Pass ST3 Interview Clinical Management Station: Realistic Examples to Learn from… Part 2

We will review two clinical management 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 Management Scenario – Interview done well:

Scenario:

You are the ST3 covering vascular surgery Friday evening. You have 6 months of vascular experience and are waiting for a below-knee amputation. The nurse informs you that the FY1 requested CT Angio for the wrong patient with an eGFR 23. They are in the Doctor’s mess, crying and refusing to return to the wards.

A 27-year-old IVDU has a bleeding pseudoaneurysm in the groin, is being abusive to staff, refusing IV access and bloods, refusing to consent to surgery, and requesting for methadone for pain control. However, the pharmacy is closed and there is no methadone in the wards.

You get a bleep from anaesthesia in theatre, the patient with BKA has ischaemic ECG changes, they are not able to anaesthetize, and they have been trying to call the vascular consultant on call, but they are not reachable.

What are the issues, and how will you address them?

Response:

Panellist:

Okay, so have you had a chance to read the management scenario?

Candidate:

Yes, I’ve had a chance to read the management scenario.

Panellist:

Good, and it’s up on screen just now as well. Okay, I’d like you to tell me what are the issues that you can see here?

Candidate:

Okay, so over here we have clinical, management issues, and organisational issues.

The clinical issues are that you have three patients who need clinical prioritisation, there is one patient who’s due for amputation, and they seem to have developed ischemic heart disease or acute cardiac ischemia that will need resuscitation, as well as early involvement of the medical team, ITU and the vascular consultant.

You have another patient who has a pseudoaneurysm that is at risk of rupture and is aggravated. They would need to be counselled, consented, and prepared for theatre.

As well as a third patient who has had a CT Angio, has a low eGFR and is at risk of kidney injury and would need resuscitation in case they have acute deterioration.

In terms of management issues, this is a Friday evening, so you have a shortage of staff, it’s at night, you have a FY1 who is overwhelmed by having made a mistake and needs mental support. Your on-call consultant is unreachable, and you need to find someone who you can escalate to or find alternatives for escalation.

You need to have multidisciplinary team involvement and early communication with the anaesthesia and theatre team as well as other supportive teams.

In terms of training and learning, this is a training and learning situation for the F1 to learn about the mistake that he made and reflect on how this can be prevented in future. For me this is a learning opportunity in terms of management and handling of a busy take.

In terms of clinical priorities, my number one priority in this situation is to handle the patient who is due for amputation and is in theatre. I would discuss with anaesthesia in theatre and inform them that I have another emergency in the ward, and I am coming over to help them with resuscitation, but I’d advise them to also call the medical emergency team as well as ITU for immediate cardiac management of the amputation patient.

As well, I’d like to try and reach out to the vascular consultant on call through the switchboard. I’d ask them to check if there’s an alternative number that they can try and find them.

After that, I want to proceed to the theatre to review that patient and ensure that the patient is adequately resuscitated. The theatre case may need to be delayed or cancelled to a later time until the cardiac arrest is managed, as that would be more detrimental to them. Then, I’d need to go and review the patient with a pseudoaneurysm.

If I have my SHO, I can go together with the SHO to review the patient with a pseudoaneurysm in the wards and try to have a discussion with them, try to find alternatives to their methadone or any medication that may be given. The patient will also need counselling in terms of definitive management for the pseudoaneurysm and also long-term counselling for prevention of this happening. Again, I would need support.

I’d want to call and find out whether my consultant has been located and inform them about the situation in the wards with the overwhelm and the range of patients that we’re having.  

And then lastly, I’d like to review the patient post-CT angiogram, and I have a duty of candour to explain what has happened. But initially, patient safety is a priority, so I’d like to ensure that the patient is stable, has not developed any complications from the CT Angio given their AKI.

But as well, there’s an additional management issue because the patient’s eGFR should be confirmed by all teams, not just the doctor requesting, and should have been confirmed by radiology. So, this is an issue that may need to be escalated, needs to be datixed and investigated to find out what caused the situation.

In terms of the other management issues, I’d like to find my F1 and be able to be empathetic and give them as much support as I can with the mistake that has been made. I’d like to try as well to understand what were the circumstances? Was the F1 overwhelmed? Is it that they’re new and there’s a induction or training issue that they need to learn? Is there a need to escalate and involve their educational supervisor for more support in terms of training?

As well, I’d like to use this as an opportunity to see whether this type of situation, overwhelm, and medical errors are happening with other F1s or other members of the team so that we can organize an audit. I’d probably involve other junior members together to do an audit, and that would also be helpful in the F1 understanding that the error that they made might be an error in the system and they’re not the only ones involved. It might help coming up with a quality improvement project as well to improve this for the entire department. I’ll be able to support the efforts, ensure that this issue is also discussed in the clinical governance meeting.

Lastly, with regards to my consultant, I’d like to as well, once my consultant has been located, do a debrief with my consultant and explain the challenges that were there during the take, review the priorities and the cases that need to be operated and use this as an opportunity to reflect and see what can be done to improve.

Panellist:

In terms of when a CT scan is arranged for the wrong patient, how would you describe that type of occurrence?

Candidate:

Yeah, so this is a never event, so this should not happen at all.

I think it’s one of those Swiss cheese model types of errors where an error has occurred in the ward. It’s been repeated again in radiology, so it’s a system failure. This would need to be datixed. There is duty of candour to explain to the patient what happened and as well as give the patient support in case they want to report this through PALS.

Panellist (interrupts):

And there’s one more thing that needs to be done as well because obviously the CT scan was arranged for the wrong patients.

Candidate:

Yes, so there’s a CT angio that needs to be done for the correct patient. So this needs to be organized, you need to discuss with radiology as well to arrange for the CT.

Panellist:

Okay, and out of all these scenarios, what outcomes would you hope for?

Candidate:

Okay, so the outcomes I’m hoping for are to prevent a ruptured pseudo aneurysm for the 27-year-old IV drug user and to support the nursing team and prevent any aggression or harm to anyone in the ward.

I’d like to ensure that the patient set for below-knee amputation is stable enough to undergo the amputation and has been adequately resuscitated and managed for their cardiac disease.

And lastly, I’d like to ensure that there’s consultant involvement and knowledge of all the issues and situations that have happened during this take.

Panellist:

Okay, anything else you want to add before we move on to the next scenario?

Candidate:

I think it’s a complex organizational situation, so ensuring that I also have received support and I’ve been able to reflect on this situation would be important for my own learning.

Panellist:

Okay, thank you very much. You can move on to the next scenario now.

Score:

Detailed Feedback and Learning Points:

1. Recognition of the Clinical Issues

Strengths:

• The candidate demonstrated excellent recognition of the primary clinical issues, including the severity and urgency of each patient’s condition.
• The candidate effectively identified the broader systemic and management challenges, such as the time of day (Friday evening), staffing shortages, and the need for multidisciplinary involvement.
• Recognition of the FY1’s emotional state and the potential for this to impact patient care was also well noted.

Weaknesses:

• While all key issues were recognized, the candidate might have benefited from a more structured approach to presenting them. Grouping clinical issues by immediate threat to life versus those that could wait might have made the analysis even clearer.
• The candidate initially missed the issue of organizing the correct CT angiogram, which had to be prompted.

2. Judgement and Prioritisation

Strengths:

• The candidate displayed very strong judgement in prioritizing the patient with ischemic ECG changes in the theatre. This reflects a clear understanding of the immediate risks and the need for rapid intervention.
• The decision to involve the medical emergency team and ITU early on, even while on the way to the theatre, shows good prioritization.
• The candidate also adequately planned to address the pseudoaneurysm next, recognizing the potential for catastrophic bleeding.

Weaknesses:

• While the prioritization was generally strong, the candidate could have articulated a more explicit plan for simultaneously managing the multiple demands. For example, they could have considered delegating tasks to the SHO more explicitly to maximize efficiency.
• The prompt about incident reporting indicates that the candidate’s initial prioritization didn’t include all aspects of the scenario, such as ensuring proper documentation and corrective action for the wrong CT angiogram.

3. Planning and Use of Investigations and/or Resources

Strengths:

• The candidate demonstrated a strong understanding of the need for thorough resuscitation and stabilization of the ischemic patient before proceeding with surgery.
• The candidate’s plan to escalate to the consultant and involve other resources, like ITU and the medical emergency team, is commendable.
• The suggestion to review systemic issues, such as whether the eGFR was confirmed by all teams, shows a broader understanding of quality improvement.

Weaknesses:

• The candidate needed prompting to remember to organize the correct CT angiogram. This indicates a slight gap in planning.

4. Communication Strategy

Strengths:

• The candidate showed empathy and concern for the FY1, recognizing the importance of providing emotional support and using the situation as a learning opportunity.
• They communicated a clear plan to involve the consultant and ensure that all relevant parties were informed of the evolving situation.
• The candidate appropriately addressed the need for a duty of candour and was ready to explain the CT angiogram mistake to the patient.

Weaknesses:

• The communication strategy, while generally strong, was marked down slightly because some responses required prompting.
• The candidate could have been more specific about how they would communicate with the aggressive pseudoaneurysm patient, particularly in terms of strategies to de-escalate the situation and gain the patient’s cooperation.

Clinical management scenarios are designed to test your ability to handle complex, stressful situations as a trainee. Your capacity to recognize, prioritize, and address multiple issues, while effectively communicating, is crucial to performing well in this station. Your approach should involve all participants, including colleagues (both junior and senior), other specialists, the patient, and any next of kin. Remember, it’s not just about what you know, but how you apply that knowledge in a dynamic, real-world environment. By learning from both successes and areas for improvement in these examples, you can refine your approach, avoid common pitfalls, and enhance your ability to respond effectively to such scenarios.

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