient had many complex alcohol and mental health issues and she didn't want any of that divulged. The mum is trying to go through the ombudsman and everything to get it. You do find that comes up quite commonly but ultimately you have to respect the patient' s wishes. ” Can those close to the patient make the overall decision? Only if they are legally appointed to do so and this is formalised as such. A patient can nominate someone to be kept informed and consulted about treatment, but this does not mean they have legal guardianship to make the final decision. You should be explicit about this when discussing such issues and make it clear that their role is advisory rather than definitive. If a patient wishes to nominate someone to make decisions on their behalf for a given situation (i. e. if they lose capacity), they need to formalise it legally (GMC 2010). End of Life care Matthew, GP “One challenging factor starting as a junior stems from the realisation that people do actually die in your care, and it' s not something you realise until it actu-ally happens. The first few times it really affects you... and you might not think it will... until it actually does. ” The End of Life (EOL) pathway includes any patient likely to die within the next twelve months. As a junior you will, in part, be expected to put patients on the EOL pathway. Prepare for situations which may require you to complete the appropriate paperwork. Moreover, if you are having difficulties dealing

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46  Patient focuswith something or feel uncomfortable, seek support from your colleagues rather than burying your head in the sand. Sophie, FY1 “Putting a patient onto the EOL pathway is something I've had to do... and was very uncomfort-able doing. My registrar made the decision, and I completed the paperwork. I asked the ward sister to check what I had written and she agreed with what I had done, but I definitely felt underprepared for this. ” Although not expected to make EOL decisions as a founda-tion doctor, you should understand the reasons for starting the EOL pathway as well as the process. Be aware that the risks and benefits of each treatment are not always clear cut. What you aim to avoid is causing the patient further undue stress or prolongation of the dying process, and this should be commu-nicated to close friends and family where appropriate (GMC 2010). to DNAR, can be difficult for relatives to come to terms with. Recognise this and be sympathetic. Imagine if your family member was in that position, how would you feel? Samyami, FY2 “Clinically making a decision not to resuscitate can be hard for relatives and they can get very angry: in their eyes you're giving up on treatment, you don't care and you're leaving them to die. I have seen it so many times on the ward. You can put your best effort into explaining it, but they usually stop listening to you. At the end of the day, you have to remember that the lead clinician has responsibility for deciding overall benefit even if the family disagree. Con-versely, it can happen when the patient is started on the EOL pathway too late. Those well-read on dignity and dying will question it and would have liked it earlier; 'you made my mum suffer for two weeks instead of one'-relatives can be angry at that as well. ” Difficult patients It is impossible to gel with all your patients. Here are some tips in dealing with patients with difficult behaviours: Be prepared to experience a multitude of emotions. Michael, GP “As a junior you are flooded with many emotions you will not have experienced before. You end up having to deal with a lot of people who are very emotional, angry and upset. Most of the time this is a natural response to the situation they are in... handling this is very tricky as a junior. Ensure that you have had some good communication skills training and recognise that empathy and understanding are very important. You will always have the odd occasion where relatives may pin you down to talk to you about difficult issues such as end of life care. Work out how to deal with certain types of emotion. ” Recognise difficult behaviour may be a defence mechanism. Terry, Consultant Surgeon “Patients may be belligerent and rude and walking away from the ward rather than to theatre ... that becomes particularly challenging to manage ... sometimes it' s just because they have a hospital phobia, so you really have to understand where they are coming from. ” Never raise your voice or get into an argument with a patient. If the situation is too heavy, politely excuse yourself. Carl, FY2 “On call I went to see a patient with chronic back problems. He had been in multiple times under the neurosurgeons. Despite being on many different analgesics, he was still in acute pain and asking for IV Morphine. The pain team reviewed his case and said he didn't need it. It was 8 p. m. before I went to see him. The nursing staff told me that in-between his IV Morphine he was going outside for a fag. He was very difficult and very aggressive straight away: The GMC (2010) outlines the EOL decision-making process as follows: 1. The doctor and patient make an assessment of the patient's condition, which will include medical history, views, experience and knowledge. 2. The specialist registrar/consultant combines their experience and knowledge with the patient's opinion about their condition (where possible) to identify the relevant options. The options should then be explained to the patient with the benefits, burdens and risks of each one. The doctor may recommend one, but they must not pressure the patient into accepting their advice. 3. The patient makes the decision-regardless of the doctor's opinion. 4. The same process applies when a legal proxy is appointed to make the decision, whilst trying to include the patient as far as is possible. What about a DNAR (Do Not Attempt Resuscitation) decision? Interestingly, a patient does not have to be informed about this. If a patient is at foreseeable risk of cardiac or respiratory arrest, and the consultant decides that resuscitation would not be successful, then they should consider carefully whether to tell the patient. This decision is never assumed and it is likely that, as a clinician with the closest relationship with the patient, it will be your respon-sibility to explore whether they would wish to know about the DNAR. If they decline, seek permission to share this information with others such as a family member. If they lack capacity, the decision should be shared appropriately but ultimately, signing the DNAR is the lead clinician's call (GMC 2010). You must remember to always record any discussions and reasoning in the patient's records as this will be your responsi-bility. Furthermore, the EOL pathway, particularly the decision

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Patient focus   47demanding IV Morphine. I told him that the pain team had reviewed his case and that I could only give him Oromorph. At which point he got up and started remonstrating... threaten-ing to go to the papers. I repeated that I couldn't offer him anything more overnight, and the pain team would see him in the morning. The patient then started screaming at me again, so I politely left and went to document everything. Half an hour later the nursing staff said he wanted to apologise. Being firm and walking away when I realised I wasn't going to get any-where worked; when a patient is angry, you need to be diplo-matic and reasoned. Before you go to see the patient, think about your options and don't give in just because they are shouting. If it is getting out of hand you should try to end the conversation reasonably. ” Support your colleagues when they have difficult patients. Respect that if they come to you with a difficult patient, it's for a good reason. Matthew, GP “Nurses do a very good job and protect a lot of staff. When you are asked to sort out an angry patient, it' s a big deal. Likewise, if you get a call at night for a patient who is agitated and wandering, the nurses will have tried everything in their locker of imagination as to how they can deal with it. They won't call you for nothing and that' s hard to appreciate at first-they deal with an awful lot of stuff you just never see. ” TOP 5 TIPS ON PATIENT FOCUS: 1. Lead by example. 2. Always make sure the patient is your first priority. 3. Don't be afraid to highlight bad practice. 4. Check who the patient wants to be involved in their treatment. 5. Be mindful of your own safety and leave if the situation gets too heated.

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48 The Situational Judgement Test at a Glance, First Edition. Frances Varian and Lara Cartwright. © 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd. 6Effective teamwork Nicola, FY1 “Make it known you are keen to be a team member.... Don't just turn up, do your job and go home. If you want to have a career, that' s inadvisable. ” A foundation doctor who is a good team-player is expected to: Have the capability and willingness to work effectively with others. Be helpful to others, collaborative, and respectful of others' views. Offer support and advice. Share tasks appropriately. Understand their own and others' roles within the team. Consult with others where appropriate. Understanding teamwork Carl, FY2 “Teamwork is all about being adaptable. As a medical student you come from a background where you structure your own work and all responsibility is up to you. Suddenly, you are in a team where you cannot simply work on your own; you have to communicate well with everyone. Even if their way of working is completely alien to yours, you have to find a way around it. That' s not always the easiest thing to do. ” Besides considering your personality type (see Chapter 1), an additional way of understanding yourself is by looking at the part you play in a team. Teamwork is vital to your job as an FY1, and one of the specific aspects covered by the SJT. A great deal of research has been done on the effective functioning of teams and the different roles that team members take in order to aid successful teamwork. The best-known model of team descriptors is Belbin's Team Roles (Belbin 2010a [first pub-lished 1993]). If you find it hard to identify the roles you prefer to adopt, try a formal questionnaire online to help you (see www. belbin. com). Belbin's Team Roles measure behaviour, not personality. People gravitate towards the roles which suit their natural style, but where team members seek to take on similar functions, some may adapt to take on other roles. No one role is better than another; they all play a component part in the overall team performance. A really effective team will display a balance in the Team Roles being performed; too much of one behaviour or the absence of another can throw a team into disarray. Understanding the different Team Roles will help you to think more clearly about your individual contribution to a team and how other people's contributions are different, but equally valid. You may be able to use this insight to spot the problems when teamwork breaks down: a consistent theme in the SJT. You can then share the problem with the team or, if necessary, adapt your behaviour to improve the situation. Belbin's Team Roles Annie, Consultant “Every member of a team in a hospital has to have their role defined... if they're not defined, you start having conflict. ” Belbin (2010b [first published 1981]) describes nine Team Roles. Each Team Role has strengths and correspond-ing “allowable” weaknesses. These are described below, coupled with some advice for a person who takes on this particular role: 1. Plant: Whilst a natural problem-solver, creative and imaginative, the plant tends to ignore incidentals: remember to fill in a Clinically Adverse Event (CAE) form, even for near misses! 2. Resource Investigator (RI): Enthusiastic and out-going, the RI creates networks outside the team but quickly loses momentum once the first flush of enthusi-asm for a project/idea is over: remember to stay focused- even if your new rotation has lost its charm after a few weeks. 3. Monitor Evaluator: Evaluates what others present, judges and weighs up the options. Unfortunately though, this can make the monitor evaluator overly critical of others: remember to give constructive rather than critical feedback when teaching medical students. 4. Coordinator: Spots other people's talents and del-egates accordingly, but this can result in coordinators avoiding their own share of the work: remember that teamwork is a two-way process-if you give bloods to the nurses, you can help them out with a catheter or two later on. 5. Implementer: Keeps it practical and turns ideas into tasks that need to be done. However, the Imple-menter can be inflexible and slow to respond: prioritise and reprioritise jobs according to their urgency; if you feel you struggle with flexibility, ask for help. 6. Completer Finisher (CF): Whilst painstakingly meticulous, seeing things through to the end, the CF worries unnecessarily and doesn't like to hand over to others: if you find yourself waking at midnight wondering if you handed over that investigation, it' s okay to ring the ward and check... just don't make a habit of it.

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Effective teamwork   49 7. Teamworker: Cooperative and diplomatic, the Team-worker brings people together harmoniously, but can be swayed too much by others' opinions: advice from the nursing staff is invaluable, but remember, at the end of the day, the buck stops with your decision. 8. Shaper: Enjoys the pressure of delivering to a deadline. The Shaper is dynamic and driven but can put others' backs up by being over-zealous: when diving in with your A to E approach, don't forget your manners! 9. Specialist: Contributes valuable expertise and knowl-edge from a narrow field, but can be unable to see things from a wider perspective: your nurse specialist can help you out with everything from pain management to stoma care but overall, your consultant sees things more holistically. Michael, GP “A key thing to understand is what your role is in the whole team. Sometimes you are dumped on as a junior so it' s recognising: 'do I have to do the bloods, do I have to do the venflons?' It' s about knowing what you're responsible for, but realising that you are part of a team. On the other hand, it may be that you are the only person there that can do that job at that particular time so sometimes you might have to do tasks that you don't con-sider part of your remit. ” Team Role Descriptors and icons reproduced by kind permission of BELBIN, UK-www. belbin. com Understanding your role Sunita, FY2 “If you're prepared to work a little bit harder it makes things easier and you'll be a better team member. ” Having considered the theoretical dimensions of a team, here are some practical tips: Never shy away from asking for help. At the end of the day, there is a person at the end of the phone-not a monster! Teamwork is about give and take. Don't take the attitude “that's not my job”. If you help a team member out, they will be there to help you when you need it. Good teamwork will lessen your workload and lighten your day. Learn to delegate. Sometimes you are dumped on, so know what tasks you can allocate to others during these times. Divide jobs evenly amongst the juniors so everyone does their fair share. Every hospital works in a slightly different way, find this out from the outset. Understand that your role is CLINICAL not theoretical: bloods, cannulas, TTOs and recognising ill patients are your bread and butter. Samyami, FY2 “What' s important to understand is that 80% of the work you do in med school is theoretical. On the wards it' s about practical skills, being sensible, organised and writing things down properly. That transition between bal-ancing theoretical and practical knowledge is key. If you're not confident in your clinical practical skills then carrying out the first steps of management-no matter how good your theoreti-cal knowledge is-becomes very difficult to execute. ” Sometimes, you may find yourself going above and beyond the standard duty of care. This is because you are human as well as being a doctor. Your sense of humanity is what makes you a great doctor. Nevertheless, be careful of going beyond the boundaries too often, as you may find you sacrifice your own well-being in the process. Learn to balance your needs with those of your colleagues and your patients. Faraz, FY1 “Some patients you have stronger relation-ships with. I had a patient on surgery that I had been looking after for a couple of months. Despite optimum treat-ment we knew he was going to die, and I was on call. He didn't have any family close by and he wanted someone to talk to and hold his hand. I had to juggle priorities of being the only FY1 on call and being with this man in his last minutes. I decided to stay with him and answer any bleeps as they came rather than talk to the nursing staff or have a break as I would usually do if it' s quiet. I spent most of that night with him just so he wasn't alone in his last minutes... even though you get used to death, it' s never easy. ” At the end of the day, if you feel you are doing too much, you probably are. Recognise your limitations and speak up. It could be that your rotation is not well enough staffed, and others before have had similar problems: Eve, FY2 “Workload can be very variable. A team may not be well staffed or may have a workload beyond their resources, so you end up staying well beyond 5 p. m. whilst your friends are going home on time in their job. I stayed 1-2 hours beyond 5 p. m. every day for the first 2 months on my first rota-tion. Part of this was learning the job and getting quicker, but the other part was not knowing what was an unreasonable workload. You need to take stock and think whether it is reason-able to expect you to work that number of hours beyond what you are being paid for and what is reasonable in terms of your health and general well-being. If you feel you are struggling, you need to raise it with your educational supervisor. There is no shame in saying you are struggling, as chances are the pre-vious house officers were, and the next one will be. There are some jobs where workload is way beyond staffing and, unless you raise it, it will never change. You can also ask for your hours to be monitored if you think it' s particularly unfair. Some people have done that and their FY1 jobs have changed... one of the ones I did now has 2 juniors rather than 1. ”

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50  Effective teamwork Effective handovers Fraz, FY1 “If you request bloods, X-rays, scans and then go home and forget to check them or hand them over, you will find yourself waking up at 2 a. m. But you have to ring the on-call and get them to check: regardless of the time. Always be aware that if you request them, they are your responsibility. ” Handovers are vital for maintaining patient care whilst you are off duty. You cannot simply leave at the end of your shift without making sure that care is safeguarded (GMC 2009a). The aim is to reach a shared understanding amongst staff about the priorities for each patient (BMA 2004b). What are the pitfalls which cause teamwork to break down? Not being reliable; avoiding doing outpatient clinic letters for 3-4 weeks. Being bleeped and not answering. Being abrupt with colleagues-especially with secretaries. Being defensive. Blaming others for mistakes. Not completing paperwork appropriately. Not writing legibly. Not being accurate and making things up! Christine, Consultant “As an FY1 you have to be approachable and nice and be able to speak to other disciplines. If we get a secretary-or a nurse-coming to tell us that an FY1 doctor was rude, we don't want the headache of managing that conflict. Being pleasant is a very important quality. ”THE ROYAL COLLEGE OF SURGEONS (RCS 2007) AND THE BRITISH MEDICAL ASSOCIATION (BMA 2004B) OFFER THE FOLLOWING TIPS FOR A SAFE HANDOVER: 1.   Set the scene. Set sufficient time aside within working hours, in a quiet area: ideally the same time every day. Keep it a “bleep free” zone. The most senior clinician should set out a brief plan. Have access to lab results, X-rays, clinical information, the intranet/internet and telephones. Structure the team discussion so only one person speaks at a time. Encourage a culture where information is challenged: there are no 'stupid' questions. 2.   Minimum  requirements. Patient's FULL name and date of birth. Date patient was admitted to hospital. Where the patient is (ward and bed). Current diagnosis. Results of any significant investigations. Outstanding tasks, e. g. chasing investigations, bloods etc. 3.   Additional  information. Patient condition, e. g. stable, sick - MEWS (Modified Early Warning Score) if used. Urgency of review - Now? 1 hour? None? Management plan including “what to do if . . . ” contingency plan. Operational issues e. g. ITU beds available? Discharge planning. What are the common difficulties compromising a handover? Including “non-essential” information means you can't see the wood for the trees. Not including enough information means the patient gets put to the bottom of the pile. Not having a checklist of information to hand over means things get missed. Not having the information handed over in writing: you cannot possibly remember everything. Speaking over one another such that information gets lost and misinterpreted. Craig, FY2 “Every shift works better with effective handovers. We work shorter shifts now, so there are more handovers. Each time a different doctor takes on the informa-tion, so, unless it' s clear what jobs you want doing, it becomes like Chinese whispers. By the third handover someone has the patient' s details and something about abdo pain but they don't have a clue what they are supposed to be doing. The worst part is that, if you don't have the information, and you are busy, that' s going to be a low priority as you can always say 'well, What are the consequences of these pitfalls? Jeff, Consultant “Not being accurate is annoying and we see that a lot. If you are not accurate with the doses of medication when taking a history and don't cross-check the dose and the letter goes to the GP, the GP comes back and says 'I'm sorry the dose you sent me is incorrect. ' That creates extra work for me. First, I have to get the records out-which might mean trawling through the 400 to 500 patients on my workload. I then have to fish out the records to look at the last consultation and look at what was written. If the handwriting isn't clear, it makes it even more difficult. Then I have to call the patient and ask what medi-cations they are on, go to the pharmacy and look at the prescription, fax a letter to the GP-all that because the junior wasn't accurate.... See how much work is created if things aren't checked properly. ”

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Effective teamwork   51we didn't know'. If you have ten patients you know aren't very well, you are not going to concentrate your time on the one you don't know anything about!” A colleague phones to say they are running late. They cannot give you a definite time they will be there and you have made dinner plans. How should you proceed? Patient safety is paramount, and therefore you should take steps to see that the handover is achieved in a suitable manner so that you can get away: you are not expected to stay hours beyond the end of your shift. The handover should be to a colleague working on the ward-most likely a registrar. This is not a responsibility you can delegate to a nurse, and it would be unfair to do so. Moreover, communication must be in verbal as well as written form, as you cannot rely on your colleague coming onto shift to prioritise patients simply on the basis of the notes. It is time consuming to fumble through notes attempt-ing to find previous management plans. This could delay review and potentially compromise patient safety. Be proactive and make sure your senior has all the information (ISFP 2012). Understanding your colleagues' roles Although there are a multitude of team members, the nursing team, your consultant, and the radiology department are the ones discussed here. You might like to consider others' roles whilst on your clinical placements. Take five minutes out of your day to have a chat with the ward clerks, the porters, the laboratory staff -anyone whose roles and responsibilities you are not certain of -and consider their relationship to the running of the hospital. The  nursing  team Undoubtedly you will have heard that you should cherish the nursing team: they are your best friends. Here are some reasons why nurses are invaluable: They can show you where everything is. Nick, FY1 “My first shifts at this hospital were night shifts and it was quite daunting as it was a new job, new hospital and I didn' t know any of the patients at all. I didn' t even know how to request bloods, and when you're on nights there are no seniors-well there are, but you only call them if it' s serious, not to ask how to request bloods! The nursing staff definitely saved me on my first three nights: showed me everything. They're your best friends when you start I would say, they really are. ” They can give you advice on management. Sarah, FY1 “Listen to the nursing staff-they do know what they are talking about. If circumstances arise where the opinion is not mutual, I explain why, so we come up with a shared understanding. Realistically, I accept advice from nurses every day. When you first start you feel like you are constantly demanding things off them-almost to the point of feeling like a nag-but as you develop your relationship you realise there' s so much give and take. ” They are closest to the patients and their relatives, and can raise their concerns to you. Des, Psychiatric Nurse “Nurses are at the bedside with the patient and the relatives see that. You build up a strong relationship surprisingly quickly. Nurses are also there for the emotional support of the family as well as the patient. We have an intimate relationship with patients; we can spot unusual things, as well as raise things that they haven't told you. That information is crucial for medics to have if they want communication to be successful. ” Above all, however, you must remember to communicate what you need in order for your relationship to blossom- nurses may be fantastic, but they are not mind readers: Tim, FY1 “It' s really important to tell the nurses what you want done. If you just write in the notes and then leave, no one will know. I was wondering for the first week why my plans weren't getting through quickly-it was only because I was being an idiot and didn't realise that I was supposed to tell the nurses. It' s really stupid and obvious now, but I learned this pretty quickly!” Besides helping the juniors, nurses have a vital relationship with patients. You should remember two things in this respect: 1. Nurses will stop at nothing to advocate the best for their patients. So if you don't respond to their request and they feel their patient is compromised, they will have no problems ringing your consultant at home, in the middle of the night (see Figure 6. 1). Des, Psychiatric Nurse “One of the patients on the ward was complaining of a cold leg. We called the consultant who bluntly told us to put a sock on her leg and he would be back in the morning to check on it. We weren't happy with this so eventually we rang a different doctor for another opinion. An hour later she was seen-her leg had gone completely white -and she was rushed to the main hospital for a DVT. If we hadn't been so vigilant and been willing to get a second opinion, she would have lost her leg. ” 2. Nurses are the guardians of safety. Lorraine, ITU Sister “As a nurse you find you are watching what everyone else is doing to safeguard the patient. It doesn't matter what level the person is, there is always potential for dangerous practice, so that is added pres-sure. I remember one incident of a patient who was seriously ill with a severe head injury. He needed some drug therapy to stop him fitting, so the nurses drew the drugs up. The doctor then came in, picked up the syringe and injected it into an arte-rial line by mistake! This caused massive problems. The patient survived-despite a necrotic arm-and it went to court. That was someone not knowing the difference between an arterial line and a peripheral cannula. It made you realise you have to

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52  Effective teamwork Figure  6. 1  Listen to the nurses: they also have the patients' best interests at heart have eyes in the back of your head. When there are a lot of people in a critical environment like that, there is added pres-sure on us to safeguard the patient and watch what everyone else is doing-particularly as they may not be familiar with the equipment. ” Nurses also have the added pressures of: Long days, long shifts and few breaks with stretched resources. Dealing with anxious relatives wanting lots of information, combating angry relatives, handling wandering patients. Delivering the prescribed drugs at the right time. Getting patients discharged. Jennifer, Nurse “Nursing is about bringing together everyone to make it safe. We try to achieve what the medics want us to achieve, in a safe manner, whilst watching and keeping everyone else safe as well. We should spot if you are about to make a mistake as we have more experience. ” The  consultant Having been on the wards, have you ever really considered the responsibilities that your consultant has? Here are a few pres-sures to appreciate: Busy workload: ward rounds, clinics, theatre, paperwork, etc. Politics of the job: staffing, resources, funding, budgets, salary and pension changes, etc. Duty to communicate with colleagues-especially with GPs. Responding to phone calls and emails. Ultimate responsibility for ALL their patients. Training and personal development for themselves and their staff. Mithun, Consultant Psychiatrist “Responsibility ends with me; if something a junior does is wrong, it goes to the consultant. My job doesn't end with the day. Juniors and SHOs can finish, but, if my job doesn't get done right, there is no-one to take it off my back. Juniors also need to understand that, at the end of the day, my priorities are to the patient. You must give us time and plan ahead; I don't want the junior coming to me wanting training expecting me to drop everything. I have a long-term relationship with my patients and I must be sensitive to their needs above all else. Juniors leave but my patients stay with me, it is important to remember this. ” The  radiology  department Negotiating a scan for your patients is something that you will have to do week in and week out. What you have to realise is that radiographers and radiologists also have a list of things that need to be done. Coupled with this, the radiologists have the added pressure of reporting all those scans so that the appropri-ate management can be made. Hence, if you go in hammer and tongs, you might not be very successful.

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Effective teamwork   53It is also worth noting that the radiologist may not neces-sarily communicate your conversation to the radiographer. It is therefore vital that you write down your reasons for the request (i. e. the patient history and examination findings) and the reasons for the scan (i. e. the differential you are consider-ing). This will help the radiographer to better tailor the scan to that patient. Fraz, FY1 “Get good at requesting scans and getting them authorised. Radiology love asking questions; you need to be asking for an appropriate scan for an appropriate history. There is no point talking about a patient with right iliac fossa pain and asking for a CT brain. They will raise those issues, so be precise about the clinical indication and radiology will be more than amenable. There are limited resources and limited slots, if you advocate for your patient, they know you are not just requesting willy-nilly-it' s all about having the right approach with people. ” SBAR These tips for negotiating can be applied when discussing patients with any colleague from a different speciality-and this is a daily occurrence. In this respect, the SBAR (Situation, Background, Assessment, Recommendation) approach is rec-ommended (Crocker et al. 2010). Situation -your name, grade, calling about (patient and their location), “ the reason for call is ... ” Background -include when the patient was admitted and relevant history and background, e. g. medications, blood results, tests or surgical procedures. Assessment -what you found on examination, e. g. MEWS 4, what has changed and your interpretation. Recommendation -what you think the patient may need, or what you need advice on. An action plan should then be agreed. The aim of SBAR is to make communication more succinct. It is particularly useful in high-risk situations (see Box 6. 1). This is something you can practise on the wards with a fellow student. Akin to summarising findings, SBAR is something you will require on a daily basis. HERE ARE SOME TIPS FOR NEGOTIATING A SCAN: Explain the context - why you are there and why you are interrupting - before launching into your request. E. g. “I was asked by Dr X to come down here because we have . . . ” Ask nicely, “Would it be possible to . . . ?” Say please and thank you. Niceties go a long way, but you'd be surprised how many people forget. If they still say no, your senior will not be surprised, it won't be the first time, nor the last. Box 6. 1 SBAR Example : Dr Coe is an FY1 working on a surgical ward. He calls his registrar about a patient who has devel-oped an irregular heart rhythm. S: Hi my name is Dr Coe, I am an FY1 calling about Mr Brown on Ward 33, bed 2. I'm concerned about a fast, irregular heart rhythm he has developed. B: Mr Brown is a 54-year-old gentleman admitted 4 days ago for a total hip replacement. His surgery was successful and there were no post-op complications. He is on 100 mg of Atenolol for hypertension. A: His heart rate is irregular, his blood pressure is 140/80, he had some shortness of breath and desaturated to 88% on air, but I have stabilised him on 2 L of oxygen. He denies any chest pain or calf pain. The ECG shows atrial fibrillation with a rate of 126 bpm. I am worried he might have a pulmonary embolus. R: I have ordered a chest Xray and sent off routine bloods to rule out infection and included clotting. Do you think he needs a CTP A? I need your advice on how to proceed. Professional conflicts Clare, Consultant “Conflicts happen all the time: either due to conflicts of interest or difficulties because of personalities. As long as you remain professional and don't personalise any issues, addressing problems objectively, you should be able to resolve them. If you are unable to resolve a problem, then raise it to the appropriate senior. Work is a com-pletely professional place. You don't have to be friends with everyone at work, but you can be friendly at work. ” If you have a concern about a colleague but are unsure how to raise it you can consider the following options (GMC 2008c): 1. Ask a senior or impartial colleague, e. g. your educational supervisor or consultant, for advice. 2. Contact your medical defence body or professional associa-tion such as the BMA. 3. Contact the GMC for confidential advice. 4. Contact Public Concern at Work: a charity which provides free, confidential legal advice. Craig, FY2 “We were working as a team of four-one colleague was worried about practical stuff and the other was very confident and they really clashed. She felt he didn't pick up his fair load of work, and he felt she wasn't any good. They ended up having a slanging match in front of the patients and the SHO-who rightly told them off. Over the next 2-3 days, the four of us had to work out how we were going to work together. In the end they never really got on but we came up with a way of dividing up the jobs evenly so we all knew what we had to do. We would lend a hand if we finished early,

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54  Effective teamworkbut they never helped one another out. It' s not an ideal situa-tion, but we found a practical way for them to work side by side. We did our best to resolve the problem amongst ourselves, and I don't think it went any higher than our immediate seniors, so I don't think the consultants or registrars knew about it. If you can try and sort it out at a lower level, then do. If that doesn't work, then raise it at a higher level with your educa-tional supervisor or consultant-but you have to be really sure that there is a need for it because stuff like that does tend to stick. They will remember it and pass judgement. At the end of the day, we are all adults and should be able to sort things amongst ourselves most of the time. ” Seeking support Matthew, Educational Supervisor “If you feel you are struggling, every deanery should have a 'doctors in dif-ficulty' programme. The unit is well financed for those who need it. If you realise you are struggling it is better to get help earlier rather than later. You don't want to make a mistake and get referred in via another mechanism. ” It is fundamental that you seek help from your seniors on the wards. Likewise, there are external team members who are always there to help you out. The foundation school There is a whole network of professionals within every founda-tion school to facilitate your training and your personal and professional development. Although the number of professionals varies with each school, Figure 6. 2 gives you a rough idea of the school's structure. This will aid your understanding of the differ-ent roles for the SJT-without overcomplicating matters. If you have any issue as a foundation doctor, it is always best to go through your educational supervisor or clinical tutor. Liaising between managers is best done internally. The Foundation Programme Director is the head of the foun-dation school and ensures that: National (UKFPO) and deanery (e. g. Northern) policy are applied to the foundation school. The training programme covers the curriculum. The foundation school curriculum is delivered to trainees. Educational supervisors are up to the proper standards. The quality of all aspects of the foundation programme from the configuration of rotations to the spread of specialties avail-able for training is assured. With respect to your direct needs, your educational supervisor is typically first port of call with: Career advice. Issues of stress and workload. Figure  6. 2  The generic structure of a foundation school Foundation school Foundation Programme Director Foundation School Manager (operational role) Postgraduate Manager (administrative issues; assist clinical tutors) Local Trust Clinical Tutors (F1/2 personal issues; assigned at a particular hospital) Educational Supervisor (changes each rotation, discuss your eportfolio and general go-to person)

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Effective teamwork   55 TOP 5 TIPS ON TEAMWORK: 1. Understand your role as part of a team. 2. Facilitate teamwork with good communication between the team players. 3. Help out your colleagues - it's about give and take. 4. Try to sort out conflicts amongst yourselves before you escalate. 5. Your educational supervisor is your first port of call for support. Interpersonal problems, e. g. pregnancy, family difficulties, financial difficulties. Lack of training. Completing eportfolios. Conflicts within your team, e. g. difficult registrar, a lazy FY1. Most issues can be dealt with by your educational supervisor. If not then your educational supervisor the supervisor may decide to escalate further to the clinical tutors and then to the foundation programme director. Although this is the typical procedure, you can always approach your clinical tutors or foundation programme director directly if you wish. They do have a wider realm of responsibility though, so it is probably best to seek advice from your educational supervisor as they will be able to help you in the most time-efficient manner. Dan, Foundation Programme Director “Most major issues get filtered up to me. For example we had one GP practice where the trainees were having a particularly hard time-to the point that they were being bullied by one practi-tioner. This was sorted locally by the clinical tutors and we no longer send doctors there, but I was still aware of it. There aren't many circumstances in which you would need to contact me directly. If I do receive things, I usually forward them to the relevant clinical tutor as they are on site to deal with the issue. Often I am away visiting other foundation schools or in meet-ings etc. If you can't get hold of your educational supervisor in the first instance-or they are the problem-your clinical tutors are who you should be contacting. ”

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56 The Situational Judgement Test at a Glance, First Edition. Frances Varian and Lara Cartwright. © 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd. 7SJT practice material How do I approach the SJT questions? Having read this book you should have valuable insight into the types of scenarios you will be asked about, what is expected of you as a FY1, and the knowledge with which to evaluate any question. Although it is important to establish a method that best works for you, the following structure is one of the ways you may wish to approach the SJT: 1. Is this a “ranking” or a “selecting” question? It is important that you answer correctly! 2. Which options are the least appropriate? This will minimise your options and aid your decision. 3. What is expected of me at this level? For example, you are not expected to break bad news as a FY1. 4. Of the options remaining-decide which option is first by thinking: “ if I can only do one thing... which would be the most important action to take?” 5. Then cover this answer up and think: “ If I can no longer do that one, what is now the most important action to take that will resolve this situation? ” and so on. “Should” and “most appropriate” imply ranking in order of importance rather than how you “would” go about tackling the situation in practice. For instance, on the wards it may be that you would speak to a nurse first for advice about a difficult patient as they are often the nearest to hand. In the scenarios, however, you should approach a more senior member of the team first such as a registrar or consultant, as they are more likely to be appropri-ately equipped to deal with a particular situation. Here is an example : You are on call in A&E. You have been very busy and failed to fully complete the patient's hospital ID number on the blood bank request form. The lab rings to ask you to rectify the error. The patient requires a “cross-match” because they are due for surgery. What should you do? Rank these responses in order from most appropriate to least appropriate: A. Apologise and ask the laboratory staff to kindly fill in the patient ID for you. B. Go to the lab to complete the details yourself. C. Ask a competent nurse to rebleed the patient as you are busy. D. Rebleed the patient yourself and rewrite the blood form for cross-match. E. Send a medical student with the patient details to practice their venepuncture and to report back to you with the bloods. This question tests your knowledge of transfusion protocol. On the basis of the reasoning set out earlier in this chapter: 1. This is a ranking question. 2. It is not appropriate for someone else to fill in the patient's details as this could potentially cause serious harm if the wrong patient were identified. This would be irresponsible and put the patient at risk. 'A' is therefore last. 3. B is also definitely not appropriate as although you could perhaps identify the sample with your handwriting, this is not something you should do as this could again put the patient at risk. 4. D is the most appropriate option and would immediately resolve the problem. This option will ensure patient safety and leave fewer margins for error. You will know yourself which patient is the right patient and can correctly fill in the form at the bedside. 5. E is the next most appropriate option. This is a perfect opportunity to teach medical students about the mistakes that can happen and the consequences of error in blood transfusion. Ideally, however, you should take the student to the patient rather than sending them with the details. You know the patient -this will ensure that they are correctly identified. 6. This leaves 'C' in the middle. Medicine is about teamwork and it is important to know when it is appropriate to delegate tasks. However, the nurses will also be busy and bloods are primarily an FY1's responsibility, hence this is less appropriate than D and E. 7. The answer is therefore DECBA. SJT example questions 1. An 8-year-old boy comes into A&E with a badly broken leg. He needs surgery. You speak to his parents about the surgery. They explain that they are Jehovah's Witnesses and they don't want their son to have a blood transfusion. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Inform your consultant about the situation B. Consult local hospital guidelines on bloodless procedures C. Ignore the parents' wishes and treat the child in his best interests D. Tell the parents that it is unlikely that their son will need a transfusion and they should agree to surgery E. Tell the parents you will see what you can do 2. You are working in a haematology clinic. You have been seeing Mrs Alcock regularly over the past 3 months. She says she would like to express her gratitude and hands you a £50 cheque. What should you do?

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SJT practice material   57Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Accept the gift with thanks B. Politely decline the gift as it is too much C. Put the money towards a staff night out for everyone to enjoy D. Say it is hospital policy not to accept monetary gifts E. Record in the notes you accepted a monetary gift 3. You are taking blood from a 70-year-old woman on the medical ward who was admitted following a fall. While you are making conversation about her home circumstances, she tells you that she recently moved in with her son after her husband died. You enquire into how she is coping, and she becomes tearful, telling you that her son has started drinking and becomes very violent when intoxicated. This is the first time she has been in hospital for injuries caused by her son. Her son has assured her he will stop drinking so she doesn't want to make a fuss. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Inform the nurse in charge about the situation B. Find out whether she has anyone else she could stay with C. Contact your specialty trainee (registrar) D. Give her contact details of a local domestic support group E. Record details of your conversation in the notes 4. A 14-year-old girl attends the GUM clinic asking for an STI check. Before you take some swabs, she tells you that she is pregnant. You confirm this with a pregnancy test. You ask her whether she has told anyone; she says no and that she especially doesn't want her parents to know. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Tell her that you have to let her parents know because she is under sixteen B. Try to persuade her it would be in her best interests to tell her parents C. Tell her that you will respect her wishes and not tell anyone D. Ask your consultant to see her E. Advise her that you are obliged to let her GP know 5. The family of one of your patients who died is registering a complaint about their treatment. The solicitor calls you and asks for the medical records of the deceased to be sent to him. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Send over the records as requested B. Say that you will get someone senior to call them back and take their details C. Remind them that any requests need to be sent in writing to the legal department D. Call your consultant and ask them to speak to the solicitor E. Take the solicitor's details and tell them you will get the nurse to fax over the information 6. You are in outpatients and you realise that your mobile phone has been stolen. You suspect one of eight patients could have taken it. You ring your insurance company and they tell you that you need to call the police and get a crime reference number. You call them, but cannot get a number without giving the police the names of the individuals in outpatients that day. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Give over the names of the patients so that you can make a claim B. Fill in a critical incident (CAE) form C. Accuse patients you suspect and question them about it D. Ignore it and just replace your phone E. Report the incident to the foundation director 7. A 16-year-old girl comes into A&E with diabetic ketoaci-dosis (DKA). She is admitted and treated. The following morning you are arranging her discharge. You discuss her diabetic control with her. She says that she can't be both-ered with the insulin as it's too much hassle. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Educate her about the importance of compliance B. Arrange for the specialist diabetic nurse to see her before she goes C. Make a note of her non-compliance on the discharge summary to the GP D. Ask her parents to speak to her about compliance if they come to collect her E. Ask her why the insulin is such a problem 8. A 32-year-old woman presents to A&E for a head lacera-tion. She claims that her boyfriend hit her, and she fell and hit her head. You smell alcohol on her breath. On question-ing you find that she has left her two children at home under the supervision of her boyfriend who has also been drink-ing. You are worried about the children, what should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Call social services to report your concern B. Call your registrar to assess the mother and discuss the case C. Fill in a referral form for social services D. Tell the mother it is protocol that you put in a referral to social services E. Tell the mother that you are concerned about the children, given her injuries

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58  SJT practice material9. Mrs Smith is 53-year-old lady who suffered with heart failure for many years. She has expressed a wish to receive no further treatment and go home to rest in peace. The nurse comes to see you the following day, saying that her husband has arrived and is angry that you are sending her home to die. He feels his wife is “out of her mind and not thinking straight”. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Go and see Mrs Smith to find out whether she remains firm in her wishes B. Ask the nurse to inform the husband it is Mrs Smith's decision C. Explore the husband's concerns D. Refer to psychiatry E. Persuade Mrs Smith to go with you to speak to her husband about her wishes 10. Your FY1 colleague Mark has turned up late again for handover, and you smell alcohol on his breath. You know he has been having some family problems recently. You suspect the alcohol is from last night, but you cannot be sure. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Report Mark immediately to the foundation programme director B. Ask your educational supervisor for advice C. Suggest to Mark that he explain the situation to the specialty trainee (registrar) D. Report the situation immediately to your consultant E. Have a quiet word with Mark after the handover to ask how he is coping 11. An elderly woman is brought in by ambulance to A&E. She doesn't speak English. The paramedics say that she was found collapsed on the street and a passer-by called 999. She is stable, but you suspect she needs to be kept in over-night. You name some languages and she nods at “Urdu”. It is 7. 30 p. m., what should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Arrange for an interpreter to come to the hospital B. Use an online translation service C. See if the patient can contact a friend or relative to interpret D. Arrange for a telephone interpretation E. Find a colleague on the ward and see if they can translate 12. You are working on an oncology ward. It is a Saturday night and a patient is asking you for the results of his myeloma screen. The nurse tells you that the patient is going to complain if they do not get the results soon. The patient is anxious and cannot understand why it is taking so long. You do not have their results yet. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Explain to the patient it is unlikely you will get the results before Monday B. Tell the nurse to go and explain to the patient that it is not possible to get the results until Monday C. Call the laboratory and put an urgent on the results D. Call the registrar and ask them to speak to the patient E. Apologise to the patient for the delay but explain that it is a weekend and unfortunately you will not have the results until Monday 13. You are working on a respiratory ward. A locum con-sultant prescribes antibiotics for Mr Jones for community-acquired pneumonia. You know these particular antibiotics are outside hospital guidelines. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Prescribe the treatment as the consultant wishes but docu-ment in the notes they are outside of hospital guidelines B. Show the guidelines to the consultant and ask whether the antibiotics should still be prescribed C. Ask the consultant the reasons for prescribing those antibiotics D. Follow the guidelines and ignore the consultant's prescription E. Ring pharmacy and find out their recommendations 14. You are working a night shift on a surgical ward. A patient already on treatment for sepsis starts to rapidly deteriorate. It is nearly midnight. You complete your A to E primary survey and the patient is stable for the moment, but you feel you are out of your depth. You call the surgical registrar, but they tell you to call the medical team because they are busy in theatre. When you bleep the on-call medical registrar, they tell you it is not their responsibility and to find someone else. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Call the surgical consultant at home B. Start basic management for the patient C. Call the surgical registrar again, explain the situation and ask for advice D. Ask a nurse to arrange for someone to help you E. Put out a periarrest call on 2222 15. A patient with end-stage motor neurone disease asks you to give them the lethal injection. You explain to them that this is not legal in this country. What should you do?

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SJT practice material   59Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Explore the patient's reasons for wanting the lethal injection B. Tell the patient's partner how they feel C. Ask the patient to talk to their partner about their feelings D. Refer the patient to psychiatry E. Explain to the patient about an advance directive and start the process 16. An 83-year-old man is brought in to A&E after a fall. He has severe dementia and is obviously in pain, but is unable to tell you where the pain is coming from. After examination you suspect he has a broken hip. This is con-firmed by X-ray. A decision needs to be made about treat-ment. However, he lacks capacity. His wife is deceased and his daughter, detailed as his next of kin, lives in Australia. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Contact your local Independent Mental Capacity Advocate (IMCA) organisation B. Try to contact his daughter in Australia C. Speak to the registrar about scheduling him onto the surgi-cal list D. Check through the notes for any legal documentation E. Start treatment anyway and give him analgesia 17. It is a quiet afternoon on your surgical ward. The consultant asks you to come and assist with a private list in the afternoon at a different hospital. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Ask your educational supervisor for advice B. Agree to help your consultant C. Decline and go down to the theatres to see if you can assist with any surgical cases D. Decline because you have responsibilities on the ward E. Ask your fellow FY1 colleague for advice 18. You are seeing a patient in minors in A&E on a Friday night. A nurse comes in to tell you that a patient is being verbally aggressive and threatening because they haven't been seen yet and thinks people are “jumping the queue”. The nurse suspects the patient has been drinking alcohol. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Go and see the patient and tell them they will not be treated unless they calm down B. Ask the nurse to call security C. Tell the nurse to get someone else to see the patient because you are too busy D. Explain to the patient that you are very busy but that you will see them as soon as possible E. Physically restrain the patient 19. A 60-year-old Indian man comes into A&E with a history of fits. He was discharged 2 days ago from ITU. His wife is with him, but she does not speak English. He is very confused, disorientated and, from your A to E assessment, clearly unwell. You cannot get a history. It is 4 p. m. on a Monday afternoon. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Proceed anyway with routine examination and investigations B. Ring the GP to get background information on the patient C. Ring the patient's family to obtain the information D. Ask ITU to fax over their notes from the previous admission E. Arrange for an interpreter before you proceed 20. You are working as an FY1 on an obstetrics and gynae-cology ward. A 29-year-old woman is admitted four hours into labour. This is her first pregnancy. She is requesting a Caesarean section (CS), but there is no medical indication for it at this stage. This is different from her birth plan, but the patient is demanding that she be given the care that she wants. What should you do? Rank these responses from most appropriate to ( =1) to least appropriate ( =5): A. Ask a midwife on the ward for advice B. Ring the consultant obstetrician to make them aware of the situation C. Explore the patient's reasons for wanting a CS D. Explain the overall risks and benefits of both a CS and vaginal birth E. Refuse the CS as it is not medically indicated 21. A 27-year-old woman comes into A&E with vomiting and mild abdominal pain. You have sent off bloods, but in the meantime the routine pregnancy test comes back posi-tive. Her fiancé rings casualty to ask how she is doing. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Tell her partner that she is pregnant B. Tell her partner that it is nothing serious and that she will be fine C. Tell her partner that he will have to speak to his fiancée directly D. Tell her partner that you will need to get her consent before you tell him anything E. Tell her partner that you are still waiting for the results of all the investigations

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60  SJT practice material22. You are an FY1 working on the gastroenterology ward. A nurse comes to tell you that one of the patients with chronic alcoholism has been very rude. This is not the first time it has happened. The nurse is clearly quite upset, what should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Tell the nurse you will speak to the patient B. Go and speak to the patient and tell them their behaviour is unacceptable C. Advise the nurse to ignore it D. Advise the nurse to avoid them and work in a different section E. Ask the patient to apologise to the nurse 23. A patient-well known to psychiatry-is admitted onto the gastro ward with a history of somatisation disorder (multiple physical complaints with a psychological cause). She is demanding a bowel resection following a colonos-copy. The results of the colonoscopy are completely normal, and surgery is not clinically indicated. She is angry that you will not treat her and threatens to “cut it out herself if you don't”. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Agree with the patient that if she calms down you will consider surgery B. Bleep the on-call psychiatrist C. Reiterate to the patient that you cannot operate because the colonoscopy was normal D. Explain to the patient that, given the normal tests, you think this is part of their mental health problem E. Call the senior registrar for advice 24. You are working as an FY1 in a GUM clinic. You are seeing a young man with newly diagnosed Hepatitis B. He is an ex-intravenous drug user who works in a bar. You question him about his partner and discover that he has not disclosed his Hepatitis B status as he is afraid this will mean his partner will leave him. He says they are having protected sexual intercourse. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Try to persuade him to tell his partner B. Do not disclose any information as there is no risk to his partner C. Explain you have a duty to tell his partner about their risk of infection D. Offer to talk to the patient and his partner together E. Recommend counselling 25. You are an FY1 working on a labour ward. One of your patients has a breech presentation. She has a birth plan which specifies that every appropriate method should be attempted before opting for a Caesarean section (CS). She has now changed her mind and decided to have a CS. Her husband disagrees; taking you to one side and saying “she's in pain, she doesn't know what she wants, she'll regret it if you operate”. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Inform her of the overall risks and benefits of a CS and vaginal birth B. Call the consultant obstetrician to review the patient C. Enquire into her reasons for the change in birth plan D. Tell the husband you accept his point and remind him that it is his wife's choice not his E. Ask the husband to leave so that you can speak to your patient in private 26. You are working on a gastroenterology ward and a nurse approaches you and says Mr Brown needs to be prescribed his usual fluids. You are finishing up a discharge summary and take home drugs for another patient. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Prescribe Mr Brown normal saline B. Go and see Mr Brown straight away C. Explain that, to enable you to get the discharges done on time, they should ask another FY1 to help D. Say you will put it on your jobs list and get to it as soon as you can E. Ask about Mr Brown's fluid status 27. A colleague has left 30 minutes early to attend a dental appointment. They have asked you to prescribe Warfarin for their patient. Your shift has already ended, and you were about to go home. The INR result from the morning's blood tests is not back yet. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Prescribe the Warfarin anyway B. Hand over the request to the ward cover C. Write it onto your jobs list for the morning D. Write that the patient needs their Warfarin dosing in their notes E. Ring the lab to see if the INR results are there 28. You are working as an FY1 on a surgical ward. On your way to ordering a CT scan from radiology, you are bleeped. You find the nearest phone to ring through. A nurse is con-cerned about Mrs Fazi's urine output (UO). You remember it was fine for her small frame when you checked two hours ago. What should you do?

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SJT practice material   61Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Ask the nurse to do some basic observations on Mrs Fazi and say you will come as soon as you have ordered the CT scan B. Go and see Mrs Fazi straight away C. Reassure the nurse that Mrs Fazi's UO was fine for her size two hours ago D. Ask the nurse whether Mrs Fazi's UO has changed since this morning E. Tell the nurse to start 1 litre of normal saline over 8 hours for Mrs Fazi, and you will prescribe it once you have been to radiology 29. You go to see a patient with whom you previously had trouble putting in a cannula. You ask them whether you can take some blood. They recognise you and say “don't come anywhere near me with that thing, you don't know what you're doing”. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Reassure the patient that you are competent at taking blood B. Go and ask a nurse to take their blood C. Apologise to the patient for yesterday D. Tell the patient you have to take their blood as there is no one else E. Take the blood from their cannula 30. A patient you recently discharged from the ward requests your friendship on a social networking site. They are a similar age to you. What should you do? Rank the following responses from most appropriate ( =1) to least appropriate ( =5): A. Accept the friend request but do not engage with the former patient B. Decline the friend request and explain your reasons C. Ignore their friend request D. Ask your FY1 colleagues for advice E. Ask your educational supervisor for advice 31. You are working on ITU, completing the morning's job list. When taking bloods from a patient-admitted following a road traffic accident-you accidently stick yourself with the needle. You had followed infection control guidelines and were wearing gloves, but you see your finger bleeding under-neath. You quickly squeeze it, clean it and put a dressing on it. You go to look on the system for anything on the patient's HIV/Hepatitis status but there is nothing. The patient is unconscious. What should you do? Choose the three most appropriate options from the following list: A. Request viral serology on the blood forms for HIV and Hepatitis status B. Ring occupational health C. Go down to A&E to get some anti-retrovirals to start immediately D. Fill in a CAE form for the stick injury E. Ask if you can go home because you are so worried F. Wait to see if the patient wakes up and ask their permission for serology G. Bleep your registrar to explain the situation H. Explain to one of the nurses what has happened 32. Your FY1 colleague turns up late again for their shift. The ward you are working on is quiet. Your colleague arrives in tears; she is feeling exhausted, stressed and says that she is not coping with anything at the minute. This is the third time in the past two weeks. What should you do? Choose the three most appropriate options from the following list: A. Apologise and say that you are busy now but that you will talk to her after your shift B. Sit her down to have a talk about her problems C. Suggest she books an appointment to see her GP D. Suggest she speaks to her registrar E. Suggest she takes sick leave F. Advise her to talk to her educational supervisor G. Seek advice about the situation from your educational supervisor H. Mention that you have to inform your consultant of her difficulties 33. You are working in Children's A&E on a Saturday night. A 13-year-old boy comes in drunk. He admits he has been drinking alcohol and says he fell over. The X-ray confirms he has broken his index and middle fingers. The boy is adamant he is fine and doesn't want any treatment because he is scared that his parents will find out he has been drinking. He wants you to just give him some pain-killers and then he'll leave. What should you do? Choose the top three most appropriate options from the fol-lowing list: A. Prescribe the painkillers and let him self-discharge B. Ring the boy's parents without telling him C. Explain that you really need to let his parents know what has happened and it would be best if he rang them D. Tell him to go and see his GP if he has any problems over the weekend E. Try to persuade him to have his fingers splinted F. Put in a referral for social services G. Refuse to let him self-discharge without getting the proper treatment H. Discuss the situation with the nurse in charge

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62  SJT practice material34. You are on a ward round with your consultant on the coronary care unit. The patient's relatives are sitting in the waiting room at the end of the corridor. Your consultant says that the patient is going to die soon and checks the Do Not Attempt Resuscitation (DNAR) form. The family approach you politely after the ward round whilst you are ordering bloods and say “so you think Mum is going to die, do you?” It is clear they have overheard your consultant's comments. What should you do? Choose the three most appropriate options from the following list: A. Ask a nurse to take the family to a side room and explain you will follow shortly B. Ask them where they heard that information C. Tell them you are busy at the moment and will talk to them later D. Apologise to the family for the fact that they overheard the conversation with your consultant E. Fill in a critical incident (CAE) form F. Ask the family if they would like to sit with their mum G. Finish ordering the bloods H. Call your consultant, explain what happened and ask them to speak to the family 35. A 9-year-old boy was admitted following an exacerba-tion of asthma. You speak with the parents about using his steroid inhaler. The boy's mother is happy to make sure he has the inhaler; however, his father is clearly not. Father says that he has heard that they will stunt his boy's growth and he doesn't want that. What should you do? Choose the three most appropriate options from the following list: A. Ignore the father's wishes and prescribe the inhaler anyway as the mother has consented B. Contact social services about the disagreement C. Ask the asthma specialist nurse for advice D. Agree with the father not to use the steroid inhaler E. Get the mother to persuade the father the steroid inhaler is necessary F. Plan to monitor the boy's growth on a growth chart and review throughout the use of his inhaler G. Educate the father about the advantages to using the inhaler H. Ask the boy what he would like to do 36. A 43-year-old man is brought in by ambulance to A&E after collapsing in a bar on a Friday night. You have no details other than his name and date of birth, which the paramedics got from his wallet. The man is incapable of giving a history due to his level of intoxication. He is stable in the resuscitation area. What should you do? Choose the three most appropriate options from the following list:A. Continue with your A to E assessment B. Ring your specialty registrar C. Ask a clerk to search the hospital database for his records D. Search through his mobile phone contacts to find a family number and call them E. Start treatment anyway F. Call the cardiac on-call SHO G. Start the appropriate investigations but do not start any new medications H. Ask one of the nurses to try and track down some informa-tion on him 37. A 24-year-old woman is admitted to A&E following a paracetamol overdose. Her boyfriend brought her in when she admitted that she had taken 50 × 500 mg paracetamol tablets one hour earlier. Her boyfriend tells you she has been suffering from depression. You speak with her alone and she refuses any form of treatment-she wants to die. What should you do? Choose the three most appropriate options from the following list: A. Respect her right to refuse treatment B. See if her boyfriend can persuade her to change her mind C. Bleep the on-call psychiatrist D. Call your registrar E. Treat her under the Mental Health Act F. Treat her under the Mental Capacity Act G. Treat her under the doctrine of necessity H. Discharge her from A&E 38. You are working on a labour ward as an FY1. A nurse comes to see you to let you know that the ex-partner of one of the mothers is demanding to see his baby in the special care baby unit. He wasn't present at the birth, and you know that the mother hasn't been in contact with him since she became pregnant. What should you do? Choose the three most appropriate options for the following list: A. Take him to see the baby because he is the father B. Check the baby's birth certificate and ask to see some iden-tification to confirm who he is C. Ask the mother to confirm whether he is the father D. Ask the midwife what you should do E. Ring the registrar and ask for advice F. Document in the notes that this man wanted access to the child G. Tell the man that he will have to come back another time once he has pre-arranged a visit H. Tell the man that he cannot see the baby until you have spoken to the mother 39. A 79-year-old male is awaiting surgical repair of a frac-tured neck of femur. He tells you that he is a Jehovah's Witness and says he will refuse the operation if he needs a

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

SJT practice material   63blood transfusion. You suspect the risk of needing a blood transfusion is high. He asks if there are any other options. What should you do? Choose the three most appropriate options from the following list: A. Explain the consequences to him of not having the operation B. Ask his permission to contact the local Hospital Liaison Committee (HLC) C. Advise him to contact the Watchtower Society for information D. Tell him that you are unsure of the options but that you will find out E. Take bloods and order routine pre-op investigations F. Bleep your registrar to review the patient G. Consult your local policy guidance on bloodless medical procedures H. Find out why he is opposed to a blood transfusion and what his preferences are on the use of blood products 40. A man is sitting in minors in A&E after having a drunken brawl with his friend. He has superficial lacerations to his shoulder and forearm. He arrived at midnight and, having been waiting for three hours, is getting increasingly agitated. The nurse comes to tell you that he is angry and threatening to self-discharge. You are busy packing the nose of his friend whom he was fighting with. What should you do? Choose the three most appropriate options from the following list: A. Allow him to self-discharge, you do not respond to threats B. Ask the nurse to let the patient know that he is next C. Call security D. Apologise to him for the long wait and thank him for his patience E. Tell the nurse to get the suture kit ready F. Ask the nurse to tell him he should wait because you are seeing to his friend G. Leave his friend and go and attend to his shoulder and forearm lacerations H. Call the SHO to review and suture him 41. You are in the surgical assessment unit, trying to consent a 55-year-old man for rigid sigmoidoscopy that you will be doing under supervision. You have been trained to consent for this procedure and are aware of all the risks and ben-efits. When you try to explain the procedure, he says “do whatever you think is best, Doc, I don't want to know”. What should you do? Choose the three most appropriate options from the following list: A. Tell him you need to give him a brief explanation of the procedure B. Ask him to sign the form without going into detail C. Tell him it is important that he understands the procedure in order to consent D. Phone your registrar to consent the patient E. Ask him whether he would prefer a family member with him whilst you explain the procedure F. Explain the procedure to a family member instead G. Cancel the investigation as you cannot go ahead without consent H. Fill in the form yourself and sign it in his best interests 42. You are looking after Mrs Chang, who is intermittently confused. Her family are all in the waiting room and are anxious to know how she is doing. You have the results of her CT scan which is normal. What should you do? Choose the three most appropriate options from the following list: A. Go and tell Mrs Chang's family the good news B. Go see Mrs Chang to find out how she is today C. Ask a nurse to go and tell the family the good news D. Tell Mrs Chang's family how she is generally doing, but say that you cannot give them any specific results until you have spoken to Mrs Chang E. Wait until Mrs Chang's family ask specifically about her results F. Let your colleagues know Mrs Chang's results G. View the scan yourself H. Ring the registrar to ask for advice 43. You are working on an oncology ward. You are sitting at the desk ordering bloods when your colleague Jane tells you she thinks that you are not picking up your fair share of work. You feel Jane is boisterous and arrogant. No one else has mentioned anything to you about being lazy, and you feel you are competent. What should you do? Choose the three most appropriate options from the following list: A. Be honest with Jane that you think she is arrogant B. Argue with Jane that you do your fair share C. Say you cannot discuss this here and suggest a more appro-priate place D. Suggest that you divide the jobs evenly E. Ask Jane why she feels you are not doing your share F. Raise the issue with your educational supervisor G. Ask your other colleagues their opinion of you H. Report the bullying to your consultant 44. You are working on a busy respiratory ward. One of your colleagues, Jack, is consistently lazy to the point where he may be compromising patient care. The nurses and ward cover at handover have commented on this. What should you do? Choose the three most appropriate options from the following list: A. Offer to take on some of Jack's workload B. Ask Jack whether he feels he is struggling C. Tell Jack he is not doing his share of the workload

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64  SJT practice material D. Inform the foundation programme clinical lead E. Recommend the nurse in charge has a quiet word F. Ask the nurses to fill in a Clinically Adverse Event (CAE) form G. Inform your consultant that Jack is struggling H. Tell Jack you will speak to your educational supervisor if things don't change 45. You send a medical student to take some bloods-for which they are trained. You check the results at 3 p. m. and realise that the samples are all coagulated. What should you do? Choose the three most appropriate options from the following list: A. Retake the bloods B. Report the student to your consultant C. Point out the mistake to the student when you see them the following day D. Ignore their mistake E. Supervise the student when taking blood next time F. Tell the student to bring the samples to you next time before they send them G. Suggest the student reflects on this incident in their portfolio H. Tell the student to get some more clinical skills training before they go on the wards 46. You are working in a GP surgery. A patient comes in to see you with symptoms of angina at rest. It says on the system that the GP told them last time not to drive. You ask them whether they have been driving, and they tell you that they have: they drove to the surgery today. What should you do? Choose the three most appropriate options from the following list: A. Report them to the DVLA B. Advise them to inform the DVLA C. Advise them to stop driving until their symptoms are under control D. Find out whether someone can drive them home E. Ask if they remember the GP advising them not to drive F. Remind them last time the GP asked them not to drive G. Speak to the GP for advice H. Ask them to hand over their keys until someone can drive them home 47. Your consultant on a ward round orders a spine MRI and asks you to put in the request. You overhear the regis-trar saying to another colleague that it is not indicated. What should you do? Choose the three most appropriate options from the following list: A. Order the MRI as the consultant has requested B. Ask the consultant the reasons for ordering the MRIC. Ignore the consultant and do as your registrar says D. Tell the consultant that the registrar does not think the MRI is indicated E. Ask the registrar why they think the MRI is not indicated F. Ring the radiologist to discuss the MRI request G. Ask the registrar to speak to consultant about their differ-ence in opinion H. Document in the notes that the MRI was ordered but that the registrar disagreed 48. You are working as an FY1 as part of the medical on-call team. A patient with type I diabetes came in with diabetic ketoacidosis (DKA), but is improving having been on a sliding-scale. The consultant prescribes short-acting insulin. The patient disagrees with this and asks that he be put back onto his regular insulin regimen of long-acting insulin. What should you do? Choose the three most appropriate options from the following list: A. Ask the specialist diabetic nurse for advice B. Call the consultant to relay the patient's disapproval of their regimen C. Prescribe the patient long-acting insulin instead D. Tell the patient that they are on the right insulin E. Tell the patient they will have to discuss it with the consult-ant the next time they see him F. Write both up on the drug chart to be delivered G. Ask the patient why they don't want to have short-acting insulin H. Ignore the patient's request as they are clearly still unwell and confused 49. A 69-year-old man is brought into A&E with symptoms later confirmed as an ischaemic stroke. Your specialist reg-istrar reviews him in A&E and writes up his prescription on a drug chart. The patient reaches you on the stroke ward one hour later with his notes and a different drug chart. Clopidogrel is written up STAT but not given. The prescrip-tion written is not the one that your registrar wrote. What should you do? Choose the three most appropriate options from the following list: A. Ring pharmacy to ask for advice B. Bleep your registrar C. Take the chart down to A&E and look for the other one D. Ask the patient whether they have been given the Clopidogrel E. Give the Clopidogrel as it is important they receive urgent anticoagulation F. Give half the dose of Clopidogrel G. Delay giving the Clopidogrel until the other chart is found H. Tell the nurses not to give Clopidogrel to the patient

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SJT practice material   65You are working on a busy cardiology ward. Your colleague is on call and asks you to hold their bleep for them whilst they go and get some lunch. What should you do? Choose the three most appropriate options from the following list? A. Agree to hold their bleep B. Offer to go with them for their lunch C. Politely decline because you have your own patients D. Suggest they get in touch with someone on the on-call team to hold their bleep E. See whether they have any outstanding jobs you can help with F. Offer to get their lunch for them G. Tell them to turn it off whilst they go and get some lunch H. Suggest they go quickly to get their lunch

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66 The Situational Judgement Test at a Glance, First Edition. Frances Varian and Lara Cartwright. © 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd. 8Answers 1.  An 8-year-old boy comes into A&E with a badly broken leg. He needs surgery. You speak to his parents about the surgery. They explain that they are Jehovah's Witnesses and they don't want their son to have a blood transfusion. What  should  you do? ANSWER: AEBCD This question is about respecting and communicating a patient's religious views in such a way as to best accom-modate them into clinical care. For more information on Jehovah's Witnesses see Chapter  5. In this scenario you are expected to seek help in a tricky situation. A.  Informing your consultant  is the most  appropriate  option  as  they  have  to make  the final  decision  in this situation.   If you  could  only  choose  one  of the options  in this  question,  this  would  be it.  Everything  else  is subsidiary  to recognising  that  you should  seek  help.   The consultant  will also be able to advise  you on what  to tell the parents  (E). E.  Telling the parents you will see what you can do  is the next  most  appropriate  option.   It is best  practice  to value  guardians'   wishes  and respect  that they  are acting  in the best  interests  of  the child - but you should  speak  to a senior  before  you say this. B.  Consulting the local hospital guidelines  is the next  most  appropriate  option  as this will  further  your  own  learning  and  development. C.  Ignoring the parents' wishes  is not appropriate,  as they  should  be respected.   Your  consultant  could  override  their  deci-sion  acting  in the child's  best interests.   However,  this is an area  that would  cause  considerable  conflict  and is best  avoided. D.  Telling the parents it is unlikely that their son will need a transfusion  is the least  appropriate  option.   You cannot  lie to the  parents  and you do not know  the likelihood  of the child  needing  a transfusion.   You  also  cannot  say for definite  that  this boy  won't  need  one.   If the surgery  went  ahead  and he needed  blood,  then  the correct  planning  would  not be in place  and you would  be going  against  the parents'  (and  child's)  wishes.   This  has  negative  consequences  for you as a clinician,  and for the patient  and their  relatives. 2.  You are working in a haematology clinic. You have been seeing Mrs Alcock regularly over the past 3 months. She says she would like to express her gratitude and hands you a £50 cheque. What  should  you do? ANSWER: DBECA The GMC recommends that: “You must not encourage patients to give, lend or bequeath money or gifts that will directly or indirectly benefit you” (GMC  2008a ). D.  Saying it is hospital policy not to accept monetary gifts  is  the most  appropriate  option.   Whether  or not it is 'officially'   hospital  policy  (in many  trusts  it is), you should  decline  the  patient's  gift in this manner  as it shouldn't  cause  too much  offence.   If you simply  decline  the gift because  it is too much  (B), then  the patient  might  bring  £20 next  time.   Under  no cir-cumstances  should  you accept  monetary  gifts,  as they  could  be  mistaken  for a bribe. B.  Politely declining the gift as 'it is too much'  is the next  most  appropriate  option.   £50 is too much  money  to accept.   Although  it is nice  to receive  gifts  of gratitude  from  patients,  you should  not be accepting  large  sums  of money.   Flowers  and chocolates  as gifts  are very  different  from  money:  you have  to make  a  sensible  judgement  on this. E.  Recording in the notes that you accepted a monetary gift  is  the next  most  appropriate  option.   Although  it is not appropriate  to accept  such  a generous  gift, you should  record  it in the notes  if you did, and explain  your  reasons  for accepting  the gift. C.  Putting the money towards a staff night out  is not appropri-ate.  Although,  ideally,  you  should  share  gifts  with  your  col-leagues,  you  cannot  simply  accept  a monetary  donation  and  record  it in another  way.   Usually  patients  will  bring  gifts  for  the healthcare  team,  and so this issue  is rarely  a problem. A.  Accepting the gift with thanks  is the least  appropriate  option.   This  may  encourage  this patient  to give  further  gifts  and things  of monetary  worth  should  not be accepted,  as this could  easily  be mistaken  as bribery. 3.  You are taking blood from a 70-year-old woman on the medical ward who was admitted following a fall. While you are making conversation about her home circumstances, she tells you that she recently moved in with her son after her husband died. You enquire into how she is coping, and she becomes tearful, telling you that her son has started drinking and becomes very violent when intoxicated. This is the first time she has been in hospital for injuries caused by her son. Her son has assured her he will stop drinking, so she doesn't want to make a fuss. What  should  you do? ANSWER: ACEBD This question is asking you to consider the risk to this elderly lady. An FY1 should always ensure the patient is the focus of care. A.  Informing the nurse in charge about the situation  is  the most  appropriate  option.   This  will  directly  deal  with  the  problem,  as the nurses  can refer  to social  services  and take   the appropriate  protective  measures  for this lady  if her son tries  to visit  her on the ward.   Remember  that nurses  are the guard-ians  of safety  and informing  them  about  this lady  is the best  thing  you can do to protect  her.

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Answers   67C.  Contacting your specialty trainee  is the next most appropriate,  as a more  senior  member  of your team can give advice  on how to  appropriately  manage  this situation.  They  should  be informed  of  those  situations  where  patient  safety  is compromised. E.  Recording details of your conversation in the notes  is the  next  most  suitable  response  as you need  to record  the patient's  situation  accurately.   It is good  practice  to document  everything  in the notes  including  the situation,  who  you  informed  and  actions  taken.   This  covers  you legally,  hence  the saying:  if it's  not written  down,  it never  happened! B.  Finding out whether she has anyone else she can stay with   is the next  most  appropriate  option.   Although  this finds  out  more  about  her social  circumstances,  it does  not formally  address  the problem.   Also,  removing  her from  her current  social  situation  would  not be your  decision  to make.   Given  her  age and fragility,  this would  require  input  from  social  services,  OT and physios  about  the suitability  of a move. D.  Giving her the contact details of a local support group  is  not appropriate.   There  has not been  a decision  made  yet as to  how  the medical  team  will best help  this lady.   Giving  her details  of a local  domestic  support  group  may  leave  her feeling  dis-missed  as there  is much  more  that can be done  to help  her.  She  should  not be made  to feel as if she has to resolve  anything  herself  at this vulnerable  time. 4.  A 14-year-old girl attends the GUM clinic asking for an STI check. Before you take some swabs, she tells you that she is pregnant. You confirm this with a pregnancy test. You ask her whether she has told anyone; she says no and that she especially doesn't want her parents to know. What   should  you do? ANSWER: DBECA This question is asking you to consider the health of the unborn baby as well as the health of the teenager. Refer to Chapter  2 for more information on under eighteens. D.  Asking your consultant to see her  is the most  appropriate  option,  as you cannot  assess  Gillick  competence  as an FY1.   You  should  recognise  that this is a difficult  situation  and you  need  senior  advice. B.  Trying to persuade her it would be in her best interests to tell her parents  is the next  most  appropriate  option.   Although  not every  situation  will warrant  this action - for example,  if it  was felt telling  the parents  could  potentially  harm  the teenager - you should  have  a sensible  discussion  about  this.   Ideally  she  will be able  to seek  support  from  her parents. E.  Advising her that you are obliged to let her GP know  is the  next  most  appropriate  option,  as you need  to consider  the health  of the unborn  baby.   This  is where  the GP steps  in.  Medical  care  will be needed  throughout  the pregnancy,  or for any other  deci-sions  she may  make.   Informing  her GP may  also be a compro-mise,  if she refuses  to let her parents  know. C.  Telling her that you will respect her wishes and not tell anyone  is not appropriate.   This  would  be dishonest,  given that you need  to at least  discuss  it with  your  consultant  and   the GP. A.  Telling her that you have to let her parents know because she is under sixteen  is the least  appropriate  response  as you  should  not break  confidentiality  without  strong  justification.   If  she is Gillick  competent,  her wish  for confidentiality  should  be  respected. 5.  The family of one of your patients who died is registering a complaint about their treatment. The solicitor calls you and asks for the medical records of the deceased to be sent to him. What  should  you do? ANSWER: CDBEA Remember that the duty of confidentiality persists after the patient has died. Moreover, no party has a general right to information, and therefore only information should be provided that is relevant to the claim. No situation where there is a poten-tial breach of confidentiality should ever be rushed. Refer back to Chapter  2 for more information on confidentiality. C.  Reminding them that any requests need to be sent in writing to the legal department  is the most  appropriate  option,  and the  solicitor  phoning  should  be aware  of this.   This  directly - and  appropriately - deals  with  this problem.   As an FY1  you should  not be involved  in the sending  of information  to third  parties,  but you can direct  them  to the appropriate  department. D.  Calling your consultant  is the next  most  appropriate  response,  as they  can more  appropriately  deal  with  this type  of  request.   They  would  also  tell the solicitor  to send  it in writing  to the legal  department. B.  Getting a senior to call them back  is the next  most  appropri-ate option.   Options  include  contacting  your  F1 clinical  lead,  foundation  programme  director  or foundation  programme  co-ordinator  for legal  matters.   This  action  will delay  tackling  the  issue  as compared  with  contacting  your  consultant. E.  Faxing over the information  - even  if a nurse  does  it - is  not appropriate.   It is the legal  department's  responsibility  to  deal  with  this matter,  not the medical  team's. A.  Sending over the records as requested  is the least  appropri-ate response  as this is a serious  breach  of confidentiality. 6.  You are in outpatients and you realise that your mobile phone has been stolen. You suspect one of eight patients could have taken it. You ring your insurance company, and they tell you that you need to call the police and get a crime reference number. You call them but cannot get a number without giving the police the names of the individuals in outpatients that day. What  should  you do? ANSWER: BEADC This question requires recognition of the need to seek senior advice in the case of a serious incident. For more informa-tion on reporting concerns, refer back to Chapter  5.

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68  Answers B.  Filling in a CAE form  is the most  appropriate  response,  because  it will put in place  a system  that should  prevent  future  thefts.   Filling  in the form  needs  to be done  at the time  of the  incident  and not retrospectively. E.  Reporting the incident to the foundation director  is the next  most  appropriate  option  as this  should  help  prevent  future  recurrence.   Your  foundation  director  will also  be able  to offer  you advice  on what  you should  do next.   Remember,  no matters  which  involve  breaking  confidentiality  are ever  urgent. A.  Giving over the names of the patients so that you can make a claim  is the next  most  appropriate  option.   Although  this does  involve  disclosing  patient  information,  it would  be justifiable,  given  the circumstances  and  having  sought  advice  from  a  senior.   You are not expected  to put up with  having  your  phone  stolen D.  Ignoring the situation and replacing your phone  is not  appropriate.   You  are not expected  to put up with  theft  and  therefore  this option - while  in reality  it may  seem  less com-plicated - is not what  you should  do. C.  Accusing patients you suspect and questioning them about it is the least  appropriate  response.   This  could  produce  potential  distrust  between  you and your  patients  creating  a potentially  difficult  situation  for yourself. 7.  A 16-year-old girl comes into A&E with diabetic ketoaci-dosis (DKA). She is admitted and treated. The following morning you are arranging her discharge. You discuss her diabetic control with her. She says that she can't be bothered with the insulin as it's too much hassle. What  should  you do? ANSWER: BEACD This question is asking you to consider your opportunities for learning. An FY1 should be willing to learn from others and from their experiences. B.  Arranging for the diabetic specialist nurse to see her  is the  most  appropriate  option,  as they  will have  a wealth  of experi-ence  with  non-compliance  and may  have  some  tricks  up their  sleeve  to deal with  the situation.   Ideally,  you should  utilise  their  skills  and expertise  by sitting  in on their  consultation  so the  nurse  can educate  you at the same  time.   This  is the type  of  experience  you  may  choose  to reflect  on in your  eportfolio  afterwards. E.  Asking her why the insulin is such a problem  is the next  most  appropriate  option.   Is it because  she can't  do the same  things  as her friends?  Or maybe  she has a problem  with  her  insulin  regimen?  Information  means  you can seek  advice  for a  more  suitable  treatment  plan. A.  Educating her on the importance of compliance  is the next  most  appropriate,  as it is your  duty  to inform  patients  of their  responsibility  for their  own  health.   You should  use every  avail-able  opportunity  you can for health  promotion.   The specialist  diabetic  nurse,  of course,  would  do this for you as part of their  consultation. C.  Making a note of her non-compliance on the discharge summary to the GP  is the next most appropriate  option.  The GP  should  be made  aware  of the issue  so that it can be followed  up. D.  Asking her parents to speak to her about compliance  is the  least appropriate  option  as - given  her age - you should  try to  engage  with the patient  first, rather  than relying  on her parents.   You should  still speak  to her parents  though,  as they may also  need educating  about  compliance.  It would  be best practice  to let  the girl know  that you would  like to speak  to her parents  about  this.  If there  were circumstances  in which  she disagreed,  you  should  seek senior  advice  from your consultant  or registrar. 8.  A 32-year-old woman presents to A&E for a head lacera-tion. She claims that her boyfriend hit her, and she fell and hit her head. You smell alcohol on her breath. On ques-tioning you find that she has left her two children at home under the supervision of her boyfriend who has also been drinking. You are worried about the children, what  should   you do? ANSWER: BEDAC This question incorporates social services protocol and expects you to demonstrate awareness of boundaries of your own competence. An FY1 should readily seek help when required. Refer back to Chapter  2 for specific infor-mation regarding social services. B.  Calling your registrar to discuss the case  is the most  appro-priate  option,  as you will  need  senior  consultation  for advice  regarding  social  services.   They  will also  be able  to guide  you  as to how  to discuss  the matter  with  the mother. E.  Telling the mother you are concerned about the children, given her injuries  is the next  most  appropriate  option  as you  first need  to explain  the reasoning  behind  your  concerns D.  Telling the mother that it is protocol that you put in a refer-ral to social services  is the next  most  appropriate  option  as you  need  to explain  what  you are going  to do about  your  concerns.   You should always try to inform the parent that you are putting  in a referral  to social  services,  unless  you feel that the child  will  be put at risk if you do so.  In either  case  you would  bring  in a  senior. A.  Calling social services  is the next  most  appropriate  option,  as they  will be able  to advise  on the phone  whether  an urgent  response  is necessary - i. e.  to call the police  to the house - or  whether  a referral  through  the usual  mechanism  is necessary.   Social  Services  are the experts  in this situation;  hence,  they  should  be the ones  dictating  the action  plan. C.  Filling in a referral form for social services  is the least  appropriate  option.  Any form  should  be filled  in at the time of  concern  when  all the relevant  information  can be collected;  but in this complex  case it should  be done  by a senior.  Moreo-ver, as there  is an immediate  concern,  the phone  call should  be made  before  the form  is completed.  However,  if this was a  more  “routine”  case,  then the phone  call would  not be neces-

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Answers   69sary and you would  simply  consult  with a senior  about  com-pleting  the form. 9.  Mrs Smith is 53-year-old woman who suffered with heart failure for many years. She has expressed a wish to receive no further treatment and go home to rest in peace. The nurse comes to see you the following day, saying that her husband has arrived and is angry that you are sending her home to die. He feels his wife is “out of her mind and not thinking straight”. What  should  you do? ANSWER: CAEBD This question is about responding to a difficult situation between a patient and their relatives and respecting the wishes of both parties. An FY1 should understand both the relatives' and the patient's views for effective communication. See Chapter  4 for more advice on effective communication. C.  Exploring the husband' s concerns  is the most  appropriate  thing  to do.  This  is because  it is important  as far as possible  to  respect  the feelings  of those  close  to the patient  and meet  their  needs  for support. A.  Going to see Mrs Smith  is the next  appropriate  option,  as  you must  find out whether  her wish  to refuse  treatment  is still  the same.   Moreover,  you  must  gain  consent  to discuss  Mrs  Smith's  wishes  with  her husband. E.  Persuading Mrs Smith to go with you to speak to her husband about her wishes  follows  on from  A, as there  is an  opportunity  for conflict  resolution  if both  parties  communicate  their  wishes  to one another.   This  should  be done  once  you have  obtained  consent. B.  Asking the nurse to inform the husband it is Mrs Smith' s decision  is not really  appropriate.   While  it is possible  for team  members  to resolve  this issue,  ideally  it should  be the person  with  the best rapport.   Nurses  have  a great  deal  of communica-tion  with  patients  and their  relatives  and it is likely  they've  approached  you because  they  feel out of their  depth.   You should  appreciate  the delicacy  of this  matter;  simply  directing  the  nurse  without  exploring  the issue  further  is not appropriate. D.  Referring Mrs Smith to psychiatry  is the least  appropriate  option  as there  is no indication  that Mrs Smith  needs  psychiat-ric assessment,  nor of it being  any benefit  to her. 10.  Your FY1 colleague Mark has turned up late again for handover, and you smell alcohol on his breath. You know he has been having some family problems recently. You suspect the alcohol is from last night, but you cannot be sure. What  should  you do? ANSWER: CDEBA This question is about recognising and reporting dangerous practice. An FY1 should challenge unacceptable behaviour that threatens patient safety. Refer back to Chapter  5 for more information on reporting concerns. C.  Suggesting to Mark that he explain the situation to the registrar  is the most  appropriate  option.   This  reduces  the imme-diate  risk  to patient  safety  as the registrar  can suggest  the  appropriate  actions  to take.   This  is an urgent  situation  as there  is a potential  compromise  for patient  care.   However,  you might  not want  to go straight  to the consultant  (D),  as issues  like this  will affect your colleague's reputation.  It is best if Mark can be  persuaded  to report  his irresponsible  behaviour. D.  Reporting the situation immediately to your consultant  is the  next most appropriate  option.  You have a responsibility  to your  patients,  and your duty of care to them  overrides  your loyalty  to  your colleague.  Serious  incidents  should  immediately  be raised,  if they compromise  patient  safety.  You are not in a position  to  deal with them  yourself,  so seniors  must get involved. E.  Having a quiet word with Mark after the handover  is the  next  most  appropriate  option,  as you  should  offer  your  col-league  the chance  of an explanation  and find  out more  about  the situation.   It is important  that you support  your  colleagues,  but having  this conversation  would  not directly  influence  the  outcome  of the scenario  as you  should  address  the issue  of  patient  safety  first and foremost. B.  Asking your education supervisor for advice  is the next  most  appropriate  option.   Getting  confidential  advice  on clinical  dilemmas  should  be considered,  but this action  will not address  the immediate  problem.   You  should  consult  those  in your  immediate  team  before  more  external  clinicians.   Although  your  educational  supervisor  will be at your  hospital,  it may  take time  to contact  them. A.  Reporting Mark immediately to the foundation programme director  is not appropriate.   Reporting  procedure  is well  out-lined,  and it is not your  place  to report  this directly  to the  foundation  programme  director.   They  would  expect  you  to   go through  the appropriate  channels  and try locally  first.   More-over,  the foundation  director  may  not be on site and may  take  considerable  time  to respond  which  may  result  in a compromise  in patient  care.   Your  foundation  programme  director  would  eventually  hear  about  it via the Doctors  in Difficulty  referral  pathway. 11.  An elderly woman is brought in by ambulance to A&E. She doesn't speak English. The paramedics say that she was found collapsed on the street and a passer-by called 999. She is stable, but you suspect she needs to be kept in over-night. You name some languages and she nods at “Urdu”. It is 7. 30 p. m., what  should  you do? ANSWER: EDABC This question includes a common problem with translation services and tests whether you can demonstrate initiative. Refer back to Chapter  4 for more information on working with interpreters. E.  Finding a colleague on the ward to see if they can translate   is the most  appropriate  option.   Whilst  it is not an ideal  solution, 

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70  Answersdoctors  and nurses  remain  impartial  translators,  and this means  that you can get any urgent  information  from  the patient  while  arranging  for a more  formal  translator.   Moreover,  Urdu  is a  common  language,  and the likelihood  of finding  someone  in  the hospital  who  speaks  it is high.   Telephone  services  (e. g.   language  line)  are expensive  and should  be considered  as the  next  option  if your  colleagues  cannot  help. D.  Arranging for a telephone interpretation  is the next  appro-priate  option,  as most  A&E  departments  should  have  access  to  this service  as arranged  by the foundation  trust.   This  service  allows  access  to interpreters  anytime,  day or night  and offers  impartiality  and confidentiality. A.  Arranging for an interpreter to come to the hospital  is the  next most  appropriate  option.   No matter  where  you are working,  the likelihood  of getting  an interpreter  at 7. 30  p. m.   is slim.   You  could,  however,  leave  a message  and arrange  this for the fol-lowing  morning.   Typically,  bilingual  services  are only  available  from  9 a. m.-5  p. m. B.  Using an online translation service  would  require  a compu-ter nearby  that allows  access  to this service.  It also requires  that  you type in the information,  which  is time-consuming.  Moreo-ver, there  are limited  languages  available,  and there  is no guar-antee  that the translation  is accurate.  These  services  are generally  inadequate  for anything  beyond  the most basic  of needs. C.  Seeing if the patient can contact a friend or relative to interpret   is not appropriate.  The use of an ad hoc interpreter  is discouraged,  and even more  so if they have a close  relationship  with the patient.   This option  should  be avoided  where  at all possible. 12.  You are working on an oncology ward. It is a Saturday night, and a patient is asking you for the results of his myeloma screen. The nurse tells you that the patient is going to complain if they do not get the results soon. The patient is anxious and cannot understand why it is taking so long. You do not have their results yet. What  should   you do? ANSWER: EDACB This question assesses your honesty and integrity with regard to the patient relationship and ensures that you make the patient your first concern. E.  Apologising to the patient for the delay  is the most appropri-ate response  - and also the most honest.  By apologising  you are  showing  empathy  and acknowledging  the patient's  distress. D.  Calling the registrar to speak to the patient  is the next  most  appropriate  response,  as this is a delicate  issue  that should  be  dealt  with  by a senior  colleague. A.  Explaining to the patient they are unlikely to get the results before Monday  is the next  most  appropriate  response.   This  is  an honest  answer,  but does  not acknowledge  the patient's  con-cerns.   It would  be more  appropriate  to have  a senior  review  the  situation  than  to provide  an inadequate  explanation - especially  when  there  has been  the threat  of a complaint. C.  Calling the laboratory to put an urgent on the results  is the  next  most  appropriate  option,  but this is unlikely  to make  any  immediate  difference  to the situation  as it is the weekend  and  other  more  urgent  results  will take  priority. B.  Telling the nurse to explain the delay to the patient  is not  appropriate.   It is important  that  you  go and see the patient  yourself  and explain  the situation.   It is likely  that the patient  is  threatening  to make  a complaint  because  they  are worried.   Hence,  they  will  appreciate  you taking  the time  to see them,  helping  to ease  their  anxiety. 13.  You are working on a respiratory ward. A locum con-sultant prescribes antibiotics for Mr Jones for community-acquired pneumonia. You know these particular antibiotics are outside hospital guidelines. What  should  you do? ANSWER: BCEAD This question analyses your consideration for hospital policy and your ability to negotiate it with colleagues in an appropriate manner. B.  Showing the guidelines to the consultant to ask whether they should be prescribed  is the most  appropriate  option  as this  addresses  the issue  and considers  the options  for prescribing. C.  Asking the consultant the reasons for prescribing those antibiotics  is the next  most  appropriate  option,  because  it may  be that the consultant  is aware  of the guidelines  but has pre-scribed  them  for a particular  reason.   Alternatively,  these  may  be the ones  that he typically  uses,  in which  case  you could  enter  into a discussion  about  local  guidelines. E.  Ringing pharmacy to find out their recommendations  is  more  appropriate  than A or D.  Pharmacy  are an excellent  source  of guidance  on the appropriate  prescribing  of medications.   You  should  consult  expert  advice  rather  than  either  brush  aside  your  concerns  or undermine  a colleague. A.  Prescribing the treatment the consultant wishes outside guidelines  without  good  reason  is not appropriate,  as you  should  not ignore  a situation  where  you  think  something  is  wrong.   However,  it is more  appropriate  to follow  your  consult-ant's  wishes  than  to undermine  their  expertise  and not carry  out  their  management  plan  (D). D.  Following the guidelines and ignoring the consultant' s pre-scription  is the least  appropriate  option,  as this means  going  against  the advice  of the consultant.   If the patient  were  to dete-riorate  after  you ignored  their  advice,  you would  be held  soley  responsible. 14.  You are working a night shift on a surgical ward. A patient already on treatment for sepsis starts to rapidly deteriorate. It is nearly midnight. You complete your A to E primary survey and the patient is stable for the moment, but you feel you are out of your depth. You call the surgical registrar, but they tell you to call the medical team because they are busy in theatre. When you bleep the on-call medical

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Answers   71registrar, they tell you it is not their responsibility and to find someone else. What  should  you do? ANSWER: CBDAE Patient safety is always a first priority. It is important that you recognise your limitations and seek appropriate support when necessary. This should ideally be someone more expe-rienced than yourself. C.  Calling the surgical registrar again  is the most  appropriate  option,  as they  should  give  you the appropriate  advice  regard-ing immediate  management  steps  that can be taken. B.  Starting basic management for the patient  is the next most  appropriate  option,  as you should  take initial  steps  such as order-ing investigations,  taking  bloods,  prescribing  fluids  etc.  as part  of your secondary  survey.  These  steps  are within  your remit,  and  you should  optimise  the care you can give in this situation.   D.  Asking a nurse to arrange for someone to help you  is the  next  most  appropriate  option  as this involves  sharing  responsi-bility  for the patient.   The nurses  are perfectly  equipped  to seek  help  for you while  you attend  to the patient.   Moreover,  they  will  have  knowledge  of who  else  could  be contacted  in this  situation - for example,  the hospital  may  have  a critical  care  outreach  team.   However,  this is less appropriate  than  informing  seniors,  as it does  not directly  address  patient  care.   Moreover,  you have  more  knowledge  of the patient's  clinical  condition  and it is better  to relay  this information  yourself. A.  Although  calling the consultant at home is not a nice thing to have to do, it is perfectly  acceptable  and would  be the next  appropriate  action  if no seniors  were  available  on site.   They  will,  however,  be 20, 30 minutes  away  from  the hospi-tal .  .  .  maybe  more.   The patient,  at the end of the day,  comes  first and as the consultant's  responsibility  overall,  he/she  would  rather  be contacted  regarding  problems  with  patient  care. E.  Putting out a periarrest call on 2222  is not appropriate,  as  the question  clearly  says that the patient  is stable.  This should  only be used if you feel the patient  is going  to arrest.  Think  of  calling  2222  like dialling  999: for instance  you would  think  twice  about  calling  if someone  in a restaurant  looked  very well and  was simply  having  heartburn  rather  than having  a heart  attack. 15.  A patient with end-stage motor neurone disease asks you to give them the lethal injection. You explain to them that this is not legal in this country. What  should  you do? ANSWER: AECDB This question explores patient focus. An FY1 is expected to appreciate needs, build relationships with patients, be respectful of patients' wishes and work in partnership about their care. However, FY1s are not expected to follow patient's wishes when it involves euthanasia! A.  Exploring the patient' s reasons for wanting the lethal injec-tion is the most  appropriate  option,  because  it is important  that  you find out from  the patient  whether  it is due to depression  or whether  they  are trying  to convey  specific  preferences  about  their  treatment. E.  Explaining to the patient about an advance directive  is the  next  most  appropriate  option,  as you  would  highlight  the  choices  available  to them  concerning  their  treatment. C.  Asking the patient to talk to their partner about their feel-ings may  result  in them  getting  additional  advice  and support  if they  so wish.  This  response,  however,  would  not address  the  immediate  issue. D.  Referring the patient to psychiatry  is not appropriate,  as it  is not clear  that the patient  has a mental  health  issue.   You would  also  need  senior  input  before  making  this decision. B.  Telling the patient' s partner how they feel  is the least  appro-priate  option  as you would  be breaking  patient  confidentiality. 16.  An 83-year-old man is brought in to A&E after a fall. He has severe dementia and is obviously in pain, but is unable to tell you where the pain is coming from. After examination you suspect he has a broken hip. This is confirmed by X-ray. A decision needs to be made about treatment. However, he lacks capacity. His wife is deceased and his daughter, detailed as his next of kin, lives in Australia. What  should  you do? ANSWER: ECADB This question tests your knowledge of consent where a patient does not have capacity in an emergency situation. Refer to Chapter 5 for more information. E.  Starting treatment  is the most  appropriate  option,  as the  patient  comes  first,  and you do not need  consent  to give  anal-gesia - this is a basic  treatment  option  that provides  overall  benefit  for a patient  in pain. C.  Speaking to the registrar about scheduling him onto the surgical list  is the next most appropriate  option.  The responsibil-ity for decisions  about  treatment  in an emergency  situation  lies  with the treating  doctors.  Emergency  treatment  must be provided  straight  away.  A senior  needs  to be made  aware  of the situation  ASAP  as a broken  hip can be potentially  life-threatening.   Although  it would  not be your responsibility  to schedule  a patient  onto the surgical  list, this option  directly  advocates  for treatment  of the patient  by directly  involving  their care. A.  Contacting your local IMCA  is the next  most  appropriate  option.   Typically,  an IMCA  is appointed  in non-emergency  situations  where  a family  member  or friend  cannot  be con-tacted.   This service advocates for patients who lack capacity to  ensure  that their  feelings  and wishes  are considered.   As broken  hips  are scheduled  onto  the trauma  list, this is an emergency  situation;  however,  as the patient  has severe  dementia,  they  will  be useful  for assistance  in less pressing  matters.   It is, therefore,  appropriate  to contact  them  early  in case  a difficult  decision  has  to be made  post-surgery. D.  Checking through the notes for any legal documentation  is  the next  most  appropriate  thing  to do, as this will give  you an  idea  of the patient's  wishes  as well  as any documents  detailing 

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72  Answersa legal  proxy  whom  you could  contact  to make  his decisions  for him.   Although  this will be useful  in informing  decisions,  a  thorough  search  should  not prevent  emergency  treatment  and  this could  take  some  time  given  his age and co-morbidities. B.  Trying to contact his daughter in Australia  is the least  appropriate  option.   Whilst  you should  contact  a patient's  rela-tives  and close  friends  when  trying  to make  a decision  about  “overall  benefit”,  they  do not have  the final  say in treatment.   You  can assume  that the patient  would  want  them  involved  if  they  lack  capacity,  but again  this is different  when  the situation  is an emergency.   This  would  not change  your  management  of  the patient  and is therefore  the last action  you would  take  in  this situation. 17.  It is a quiet afternoon on your surgical ward. The con-sultant asks you to come and assist with a private list in the afternoon at a different hospital. What  should  you do? ANSWER: CDAEB This question is about juggling your work commitments with opportunities for career progression. C.  Declining and going to assist in theatres  is the most  appro-priate  option,  as you should  utilise  quiet  times  on the ward  to  seek  out additional  learning  opportunities.   This  option  is appro-priate  and enhances  your  educational  development.   Whilst  it is  not appropriate  to leave  the hospital,  it is perfectly  acceptable  to seek experiences  on site and, as a trainee,  you should  be  taking  advantage  of such  situations. D.  Declining because you have responsibilities on the ward  is  the next most appropriate  option,  as this immediately  addresses  the issue.  Whilst  this would  be a good  opportunity,  you should  not leave  the hospital  during  paid working  time.  It would  not be  fair to your colleagues  to increase  their workload.  Nor would  it  be fair to your patients  whose  care may suffer  as a result.  If you  explained  this to the consultant,  they should  understand  this. A.  Asking your education supervisor  is the next  most  appropri-ate option  as you should  ask for senior  advice  when  faced  with  a dilemma.   Moreover,  educational  supervisors  should  be in  your  hospital;  therefore,  you should  receive  a timely  response  from  them. E.  Should  you not be able to contact  your  educational  supervi-sor, seeking advice from a fellow FY1  is the next  most  appropri-ate response.   Although  they  won't  have  the same  level  of  expertise,  they  may  have  faced  a similar  situation,  or know  someone  else who  has. B.  Agreeing to help your consultant with the private list  is the  least  appropriate  option  as it is unacceptable  to leave  without  formally  handing  over  patients.   Moreover,  it is not appropriate  to leave  your  patients  while  you are being  paid  by the NHS  to  care  for them - no matter  how  quiet  the ward  is! 18.  You are seeing a patient in minors in A&E on a Friday night. A nurse comes in to tell you that a patient is being verbally aggressive and threatening because they haven't been seen yet and thinks people are “jumping the queue”. The nurse suspects the patient has been drinking alcohol. What  should  you do? ANSWER: BDACE Nurses handle a great deal on the wards. If they come to see you about an aggressive patient, they will likely have tried everything to calm them down, so be sympathetic. B.  Asking the nurse to call security  is the most  appropriate  option.   Staff  are not expected  to tolerate  abuse  and  calling  security  is a necessary  precaution  as there  is a potential  for   this situation  to get worse.   Security  can act quickly  if it does  escalate. D.  Explaining to the patient you are busy but will see them as soon as possible  is the next  most  appropriate  option,  as patients  will often  calm  down  if given  a rational  explanation. A.  Going to see the patient and telling them they will not be treated unless they calm down  is more  appropriate  than  C and  E.  However,  a patient's  right  to treatment  should  never  be  influenced  by their  behaviour,  and the GMC  recommends  that  you do not use treatment  as a bargaining  power. C.  Telling the nurse to get someone else to see the patient  is  not appropriate.   You  might  be the only  person  that the nurse  could  find to help.   If you did nothing  and something  were  to  happen  to the nurse  because  there  was no one else around,  then  you  would  be held  accountable.   This  would  be an error  in  judgement.   You  should  prioritise  this situation  as more  urgent  than  the patient  you are seeing  to in minors,  as there  is a poten-tial for harm. E.  Physically restraining the patient  is the least  appropriate  option.   You  cannot  physically  restrain  a patient  without  just  cause,  as restraint  may  be considered  physical  assault.   This  would  be the role of security. 19.  A 60-year-old Indian man comes into A&E with a history of fits. He was discharged 2 days ago from ITU. His wife is with him, but she does not speak English. He is very confused, disorientated and, from your A to E assessment, clearly unwell. You cannot get a history. It is 4 p. m. on a Monday afternoon. What  should  you do? ANSWER: ADBEC This question is about prioritisation and problem-solving. An FY1 should demonstrate initiative when it comes to informa-tion gathering and think creatively to solve problems. A.  Proceeding anyway with routine examination and investi-gations  is the most  appropriate  option  as you  must  rule  out  anything  potentially  life-threatening  before  you get more  infor-mation  on this patient's  history.   You can obtain  a lot of informa-tion  from  examination  alone.   It is not acceptable  to neglect  examining  a patient  just because  you can't  get a good  history.   Patient  care  is your  clinical  priority  and should  always  be done 

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Answers   73first.   If needs  be, he can be treated  as a new  patient  rather  than  as a failed  discharge. D.  Asking ITU to fax over the notes from the previous admis-sion is the next  most  appropriate  option,  as this will give  you  access  to the notes  quickly - if they  have  them.   They  also might  have  information  on the patient's  family,  translators,  etc. B.  Ringing the GP to get background information  is the next  most appropriate  option.  The GP should  be the first port of call  for patient  information.  In this case,  however,  the GP may not  have the most recent  information  on the patient,  given  that it is  only two days since  discharge  and it typically  takes  longer  for  discharge  information  to be received.  Don't  be alarmed  if the GP  asks to call you back on your bleep,  or to fax the notes  over - this  should  be standard  protocol  to protect  patient  confidentiality. E.  Arranging for an interpreter  is the next  most  appropriate  option.   However,  interpreters  take  time  to arrange  and it is  unlikely  that you will get one within  an hour.   This  situation  is  potentially  urgent  and  therefore  other  options  should  be  explored  in preference  to this. C.  Ringing the patient' s family  is the least  appropriate  option.   This  would  break  confidentiality  and there  is no guarantee  that  they  speak  English  either.   His wife  is already  present  with  whom  the interpreter  could  consult. 20.  You are working as an FY1 on an obstetrics and gynae-cology ward. A 29-year-old woman is admitted 4 hours into labour. This is her first pregnancy. She is requesting a Cae-sarean section (CS), but there is no medical indication for it at this stage. This is different from her birth plan, but the patient is demanding that she be given the care that she wants. What  should  you do? ANSWER: CBDAE This question is about working in partnership with patients about their care whilst bearing in mind their best interests. In terms  of a patient's  best  interests  concerning  a CS, indica-tions  for a CS include  (NICE  2011):  Presumed  foetal  compromise  'Failure  to progress'  in labour  Breech  presentation  (∼10%  of all CS)  Placenta  praevia  Multiple  pregnancy  When  a woman  requests  a CS NICE  (2011)  recommends:  Discussing  the overall  risks and benefits  of a CS and vaginal  birth,  taking  into account  circumstances,  concerns  and priorities  Including  a discussion  with other  members  of the obstetric  team  (obstetrician,  midwife  and anaesthetist)  to explore  reasons  for a  request  and to ensure  the woman  has the accurate  information  Offering  perinatal  mental  health  support  for women  with  anxiety  about  childbirth   If this is unsuccessful,  offering  a planned  CS with  a willing  obstetrician.   If the consultant  obstetrician  is not willing,  the  team  should  refer  to one who  is. C.  Exploring the patient' s reasons for wanting a CS  is the most  appropriate  option.   This  demonstrates  consideration  for their  needs  and is the first step  towards  reaching  a solution. B.  Ringing the consultant obstetrician  is the next  most  appro-priate  option  as they  will be making  the final  decision  and need  to be made  aware  of the situation  as soon  as it arises.   You will  also  be able  to discuss  with  them  over  the phone  the risks  and  benefits  of both  a CS and vaginal  birth  (D),  which  you could  relay  to the patient  before  the consultant  arrives. D.  Explaining the overall risks and benefits of a CS and vaginal birth  is the next  most  appropriate  option.   NICE  (2011)  recom-mends  this is carried  out before  any decision  is made  regard-ing a CS.  If the patient  still wants  to change  her birth  plan  at  this point,  then  you have  already  appropriately  informed  your  seniors. A.  Asking the midwife on the ward for advice  is the next  most  appropriate  option.   The  midwife  is part  of the obstetric  team  and  will  undoubtedly  have  dealt  with  this  situation  before.   However,  they  would  not make  a final  decision  for this patient,  and therefore  you should  approach  an obstetrician  in preference  in this case. E.  Refusing the CS  is the least appropriate option.   This patient  has a right  to a CS regardless  of whether  it is medically  indi-cated,  and you are not in a position  to refuse  such  treatment  to  this patient. 21.  A 27-year old woman comes into A&E with vomiting and mild abdominal pain. You have sent off bloods, but in the meantime the routine pregnancy test comes back posi-tive. Her fiancé rings casualty to ask how she is doing. What   should  you do? ANSWER: DCEBA This question is about patient confidentiality. Refer to Chapter  2 for more information on confidentiality breaches. D.  Telling her partner that you will need to get her consent before you tell him anything  is the most  appropriate  option,  as  you must  respect  patient  confidentiality.   Generally,  members  of  the public  understand  this and will  appreciate  your  honesty.   This  option  immediately  resolves  the issue. C.  Telling her partner that he will have to speak to his fiancée directly  is the next  most  appropriate  response,  as you  are  respecting  confidentiality  whilst  being  honest  with  her fiancée. E.  Telling her partner that you are still waiting for the results of all the investigations  is the next  most  appropriate  option,  as  this does  not involve  giving  the fiancé  false  reassurance  (see  B).  Although  this woman  is pregnant,  there  could  also be other  explanations  for her symptoms  which  you  would  want  to  exclude  before  she was discharged.   You are not being  dishonest  with  this explanation,  as there  are bloods  pending. B.  Telling her partner that it is nothing serious and that she will be fine  is less  appropriate,  given  that  you  cannot 

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74  Answersconfidently  make  this claim.   This  however  is more  appropriate  than  A - actually  breaking  confidentiality. A.  Telling her partner that she is pregnant  is not appropriate.   You do not have  the patient's  consent  to reveal  this information,  and this would  break  patient  confidentiality. 22.  You are an FY1 working on a gastroenterology ward. A nurse comes to tell you that one of the patients with chronic alcoholism has been very rude. This is not the first time it has happened. The nurse is clearly quite upset, what   should  you do? ANSWER: ABEDC This scenario involves prioritising your colleague's needs over the patients by offering them your support. A.  Telling the nurse you will speak to the patient  is the most  appropriate  option,  as this shows  your  colleague  that you take  their  complaint  seriously  whilst  giving  the patient  the opportu-nity  to express  their  own  opinion  on the situation.   There  are  two  sides  to every  story  and it is best  to elicit  them  before  intervening. B.  Going to speak to the patient  is the next  most  appropriate  option,  as abuse  towards  the staff  should  not to be tolerated  and  the patient  should  be made  aware  of this.   This  option  also  allows  you to find  out the patient's  reasons  for acting  in the  manner  the nurse  described. E.  Asking the patient to apologise to the nurse  is the next  most  appropriate  option.   Out  of respect  to the nurse,  it would  be  polite  to request  that the patient  apologise. D.  Advising the nurse to work in a different section  is not  appropriate,  as it does  not directly  address  the problem.   It will  be difficult  for the nurse  just to ignore  part of the ward  when  resources  are already  stretched.   Moreover,  this patient's  behav-iour may  extend  to abusing  other  members  of the team,  which  is unacceptable. C.  Advising the nurse to ignore it  is the least  appropriate  option  as the question  clearly  states  that this isn't  the first time  it has  happened.   Moreover,  your  colleague  is upset;  staff  are not  expected  to tolerate  abuse  in any form. 23.  A patient-well known to psychiatry-is admitted onto the gastro ward with a history of somatisation disorder (multiple physical complaints with a psychological cause). She is demanding a bowel resection following a colonos-copy. The results of the colonoscopy are completely normal and surgery is not clinically indicated. She is angry that you will not treat her and threatens to “cut it out herself if you don't”. What  should  you do? ANSWER: DCEBA This question is about responding appropriately to a diffi-cult patient with a mental health issue. D.  Explaining to the patient you think this is part of their mental health problem  is the most  appropriate  option.   You  are  explaining  honestly  the reasons  for not operating.   Moreover,  it  may  help  calm  the patient  if you show  that you have  taken  them  seriously,  but that you are aware  of their  condition.   You  can  also assess  the patient  at this point  to see how  unwell  they  are. C.  Reiterating to the patient that you cannot operate because the colonoscopy was normal  is the next  most  appropriate  option.   Repeating  honestly  why  you cannot  operate  makes  sure  you are consistent  in your  explanation. E.  Calling the senior registrar for advice  is the next  most  appropriate  option.   This  is a difficult  patient,  and there  is a  potential  for serious  harm  should  she act on her threats.   You  should  recognise  that this is beyond  your  remit  and seek  help  accordingly.   The  registrar  will  also  be able  to advise  you on  how  to manage  this patient  further  and on any other  explana-tions  you can give  to try and calm  the patient  down. B.  Bleeping the on-call psychiatrist  is the next most appropriate  option.  As the patient  is already  known  to psychiatry,  you should  seek their opinion,  particularly  given  the serious  threat  of self-harm.  Following  psychiatric  assessment  she may need admitting  to a psychiatric  unit where  she can receive  alternative  care. A.  Agreeing with the patient she can have surgery if she calms down  is the least  appropriate  option  as under  no circumstances  should  you lie to a patient.   This  would  have  disastrous  conse-quences  for the patient's  mental  health:  never  bargain  treat-ments  with  patients. 24.  You are working as an FY1 in a GUM clinic. You are seeing a young man with newly diagnosed Hepatitis B. He is an ex-intravenous drug user who works in a bar. You question him about his partner and discover that he has not disclosed his Hepatitis B status as he is afraid this will mean his partner will leave him. He says they are having pro-tected sexual intercourse. What  should  you do? ANSWER: CADEB This question requires you respect patient confidentiality. In the case of communicable diseases the GMC recom-mends (GMC 2009f):  You  should  tell the patient  that you will share  their  informa-tion  with  those  in the immediate  healthcare  team  involved  in  their  care - unless  they  object.  You  cannot  force  a patient  to reveal  their  infection  status  unless  someone  is at risk of infection.  You  should  explain  to the patient  how  to minimise  infection  risk to others.  As with  any  issue,  you  can disclose  information  without  consent  if justifiable  e. g.  serious  harm.  When  tracing  contacts,  identity  should  not be revealed. For more information on confidentiality see Chapter 2. C.  Explaining you have to duty to tell his partner about their risk of infection  is the most  appropriate  option,  as this response 

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Answers   75most  directly  considers  the safety  of his partner  without  putting  the patient  in a more  difficult  situation.   You  have  a legal  requirement  to disclose  the information  to the person  at risk  (GMC  2009f).   It is also recommended  that you tell the patient  before  you make  any disclosures  and reiterate  that they  will not  be identified  in the process. A.  Trying to persuade him to tell his partner  is the next most  appropriate  response,  as the GMC  (2009f)  recommends  that you  make  every  effort  to persuade  infectious  patients  to inform  those  at risk.  Given  the hesitancy  in this scenario,  however,  it is unlikely  that you will change  his mind,  and patients  cannot  be forced  into  disclosing  their diagnosis.  It is therefore  your responsibility  rather  than the patient's  to ensure  that information  is shared. D.  Offering to talk to the patient and his partner together  is  the next  most  appropriate  option,  as offering  your  support  may  be all that is necessary  for the patient  to agree  to disclosure.   This  will  relieve  some  of his pressure,  as many  patients  find  breaking  bad news  extremely  challenging.   Lending  an expert  opinion  could  make  all the difference. E.  Recommending counselling  is the next  most  appropriate  option.   This  should  have  been  offered  at time  of diagnosis  but  the scenario  suggests  they  may  be having  difficulties  coping  with  the issue. B.  Not disclosing information because there is “no risk”  is the  least  appropriate  option.   As mentioned  above,  there  is a poten-tial risk to the partner,  and you have  a duty  to protect  them,  as  well  as a duty  to the patient. 25.  You are an FY1 working on a labour ward. One of your patients has a breech presentation. She has a birth plan which specifies that every appropriate method should be attempted before opting for a Caesarean section. She has now changed her mind and decided to have a CS. Her husband disagrees; taking you to one side and saying “she's in pain, she doesn't know what she wants, she'll regret it if you operate”. What  should  you do? ANSWER: DCBAE This question is about managing contrasting views of patients and their relatives, necessitating good communica-tion skills. An FY1 is expected to adapt their style of com-munication according to the context. D.  Reminding him that this is his wife' s choice  is the most  appropriate  option.   You should  respect  the opinions  of relatives,  but,  at the end of the day,  decisions  about  treatment  should  always  be made  by the patient  (provided  they  have  capacity). C.  Enquiring into her reasons for the change in birth plan  is  the next  most  appropriate  option.   You  can then  communicate  this to your  consultant.   It is best practice  to get as much  infor-mation  on the case  before  seeking  senior  advice. B.  Calling the consultant obstetrician to review the patient  is  the next  most  appropriate  option,  as this is a decision  above  your  level;  hence  you  need  help.   The  situation  is relatively urgent  given  the potential  risk to the mother  and the unborn  child.   The consultant  will also be able  to advise  you on how  to  best  proceed  with  management  in the interim. A.  Informing the patient about a CS and vaginal birth  is  the next  most  appropriate  option,  as the patient  needs  to   be aware  of the risks  and benefits  for both  procedures.   It is  likely  that  she will  have  been  over  this  in her birth  plan.   However,  it is important  to cover  this again  before  any deci-sions  are made. E.  Asking the husband to leave so you can speak to the patient in private  is the least  appropriate  option.   This  removes  the  support  of her husband  and could  potentially  cause  more  dis-tress  to the patient.   Also,  the consultant  would  make  a decision  whether  the patient  was being  coerced  by her husband  or not.   You should  try to maintain  harmony  in this scenario  and remov-ing the husband  is not the way  forward. 26.  You are working on a gastroenterology ward and a nurse approaches you and says Mr Brown needs to be pre-scribed his usual fluids. You are finishing up a discharge summary and take home drugs for another patient. What   should  you do? ANSWER: EDCBA This question requires you to consider prescribing errors and patient safety in a pressured environment. An FY1 is expected to remain calm when under pressure, demonstrate good judge-ment and manage uncertainty. Refer to Chapter  3 for more information on safe prescribing and prioritisation. E.  Asking about Mr Brown' s fluid status  is the most  appropri-ate option.   You  need  to find  out more  information  from  the  nurse  about  Mr Brown  before  you can make  an educated  deci-sion  about  the urgency  of this task.   For example,  if the nurse  was concerned  about  a low urine  output,  you might  go and see  him  straight  away.   If there  was  no concern,  then  you would  finish  the prescription  and  see him  afterwards.   You  should  always  prioritise  tasks  according  to clinical  need. D.  To say you will put it on your jobs list and get to it as soon as you can  is the next  most  appropriate  option  as this means  you  can  prioritise  it accordingly.   Discharge  summaries  are  important  and involve  prescribing  and dosages.   You should  not  be distracted  from  this task if possible  as it may  mean  that the  patient  is discharged  without  the appropriate  medications,  or  on the wrong  medication  etc. C.  Explaining that to enable you to get the discharges done they should ask another FY1  is an abrupt  response,  but prioritis-ing the discharge  summaries  over  this routine  prescription  is  more  appropriate  than  (B) or (A).   You  should  be supportive  towards  colleagues,  but recognise  when  to say no.  Moreover,  the nurses  and  ward  clerks  are under  pressure  to discharge  patients  and they  should  understand  your  reasons. B.  Going to see Mr Brown straight away  is a less appropriate  option.   In this case,  the priority  of care  is ensuring  that  the 

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76  Answerspatient  you are discharging  gets  the right  medication  and has  the relevant  information  communicated  to their  GP.  There  is no  indication  in this scenario  that Mr Brown  is unwell  and there-fore  his “usual”  fluids  can wait. A.  Prescribing Mr Brown his normal saline  is the least  appro-priate  option,  as this is potentially  dangerous.   If you overload  Mr Brown  with  fluid  you  could  cause  pulmonary  oedema.   Always  remember  to see the patient  before  you prescribe  in  order  to minimise  error. 27.  A colleague has left 30 minutes early to attend a dental appointment. They have asked you to prescribe Warfarin for their patient. Your shift has already ended, and you were about to go home. The INR result from the morning's blood tests is not back yet. What  should  you do? ANSWER: EBDCA This question is about safe prescribing and prioritising patient care. Refer to Chapter  3 for information on pres-sures, prescribing and prioritisation. E.  Ringing the lab to see if the INR results are available  is the  most  appropriate  option,  as you should  find out why  the results  have  taken  so long.   It may  be that the sample  has been  missed  off, in which  case  you would  need  to rebleed  the patient - or  ask them  if they  can do a repeat.   Usually  the lab will save  part  of the sample  for such  cases.   Whilst  you are not expected  to  stay long  after  your  shift  has ended,  you have  accepted  respon-sibility  for this patient  and therefore  you should  make  their  care  a priority  before  you leave. B.  Handing over the request to the ward cover  is the next most  appropriate  option,  as you should  make  sure that the patient  has a  continuation  of care and receives  their Warfarin  in a safe manner. D.  Recording that the patient needs their Warfarin dosing in the notes  is the next  most  appropriate  option.   Although  writing  in the notes  does  not ensure  that it will get done,  having  a record  means  you can check  it in the morning.   Not having  the patient's  Warfarin  dosed  could  be equally  as detrimental  as overprescrib-ing it.  It is always  good  practice  to write  in the notes  as well  as make  a personal  list. C.  Writing it onto your job list for the morning  is the next  most  appropriate  option,  as you should  make  a note  to yourself  to  check  that this has been  done.   After  all, this patient  is now  your  responsibility. A.  Prescribing the Warfarin anyway  is not appropriate,  as pre-scribing  this without  the INR  result  potentially  puts  the patient  at risk of bleeding. 28.  You are working as an FY1 on a surgical ward. On your way to ordering a CT scan from radiology you are bleeped. You find the nearest phone to ring through. A nurse is con-cerned about Mrs Fazi's urine output (UO). You remember it was fine for her small frame when you checked two hours ago. What  should  you do?ANSWER: DACBE This question is about coping with pressure. An FY1 is expected to adapt to changing circumstances and manage uncertainty. They should also be able to re-prioritise tasks as necessary. D.  Asking the nurse whether Mrs Fazi' s UO has changed since this morning  is the most  appropriate  option  as you need  to find  out more  about  Mrs  Fazi  before  you can make  a decision. A.  Asking the nurse to do some basic observations whilst you order the CT  is the next  most  appropriate  option  as you need  to get scans  approved  early  in the day for them  to get done.   The scan  is, therefore,  prioritised  as urgent.   Not completing  this  task  may  cause  that patient  to suffer.   Your  consultant  will not  be impressed  if you don't  get the scan,  as it will mess  up the  patient's  management  plan. C.  Reassuring the nurse that Mrs Fazi' s UO was fine for her size is the next  most  appropriate  option,  as it may  be that the  nurse  hasn't  accounted  for her small  frame.   If it was fine two  hours  ago,  you can reassure  the nurse  that it is sensible  to order  the CT scan  first before  going  to check  on Mrs  Fazi. B.  Going to see Mrs Fazi immediately  is not appropriate.   You  should  not drop  everything  when  there  is no indication  that  there  is an emergency.   You should  address  the nurse's  concerns  in a timely  manner,  whilst  making  sure  that  you  prioritise  effectively.   It is better  to spend  15 minutes  ordering  a CT scan  and attend  to Mrs  Fazi  after. E.  Telling the nurse to start fluids  is not appropriate,  as you  should  not prescribe  over  the phone,  nor should  you prescribe  for a patient  that you haven't  been  to see yourself. 29.  You go to see a patient with whom you previously had trouble putting in a cannula. You ask them whether you can take some blood. They recognise you and say “don't come anywhere near me with that thing, you don't know what you're doing”. What  should  you do? ANSWER: ACBDE This question is about taking responsibility for your own actions and owning up to mistakes. A.  Reassuring the patient that you are competent at taking blood  is the most  appropriate  option  as you should  reassure  the  patient  of your  clinical  skills.   This  response  directly  addresses  the situation. C.  Apologising to the patient for yesterday  is the next  most  appropriate  option,  as you need  to show  the patient  that you  accept  responsibility  for causing  them  distress.   The patient  may  also  be more  likely  to consent  to venepuncture  on acceptance  of your  apology.   This,  however,  would  be best after  some  reas-surance  of your  ability. B.  Asking a nurse to take their blood  is the next  most  appropri-ate option,  as you should  not lie to force  the patient  to consent  (D) and you cannot  take  blood  from  the cannula  (E) as it will 

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Answers   77be contaminated.   Although  nurses  are busy,  they  can always  help  you out and some  will be trained  in taking  blood. D.  Telling the patient that you have to take their blood because there is no-one else  is not appropriate.   This  is coercing  the  patient  to consent.   You  should  attempt  to find someone  else to  take  it before  you tell them  that they  have  no other  options. E.  Taking blood from their cannula  is not appropriate.   There  are few occasions  when  you can take  blood  from  a cannula  as  fluids  and drugs  will have  passed  through  it.  The sample  would  be contaminated,  which  means  the lab would  process  the bloods  erroneously. 30.  A patient you recently discharged from the ward requests your friendship on a social networking site. They are a similar age to you. What  should  you do? ANSWER: BECDA This question is about professionalism. For advice on social networking refer to Chapter  2. B.  Declining the friend request and explaining your reasons  is  the most  appropriate  option.   The BMA  (2011)  recommends  that  you  decline  any offers  of friendship  and explain  why  to the  patient.   This  most  effectively  addresses  the problem. E.  Asking your educational supervisor for advice  is the next  most  appropriate  option,  as they  will  be able  to explain  what  to do in this situation  and turn it into a learning  experience.   You  gain  more  from  this than  you would  from  ignoring  the situation  and not seeking  advice. C.  Ignoring the request  is the next  most  appropriate  option,  as  it is better  to ignore  a friend  request  than  accept  it.  This  would  address  the problem  but not necessarily  solve  it.  It would  be  more  appropriate  to learn  from  the experience  by seeking  advice. D.  Asking your FY1 colleague for advice  is the next  most  appropriate  option.   Although  this will  not directly  solve  the  issue,  your  colleagues  should  have  an understanding  of profes-sionalism  and best  practice  and may  be able  to give  advice. A.  Accepting the request  is not appropriate.   It is not advisable  to accept  online  friendships  with  patients  or former  patients.   Irrespective  of their  discharge,  they  could  at any point  come  under  your  care  again,  and it is unprofessional  to enter  into this  kind  of relationship. 31.  You are working on ITU, completing the morning's jobs list. When taking bloods from a patient-admitted follow-ing a road traffic accident-you accidently stick yourself with the needle. You had followed infection control guide-lines and were wearing gloves but you see your finger bleed-ing underneath. You quickly squeeze it, clean it and put a dressing on it. You go to look on the system for anything on the patient's HIV/Hepatitis status but there is nothing. The patient is unconscious. What  should  you do?ANSWER: BDG This question is asking whether you understand best prac-tice following a stick injury. B.  Ringing occupational health  is appropriate,  as they  will be  able  to tell you immediately  the protocol  for stick  injuries. D.  Filling in a CAE form  is appropriate,  as when  you go to occu-pational  health,  they will ask whether  you have filled  this in. G.  Bleeping your registrar to explain the situation  is appropri-ate, as you  will  have  to go to occupational  health,  thereby  leaving  ITU.   You  should  always  notify  a senior  of a serious  incident - as in this case - so they  can make  the appropriate  arrangements  such  that neither  your  own  nor the patient's  safety  is compromised. A.  Requesting viral serology  is not appropriate,  as the patient  has not consented  to having  these  investigations  and it would  not be in their  best interests  to have  them  done.   If they  were  in  ITU  for an illness  in which  HIV status  could  benefit  their  treat-ment,  then  this could  be considered.   You,  however,  would  not  request  this;  it would  have  to be done  by a senior. C.  Going to A&E for anti-retrovirals  is not appropriate  during  working  hours.   Occupational  health  will  be able  to give  you  the appropriate  advice  and treatment.   If occupational  health  cannot  be contacted,  you should  go to A&E  where  an appropri-ate risk assessment  and management  can be carried  out. E.  Asking if you can go home  is not appropriate,  as this would  be a way  of avoiding,  rather  than  helping,  this situation. F.  Waiting to see if the patient wakes up to ask for their per-mission for serology  is not appropriate.   The patient  is uncon-scious  and therefore  you have  no idea  when  they  will wake  up.   You  should  act quickly  and promptly  after  a stick  injury  to  reduce  the risk to yourself  as far as possible. H.  Explaining to one of the nurses what has happened  is not  a preferred  option  as you should  inform  your  senior  before  the  nurses.   The nurse's  priority  is largely  patient  safety,  whereas  a  senior  colleague  will  be able  to analyse  the situation  and  manage  the team  to best  support  your  needs  and ensure  the  patient's  best  interests  are considered. 32.  Your FY1 colleague turns up late again for their shift. The ward you are working on is quiet. Your colleague arrives in tears; she is feeling exhausted, stressed and says that she is not coping with anything at the minute. This is the third time in the past two weeks. What  should  you do? ANSWER: BFC This is about supporting a doctor in difficulty and prioritis-ing your colleagues. B.  Sitting your colleague down to talk about her problems  is  the most  appropriate  option.   Your  colleague  is clearly  distressed  and therefore  you should  deal with  this issue  in a timely  manner. F.  Advising your colleague to talk to her educational supervi-sor is also appropriate,  as their  supervisor  should  be the “go-to” 

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78  Answersperson  for support.   They  have  access  to the “doctors  in diffi-culty”  programme,  if needed.   It is always  better  that you flag  up issues  with  your  supervisor  rather  than  ignoring  them  and  letting  them  be referred  in via a different  avenue. C.  Suggesting she book an appointment to see her GP  is an  appropriate  option.   Although  you  don't  yet know  what  is  causing  her stress,  it might  be good  for her to talk to someone  external  without  the added  pressure  of feeling  judged  by her  seniors.   GPs  are also  used  to seeing  patients  with  health  prob-lems  caused  by stress  on a daily  basis  and will be able  to rec-ommend  a sensible  way  forward - including  recommending  sick  leave. G.  Seeking advice from your educational supervisor  is not a  preferred  option.   Although  your  educational  supervisor  is a  good  point  of contact  when  you are unsure  how  to handle  a  situation,  your  supervisor  can't  do much  to help  your  colleague  if she has a different  educational  supervisor.   Your  educational  supervisor  could  be helpful  if you needed  to debrief  on how  you handled  the situation. E.  Suggesting she take sick leave  will not address  the issue  and  is therefore  not appropriate.   If it involves  stress  at work,  taking  leave  will only  prolong  it until  they  return.   Also  her GP would  be the most  appropriate  person  to make  this decision. A.  Apologising and saying that you are busy  is not appropriate,  given  how  upset  your  colleague  is, and the question  clearly  states  that you are on a quiet  ward.   Moreover,  this isn't  the first  time  she has displayed  a significant  amount  of distress. D.  Suggesting your colleague speak to her registrar  is not a  preferred  option.   While  she could  speak  to her registrar,  it is  sensible  to seek  advice  from  those  in the best position  to help. H.  Mentioning that you have to inform your consultant of her difficulties  is not appropriate,  as this may  alienate  your  colleague  further.   As there  is no indication  of compromise    to patient  safety,  you should  be supportive  rather  than  accusa-tory  and  recommend  she seek  help  through  the appropriate  channels. 33.  You are working in Children's A&E on a Saturday night. A 13-year-old boy comes in drunk. He admits he has been drinking alcohol and says he fell over. The X-ray confirms he has broken his index and middle fingers. The boy is adamant he is fine and doesn't want any treatment because he is scared that his parents will find out he has been drinking. He wants you to just give him some painkill-ers and then he'll leave. What  should  you do? ANSWER: HEC This question is asking you about acting in the patient's best interests for someone who does not have the capacity to refuse treatment. See Chapter  2 for more information on patient advocacy for the under eighteens. H.  Discussing the situation with the nurse in charge  is appro-priate,  as the nurses  on this unit will have  experience  in dealing with  teenagers  refusing  treatment.   They  will be able to give  you  advice.   They  also might  be able  to talk to the boy and get him  to stay. E.  Trying to persuade him to have his fingers splinted  is appro-priate,  as you should  make  every  effort  to help  this boy under-stand  that he should  have  treatment.   This  is easier  than  having  to force  him to stay. C.  Explaining that you really need to let his parents know what has happened and it would be best if he rang them  is appropri-ate, as this boy is a minor  and has been  drinking  alcohol,  and  therefore  is unlikely  to be Gillick  competent.   He is also at risk  of harm  from  further  alcohol  abuse  and injury.   If he self-dis-charged  and his parents  knew  nothing  about  it, your  profes-sionalism  could  be questioned. A.  Prescribing the painkillers and letting him self-discharge  is  not appropriate.   You  should  not prescribe  pain  relief  if he has  been  drinking  alcohol;  moreover,  it is in his best  interests  that  he does  not self-discharge. B.  Ringing the boy' s parents without telling him  is not appro-priate,  as this is breaking  confidentiality.   You  should  always  inform  the patient  if you are going  to do this. D.  Telling him to go and see his GP if he has any problems over the weekend  is not appropriate,  as he has not self-dis-charged  yet. F.  Putting in a referral for social services  is not appropriate  at this stage  as there  is no need  for intervention  by social  serv-ices on this evidence  alone. G.  Refusing to let him self-discharge without getting the proper treatment  is not a preferred  option.  A teenager  can only  consent  to treatment;  they cannot  refuse  treatment  even  if   they are Gillick  competent,  as this must  be overridden  if   you consider  treatment  to be in their best interests.  It is, there-fore,  more  appropriate  to get senior  support.  Remember  to  select  the options  that are the most  appropriate  to your role  as an FY1. 34.  You are on a ward round with your consultant on the coronary care unit. The patient's relatives are sitting in the waiting room at the end of the corridor. Your consultant says that the patient is going to die soon and checks the Do Not Attempt Resuscitation (DNAR) form. The family approach you politely after the ward round whilst you are ordering bloods and say “so you think Mum is going to die, do you?” It is clear they have overheard your consultant's comments. What  should  you do? ANSWER: HAD This question considers how you deal with a difficult situa-tion involving relatives. Remember that good communica-tion is TPP: at the right Time, with the appropriate People in the appropriate Place. H.  Calling your consultant to explain what has happened  is  appropriate.   This  is a complex  situation  and your  consultant 

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Answers   79really  is the most  appropriate  person  to deal  with  this matter.   You  can discuss  with  the consultant  over  the phone  how  you  should  proceed. A.  Asking a nurse to take the family to a side room  is appropri-ate, as this is a sensitive  issue  that would  best  be approached  in a neutral  space.   Moreover,  as it is a potentially  volatile  situ-ation,  having  a colleague  for support  is a good  idea. D.  Apologising to the family  is appropriate,  as you will clearly  have  caused  the relatives  some  distress  in hearing  about  their  mother  in such  frank  terms.   An apology  demonstrates  your  sensitivity  towards  their  needs. F.  Asking the family if they would like to sit with their mother   is not a preferred  option,  given  the nature  of the situation.   They  should  be directed  to an appropriate  room  to await  the consult-ant to have  a detailed  conversation.   They  may  wish  to sit with  their  relative  after  this time,  but it would  be best  to have  a  discussion  on neutral  ground  rather  than  at the bedside. B.  Asking where they heard that information  is not appropri-ate, as it is obvious  there  has been  error,  irrespective  of where  they  heard  this information. C.  Telling them you are busy  and G.  Finishing ordering the bloods  are not appropriate,  as both  actions  are rude  and do not  appropriately  deal  with  this situation.   Bloods  can wait  for 20  minutes  whilst  this issue  is addressed. E.  Filling in a CAE form  is not a preferred  option.   This  could  be considered  at a later  stage  after  the incident  has been  managed  appropriately.   Also,  the consultant  may  wish  to com-plete  the form  in this case. 35.  A nine-year-old boy was admitted following an exac-erbation of asthma. You speak with the parents about using his steroid inhaler. The boy's mother is happy to make sure he has the inhaler; however, his father is clearly not. The father says that he has heard that they will stunt his boy's growth and he doesn't want that. What  should   you do? ANSWER: GFC This question is about acknowledging a parent's concerns and managing them appropriately to ensure compliance with medication which is in the best interests of your patient. G.  Educating the father about the advantages of using an inhaler  is appropriate,  as the father  may  have  some  misconcep-tions - in which  case  you can iron them  out through  education  and help  change  his mind  about  the inhaler. F.  Planning to monitor the boy' s growth on a growth chart  is  also appropriate,  as this is addresses  the concerns  of the father  by diligently  monitoring  for any side effects.   By recording  the  boy's  growth  on the chart,  you are showing  that you take  his  misgivings  seriously,  which  will hopefully  improve  compliance  in the long  term. C.  Asking the asthma specialist nurse for advice  is another  appropriate  option,  as it is likely  the specialist  nurse  will have dealt  with  a similar  scenario  before  and may  have  some  tricks  to help  handle  the situation. H.  Asking the boy what he would like to do  is not a preferred  choice  as although  you should  try to involve  any child  as much  as possible  in their  care,  acknowledging  the parent's  disagree-ment  should  be the priority.   Moreover,  this boy is only  nine  years  old and too young  to consent  to treatment  himself. E.  Getting the mother to persuade the father  is not a preferred  option  as you must  try to educate  the father  first,  and get some  more  advice,  before  using  the other  parent  as the mediator.   The  evidence  of healthcare  professionals  should  be much  more  effective  than  the mother's  opinion  alone.   Moreover,  this would  not adequately  address  the father's  concerns. B.  Contacting social services about the disagreement  is not  appropriate,  as there  is nothing  to indicate  that this child  is at  risk of harm. D.  Agreeing with the father not to use the steroid inhaler  is not  appropriate,  as it would  not be in the best interests  of the child  to stop  his asthma  medication. A.  Ignoring the father' s wishes  is not appropriate,  as you  should  make  every  effort  to resolve  the dispute  so that the child  receives  the same  message  from  both  parents.   If they  conflict,  mixed  messages  can lead  to increased  non-compliance.   Be  careful  not confuse  the issue  of consent  with  the issue  of com-pliance.   Although  only  one parent  is needed  to consent  to treat-ment,  in this case  you want  both  parents  on the same  page  so  that the boy receives  his medication  in the appropriate  manner. 36.  A 43-year-old man is brought in by ambulance to A&E after collapsing in a bar on a Friday night. You have no details other than his name and date of birth, which the paramedics got from his wallet. The man is incapable of giving a history due to his level of intoxication. He is stable in the resuscitation area. What  should  you do? ANSWER: AGC This is about patient prioritisation in an emergency situa-tion and recognising your job role and limitations. An FY1 should be proactive and able to initiate assessment and investigations but know when to seek help: in this case for starting treatment. A.  Continuing with your A to E assessment  is appropriate,  as  you should  always  go back  to basics  for every  patient. G.  Starting the appropriate investigations but no new medica-tions  is appropriate,  as you must  treat  the patient  as new  if you  don't  know  anything.   You can hold  off starting  any medications  until  you have  tried  to find out whether  he has any allergies  or  is on any medications  that may  interact. C.  Asking a clerk to search the hospital database for any records  is appropriate.   Patient  care  should  be your  priority,  and  finding  more  about  his medications  and past medical  history  is  essential.   A clerk  should  have  time  to look  through  the database  and print  off any old clinical  letters  to find out more  about  him.

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80  Answers B.  Ringing your registrar  is not a preferred  option.   You should  complete  your  A to E assessment  and then  see what  you can  find out about  his history.   It says  in the question  that this man  is stable;  therefore  you can assume  that it is better  to find out  as much  as you can before  calling  for help  in this case.   If the  scenario  was an emergency,  however,  you would  call for help  immediately. D.  Searching through his mobile phone  is not an appropriate  option,  as you should  not be using  friends  and family  to get  information about a patient unless it is a last resort.   You should  check  the hospital  database  first. E.  Starting the treatment anyway  is not a preferred  option,  as  you should  start  investigations  before  management, G is there-fore  more  suitable. H.  Asking one of the nurses to try and track down some infor-mation  is not appropriate.   Nurses  are busy,  and you are expected  to take  responsibility  for finding  patient  information - or del-egate  it to the ward  clerk  if you are busy  with  the patient. 37.  A 24-year-old woman is admitted to A&E following a paracetamol overdose. Her boyfriend brought her in when she admitted that she had taken 50 × 500 mg paracetamol tablets one hour earlier. Her boyfriend tells you she has been suffering from depression. You speak with her alone and she refuses any form of treatment-she wants to die. What  should  you do? ANSWER: CBD This is about recognising the need for senior help and tests your ability to handle patients who refuse to consent to treatment. Refer to Chapter  4 for more information on dif-ficulties consenting patients. C.  Bleeping the on-call psychiatrist  is appropriate,  as you have  information  from her boyfriend  that she has been suffering  from  depression.  Moreover,  this should  be treated  as an attempted  suicide  and therefore  warrants  psychiatric  assessment.  If you  spoke  to your registrar,  they would  advise  you on a psychiat-ric referral.  In this case you would  need a rapid  assessment  on  whether  she has the capacity  to refuse  treatment. B.  Seeing if the boyfriend can persuade her to change her mind  is appropriate.   Using  family  and friends  can be extremely  helpful  in getting  patients  to comply  with  treatment.   Although  this also puts him in a difficult  situation,  she may  find it helpful  talking  to someone  that she knows  and has a close  relationship  with.   You  would  still need  to speak  to psychiatry  however. D.  Calling your registrar  is appropriate,  as this is not some-thing  that you would  be expected  to handle  on your  own  as an  FY1.   You should  call for senior  help  as soon  as possible  as this  is a challenging  situation. E.  Treating her under the Mental Health Act (MHA)  is not  a top selection,  but is more  appropriate  than  options  F-  Treating her under the Mental Capacity Act (MCA)  - and G-  Treating her under the doctrine of necessity  - but you would need a full assessment  before  jumping  to commit  her to treatment  without  consent.  You would  choose  E over F as she doesn't  meet  the criteria  for the MCA  in that she understands  that not having  treatment  will kill her.  However,  she is suffering  from a mental  health  disorder  and therefore  can be treated  against  her will under  the MHA.  The situation  of urgency  is not so great  that the doc-trine of necessity  (G) is warranted.  Although  this is an emer-gency,  it is not such that you override  the patient's  wishes  and  act in their best interests  anyway.  She needs  further  assessment  of her competence  to refuse  treatment. A.  Respecting her right to refuse treatment  is not appropriate,  as the history  suggests  that  this patient's  judgement  may  be  com promised  and therefore  you should  explore  other  options  first. H.  Discharging her from A&E  is not appropriate.   You  have  a  duty  of care  to this patient  and dismissing  her would  question  your  professionalism. 38.  You are working on a labour ward as an FY1. A nurse comes to see you to let you know that the ex-partner of one of the mothers is demanding to see his baby in the special care baby unit. He wasn't present at the birth and you know that the mother hasn't been in contact with him since she became pregnant. What  should  you do? ANSWER: CEH This is about patient confidentiality and protecting both the mother and the baby. This is also about recognising paren-tal rights, and that you cannot refuse a parent access to a child just because of what the other parent says-providing, however, that you have confirmed identity. C.  Asking the mother to confirm whether he is the father  is one  of the most appropriate  options,  as you should  seek consent  from  the mother  whether  to allow  access  to her baby - particularly  as  the father  has been out of the picture  for such a long time. E.  Ringing the registrar to ask for advice  is appropriate,  as you  must  consult  a senior  in tricky  situations  such  as this.   There  could  be potential  problems  from  either  the mother  or this man,  and you should  alert  seniors  to this as soon  as possible. H.  Telling the man that he cannot see the baby until you have spoken to the mother  is one of the most  appropriate  options,  as  you must  explain  to him that the mother  also  has the right  to  know  who  will be visiting  her child. B.  Checking the baby' s birth certificate  is not one of the pre-ferred  options,  as you should  always  confirm  whether  the father  is who  he says  he is.  Another  way  would  be to get the mother  to confirm  that he is the father. A.  Taking this man to see the baby  is not appropriate,  as -  given  the nature  of their  relationship - you should  not allow  the “alleged”  father  to see the baby  without  the mother's  permission. D.  Asking the midwife for advice  is not one of the preferred  options  as a nurse  has come  to you already  asking  for advice 

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

Answers   81(rather  than  the midwife),  suggesting  that  you  are the most  appropriate  person  to handle  this situation. F.  Documenting in the notes that this man wanted access to the baby  is also  not one of the top selections;  however,  you  would  note  this down  at a later  stage,  as well  as the conversa-tion that you had with  both  parents. G.  Telling the man to come back another time once he has pre-arranged a visit  is not one  of the preferred  options  as  fathers  do not have  to pre-arrange  visits  to see their  children.   Confirming  his identity  and getting  consent  is therefore  more  appropriate  in this case. 39.  A 79-year-old man is awaiting surgical repair of a frac-tured neck of femur. He tells you that he is a Jehovah's Witness and says he will refuse the operation if he needs a blood transfusion. You suspect the risk of needing a blood transfusion is high. He asks if there are any other options. What  should  you do? ANSWER: AHF This question is about respecting a patient's wishes and acknowledging their rights to refuse treatment on the grounds of religious principles. See Chapter  4 for more information on Jehovah's Witnesses. A.  Explaining the consequences of not having the operation  is  appropriate.   He should  fully  understand  the risks  of refusal.   Moreover,  there  are conservative  options  but they  are also risky. H.  Finding out why he is opposed to a blood transfusion and his preferences  is also  appropriate.   You  need  to fully  explore  the patient's  personal  beliefs  before  deciding  on a management  plan.   You can then  relay  this information  to the registrar  so that  they  are better  informed  of the patient's  wishes. F.  Bleeping your registrar to review the patient  is appropriate,  as you always  need  senior  advice  in complex  situations  involv-ing patient care.   They will know whether there are cell-salvage  facilities  at your  hospital,  or whether  he needs  to be transferred  to a different  hospital.   They  can also enter  into a more  complex  discussion  with  the patient  regarding  the relative  risks  and  benefits  of the various  options  available. D.  Telling him you are unsure of the options but you will find out is not a preferred  option  as your  registrar  must  review  the  patient,  in which  case  they  can explain  the options  to him. G.  Consulting your local guidelines  is also  not a preferred  option.   Although  there  should  be clear  guidance  on this at your  local  trust,  this can be accessed  after  you have  all the informa-tion from  the patient  and passed  that on to the relevant  senior.   You would  not want  to delay  this patient's  treatment  and there-fore  should  act appropriately  to make  sure  they  receive  senior  review  in a timely  manner.   Always  be aware  of where  you can  access  such  policies  to read  up at a later  stage. B.  Asking permission to contact the HLC  is not a top-ranked  option.   You  need  to gain  consent  before  you can discuss  his  case  with  an external  body.   The HLC  will be able  to give  you information  on the options  available  to him,  but this will take  longer  than  getting  an internal  senior  review  where - knowing  the options - it is likely  that the HLC  need  not be contacted. C.  Advising him to contact the Watchtower society  is not  appropriate,  as the patient  does  not have  enough  information    to enquire  about  such  a significant  procedure  at this stage.   It   is your  responsibility  to be an advocate  for this patient  and   his care. E.  Taking bloods and ordering pre-op investigations  is not  appropriate,  as the patient  has not consented  to the operation,  and therefore  these  investigations  are not considered  a neces-sary  part of their  care. 40.  A man is sitting in minors in A&E after having a drunken brawl with his friend. He has superficial lacera-tions to his shoulder and forearm. He arrived at midnight and, having been waiting for three hours, is getting increas-ingly agitated. The nurse comes to tell you that he is angry and threatening to self-discharge. You are busy packing the nose of his friend whom he was fighting with. What  should   you do? ANSWER: BED This question is about staying calm whilst under pressure and maintaining a good relationship with patients through effective communication. See Chapter  4 for more informa-tion on verbal communication skills. B.  Asking the nurse to let the patient know he is next  is the  most  appropriate  response  as it is clear  he has been  waiting  a  while  and needs  treatment. E.  Telling the nurse to get the suture kit ready  is an appropriate  response  as this will  help  you out and save  some  time.   It is  important  to recognise  when  it is appropriate  to delegate  tasks. D.  Apologising to him for the long wait  is an appropriate  response  as this shows  empathy.  Hopefully  this will diffuse  his agitation  and  allow  him to be treated.  He could  very well be agitated  because  he is in pain or he doesn't  like hospitals.  It is important  not to label  patients  as “difficult”  or “drunk”  as this could  impair  your respon-sibility  to treat them  in their best interests. A.  Allowing him to self-discharge  is not appropriate,  as you  have  a duty  of care  to your  patients.   There  is no indication  that  this patient  is going  to physically  abuse  the nurse,  or that the  nurse  feels  threatened  in any way.   Therefore  it is best  if they  are persuaded  to stay  and receive  treatment. C.  Calling security  is not appropriate  at this stage,  as he is not  being  threatening  towards  staff  or others;  he is merely  saying  that he will discharge  himself  against  medical  advice. F.  Asking the nurse to tell him he should wait because you are seeing his friend  is not appropriate,  as it is better  to let him  know  he is next  (B).  Although  he may  be aware  that his friend  is also  in hospital,  this could  still be considered  a breach  of  confidentiality.   It is better  to keep  information  as anonymous  as possible.

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

82  Answers G.  Leaving his friend and going to attend to his shoulder and forearm lacerations  is not appropriate,  as you  should  finish  treating  one patient  rather  than  abandoning  them  to attend  to  another  patient. H.  Calling the SHO to review and suture him  is not appropri-ate.  You should  be able to manage  this situation  as an FY1.   You  should  avoid  calling  the SHO  for minor  disagreements  that   you are more  than  capable  of handling.   However,  if this was a  laceration  to the forehead,  you  might  be concerned  that  the  increasing  agitation  was a manifestation  of a more  serious  head  injury,  in which  case  you would  consider  bleeping  the SHO  for  a full head  injury  assessment. 41.  You are in the surgical assessment unit and trying to consent a 55-year-old man for rigid sigmoidoscopy that you will be doing under supervision. You have been trained to consent for this procedure and are aware of all the risks and benefits. When you try to explain the procedure, he says “Do whatever you think is best, Doc, I don't want to know”. What  should  you do? ANSWER: CAE This is about handling a situation where a patient does not wish to consent to treatment. See Chapter  3 for more infor-mation on consent in patients with capacity. C.  Telling him it is important that he understands the proce-dure in order to consent  is appropriate,  as you should  reiterate  the need  for an explanation  of the procedure.   The patient  may  still change  his mind  about  knowing. A.  Telling him you need to give him a brief explanation of the procedure  is appropriate,  as you  must  be honest  with  your  patient  and reason  with  him as to why  he should  be involved  in his care.   Patients  should  know  the broad  nature  of the pro-cedure,  as it is possible  to proceed  without  providing  all the  information  on the risks  and benefits. E.  Asking him whether he would prefer to have a family member with him  is appropriate.   Even  though  this man  has to  consent  to the procedure  himself,  many  patients  prefer  to have  a relative  present.   The added  benefit  of having  a relative  is that  they  are likely  to take  on board  more  information  than  the  patient  and can ask questions  that the patient  otherwise  wouldn't.   This  is a way  of indirectly  engaging  the patient  in a conversa-tion about  the procedure  beyond  the brief  explanation  given  to  him and may  encourage  the patient  to ask questions  himself. D.  Phoning your registrar to consent the patient  is not a pre-ferred  option.   You  have  all the knowledge  that the senior  has  to consent  this patient.   Moreover,  as you  will  be doing  the  procedure  yourself  (under  supervision),  it would  be more  appropriate  for you to gain  the consent.   You should  try persuad-ing the patient  first,  before  seeking  senior  help. B.  Asking him to sign the form without going into detail  is not  appropriate,  as this is not getting  appropriate  consent - select-ing this option  would  question  your  probity  and integrity F.  Explaining the procedure to a family member instead  is not  appropriate,  as a family  member  cannot  consent  for a patient  with  capacity  and can only  do so in a patient  who  lacks  capacity  if they  are named  as a legal  proxy. G.  Cancelling the investigation  is not appropriate,  as this  response  is premature.   You  should  try alternatives  before  jumping  to cancel  an investigation  that is designed  to help  the  patient - a senior  would  be expected  to make  this decision. H.  Filling in the form yourself and signing in his best interests   is not appropriate - this is breaking  the professional  code  of  conduct  and questions  your  honesty  and professionalism. 42.  You are looking after Mrs Chang who is intermittently confused. Her family are all in the waiting room and are anxious to know how Mrs Chang is doing. You have the results of her CT scan which is normal. What  should  you do? ANSWER: BDH This is about ensuring patient confidentiality in a patient who may or may not have the capacity to consent. It is also about strengthening relationships with relatives and main-taining good communication. B.  Going to see how Mrs Chang is today  is appropriate,  as you  should  determine  whether  she has capacity  or not.  As she is  intermittently  confused,  you should  wait  to tell her the news  until  she can comprehend  it.  Telling  the family  before  the  patient  is never  acceptable - unless  you  are sure  that  she is  never  going  to have  capacity. D.  Telling her family about her general well-being without going into specific details  is appropriate.   The family  will want  to know  how  she is today  and  it is important  that  family  members  are kept  up to date  with  her clinical  situation.   If you  explain  that  you  have  to get consent  from  the patient  they  should  understand  and will appreciate  that you have  addressed  their  anxieties. H.  Ringing the registrar to ask for advice  is appropriate,  as you  have  a duty  to relay  results  to patients  in a timely  manner.   You  will need  advice  on this matter  as it is likely  that the family  are  worried  and will ask you about  this.  Confidentiality  and consent  are complex  issues  which  often  extend  beyond  what  you can  see.   In this respect,  it is always  a good  idea  to get a senior  involved  early  rather  than  having  to undo  a mistake  later. G.  Viewing the scan yourself  is not a preferred  option.   Although  it is good  practice  to look  at all scans  as well  as the radiology  report,  Mrs Chang  and her family  should  take priority.   Viewing  normal  CT scans  is just as important  as viewing  abnormal  ones  and this is a learning  opportunity,  but, ideally,  you would  need  a senior  to talk you through  the scan  to consolidate  information  accurately. F.  Letting your colleagues know Mrs Chang' s result  is not a  preferred  option.  You should  let your colleagues  know  the results  at handover  or a more  appropriate  time.  The priority  here is to  ascertain  how you are going  to get the results  to Mrs Chang.

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Answers   83E.  Waiting until Mrs Chang asks specifically for her results  is  not a top selection  because  you should  actively  seek  to speak  to relatives  when  results  are available - provided  you have  the  consent  from  the patient  to do so. A.  Telling the family the good news  and C Asking a nurse to tell the family the good news  are not appropriate,  as the patient  has a right  to know  their  results  before  the family,  regardless  of who  delivers  the news. 43.  You are working on an oncology ward. You are sitting at the desk ordering bloods when your colleague Jane tells you she thinks that you are not picking up your fair share of work. You feel Jane is boisterous and arro-gant. No one else has mentioned anything to you about being lazy and you feel you are competent. What  should   you do? ANSWER: CED This is about managing interpersonal relationships and con-flict within a team. You are expected to maintain harmony and work effectively as a team-player. Refer to Chapter  6 for more information on teamwork. C.  Saying you cannot discuss this here and suggesting a more appropriate place  is a top selection,  as you never  want  to get  into an argument  on the ward  in front  of patients.   This  would  be unprofessional. E.  Asking Jane why she feels you are not doing your share  is  appropriate,  as you should  find  out from  your  colleague  why  she has a problem  with  you.   That  way you can discuss  it openly  and hopefully  reach  a compromise. D.  Suggesting that you divide the jobs evenly  is appropriate,  as this means  that neither  of you can complain  about  the work-load.   Resolving  the problem  between  you is far more  appropri-ate than  involving  seniors.   You  are adults  and should  be able  to work  through  this. H.  Reporting the bullying to your consultant  and F Raising the issue with your educational supervisor  are not appropriate,  as  you should  not escalate  things  at this stage.   Try to resolve  the  conflict  amongst  yourselves. A.  Telling Jane you think she is arrogant  and B Arguing that you do your fair share  are not appropriate,  as neither  response  is constructive  and will  likely  lead  to more  arguments  rather  than  a solution. G.  Asking your other colleagues their opinion of you  is not  appropriate,  as involving  team  members  may  mean  asking  col-leagues  to take  sides.   You  are expected  to maintain  harmony  within  the team  as far as possible. 44.  You are working on a busy respiratory ward. One of your colleagues, Jack, is consistently lazy to the point where he may be compromising patient care. The nurses and ward cover at handover have commented on this. What  should   you do? ANSWER: BEG This question is also about teamwork and knowing how to handle a struggling colleague. B.  Asking Jack whether he feels he is struggling  is appropriate,  as you should  find out whether  your  colleague  feels  there  is a  problem.   You  can then  engage  in a conversation  as to whether  Jack  has insight  into his behaviour,  whether  he feels  he is strug-gling,  or whether  he is just attempting  to get out of his share  of the work. E.  Recommending the nurse in charge has a quiet word  is  as appropriate.   Given  that  the nurses  have  commented  on   Jack's  behaviour,  it would  be appropriate  for them  to intervene.   Working  as part  of a multi-disciplinary  team,  the nurse  in  charge  should  feel they  have  authority  to speak  to an FY1  if  they  are concerned  about  their  behaviour. G.  Informing your consultant that Jack is struggling  is appro-priate.   Whilst  it is courteous  to share  this information  with  your  colleague  before  your  consultant,  the question  suggests  that  patient  care  is being  compromised.   Hence,  your  consultant  needs  to be informed  of the situation.   Moreover,  given  a few  members  of the team  have  commented,  it is right  to escalate  this further.   If you did nothing,  you would  be letting  down  your  colleagues,  Jack  and the patients  under  his care. C.  Telling Jack that he is not doing his share of the workload   is not as appropriate.   Highlighting  your  awareness  of the situ-ation  to your  colleague  may  produce  very  little  gain  in terms  of resolving  the problem.   Moreover,  it may  be better  that this  information  comes  from  the nurse  in charge  who  has expressed  a concern. H.  Telling Jack you will speak to your educational supervisor if things don't change  is not a preferred  option  as your  educa-tional  supervisor  is only  in a position  to give  you advice  and,  unless  they  happen  to be Jack's  educational  supervisor  too,  cannot  help  him  in the same  way  that  his own  educational  supervisor  should. A.  Offering to take on some of Jack' s workload  is not appropri-ate.  This  would  increase  pressure  on you,  in an already  busy  situation.   Moreover,  this is not addressing  the real issue.   You  could  always  help  them  out if you have  finished  your  jobs,  but,  ideally,  they  need  to seek  help  from  their  educational  supervisor  if they  cannot  cope. D.  Informing the foundation programme clinical lead  is not  appropriate,  as there  are more  suitable  reporting  channels. F.  Asking the nurses to fill in a CAE form  is not appropriate,  as you should  speak  Jack before  filling  in a CAE  form  regard-ing his conduct.  This would  also be escalated  outside  the team  and Jack would  be referred  to see the foundation  programme  clinical  lead.  There  is no indication  in the question  of one  specific  incident  compromising  care that would  require  filling  in this form.

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84  Answers45.  You send a medical student to take some bloods; for which they are trained. You check the results at 3 p. m. and realise that the samples are all coagulated. What  should  you do? ANSWER: AEG This question is about teaching medical students to take responsibility for their own actions and own up to mistakes. A.  Retaking the bloods  is appropriate,  as the patient  comes  first,  and the mistake  must  be corrected. E.  Supervising the student when taking bloods next time  is  appropriate,  as the question  indicates  an issue  with  the samples  taken.   It would  be helpful  for you to go with  the student  to  ensure  they  are doing  the job correctly  and to give  them  practi-cal advice.   You  can also  take  this opportunity  to discuss  with  them  the difficulties  associated  with  venepuncture. G.  Suggesting the student reflects on this incident in their port-folio is appropriate.  Reflecting  means  the student  can learn  about  the consequences  of not checking  what they have done is right,  and the implications  for the patient.  This will be an important  learning  point  for the student  which  they should  not ignore. C.  Pointing out the mistake to the student  is not a preferred  option.   Although  you are responsible  for teaching  and learning,  it would  be better  to supervise  them  where  a problem  has  occurred  rather  than  highlighting  the error  and moving  on. F.  Telling the student to bring the sample to you next time  is also  not a top selection,  as it would  be better  to supervise  the student  rather  than just checking  that the bloods  are OK before  sending  them  to the laboratory.  It is good  practice  to check  them  regardless - especially  if it is for something  like a blood  transfusion. B.  Reporting the student to your consultant  is not appropriate,  as  this puts the student  in an awkward  position  and you don't  want  to scare  them  away  from attempting  venepuncture  ever again. D.  Ignoring their mistake is not appropriate, as the student  will  not learn  if it is ignored. H.  Telling the student to get some more clinical skills training before they go onto the wards  is not appropriate,  as the best  practice  involves  real patients.   They  have  already  been  trained  in venepuncture  and telling  them  to go back  to square  one will  dent  their  confidence  further.   You should  be supportive  towards  students  to most  effectively  enable  their  learning. 46.  You are working in a GP's surgery. A patient comes in to see you with symptoms of angina at rest. It says on the system that the GP told them last time not to drive. You ask them whether they have been driving, and they tell you they have: they drove to the surgery today. What  should  you do? ANSWER: ECG This question tests your knowledge of effective communica-tion concerning patient guidance. See Chapter  2 for more information on the DVLA. E.  Asking if they remember the GP advising them not to drive   is appropriate,  as you should  reiterate  that you know  they  have been  given  this information  already.   This  is more  polite  than  option  F. C.  Advising them to stop driving until their symptoms are under control  is appropriate,  as you should  relay  the advice  they have  already  received  about  not driving  with symptoms  of angina. G.  Consulting the GP for advice  is appropriate.   Although  you  should  be aware  of the guidance  and can give  patient  the appro-priate  advice  (C), this is a tricky  situation  and you should  seek  senior  help  on how  to proceed. D.  Finding out whether someone can drive them home  is not  a preferred  option  as you should  find out from  the GP how  best  to proceed  with  getting  the patient  home.   This  would,  however,  establish  whether  someone  could  come  and collect  them  to  drive  them  home. A.  Reporting them to the DVLA  is not appropriate,  as you  should  not inform  the DVLA  without  the patient's  consent.   Also,  it is the patient's  responsibility  to do this,  if necessary. B.  Advising them to inform the DVLA  is not appropriate,  as it  may  be that the patient  misinterpreted  the advice  given  by the  GP.  Also,  the DVLA  guidance  suggests  that driving  must  cease  until  symptoms  are under  control  but they  need  not be notified  for angina. F.  Reminding them that last time the GP asked them not to drive  is not a preferred  option  as it is more  aggressive  than  E  and the patient  may  have  forgotten  they  were  asked  not to drive. H.  Asking them to hand over their keys  is not appropriate,  as,  once their symptoms  are adequately  controlled,  they should  be  allowed  to drive.  It would  be advisable  for someone  to pick them  up, but if you are so worried  you have to confiscate  their keys - they probably  should  be going  to hospital  rather  than home. 47.  Your consultant on a ward round orders a spine MRI and asks you to put in the request. You overhear the regis-trar saying to another colleague that it is not indicated. What  should  you do? ANSWER: BEF This question is about managing conflicts within a team and maintaining harmony whilst making sure the more appro-priate action is taken. B.  Asking the consultant the reasons for ordering the MRI  is  appropriate,  as this could  simply  be an opportunity  for learning  about  indications  for a particular  scan.   Moreover,  you should  be putting  this on the request  form. E.  Asking the registrar why they think the MRI is not indicated   is appropriate,  as this would  be an opportunity  for conflict  reso-lution.   If you find  out the reasons  that the registrar  disagrees  with  the indication,  you can explain  clearly  why  the consultant  ordered  the MRI. F.  Ringing the radiologist to discuss the MRI request  is appro-priate.   Radiologists  are busy,  but they  would  appreciate  you  politely  ringing  to discuss  an MRI  request.   Moreover,  you can  include  any indications  you discuss  on the form  which  will help 

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

Answers   85the radiographer  select  the best  images.   The radiologist  could  also  raise  concerns  if they  felt that the scan  wasn't  indicated,  in which  case  you could  relay  that information  back  to your  consultant. A.  Ordering the MRI as the consultant has requested  is not  appropriate.   Although  you should  never  undermine  your  con-sultant,  you  cannot  ignore  the comments  of your  registrar.   Patient  care  should  come  before  disagreements,  and patients  should  only  have  scans  when  indicated. C.  Ignoring the consultant and following your registrar  is  rarely  appropriate,  if ever.   You should  not ignore  your  consult-ant or go against  their  decision  without  their  knowledge.   In the  event  there  was  a change  to their  management  plan  and they  could  not be contacted,  you would  have  to document  every-thing  in the notes  including  the arguments  on both  sides  and  why  the final  decision  was  made.   Under  no circumstances  should  you deliberately  undermine  your  consultant. D.  Telling the consultant that the registrar does not think the MRI is indicated  is not appropriate,  as you have  a duty  not to  create  conflict  within  your  team. H.  Documenting in the notes that the MRI was ordered but that the registrar disagreed  is not a preferred  option.   Ideally  you  should  not document  disagreements  within  the team  in the  notes - unless  they  are directly  relevant  to patient  safety. 48.  You are working as an FY1 as part of the medical on-call team. A patient with type I diabetes came in with dia-betic ketoacidosis (DKA), but is improving having been on a sliding-scale. The consultant prescribes short-acting insulin. The patient disagrees with this and asks that he be put back onto his regular insulin regimen of long-acting insulin. What  should  you do? ANSWER: AGB This question is about advocating for your patient and uti-lising expert knowledge within your team. A.  Asking the specialist diabetic nurse for advice  is appropri-ate, as they  have  a wealth  of knowledge  regarding  the prescrib-ing of insulin  and,  if needs  be, can act as another  advocate  for  the patient  using  their  expertise. G.  Asking the patient why they don't want to have short-acting insulin  is appropriate,  as you  want  to find  out the patient's  wishes  before  you  can  discuss  them  with  the senior  in   charge. B.  Calling the consultant to relay the patient' s disapproval of their regimen  is also appropriate,  as you must - at all times - be  an advocate  for your  patient  and meet  their  wishes  as far as  possible.   If a patient  is unhappy  with  their  care,  you have  a duty  to let your  consultant  know  about  it - tactfully! C.  Prescribing long-acting insulin  D Telling the patient they are on the right insulin  and H Ignoring the patient' s request   are not appropriate,  as these  options  all ignore  the patient's  wishes  and their  rights  to be involved  in treatment. E.  Telling the patient they will have to discuss the option with the consultant  is not appropriate,  as this postpones  the issue  and it is your  job to broach  the subject  with  the consultant,  not  theirs. F.  Writing both up on the drug chart to be delivered  is not  appropriate,  as this leaves  potential  for a prescribing  error  if   it is not clear  which  insulin  should  be delivered  to the patient  and when. 49.  A 69-year-old man is brought into A&E with symptoms later confirmed as an ischaemic stroke. Your specialist reg-istrar reviews him in A&E and writes up his prescription on a drug chart. The patient reaches you on the stroke ward one hour later with his notes and a different drug chart. Clopidogrel is written up STAT but not given. The prescrip-tion written is not the one that your registrar wrote. What   should  you do? ANSWER: BCG This is about recognising the potential for a prescribing error which could potentially harm the patient. Remember not to PANIC when prescribing: Prescription, Allergy, Notes, Interactions, Clear. This error involves the prescrip-tion, i. e. ensuring that only one dose of the medication is given (where 85% of errors occur), and the notes i. e. two drug charts. See Chapter  3 for more details. B.  Bleeping your registrar  is appropriate,  as you need  to find  out what  happened  to the other  drug  chart  and whether  the  patient  has received  their  Clopidogrel. C.  Taking the chart down to A&E whilst looking for the other one is appropriate,  as you can ask the nurses  where  this patient  was and whether  they  know  anything  about  the prescription  as  well  as having  a look  for the drug  chart.   This  should  quickly  resolve  the situation  and,  as a matter  of urgency,  should  be your  responsibility. G.  Delaying giving the Clopidogrel until the other chart is found  is appropriate.   Although  nearly  all patients  receive  anti-coagulation  in hospital  for deep  vein  thrombosis  (DVT)  proph-ylaxis,  you would  not want  to put them  at risk of an intracranial  bleed  by titrating  them  outside  of the therapeutic  range.   Given  this patient  has had an ischaemic  stroke,  this situation  does  need  to be resolved  promptly,  but delaying  is the safer  option. A.  Ringing the pharmacy to ask for advice  is not appropriate.   It is unlikely  that pharmacy  will be able to give  you any indica-tion of whether  the patient  has received  the Clopidogrel  or not.   They  can provide  advice  on the correct  protocol - but these  options  are available.   This  question  tests  your  knowledge  of  safe  practice. D.  Asking the patient whether they have been given the Clopi-dogrel  is not appropriate,  as the patient  may  not have  an idea  of what  they  have  been  given  and you  could  be given  false  information.   It is best to rely on the facts - which  means  finding  both  charts.

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf

86  Answers E.  Giving the Clopidogrel  and F Giving half the dose of Clopi-dogrel  are not appropriate,  as they  both  put the patient  at risk  of bleeding.   Medication  should  not be changed  or given  without  having  all the accurate  and relevant  information. H.  Telling the nurses not to give Clopidogrel to the patient  is  not a preferred  option.   Although  communication  is key to pre-venting  errors,  the nurses  would  not give  the prescription  without  seeing  the chart  (nor  if you crossed  it out).   If you take  the chart  down  with  you to A&E,  this will prevent  the patient  receiving  the medication. 50.  You are working on a busy cardiology ward. Your col-league is on call and asks you to hold their bleep for them whilst they go and get some lunch. What  should  you do? ANSWER: CEF This question is about trying to help out your colleague but recognising that it is not appropriate to pass over your bleep. C.  Politely declining because you have your own patients  is  appropriate,  as you should  not take  someone  else's  bleep  when  you  are not on-call.   You  have  a responsibility  for your  own  patients  and they  have  to be your  priority.   Taking  on another  workload  on an already  busy  ward  is not acceptable. E.  Seeing if they have any outstanding jobs you can help with   is appropriate,  as this is offering  your  colleague  support  so they  can find some  time  to go and get their  lunch.   That  way you stay  on the ward  without  taking  on any new  patients. F.  Offering to get their lunch for them  is appropriate,  as this  will be helping  out your  colleague  by saving  them  time  so they  can take  a shorter  break  to sit down  and eat it. A.  Agreeing to hold their bleep  is not appropriate.   You should  not hold  someone  else's  bleep - unless  under  exceptional  cir-cumstances  such  as breaking  bad news. B.  Offering to go with them for their lunch  is not appropriate.   If you want  to help your colleague  out, you should  stay   on the ward  and go for your own lunch  when  you get an  opportunity. D.  Suggesting they get in touch with someone from the on-call team to hold their bleep  is not appropriate.   You should  not give  your  bleep  to anyone  else.   More  importantly,  if your  colleague  is busy,  the other  members  of the on-call  team  are also  likely  to be busy. G.  Telling them to turn it off whilst they go and get some lunch   is not appropriate.   There  might  be a sick  patient  whom  your  colleague  needs  to attend  to, and therefore  not being  accessible  could  compromise  patient  care. H.  Suggesting they go quickly to get their lunch  is not appro-priate,  as this does  not help  out your  colleague. Beyond this book Try to expand  on your  experiences  with  scenarios.   Box  8. 1  includes  a list of useful  questions  for you to ask your  FY1  col-leagues  whilst  on clinical  placements  as well  as some  tasks  for  you to observe. Finally,  Box 8. 2 is designed  to show  you how you can build  your own examples  on the wards.  Comment  on the area   you feel the situation  most  accurately  highlights  and then  describe  the situation  and why there  was a problem.  You  should  then analyse  how that situation  played  out and con-sider  it against  the best practice  material  that is outlined  in  this book.  At the end of this exercise  you should  reflect  on  your learning  as that way you will cement  the example  well  and truly  for the future! One final  bit of advice  to remember  is, “It is a really  stressful  job at times  but it's really  good  fun” - Nick  FY1. Box 8. 1 Useful Questions Commitment to professionalism:  Where  have you seen confidentiality  being  compromised?  Have  you ever had to challenge  inappropriate  behaviour?  Ask  about  the teaching  available  and find  out how  they  juggle  their  priorities. Coping with pressure:  What  pressures  do you find yourself  under?  Have  you ever  made  a mistake?  What  did you do about  it?  Have  you ever  experienced  a confrontational  situation?  Who  do you turn  to when  you need  help? Effective communication:  Go with  a doctor  to see how  they  negotiate  a scan  for  radiology.  Go with  a doctor  to see a death  certificate/cremation  form  being  filled  in.  Listen  to a referral  and practise  the SBAR  approach. Patient focus:  Observe  times  where  patient  concerns  and views  are inte-grated  into management.  Observe  the options  given  to patients  about  their  treatment.   What  did you  learn  about  their  needs  and were  they  ade-quately  addressed? Team working:  Have  you ever  had difficulties  with  a colleague?  What  were  they?  Offer  assistance  to the juniors  on the ward  and ask them  how  they  prioritise  their  jobs  on a daily  basis.  Speak  to other  healthcare  professionals  about  their  roles  and  responsibilities.

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Answers   87Box 8. 2 Build your own scenario Judgement area : Commitment  to professionalism Situation : Doctor  was needed  on the ward  but also had  teaching  scheduled. Dilemma:  Patient  care  comes  first,  but doctors  are also  responsible  for their  own  learning.   How  urgent  are the   tasks  on the ward?  How  essential  is it that they  attend  the  teaching?  Can  they  rely on their  colleagues  to get the rel-evant  information  for them  if they  cannot  get away? What the doctor did:  Got very  stressed  about  the fact that  they  had to be two places  at once. What the doctor should have done:  Analysed  the dilemma  calmly  and weighed  the positives  and negatives  of going  to  teaching  or not before  acting  on their  decision.   The doctor  decided  to stay on the ward  and asked  a colleague  to make  notes  for them  as otherwise  they  would  be delayed  at work  for too long. Reflection : I learned  that you should  always  try to meet  your  commitment  to attend  teaching,  but that patient  care  comes  first;  hence,  there  may  be times  where  you have  to compro-mise  and sacrifice  your  own  learning.

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88 The Situational Judgement Test at a Glance, First Edition. Frances Varian and Lara Cartwright. © 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd. 9References AMRC (Academy of Medical Royal Colleges) (2010) ST1 Selection Pilot 2010: Project Report. London: UCL. Baille, W. F., Buckman, R. and Lenzi, R. (2000) SPIKES-a six-step protocol for delivering bad news: application to the patient with cancer. The Oncologist, 5(4): 302-311. Belbin, M. R. (2008) The Belbin Guide to Succeeding at Work (2nd ed. ). Cambridge: Belbin Associates. Belbin, M. R. (2010a [1981]) Management Teams. Why They Succeed or Fail (3rd ed. ). Oxford: Butterworth-Heinemann. Belbin, M. R. (2010b [1993]) Team Roles at Work (2nd ed. ). Oxford: Butterworth-Heinemann. BMA (British Medical Association) (2004a) Communication Skills Education for Doctors: An Update. London: BMA. Also available at: http://faculty. ksu. edu. sa/nadalyousefi/ communication%20skills/Communication%20skills. pdf (accessed 7 August 2012). BMA (British Medical Association) (2004b) Safe Handover: Safe Patients. Guidance on Clinical Handover for Clinicians and Managers. London, BMA. Also available at: http://bma. org. uk/-/media/Files/PDFs/Practical%20advice%20at%20 work/Contracts/safe%20handover%20safe%20patients. pdf (accessed 11 August 2012). BMA (British Medical Association) (2011) Using Social Media: Practical and Ethical Guidance for Doctors and Medical Students. Available at: http://www. medschools. ac. uk/Site Collection Documents/social_media_guidance_ may2011. pdf (accessed 11 August 2012). BPS (British Pharmacological Society) (2010) Ten Principles of Good Prescribing. Available at: http://main. bps. ac. uk/ Springboard Web App/userfiles/bps/file/Guidelines/BPSPre-scribing Principles. pdf (accessed 6 August 2012). Covey, S. (2004) The Seven Habits of Highly Effective People (2nd edition). London: Simon and Schuster. Crocker, C., Kapila, R., Carney, A. et al. (2010) Improving Patient Safety: SBAR. University of Nottingham [elearning tool]. Available at: http://www. nottingham. ac. uk/nmp/sonet/ rlos/patientsafety/sbar/ (accessed 6 August 2012). DCA (Department for Constitutional Affairs) (2005) Mental Capacity Act: Code of Practice (section 3. 6). London: The Stationery Office. DH (Department of Health) (2000) An Organisation with a Memory. London: The Stationery Office. DH (Department of Health) (2001), Building a safer NHS for patients. London: The Stationery Office. Department of Health (2010) The Caldicott Guardian Manual 2010. London: Department of Health. Also available at: http://www. dh. gov. uk/en/Publicationsandstatistics/Publications/Publication-s Policy And Guidance/DH_114509 (accessed 11 August 2012). Directgov (2011) Communication Support for Deaf People. Available at: http://www. direct. gov. uk/en/disabledpeople/everydaylifeandaccess/everydayaccess/dg_10037996 (accessed 7 August 2012). Directgov (2012) Disabled people. Available at: http://www. direct. gov. uk/en/Disabled People/index. htm (accessed 7 August 2012). Disability Discrimination Act (DDA) (1995) Disability Dis-crimination Act 1995. London: HMSO. Also available at: http://www. legislation. gov. uk/ukpga/1995/50/contents (accessed 7 August 2012). DVLA (Driver and Vehicle Licensing Agency) (2011) At a Glance Guide to the Current Medical Standards of Fitness to Drive. Swansea: Drivers Medical Group. EHRC (Equality and Human Rights Commission) (2010) Good Medical Practice and Disability Equality. Available at: http://www. equalityhumanrights. com/advice-and-guidance/ before-the-equality-act/guidance-for-service-providers-pre-october-2010/good-medical-practice-and-disability-equal-ity/ (accessed 11 December 2011). GMC (General Medical Council) (2006) The Meaning of Fitness to Practise. Available at http://www. gmc-uk. org/ the_meaning_of_fitness_to_practise. pdf_25416562. pdf (accessed 12 August 2012). GMC (General Medical Council) (2008a) Consent Guidance: Patients and Doctors Making Decisions Together. London: GMC. Also available at: http://www. gmc-uk. org/guidance/ ethical_guidance/consent_guidance_index. asp (accessed 12 August 2012). GMC (General Medical Council) (2008b) Personal Beliefs and Medical Practice: Supplementary Guidance. London: GMC. Also available at: http://www. gmc-uk. org/static/documents/ content/Personal_Beliefs. pdf (accessed 7 August 2012). GMC (General Medical Council) (2008c) Raising Concerns about Patient Safety. Available at: http://www. gmc-uk. org/ static/documents/content/Raising_concerns. pdf (accessed 7 August 2012). GMC (General Medical Council) (2009a) Good Medical Prac-tice. Available at: http://www. gmc-uk. org/guidance/good_ medical_practice. asp (accessed 11 August 2012). GMC (General Medical Council) (2009b) Confidentiality: Reporting Concerns about Patients to the DVLA or the DVA. Available at http://www. gmc-uk. org/Confidentiality_report-ing_concerns_DVLA_2009. pdf_27494214. pdf (accessed 8 August 2012). GMC (General Medical Council) (2009c) Confidentiality: Reporting Gunshot and Knife Wounds. Available at: http:// www. gmc-uk. org/Confidentiality_reporting_gunshot_ wounds_2009. pdf_27493825. pdf (accessed 8 August 2012). GMC (General Medical Council) (2009d) Confidentiality. Avail-able at: http://www. gmc-uk. org/Confidentiality___English_ 0910. pdf_48902982. pdf (accessed 8 August 2012).

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References   89GMC (General Medical Council) (2009e) 0-18 Years Guidance for All Doctors. London: GMC. Also available at: http:// www. gmc-uk. org/guidance/ethical_guidance/children_guid-ance_index. asp (accessed 11 August 2012). GMC (General Medical Council) (2009f) Confidentiality: Dis-closing Information about Serious Communicable Diseases. Available at: http://www. gmc-uk. org/Confidentiality_dis-c l o s i n g _ i n f o _ s e r i o u s _ c o m m u n _ d i s e a s e s _ 2 0 0 9. pdf_27493404. pdf (accessed 12 August 2012). GMC (General Medical Council) (2010) Treatment and Care towards End of Life: Good Practice in Decision-Making. London: GMC. Also available at: http://www. gmc-uk. org/ End_of_life. pdf_32486688. pdf (accessed 12 August 2012). GMC (General Medical Council) (2011a: 28) 0-18 years guid-ance for all doctors. London: GMC. Also available at: http:// www. gmc-uk. org/guidance/ethical_guidance/children_guid-ance_index. asp (accessed 18 August 2012). GMC (General Medical Council) (2011b: para 60) 0-18 years guidance for all doctors. London: GMC. Also available at: http://www. gmc-uk. org/guidance/ethical_guidance/chil-dren_guidance_index. asp (accessed 18 August 2012). GMC (General Medical Council) (2012) Raising and acting on concerns about patient safety. Manchester: GMC. Also available at: http://www. gmc-uk. org/guidance/ethical_guid-ance/raising_concerns. asp (accessed 7 August 2012). Howard, R., Avery, A. J., Slavenburg, S. et al. (2007) Which drugs cause preventable admissions to hospital? A systematic review. British Journal of Clinical Pharmacology 63(2): 136-147. ISFP (Improving Selection to Foundation programme) (2012) website. Available at http://www. isfp. org. uk/Pages/default. aspx [accessed March 2012]. Kurtz, S. M. (1989) Curriculum structuring to enhance com-munication skills development. In M. Stewart and D. Roter (eds), Communication with Medical Patients. Newbury Park, CA: Sage Publications. Lee, S. (2007) Making Decisions: The Independent Mental Capacity Advocate (IMCA) Service. London: Mental Capac-ity Implementation Programme. Lesar, T. S., Briceland, L., and Stein, D. S. (1997) Factors related to errors in medication prescribing. Journal of the American Medical Association 277: 312-317. Maxwell, S. and Walley, T. (2003) Teaching safe and effective prescribing in UK medical schools: a core curriculum for tomorrow's doctors. British Journal of Clinical Pharmacol-ogy 55(6): 496-503. Myers and Briggs Foundation (n. d. ) MBTI Basics. Available at: http://www. myersbriggs. org/my-mbti-personality-type/ mbti-basics/ (accessed 6 August 2012). MCA (Mental Capacity Act) (2005) Act of Parliament UK ; avail-able from: http://www. legislation. gov. uk/ukpga/2005/9/contents. Mc Crae, R. R., Terracciano, A. et al. (2005). Universal features of personality traits from the observer's perspective: data from 50 different cultures. Journal of Personality and Social Psychology ; 88: 547-561. MHRA (Medicines and Healthcare products Regulatory Agency) (2012) MHRA website. Available at: http://www. mhra. gov. uk/#page=Dynamic List Medicines (accessed 9 August 2012). MPS (Medical Protection Society) (2010) GP Trainee: Confi-dentiality. Available at: http://www. medicalprotection. org/ D e f a u l t. a s p x ? D N = 0 d 6 7 6 4 4 8-3 1 6 d-4 6 d 7-b 1 c 3-ac34b3ff4c8a (accessed 9 August 2012). MPS (Medical Protection Society) (2011) Avoiding Easy Mistakes: Five Medicolegal Hazards for Interns and SHOs. London: MPS. Also available at: http://www. medicalprotection. org/ireland/ booklets/medicolegal-hazards (accessed 9 August 2012). Ministry of Ethics (2010) Consent and Confidentiality. Available at: http://ministryofethics. co. uk/index. php?p=6 (accessed 8 August 2012). Ministry of Justice (2012) The Cremation (England and Wales) Regulations 2008: Guidance to Medical Practitioners Com-pleting Forms Cremation 4 and 5. [pdf] NICE (2011) Caesarean Section. London: NICE. Also available at: http://guidance. nice. org. uk/cg132 (accessed 12 August 2012). ODI (Office for Disability Issues) (2010) Equality Act: Guid-ance on Matters to be Taken into Account in Determining Questions Relating to the Definition of Disability (A1. A3. C1). London: ODI. ONS (The Office of National Statistics) (2010) Guidance for Doctors Completing Medical Certificates or Cause of Death in England and Wales. Available at: http://www. kentlmc. org/ kentlmc/website10. nsf/0/61a64422c4e7aa1b80257a38003f6b f1/$FILE/medcert_July_2010. pdf (accessed 7 August 2012). PALS (Patient Advice and Liaison Service) (2009) What is PALS? Available at: http://www. pals. nhs. uk/cms Content View. aspx?Item ID=932 (accessed 7 August 2012). Patel, V. and Morrissey, J. (2011) Practical and Professional Clinical Skills. Oxford: Oxford University Press. Patterson, F., Archer, V., Kerrin, M. et al. (2010) Appendix D: FY1 Job Analysis. In Medical Schools Council, Improving Selection to Foundation Programme Final Report. Work Psychology Group and University of Cambridge, pp 126-240. Available at: http://www. medschools. ac. uk/Site Collec-tion Documents/Final%20Report%20of%20ISFP%20 Project%20Group. pdf (accessed 7 August 2012). Phelan, M. and Parkman, S. (1995) How to work with an inter-preter. British Medical Journal 311: 555-557. Rosen, S. and Tesser, A. (1970). On reluctance to communicate undesirable information: the MUM effect. Sociometry 33(3): 253-263. RCS (The Royal College of Surgeons of England) (2007) Safe Handover: Guidance from the Working Time Directive working party. Available at: http://www. rcseng. ac. uk/publi-cations/docs/publication. 2007-05-14. 3777986999/ (accessed 12 August 2012). Scottish Government (2009) Guidance for Medical Staff Com-pleting Medical Certificates of the Cause of Death. Available at: http://www. sehd. scot. nhs. uk/cmo/CMO(2009)10. pdf (accessed 12 August 2012).

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90 The Situational Judgement Test at a Glance, First Edition. Frances Varian and Lara Cartwright. © 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd. Index abortion, under eighteens 18 adolescents see under eighteens bad news, breaking 40-1 Belbin's Team Roles 48-9 “Big Five” personality traits 11-13 birth plan 59, 60, 73, 75 bleeps 31-2, 60, 65, 76, 86 blood forms 35 breaking bad news 40-1 Caesarean section (CS) 59, 60, 73, 75 capacity confidentiality issues 45, 63, 82-3 to give consent 45, 59, 71-2 to refuse treatment 45, 61, 78 career development 28-9, 59, 72 child protection 18-20, 24-5, 57, 68-9 parental rights and 62, 80-1 clinical coding 35 communicable diseases, confidentiality issue 60, 74-5 communication 12, 33-41, 60, 75, 81 barriers 33, 36-8, 58, 69-70 breaking bad news 40-1 disability 37-8, 60, 74 patient guidance 64, 84 principles 33-4 verbal 36-41 with difficult patients 46-7 with relatives 39-40, 58, 62, 63, 69, 78-9, 82-3 working with interpreters 36, 58, 69-70 written 34-6 confidentiality 15, 57, 59, 67, 73-4 breach of 15 capacity and 45, 63, 82-3 communicable disease issue 60, 74-5 criminal behaviour and 16-18 fitness to drive 15-16 parental rights and 62, 80-1 under eighteens 18, 20, 57, 67 conflicts 53-4, 63, 64, 83, 84-5 consent issues 26-7, 63, 82 capacity to consent 45, 59, 71-2 emergency situations 27, 59, 71-2 refusal to consent to treatment 45, 56, 61, 62, 66, 78, 80 consultant 52 contraception, under eighteens 18 cremation forms 36 crimes 16-18, 57, 67-8 dangerous practice concerns 43-4, 58, 69 see also mistakes death certificates 35-6difficult patients 46-7, 59, 60, 72, 74 communication with 46-7 disability, communication and 37-8 DNAR (Do Not Attempt Resuscitation) decisions 39, 46 documentation 34-5 domestic violence 17-18, 57, 66-7 driving, fitness for 15-16, 64, 84 DVLA notification 15-16, 64, 84 emergency situations 58, 62, 70-1, 79-80 consent issues 27, 45, 59, 71-2 end of life care 45-6, 58, 58-9, 69, 71 DNAR (Do Not Attempt Resuscitation) decisions 46 Fitness to Practise (FTP) issues 44 foundation school 54-5 gifts from patients 56-7, 66 handovers 50-1 hospital policy 58, 70 implied consent 26-7 important/urgent grid 29, 30 see also prioritisation integrity 14, 70 interpreters 36, 58, 69-70 Jehovah's Witnesses 44, 56, 62-3, 66, 81 Kohner Medical Record (KMR) 35 language barriers 36, 58, 69-70 see also communication learning 28-9 on the job 28, 68 procedural 29 mental impairment, communication issues 38, 60, 74 minors see under eighteens mistakes dealing with 20, 61, 64, 76-7, 84 prescribing 25-6, 64, 85-6 see also dangerous practice concerns needle stick injury 61, 77 nursing team 51-2 patient advocacy 51 organisation 22 see also prioritisation parental rights 62, 80-1 patient discharge 23-5 self-discharge 24-5patient focus 12, 42-7, 73 difficult patients 46-7, 59, 60, 72, 74 end of life care 45-6, 58, 58-9, 69, 71 patient advocacy 42-4, 51, 64, 85 respecting personal beliefs 44, 56, 62-3, 66, 81 patient safety concerns 43-4, 57, 58, 66-7, 69, 70-1 parental rights and 62, 80-1 prescribing 25-6, 58, 60, 64, 70, 75-6, 85-6 see also child protection personal beliefs, respect for 44, 56, 62-3, 66, 81 personality 11-13 police, dealing with 17 see also crimes pregnancy birth plan 59, 60, 73, 75 confidentiality issues 57, 59, 67, 73-4 under eighteens 57, 67 prescribing 25-6, 58, 60, 64, 70, 75-6, 85-6 pressures 12, 22, 60-1, 75-6 prioritisation 12, 29-31, 59, 60-1, 72-3, 75-6 probity 22 professional conflicts 53-4, 63, 64, 83, 84-5 professionalism 11, 14-21, 61, 77 radiology department 52-3 record-keeping 34-5 refusal to consent to treatment 45, 56, 61, 62, 66, 78, 80 capacity issues 45, 61, 78 respect for personal beliefs 44, 56, 62-3, 66, 81 relatives, communication with 39-40, 58, 62, 63, 69, 78-9, 82-3 reporting concerns 43-4, 57, 58, 66-7, 69 safety issues see child protection; patient safety concerns SBAR (Situation, Background, Assessment, Recommendation) approach 53 scans, negotiating 52-3 self-discharge 24-5 sexual activity, under eighteens 18, 57, 67 social networking 14, 61, 77 social services, dealing with 19-20, 57, 68-9 stick injury 61, 77 support 54, 61, 77-8 teamwork 13, 48-55, 63-4, 83 handovers 50-1 pitfalls 50

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Index   91professional conflicts 53-4, 63, 64, 83, 84-5 seeking support 54 team roles 48-53 training 28 see also learningunder eighteens 18-20, 57, 61, 67, 68, 78 child protection issues 18-20, 24-5, 57, 68-9 confidentiality issues 18, 20, 57, 67 pregnancy 57, 67verbal communication 36-41 ward rounds 22-3 written communication 34-6 written consent 27

At a Glance Varian - Situational Judgement Test at At a Glance-John Wiley Sons 2013.pdf