We will review two clinical scenario interview sample simulations. One has gone well, and the other has gone sideways. This is meant to help you reflect on your own interview approach, identify what to keep doing, what to avoid and what to improve for your ST3 interview.
Vascular Surgery Clinical Scenario – Interview gone wrong:
Scenario:
You are the ST3 on call, covering the dialysis unit. You are called by the duty nurse to review a 56-year-old male patient with a 1-week history of difficult dialysis access and bleeding at the puncture site. His past medical history includes ischemic heart disease and type 2 diabetes. He has a left AV PTFE dialysis graft. His current medications include Metformin, Bisoprolol, and a statin. He does not smoke or drink alcohol. On examination, his pulse is 62 bpm, and his blood pressure is normal. He has a left brachial to axillary PTFE graft with necrotic skin and a hematoma. His blood tests show a hemoglobin level of 92, white cell count of 18, creatinine of 653, urea of 12, potassium of 5.8, and sodium of 138.
| Blood Test | Result |
| FHG | Hb: 92 g/L, WBC: 18 x10^9/L, Platelets: 200 x10^9/L |
| UEC | Urea: 12 mmol/L, Creatinine: 653 µmol/L, Sodium: 138 mmol/L, Potassium: 5.8 mmol/L |
| LFTs | AST: 45 U/L, ALT: 50 U/L, ALP: 100 U/L, Bilirubin: 15 µmol/L |
| Coagulation | INR: 1.1, aPTT: 32 seconds |
| Observations | |
| Pulse | 62 bpm |
| Blood Pressure | 110/72 mmHg |
| Temperature | 37.0°C |
| Respiratory Rate | 16 breaths/min |
| O2 Saturation | 98% on room air |
Response:
Panellist:
Hi JW(Candidate),
Welcome to your interview. I’m going to ask the panel members to introduce themselves first, and then you can introduce yourself right after. I’ll let you know when to start.
OK. Hi JW, I’m FP. Hi JW, I’m GH.
Hi JW, I’m KJ. Pleasure to meet you.
Could you start, please?
Candidate:
OK. Thank you for this interview. In this clinical scenario, we have a complex situation.
We have a patient who has a clinical issue: they are 56 years old, known to have ischemic heart disease and type 2 diabetes and as well, they have a dialysis graft, which seems to be having complications. It seems to be having a sepsis infection. Also, the patient is anaemic and has necrosis of the skin as well.
They could be having a steal syndrome. They could be having a failure of the dialysis graft. So in this situation as well, we have management issues because we’ll need to have early involvement of the vascular consultant as well as a nephrologist and take a multidisciplinary approach to diagnosis and management of the patient presenting.
The initial thing I’d like to do with this patient is to ensure that my patient is stable, resuscitate the patient appropriately, and take history and investigate the patient to be able to have a definitive diagnosis and management.
So from my initial assessment, I’d like to see whether my patient is stable and if they’re not stable, approach them according to a CCRISP approach in an A to E approach. For the main issue that patient is having as well, I’d like to gather some more information. I’d like to find out about his history of ischemic changes to the limb, skin colour changes, if he has any systematic symptoms of fever and if he has any changes in terms of sensory or motor changes to the limb.
As well, I’d like to find out if there’s any history of trauma, any history as well of past discharge. I’d like to understand his compliance to treatment for diabetes and ischemic heart disease. As well, I’d like to get a bit more of the patient’s vitals because we had a pulse rate.
I’d like to find out the patient’s temperature. I’d like to as well do an adequate physical examination by examining both upper limbs, checking for skin colour changes, checking for the ulcer or the necrotic skin, the borders of the skin, checking to see as well if there’s any pulse. Checking for both motor and sensory function, as well as checking for the pulses from distal to proximal, and as well comparing with the alternate limb and comparing the blood pressures on both limbs.
In terms of additional investigations that I’d like to have; the patient’s creatinine is elevated. I’d like to understand his baseline. I’d like to also understand his eGFR baseline. He has some slightly elevated potassium. I’d like to get his CRP as well, which was not given. I’d like to get his coagulation profile, his blood sugars as well.
Panellist:
So I can fill you in on a little bit of information. He’s got no sensorimotor deficit in the arm. It’s well vascularized.
He’s apyrexial. The rest of the clinical findings are, as described, the nursing staff aren’t keen to do a blood pressure on the affected arm.
You mentioned investigations. How would you investigate in terms of imaging, so on and so forth?
Candidate:
Okay. I’d like to get a duplex scan, ultrasound scan.
Panellist (interrupts):
Okay.
So you talked to your consultant, as you recommended earlier, and your consultant asked for a CT scan. The CT scan confirms a pseudoaneurysm near the area of skin breakdown. The remainder of the PTFE graft looks healthy with no radiological evidence of infection.
So how would you like to proceed from this point onwards?
Candidate:
Okay. The patient has a pseudoaneurysm. This is at risk of rupture as well.
The patient as well has sepsis with white cell count was elevated at 18. So I’d like to start the patient on antibiotics to begin with, take some blood for blood culture. As well, I’d like to discuss microbiology for the cultures.
I’d want to discuss with my consultant as well because this patient might have risk of rupture and will need repair in theatre. So we’d need to have an anaesthetic review. I’ll need to call and discuss with the CEPOD theatre coordinator as well as discuss with the patient and consent them for surgery.
Panellist (interrupts):
Okay. And what are you going to consent them for?
Candidate:
Okay. So I’m consenting them for exploration and possible ligation of the graft or the aneurysm.
Panellist:
Okay. And if you’re consenting them and telling about this operation, what do you think the likely outcome is going to be?
Candidate:
Okay. So we have some risks.
There is a risk of ischemia in the limb, in which case this may lead to need for amputation in worst-case scenario. As well, they will need to have a revision or another graft done in the other limb for long-term management of their dialysis.
Panellist (interrupts):
Okay, getting to that, what are your thoughts on the short-term management of their dialysis?
Candidate:
So, on the short-term management of their dialysis, they may need to have alternative options for dialysis access, so we’ll need to discuss with their nephrology consultant as well for alternative options. They could essentially still have peripheral lines in the alternate limb.
Panellist (interrupts):
Okay, and how else would you prepare the patient for theatre who’s at risk of bleeding?
Candidate:
Okay, so I’d like to group and save, check their coagulation profile, if there are derangements, I’d like to discuss this with the hematologist.
I want to, as well, ensure that the patient is adequately resuscitated, has IV fluids, and has IV access, considering we won’t have IV access in that limb due to the pseudoaneurysm, we’ll need to have alternative IV access, we’ll need central line access, possibly this could be, as well, one of the alternatives that you may need for dialysis. We’ll need to discuss with ITU in case the patient needs to be stepped up.
Panellist (interrupts):
So bearing in mind you’ve said this patient has a likely infected pseudoaneurysm of a prosthetic graft, what is the likely definitive operation that you’ll do for them, and are there any alternatives?
Candidate:
Okay, so because of the infection, the graft has a high risk of infection as well, so the graft will need to be removed, and they’ll need to have the pseudoaneurysm…. , it’s going to be, you’ll debride the skin as well because the skin was infected, and the patient will need to have some long-term wound care, as well as antibiotic management, and the pseudoaneurysm itself may need to have to be ligated.
Panellist (interrupts):
Thank you, you’ve, communication-wise, you’ve spoken to your, to the vascular consultants and a number of other professionals, who else would you communicate with in this?
Candidate:
Okay, so the patient is diabetic, I’d need to communicate to the diabetes consultant, I mentioned need to communicate with the patient’s next of kin as well, for full consenting, we’ll need to as well communicate with theatre, hematology, nephrology.
Panellist (interrupts):
Sorry to interrupt, we’ll have to move on to the next section.
Candidate:
Thank you.
Score:
| Clinical Scenario | Score out of 5 |
| Recognition of the clinical issues | 3 |
| Judgement and Prioritisation | 2 |
| Planning and use of investigations and/or resources | 3 |
| Communication strategy | 3 |
| Aggregate score: | 55% |
| Panellist comments: 1. Initial resuscitation and recognition of comorbidities and risks were appropriate. 2. Recognized the problem of an infected graft and the associated risk of bleeding. 3. Started well but lost focus, leading to an illogical order in management steps. 4. Initial plan for repair was vague and had to be adjusted after prompting. 5. Operative plan was not clear, though the candidate understood the necessity of removing the graft. 6. Required significant prompting throughout the interview. 7. Displayed limited knowledge of various management options, indicating a need for further study and preparation. | |
Detailed Feedback and Learning Points:
1. Recognition of Clinical Issues
Strengths:
- The candidate identified several critical aspects of the patient’s condition, including the infected dialysis graft, necrotic skin, and elevated white cell count suggesting infection.
- Recognized the patient’s comorbidities, such as ischemic heart disease and diabetes, which are relevant to the management plan.
Weaknesses:
- The candidate missed some critical nuances in the initial scenario, such as the specifics of the patient’s hemodynamic stability and the exact implications of the elevated creatinine and potassium levels.
- Initial recognition of potential sepsis was correct but lacked depth in terms of discussing the differential diagnoses.
2. Judgement and Prioritisation
Strengths:
- The candidate demonstrated an understanding of the need for a multidisciplinary approach and the importance of consulting vascular and nephrology specialists early in the process.
- Attempted to use a structured approach (A to E) for initial assessment and stabilization.
Weaknesses:
- The approach to management was unfocused and somewhat disorganized, which led to an illogical order of prioritization.
- The candidate needed prompting to identify the most immediate and critical steps, indicating a lack of confidence or knowledge in prioritizing tasks.
3. Planning and Use of Investigations and/or Resources
Strengths:
- Recognized the need for additional investigations, such as duplex ultrasound and blood cultures.
Weaknesses:
- Identified the necessity of a CT scan only after the consultant suggested it.
- The candidate’s initial plan for repair was not clear and had to be adjusted after prompting.
- Limited knowledge of the various management options available, including specifics of operative procedures.
- Suggested investigations were appropriate but lacked a clear plan for how these would directly influence the management steps.
4. Communication Strategy
Strengths:
- Communicated the need for involving multiple specialists, including vascular surgery, nephrology, and hematology.
- Recognized the importance of discussing with the patient and obtaining informed consent.
Weaknesses:
- Communication with the panel was often interrupted, indicating either an inability to clearly articulate the plan or reliance on the interviewers to guide the discussion.
- Failed to communicate a clear and comprehensive plan for the patient’s short-term and long-term management effectively.
5. General Interview Technique
Strengths:
- Demonstrated polite and professional communication with the interview panel.
- Attempted to use structured approaches (e.g., CCRISP, A to E) in discussing the patient’s management.
Weaknesses:
- The candidate appeared nervous and lacked confidence, leading to significant prompting by the panel.
- The responses were often unfocused and lacked logical flow, which affected the overall impression of their clinical reasoning skills.
- Failed to adequately address some of the panel’s specific questions and sometimes provided incomplete answers.
This review of a failed ST3 clinical scenario interview provides realistic insights into the common pitfalls candidates may encounter. By analysing a scenario where the interview went wrong, you can reflect on your own approach, identify areas for improvement and hone your skills for future interviews. Use this example to practice and refine your strategies to ensure you are well-prepared and confident for your ST3 interview. Next, we will review an exemplar clinical interview scenario. This will provide a comprehensive perspective on best practices and effective interview techniques.