Effective Communication

Question 1

1. You are covering medical wards at the weekend when you are
   asked by a nurse to speak to the relatives of a patient about his
   newly diagnosed malignancy. You have not met the patient before but
   are told that his relatives are very anxious.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Establish how much the relatives wish to know, and respond to their
   requests honestly and with compassion.
   B Politely decline to discuss the health of the patient without his explicit
   permission.
   C Ask the nurse to read the medical notes and speak to the family after
   doing so.
   D Explain that you do not know the patient and that they should speak
   to the regular ward team instead.
   E Collectively address both the patient’s and the family’s concerns, and
   answer each of their questions in turn.

Answer 1

1. B, E, D, C, A
   (B) is the only correct answer, as you do not know the patient, the relationship
   with their family, and what each party already knows about the
   condition. In most circumstances it is necessary to gain express consent
   before discussing with relatives, and this becomes even more important
   in the context of a serious discussion, e.g. a new diagnosis of cancer.
   Therefore (A) is the worst answer as it implies that you have not sought
   consent from the patient, despite subsequent steps being correct. By talking
   to the family in the presence of the patient, you are giving the patient
   an opportunity to indicate they are unhappy about further information
   being disclosed, and they are present when any information is shared.
   Therefore (E) is the next best answer. Although usually it would be more
   appropriate for the day team to deal with this as they know the case
   much better and can provide continuity, we are told the family is anxious
   and it would be inhumane to leave them uninformed if the patient
   agreed to a discussion at this time; hence (D) is less appropriate than (E).
   (C) is a bad option as this is not the nurse’s primary role and she should
   not be expected to take responsibility for informing the family about the
   patient’s signifi cant medical developments. However, (A) remains worse,
   as you are explicitly disclosing information without patient consent.

Question 2

2. You are a respiratory FY1 doctor and have inserted a number of
   chest drains before and have been asked to do so for a patient on
   your ward. Previous consents have always been obtained by diff erent
   doctors. You intend to obtain consent for this patient but recall that this
   can be found to be invalid afterwards unless the patient is warned about
   important complications.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Obtain verbal consent and document that the patient has been
   consented in the notes.
   B Obtain legal advice before consenting.
   C Obtain verbal consent with a nurse as a witness.
   D Complete a formal written consent form.
   E Refuse to complete the procedure as only SHO grade or above
   should consent.

Answer 2

2. D, A, C, E, B
   This question tests your understanding of the consent requirements
   for diff erent types of procedure. In general you should only consent a
   patient for a procedure that you are able to perform by yourself or have
   suffi cient understanding of the risks and benefi ts to counsel the patient.
   In this case a chest drain is an invasive procedure with potentially serious
   risks and it would be most appropriate to obtain formal written consent
   (D). The other answers are therefore incorrect; however the best of
   these is (A). (A) is better than (C) because a written record is less fallible
   than human memory, and you may not recall in years to come which
   nurse witnessed the conversation.
   Thorough documentation of consent is always mandatory and has to be
   the correct answer (D). (E) is clearly wrong as you are able to consent the
   patient for this procedure; however, (B) is in some ways worse, as it suggests
   a complete misunderstanding of what you should do when consenting
   patients for a relatively simple procedure that you are able to perform

Question 3

3. You are working as an FY1 doctor at night in the surgical assessment
   unit, when you are asked to clerk an elderly patient who is
   profoundly deaf and unable to write.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Attempt a brief verbal history.
   B Skip the history, and focus your management on the examination and
   investigations.
   C Do not attempt to clerk the patient without an interpreter present.
   D Complete your detailed history via handwritten questions.
   E Extrapolate a history based on the limited fi ndings of the ambulance
   crew on their initial assessment sheet.

Answer 3

3. D, E, B, A, C
   (D) is the best answer as it is important to adapt to individual patients’
   disabilities and ensure that they are not disadvantaged simply because a
   task might become harder. (E) is largely incorrect, although an attempt
   is being made to obtain a history and there may be useful collateralinformation in the handover sheet. (B) is a worse option as no sensible
   attempt is made at obtaining a history; however, the examination should
   be suffi cient to ensure that the patient is stable, which is your minimum
   duty in this case. (A) is unnecessary and will not yield any useful information
   with a profoundly deaf patient if you can communicate this way.
   (C) is clearly incorrect as it amounts to doing nothing at all, and may
   disadvantage the patient unnecessarily.

Question 4

4. Your next patient at the gynaecology clinic arrives with her
   brother-in-law, who explains that she is unable to speak any English.
   As you begin the interview you start to suspect that her brother-in-law
   is only communicating some of the information.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Reiterate to the brother-in-law that you need him to translate word for word.
   B Try to establish whether the patient is happy with her brother-in-law
   acting as interpreter.
   C Schedule another appointment with a formal interpreter.
   D Invite the clinic receptionist into the consultation as she claims to
   speak a similar language to the patient’s.
   E Ask the brother-in-law to leave and complete the consultation without
   any interpreter.

Answer 4

4. C, A, B, D, E
   The success of this interview relies on accurate translation of information.
   For this reason, the best answer which ensures you can communicate
   eff ectively with your patient is to arrange an interview with
   a professional interpreter present (C). The other options are less than
   ideal, but the next best is probably (A), to address the brother-in-law
   directly and insist that he translates word-for-word what is said, as this
   may achieve the desired outcome. The diffi culty arises because, once
   doubt has been raised about your ability to trust the brother-in-law’s
   translation, you are then unable to use him as a way of clarifying whether
   the patient is happy with him translating. (B) is therefore less eff ective.
   The diffi culty with (D) is that the receptionist speaks a similar language
   to the patient, which introduces another uncertain variable into this
   already complex scenario. Trying to ascertain the patient’s wishes even
   through the imperfect conditions of the brother-in-law is preferable to
   introducing a third party who may not be able to communicate with
   the third party at all or may introduce misunderstandings. The worst
   option is (E) as you are unlikely to fi nd that the consultation either fl ows
   or becomes more informative as you attempt communication with a
   patient who speaks a diff erent language.

Question 5

5. You are on a busy orthopaedic ward round with your consultant
   when a nurse mentions that one of your patients drinks 60 units of
   alcohol per week. He is scheduled for an elective knee replacement in
   two days but is otherwise fi t and healthy.
   Choose the THREE most appropriate actions to take in this situation
   A Ask the consultant to review the issue during the ward round.
   B Return to the patient after the ward round to discuss the matter further
   with him.
   C Prescribe Pabrinex and chlordiazepoxide while the consultant consents
   the patient.
   D Discuss the matter further with the patient during the ward round.
   E Tell the patient to stop drinking alcohol.
   F Mention the issue to the registrar after the ward round.
   G Ask the nurse to keep superfl uous information until after the ward
   round to avoid interruptions.
   H Inform the drug and alcohol services representative.

Answer 5

5. B, F, H
   Although alcohol intake my be pertinent to this elective admission, it can
   be addressed more eff ectively after the ward round (B). After your initial
   assessment, it may be advisable to inform your senior (F) and involve an
   alcohol services representative (H) if the patient agrees. You should not
   stop a busy ward round to address non-urgent issues (A) (D), blindly prescribe
   medication for alcohol withdrawal (C), or give the patient instructions
   without a full history (E). It would be unprofessional and unhelpful
   to discourage the nurse from sharing important information (G).

Question 6

6. A 50-year-old is admitted to hospital with a severe sudden-onset
   headache, which you think is probably a migraine. Your registrar
   asks you to telephone the on-call radiologist at home to authorize an
   urgent CT scan. You become distracted completing other jobs for the
   registrar and only remember to telephone the radiologist an hour later.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Inform the registrar about the delay, and phone the radiologist immediately
   to request the CT head scan.
   B Phone the radiologist and explain that the registrar only just asked you
   to arrange the CT scan.
   C Phone the radiologist and explain that the registrar wants the CT head
   scan but you think that it is likely to be a migraine.
   D Ask the registrar to call the consultant radiologist himself.
   E Phone your own consultant and ask for advice fi rst.

Answer 6

6. A, C, D, E, B
   The best answer is to be honest to your colleagues at all times (A). (C) is
   an unusual but acceptable way to approach radiology. It would be better
   to raise objections directly with your team, but you are being honest
   as you are not sure what the diagnosis is but are raising the concerns
   of your seniors and their request for a CT head scan. (D) is less good
   than (C) because, while still ensuring the scan is done, it will burden
   your registrar unnecessarily and is unlikely to expedite your scan, as theradiologist will understand the urgency of the indication if you explain
   the circumstances. The objective should be to obtain the scan as quickly
   as possible and (E) will not assist you with your cause in any way. (B) is
   the worst answer because lying to a colleague can never be justifi able.

Question 7

7. At the end of your shift, you are told that a new patient has arrived
   under the care of your team. The nurse reads a long list of jobs
   that need completing and asks if you would address these before leaving.
   This is the third consecutive day that you will leave the ward late.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Leave and review the jobs in the morning.
   B Review the jobs and perform those that will take less than 15 minutes.
   C Review the jobs that appear most urgent and complete these before
   handing over to the on-call doctor.
   D Ask the nurses to contact the on-call doctor who can then review the
   patient.
   E Ask the nurses to do what they can and to contact the on-call doctor
   if they feel that anything else must be done before the next morning.

Answer 7

7. C, D, E, B, A
   It is important that doctors do not routinely work beyond their
   required hours.
   This question is about distinguishing urgent hours which merit working
   out of hours, and routine tasks which are better delegated to a colleague.
   Therefore (C) is the best answer. (D) achieves the same goal
   but is less ideal as the on-call doctor may not be available immediately
   and urgent tasks may then be delayed. (E) is less ideal for the same reason
   as (D) in that urgent tasks may be delayed, but in addition a doctor
   must be asked to review this new patient who has arrived on the ward.
   (B) is incorrect because jobs are completed based on an arbitrary selfimposed
   time period rather than by clinical urgency. The worst option is
   to make no eff ort for the patient to be reviewed (A).

Question 8

8. You are the surgical FY1 doctor on call and are assessing an acutely
   unwell patient. This takes you until the end of your shift and leads
   to the accumulation of many ward jobs. The overnight surgical FY2 doctor
   to whom you hand over is infuriated with your ‘slow pace’ and threatens
   to complain to your consultant in the morning unless you assist her.
   Choose the THREE most appropriate actions to take in this situation
   A Apologize for your failure to complete the ward jobs.
   B Ask for feedback in order to improve your management and handover.
   C Off er to continue working up the previously unwell patient who is
   now stabilized.
   D Off er to assist with the ward jobs until she feels that the list of jobs has
   become more manageable.
   E Do not hand her any more jobs, in an eff ort to avoid antagonizing her.
   F Explain that you are unable to complete any more jobs now that your
   shift is over.
   G Phone the surgical registrar in order to help resolve the apparent
   confl ict.
   H Complain to her consultant in the morning.

Answer 8

8. A, B, F
   An apology may help to appease the situation (A) and the opportunity
   could be used as a learning exercise to obtain feedback on your
   performance (B). However, you should not be coerced into continuing
   working in this situation (F), and your only responsibility is to ensure that
   a thorough and safe handover is completed (E) so that the FY2 doctor
   can fi nish the remaining tasks herself (C) (D). It should not be necessary
   to involve the surgical registrar (G) or consultant (H) unless the situation
   could not otherwise be resolved.

Question 9

9. You are an FY1 doctor in rheumatology looking after a patient who
   is about to be discharged this afternoon. During his stay a CTPA
   was completed for chest pain which was negative but showed a lung
   mass of unknown signifi cance with a suggestion for interval scanning.
   Rank in order the following actions in response to this situation (1 = Most
   appropriate; 5 = Least appropriate)
   A Use capital letters in the discharge letter to highlight the incidental
   fi nding and requirement for an interval CT scan.
   B Phone the GP to inform them of this fi nding.
   C Explain the problem to the patient and ensure he sees his GP to
   arrange an interval CT scan.
   D Inform the ward clerk to relay the report fi ndings to the patient.
   E Advise that the patient returns to the rheumatology clinic to see your
   consultant for further review of the mass.

Answer 9

9. B, C, A, E, D
   The correct answer is (B) because a doctor-to-doctor handover will be
   most likely to ensure that this fi nding is not missed and clarifi es responsibility
   for following up the result of the interval CT scan. (C) is a less ideal
   option as it is less foolproof and places responsibility (perhaps unfairly)
   on the patient to ensure that interval CT scanning is arranged. However,
   it is better than (A) which, despite your heroic eff orts at highlighting the
   fi nding, is likely to be overlooked and could result in the patient being lost
   to follow up. Your rheumatology consultant is unlikely to be able to provide
   the required hospital follow up this patient may need, and this would
   be better managed by the GP (E). (D) is the worst answer because it is
   not the ward clerk’s responsibility and they are not suffi ciently qualifi ed
   to undertake this task.

Question 10

10. As the FY1 doctor for a medical team, you are seeing a patient
    for the fi rst time on the Monday ward round. You realize that
    the admitting doctors on Friday did not arrange a review by the weekend
    medical team, despite grossly abnormal blood results. What would you
    include as part of your written entry in the medical notes?
    Choose the THREE most appropriate in this situation
    A Your opinion as to whether it was appropriate to be reviewed by the
    weekend medical team.
    B ‘This patient was not seen by a weekend review team.’
    C Medical entries for the weekend by assessing the patient
    retrospectively.
    D Both Friday’s and Monday’s blood results.
    E Today’s blood results only.
    F Today’s management plan.
    G Avoid writing anything but review the patient.
    H Tell the patient that the doctors treating him initially had done so
    incorrectly.

Answer 10

10. B, D, F
    As part of your review, you should include the trend in blood results
    (D) rather than values from a single day (E), which are less informative.You should also document your current management plan (F). As a junior
    member of the team, you should avoid commenting on the perceived
    defi cits of colleagues (A) unless limiting yourself to factual statements
    (B). It is not possible to assess a patient retrospectively (C), and notes
    should only be written retrospectively if this is made very clear. It is never
    appropriate to avoid documenting your fi ndings (G) and rarely appropriate
    to undermine colleagues when talking to patients in this way (H).

Question 11

11. Your consultant asks you to insert a peripheral cannula into
    the vein of a large 14-year-old boy with learning diffi culties. His
    parents are very anxious about the procedure after the distress caused
    during previous attempts at venepuncture. They ask whether a sedative
    could be used just before the procedure.
    Choose the THREE most appropriate actions to take in this situation
    A Trick the boy into having the cannula inserted by hiding the equipment
    from him until the last possible moment.
    B Use a play therapist to familiarize the patient with the procedure, even
    though this might take several hours.
    C Explain to the parents that you will insert the cannula in the middle of
    the night when the patient is least likely to resist.
    D Explain to the parents that it would be safer to physically restrain
    the child.
    E Explore the anxieties of the parents before pursuing a mutually
    agreed plan.
    F Off er to use an intramuscular sedative to ‘help him sleep’ during the
    procedure.
    G Ask to cannulate the parents fi rst in order to demonstrate the procedure
    to the patient.
    H Talk to the patient to see how he would feel about the procedure.

Answer 11

11. B, E, H
    Play therapists are a particularly eff ective resource as they can invest
    appropriate time working with children to facilitate successful procedures
    (B). Before implementing any intervention, it is necessary to
    explore any concerns of the parents and/or patient and gain their cooperation
    (E). It is imperative to establish what the patient can comprehend,
    as learning diffi culties span a vast range of cognitive abilities (H).
    Tricking the patient into the procedure (A) or attempting it in the middle
    of the night (C) could jeopardize the relationship between clinicians and
    patient. It would be sensible to attempt options (B), (E), and (H) before
    resorting to restraints (D) or sedation (F). Inserting a cannula in parents
    is unnecessary, and is unlikely to alleviate the child’s concerns (G).

Question 12

12. You are involved in a clinical research project, taking consent
    for the collection of an additional oesophageal biopsy during
    oesophagogastroduodenoscopy (OGD). A patient with long-standing
    gastric refl ux disease arrives for her regular OGD. She is very pleasant
    and accommodating but is known to be anxious prior to OGD
    procedures.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A As she is anxious and unlikely to want further information, briefl y
    explain that she can help with medical research if she signs a
    consent form.
    B Explain the complications from the OGD, and how one additional
    biopsy adds very little to her total risk from the procedure.
    C Try to alleviate her future anxiety by explaining that she is participating
    in a trial that will eventually lead to the development of less invasive
    methods of oesophageal examination.
    D Take the extra biopsy, but wait until after the procedure to obtain
    consent from the patient and before using any of the samples for
    research.
    E Do not include the patient in the study, given her level of anxiety.

Answer 12

12. B, C, E, A, D
    A clinician of appropriate experience must consent the patient as usual
    for her OGD. However, you might be an appropriate person to consent
    the patient for the additional biopsy and participation in the trial. It
    is essential that additional consent is obtained, irrespective of her perceived
    anxieties; therefore (B) is the correct answer. (C) is a little unclear
    but is a fairly neutral statement in that you are not told whether the
    biopsy is going to go ahead or whether you are going to continue seeking
    consent. It cannot be far wrong to address the patient’s anxieties in this
    way, although obviously it does not directly address the current problem
    of seeking consent for the biopsy. It is, however, better than (E), which
    deprives the patient of participating in the trial and potentially weakens
    the study, but if you feel unable to proceed with the consent process and
    no one else is available to help then the patient must be excluded from
    the study. (A) and (D) are the worst answers; (A) is coercive and seeks
    to obtain inadequate consent, but this is marginally better than unlawfully
    removing a biopsy from the patient with no legitimate indication
    with no permission from the patient (D).

Question 13

13. You are looking after several unwell patients as the medical FY1
    doctor covering wards at the weekend when a Sister asks you
    for an urgent discharge summary to help relieve a bed crisis in the hospital.
    She sympathizes with your workload but insists that a discharge letter
    must be written immediately.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Acknowledge the severity of the bed crisis, but refer her to your registrar,
    explaining that you have more urgent matters to attend to.
    B Phone the registrar and ask if there are any spare junior doctors who
    can assist with your tasks.
    C Off er to write the discharge letter once you have stabilized your
    patients.
    D Ask the Ward Sister to complete the discharge letter but sign a blank
    copy in advance to expedite the discharge.
    E Take two minutes to write a brief discharge letter before returning to
    the care of your patients.

Answer 13

13. C, A, B, E, D
    Ensuring the prompt and eff ective discharge of patients is an important
    part of being an FY1 doctor. (C) is the best answer as you are being helpful
    and providing a realistic estimate of the delay before you will be able to
    complete the discharge letter and have correctly prioritized your unwell
    patients. (A) is slightly less helpful as it needlessly involves your registrar
    who is likely to be busy with other duties. (B) is a further attempt to assistbut is a more complex intervention than (C) and (A) and would be more
    appropriate if clinically urgent commitments were arising together. (E) is
    less than ideal because it implies that a discharge letter has been rushed
    and is shorter than it should otherwise be; however, depending on the
    case, a brief letter may be suffi cient to summarize the pertinent aspects
    of the patient’s care. It is certainly preferable to (D) which requires the
    Sister to complete a duty with which she is likely to be unfamiliar and putting
    your signature against a document you have not seen.

Question 14

14. A patient with newly diagnosed terminal lung cancer asks to
    see you on the general medicine ward. He would like to make
    a complaint about your registrar, whom he feels has failed to off er him
    treatment that might prolong his life.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Empathize with the patient’s traumatic experience and off er to raise
    the matter with the registrar and consultant.
    B Defend the registrar’s actions, highlighting their knowledge and experience,
    and the generally poor prognosis of most lung cancers irrespective
    of the treatment modality.
    C Explore the patient’s concerns further.
    D Inform the patient that you will refer him to the oncologist to consider
    chemo/radiotherapy.
    E Off er him the services of an appropriate religious leader to address
    any spiritual questions he may have.

Answer 14

14. C, A, B, E, D
    The key issues here are keeping an open mind while trying to support
    your colleague. (C) is clearly correct as there may well be a simple misunderstanding
    which can be clarifi ed, and you cannot proceed much further
    without understanding the patient’s concerns in detail. (A) is also clearly
    correct, although in itself does not off er you the best chance at resolving
    the issue as there has been no attempt to understand the complaint in
    any detail. (B) could represent many diff erent actions depending on your
    communication skills and approach to your patient. It may well be appropriate
    to explain to your patient that the registrar is a very senior doctor
    and that lung cancer is diffi cult to tolerate. But this seems unlikely to placate
    the patient completely and it is probable that some other intervention
    is also required (e.g. (C) and (A)). (E) and (D) are wrong. The patient
    has not indicated he has any spiritual questions at the moment or would
    like to meet a spiritual leader; however, this is perhaps less incorrect than
    (D) as it is not the role of the FY1 doctor to refer for a treatment which
    it sounds as if your seniors have deemed to be inappropriate.

Question 15

15. You are working in a team of three surgical FY1 doctors. Tim,
    one of the surgical FY1 doctors, leaves the ward on time every
    day but routinely fails to complete his daily tasks. You decide to address
    the matter after leaving another shift more than an hour late in order to
    complete Tim’s tasks.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Share any additional workload between yourself and the other surgical
    FY1 doctor without involving Tim in the matter.
    B Inform Tim of your additional workload and ask him whether he is
    experiencing any diffi culties in completing his routine jobs.
    C Speak to your other surgical FY1 colleague and encourage her not to
    complete Tim’s routine tasks.
    D Demand that Tim arranges a meeting with his foundation and clinical
    supervisors in order to ‘address his failings’.
    E Inform your consultant.

Answer 15

15. B, E, A, D, C
    The correct answer is (B) as it allows you to identify if there are any
    problems or diffi culties that might be impacting on Tim’s performance,
    as well as ensuring he is aware of the developing situation. This is better
    than (E) as it attempts to resolve the problem itself. (A) is the fi rst incorrect
    answer as it fails to address the underlying problem, although it does
    ensure that the work is completed. (D) and (C) are not constructive suggestions;
    (D) is unlikely to yield a positive result because of the approach
    taken, but (C) could easily be interpreted as vindictive, working behind
    Tim’s back, and could result in important tasks going uncompleted.

Question 16

16. Phlebotomy rounds have been cancelled. You delegate venesection
    to your ward team. A nurse refuses to take blood from
    a patient who is being investigated for HIV.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Explain the ethical responsibility of medical staff to all patients.
    B Demand that the nurse attempts to take the blood sample or else she
    will be reported.
    C Ask about her concerns about the task and what could be done to
    improve her confi dence in this situation.
    D Take the sample yourself.
    E Instruct another nurse to take the sample, but avoid telling them
    about the patient’s possible HIV status to avoid frightening them.

Answer 16

16. C, D, A, B, E
    In any scenario where a colleague voices concerns, you should explore
    these further to identify ways of alleviating the problem; therefore (C) is
    the correct answer. (D) is the next best answer as it achieves an outcome.
    The reason that (A) is not better than (D) by itself is that it is a
    statement of principle and does not resolve the problem at hand. (B) is
    wrong because you are not in a position to demand that your colleague
    must perform a particular task, and it is likely to lead to a poor outcome.
    (E) is the worst answer because it unnecessarily misleads a colleague and
    exposes them to a health risk.

Question 17

17. You are preparing to fi nish your ward shift and must leave on
    time to catch a fl ight to the test centre, where you are due to
    sit an important examination. There are still two patients left to see as
    part of your ward round. Both are stable and awaiting input from social
    services, but your visit is likely to be prolonged by family members who
    are currently visiting.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Perform a quick examination of each patient without speaking to
    them or their families.
    B See the patients but explain that you cannot spend much time with
    their relatives today, and that someone will be available to answer
    questions tomorrow.
    C Ask the nurses to remove the families before briefl y reviewing each
    patient.
    D Assess the patients as usual and answer any questions the family
    members may have, even if this results in missing your fl ight.
    E Explain to the nurses that the patients will be seen on tomorrow’s
    ward round, and catch your fl ight.

Answer 17

17. B, A, D, C, E
    Ward duties must be completed to ensure that patients are safe. In
    this scenario, you should complete your ward round but postpone any
    non-urgent discussions until the following day. For this reason, (B) is correct.
    The other answers are incorrect to various degrees. (A) is the best
    of these as it at least allows you to exclude any immediate clinical concerns
    about the patient, even if it is impolite.
    It is diffi cult to decide between missing your own fl ight (D) and asking
    the nurses to remove the families (C), which is impolite. Which of these
    options is worse will depend on a number of factors. However, it is not
    without precedent to ask for a few moments alone with a patient and
    this is unlikely to cause much distress if done politely. For this reason, it
    might be preferable to do this than stay late for a non-urgent task and be
    penalized for doing so by missing your examination.
    The worst answer is (E) as by not seeing the patients at all over the
    course of a day you could miss their slow deterioration.

Question 18

18. You are interested in orthopaedic surgery and have been
    asked to ‘scrub in’ and assist with a total knee replacement.
    The orthopaedic surgeon is willing to spend longer with you in theatre
    provided that you consent the patient. You have not obtained consent
    for a surgical procedure before, but understand about some possible
    complications.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Admit to the patient that you are unfamiliar with consenting for the
    procedure but that he can ask the consultant later on if he has questions
    that you cannot answer.
    B Attempt to consent the patient, and refer any specifi c questions to the
    anaesthetist who will conduct a preoperative assessment later on.
    C Refuse to consent the patient.
    D Ask the consultant to run through the procedure with you before
    consenting the patient.
    E Ask the surgical registrar to consent the patient

Answer 18

18. C, D, E, A, B
    GMC guidelines require consent for operations to be taken by someone
    competent to perform the procedure or an appropriate delegate.
    The latter must be suffi ciently well informed to act as such, and this is
    likely to exclude FY1 doctors for complex operations such as total knee
    replacement. The best answer is (C), as in similar questions in other
    chapters, as you are not suffi ciently well informed to counsel a patient
    thoroughly. All of the remaining answers are wrong as they involve you
    obtaining consent for the operation which you must not do. (D) would
    be the least inappropriate as it involves you essentially translating information
    directly from a suitably qualifi ed person. The next ‘best’ option
    might be speaking to the general surgical registrar (E), not because they
    are able (or likely) to consent the patient but because they are a senior
    doctor with experience of the consent process and are likely to set you
    on the right track, e.g. reminding you that you must not consent the
    patient for this operation. (A) and (B) are most incorrect because they
    involve you attempting to directly consent the patient, although (A) is
    marginally better as you have at least tried to involve a more senior
    doctor.

Question 19

19. You are asked to speak to a new patient who is a suspected
    intravenous drug user and has been admitted recently following
    an opiate overdose. He has repeatedly been asked to stay in bed but
    continues to wander and demands to be allowed to leave.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Explain the nature of his admission and the dangers of discharge, and
    reiterate the risk of death if he were to self-discharge.
    B Explore his reasons for wanting to self-discharge.
    C Obtain the details of his family and ask them to get involved.
    D Address any concerns or approaches adopted by the nursing staff that
    may be antagonizing the patient.
    E Do not attempt to engage with a person who has recently used intravenous
    drugs, as they are unlikely to be cooperative.

Answer 19

19. A, B, D, C, E
    The best answer is (A). It might be tempting to answer (B) fi rst as this
    is naturally the fi rst thing you would do before (A). However, as a single
    intervention, (A) is more likely to achieve your aim and at least ensures
    you have discharged the most important aspect of your responsibility to
    keep the patient informed. (D) seems less likely to solve the problem as
    it assumes that the nurses are somehow responsible for his agitation. You
    have been given no reason in the question to think this might be true.
    (C) and (E) are clearly incorrect. (E) is the worst because you cannot
    choose to treat patients less favourably based on their lifestyle
    choices.

Question 20

20. You have been asked to complete a death certifi cate for a
    patient whose care you were briefl y involved in during the last
    few days of his life. There were no suspicious circumstances surrounding
    his death, but you are unclear about its precise cause. The mortuary
    staff suggest that you speak with someone else fi rst if you are not sure.
    Choose the THREE most appropriate actions to take in this situation
    A Telephone your consultant.
    B Telephone your registrar.
    C Telephone the duty pathologist.
    D Telephone the coroner’s offi cer.
    E Contact the ward clerk.
    F Contact the nursing staff who looked after the patient.
    G Telephone the patient’s next of kin.
    H Telephone the local police.

Answer 20

20. A, B, C
    Death certifi cates must be completed accurately as they are a legal
    record. Senior members of your team (A) (B) are most likely to have
    a clear idea of the precise cause. A pathologist (C) could help separate
    multiple complicated circumstances into causes acceptable to the registrar
    of deaths. The other people listed might contribute under specifi c
    circumstances but would not routinely be contacted to establish cause
    of death (D) (E) (F) (G) (H).

Question 21

21. You are clerking a young child in A&E who has been admitted
    with suspected bronchiolitis. Physical examination is unremarkable
    except for a moderate wheeze, although you note that the parents
    appear somewhat unkempt, with dirty hands and clothes. You consider
    what to document as part of your fi ndings in the medical notes.
    Rank in order the following in response to this situation (1 = Most appropriate;
    5 = Least appropriate)
    A Your opinion of the parents’ treatment of the child, based on their
    appearance.
    B Detailed physical examination and objective clinical assessment of
    the child.
    C A brief summary of your clinical assessment.
    D Complete your notes after they have been confi rmed by a senior.
    E Complete your notes later on after getting through a few more
    patients, to keep the clinic moving.

Answer 21

21. B, C, E, D, A
    The minimum you should document in the notes is your fi ndings on
    examination, and therefore (B) has to be correct. It is better than (C) as,
    by defi nition, it off ers a more detailed account of your fi ndings than a
    brief summary. (E) is worse as documentation should ideally be contemporaneous
    to ensure maximum accuracy, and you should not usually see
    other routine cases before writing in the notes for this child. (D) is wrong
    as your assessment does not require input from a senior, and represents
    a greater transgression than (E) as your notes should never be modifi ed
    by anyone else’s opinion. The worst answer is (A) as it is opinionated and
    prejudiced, and you should confi ne yourself to objective statements and
    not infer too many details from the parents’ appearance.

Question 22

22. You are working as the only junior doctor for the orthogeriatric
    team, assessing a patient who has had a fall. You are bleeped
    by a nurse on another ward about one of your outliers who has become
    febrile. While you are taking this call, your crash bleep starts to sound.
    Rank in order the following actions in response to this situation (1 = Most
    appropriate; 5 = Least appropriate)
    A Document your current assessment of the patient who has fallen and
    then attend your other commitments.
    B Attend the crash call and then return to write in the notes
    retrospectively for the fallen patient.
    C Attend the crash call and then see the pyrexial patient before documenting
    your assessment of the patient who fell.
    D Avoid documenting the fallen patient as you are likely to be distracted
    by other tasks after attending the crash call and seeing the pyrexial
    patient.
    E Allow other members of the crash team to attend the arrest while
    you complete all your documentation.

Answer 22

22. C, B, D, A, E
    Documentation is important but must be prioritized after emergencies.
    You should attend the crash call, even though other doctors will
    do so, unless another emergency prevents you from going; therefore
    (C) is the best answer. (B) is incorrect because, although the immediate
    life-threatening event is attended to correctly (i.e. the crash call), you
    return to write in the notes for the fallen patient before attending the
    next most unwell patient who is febrile. (D) may be judged as worse as
    the implication is a complete failure to document clinical encounters in
    the face of urgent tasks. While it is important to attend crash calls immediately,
    it would not be prudent to begin deferring or completely avoiding
    documentation in the notes as you are asked to see more patients.
    The implications for (D) are greater than a slight delay in reviewing the
    febrile patient and therefore (D) is a worse answer than (B). (A) and
    (E) are both terribly erroneous, with (A) only being marginally better
    than (E) as it implies attending to all the other commitments, rather than
    ignoring the crash call completely (E).

Question 23

23. You are working alone in the afternoon on your colorectal
    ward as the FY1 doctor being shadowed by a fi nal-year medical
    student. The nurse informs you that a patient is looking increasingly
    unwell, a peripheral venous cannula needs siting for a blood transfusion,
    and another patient’s family wishes to speak with you in private.
    Choose the THREE most appropriate actions to take in this situation
    A Assess the unwell patient alone.
    B Assess the unwell patient with the medical student.
    C Ask the medical student to assess the patient alone, and join him as
    soon as possible.
    D Ask the student whether he wishes to try to place the peripheral
    venous cannula.
    E Attempt to insert the peripheral venous cannula yourself.
    F Speak to the patient’s family with a nurse present.
    G Speak alone to the patient’s family.
    H Ask the student whether he would be comfortable speaking to the
    family.

Answer 23

23. B, D, F
    You must review the potentially unwell patient as a priority. Doing so
    with the medical student will provide an extra pair of hands and a valuable
    learning opportunity (B) (A). Responsibility for reviewing the patient
    should not be delegated to the student, even if you soon join him (C).
    You might then ask the student to place the cannula, which should be
    within his range of experience (D). Although you could site the cannula,this would deprive the student of practice and prevent you from attending
    to the waiting family (E). You should speak with the patient’s family,
    ideally with a nurse present (F) (G). Although you could speak with the
    family alone, it is often helpful to have a nursing colleague handy for additional
    perspective. The family are anticipating a conversation with the
    medical team and are unlikely to be impressed by a medical student (H).

Question 24

24. While you are working in A&E, a nurse informs you that a 33-week
    pregnant woman is being brought by helicopter into resuscitation
    following a road traffi c collision. She asks you to prepare for her arrival in
    approximately fi ve minutes. Your registrar has already been informed, and
    he asks you to call for assistance while he bleeps the obstetric team.
    Choose the THREE most appropriate actions to take in this situation
    A Inform the neonatal registrar.
    B Call the orthopaedic consultant at home.
    C Fast bleep the haematology registrar.
    D Summon the cardiac arrest team.
    E Request a phototherapy light.
    F Call the switchboard and ask them to put out a trauma call.
    G Ask a nurse to fi nd a neonatal incubator and bring it to resuscitation.
    H Ensure that there are medical students present, to maximize the
    learning opportunity.

Answer 24

24. A, F, G
    Eff ective management of trauma requires a rapid multi-disciplinary
    approach. This is achieved in most hospitals by putting out a trauma call
    through the switchboard (F). The trauma team will include a general
    surgeon, an orthopaedic surgeon, an anaesthetist, and emergency
    physicians. It will also alert ancillary staff (e.g. the on-call radiographer).
    There should be no additional need to contact the orthopaedic
    consultant (B). The facts do not suggest major haemorrhage or
    haematological complications and so there is not yet a reason to contact
    the duty haematologist (C).
    The trauma team will not routinely include an obstetrician or a neonatologist.
    Your registrar is contacting obstetrics and so you should contact
    the neonatology registrar (A). You might also consider sourcing specialist
    equipment (G) in case an emergency Caesarean section becomes necessary
    in resuscitation.
    The cardiac arrest team will be diff erently composed to the trauma
    team (D) and there is no obvious benefi t from sourcing a phototherapy
    light (E). Medical students might like to observe if they are present, but
    given the circumstances this should not be prioritized (H).

Question 25

25. While working on call, you are asked to cannulate a large patient who requires intravenous antibiotics for a suspected diarrhoeal infection. Your bleep sounds for a third time during your fourth cannulation attempt when you fi nally believe that you have obtained access. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Stop your attempt immediately and answer your bleep. B Secure and fl ush the cannula before answering your bleep. C Try to get the attention of the Ward Sister so that she can answer your bleep. D Answer your bleep after securing and fl ushing the cannula, cleaning the work area, and saying goodbye to the patient. E Ignore the bleep as they will call again if it is important.

Answer 25

25. B, C, D, E, A Other colleagues in the hospital will depend on your answering your bleep promptly. However, this must be balanced against the need to complete tasks that you have already started. In this case, it would be unfair to subject the patient to a further needle attempt so you can answer the call, especially now that you have gained access, and so (B) is the correct answer. In attempting (C) you are likely to dislodge the cannula and/or distract your nursing colleagues, and (B) is a simpler option which if completed will only lead to a minimal additional delay in answering the bleep. While it is important to do all of the things in (D), after securing the cannula they can be postponed until you answer the call to avoid further unnecessary delay, and taking longer to answer than in (C). Ignoring the bleep is clearly unacceptable (E) and only marginally better than subjecting the patient to further unnecessary needles (A).

Question 26

26. A patient on your ward is diagnosed with anal cancer. He tells you that his community would react very negatively if they knew of his diagnosis. As a result, he is very anxious that no one fi nds out, including his family. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Promise to remove any mention of anal cancer from his notes. B Tell the patient that you will remove any mention of his diagnosis from patient lists. C Tell the patient that his family are bound to fi nd out at some point and it would be better if he told them. D Let the nursing staff know that his family are not aware of the diagnosis. E Treat him as any other patient under your care.

Answer 26

26. B, D, E, C, A Additional steps should be taken to protect any patient who is particularly anxious about confi dentiality. The easiest and most eff ective step would be to remove sensitive details from your patient list (B). While (D) is also a sensible option, it should already be clear to all healthcare professionals not to disclose clinical information about patients to any family withoutthe patient’s consent, although reiteration would not harm the patient. The patient’s confi dentiality should be respected like any other patient, but following his request it may be appropriate to employ added precautions, and therefore (B) and (D) might be considered more appropriate than (E) alone. It is incorrect to coerce the patient into telling his family (C), although you might choose to explore reasons for the patient wanting to keep his diagnosis secret. However, the worst answer is doctoring the medical notes, and this information might be necessary to ensure that he is managed appropriately in future (A).

Question 27

27. You hear Karen, one of the nurses, speaking unpleasantly to a child on the paediatric ward. The child is known to be particularly challenging to work with, and has a history of learning diffi culties and behavioural problems. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Approach the pair, and ask to speak to Karen. B Speak to a senior nurse before approaching Karen. C Ask other staff working on the ward whether they have noticed any inappropriate behaviour recently. D Do not raise any concerns as the child is not at risk. E Inform the hospital Trust.

Answer 27

27. A, B, C, E, D You have a duty to confront behaviour that threatens patient dignity. As Karen is currently speaking to the child in a way that you think is inappropriate, you should raise the issue immediately, and therefore (A) is the best answer. You may wish to approach the nursing hierarchy instead of speaking to Karen directly (B), although this would be a more appropriate fi rst step if the behaviour causing you concern had already happened (as opposed to currently happening). It is incorrect to attempt to investigate Karen’s behaviour by talking to other staff (C), which might be seen as gossip or bullying. However, gaining additional corroboratory evidence in this way is probably less extreme than informing offi cials in the Trust at this stage; from the scenario description it would seem fair to escalate concerns within the ward hierarchy before doing so anywhere else (E). It is clearly never appropriate to ignore this issue, and once you have developed a concern, it should always be acted upon in a way that satisfi es you that the issue will not arise again (D).

Question 28

28. A patient who was admitted for an exacerbation of chronic obstructive pulmonary disorder (COPD) is upset about the standard of care she has received over the weekend. She would like to speak with you about the possibility of making a complaint. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Suggest that making a formal complaint is unlikely to resolve the situation. B Provide contact details for the Patient Advice and Liaison Service (PALS) to see what they can off er. C Discuss what happened over the weekend to upset her. D Inform your consultant that the patient is considering making a complaint. E Inform the patient that weekend medical cover is often inadequate and that a formal complaint might help to improve staffi ng levels.

Answer 28

28. C, B, D, A, E The most sensible immediate course of action is (C). This may allow you to facilitate immediate improvements, and you might discover that the patient is more interested in communicating her concerns than making a formal complaint per se. It may become apparent that the patient should be directed to PALS (B) which will off er her a formal route through which to lodge her complain, but this is a less ideal immediate course of action, and (C) may resolve the concerns with greater expediency. While the consultant should be informed that the patient is considering making a complaint (D), in order to facilitate a discussion between them and the patient, it is a less appropriate response to the patient than responding to her query and providing her the option of PALS. The patient should never be discouraged from lodging a complaint (A), but perhaps marginally worse than dissuading the patient is inciting them to generate a complaint that you believe is necessary (E)—instead your own concerns should be raised openly with the senior team.

Question 29

29. You are being shadowed by a medical student during a long day in A&E. The student is very keen to help with procedures and you ask him to catheterize Mr Wills. When you enter the room, the urinary catheter is partly inserted but you realize that you have directed the student to the wrong patient. Choose the THREE most appropriate actions to take in this situation A Ask the student to stop catheterizing the patient immediately. B Write a clinical incident form. C Tell the student that he should go home as he should have checked the patient’s wristband. D Allow the student to continue inserting the catheter in case it is necessary anyway. E Allow the student to insert the catheter, but take it out afterwards before telling the patient it was to obtain a clean urine sample. F Ask the student to apologize to Mr Wills. G Accept full responsibility for the error. H Obtain an ultrasound kidney–ureter–bladder (KUB).

Answer 29

29. A, B, F Patient safety is always your priority and this patient should be saved an unnecessary catheterization (A) (D).Although you are the responsible clinician in this case, you cannot accept full responsibility for the error (G). The student is not yet a doctor, but he must take some responsibility for any procedures he performs. He should have checked the patient’s identity and indication before proceeding. For this reason, both you and the student should apologize to the misidentifi ed patient (F). However, it would be unfair to blame the student entirely and mistakes are best learned from by helping to rectify the consequences, not by being sent home (C). A clinical incident form should then be completed (B) to create a paper trail and in case lessons can be learned for the future. You should identify any contributing factors, e.g. a patient in the wrong bed or not wearing a wristband. You should certainly not mislead the patient (E) and there is no clinical indication for an ultrasound KUB (H).

Question 30

30. Your registrar asks you to consent a patient whom you have clerked in A&E for a scrotal exploration with possible orchidopexy/ orchidectomy. He is unable to consent the patient as he is in the emergency theatre with the patient already in the anaesthetic room. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Ask that he consent the patient with an ‘acute scrotum’ as soon as the emergency case is fi nished. B Ask the registrar to contact the consultant at home. C Phone the medical registrar on call. D Attempt to take consent as well as you are able to. E Ask a surgical SHO who has performed the operation in the past to take the consent.

Answer 30

30. A, E, B, C, D The patient requiring scrotal exploration needs to be consented promptly so that he can be taken to theatre. However, GMC guidance clearly states that the person taking consent should usually be able to perform the procedure themselves. In this case, your registrar is the most appropriate person to take consent once they are available (A). Clearly it is less ideal to involve someone else outside of care of this patient, but (E) does off er a reasonable solution. The consultant would have enough experience to consent the patient, but contacting him at home is unlikely to persuade him to come in for this purpose and is unlikely to refl ect best on your own abilities to resolve this matter with more practicable solutions above (B). (C) is in fact useless, as the medical registrar is unlikely to off er advice beyond telling you not to take the consent yourself. (D), however, is the worst answer, as an incorrect consent can amount to negligence if an issue were to arise afterwards.

Question 31

31. You are asked to speak to a patient’s relative who appears angry. He tells you outright that he is recording the conversation ‘for legal purposes’. He has a number of questions, one of which is why his brother had a CT head scan instead of an MRI scan. Choose the THREE most appropriate actions to take in this situation A Say ‘no comment’ and refuse to speak until the tape recorder is turned off . B Ignore the tape recorder and act as you would if it was not there. C Explain that you are unable to answer his questions. D Tell the relative that the Ward Sister is in a better position to answer his questions. E Contact security if you feel threatened or his presence is obstructing your work. F Answer his questions politely. G Tell the man that you are from another team and have never heard of this particular patient. H Try to turn off the tape recorder yourself.

Answer 31

31. B, C, E Although the man’s tape recorder and aggressive tone apply pressure, you should remain resilient and adhere to the general principles of professionalism. You should try to ignore the tape recorder (B) and explain that you cannot discuss a patient’s care without their consent (C) (F). If he persists and/or is threatening, you might like to ask him to leave and contact security if necessary (E). Saying ‘no comment’ is unhelpful (A), as is passing the problem on to a colleague (D) who is unlikely to appreciate the gesture. You should certainly not lie to the relative (G), despite his aggressive tone, or exacerbate the situation by attempting to turn off the tape recorder (H).

Question 32

32. You have arranged a bedside teaching session using a patient with known inoperable lung malignancy. The patient has a good history and clinical signs and so will be a particularly eff ective case with which to teach your students. He has agreed to help with the session. However, as you approach the bed with your students, he appears to be crying. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Do not enter the room as he is unlikely to agree to the teaching. B Explain to the students that emotional turbulence is a normal part of terminal disease. C Continue as planned to take his mind off his condition. D Talk to the patient about how he is feeling and whether there is anything you can do to help. E Ask the patient whether he would be interested in helping you teach medical students.

Answer 32

32. D, E, B, A, C Although you are with medical students, this should not stop you exercising compassion when one of your patients is visibly upset. You should leave the students at a distance and ascertain what has happened to lower his mood, and therefore (D) is the most appropriate action.While (E) implies you are raising the topic of whether he would feel comfortable with the teaching session, it ignores the patient’s current emotional state. It seems unfair to trivialize the patient’s emotional state (B) into a teaching point for the students, and this still does not immediately address whether he wishes to continue with the teaching session. However, this is probably still more fair than asking the patient to assist with student teaching earlier, and then not giving him the opportunity to choose (A). It is imperative to give the patient a choice, and worse than not off ering is insisting, ignoring his crying, and continuing with the teaching session, as this is likely to be awkward for your students and potentially further upsetting for the patient (C).

Question 33

33. The nurse on the ward wants you to speak to Meredith who has become increasingly anxious about a bilateral mastectomy planned for the following day. Choose the THREE most appropriate actions to take in this situation A Encourage Meredith to express her concerns. B Ask the nurse to identify any problems and get back to you if they are surgical. C Refer to the psychologist. D Speak to the family to identify any of the patient’s concerns. E Talk Meredith through the procedure and what will happen afterwards. F Inform your registrar early on if she appears to show doubt about the procedure. G Inform Meredith that other patients will have missed out on the operating slot if she changes her mind. H Tell Meredith she shouldn’t worry as breast reconstructions are very good these days.

Answer 33

33. A, E, F You should listen to Meredith and try to understand her perspective (A) before talking her through the procedure again with reference to any specifi c concerns she might have expressed (E). If there is a possibility that she might opt to cancel the procedure, you should speak with your registrar early (F). She might benefi t from counselling by a more senior doctor, and cancellations are best anticipated early in case other patients can fi ll the operating slot. However, you should not coerce the patient’s decision (G) or make light of the operation that she is worried about (H). Patient concerns about an operation fall squarely within your remit, and the nursing staff should not be discouraged from contacting you about similar problems in future (B). Speaking to the patient’s family (D) or referring her to a psychologist (C) would be presumptuous as you do not know whether this is what she would want.

Question 34

34. Stephen has recently been diagnosed with congestive heart failure. During a ward round he asks the consultant to explain what this means and the consultant says that you will come back later on for this purpose. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Tell Stephen that ‘heart failure is an inability of the central pump to adequately perfuse the peripheral tissues’. B Ask what Stephen understands so far and what he wants to know. C Tell Stephen that ‘congestive heart failure’ essentially means that the heart isn’t working properly. D Print out a patient information leafl et provided by the Trust. E Tell Stephen that there are some good websites online and that he should read around the subject once he is discharged.

Answer 34

34. B, D, A, C, E Ideally, any explanation should start by fi nding out what your audience already knows and therefore (B) is the best answer. This prevents repetition of knowledge and allows you to clarify any specifi c misunderstandings. It is also often helpful to provide patient information leafl ets (D) for patients to read in their own time; however, this is somewhat less sensitive as a fi rst measure and does not off er any opportunity for a two-way discussion; they are best used as an adjunct to verbal explanation so that patients have an opportunity to ask questions. Although heart failure is inability of the pump to perfuse the tissues (A), this textbook defi nition might be lost on a patient hearing it for the fi rst time and is probably less helpful than providing a pamphlet written for patients. However, this accurate description is probably preferable to an over-simplifi cation (C) which can sound frightening, and you should beware of letting patients who present with occasional ankle swelling go home thinking that you have diagnosed a terminal illness. Although Stephen should read about heart failure if he wishes, patients can easily become lost in the masses of information available online, and therefore the least helpful advice is to recommend this as the fi rst source of information; hence (E) is the worst answer.

Question 35

35. Rachel is being treated for severe renal failure but refuses to accept that she will need dialysis and/or a transplant in future. She says that she would prefer not to know about the disease. Your consultant informs her that it is serious and asks you to reiterate the treatment options and poor prognosis. When you return to speak to Rachel, she appears very happy. Choose the THREE most appropriate actions to take in this situation A Inform Rachel that it can be helpful to know what to expect, and to plan treatment, if you are able to discuss the disease with her. B Encourage her to share how she is feeling about her disease at the moment. C Inform her family instead about the things that Rachel does not want to know about. D Place detailed written information on the condition at Rachel’s bedside. E Ask her why she feels happy as it is clearly not appropriate at this time. F Agree not to discuss the topic any further if she insists on not being told. G Ask the transplant nurse to approach the topic of prognosis and survival rates. H Ask one of the nurses who gets on particularly well with Rachel to raise the issue.

Answer 35

35. A, B, F It is important to share information with patients, but only if this is what they want. We should not force information on them any more than we should force anything else. However, you do have a duty to make sure that Rachel understands why it would be helpful to her to talk about her disease (A). You should try to understand her perspective by listening carefully (B). If she continues to choose not to know, the issue should not be raised again unless there is reason to think that she has changed her mind (F). You should certainly not coerce her to accept information by providing written leafl ets (D) or asking other team members to approach the subject (G) (H). If Rachel consents, you could talk to her family, but in the absence of such an agreement they should not be told anything more than normal (C). It would be callous to obstruct Rachel’s happiness by telling her that she should be otherwise (E).

Question 36

36. The palliative care nurse asks you to join her for a meeting with Jenny, whose husband is close to the end of life. You have been on leave for the last two weeks and are not familiar with the patient. Your seniors are all in clinic and you are alone on the ward. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Agree to see Jenny with the nurse, after reading through the medical notes. B Ask the nurse to familiarize you with the case details before meeting Jenny. C Agree to be present during any discussion but not to answer any medical questions. D Ask the palliative care nurse if she can wait until your seniors are back from clinic as they know the patient better. E Go into the meeting and pick up the story as the nurse talks to Jenny.

Answer 36

36. D, A, B, E, C Your seniors are better placed to attend this meeting (D) as they will know the patient and might already have a rapport with Jenny. They will also have greater experience with conversations of this nature. The next best option if you do attend the meeting is to familiarize yourself with the patient’s notes beforehand (A). Asking the nurse to brief you would be inadequate preparation for such an important meeting and therefore (B) is less appropriate. Even less appropriate would be attempting to identify the issues as the conversation unfolds (E). The worst answer is (C) as it would be unhelpful and awkward for all parties if you attended the meeting but declined to contribute.

Question 37

37. The registrar asks you to book a foot X-ray for a patient on the orthopaedic ward. When booking the scan, you are only able to fi nd an option for ‘CT foot’. He asks you to book a CT scan but call radiology to amend the request. You are apprehensive about this strategy as you have previously seen it lead to inappropriate imaging. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Book a CT foot scan and then call radiology to amend your request. B Voice your concerns and explain that you have seen this strategy fail before. C Speak with radiology fi rst, and then book the ‘CT foot’. D Complete a clinical incident form about the registrar’s willingness to compromise patient safety. E Ask the registrar to book the scan under his name.

Answer 37

37. B, C, E, A, D You should learn from previous mistakes, whether your own or a colleague’s. You will want to let your registrar know that errors have occurred in this way previously and therefore (B) is the best response. He might then amend his strategy or decide that the investigation is suffi ciently urgent to proceed with the original plan. (C) represents a less foolproof mechanism of booking the scan, but should also lead to the correct imaging being performed. Although it may be preferable for the registrar to take responsibility for requesting the scan (E) this is unlikely to foster a good working relationship between you, and you are still failing to address the issue of mistaken imaging requests being submitted. It is clearly less preferable to attempt to establish contact with radiology after making the imaging request, as this increases the likelihood that the request will be processed incorrectly (A). (D) is the worst response as it would not be a measured response to complete a clinical incident form.

Question 38

38. Your consultant is about to close the abdomen after a very long emergency laparotomy. He is a formidable personality and earlier told you to stop talking so that he could concentrate on fi nishing the operation. Although you have not been paying full attention, you think that a swab might have been left behind but are far from certain. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Immediately inform the consultant of your suspicion. B Ask the scrub nurse to recount the swabs. C Ask another question to ‘break the ice’, before raising the possibility of a swab being left in the abdomen. D Remain quiet as you were not really paying attention. E Ask an indirect question such as: ‘How harmful would it be if a swab was left in the abdominal cavity?’

Answer 38

38. A, B, C, E, D In this unenviable position, you are nevertheless duty bound to raise your concern and should do so with the operating surgeon (A). Thescrub nurse should certainly recount the swabs, but this instruction might be better coming from the surgeon himself; therefore (B) is less ideal. Many studies of human error have found that juniors are too indirect when questioning more experienced colleagues. If you believe that a swab might have been left in the abdomen, you should say so, and asking other questions fi rst is likely to try your consultant’s patience when a direct question would have been suffi cient (C). (E) is similarly unfavourable and perhaps more irritating (and therefore may be worse). However, clearly the worst option would be to remain quiet, as you might have been the only person with the opportunity to stop the patient undergoing a second operation to remove an aberrant swab (D).

Question 39

39. Your consultant has agreed to complete a work-based assessment for you on numerous occasions but has not yet done so. The deadline for completion of all assessments is approaching. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Ask for your consultant’s login details to complete the form yourself. B Find another consultant to complete a work-based assessment. C Let the foundation school know that you are having diffi culty fi nding assessors. D Remind your consultant that the deadline is approaching. E Let your Educational Supervisor know you are having diffi culty fi nding assessors.

Answer 39

39. D, B, E, C, A Finding people who are suffi ciently senior to complete work-based assessments can be diffi cult. However, these are useful learning experiences and a minimum number are necessary to pass FY1. The Foundation Programme is ‘trainee led’ which means that you are responsible for fi nding suffi cient learning opportunities and assessors to complete the minimum number. For this reason, you should remind the consultant who promised you a work-based assessment (D). The next option (B) is less ideal as it also involves you discussing more cases with that individual who you might not have the time or opportunity for. It would only be after attempting both these strategies that you might consider informing your Educational Supervisor (E), but to do so before would be premature and ineffi cient. The foundation school is unlikely to be interested at that time and therefore (C) is a less ideal option. Of course, it would be dishonest to masquerade as your consultant and complete the assessment yourself and therefore the worst answer is (A).

Question 40

40. You have clerked Mr Smith, a 56-year-old man with abdominal pain, who was also reviewed by Dr Mayer, the duty consultant. The following day, the new duty consultant reads your clerking and proposes a completely diff erent management plan. He has no new information to hand and did not examine the patient, and you are unhappy with his suggestions. Rank in order the following actions in response to this situation (1 = Most appropriate; 5 = Least appropriate) A Politely decline to follow the second consultant’s management plan until he sees the patient. B Clarify with the second consultant to whom you are ultimately responsible. C Highlight the diff erences in management between the two consultants. D Accept the plan instigated by the second consultant. E Ask the registrar to see the patient afterwards for a ‘tie-breaker’ opinion.

Answer 40

40. C, D, E, B, A Management plans change with time according to new information, evolving clinical signs, and the approach of the clinicians involved. It is important that doctors—and particularly consultants—have discretion in managing patients. However, you should point out the discrepancy between the two plans (C) as this might make the second consultant consider why they diff er. It would only be if he insists that you should generally implement his plan as he is now ultimately responsible for the patient, but clearly (D) would be less preferred to (C). (E) risks undermining the consultant by seeking an uninvited third opinion. If you have serious concerns about a new management plan, you should of course raise these and take necessary action to avoid harm occurring. If you are uncertain, your registrar might be able to explain the reason for this new approach. Clarifying to whom you are ultimately responsible might be interpreted as impertinent (B)—you are clinically accountable to the consultant on duty that day, and therefore (B) is probably marginally more unprofessional than (E). (A) is likely to be slightly worse than (E) as the implication here is that the consultant simply needs to see the patient in order for his management plan to be followed. Although it would be sensible to ask the consultant to see Mr Smith, you should not coerce him to do so by refusing to implement his plan otherwise (A). It is pragmatic to accept that senior doctors will not always review patients before instigating a management plan.