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.
General Surgery Clinical Management Scenario – Interview gone wrong:
Scenario:
You are the on-call General Surgery ST3 Registrar during a busy weekend. There is only one operating theatre available for urgent and emergency cases, and several urgent cases need your attention.
There is a 19-year-old male presenting with clinical signs of appendicitis. His vital signs include a heart rate of 110 beats per minute, a respiratory rate of 25 breaths per minute, a temperature of 38.0°C, and a total NEWS score of 8.
The second patient is an 85-year-old lady with a suspected perforation of a sigmoid diverticulum. She is at a significant risk of sepsis and requires urgent surgical attention.
The Maxillofacial Surgery team has a patient with a fractured mandible that requires emergency plating. The patient is stable but in considerable pain, and the maxillofacial team is pushing for urgent surgical repair in the theatre as soon as possible.
In addition, the ST7 trainee requests you to let them perform the laparotomy for the patient with suspected diverticular perforation, as they have not yet achieved the required laparotomy numbers for their CCT.
Response:
Panellist:
Hello. Can you just confirm your name, please?
Candidate:
My name is JW. Nice to meet you.
Panellist:
Nice to meet you as well. So you’ve read your scenario. Can you go through what the issues are and how you’d manage it, please?
Candidate:
Okay. Thank you for having me in this interview. In the scenario that I’ve read through, we have three issues. One is a management issue. Another is a clinical issue as well as a training issue.
So in terms of the clinical issue is patient prioritization in theater. We have three patients.
One who needs an appendicectomy. And another 85-year-old lady who is in need of laparotomy as well as maxillofacial that have a patient with a fractured mandible. And there’s need to prioritize and have the cases done without putting the patients at risk.
The next one is there’s a management issue in that it’s a weekend. You have limited staff. You have limited theater as well. And you need to share the theater between different specialties. And there’s need to negotiate and prioritize the patients as well so that you do not have any adverse outcome.
And lastly is a training issue where one of the trainees, ST7, would like to do the laparotomy in my stead in order for them to be able to fulfill their training hours. I’d like to know whether this also has an implication on my training needs as well.
The priority here would always be on patient safety. So I’d like to ensure that the two patients, all the patients, all the three patients are safe and are stable and the right patient gets the right procedure.
The one patient who is at most risk here is a 85-year-old. We want to ensure that the decision made by anesthesia that the patient is not fit for surgery is objective and is multidisciplinary. So this would need me to discuss with the anesthesia, understand the anesthetist’s concerns, as well as have some objective review like a NELA score or a P-POSSUM.
Also discuss with critical care and understand whether this patient is a candidate for critical care and if there are critical care beds to take care of this patient after surgery. Also I’d need to escalate this to my consultant so that I can have his view on the need for surgery and the prioritization. I’d also want to evaluate the patient and ensure the patient is adequately resuscitated and stable.
So ensure that we follow the CCRISP protocol in evaluation of the patient and ensure that I’m there with my juniors and any investigations and support information has been provided. And also we want to check whether there is any discussion that has been held in terms of ceiling of care or priorities of care for this patient. And have any supportive discussions with the patient and the patient’s family.
When it comes to the patient with appendicectomy as well, for the appendicectomy I’d like to ensure that the patient is stable. I’d like to review them or send my SHO to go and review them and update me and ensure that the patient’s vitals are stable. They haven’t developed any perforation or any peritonitis in which case they might be able to wait for the other procedures to be done.
And lastly I’d like to have an open discussion with the maxillofacial registrar in order for us to be able to objectively prioritize all the three patients and understand who should be the first patient to go in. When it comes to the management issue with the registrar, I would want to have an open discussion as well with my ST7 registrar to try and understand how come they have low numbers in terms of the laparotomy that they are supposed to do. Is it because there are not enough training lists and is there a way to support the ST7 through having him or her have exposure through the duty manager, rota manager to other training lists that might expose them to laparotomies as well.
In addition, I would advise them to also seek help from their educational supervisor so that they’re able to be provided support from a higher level in terms of being able to get other lists or even get rotations where they may be able to do more laparotomies. I’d want to take this as an opportunity as well to see whether the same issue is affecting other trainees. So this is an opportunity for an audit.
I’d like to involve my team, including the junior, so that it’s a learning experience for everyone to audit and see whether the trainees are meeting their training needs and meeting their portfolio requirements. I’ll do an audit and review the audit with the team, look at the statistics. If it’s below the standard, we’d want to have a discussion and escalate this to probably the clinical lead in order for us to be able to see whether there are interventions that can be implemented to improve this and work together and support the team in the implementation of those interventions.
And probably close the loop to see whether it’s been able to achieve the intended outcome. I would also, in terms of management issues, want to see whether the issue with theatre shortfall has led to any morbidity or mortalities in the past. This would also need to be audited to see whether…
Panellist (interrupts):
Let me stop you there. Why prioritise the perforation? So you went to the perforation first as opposed to the appendicitis. Can you give me a reason?
Candidate:
Okay. For the patient with appendicitis, if the patient is stable, depending on a review, if their vitals are stable, they’re not in any acute deterioration, they’re able to wait whilst they’re 85 years old.
Panellist:
The scenario mentions that the 19-year-old has a NEWS score of 8. Okay.
Candidate:
Sorry, let me just open the scenario.
Panellist:
Does that change your mind at all?
Candidate:
Yes, with a NEWS score of 8, then it means the patient is unstable and will need urgent appendicectomy.
So I would prioritise the 19-year-old considering their outcome would be better. As well, I would discuss with the theatre manager, theatre coordinator, to see the possibility of having two theatres opened at the same time, because this might allow both the maxillofacial and the general surgeon to be able to run two consecutive lists.
Panellist (interrupts):
Okay. What are your thoughts about the diagnosis of appendicitis and someone scoring an 8? It was seen by the night registrar, wasn’t it?
Candidate:
Yes. That was his diagnosis. So I think also it needs to be explored how come the surgery was not done by the night registrars and if there was a busy shift and they were unable to perform surgeries during the night, are there any issues with staffing as well or overloading as well?
Panellist:
Okay. And how would you communicate with the max fax doctor now that you have an appendicitis patient scoring an 8 that you want to take to theatre? How would you communicate?
Candidate:
Okay. So I’d like to explain to them that I have a patient who might have a perforated appendix that would need urgent treatment in order to prevent further deterioration. And if their patient is stable, then their patient can come in next after my patient.
Panellist (interrupts):
Before your diverticular perforation?
Candidate:
However, with the diverticular perforation as well, if the patient has peritonitis, there would need to be prioritised and might have to go before the maxillofacial patient.
Panellist:
Okay, Tell me about your fitness assessment of this patient.
Candidate:
Okay. The diverticular perf. He’s 85. Yeah. So the 85-year-old will need to see whether they had any previous prior exercise tests that are available.
We’ll need to see or calculate a NELA and P-POSSUM score and cardiac risk indexing as well by anaesthesia.
Panellist (interrupts):
Do you know of any frailty scores?
Candidate:
Yes. There’s a WHO frailty scoring.
Panellist:
Okay. You ask the ICU doctor to let this patient come to ICU after surgery and they say not suitable for ICU. Do you operate yes or no? You’ve got like three seconds left.
Candidate:
No.
Panellist:
Alright.
Score:
| Clinical Management Scenario | Score out of 5 |
| Recognition of the issues | 3.5 |
| Prioritisation and timescale | 3 |
| Communication strategy and solutions | 3 |
| Realism and Situational Awareness | 3 |
| Overall interview performance | 2.5 |
| Aggregate score: | 60% |
| Panellist comments: 1. Candidate didn’t read scenario well and didn’t notice that appendix had a NEWS of 8 so wasn’t prioritised. When prompted he did get flustered and struggled with remaining questions, saying that he did have organised thoughts in the beginning but he based it on incorrect info. 2. Good understanding of the issues but failed to prioritise the sick appendicitis patient. Needed prompts. | |
Detailed Feedback and Learning Points:
1. Recognition of the Issues
Strengths:
- The candidate identified multiple issues in the scenario, including clinical, management, and training issues.
- They acknowledged the need to prioritize patient safety and the importance of discussing patient status with the anaesthesiology and critical care team.
Weaknesses:
- There was some confusion about the details of the scenario, which suggests that the candidate did not thoroughly read or recall the specifics.
- The candidate initially failed to recognize the critical nature of the 19-year-old patient with appendicitis despite the NEWS score of 8.
2. Prioritization and Timescale
Strengths:
- The candidate attempted to triage the patients based on clinical need, starting with the 85-year-old lady due to her critical condition.
- Recognized the importance of stabilizing and resuscitating patients as part of their management plan.
Weaknesses:
- The initial prioritization was flawed due to the misunderstanding of the severity of the appendicitis case.
- The initial confusion made the candidate appear disorganized under pressure, especially when prompted about the NEWS score, leading to changes in the prioritization order.
3. Communication Strategy and Solutions
Strengths:
- Demonstrated a willingness to engage in multidisciplinary discussions with anaesthesiology and other departments.
- The candidate planned to involve their consultant for further advice, showing an understanding of available support systems.
Weaknesses:
- The communication strategy was disorganized as he did not recognize the importance of prioritizing the appendicitis patient.
4. Realism and Situational Awareness
Strengths:
- The candidate was aware of the weekend staffing limitations and the need to coordinate with different specialities.
- Recognized the potential need for additional theatre resources if possible.
Weaknesses:
- Initially showed limited situational awareness regarding the critical urgency required for the appendicitis case.
- The candidate needed prompting to consider a detailed assessment of the 85-year-old’s fitness for surgery.
5. Overall Interview Performance
Strengths:
- Displayed a good foundational understanding of the clinical and management issues at play.
- Initially presented organized thoughts and a structured approach to handling the scenario.
Weaknesses:
- The overall interview performance was hindered by the initial misprioritization and the candidate’s inability to maintain focus and composure throughout the rest of the interview after being prompted and challenged about the appendicitis patient’s NEWS score.
- The candidate needed significant prompting, indicating a lack of thorough reading and understanding of the scenario.
This ST3 clinical management interview station highlights the importance of thoroughly reading the scenario, identifying key clues, effective prioritization, and clear communication. The candidate’s misprioritization of the patient’s issues led to confusion and disorganization when later challenged by the panellists. This demonstrates how a simple misstep can trigger a vicious cycle, resulting in poor interview performance. It is crucial to recognize the multifaceted nature of clinical, management, and training issues in these stations, and equally important to remain composed and organized under pressure. Learning from and reflecting on these realistic examples can significantly enhance preparation for ST3 interviews, ensuring better performance.