Working Effectively As Part of A Team

Question 1

1. A porter tells you that he has seen an HCA take something from a
   patient’s personal belongings.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Ask the HCA to open her locker and empty her pockets.
   B Establish exactly what the porter has seen, and confi rm with the
   patient that they have something missing before informing the Ward
   Sister.
   C Call the police.
   D Ask the porter to fi nd out more by speaking to the patient and HCA.
   E Report the incident to your consultant.

Answer 1

1. B, E, D, A, C
   All healthcare professionals are in positions of trust and must act within
   the highest standards of integrity. The porter has made a very serious
   allegation which could have damaging legal and professional consequences.
   For this reason, the initial claim justifi es some preliminary
   investigation to broadly establish the facts (B) before informing the
   Ward Sister. The Ward Sister is a more practical and appropriate port
   of call than your consultant (E), particularly as she is responsible for the
   nurses and HCAs on the ward. However, your consultant might have
   useful advice and would be more appropriate to contact than delegating
   responsibility for investigating further to the porter (D). (A) and (C) are
   very incorrect but (C) is marginally worse as it could represent an even
   greater over-reaction. Although it may be necessary to call the police
   later on, this is likely to be handled by hospital security that will have
   more experience of dealing with similar issues.

Question 2

2. You are on a renal medicine ward round and notice your consultant
   lose his balance but quickly correct himself. You fi nd his behaviour
   slightly unusual and can smell alcohol on his breath. Although the decisions
   he is making appear appropriate, you wonder if he has been drinking
   alcohol earlier in the day.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Ask the consultant whether he has been drinking alcohol.
   B Speak to the consultant’s secretary about his behaviour.
   C Discuss your concerns with your registrar and ask whether he feels
   that the consultant is acting out of character.
   D Inform the Clinical Director.
   E Speak with the consultant, and share your concerns about what you
   think you have seen recently.

Answer 2

2. E, A, D, C, B
   It is essential to ensure the safety of patients. However, you should fi rst
   explain your concerns privately (E) in case a good explanation is forthcoming
   before asking directly whether your consultant may be under the
   infl uence of alcohol (A). If this is admitted or you are not convinced by
   his denial, you should ensure that he leaves the clinical area. This should
   be done discreetly but involving other staff and/or security if necessary.
   Once the situation has been made safe, you have a duty to escalate
   the incident to an appropriate person, in this case the Clinical Director
   (D). Involving other members of staff would only be justifi able if you
   are insuffi ciently certain to approach your consultant directly (C) (B).
   However, these answers are not ideal until the other approaches have
   been tried unsuccessfully. Escalating to your registrar (who is an immediate
   senior and probably better known to you) (C) seems more appropriate
   than contacting your consultant’s secretary (B). Even if your concern
   is justifi able and genuinely held, you should involve as few colleagues as
   possible to minimize professional embarrassment.

Question 3

3. You have asked a nurse to administer a heparin infusion. On
   returning to the ward three hours later you fi nd that the infusion
   has still not been given as the nurse has been busy with other tasks.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Explain the urgency of giving the heparin, and ask her to prepare the
   infusion straight away.
   B Avoid antagonizing the nurse by leaving her to complete her jobs.
   C Speak to the nurse in charge about the delay.
   D Confront the nurse on the ward and insist that she prepares the infusion
   straight away.
   E Go to the preparation room and prepare the heparin infusion yourself.

Answer 3

3. A, C, E, D, B
   Eff ective working relationships require individuals to have some discretion
   about planning their workload. However, the nurse may not
   appreciate the urgency of the task which should be reiterated in the
   fi rst instance. For this reason, the best answer is (A). If a further delay
   is anticipated, it may be necessary to escalate the issue as the nurse in
   charge (C) might intervene or allocate a nurse from elsewhere to help.
   (E) is correct but not as much as (A) and (C) as you are likely to have
   other tasks and will not be as familiar with preparing infusions as the nursing staff . It is, however, preferable (if you can do so safely) than
   insisting it is done immediately (D) which may be unsuccessful and risks
   jeopardizing future working relationships. The worst answer is (B) as you
   must advocate for your patient and it is not suffi cient to satisfy yourself
   that a drug was prescribed if you know that it has not been administered.

Question 4

4. It is your fi rst day on the neurology ward and all junior doctors
   are changing jobs. You are asked by the ward clerk to complete a
   discharge summary for a patient who was discharged last week, including
   arrangements for follow-up.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Refuse and ask the ward clerk to fi nd the foundation doctor who was
   looking after the patient.
   B Ask the new SHO to try to complete it.
   C Attempt to complete the discharge summary and try to fi nd the consultant
   and ask them about follow-up arrangements.
   D Write a letter to the previous junior doctor for the neurology ward
   and ask them to complete the discharge summary for their patient.
   E Complete the discharge summary to the best of your ability and
   arrange routine clinic follow-up in six weeks.

Answer 4

4. C, E, B, D, A
   Ideally, discharge summaries should be completed by an individual
   involved in the patient’s care. However, if the outgoing team neglected
   to complete one, it is important that it is completed to the best of
   your ability. As you are unfamiliar with the patient and local policy for
   follow-up, the best answer is to check with a senior colleague who might
   remember the case (C). This is preferable to blindly arranging a routine
   appointment in six weeks (E). This would, however, ensure that
   the patient was not lost to follow-up and might be preferable to asking
   your SHO to complete the task (B), as they have also rotated posts and
   are unlikely to add anything further to the discharge summary. Although
   courtesy requires completing routine tasks before rotating to a new job,
   it would be inappropriate to expect your predecessor to complete the
   discharge summary when they are now in a new post and/or hospital.
   For this reason, (D) and (A) are both incorrect. However, (A) is slightly
   worse as it puts the ward clerk in the diffi cult position of having to inappropriately
   pursue your predecessor after they have moved posts.

Question 5

5. A patient approaches you to say that she overheard your registrar
   swearing repeatedly when he was at the nursing station. She does
   not wish to make a formal complaint at the moment, but suggests that
   you do something about his language.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Raise the concern privately with your registrar.
   B Inform PALS.
   C Apologize to the patient and assure her that you will speak to the
   doctor involved.
   D Establish what exactly was said and when.
   E Explain that the registrar is ‘only human’ and that she should not listen
   to conversations at the nursing station as they might be confi dential

Answer 5

5. D, C, A, B, E
   Doctors have a duty to act professionally at all times and it would seem
   that your registrar might have erred in this respect. The best answer is
   (D) as you should fi rst fi nd out what was overheard to best inform your
   conversation with the registrar. (C) is also correct as you should assure
   the patient that you will raise her concerns, even if she does not wish
   to make a formal complaint. It is only a ‘worse’ answer than (D) as you
   could only really do so with a little more information. Only after completing
   (D) and (C) should you speak privately to the registrar so that he
   is aware of the concerns (A). (E) and (B) are incorrect answers. Although
   (B) would be inappropriate, it is not as destructive as (E) which would
   be unfair and might either precipitate a formal complaint or reduce the
   likelihood of her raising concerns in future.

Question 6

6. You are working with Dr Green, a GP, about whom you are
   concerned because he never seems to examine his patients. He
   appears willing to refer some patients and send others home without
   as much as a basic physical examination. However, he is well liked by his
   patients and colleagues, and he has never been subject to a complaint or
   any disciplinary action.
   Choose the THREE most appropriate actions to take in this situation
   A You have no substantial proof of malpractice and therefore cannot
   report your concerns at the moment.
   B The collective support of Dr Green at the practice should dissuade
   you from making a complaint.
   C Telephone the GMC to raise your concerns with them.
   D Ask the GP about his decisions not to examine patients.
   E Attempt to discuss the issue privately with other colleagues at the
   practice.
   F Inform the Primary Care Trust.
   G Contact your Educational Supervisor.
   H Inform the British Medical Association.

Answer 6

6. D, E, G
   If you have concerns with the standard of care given to patients, you
   have a duty to report them, particularly if patients are potentially at risk.
   You should not be dissuaded from raising concerns because a doctor
   is popular (B) or you do not have proof (A). Ideally, concerns of this
   nature should be raised with the doctor involved in the fi rst instance
   (D). He might explain his decisions and/or modify his practice without
   further action being necessary. If advice is needed as to how to proceed,
   other senior colleagues (E) and/or your Educational Supervisor (G) are
   appropriate contacts. Informing the Primary Care Trust (F) or the British Medical Association
   (H) would be inappropriate and, although a GMC referral might be
   necessary at some point (C), a concern of this nature might be more
   eff ectively dealt with informally.

Question 7

7. Your registrar inadvertently prescribes a ten times dose of methotrexate
   which you spot before the fi rst dose is given. The registrar
   breathes a sigh of relief that the error was spotted and tells you both he
   and the patient had a ‘lucky escape’.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Agree that you are lucky as well, as you would have to complete a
   long clinical incident form if it had been administered.
   B Raise the issue with the nursing staff so that they are aware of common
   mistakes to look out for.
   C Mention the prescribing error to the lead pharmacist.
   D Raise the issue with your consultant at the next ward round.
   E Complete a formal incident report.

Answer 7

7. E, C, D, A, B
   Clinical incident reporting is important for identifying local error patterns.
   For this reason, a report should be completed for the ‘near miss’
   even though the patient came to no harm. A clinical incident report (E) is
   the most appropriate method of error reporting as it will be dealt with
   through a formal process and creates a paper trail. (C) is unnecessary,
   although the lead pharmacist would at least know the correct procedure
   and ensure you completed a formal incident report. Your consultant
   could be told (D) but is likely to be sent a copy of the incident report, and
   you do not wish to cause your registrar unnecessary professional embarrassment
   by raising the issue too often. For this reason, it is worse than
   (C). Your consultant would, however, correctly direct you to complete
   an incident form. (A) is the next worst answer as it implies no attempt to
   report ‘near misses’ and hints at covering up a clinical error to protect a
   colleague. It is, however, perhaps less important given that the error was
   corrected at such an early stage. Informing the nursing staff (B) is probably
   the least helpful response as it implies no attempt to report the issue
   formally and potentially undermines your registrar. The only exception
   might be if this was necessary to stop the dose being administered once
   it has been crossed off the drug chart.

Question 8

8. At a multi-disciplinary team meeting, a nurse expresses concern
   about a patient’s ability to mobilize safely at home. The occupational
   therapy team disagrees and an argument ensues. Five minutes later
   they are continuing to argue, and no progress has been made.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Move the agenda on to the next patient, and return to the controversial
   case at the end.
   B Ask the nurse to elaborate on her concerns.
   C Ask the occupational therapist to leave the meeting.
   D Invite the social worker to share her opinion.
   E Do not become involved.

Answer 8

8. B, A, D, E, C
   Multi-disciplinary team meetings are important forums for identifying
   and solving medical and social problems in conjunction with allied health
   professional colleagues. It is not necessarily the doctor’s responsibility
   to lead such meetings, but you do have a shared responsibility to ensure
   that the team is working eff ectively. In this case, time is being wasted
   and you should help to facilitate the team arrive at a decision. The best
   response is (B) as the nurse should be given space to voice her concerns
   uninterrupted and it might yet be possible to resolve the disagreement.
   An alternative approach would be to revisit the case later on (A) so that
   it can be addressed with fresh minds and progress can be made through
   the agenda. However, this might simply postpone the disagreement and
   risks the case being forgotten or not considered for lack of time. For this
   reason, it is not as good an answer as (B).
   Although the social worker might have an opinion, she has not contributed
   so far and this might suggest that she has nothing specifi c to add
   (D). For this reason, it is not as good a strategy as (B) and (A), although
   an additional perspective could help. It is probably incorrect to leave the
   nurse and occupational therapist to resolve their diff erences (E) as they
   have not made any progress alone so far. The worst answer is (C) as it is
   not your place to ask anyone to leave the meeting, and this would be the
   wrong time to lose the occupational therapist’s expertise.

Question 9

9. You are an FY1 doctor in orthopaedics. You have found the
   physiotherapist to be particularly challenging to work with. She
   frequently ignores the postoperative plan for mobilizing patients and
   seems to actively discourage patients being discharged home. Your
   registrar says that the physiotherapist is ‘obstructive’.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Speak to the other members of the multi-disciplinary team prior to
   weekly meetings to establish the discharge plan.
   B Ask for the physiotherapist to be replaced.
   C Invite the physiotherapist to join your consultant ward round so that
   discharge arrangements can be made face-to-face.
   D Ask an impartial senior colleague for advice.
   E Follow the physiotherapist’s advice, as she is ultimately responsible
   for the patient’s safe mobilization.

Answer 9

9. D, C, A, B, E
   Personality clashes and diff erences in approach are inevitable consequences
   of multi-disciplinary team working. However, these must not be allowed
   to impact on patient care. Although neither surgeons nor physiotherapists
   are necessarily ‘correct’ about optimal mobilization arrangements,
   consensus is more likely to follow collaborative working. The best answer
   is (D) as a senior colleague might have a better understanding of the
   situation and might be able to suggest a way forward. (C) might be a
   positive development but might be better suggested by someone other
   than the FY1 doctor—your senior colleague might help. For this reason,
   (D) is preferable to (C). It is always helpful to involve other members of
   the multi-disciplinary team (e.g. nurses and occupational therapists) in discharge
   arrangements so that a consensus is established before meetings
   take place (A). However, this is worse than (D) and (C) as it risks alienating
   the physiotherapist and making her feel as if the outcome of meetings
   has been determined without her beforehand.
   (B) and (E) are the two wrong answers. Asking for the physiotherapist
   to be replaced (B) is likely to damage working relationships, and this
   is rarely the place of a junior doctor rotating temporarily through a
   post. However, (E) is the worst answer as you cannot blindly accept the
   physiotherapist’s advice when this confl icts with that of your consultant.
   Mobilization arrangements will depend on operative considerations (e.g.
   bone quality, fracture pattern, and choice of metalwork), details to which
   the physiotherapist may not have access. The consultant is ultimately
   responsible for patient care and should be informed if his instructions
   are routinely being disregarded.

Question 10

10. You have been working as the FY1 doctor in the Medical
    Assessment Unit for two months. On many occasions during the
    rushed morning handover, you have found that tasks are not appropriately
    transferred from the night doctors to the morning team. The ethos is focused
    on handing over quickly so that the night team can get home to sleep.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Ensure that your own handover is eff ective.
    B Arrange a meeting with your colleagues to explain your concerns.
    C File incident reports for each individual whom you believe to be failing
    in their responsibilities.
    D Only comment if urgent tasks are not handed over as it is not worth
    making a fuss over routine jobs.
    E Inform the consultant in charge that handover arrangements are
    inadequate.

Answer 10

10. B, E, A, C, D
    Handover between teams must be done correctly to ensure that important
    tasks are not missed. This is particularly vital given current employment
    regulations which have made shift working more commonplace.
    As this issue relates to a group of doctors, the best answer is (B) which
    would allow you to assess the degree of support that you have for change
    and collect helpful suggestions. Informing a senior consultant might lead
    to change more quickly but could alternatively lead to no change at
    all, depending on the individual concerned. As a handover meeting is
    already scheduled but being used inadequately, it would be preferable
    to address the problem with your colleagues if possible (B) before
    approaching a senior colleague (E) to suggest changes, for example
    starting the handover meeting at an earlier time. Your own handover
    should already be eff ective (A), but this might be hindered if there are
    adverse structural issues, such as other doctors wanting you to hurry
    up. In this case, the culture of accepting poor-quality handovers must be
    challenged. For this reason, (A) is a worse answer than (B) and (E) as it
    does not address the wider problem. (C) and (D) are wrong answers.
    Submitting incident reports for many diff erent doctors (C) will make you
    unpopular. Although it might result in change, it risks creating a personal
    issue out of a cultural problem and would not be a measured response
    to your problem. There is no such thing as a ‘routine’ task—either itneeds to be done or it doesn’t. Even checking a ‘routine’ blood test is
    important if the patient is found to be severely hyperkalaemic. Doing
    nothing (D) in this case is the worst option.

Question 11

11. Frances, an FY1 colleague, confi des in you that she was
    recently diagnosed with thyroid cancer. She does not appear
    to be symptomatic and is scheduled to undergo a biopsy and surgical
    treatment at another hospital in a month’s time. Although she is not as
    spritely as usual, you have not noticed any change in her performance.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Suggest that she refers herself for counselling via Occupational Health.
    B Advise Frances to inform her Educational Supervisor.
    C Inform your consultant immediately.
    D Gently explore how she is feeling about the diagnosis.
    E Keep an eye on Frances at work but do not say anything to anyone else.

Answer 11

11. D, B, E, A, C
    You should be aware of factors that might cause colleagues to underperform,
    including poor health. As Frances has confi ded in you, it would
    seem appropriate to ask how she feels (D) and whether she is coping.
    This is a fairly uncontroversial answer and is undoubtedly the best
    in this case. Ideally, she should let her Educational Supervisor know in
    case anything can be done, or must be done in future, to support her
    at work (B). (B) is not as good as (D) simply because you are likely to
    solicit more information discreetly before proff ering advice. (E) is correct
    although not as good as (D) and (B) in isolation, as your immediate
    concern should be to acknowledge the information Frances has chosen
    to share. The two worst answers are (A) and (C). Although Frances may
    benefi t from counselling (A), you cannot presume that this is something
    she would want. The worst answer is of course (C) as it would not be
    your place to tell other people about Frances’ health unless there is evidence
    of her underperforming and putting patients at risk.

Question 12

12. Rachel, a fellow FY1 doctor, is a budding surgeon and frequently
    abandons the ward so that she can assist in theatre.
    Except for the morning ward round, you have not seen Rachel on the
    ward for at least fi ve weeks. Your consultant appears content with this
    arrangement as long as the tasks are completed, and you do not have a
    particular interest in surgery.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Do nothing as you enjoy the ward and Rachel clearly wants to be in
    theatre.
    B Speak to Rachel and insist that she spends more time on the ward.
    C Go to theatre and leave any ward jobs until after hours when both you
    and Rachel can attend to them.
    D Suggest that FY1 doctors should be prohibited from going to theatre.
    E Talk to Rachel and suggest dividing theatre and ward time more
    evenly.

Answer 12

12. E, B, D, A, C
    As foundation doctors, both you and Rachel are expected to gain specifi
    c competencies. Rachel is at risk of not doing this eff ectively. Similarly,
    as an FY1 doctor on a surgical placement, you should assist in theatre if
    there is time available, as this is also relevant experience. Although it is
    reasonable to divide tasks according to your respective interests, you
    should both aim to gain experience of each setting.
    The best answer is usually to try to resolve problems locally fi rst, in
    this case by speaking to Rachel (E). Trying to alter her behaviour by
    achieving consensus is preferable to insisting she spend more time on
    the ward (B), which might be unsuccessful and risks souring your relationship.
    (D) is also unnecessarily confrontational and additionally risks
    limiting both FY1 doctors’ exposure to an important part of their surgical
    experience. As usual, doing nothing when presented with a problem
    (A) ranks poorly and you should not accept such a stark discrepancy
    without challenge. (C) is, however, clearly the worst answer as leaving
    tasks until after hours means both FY1 doctors routinely staying late and
    risks either inconveniencing patients or exposing them to danger.

Question 13

13. You overhear a medical student on the bus who is giving a
    rather unfavourable description of your consultant’s clinical
    competence. You do not believe that it is his intention to be deliberately
    heard, but it is clear that other passengers are listening.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Explain that the student might have misunderstood the reasons for
    the consultant’s decision.
    B Do nothing as it is a public place and medical students are not Trust
    employees.
    C Try to catch the medical student another day to explain that his comments
    were unhelpful.
    D Write a letter to the dean of his medical school.
    E Suggest to the student that he exercises caution when talking about
    colleagues in public.

Answer 13

13. E, A, C, D, B
    Your fi rst step should be to stop the medical student continuing this
    conversation in public as colleagues (like patients) are entitled to a
    degree of privacy. The best way to achieve this would be to let the
    student know he can be overheard and that this is unacceptable (E). It is
    likely that most students would respond to such a warning, even away
    from a teaching environment. Although (A) achieves a similar goal of letting the student know he has been overheard, it is a worse option
    as it risks entering a debate about your consultant’s ability. (C) is not
    as good as (E) and (A) as it does not stop the conversation, although
    it might address the student’s long-term behaviour. (D) is incorrect as
    it is an overescalation of a situation that could be more appropriately
    resolved in other ways. You might contact the medical school dean if
    you became aware of more serious concerns regarding a student, e.g.
    cheating or criminal activity. However, (D) is not as bad as (B) because
    the medical school dean would probably forward your concern to a
    more appropriate person (e.g. the student’s personal tutor), which
    would lead to the issue being addressed. (B) is the worst answer as it
    does not help the medical student (who needs guidance), your consultant
    (who needs support in his absence), and other passengers (whose
    trust in the medical profession might be damaged).

Question 14

14. Your registrar frequently undermines your organizational skills
    on the morning ward round. He expects you to take what you
    believe is unfair initiative in terms of organizing investigations before the
    patients are reviewed by a senior member of the team. He also criticizes
    your note writing and you cannot seem to avoid this, whatever changes
    you make to your documentation style.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Explain to the registrar privately that you feel that he expects too
    much initiative from an FY1 doctor.
    B Ask the registrar to show you how he would like notes taken on the
    ward round.
    C Inform your consultant that the registrar is constantly belittling your
    abilities as a doctor.
    D Arrange a meeting with Medical Staffi ng and ask that you are
    timetabled so as to avoid the registrar as much as possible.
    E Ignore your registrar’s interpersonal style but try to accommodate
    his whims.

Answer 14

14. A, B, E, C, D
    Mutual respect is essential to any eff ective professional relationship. Your
    registrar might not realize how unconstructive his style has become and
    he might improve if approached directly. For this reason, (A) is the best
    answer. Asking his advice about note taking might help reduce confrontation
    (B) and this answer is only less correct as it seems you have already
    made considerable eff ort to adapt your style. (E) is similar to (B) but is a
    worse answer as it does not demonstrate to your registrar that you are
    trying hard to understand how to improve. (C) and (D) are incorrect, at
    least initially, as they represent premature escalation of your diffi culties
    which are best resolved in other ways. (D) is only worse as it is a more
    signifi cant escalation than (C).

Question 15

15. Each time you phone radiology, you receive a barrage of criticism
    from a particularly discourteous radiology registrar. Your
    colleagues now try to make fewer requests whenever this particular registrar
    is on duty. He once criticized your ‘incoherent’ radiology requests
    and, when you asked how your requests could be improved, he hung up
    the phone.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Arrange a meeting between the radiology registrar and the Mess
    President.
    B Raise the issue with your Clinical Supervisor.
    C Ask for a slot at the monthly radiology meeting to discuss communication
    between junior doctors and duty registrars.
    D Contact the Clinical Director for Radiology to explain your diffi culty.
    E Avoid making radiology requests when this registrar is on duty unless
    they are absolutely necessary.

Answer 15

15. B, D, C, A, E
    The NHS employs 1.4 million people, some of whom have challenging
    personalities. However, if junior doctors are dissuaded from requesting
    investigations because of an obstructive radiologist, this has to be
    addressed. As you are unlikely to know the registrar and work in a diff erent
    department, you should initially escalate the issue up your own hierarchy
    fi rst (B). (D) is a worse answer as it represents a bold step and would
    be best done with the support of your Clinical or Educational Supervisor.
    The remaining answers are incorrect. Although (C) addresses the issue,
    opening a dialogue in such a public forum is inappropriate when your
    concerns are about a specifi c colleague. It is, however, a better option
    than (A) as the Mess President is unlikely to contribute very much. The
    worst answer has to be (E) as your clinical judgement should not be
    swayed by an impolite colleague who would risk patient safety.

Question 16

16. Your SHO discloses to you that she is going through a very diffi
    cult separation and occasionally has suicidal thoughts.
    Choose the THREE most appropriate actions to take in this situation
    A Reassure her and tell her that everything will be OK.
    B Do not get involved with her personal aff airs.
    C Off er a friendly ear if and when she wishes to talk further.
    D Suggest that she attends counselling.
    E Suggest that she books an appointment with her GP.
    F Suggest that she speaks to her Educational Supervisor.
    G Ask the registrar to prescribe antidepressants.

Answer 16

16. C, E, F
    It is important for medical professionals to ensure their own personal
    health and well-being. In this scenario, your SHO has revealed a serious
    psychological symptom which needs to be addressed (B). This might be
    alleviated through some form of counselling (D) or with antidepressants(G), although she initially requires a full medical assessment by an independent
    and objective healthcare professional (E). Professionally, she
    may benefi t from the advice and support of her Educational Supervisor
    who has responsibility for her pastoral care (F). It is also reasonable to
    off er your own time and attention if she feels that she can speak freely
    to you (C), but you should avoid false reassurances (A).

Question 17

17. You are reviewing your patients on the ward round, and Mrs
    Egbert asks if you will need to perform another examination
    ‘down below’ as it was uncomfortable yesterday. You cannot understand
    why this was performed during the SHO’s ward round, and the examination
    had not been detailed in the medical notes.
    Choose the THREE most appropriate actions to take in this situation
    A Inform the vulnerable adults’ nurse.
    B Inform your consultant.
    C Attempt to establish more detail about Mrs Egbert’s complaints and
    the nature of the examination.
    D Ask your SHO to describe his review of Mrs Egbert yesterday.
    E Speak to the SHO in front of the registrar at the evening handover.
    F Contact your Medical Director.
    G Inform the patient’s family about what has happened.
    H Ask the patient not to reveal any information about the incident to
    anyone else until her consultant has spoken to her.

Answer 17

17. B, C, D
    All health professionals have a duty to protect their patients, and we
    should always be aware of the potential risk to children and vulnerable
    adults. Nevertheless, we also have a duty to respect our colleagues, and
    in this scenario it would be inappropriate to raise a serious concern in
    front of an unnecessary audience (E) without fi rst establishing more
    information (C) and speaking to the SHO privately, as there may be a
    legitimate explanation (D). It is likely that your concerns will need escalation
    to your consultant (B), who might involve more senior colleagues if
    necessary, although this would not usually be something an FY1 doctor
    would organize themselves (A) (F). Informing the patient’s family before
    establishing all the facts is premature and risks unnecessarily compromising
    the patient’s trust if unfounded (G). If a serious assault has occurred,
    this would be managed by much more senior doctors and the hospital
    management. However, no doctor should conspire to silence patients
    and therefore should avoid telling patients what they can and cannot
    say (H).

Question 18

18. Despite your best eff orts, your Educational Supervisor refuses
    to see you because he is too busy. Eight weeks into your rotation,
    he eventually asks you to attend theatre and tries to complete your
    induction meeting between surgical cases but only manages to spend a
    few minutes talking to you. He concludes your brief encounter by asking
    you to sign an online educational agreement.
    Choose the THREE most appropriate actions to take in this situation
    A Sign the agreement, and go home and read it in more detail.
    B Do not sign the educational agreement.
    C Establish whether it will be possible to arrange a more eff ective meeting
    in the near future.
    D Ask your favourite consultant to act as your Educational Supervisor
    instead.
    E Ask your Clinical Supervisor to act as your Educational Supervisor
    instead.
    F Report your Educational Supervisor to the deanery.
    G Arrange a meeting with the Foundation Programme Director.
    H Persist with future brief meetings

Answer 18

18. B, C, G
    Your Educational Supervisor has responsibility for providing appropriate
    supervision. This includes fi nding time for regular meetings. The scenario
    suggests that you have made substantial eff orts to make alternative
    arrangements, without any meaningful success (H). You might wish to
    try again to arrange a more eff ective meeting (C); otherwise it appears
    reasonable to initiate the process of fi nding a suitable replacement (G). It
    would be irresponsible to sign an educational (or any other) agreement
    without being aware of its contents (A) (B). It is not your responsibility
    to ask another consultant to take over the role of Educational Supervisor
    (D) (E), and involving the deanery would not be a measured response
    at this stage (F).

Question 19

19. Your registrar asks you to prepare a presentation for the hospital
    grand round. You are very keen to present at the grand
    round, although eventually you realize that she intends to present the
    case in its entirety and merely wants you to do the preparation work.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Ask the registrar if you can present at least part of the case, as it will
    be good experience.
    B Ask the registrar to make a case presentation for you to present the
    following week.
    C Inform your consultant about your registrar’s lack of fairness.
    D Refuse to hand over the slides for the presentation.
    E Do nothing as she is your senior and there has been educational value
    in producing the slides.

Answer 19

19. A, E, B, D, C
    As a junior trainee, your control over a project may not always correlate
    with your eff orts. This should not preclude you from striving for fairness.
    In this instance, your hard work might be compensated with the chance
    to present some of your work, and so (A) is the best answer. Although
    there is value in preparing a presentation, doing nothing is only an option
    if you are somehow acknowledged in the presentation, to avoid the
    charge of dishonesty (E). This would still be a more measured response
    than those remaining. (B) is incorrect as it is probably unreasonable to expect your registrar
    to prepare a presentation for you the following week, although this
    might lead to genuine collaboration on further presentations. However,
    it would not be as bad as refusing to share your slides (D) or, worse,
    escalating unnecessarily to your consultant (C).

Question 20

20. Your registrar suff ers from refl ux disease and is experiencing
    very bad heartburn after lunch. His symptoms stop him from
    carrying out the ward round. He informs a nurse he forgot to take his
    usual proton pump inhibitor (PPI) that morning and is given omeprazole
    from the drug cabinet.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Report the registrar for taking patient medication.
    B Suggest that he obtains the medication from A&E by admitting himself
    as a patient and having the medicine formally prescribed.
    C Off er to prescribe omeprazole for your registrar on a discharge summary
    prescription.
    D Reprimand the nurse who has given him the PPI.
    E Do nothing.

Answer 20

20. B, C, D, A, E
    Doctors should not treat themselves and taking medication from a drug
    cupboard is likely to contravene Trust policy. Ideally, the registrar should
    book in to A&E for an objective assessment if necessary to obtain a
    prescription drug (B). Although this is the best option, it might not be
    practical and you could alternatively prescribe omeprazole if you are
    willing to accept responsibility for the prescription (C). However, you
    should recall that symptoms of heartburn might indicate more serious
    pathology. (D) is a less positive step than suggesting the earlier alternative
    approaches, particularly as it is your registrar and not the nurse
    who has instigated this dilemma. However, speaking to those involved is
    preferable to escalating them prematurely (A). Doing nothing is, as usual,
    an unacceptable response (E).

Question 21

21. You overhear a conversation between two of your foundation
    colleagues, Peter and James. Peter describes receiving a police
    caution the previous weekend during a raucous outing that followed a
    stressful week of on-call nights. The nature of the off ence sounds fairly
    benign, but it does not seem as if your colleague has any intention of
    informing anybody else.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Tell Peter that you will be informing the GMC.
    B Arrange a meeting with Peter’s Educational Supervisor to discuss what
    you heard.
    C Speak to Peter about what you have heard, and whether he is aware
    of the guidance related to receiving cautions.
    D Do nothing as the off ence sounds relatively benign and no harm has
    been done.
    E Speak to James, and establish more details about the nature of the
    events.

Answer 21

21. C, B, A, E, D
    GMC guidance states that all doctors must declare any caution or criminal
    conviction received anywhere in the world. Your professional relationship
    is most likely to be preserved by speaking to Peter and encouraging
    him to inform the GMC himself (C), or (less good) via his Educational
    Supervisor (B), before you consider declaring it yourself (A). Speaking to
    James will not change the situation as any caution that is received must
    be declared irrespective of the nature of the criminal off ence (E). For
    this reason, (E) is a worse answer than the three which involve someone
    informing the GMC. (D) is last as it contravenes GMC guidance and
    misses an opportunity to help your colleague ensure he does not fi nd
    himself in additional trouble later on.

Question 22

22. You learn that your colleague is struggling to cannulate patients,
    despite being in his second FY1 placement.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Help to train your colleague by guiding him through cannulation and
    practising in the clinical skills laboratory.
    B Ignore the problem unless a serious incident occurs.
    C Tell your colleague to ask a senior for help.
    D Fast-bleep the consultant in order to share your concerns with him.
    E Email his Clinical Supervisor.

Answer 22

22. A, C, E, B, D
    It is not obvious from this scenario that there is any immediate danger to
    patients, although cannulation is a fundamental skill for any junior doctor
    and your colleague must learn to master it quickly. Hence, if it is possible
    to train him to cannulate eff ectively yourself, with minimal disruption to
    your duties, this should be attempted in the fi rst instance (A). Although
    taking responsibility yourself (A) is preferable, seeking senior guidance
    might also be appropriate, in which case it is better to encourage your
    colleague to seek help (C) rather than impose it upon him (E). (B) is
    incorrect but is unlikely to cause serious harm, as people learn skills at
    diff erent rates and others are also in a position to help your colleague.
    The worst answer in this case is (D) as the problem is not one that
    could be resolved immediately, and it does not warrant fast-bleeping
    your consultant.

Question 23

23. You are assisting a senior registrar in theatre during an inguinal
    hernia repair. You have seen a lot of hernia repairs during your
    training, and you are certain that the registrar has inadvertently tied off
    the vas deferens during this operation. Your registrar denies this but,
    when you ask him to identify the vas, he does not respond convincingly.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Accept that your registrar is much more experienced and probably
    correct.
    B Ask the anaesthetist to become involved.
    C Allow the procedure to be completed before raising the issue with the
    consultant in charge.
    D Insist that the surgeon stops as you are confi dent that a mistake has
    been made.
    E Leave the operating table and contact the consultant, asking him to
    attend the theatre

Answer 23

23. D, E, B, C, A
    This is a very challenging situation, which depends on a number of factors,
    particularly how confi dent you are that a mistake has been made
    and whether this can be reversed if correctly identifi ed intraoperatively.
    This is an issue of patient safety and you have a duty to raise concerns
    immediately to ensure the best possible chance of rectifying the error.
    The best person to raise your concern with initially is the operating surgeon,
    in this case the registrar (D). (E) addresses the problem intraoperatively
    but leaves the surgeon unassisted and could be very embarrassing
    if your concerns prove unfounded. For this reason it is worse than (D).
    (B) ranks lower because the anaesthesist is unlikely to have seen what
    happened or to want to become involved in any disagreement. However,
    they are a senior doctor and might contribute, e.g. by insisting that the
    consultant surgeon attend the operating theatre. However, waiting until
    after the operation (C) is worse if your opinion was strongly held as the
    immediate opportunity to rectify the error will have been missed. (A) is
    of course unacceptable as you must speak out if you believe a serious
    error has occurred.

Question 24

24. Jill is a specialist nurse on your renal team. She is very knowledgeable,
    but you feel that she can be overbearing in clinical
    situations and you frequently feel undermined in your position as a junior
    doctor.
    Choose the THREE most appropriate actions to take in this situation
    A Discuss your feelings with Jill and ask how she thinks you could overcome
    this diffi culty.
    B Remind Jill of your superior position as a doctor.
    C Adopt a more confi dent approach to patient care.
    D Try to gain Jill’s respect by fi nding an opportunity to challenge her clinical
    judgement and demonstrate your superior knowledge.
    E Adopt a more subordinate position as you are less experienced.
    F Speak to your senior colleagues for advice.
    G Ask the nursing staff whether they fi nd Jill diffi cult to work with.
    H Do nothing as long as her behaviour does not impact on clinical care.

Answer 24

24. A, C, F
    Although Jill probably brings a wealth of knowledge and experience to
    the team, it is also important to foster a positive environment in which
    all members of the team are respected. It may not immediately impact
    on patient care, but, indirectly, poor working relationships are likely
    to lead to less effi cient care in the long term and so the issue should
    be addressed (A) (H). Eff ective work within a multi-disciplinary team
    requires mutual respect, rather than trying to establish dominance or
    accepting subordination (B) (D) (E). Nevertheless, your position of
    equal worth within the team may be reiterated by adopting a more confi
    dent approach (C). Asking the nursing staff whether they fi nd Jill diffi cult
    to work with is a leading question, implies fault, and is unlikely to gain you
    favour with her colleagues (G). In any challenging scenario, it is rarely
    incorrect to approach a senior colleague for advice (F).

Question 25

25. Annabelle, the Ward Sister, has bleeped you and asks you
    to prescribe atenolol to a patient who is hypertensive. After
    reviewing the patient, you disagree and feel that antihypertensives are
    not clinically indicated. Annabelle is not convinced by your explanation,
    saying that in her ‘extensive experience’ they are needed.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Explain how and why you arrived at your decision not to prescribe
    antihypertensives.
    B Insist on your management plan as you are responsible for signing the
    prescription.
    C Agree to prescribe antihypertensives, but ask the patient’s GP to stop
    them on discharge.
    D Inform Annabelle that you will discuss the issue with a senior colleague,
    but that she should not give any medication for the time being.
    E Agree that she should give the medication but do not sign the
    prescription chart.

Answer 25

25. D, A, B, C, E
    Your response to Annabelle’s request must balance exercise of your
    clinical judgement with maintaining an eff ective working relationship.
    Given Annabelle’s confi dence in her judgement and the fact that she has
    not accepted your initial explanation, it may be sensible (and diplomatic)
    to discuss her concerns with a senior colleague at a convenient time (D).
    (A) is ranked lower only because it seems some attempt has already
    been made to explain your decision-making. Nevertheless, (A) is better
    than (B) as insisting seems unlikely to nurture a harmonious working
    relationship with an important colleague. (C) and (E) are both incorrect
    answers as you should never prescribe a drug that you do not believe is
    indicated. Prescribing them initially but stopping them later on (C) would
    be deceptive and confusing for the patient. However, the worst answer
    is (E) as you should never suggest that a drug is administered without a
    prescription.

Question 26

26. Vera is an elderly patient on the orthogeriatrics ward who is
    currently receiving 20 minutes of counselling a week from the
    psychologist. After reviewing her, you believe that she might benefi t from
    more regular counselling.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Speak to other multi-disciplinary team members before the weekly
    meeting to gauge their thoughts.
    B Invite Vera and her family to the multi-disciplinary team meeting to
    voice their concerns.
    C Continue with the psychologist’s current treatment plan.
    D Tell the psychologist he should visit Vera at least twice a week.
    E Ask the psychologist whether they think Vera might benefi t from
    additional input.

Answer 26

26. E, A, C, B, D
    You should respect the ability of colleagues to deliver their own specialist
    services and manage their workload. However, this must be balanced
    with a duty to advocate for your patient.
    In this case, you should speak to the psychologist to determine
    whether they are happy with their current input (E). They might agree
    or give reasons as to why so little time is being spent with Vera (e.g.
    volume of patients requiring attention or staffi ng pressures). (A) is also
    an acceptable approach, although (E) is better as the psychologist would
    be more likely to have an informed opinion than other members of the
    team. You could certainly accept the psychologist’s plan (they are likely
    to know best), but you have a duty to speak up if you think care could be
    improved, and so (C) is worse than (E) and (A).
    (B) and (D) are incorrect. Although patients can sometimes attend
    multi-disciplinary team meetings (B), this is unusual and probably inappropriate
    as other patients are usually discussed as well. In addition
    we are given no indication that Vera wants to attend or has indicated
    any concern about the amount of psychologist input she is receiving.
    However, the last answer is (D) as it is not your place to instruct the psychologist
    and such an intervention would probably not be well received.

Question 27

27. There is a cardiac arrest call in the outpatients clinic at the other
    side of the hospital. You arrive to fi nd a nurse performing chest
    compressions being watched by a domestic assistant and a fi nal-year
    medical student.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Instruct the medical student to take over chest compressions.
    B Encourage the medical student to lead the crash call to develop his
    leadership skills.
    C Instruct the domestic assistant to bring the crash trolley.
    D Instruct the medical student to bring the crash trolley, while you take
    over chest compressions.
    E Wait for instructions from the nurse doing compressions.

Answer 27

27. D, A, C, E, B
    The most appropriate person arriving at a cardiac arrest should assume
    the role of team leader. In most cases, this will be the most senior doctor
    present, even if that person is an FY1 doctor. A cardiac arrest should
    be managed according to established protocols. However, whether the
    arrest is successful depends in part on how well it is led and whether
    each team member’s skills are optimally utilized.
    In this case, the best answer is (D) as the nurse is likely to be
    exhausted at this point (possibly delivering ineff ective compressions)
    and the student should know what a crash trolley looks like. (A) is an
    acceptable alternative although there may be insuffi cient time to confi rm
    that the student is confi dent giving compressions and has good technique.
    (C) unfairly assumes that the domestic assistant would recognize
    a crash trolley and does not ensure relief of the nurse delivering chest
    compressions. As eff ective chest compressions are one of the most
    important components of managing a cardiac arrest, (C) is ranked lower
    than (D) and (A). (E) is incorrect as you should usually (unless the nurse
    is exceptionally qualifi ed, e.g. critical care outreach or a resuscitation
    offi cer) take responsibility for the situation. However, the worst answer
    is (B) as it would be inappropriate to encourage a student (particularly
    one you do not know) to lead the resuscitation eff ort.

Question 28

28. You are planning to review all your patients quickly before the
    consultant’s weekly ward round. The pharmacist insists that
    you immediately change all your ‘as required’ prescriptions of paracetamol
    from ‘1g qds’ to ‘500mg—1g qds’ according to a new Trust guideline.
    She says that she will have to call your consultant if you don’t do this
    immediately. You have no concerns about your original prescription, and
    there are 25 patients for whom this would need to be rewritten.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Tell the pharmacist to call your consultant as you have other tasks to
    complete before the ward round.
    B Explain to the pharmacist that there is no substantial diff erence
    between the prescriptions but that you will speak to your consultant
    when he begins the ward round.
    C Tell the pharmacist that you will correct your prescription charts
    immediately.
    D Tell the pharmacist that you will return after the ward round if possible
    to complete the task.
    E Tell the pharmacist that you will hand this over to the evening team.

Answer 28

28. B, D, A, C, E
    The pharmacist’s request appears unnecessary and at best non-urgent.
    Other healthcare professionals should not generally attempt to prioritize
    your work as no one else can fully appreciate the pressures on you at any
    one time. However, as the pharmacist is concerned, you should off er to raise the issue with a senior colleague at the fi rst convenient opportunity
    (B). An alternative approach would be to off er to complete the task later
    on (D) and this is only ranked lower because the task is non-urgent and
    you cannot guarantee that your priorities will not have changed by the end
    of the ward round. The pharmacist is unlikely to call your consultant to
    demand completion of a non-urgent task. However, challenging her to do
    so (A) would be incorrect as it risks escalating the situation and embroiling
    your consultant unnecessarily in the dispute. Nevertheless, this might
    be preferable to (C) which could mean neglecting important tasks (e.g.
    reviewing your patients so that the consultant can make better plans on
    his ward round) to keep the pharmacist happy. The worst answer is (E) as
    the on-call team is unlikely to be available for routine tasks, which risk
    distracting them from more urgent demands on the team’s time.

Question 29

29. You are working on a busy surgical on-call shift when you are
    bleeped for a fi fth time by a junior nurse for another ‘trivial’ task
    which could wait until the regular team arrives the following day.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Tell her not to phone you again.
    B Explain how few doctors are working out of hours and how to decide
    which jobs require urgent attention.
    C Go to the ward and ask the senior nurse to triage all further bleeps.
    D Take the referral and add it to your list of tasks.
    E Listen to the referral while asking for appropriate details.

Answer 29

29. E, B, D, C, A
    You must balance your workload against the risk of dissuading the nurse
    from bleeping doctors in future. The best answer is (E) as you are obliged
    to listen to the nurse so that she can be satisfi ed that you have all the
    details and to ensure that this really is another inappropriate bleep. It may,
    however, become appropriate to modify her expectations at some point
    (B) as she is possibly unaware of the skeleton medical team available out
    of hours, and this might be a valuable education point. (B) is worse than
    (E) as it is more important to listen and understand the nurse’s concern
    than to emphasize her inappropriate bleeping. Agreeing to complete an
    inappropriate task (D) risks neglecting other responsibilities and does not
    address the misunderstanding of which tasks need escalating to a doctor
    out of hours. For this reason, it is a less helpful response than (E) and (B).
    Senior nurses sometimes triage bleeps to reduce pressure on the medical
    team out of hours. However, if this is not already local policy, you risk
    antagonizing the ward staff by suggesting it (C) at this point. The worst
    answer is (A) as, next time, it might be a genuine emergency.

Question 30

30. You are confi dent that your patient requires an abdominal ultrasound
    scan but the radiologist has refused your request twice,
    initially because of insuffi cient clinical details, and then for unconvincing
    blood results. Your consultant has insisted that the scan is done today.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Speak to another radiologist.
    B Explain that your consultant has examined the patient and, unless the
    radiologist is willing to do the same, he should accept the request.
    C Ask your consultant for advice.
    D Take the medical notes and go to speak with the radiologist in person.
    E Do not order the ultrasound scan.

Answer 30

30. C, D, A, B, E
    The radiologist must also be satisfi ed that an investigation is indicated
    before agreeing that it should take place. This can lead to diffi culties, as
    the most junior person on the team (who probably has the least understanding
    of why the scan is necessary) is often expected to communicate
    with the radiology consultant.
    The best answer is (C) as your consultant might clarify his particular
    reason for needing an ultrasound scan or think of a diff erent approach
    to the same problem. (D) is a less appropriate response and will only
    help if you are armed with additional information—simply harassing the
    radiologist to accept your request is unlikely to succeed. However, (A) is
    incorrect as it is bad form to speak to another consultant as a way of
    skirting a decision made by their colleague. (A) is only marginally better
    than (B) if only because the latter is unlikely to succeed and may
    jeopardize any future working with this radiologist. The worst answer is
    (E) as simply accepting the radiologist’s refusal without informing your
    team risks your patient’s well-being by depriving them of a potentially
    important investigation.

Question 31

31. While working as the surgical FY1 doctor over the weekend,
    you are asked to complete a discharge letter for a patient
    whom you have never met. After searching his medical notes, you are
    unable to fi nd any clear plan for follow-up. The Ward Sister is unsure,
    and the registrar is in emergency theatre. The patient and his family are
    insistent on leaving as they have waited more than four hours for his
    discharge letter.
    Choose the THREE most appropriate actions to take in this situation
    A Keep trying to contact your surgical registrar.
    B Apologize for the delay and explain that you have been seeing unwell
    patients for the last few hours.
    C Ask the patient to telephone the consultant’s secretary in two weeks
    if he has not received a follow-up appointment.
    D Book a routine postoperative clinic appointment with the consultant
    in six weeks.
    E Leave a clear note for the attention of the surgical team asking them
    to contact the patient to arrange further follow-up.
    F Ask the GP to decide the follow-up.
    G Ask the medical registrar for advice.
    H Ask the patient to sign a disclaimer stating he is leaving against medical
    advice.

Answer 31

31. B, C, E
    Although a discharge summary is clinically non-urgent, the patient has
    already been put to some inconvenience waiting for it to be completed.
    The regular team should have anticipated a weekend discharge and
    already completed the paperwork.
    You should certainly apologize for the delay so that it is clear that
    the wait was necessary (B). You could complete the discharge summary
    from the notes to the best of your ability but ask the regular team to
    make arrangements for follow-up (E). This will prevent the patient from
    having to attend an appointment unnecessarily or being prematurely discharged
    from surgical care. Although asking the patient to contact the
    team (C) might challenge his faith in the system, it is an honest approach
    and adds another layer of reassurance that follow-up will take place.
    As the discharge summary is clinically non-urgent, you should not interrupt
    the surgical registrar in theatre (A). Neither the medical registrar
    (G) nor the GP (F) should be expected to determine the appropriateness
    of surgical follow-up. A routine follow-up appointment (D) might
    ensure further contact with the surgical team but may unnecessarily
    waste everyone’s time.
    The patient should not be asked to self-discharge (H) as the only reason
    for him to remain in hospital is administrative.

Question 32

32. You are trying to arrange two weeks of annual leave in six
    months’ time to attend your friend’s wedding abroad. Despite
    emailing and telephoning the rota coordinator at the hospital where you
    will be working, you have been unable to secure the time off .
    Choose the THREE most appropriate actions to take in this situation
    A Write a formal letter of complaint to the hospital.
    B Try to arrange cover by swapping your annual leave with a colleague
    once the rota is published.
    C Inform your future Clinical Supervisor that you will be requesting
    annual leave.
    D Send a further email to the rota coordinator, copying in anyone else
    who might be able to help, such as the Human Resources representative
    looking after new foundation doctors.
    E Contact a locum agency to assess the cost and availability of cover.
    F Do not make any further attempts to arrange your leave for fear of
    antagonizing the rota coordinator.
    G Cancel your plans to attend the wedding.
    H Inform your current Clinical Supervisor.

Answer 32

32. B, C, D
    Booking annual leave in advance can be diffi cult as rotas are not published
    and you might not be currently based at the hospital concerned.
    However, this should not be an impenetrable barrier and you are entitled
    to make annual leave requests in advance (F) (G). You should aim to
    let all appropriate people at the hospital know your intention so that
    workforce arrangements can be made. These people are likely to include
    (at a minimum) your new Clinical Supervisor (C) and the rota coordinator
    (D). Once the rota is published, you will be responsible for arranging
    to swap any on-call shifts (B).
    Your current Clinical Supervisor is unlikely to have very much infl uence,
    particularly if your leave request involves a diff erent hospital (H).
    A formal letter of complaint (A) is unlikely to have much impact, might
    antagonize future colleagues, and will not change the annual leave policy.
    It is not your responsibility to arrange locum cover for any shifts that you
    might miss (E).

Question 33

33. After the afternoon surgical ward round, you have amassed a
    long list of tasks. These include seven venepunctures and an
    outpatient venesection which was scheduled for an hour ago, two cannulas,
    and three discharge summaries. You consider how you will complete
    these tasks.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Bleep the phlebotomy team to ask for assistance while you approach
    the outpatient venesection.
    B Attend the outpatient department where you were scheduled to perform
    a venesection an hour ago, and then prioritize the other tasks.
    C Hand over your list of jobs to the ward nurse and ask her to bleep you
    if there are any problems.
    D Head to the coff ee shop with FY1 friends to prioritize your tasks and
    recruit help if possible.
    E Ask another FY1 colleague for help.

Answer 33

33. A, E, B, C, D
    The two most important qualities of an FY1 doctor are eff ective communication
    skills and an ability to prioritize. (A) is the best answer as
    informing the phlebotomy team about your dilemma early on increases
    the likelihood of them being able to help. Similarly, another FY1 doctor
    might be willing to help (E) although this is less ideal as they are likely to
    have their own tasks to complete. Both answers are, however, better
    than (B) as they might save you from falling behind on other tasks later if
    others are able to help. (C) and (D) are incorrect. It would be inappropriate, and unlikely to
    foster positive working relationships, if you were to hand over your tasks
    to the ward team (C). However, you might enlist the help of nurses who
    are able to take blood if they are available to do so. Although it is worth
    taking a few minutes to prioritize tasks, taking a coff ee break at this point
    (D) would waste time and risk leaving a patient waiting unnecessarily in
    the outpatient department. For this reason, (D) is ranked last.

Question 34

34. As the FY1 doctor in gastroenterology, you are arranging the
    discharge of a patient who is dependent on alcohol and was
    admitted with symptoms of withdrawal. He has many social problems,
    including unemployment and long-term disability. In an eff ort to maintain
    abstinence from alcohol, you consider the diff erent healthcare professionals
    you will need to involve, as well as outpatient follow-up with your
    consultant.
    Choose the THREE most appropriate in this situation
    A Ward Sister working on the admitting ward.
    B General practitioner.
    C Drug and alcohol liaison offi cer.
    D Housing assistant.
    E Social worker.
    F Citizen’s Advice Bureau.
    G Psychologist.
    H Liver transplant services.

Answer 34

34. B, C, E
    Your patient may benefi t from all manner of services but you must balance
    this against the appropriateness of each referral.
    The patient’s GP (B) will provide long-term follow-up and will be able
    to access many diff erent services of potential benefi t to your patient. He
    may also require specialist drug and alcohol input which can be provided
    by an appropriately qualifi ed person (C). A social worker (E) could also
    help assess the patient’s need for additional services.
    The Ward Sister is not likely to expect continued involvement with
    this man unless he becomes an inpatient again (A). Similarly, there is no
    reason to think that he would benefi t substantially from housing services
    (D), the Citizen’s Advice Bureau (F), a psychologist (G), or the transplant
    service (H). These may become necessary in future, which is all the more
    reason to ensure that he remains engaged with key people such as his
    GP and social services.

Question 35

35. You are coming to the end of your fi rst FY1 rotation in endocrinology.
    The job was challenging and you felt inadequately
    prepared for many of the responsibilities during induction. You consider
    how you might go about helping your successor.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Feed back your thoughts on the induction to your Clinical Supervisor
    during your fi nal meeting.
    B Write a list of useful tips for your successor.
    C Take a week off your next rotation to help support your successor
    during their fi rst week.
    D Leave your mobile phone number for your successor to contact you
    if they encounter diffi culties.
    E Leave the induction process to the Foundation Programme
    management team.

Answer 35

35. A, B, D, E, C
    Handover is not only important between shifts but it is also necessary
    when moving jobs. You should endeavour to leave all routine tasks completed
    and a clear set of instructions for your successor.
    If there are ways of improving the induction process, you should let an
    appropriate person (e.g. your Clinical Supervisor) know (A). They will
    provide continuity between trainees and are best placed to ensure the
    induction process is improved based on your feedback. (B) is also appropriate
    so your successor inherits your hard-won tips, such as schedules
    and useful bleep numbers. (B) is ranked lower than (A) only because
    an improved induction process will ensure benefi ts for trainees at every
    stage, not just your immediate successor. (D) is a great idea but in isolation
    cannot be better than (B) or (A).
    (E) and (C) are both incorrect. (E) is unhelpful as the Foundation
    Programme cannot provide the post-specifi c advice that is likely to be
    most useful to your successor. It therefore misses an opportunity to help
    your successor and their patients. (C) is the worst answer because it is
    excessive, defeats the purpose of annual leave (rest and recuperation!),
    and perhaps most importantly would disrupt your new team which
    would have to cope without its FY1 doctor in the fi rst week.

Question 36

36. Your SHO has a habit of sending text messages on his phone
    during the ward round. Your consultant has not noticed, but
    you have seen a number of patients and relatives appear less than
    impressed with his inattention.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Let the SHO know that others have noticed him sending text messages.
    B Ask the SHO whether everything is OK.
    C Suggest that the SHO put his phone away immediately.
    D Inform the consultant.
    E Initiate a ‘politeness code’, including a rule against excessive texting,
    which all members of the team should sign.

Answer 36

36. B, A, C, D, E
    Although people will have diff erent priorities, a minimum standard of
    professional behaviour is expected of all doctors. It is usually possible to enforce this (largely unwritten) code of behaviour informally. In this
    case, the transgression is relatively minor and so calls for a measured
    approach. (B) is the best answer as it raises the issue discreetly in a way
    that would allow your SHO to modify his behaviour without embarrassment.
    There may actually be a problem (e.g. an emergency at home) and
    he might elect to leave the ward round. (A) is ranked lower than (B) as
    it is more direct and could lead to defensiveness in some colleagues.
    (C) ranks lower than (A) for the same reason, i.e. it is excessively direct.
    (D) and (E) are incorrect as they are not measured responses to a relatively
    minor problem. (E) is particularly excessive and is unlikely to garner
    much support from other members of your clinical team.

Question 37

37. You are working on a busy medical ward which is famously
    understaff ed. Since your new SHO started the rotation two
    weeks ago, she has left work 45 minutes early every day to collect her
    children from school. You are working until 8 p.m. most days and still feel
    that you are not on top of the workload.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Ask her to cover you for the fi rst 45 minutes of your shift.
    B Ask her to work during her lunch break to make up the missing time.
    C Arrange a meeting with your consultant to discuss her early departure.
    D Tell the SHO that you will be informing the consultant unless she is able
    to make alternative arrangements for the collection of her children.
    E Establish whether the childcare arrangements are temporary.

Answer 37

37. E, D, C, B, A
    In any diffi cult situation involving colleagues, it is important to establish
    the facts early on. For this reason, (E) is the best answer. You might be
    willing to help out your SHO if there is a temporary problem with childcare,
    but she will be working normal hours in the near future. However,
    it might become necessary to confront the SHO and make it clear that
    you are unwilling to accept the current arrangement (D) which risks
    patient safety and your own well-being. (D) is ranked lower as (E) is
    more likely to resolve the issue to everyone’s satisfaction without causing
    unnecessary ill feeling. (C) may become necessary later on but is a
    worse initial response than (D). If the matter cannot be resolved through
    discussion, it must be escalated to your consultant. (B) is the fi rst wrong
    answer. Although time might be made up elsewhere, working through
    lunch is not an optimal long-term strategy and should not be imposed on
    the SHO, particularly by the FY1 doctor. The worst answer is (A) as it
    leaves only one doctor on site for 1.5 hours every day.

Question 38

38. Your registrar is known for his strong opinions. As an aside
    from the ward round, he tells the group of juniors that migrants
    from Eastern Europe are stretching the NHS to breaking point. You are
    aware of a Polish patient nearby who is listening intently and appears to
    be taking off ence.
    Choose the THREE most appropriate actions to take in this situation
    A Apologize to the patient for your registrar’s comments.
    B Try to move the ward round on to the next patient.
    C Challenge the registrar’s viewpoint by outlining the contribution immigrants
    have made to the NHS.
    D Agree with the registrar to appease him and move the ward round on.
    E Speak to the registrar privately after the ward round about how you
    felt that the patient was reacting.
    F Leave the round to speak to the consultant.
    G Share your concerns with the consultant if your registrar does not
    become more sensitive.
    H Return to the patient after the ward round to suggest that they make
    a formal complaint.

Answer 38

38. B, E, G
    The immediate goal should be to de-escalate what could become an
    infl ammatory situation if an argument was to develop. Your best move
    would be to steer the ward round back to its original business of reviewing
    patients (B). However, you should also let the registrar know afterwards
    that his behaviour raised concerns (E). If this is unsuccessful, the
    matter should be raised with your consultant (G).
    You should avoid becoming embroiled in controversial discussions
    when these are likely to cause off ence in the workplace. This includes
    agreeing (D) or disagreeing (C) with the registrar.
    It would be an overreaction to leave the ward round (F) or apologize
    on your registrar’s behalf (A), although he might wish to approach the
    patient after you have brought the issue to his attention. Similarly, you
    should not usually solicit complaints from patients about colleagues (H).

Question 39

39. A fellow FY1 doctor regularly takes home surgical supplies (e.g.
    disposable tools and sutures) to practise surgical skills.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Speak to the theatre manager about equipment being taken
    inappropriately.
    B Insist that if your colleague continues to take hospital property you
    will have to report him.
    C Email his Clinical Supervisor with the details.
    D Do nothing as it is good that your colleague is practising to become a
    better doctor.
    E Insist that he returns the hospital property immediately.

Answer 39

39. E, B, A, C, D
    Dishonest removal of hospital equipment constitutes theft with its
    attendant legal and professional consequences. The situation would be much diff erent if he had asked an appropriate person (e.g. theatre
    coordinator) and been given equipment with which to practise. The
    best answer is (E) as you should give your colleague an opportunity to
    recognize his actions were incorrect (he might not have thought through
    the consequences thoroughly) and return any remaining equipment.
    (B) is correct but would be unnecessarily confrontational as an initial
    response.
    You might wish to let the theatre manager know that property is going
    missing (A) so that items can be appropriately secured and warnings
    distributed to staff . However, (A) is not as good as (E) or (B) as it does
    not directly address the person responsible.
    Reporting your colleague outright (C) under these circumstances
    seems excessive as it is likely he has not thought through the consequences
    and does not view his behaviour as stealing. If he had stolen
    something more obvious (e.g. a hospital computer), you would clearly
    have to involve the hospital authorities early on.
    The worst answer is (D). Although a surgical registrar could perhaps
    argue that the Trust should make reasonable allowances for practice,
    this argument is rather less convincing for an FY1 doctor. Instead, he
    is forcing his employer to subsidize his further professional education
    without their agreement.

Question 40

40. It is the third consecutive week that your SHO has not covered
    your duties in the preoperative assessment clinic for an hour
    whilst you attend mandatory teaching. Each time she has arrived 30 minutes
    late, despite being given plenty of warning. She always says she has
    been busy with the ward patients.
    Choose the THREE most appropriate actions to take in this situation
    A Leave the preoperative assessment clinic with instructions that the
    SHO should be bleeped if she does not arrive.
    B Bleep the registrar and ask her to contact the SHO before each teaching
    session.
    C Inform your Clinical Supervisor that you are not meeting teaching
    commitments because there is inadequate cover for your absence.
    D Ask a colleague to sign you into the teaching and pick up an extra
    handout.
    E Speak to your SHO to identify what is stopping her from arriving and
    whether her tasks can be reprioritized.
    F Email the teaching coordinator to explain your absence.
    G Arrange for the nurse specialist to cover your duties for the hour during
    teaching.
    H Ask the clinical secretaries to shorten the preoperative assessment
    clinics by an hour.

Answer 40

40. C, E, F
    Attending a set number of teaching sessions is a mandatory requirement
    for completion of FY1. If you identify diffi culties attending sessions,
    these must be raised early on so that you do not fi nd yourself in diffi culty
    towards the end of the year.
    You could certainly speak with the SHO to emphasize the importance
    of suffi cient cover so that you can attend teaching (E). However, the
    issue should be escalated swiftly if it persists. Your Clinical Supervisor
    (C) is a good place to start, followed by your Educational Supervisor if
    issues are still not resolved. It would also be polite to inform the teaching
    coordinator as well by way of apology for not arriving (F).
    You should not leave the clinic without cover, particularly if you doubt
    that your SHO will arrive on time (A). Similarly, you should not delegate
    to another healthcare professional (G) unless this has been agreed
    locally. The secretaries are unlikely to be able to manipulate the clinic
    volume without impacting on the elective operating list (H). Involving a
    senior doctor for the simple task of reminding your SHO is unlikely to
    be received well (B). Asking a colleague to sign you in to teaching casts
    doubt on both your own and your colleague’s probity (D).