From past papers

Question 1

If need to prescribe antibiotics but consultant gone home and unsure, rank appropriateness:

on-call microbiologist
BNF
national guidance
nurse
specialty trainee

Answer 1

specialty trainee
on-call microbiologist
BNF
nurse
national guidelines (local best)

Question 2

what to remember in breaking bad news scenario

Answer 2

always best for a senior colleague to do this

Question 3

is monitoring the situation often a good answer?

Answer 3

not if the issue can be addressed more immediately via other answers

Question 4

what to aim to do before raising a concern about a colleague?

Answer 4

speak directly to your colleague to explore the issue/cause of the problem

Question 5

what about when there is uncertainty whether the patient’s situation has changed and the family is involved?

Answer 5

should seek the opinion of a senior colleague, if not a consultant, should inform the patient/relative of a possible delay while the team decides on a plan

Question 6

if someone else is raising a concern what is a good first step?

Answer 6

ask why they have a concern/explore their concern

Question 7

communicating with patients whose first language is not English?

Answer 7

clear NHS guidelines - you should always consult these (e.g. on your hospital’s intranet)

If a ?-speaking doctor was available, asking for assistance would be most appropriate as she/he would be communicating directly and fluently with the patient

The second most appropriate action is to telephone (or arrange in advance where known) to obtain a qualified translator although this can take longer

Question 8

can an F1 discharge patients without close supervision?

Answer 8

No!

Question 9

how to maintain your duty of care towards your patient while preserving their confidentiality and maintaining good communication with the patient’s family?

Answer 9

Informing the patient’s family member that you need to seek the patient’s permission before divulging any clinical information is the most preferred option

Sharing only the information that the family member is aware of (abdominal pain) would buy you some time

Always ensure an option which entails patient’s consent

Question 10

what to remember when finding another Dr to do a task for you

Answer 10

try to contact them directly (rather than via a nurse)

try to contact someone at the appropriate level first (your level, then escalate)

Question 11

what to remember about educational supervisors?

Answer 11

your end of placement meetings with them are every 4 months (waiting until a meeting is unlikely to resolve an issue)

they are responsible for

• regular formative appraisal
• supporting e-portfolio
• ensuring understanding and engagement in assessment
• 1st point of call for training concerns/issues
• ensuring appropriate training opportunities available for learning + gaining competences

Question 12

if a colleague has a complaint about another colleague, what should you encourage 1st?

Answer 12

give them the opportunity to speak to their colleague

encourage them to seek advice/speak to senior colleague (better 1st before
immediate escalation)

establish if any patient safety concerns

Question 13

the mental capacity act

Answer 13

in brief to give informed consent the patient should be able to “URWC”

• understand the information
• retain the information
• use or weigh the information
• be able to communicate the information

Question 14

If concerns have been relayed to you by a nurse?

Answer 14

you should take responsibility for resolving them or passing them up the chain of command yourself, not asking the nurse to do this for you

Question 15

when to inform a senior colleague about a colleague’s pics on social media/dubious behaviour?

Answer 15

if no adequate explanation forthcoming

the doctor did not show genuine remorse and learning

or there were on-going concerns regarding patient safety

Question 16

rank forms of communication from clearest to least clear:

Answer 16

face to face

telephoning

asking a colleague to contact

sending a text message

Question 17

who has the ultimate responsibility for any drug or device?

Answer 17

the the prescriber/user, and therefore any queries should be posed directly to this individual

Question 18

who has formal clinical responsibility for a patient?

Answer 18

the medical team

Question 19

If there is any concern about a dosage but if it is imperative that a drug is given?

Answer 19

it is safer to administer the drug at a dose that is familiar to all in order to minimise the chance of a complication or adverse effect (even if this isn’t what the consultant prescribed)

Question 20

if you need to handover but your colleague is running 30 minute late?

Answer 20

Although it is not appropriate for trainees to stay for an extensive period of time after their shift ends, or do this on a regular basis, staying an extra 30 minutes on this occasion is important to ensure an effective handover

if not, wait and do it in person

then via specialty trainee

then in notes at end of bed

then in doctors office (unlikely to know it’s there)

Question 21

if you have a problem with a nurse, is it best to inform the nurse in charge or your consultant?

Answer 21

You should inform your consultant or Foundation Programme Director, who would then make enquiries, leading to action if deemed appropriate.

informing the nurse in charge is best left to your consultant

Question 22

what if patient is intoxicated, loud and demands immediate medical treatment. There are four patients waiting ahead of him. He is upsetting the other patients and at one point, threatens another patient with physical violence

Answer 22

Call security for assistance

Tell the patient that his behaviour is inappropriate and will not be tolerated

Ensure the other patients are not distressed by the situation

(Other staff should not be asked to confront the patient as this may place them at risk)

(this behaviour however should not constitute a threat to his right to treatment)

Question 23

is it okay to handover non-emergency jobs to the on-call team?

Answer 23

It should not be necessary for anyone to work for longer than their required hours because of what is essentially an organisational problem, not a medical emergency

Question 24

if you find instructions were not followed by the night nursing team and a patient has deteriorated as a consequence?

Answer 24

Inform the nurse in charge of the ward and a senior member of the medical team of the incident ( so that the incident can be logged, investigated and any action taken)

Find out whether the nurses were aware of the instructions regarding changes to the patient’s care ( clarification as to whether these were communicated)

Whilst you should record the events in the patient’s notes this is not an immediate priority

Question 25

if a patient can’t speak English?

Answer 25

Every patient should be offered a translator wherever possible (involving the relatives clearly breaches issues of patient confidentiality)

drawings could be open to misinterpretation and would not be considered medico-legally robust behaviour

Whilst the incident will require reporting, the immediate issues of patient safety, patient explanation and gathering the relevant information to accurately describe the circumstances surrounding the incident are more pressing and required BEFORE speaking to the senior nurse

Question 26

if a medical condition is affecting your ability to work?

Answer 26

This constitutes a risk to the patients you are caring for and will impose a greater workload on your colleagues. In this circumstance you should inform and seek the advice of the senior clinician responsible for your work and alert your colleagues

consult your GP and do not make any unilateral decisions about your medical treatment

do not use your annual leave to compensate for a medical problem

Question 27

if strong suspicion that your colleague has been drinking alcohol?

Answer 27

confirmed first-hand

concern should be for the patients under his care, so it is essential that he does not remain at work if his judgement and ability are impaired

It is also appropriate to ask for senior help and advice in this situation

(Informing the consultant in charge of the ward is unnecessary unless your colleague insists on remaining at work)

(Exploring the underlying issues at the time will be fruitless, and is best done in a more appropriate environment by a trained counsellor)

Question 28

if colleague is having very difficult personal circumstances?

Answer 28

compassionate advice to seek time off work from their consultant ( consultant is most likely to be able to organise cover for the doctor)

Advice to discuss with educational supervisor (educational supervisor is most involved with pastoral care of the trainees)

somewhere private to discuss further will help get a full and confidential disclosure of the problems

if insufficient evidence of a clear and present danger to patients to warrant informing a senior without the colleague’s consent, no need to discuss this with their educational supervisor

Question 29

when is it appropriate to work later than shift end?

Answer 29

medical emergency (not organisational problem)

Question 30

is it customary for nursing staff to provide telephone updates to patients?

Answer 30

yes!

Question 31

if you have spotted a possible prescribing error with the potential to result in a fatality or serious injury?

Answer 31

first duty is to ensure that this danger is eradicated (cross out the prescription on drug chart, dating and initialling the amendment - this should ensure no need to tell the nursing staff on duty not to administer drug)

establish the facts of the matter by taking a history from the patient (ie are they allergic)

looking for further evidence in the medical notes

(while it is always appropriate to acknowledge errors to patients, if a probable error did not reach the patient and little is to be gained from explaining it)

Question 32

if patient is violent but with no capacity (ie delirium tremens)?

Answer 32

even if confused, they will often calm down if approached in a reasonable manner, reducing the emotion in the situation

checking on any physical harm done to staff is important

asking nursing staff to call the police or informing the patient that his behaviour is inappropriate and will not be tolerated is not necessary if no insight into actions

Question 33

if a patient doesn’t want to be discharged?

Answer 33

understand why

inform the consultant (as they are in charge)

involve relatives ONLY with consent

Question 34

what about if you see an unprofessional social media post?

Answer 34

advise them to remove it

tell them it’s unprofessional

advise them to discuss this with their clinical supervisor

(Although the advice to change media settings to private is sensible that could be interpreted as condoning the original post which is inappropriate irrespective of settings)

Question 35

if a patient is demanding to know when surgery is?

Answer 35

do not go promising something that you do not know you can deliver (ie time of a surgery), which is unprofessional

Question 36

if need someone to answer a medical question for you, and consultant at home?

Answer 36

Contacting your consultant out of hours while he is at home is less acceptable than discussing the problem with appropriate members of the team who are still at work

Question 37

why is it often not appropriate to tell patients that they must be discharged this evening to free up their bed?

Answer 37

Discussions about other patients’ needs are seldom helpful in these circumstances and risk giving the impression that the discharge decision has been taken on resource not clinical need grounds

(It would be reasonable to check if a bed is available overnight with the bed manager)

Question 38

what if a patient inappropriately films you?

Answer 38

Ask the patient about their reasons for recording the conversation

Discussing the episode with your clinical supervisor is recommended as they are likely to have prior experience and will be familiar with your organisation’s guidance

It’s their choice how they use the recording and whether they retain it

Options that risk confrontation with the patient are unlikely to help and you cannot insist that the patient deletes the footage

Explaining that it is inappropriate is a more oblique approach and explains your rationale, whereas insisting they delete the footage is blunt and direct

Question 39

when a request for urgent MRI imaging has been declined as you are unable to explain to him why the scan is required?

Answer 39

Telephone your consultant immediately, asking him to explain to you why the scan is needed

Ask the radiologist to contact the consultant to determine why the scan is required

Wait until this afternoon’s ward round to speak to the consultant about the scan

(“Politely explain to the radiologist that as the scan is urgent, you do not have time to ascertain why it is required” - contradicts guidelines on ordering investigations for patients - you have to supply clinical information and a justification for ordering the test)

Ask an available doctor for advice about ordering MRI scans is inappropriate for this situation as it refers to generic advice, not specific to resolving this clinical situation

Question 40

if consultant recommends that several invasive procedures are conducted to determine the cause of pts illness, but pt told you when he was admitted to the ward that he did not want to have any invasive procedures conducted

Answer 40

During the ward round, inform the consultant that pt told you that he did not want any invasive procedures to be conducted (prevents the patient undergoing any test which they do not consent to)

Talk to the consultant after the ward round about whether the procedures are a necessary option for pt (but delays discussion, and depending on length of ward round the procedures might go ahead)

Involving another senior colleague is less direct

Question 41

a specialty trainee notices that a blood test that he had asked your FY1 colleague to do earlier on has not been done. The specialty trainee turns to you and asks why you have not done the blood test

Answer 41

Apologise that the blood was not taken and offer to take the blood test now (patient’s safety is the priority)

Liaise with your FY1 colleague regarding who will take the blood test now (appropriate but an indirect way of ensuring that the blood test is done in a timely manner)

Explain to the specialty trainee that he had asked your colleague to take the blood test, not you (is important as it ensures that the specialty trainee is aware that you were not responsible for the error, but can be addressed after the immediate patient safety issue is dealt with and the test sent)

Asking your FY1 colleague why he has not taken the blood test seeks clarification of why the test hasn’t been sent as there may be a valid reason, although is looking at the situation retrospectively

Question 42

If unable to answer pt’s Qs about disease?

Answer 42

Contact the senior doctor treating, asking her to come and speak to relatives as soon as possible

Explain to relatives that, due to the rarity of the case, they should wait to speak to a senior doctor

Explain the details that you understand about disease and treatment plan to his relatives (may be drawn into answering more questions)

Question 43

If you are unsure about why a referral has been requested?

Answer 43

check with the person requesting it (they may have forgotten to explain the details to you, and it furthers your learning and understanding)

Failing this, speaking to another senior member of the team for generic information about this type of referral will be helpful

Taking a proactive approach and researching your questions will be appreciated by the team you are referring to and will also further your knowledge (ie via internet)

Contacting the end team consultant without understanding why you are calling is likely to be unproductive and frustrating for yourself and the team you are referring to

Asking a colleague to make the referral for you is inappropriate as you are passing work to a colleague and failing to address your own learning needs

Question 44

You’re on-call on night shift and relative calls asking about pt whose care you have not been iv

Answer 44

Prior to any conversation you should check the clinical notes to ensure you can communicate with the relative in question and to give accurate information about the correct patient

It is also appropriate to ask a doctor who has been involved in Mrs Appleton’s care

As you are the on call doctor it is reasonable to ask Sally to telephone to speak to the base team for information in the day time

It may not be possible to give information if you are unfamiliar with the patient or uncomfortable communicating by telephone with relative unknown to you

Asking the nurse in charge to tell relative that there is no-one available to speak to her at present is a delegation of the task and risks undermining the relationship between relative and the ward staff

Question 45

your response to if a patient who raised concerns about a nurse and the impact on their care

Answer 45

gather further information before acting

The second most important point is to listen and act on these concerns with nurse

If you did not feel able to do this then raising the concern with the nurse in charge

The nursing team would be better placed to raise it with the consultant than yourself

Question 46

You are working on a surgical ward. Your specialty trainee* arrives on the ward looking unkempt and you notice that he smells of alcohol. He is due to operate in one hour, and you believe that his ability to operate may be impaired.

Answer 46

Inform your consultant of the situation (Patient safety is at risk, and therefore this is a serious issue that must be addressed immediately. As this is a potentially delicate situation, the most appropriate course of action is to immediately raise your concerns with your consultant who is best placed to handle this situation -The trainee has an hour until he is due to operate and therefore telling the consultant who is overall in charge may be a better option as they could ensure appropriate cover is requested)

Telling your specialty trainee that he should not operate if he is drunk is appropriate, but the confrontation may create further problems, particularly if the specialty trainee is drunk and reacts badly

Asking the team for their opinion may help you to decide how to further proceed, but will draw wide attention to the situation and your colleague deserves to be treated with discretion until the facts are established

Asking the theatre team to prevent your specialty trainee from operating would be effective but is overly dramatic

Question 47

ability to respond to the situation of a colleague who appears to be overworked and tired

Answer 47

that you are concerned about how hard she is working

involve an appropriate clinical supervisor - this is appropriate, but a less direct solution

Suggest to Funmilayo that if she is tired at work, this may have a negative impact on patient safety ( raises the important issue of patient safety but doesn’t deal specifically with the impact on Funmilayo which is the focus of the situation)

Question 48

Through the wall, you both hear a colleague making loud derogatory remarks towards his patient. This behaviour is completely uncharacteristic

Answer 48

(This question focuses on an event which is having an immediate impact on the quality of patient’s care. It requires an immediate response to prevent harm to the patient and involves unprofessional behaviour which could have serious repercussions for Max including receiving a formal complaint or referral to the General Medical Council)

Take Max aside and ask him privately about the incident

Immediately inform a senior doctor

Inform Max that this behaviour is highly inappropriate

(This is to ensure that the immediate assessment of the impact on the patient can be made and a plan put in place to mitigate any harm)

Question 49

pt has cancer but doesn’t want fam to know. they’re angry because they think he’s being mismanaged

Answer 49

explain that he has a right to confidentiality

ask the fam why they think he is being mismanaged

suggest to fam that they are best speaking to pt about their concerns

(no need to escalate yet)

Question 50

crash call to extremely frail pt but no DNAR in place. specialty trainee arrives

Answer 50

Ask the nursing staff involved in Eileen’s care, whether there have been any DNAR discussions with the patient or her family

Following this you should commence CPR with your senior as there is currently no evidence that you should not attempt resuscitation

and if concerned, ask senior whether they think CPR is likely to be successful and in the patient’s best interests

Question 51

if approached on your only break by a nurse who is concerned about an unwell pt

Answer 51

you must safeguard patient care despite inconvenience to yourself. You should finish your break

assess the patient

having asked the nurse to return to the patient and take a full set of observations

Question 52

if a colleague has accused another of lying?

Answer 52

emphasise the severity of the allegation

seek early senior advice

suggest the colleague talks to the other about it (it is not your duty to do this)

Question 53

if you believe you are being given a disproportionate amount of the workload?

Answer 53

approach your clinical supervisor (or senior nurse if appropriate - if nurses are requesting jobs)

explain to your colleague how you feel

Question 54

distressed pt wakes up from surgery and demands to go home?

Answer 54

Try to find out what is troubling the patient (exclude a reversible cause of confusion or distress and then to explore what is troubling the patient, when confident that there is no immediate action required such as administering oxygen)

You need to know what the post-operative plan is before you can proceed further

and this will allow you to explain to the patient the rationale for her remaining in hospital

Question 55

pt with psychiatric illness refuses to be treated

Answer 55

Attempt to explore reasons for refusing

Find out from your specialty trainee* if it would be appropriate to assess capacity

Inform your consultant that refusing to cooperate

Question 56

due to handover, other F1 is late, frequently so and experiencing personal problems

Answer 56

In this situation, you need to ensure there is a safe handover, and encourage the colleague to seek help and advice about coping with her workload and personal issues

The first action is to contact Lucie to see if she is just a few minutes late or whether there will be a significant delay

Contacting another doctor who is on call to see if you can handover to them may then be appropriate

You should encourage Lucie to seek help from her clinical supervisor

(If there is a clinical risk you should remain on the ward until Lucie arrives or alternative cover can be found but that would depend on the situation and nature of the cover required )