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Flashcards in SJT Paper 2 Deck (70):
1

You are attending to Harry, an 89 year old long-term patient requiring palliative care. It has been recorded in Harry’s medical notes that he will be transferred from the hospital to a nursing home within the next few days and he has agreed to this management plan. Later on during the day, Harry informs you that he has changed his mind and no longer wants to move to the nursing home.

Rank in order the appropriateness of the following actions in response to this situation.
A. Explain to Harry that a nursing home is better suited to his needs
B. Ask Harry why he has changed his mind
C. Explain to Harry that the nurses are too busy to meet his needs in the busy hospital environment
D. Inform your consultant that Harry is unsure about going to a nursing home
E. Ask Harry’s relatives to come in and discuss his options with him

Answer: BDEAC
Rationale: This question is about maintaining the patient as the central focus of care and hence the first thing that should be done is to understand why Harry has changed his mind (B). It would be important to understand his situation and this should be the priority, which may also inform any future action. It would be important for the consultant to be advised that the
patient is unsure as the consultant is in charge of the patient (D) and the discharge may have been agreed between them. There is nothing to say relatives have been involved previously, hence speaking to them is less appropriate than approaching the consultant. It may be appropriate to discuss options with Harry's relatives (E) but only once Harry has made his wishes clear as to whether he consents to his family being involved in the decision-making process. Simply explaining to Harry that a nursing home is better suited to his needs (A) may be appropriate as a later action if Harry's wishes as to where he wants to be looked after are not realistic - however, there is nothing in the scenario which suggests this may be the case. Finally, explaining that the hospital nurses are too busy (C) undermines
Harry's confidence in the nurses caring for him for the remainder of the admission and fails to acknowledge that his wishes have change so it is least appropriate

2

Mrs Jenson has arthritis and works in the pharmaceutical industry. She appears very well informed about her arthritis medication. She tells you that she can show
you evidence that using double the recommended dose of her current medication will be safe for her and will allow her to return to her job more quickly. She asks
you to prescribe to her double the recommended dose.

Rank in order the appropriateness of the following actions in response to this
situation
A. Advise Mrs Jenson that if she chooses to self administer the double dose she is going against medical advice
B. Tell Mrs Jenson that you cannot prescribe more than the recommended dose without senior consultation
C. Ask your consultant to speak with Mrs Jenson
D. Ask Mrs Jenson to show you the evidence that she cites
E. Seek advice from the ward pharmacist

Answer: BECDA
Rationale: This question tests your ability to respond to an inappropriate request from a patient for an inappropriate dose of a medication. (B) is the
most appropriate answer - whilst senior doctors occasionally provide alternative doses of level, as a foundation doctor it is neither safe nor appropriate to make that decision yourself. (E) provides appropriate
additional input from a more experienced colleague but is likely to just confirm the correct course of action (B) rather than initiating it, making it a less direct route to resolution. (C) provides appropriate input for the patient
but will take time to provide, and is again less direct than (B). (D) may provide interesting information and demonstrates you are responding to Mrs Jenson's query but won't change your response. Option (A) addresses none of the issues raised by the condition – acknowledging selfadministration without taking action is an unsafe response.

3

You and an FY1 doctor, Lorraine, are on your first rotation at the hospital. Since beginning this rotation three weeks ago, you have noticed that Lorraine is always eager to undertake additional ward tasks that are delegated by the consultant. As a result of completing too many tasks, Lorraine is staying several hours after her shift should finish every day. Lorraine often appears to be tired, and you have noticed a decrease in the quality of her work. When you sensitively raise this with Lorraine, she informs you that you must be mistaken and appears to be offended. The quality of her work has not improved since your last conversation and you must decide whether you will discuss the matter with her again.
Rank in order the importance of the following considerations in the management of this situation (1= Most important; 5= Least important).
A. The likelihood of effectively improving Lorraine’s quality of work by speaking to her for a second time
B. Maintaining the quality of patient care
C. The timely completion of all ward tasks
D. The way Lorraine reacted when you have raised the issue with her last time
E. The extent that Lorraine understands that her tiredness could be affecting patient safety

Answer: BAECD
Rationale: This is about maintaining the quality of care for patients on your ward (B) and helping Lorraine improve the quality of her work (A). Lorraine may not appreciate that her tiredness could affect patient safety and this should be discussed tactfully so that she is aware of the impact this may have (E). Timely completion of ward tasks is desirable but not at the expense of potential errors (C). The previous conversation should not be a deterrent to addressing the issue again (D).

4

Your FY1 colleague, Amirah, has been working alongside you during a busy night shift. You have both been on-call for the last seven hours without a break or meal. Amirah has complained about feeling dizzy throughout the shift. Amirah tells you that she needs to go and lie down but suddenly she faints in the middle of the ward. She regains consciousness two minutes later.
Rank the order in which the following tasks should be undertaken (1= Do first; 5= Do last).
A. Discuss with Amirah whether she will be able to undertake her remaining tasks for the day
B. Ask a nurse to help you transfer Amirah onto an available bed
C. Alert your specialty trainee* of the incident
D. Speak to the patients on the ward and reassure them that they will be seen to soon
E. Give Amirah a blanket and a cup of water

Answer: BECDA
Rationale: Just as you would approach an unwell patient, the first step here is to ensure your colleague is stable and that they are in a safe and appropriate place, therefore moving her onto a bed (B) is the first priority. Making her comfortable and addressing any possible causes for her faint (dehydration etc) would be the next logical step (E). Once you have done this, making your senior aware of what has happened should be the next priority (C), as they may wish to speak with Amirah directly to check she is okay and they may need to make alternative arrangements for the rest of the shift (directing flow of tasks, arranging cover). As this event occurred on a ward, it is likely that patients will have witnessed it and may be concerned. Reassuring them about the situation and that they will be seen as soon as possible should happen once the immediate concerns have been addressed (D). Finally, once your colleague has had chance to recover from her faint, it would be appropriate to ask how she is feeling and whether she feels able to continue with work (A).

5

You are working on a busy ward, completing some administrative tasks for your consultant, Dr Findlay. She has asked you to complete some discharge letters which should have been sent out a week ago. A new patient is admitted to the ward and the senior nurse asks you to assess him, as your colleagues are all busy completing other tasks. When you explain that you are currently completing the discharge letters for Dr Findlay, the nurse suggests that you ask the fourth year medical student on the ward to assess the patient instead.
Rank in order the importance of the following considerations in the management of this situation (1= Most important; 5= Least important).
A. The medical student's confidence to assess the patient independently
B. The medical student's level of clinical competence to assess the patient effectively
C. The discharge letters should have been completed a week ago
D. The urgency for the patient to be assessed is not yet clear
E. The possible time delay before the senior nurse is able to find another available colleague to assess the patient

Answer: BAECD
Rationale: This question is about prioritisation. The medical student's competence to assess the patient should first be established (B) as not only would it impact patient safety but the medical student's initial findings could help you to establish the urgency for a full assessment of the patient. The medical student's level of confidence is also important although it is secondary to their competence (A). As all your colleagues are busy, there is a risk that the senior nurse may not find another available colleague to assess the patient soon enough (E) thereby risking clinical delay. The discharge letters do not constitute an urgent clinical priority (C). The urgency of the assessment required will only be determined by an initial assessment (D) which should happen with a minimum of delay

6

You are observing your specialty trainee*, Allan, in an operating theatre, working with a large team on a complex procedure. The patient begins to deteriorate unexpectedly and the team is under pressure to resolve the situation quickly. As all members of the team are working, Allan begins to use some extremely bad language while talking to another team member. The team member appears to be shocked by Allan's remarks but does not respond to it and continues to focus on the procedure. You must decide whether to speak up about Allan's behaviour immediately.
Rank in order the importance of the following considerations in the management of this situation (1= Most important; 5= Least important).
A. Allan's likely intention to be offensive given that he is under pressure to resolve the situation quickly
B. The team member's reason for not responding to Allan's remarks
C. The disruption that your interjection may cause to the procedure
D. All healthcare professionals are entitled to work in a respectful environment at all times
E. The impact on other team members if Allan continues to use similar language during the rest of the procedure

Answer: DECBA
Rationale: This question tests your ability to respond to unprofessional behaviour in a clinical situation. The most important consideration in management of your response here is the right for colleagues to work in a respectful environment), thinking about the impact that Alan’s outburst may have on this environment (D). This is followed by a consideration of how uncomfortable colleagues may become and the impact on their performance for the rest of the procedure (E). The impact of interjecting (C) should then be considered -whilst this behaviour clearly should be challenged, the priority is to complete the complex procedure. This may mean than considering when it is most appropriate to interject (for example during a break or after the procedure is complete) should be considered. The team members rationale for not responding is an issue (B) but is less important than the broader issues of a respectful workplace environment and safe completion of the procedure. Finally, (A) offers a partial justification rather than a consideration so is least likely to influence your management of the situation.

7

You are browsing your social media page in the evening and notice that your FY1 doctor colleague and good friend, Neal, has written a post. Neal writes that he has had a very long day in theatre today, with a patient who had a big bleed. Although there are no direct patient details in Neal's post, you are aware that it would be possible to identify the patient from the details regarding her bleed, and the fact that the surgery occurred earlier today. The patient is still currently on the ward. As Neal's social media page is set for public viewing, individuals who are not direct contacts are able to read Neal's post.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Contact Neal, advising him to remove the social media post
B. When you next see Neal, suggest that he removes the social media post
C. Tell Neal that posting about a patient on social media is unprofessional
D. Inform your on-call consultant of Neal's social media post
E. Advise Neal to change his social media settings to 'private' so that only his contacts are able to read his posts

Answer: ACBDE
Rationale: In this case the post should be removed as a priority (A) and Neal needs to be reminded that this kind of post is unprofessional (C). Waiting to see Neal in person could take time so it is less effective (B). It may be appropriate for Neal to discuss this with his clinical supervisor but involving the on call consultant it is unlikely to be helpful (D). Although the advice to change media settings to private (E) is sensible that could be interpreted as condoning the original post which is inappropriate irrespective of settings.

8

Your fellow FY1 doctor, Katrina, regularly arrives at work late and, consequently, often misses morning ward rounds. During these ward rounds, the consultant provides direction to the team regarding the tasks to be completed for the day. You and members of the healthcare team make notes and discuss the allocation of the tasks based on the consultant’s direction. Katrina asks you for an update on the allocation of ward tasks when she arrives at work late. This causes significant delays to the completion of the tasks that have been assigned to you.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Ask the consultant to delay the ward round until Katrina arrives
B. Make separate notes for Katrina to refer to when she arrives, regarding the tasks assigned to her
C. Discuss with Katrina methods that may help to improve her punctuality
D. Suggest to Katrina that she should ask another member of the healthcare team to provide her with ward round updates
E. Discuss Katrina’s repeated lateness with a senior colleague

Answer: CEBDA
Rationale: As is often the case, the most appropriate method to address this problem is to discuss your concerns directly with the individual involved (C). If you can offer any advice that may help, then that should be your first approach. It would also be appropriate to escalate your concerns to a senior colleague for their input (E). It is less appropriate to make notes for your colleague, as this fails to address the problem of her punctuality and creates increased workload for yourself (B), however it is preferable to shifting the handover to another member of the team (D). Delaying a ward round to wait for a repeatedly late member of the team is not appropriate as it fails to address the actual problem, and delays the entire team (A).

9

You have been completing an audit with another FY1 doctor, Zara. You are near the end of your rotation and have only collected half of the data; there are two wards remaining to collect data from. You and Zara have both observed that a general trend has emerged in the data that you have collected so far. One morning, Zara informs you that she has fabricated the rest of the data, based on the trend that had emerged in the existing data, and that she has submitted the report to your joint clinical supervisor*, Dr Hadi. The following week, Dr Hadi informs you that she is very pleased with the audit and wants both you and Zara to attend an international conference to present the findings
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Inform Dr Hadi that the data was fabricated by Zara
B. Tell Dr Hadi that you did not have any input into the audit so Zara should attend the conference alone
C. Tell Dr Hadi that there was a mistake with the data, so you and Zara will need to collect some more before presenting at the conference
D. Attend the conference with Zara, but refuse to present any of the findings
E. Suggest to Zara that she admits to Dr Hadi that she fabricated the data

Answer: EACBD
Rationale: This question tests your probity. (E) addresses the probity issue and is the most appropriate response as it allows the individual responsible to take ownership and responsibility for their behaviour. (A) addresses the probity issue but doesn't create the opportunity for Zara to admit her mistakes which is the preferred option. If she won't inform Dr Hadi it is the most appropriate next action. (C) ensures that you aren't involved in delivering fraudulent data but doesn't address the key issue. (B) ensures that you aren't involved but directly permits fraudulent data to be presented, which potentially creates a fitness to practise issue for you and Zara. (D) doesn't address any of the issues and not taking any action at all clearly implicates you in the delivery of fraudulent data. This is the least appropriate response.

10

You are working on a surgical ward and are due to assist your consultant in theatre with a gallbladder removal. The consultant has completed seven hours of a shift without eating or drinking anything. During a conversation with him shortly before the surgery, you notice that he appears to be having difficulty concentrating on what you are saying and that his hands are shaking slightly. You are aware that there may be implications for patient safety if the consultant carries out the surgery when he is not able to perform to the best of his ability.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Explain your concerns to the consultant
B. Raise your concerns in the surgical team’s pre-operative discussion
C. Continue with the surgery and discuss the incident with your clinical supervisor* afterwards
D. Bleep* the on-call consultant, explaining the situation and asking for advice on what to do
E. Suggest to the consultant that another doctor carries out the surgery

Answer: ADEBC
Rationale: (A) is the most appropriate response as this involves speaking to the person directly. (D) is also appropriate as this raises an appropriate concern and ensures senior, supportive input. It is also most likely to achieve the desired outcome with the least potential difficulty. (E) addresses patient safety but is less direct in that it doesn't explain to the consultant why you are concerned. (B) is an even more indirect route but ensures patient safety. (C) does not address the patient safety issue.

11

In your hospital, if members of staff make more than three errors when labelling blood bottles they are required to attend training to learn how to do this correctly. Your FY1 doctor colleague, Declan, has been required to attend this training three times as he has made repeated labelling errors. Despite this, Declan says to you, "It shouldn't be my job to label blood bottles anyway, so I don't pay attention".
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Inform Declan that incorrectly labelling blood bottles could have an adverse impact on patients
B. Offer to label blood bottles for Declan in future
C. Tell Declan's clinical supervisor* about his comment
D. Advise Declan to speak to his clinical supervisor about his repeated labelling errors
E. Tell Declan that he should be more careful when labelling blood bottles

Answer: ADECB
Rationale: This question addresses professionalism. All doctors have to complete mundane but patient safety critical tasks. In this case pointing out that errors in this task may affect patient safety would be a good start (A). Advising Declan to discuss his concerns with his clinical supervisor allows him to address what might be a genuine issue about resources and phlebotomy in the service (D). Reminding him to be more careful can be tactfully done (E) and failing that you have a responsibility to discuss it with his supervisor as a patient safety issue (C). Offering to label the bottles avoids the issue and reinforces Declan's behaviour (B).

12

You are the only doctor on a ward. A patient, who is talking to one of the nurses, starts to raise his voice. He tells the nurse that he is hungry, as he has not eaten for two days due to his surgery being delayed. He is being very loud and beginning to disturb the other patients on the ward. You do not know the history of this patient, other than the fact that his surgery has been delayed. You do not know why it has been delayed.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Suggest to the nurse that she should attempt to calm the patient as he is disturbing other patients
B. Explain to the patient that you are sorry that he is hungry but he cannot eat as he is due to have surgery
C. Explain to the patient that he should calm down as he is disturbing the other patients on the ward
D. Explain to the patient that you are sorry that he has had to wait for two days and you will try and find out when his surgery will be
E. Reassure the patient that he will have his surgery soon and that he will be able to eat in the next few hours

Answer: DB[AC]E
Rationale: This question tests your ability to respond to an agitated patient admitted to hospital. The most appropriate option is (D) as this is the only one that addresses directly the patient's legitimate concerns. Whilst (B) is similar, it is only a partial response to the issues. It explains why the patient cannot eat but does not address the underlying issue of when he will receive the delayed surgery. (A) and (C) are both legitimate issues to address but they cannot be addressed in isolation. As neither deals with the issue of why the surgery is delayed or when the patient can eat they are unlikely to resolve the situation. (E) is the most inappropriate option as you are promising something that you do not know you can deliver, which is unprofessional. If the surgery is cancelled again this is likely to upset the patient further and lead to a formal complaint which you may be implicated in.

13

One of your patients, Roisin, who you have been looking after on the Cardiology ward, invites you to attend her birthday party at her home next weekend. You have been on the medical team that has been looking after Roisin for the past two months, and she is due to be discharged tomorrow. You do not have any plans for next weekend; however, you are aware that it is inappropriate to see a patient socially outside of work.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Thank Roisin for the invitation but explain that it would not be appropriate for you to attend
B. Invite other individuals from the medical team that has looked after Roisin to attend the party with you
C. Politely decline Roisin's invitation, saying that you cannot attend
D. Ask another doctor on the ward to manage Roisin's care until she is discharged
E. Explain that you are unable to attend, but buy Roisin a small gift

Answer: ACDEB
Rationale: This question explores professional boundaries between a doctor and their patient. The most appropriate action is to maintain an appropriate professional boundary and give Roisin an explanation as to why you cannot attend (A). Declining to attend without an explanation (C) would maintain the required boundary, but without an explanation it may upset Roisin or cause her to repeat the request at a later time. Asking another doctor on the ward to manage Roisin's care until she is discharged does not adequately address the invitation (D) and may similarly cause her to repeat her request. Explaining you are unable to attend without explanation and buying a gift (E) conveys a mixed message and would most likely be viewed as inappropriate. It is clearly not appropriate to attend the party (B). Inviting other members of the healthcare team compounds the blurring of professional boundaries.

14

Your specialty trainee*, Kimberley, informs you that at the weekend she was issued with a speeding ticket by the police. You were on-call at the weekend and Kimberley was not working. She states that in order to avoid having to pay the speeding fine, she informed the police that she was working on-call and was caught speeding while driving to the hospital to deal with an emergency. Kimberley asks you to corroborate her story and inform the hospital rota coordinator* that she was working at the weekend.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Advise Kimberley to tell the police the truth about the situation
B. Inform your clinical supervisor* of Kimberley's request, without naming her, seeking his advice on how to proceed
C. Inform the police that Kimberley was not working on-call at the weekend
D. Decline Kimberley's request
E. Explain to Kimberley why her request is inappropriate

Answer: AD[BE]C
Rationale: This question tests your probity and professionalism, and in practice a situation like this one would be viewed very seriously by the GMC. The best option would be to advise your colleague that she should be honest with the police (A) as this addresses the underlying issue of dishonesty. Failing this, it would also be appropriate to simply decline your colleague's request to lie (D), though this does not directly challenge the problem. Seeking advice from a senior colleague would also be acceptable (B) though an FY1 would be expected to recognise themselves that lying for a colleague is not acceptable. Explaining to Kimberley why her request is inappropriate may be helpful after you have addressed the immediate concerns although does not involve declining the request (E). Lying to the police is simply not appropriate (C)

15

You are on a ward round with your consultant and the surgical specialty trainee*. Mr Ahmadi is due to have an elective resection of a colonic tumour. Your consultant confirms tomorrow's theatre list, placing Mr Ahmadi first, as he wants to be present for the case. After your consultant has left for the day you realise that he did not notice Mr Ahmadi is taking warfarin for atrial fibrillation, which will increase the risk of haemorrhage during the procedure. The surgical specialty trainee is still on shift, as is the anaesthetist, who is due to do the theatre list.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Raise the problem at the consultant pre-operative ward round
B. Inform the surgical specialty trainee of the problem
C. Inform theatre that Mr Ahmadi's case needs to be cancelled
D. Discuss the situation with the anaesthetist who is doing the list with your consultant
E. Contact your consultant on his mobile telephone to inform him of the situation

Answer: BDEAC
Rationale: The most appropriate option here is to discuss the problem with your specialty trainee (B) who will be able to advise you how to proceed. Failing this, discussing the situation with the anaesthetist would also be appropriate (D). Contacting your consultant out of hours while he is at home is less acceptable than discussing the problem with appropriate members of the team who are still at work (E). Waiting until the preoperative ward round leaves little time to correct the situation and may compromise patient care (A). You do not know yet if the operation needs to be cancelled and it would be inappropriate for you to make this decision (C).

16

You are completing a ward round in the Acute Admissions Unit* (AAU). During the ward round your consultant repeatedly questions the patient management plans of the specialty trainee*, Craig. At the end of the ward round you hear the consultant telling Craig that he is not suitable to work in acute medicine. The consultant is then called away to attend to an emergency. Craig appears to be upset and leaves the ward. You are unable to contact Craig on his hospital bleep*. There are unwell patients arriving, on whom you need to seek his advice.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Leave the ward to attempt to locate Craig, and ask that he returns to the ward
B. Report Craig to the medical director* for leaving the AAU
C. Seek advice regarding the new patients from another specialty trainee working on the AAU
D. Telephone the consultant, explaining the situation to her and request that she attends the AAU as soon as possible to assist with the new patients
E. Discuss how best to deal with the new patients with the other FY1 doctors on the AAU

Answer: CDEAB
Rationale: This question looks at maintaining the safety of patients when a senior colleague is unavailable. Given that you know Craig is upset and has left the ward, he may be unable or feel unsafe to work until he is less upset. In this circumstance, seeking another specialty trainee (C) would be a reasonable initial response. If this was not possible to maintain safety, contacting the consultant (D) would be the next step in escalation to maintain safety. Discussing with other FY1 doctors (E) may be helpful but is ultimately not an acceptable substitute for a senior opinion for unwell patients. Leaving the ward (A) compounds this issue of safety by leaving the AAU with one less doctor and a lack of senior support. Finally reporting Craig (B) to the medical director is an inappropriate initial action to take as it doesn't resolve the patient safety issue and would not be the right level at which such a concern should be raised initially.

17

Your consultant has asked you to take an urgent blood sample from a 65 year old female patient. Five of the patient's adult children are visiting her and start complaining to you about the care that their mother is receiving and criticising the hospital. Although the relatives are not aggressive, they are being loud and rude and their behaviour is delaying you in taking the patient's blood sample.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Ask the relatives to be quiet whilst you take the blood sample
B. Ignore the relative's comments whilst you take the blood sample
C. Ask a nurse to take the blood sample whilst you talk to the relatives elsewhere
D. Ask the relatives to leave whilst you take the blood sample and offer to speak to them afterwards
E. Wait for the relatives to leave, then take the blood sample

Answer: DCABE
Rationale: This question is testing your ability to prioritise safe patient care in a difficult situation. Your priority at work is the patient safety and ensuring high quality care - (D) ensures that the urgent patient care is delivered timeously. (C) will also deliver patient care but involves other staff and may take more time. (A) delivers safe patient care but doesn't defuse a stressful situation. Further, it doesn't maintain patient privacy and puts added pressure on the procedure. (B) is likely to exacerbate the situation further - not communicating with the relatives is likely to add to their anger as they will feel ignored. (E) delays timely and safe patient care as well as not addressing the family, which is why it is the least appropriate answer.

18

Whilst working in the Medical Assessment Unit, you treated a patient for an asthma attack. The patient made a good recovery and was discharged from hospital last week. Today, you receive a short complimentary message from the patient through social media, thanking you for your care. The patient also sends you a friend request on social media.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Ignore the message and friend request on social media
B. Print an anonymised copy of the complimentary message for your development portfolio
C. Respond through social media, asking how the patient's asthma has been since discharge
D. Talk to your educational supervisor* to reflect on the situation
E. Decline the friend request, politely explain via social media that any further contact would be inappropriate

Answer: EADBC
Rationale: This question is about understanding the boundaries of patient contact via social media in the context of GMC social media guidance. The most appropriate response is (E) as this would hopefully prevent any further contact from arising. It would also be appropriate to simply ignore the request (A), however this does not provide an explanation for the patient, and they may repeat the request at a later time. If unsure what to do, the next most appropriate choice would be to seek senior advice (D). Whilst it would be nice to place the comment in a portfolio (B), this is less appropriate than the first two options and may require consent. Discussing medical conditions via social media (C) is inappropriate.

19

This is your first post on a busy surgical rotation, and you are struggling with your workload. You have been assigned a combined clinical and educational supervisor*, Mr Jones, for your placement. So far you have emailed Mr Jones twice, with no response, and your initial induction meeting was due two months ago.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Refrain from attempting to make contact with Mr Jones, waiting for him to contact you
B. Report to the Foundation Programme Director* the lack of response from Mr Jones
C. Contact Mr Jones' secretary, in order to find Mr Jones and discuss your induction meeting
D. Ask the Foundation Programme Director to assign you a new educational supervisor
E. Ask the hospital switchboard* to transfer your call to Mr Jones' mobile telephone number

Answer: CBEDA
Rationale: This scenario is asking you to rank the appropriateness of a series of steps to ensure you receive and are able to evidence your essential supervision meetings as an FY1 doctor. Whilst the question does not specify why Mr. Jones has not been in contact, attempting to reach him through his secretary (C) is the most appropriate initial step. Highlighting your difficulty to the Foundation Programme director is also important (B) - as they may be able to support you in obtaining a response and they need to be aware of the issue. The Foundation Programme Director's awareness of the problem and the steps you have taken to resolve it will prevent the delayed meeting reflecting badly on you, which could potentially impact on your progression through the foundation programme. Option (E) is an alternate method of contacting your supervisor but is likely to be less appropriate than seeking information through Mr Jones secretary of when he might be available. Similarly, requesting an alternate educational supervisor (D) is not unreasonable but is a final resort if a meeting cannot be arranged with Mr Jones with the support of the Foundation Programme Director. Taking no action here (A) is not an appropriate response as there is a risk that no meeting will occur at all. This would reflect poorly on you and is likely to have an impact on your progression through training

20

You recently attended a training session, which highlighted the importance of keeping accurate patient records for medical care and legal purposes. Your specialty trainee* with whom you regularly work also emphasises this frequently. While working with a consultant you notice that he is writing patient records but is not recording the time and date on the records at the time of creation. He is subsequently revisiting some of the records and estimating the times and dates before submitting them to the archive.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Explain to the consultant that his record keeping is inadequate
B. Search the archive for those records that the consultant has not fully completed, to show to a senior colleague
C. Speak to the consultant about the recent training session highlighting the importance of completing accurate records
D. Discuss the consultant’s behaviour with your specialty trainee, asking what form of action he would advise
E. Return to the notes to record the correct time that the consultant wrote his notes

Answer: CDABE
Rationale: This question relates to the importance of accurate and timely documentation, and the difficulties posed when you are concerned about conduct of a senior member of the team. Politely addressing the consultant directly is the most appropriate approach as it addresses the problem and involves fewer additional and unnecessary members of the team in the situation (C). You are able to use your recent training session as a starter for the conversation. Option D and A are both reasonable approaches, though telling the consultant that his record keeping is inadequate is blunt and likely to cause offence. Therefore, escalating your concerns to your specialty trainee and asking for advice about how to proceed (D) is more appropriate than a confrontational conversation with your consultant (A). Searching through all relevant records would involve a huge amount a work and time on your part, and is not really required in order to raise your concerns. Passing on your concerns to somebody else in the team is not the best approach as it does not directly address the problem (B), though it is slightly more appropriate than retrospectively adding to your consultant’s notes (E), which constitutes a potential probity issue and does nothing to address and correct the overall problem (which is the consultant's documentation skills).

21

You have been called by a general medical ward consultant, Dr Patrick, to help cover the ward, which is extremely busy. The FY2 doctor, Chantelle, gives you a list of three patients on the ward who require blood tests urgently. Their samples need to be processed in the next hour and the results will be used to inform a management plan. While you are taking blood from one patient, a senior nurse, Reuben, informs you that you need to examine another patient immediately as she is a relative of one of the surgical consultants. When you read this patient's notes, there is no clinical urgency to examine the patient.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Tell Reuben that, at the moment, you must prioritise taking the blood samples
B. Ask Chantelle whether you should continue taking blood samples or examine the patient
C. Tell Reuben that you will examine the patient once you have taken all the blood samples
D. Ask Dr Patrick to examine the patient next, explaining that she is a relative of the surgical consultant
E. Examine the patient, as Reuben requested

Answer: CABDE
Rationale: This question looks at managing the request for preferential treatment for a patient by a team member while you need to complete urgent patient tasks. It is clear that the blood samples have been identified as urgent, they would therefore take priority over the non-urgent task. (C) conveys this and reassures Reuben that it will be dealt with when you are available; it is therefore the most appropriate response. (A) conveys the urgency and need to take blood samples but is less appropriate as it does not address Reuben's query specifically. Seeking clarification from the FY2 (B) is reasonable if you are unsure what to do - however, in this case the prioritisation of the blood samples has already been made clear. Asking Dr Patrick to examine the patient (D) is less appropriate as it has been established that the ward is busy and that examining the patient is a nonurgent task. Finally, simply examining the patient (E) means that you have moved from completing a specific urgent task to a non-urgent task without informing your colleagues. This may please Reuben and the relative of the surgical consultant but has stopped you from completing an urgent task and could place the safety of the patients requiring the urgent blood samples at risk.

22

You are working on a surgical ward with a specialty trainee* and two other FY1 colleagues. You get on well with your specialty trainee, but have noticed that he often gives you most of the jobs to do rather than delegating the tasks evenly between you and your FY1 colleagues. As a result, you regularly have to work past the end of your shift to complete all the tasks.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Discuss your concerns with the specialty trainee
B. Continue to complete the jobs to the best of your ability
C. Talk to the specialty trainee if the situation has not improved after a month
D. Inform your educational supervisor* of the difficulties you are experiencing with your workload
E. Delegate some of your tasks to your FY1 colleagues

Answer: AEDCB
Rationale: This issue assesses your response to a situation when you feel work is being unfairly delegated which is impacting on your ability to leave your shift on time. (A) is the most appropriate response - it allows discussion of the issue and exploration of possible solutions. (E) will assist your personal wellbeing and it addresses the problem in real time - however it does not stop your speciality trainee delegating so much work to you. (D) is appropriate but may take some time to arrange and may not be required if the issue can be resolved directly with the speciality trainee. (C) fails to address the issue in a timely and appropriate manner. (B) doesn't address the issue and simply maintains the status quo. Over time this could impact on your health and work/life balance, making it the least appropriate response.

23

You are attending a social gathering at your fellow FY1 doctor, Susanna's, home when you notice a patient task handover sheet on the kitchen table, with Susanna's name on it. The document has specific confidential patient information on it.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Inform Susanna that this is a breach of patient confidentiality
B. Advise Susanna to destroy the handover list
C. Report the incident to your consultant the following day
D. Destroy the handover list
E. Advise Susanna to discuss the breach of patient confidentiality with her educational supervisor*

Answer: ABEDC
Rationale: This question focuses on a professional commitment to maintaining patient confidentiality and the sequence of actions required if a colleague had apparently broken this duty of confidentiality to her patients. Susanna may not be aware she has done so, meaning the most appropriate response is to inform her (A). Advising her to destroy the list is important (B) but to do this without an explanation may mean she repeats this action. Discussion and reflection with her supervisor (C) are important but represent an action that will become more appropriate later once the immediate issue with the handover sheet has been dealt with. Destroying the list (D) may mean that Suzanna is unaware of what has happened to the document which may cause problems when reporting the breach of confidentiality at work. Reporting the incident to your consultant (C) is the least appropriate answer as this consultant may have no connection to Susanna, or the information. The responsibility to discuss the breach of confidentiality lies with Susanna and her supervising consultant.

24

Mrs Davies is a patient on the ward. You are informed by a ward nurse that one of her relatives has commented on your attitude towards Mrs Davies. Apparently, she has claimed that you were dismissive of Mrs Davies' concerns about her treatment and did not spend enough time listening to her. You do not remember the particular incident and it is the first time that you have received any complaints about your attitude.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Approach Mrs Davies and talk to her about any concerns that she has
B. With Mrs Davies' permission, arrange to meet her relative to discuss her concerns
C. Inform your clinical supervisor* about the situation
D. Seek advice from your Medical Defence Organisation* about how to respond
E. Thank the nurse and inform her that you will reflect upon your communication with patients in the future

Answer: ABCED
Rationale: It is sensible to confirm and corroborate any reported concerns directly with the patient (A), as there may have been a breakdown in communication or misinterpretation along the way. It may also be appropriate to ask the patient for permission to talk to the relative about her concerns, however this is a less direct way of resolving the issue as your responsibility is with the patient (B). It would then be appropriate to escalate this to your clinical supervisor to access support and advice, but it is again less direct than addressing concerns with the patient and her relative (C). Thanking the nurse and informing them that you will reflect on your communication skills is nice, but does not directly address the issue here (E). Similarly, approaching your defence union will not directly address the issue raised and is a drastic action before you obtain more information about the relative's concerns. Before contacting your defence union, gather a little more information (A and B), and discuss with your supervisor (C), then, if necessary, approach your union (D).

25

You and an FY1 colleague, Liam, are working a day shift on a ward together. Your senior consultant, Mr Parry, approaches both of you and asks you to assist with a hip replacement operation. You agree to assist and, near the end of the operation, Mr Parry asks you to suture the wound. This is something that you have not done before and you are unsure whether you are competent enough to do it.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Ask Mr Parry to provide instructions and supervise you as you suture the wound
B. Explain to Mr Parry that you do not feel comfortable suturing the patients’ wound
C. Ask Mr Parry whether he will suture the wound so that you can observe
D. Suture the wound to the best of your ability
E. Ask Liam whether he would feel more comfortable to suture the wound instead

Answer: BACED
Rationale: This question is testing your ability to work within the limits of your capability. Explaining to your consultant that you have not performed this skill before and that you do not feel comfortable proceeding is the most appropriate option (B). It is always possible to learn but the consultant should be aware of your level of competency and you should never work above your level of capability. Asking for assistance is another sensible approach, it implies that you are uncertain though you could be clearer about the fact that you have not performed this procedure before (A). Asking for a demonstration is an appropriate approach, though you will not be able to practice the skill yourself (C). Asking a colleague if he would like to perform the skill instead detracts from your own learning opportunity (E), however it is preferable to attempting a task that you are not competent in and comfortable performing (D), which is unsafe and inappropriate.

26

You are called to help Simon, your specialty trainee*, review a sick patient. When you arrive, the nurse takes you to one side and she tells you that Simon smells of alcohol. You confirm that this is the case. The review is urgent and Simon is needed as you are unable to conduct the review by yourself.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Suggest to the nurse that she asks Simon whether he has been drinking
B. Explain to Simon that he should not conduct the review if he is under the influence of alcohol
C. Contact the consultant immediately to explain the situation
D. Ask a specialty trainee from another ward to review the patient with you
E. Continue with the review, but explain to Simon afterwards that he smells of alcohol

Answer: BDCAE
Rationale: Your initial action is to safeguard the patient, asking your specialty trainee to refrain from any interaction if under the influence of alcohol (B) is appropriate as Simon is directly working with the patient at this time and it is important to safeguard them. It is possible there is an alternative explanation e.g. ketotic breath or contamination of clothing and this allows Simon to take suitable action himself. You should seek help from another specialty trainee to avoid delaying the patient's review (D) and inform the consultant (C) after prioritising the patient's needs. Delegating the difficult conversation to your nursing colleague is not appropriate unless the nurse is very senior and has a good working relationship with Simon (A). You should not continue with the review with Simon as this could put the patient at risk (E).

27

It is 18:00 and you have just been informed by a nurse that a patient, Jane, who has been treated for a chest infection, is ready to be discharged. Jane was ready to go home earlier that day; however, you are aware that there was a delay caused by a lack of hospital transport. Hospital transport is now available and you inform Jane that she can go home. However, Jane refuses, saying that it is too late for her to go home now and that she would prefer to be discharged in the morning. There are no medical reasons why Jane should stay in hospital overnight, and a nurse has just informed you that she has already allocated Jane's bed to another patient.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Go through Jane's patient notes to check that there are no outstanding medical issues
B. Ask Jane if she would like a next of kin to accompany her to be discharged
C. Ask the bed manager if they could arrange for Jane to stay for another night in the hospital
D. Explain to Jane that she must be discharged this evening to free up her bed
E. Ask Jane if there is a reason why she does not want to go home this evening

Answer: EBCAD
Rationale: Your initial action should be check with Jane that there is no good reason to prevent her discharge (E). She is assumed to have capacity, so discussion with the patient is the appropriate first response. After ascertaining Jane's thoughts, it would be supportive to offer to help her inform her next of kin to accompany her to be discharged (B). It would be reasonable to check if a bed is available overnight with the bed manager (C). She was declared fit for discharge earlier so the medical notes should reflect this (A). Discussions about other patients' needs are seldom helpful in these circumstances and risk giving the impression that the discharge decision has been taken on resource not clinical need grounds (D).

28

You are working on-call on the Trauma and Orthopaedics ward. You receive a referral from a GP* for her daughter to be admitted to the ward. The GP explains to you that her daughter has sustained a rotator cuff injury to her shoulder through playing sport. You explain to her that she should take her daughter to see their own GP; however, she insists that you accept the referral.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Seek advice from the on-call consultant about whether to accept the GP's daughter as a referral
B. Re-emphasise to the GP that it is inappropriate for her to refer her own daughter
C. Suggest that the GP take her daughter to the Emergency Department if she needs to be seen urgently
D. Complete a critical incident form* relating to the GP's inappropriate request
E. Tell the GP that you will accept her daughter's referral on this occasion only

Answer: BCAED
Rationale: This question tests your ability to respond to an inappropriate request for treatment of another doctor's family member as the scenario is suggesting that the mother is trying to circumvent normal procedure for her daughter to be seen as a priority. (B) is the most appropriate course of action as per GMC Guidance. (C) advises of the correct referral route if the patient requires urgent assessment. (A) is helpful if you feel you require support to ensure that the correct patient pathway is followed but the GMC guidance makes a clear case for declining this request and (B) remains the most appropriate option. (E) would be against GMC guidance and is therefore a less appropriate answer. It would result in the patient receiving urgent care but it would reinforce inappropriate behaviour. (D) is the least appropriate as this doesn't help the patient to receive appropriate emergency care and it does not resolve the situation.

29

A 50 year old patient, Mr Cox, is referred by his GP* to the Emergency Department with severe chest pain. You suspect that Mr Cox has acute coronary syndrome. In line with your hospital's guidelines, you request that the cardiology specialty trainee*, Lynda, attends to assess him. However, she refuses as she is too busy.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Contact Lynda again, reiterating the urgency for her to assess Mr Cox immediately
B. Contact the cardiology consultant, asking him to review Mr Cox since Lynda is too busy
C. Document in Mr Cox's notes Lynda's refusal to attend
D. Contact a senior colleague from your own team, seeking support in managing the situation
E. Continue managing Mr Cox yourself, following hospital guidelines for managing acute coronary syndrome

Answer: DABEC
Rationale: This question focuses on negotiating with a colleague for a patient review in accordance with local guidance on best management of this patient. The most appropriate option is (D), as this patient is critically unwell and you need support to manage both the clinical scenario and the declined referral. Similarly, involvement of a senior colleague may highlight, for example, any issues with the initial referral which led to it being declined. Calling the cardiology specialty trainee back (A) to restate the position may have the desired outcome of getting her to attend, but is less likely to succeed as it has already been tried. Contacting the specialty trainee's consultant (B) would be reasonable to ensure ongoing patient safety but it does not directly address the issue of dealing with the declined referral and this would usually be an action taken by a senior colleague. In the absence of senior help, continuing to follow the guideline is advisable (E) though it has been established this would still entail expediting the cardiology referral so it would not resolve the situation. Documenting Lynda's refusal in the notes (C) is important but is not an action which will help you resolve the situation or restore the ongoing safe management of the patient

30

You are completing a ward round with your consultant, Dr Dixon. You notice that Dr Dixon is not washing his hands in between examining patients. You are aware that all hospitals have an Infection Control* policy that requires all staff to wash their hands in between examining and treating patients. When you inform Dr Dixon of your observation that he is not washing his hands, he becomes annoyed and tells you that he does not have time to wash his hands in between examining every patient.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Offer Dr Dixon alcohol hand gel in between each patient
B. Suggest to the hospital's Infection Control team that they place posters around the hospital reminding people to wash their hands
C. Report Dr Dixon to the hospital's Infection Control team
D. Raise the importance of hand washing at the next team meeting, when Dr Dixon is present
E. Tell Dr Dixon that he is putting patients' safety at risk by not washing his hands

Answer: EADCB
Rationale: Remember to approach this question as what you should do, and not what you necessarily think you would do in this situation. Though it may feel blunt and uncomfortable, explaining to your consultant that there is a hand-washing policy in place to protect patient's safety is the most direct and appropriate way to address the problem (E), ideally do this in a gentle and polite way. Prompting you consultant between patients with hand gel will possibly overcome the problem in the short-term, but may not cause Dr Dixon to change his opinion and behaviour around hand-washing in the longer term (A). Raising the problem in a team meeting, at which Dr Dixon is present provides another, less confrontational, opportunity to raise your concerns and reminds everyone on the ward about the policy (D) but is less direct and timely. Reporting your consultant to the infection control team may lead to a change in his behaviour, however it is likely to aggravate your senior and there are less confrontational ways to raise your concerns (C). Suggesting posters are placed around hospital is the least direct and effective way to address this problem (B).

31

A nurse on the ward asks you to speak to a patient, Miss Sharif, who became distressed after she was mistakenly told that she was due to have a biopsy later that afternoon. You look through Miss Sharif's notes and then talk with her to apologise for the error, reassuring her that she does not need to have a biopsy. When you finish talking to her, Miss Sharif informs you that she has filmed your conversation, without your consent
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Explain to Miss Sharif that it is her choice whether or not to keep the recording
B. Seek advice from your clinical supervisor* about how to manage the situation
C. Inform Miss Sharif that filming your conversation is very inappropriate
D. Discuss with Miss Sharif her reasons for wanting to record the conversation
E. Ask Miss Sharif to delete the footage

Answer: DBACE
Rationale: This situation arises increasingly frequently and needs to be handled sensitively. Asking Miss Shariff about her reasons for recording the conversation (D) may allow you to offer further reassurance or deal with unresolved issues. Discussing the episode with your clinical supervisor is recommended (B) as they are likely to have prior experience and will be familiar with your organisation's guidance. It is Miss Shariff's choice how she uses the recording and whether she retains it (A). Options (C) and (E) risk confrontation with the patient and are unlikely to help and you cannot insist that Miss Shariff deletes the footage. (C) is a more oblique approach and explains your rationale, whereas (E) is blunt and direct.

32

You are one of eight FY1 doctors working in the Acute Admissions Unit*. All FY1 doctors have been allocated to cover one day of a four-day bank holiday weekend. However, one of your FY1 colleagues, Lydia, feels that this is unfair as she has worked a previous holiday weekend in the same rotation. Lydia sends an email to the hospital's rota coordinator* and states that since it is a public holiday, she does not think that all of the FY1 doctors should be allocated to work. She has copied in all of the FY1 doctors to the correspondence, including yourself, and listed everyone as co-signatories, indicating that everyone is in agreement with her assertions. You have had no discussions with Lydia regarding this matter and were not aware that she was going to send this email. You do not agree with Lydia's views. You and Lydia are not allocated to work on the same day of the bank holiday weekend.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Explore Lydia's reasons for including you as a co-signatory without your permission and whether she has permission from the other FY1 doctors to include them in her email
B. Offer to also cover the day that Lydia is allocated to work
C. Inform the rota coordinator that you had not been consulted prior to this email being sent
D. Advise the rota coordinator to produce an alternative rota for the bank holiday weekend, excluding Lydia
E. Ask Lydia to send a further email to the rota coordinator, clarifying that you were not a co-signatory

Answer: AECDB
Rationale: Lydia is entitled to express her views and may be justified in her assertion but she should not have sent an email representing her colleagues without prior discussion. The issue rests with Lydia and the administrator and you can sensitively explore with Lydia (A) whether it was on oversight on her part not to discuss this with you. If Lydia declines to clarify the situation by sending a clarification email (E) it may be necessary for you to do so (C). It is not appropriate for you to advise the rota coordinator to produce an alternative rota (D) and this request is likely to further complicate matters. Offering to work Lydia's shift does not solve the underlying communication difficulty between her and the rota co-ordinator (B).

33

You are working an on-call shift on a Friday evening. You are called to a ward to see the family of a patient who has just died. The patient and relatives are members of a religion that states burials should happen as soon as possible after death. You do not know the patient, although you are aware that your FY1 colleague, Claire, was treating the patient earlier today. As you enter the ward, the patient's relatives immediately request that you contact Claire as they want her to sign the death certificate.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Telephone Claire to ask that she comes back to the hospital to sign the patient's death certificate
B. Escalate the relatives' request to the on-call consultant
C. Tell the relatives that Claire has left the hospital and will not be able to return to sign the death certificate until her next shift on Monday
D. Sign the patient's death certificate
E. Contact the ward manager to see if there are any other doctors in the hospital who are able to sign the death certificate

Answer: EBCAD
Rationale: This question is testing your ability to respond to a family request when the doctor that the family was previously in contact with is no longer on shift. (E) offers the quickest solution to the issue and allows you to continue with your on call duties whilst an alternate doctor who is working is identified. (B) will provide appropriate senior input in real time, which will give advice as to the next steps for action. However, the on call consultant may also not have seen the patient and may not advance the attempt to provide a prompt death certificate. (C) will disappoint the relatives but may in some circumstances be an appropriate response if noone is in a position to issue the certificate. (A) is inappropriate in that Claire is not on duty at the hospital and may be on protected rest time. (D) is least appropriate - as you have never met the patient you should not complete their death certificate.

34

You have just completed a ward round with the consultant and he has asked you to organise an urgent MRI* scan for a patient. The consultant then leaves the ward, but informs you that he will return this afternoon to conduct another ward round. You begin to complete the MRI scan request form, but you are unsure of the reason that the scan is required, even after consulting the patient’s notes. However, you decide to take the form to the Radiology Department, as you know that the scan is urgent. When you arrive, the radiologist tells you that he will not conduct the scan as you are unable to explain to him why the scan is required.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Telephone your consultant immediately, asking him to explain to you why the scan is needed
B. Ask an available doctor for advice about ordering MRI scans
C. Wait until this afternoon’s ward round to speak to the consultant about the scan
D. Ask the radiologist to contact the consultant to determine why the scan is required
E. Politely explain to the radiologist that as the scan is urgent, you do not have time to ascertain why it is required

Answer: ADCEB
Rationale: This question tests your ability to respond under pressure when a request for imaging has been declined. (A) is the most appropriate response as it ensures the correct information is supplied to the radiologist, ensures your understanding of the request and ensures the desired patient outcome. (D) also ensures that the radiologist receives the referring clinician but does not help your understanding of the situation and what steps you can take yourself to resolve the situation. (C) will ensure that the correct clinical information is supplied but will delay patient care and dependent on the urgency of the case, could even lead to patient harm. (E) contradicts guidelines on ordering investigations for patients - you have to supply clinical information and a justification for ordering the test. (B) is inappropriate for this situation as it refers to generic advice, not specific to resolving this clinical situation.

35

It is almost the end of your shift. You recently spoke with a patient's family, accompanied by a nurse, Camilla, to provide an update on the patient's treatment. Camilla now approaches you to say that the relatives were very upset after you had spoken with them. She explains that in her opinion the information that you provided was confusing, which she thinks is the cause of the relatives being upset.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Ask Camilla for further feedback as to why she thought that the information that you provided was confusing
B. Speak to the relatives again, to determine whether they understood the information that you provided
C. Ask a senior colleague to accompany you to speak with the relatives
D. Ask Camilla to explore with the relatives what has upset them
E. On your handover list, indicate that a further discussion is required with the patient's relatives

Answer: BDACE
Rationale: This question is based on effective management of a situation where initial communication with a patient's family has not happened as well as planned. It tests your ability to rectify the situation in an effective manner where the nurse has suggested that confusing information has led to this family being upset. To avoid further confusion and speculation as to why the family members are upset, the most effective course of action would be to speak with to them directly (B). Asking Camilla to explore why the relatives are upset (D) may obtain similar information. However, Camilla may interpret this information in her own way and obtaining this information indirectly means your do not have an opportunity to clarify any confusion the relatives may have. Asking Camilla to further feedback without exploring issues with the family (A) may be helpful but invites further speculation rather than direct clarification. Asking a senior colleague (C) to accompany you is reasonable but without an understanding of why the family members are upset or confused, there is likely to be little benefit. (E) is not appropriate as it is not clear who will undertake this action or when, potentially leaving the patient's family confused or upset for a longer period.

36

You are in the Acute Admissions Unit* (AAU) and are writing up a patient’s drug chart. The nurse tells you that one of the patients has been waiting 10 minutes for a cannula to be inserted. You know that the patient was seen by your FY1 colleague, Alex, five minutes ago. Alex has now left the AAU but you do not know the reason why. The nurse informs you that Alex did not insert the cannula when he was with the patient. There is no clinical urgency to insert the cannula
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Ask the staff if they know why Alex has left the ward
B. Contact Alex and ask him to return to the ward and insert the cannula
C. Ask the nurse to contact Alex to request that he returns to AAU to insert the cannula
D. Tell the nurse you will insert the cannula as soon as you have finished writing up the patient’s drug chart
E. Contact your specialty trainee* for advice

Answer: ADCBE
Rationale: The most appropriate response is to establish why Alex left the ward (A) as this may have been to attend an emergency or obtain equipment for the procedure. Doing the cannula when you are able can ensure the ongoing care of the patient (D), but it does not address why a member of the team (Alex) has left. Contacting Alex is reasonable but it is more important to establish why he left the ward first from the staff as he may be busy with an important task. As you are in the process of dealing with a patient critical action i.e. completing a drug chart, this should take priority so asking the nurse to find where Alex is would be more appropriate (C) than leaving the task to contact him on your own (B). Finally contacting the specialty trainee (E) is a reasonable last resort - however, for a simple procedure like cannulation it would be expected that the FY1 doctor would attempt the procedure first.

37

You are on a ward round with your consultant. One of the patients on the ward, Mr Andersen, is very ill and frail although he still has full capacity and is able to communicate. Your consultant recommends that several invasive procedures are conducted to determine the cause of Mr Andersen's illness. Mr Andersen told you when he was admitted to the ward that he did not want to have any invasive procedures conducted
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. During the ward round, inform the consultant that Mr Andersen told you that he did not want any invasive procedures to be conducted
B. Talk to the consultant after the ward round about whether the procedures are a necessary option for Mr Andersen
C. Seek advice on what to do from another senior doctor
D. Discuss with Mr Andersen why it is in his best interest to undergo the procedures
E. During the ward round, ask Mr Andersen whether he wants to undergo these procedures

Answer: AEBCD
Rationale: This question is testing your ability to advocate for a patient who has provided specific information as to what interventions he will and will not to consent to in hospital. It is essential that this is conveyed immediately to the consultant to prevent the patient undergoing any test which they do not consent to - this makes (A) the most appropriate response, and is less confrontational than (E), although it is reasonable to check as the patient may have changed their mind since the initial discussion. (B) ensures that the patient's decision is eventually discussed with the consultant, but delays the discussion. Dependant on the length of the ward round this may mean the patient undergoing unwanted procedures before the ward round is complete. (C) may be helpful but is an indirect way of addressing the issue - however, most consultants would want to be aware of this information immediately making this a less desirable option. Finally, whilst (D) may be appropriate if, for example, a patient is unsure of what tests they may wish to undergo, in this circumstance, the patient appears to have made a direct request not to undergo the tests - in which case the job of the team is to respect the patient’s wishes and/or organise a less invasive alternative investigation if appropriate.

38

You are on a surgical ward round with an FY1 colleague, a specialty trainee* and a consultant. The specialty trainee looks at the notes and drug chart of a patient who is due to go for colorectal surgery. The specialty trainee notices that a blood test that he had asked your FY1 colleague to do earlier on has not been done. The specialty trainee turns to you and asks why you have not done the blood test.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Apologise that the blood was not taken and offer to take the blood test now
B. Explain to the specialty trainee that he had asked your colleague to take the blood test, not you
C. Ask your FY1 colleague why he has not taken the blood test
D. Tell the specialty trainee that you will take the blood test later
E. Liaise with your FY1 colleague regarding who will take the blood test now

Answer: AEBCD
Rationale: This tests your ability to respond to an omission in a patient's care made by a colleague. The patient's safety is the priority and (A) is the most appropriate response. (E) is appropriate but an indirect way of ensuring that the blood test is done in a timely manner. (B) is important as it ensures that the specialty trainee is aware that you were not responsible for the error, but can be addressed after the immediate patient safety issue is dealt with and the test sent. (C) seeks clarification of why the test hasn't been sent as there may be a valid reason, although it is looking at the situation retrospectively. (D) is the least appropriate as it is clear that the test is delayed and to postpone it further still delays patient care.

39

You recently started working on the Rheumatology ward where visiting hours are in the afternoon, a time when senior doctors are often not present. The relatives of a patient, Mr Cheung, have come to visit him. He has recently been diagnosed with a rare disease and his relatives ask you to explain his diagnosis and treatment plan. You have been reading about the disease; however, you are not very familiar with it and you do not understand the full details of Mr Cheung's treatment plan. You explain this to the family, advising them to wait for a senior doctor to speak to them. They insist that you give them further details now, asking why you do not know about the disease or treatment plan if you are looking after Mr Cheung.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Contact the senior doctor treating Mr Cheung, asking her to come and speak to his relatives as soon as possible
B. Explain the details that you understand about Mr Cheung's disease and treatment plan to his relatives
C. Explain to the family that as an FY1 doctor you are not expected to know the details of all rare diseases
D. Apologise to Mr Cheung's relatives, excusing yourself
E. Explain to Mr Cheung's relatives that, due to the rarity of the case, they should wait to speak to a senior doctor

Answer: AEBCD
Rationale: This question involves responding to a request made in a difficult conversation. It is better to seek support than risk trying to explain and giving incorrect information or miscommunicating and causing worry or confusion. (A) ensures that the relatives receive the correct information. (E) is a clear statement that very specialist knowledge is required for this rare condition. Whilst it is not unreasonable to act as per (B) to share the limited insight that you have, this may lead to further questions and you becoming drawn into areas you are unable to answer. (C) is helpful as it explains that you are not a senior expert, but it does not further assist the family, and could be misconstrued as being unhelpful. (D) is not appropriate as you have not done anything to assist the relatives in getting the information they have requested.

40

You are working on your first rotation in surgery. Whilst assessing a 65 year old female patient with jaundice, the consultant surgeon asks you to refer the patient to the Gastroenterology department regarding further treatment. You are unsure why this referral is required.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Ask a more experienced colleague to make the referral
B. Conduct research on the Internet into why the referral could be required
C. Contact the gastroenterology consultant to explain that you need to make the referral, and ask what information they need to proceed
D. Ask a more experienced colleague what information the Gastroenterology department will require to make the referral
E. Speak to the consultant surgeon again to gain more information before making the referral

Answer: EDBCA
Rationale: If you are unsure about why a referral has been requested, check with the person requesting it (E). They may have forgotten to explain the details to you, and it furthers your learning and understanding. Failing this, speaking to another senior member of the team for generic information about this type of referral will be helpful (D), however they may also be unsure of the consultant's reason for requesting this referral. Taking a proactive approach and researching your questions will be appreciated by the team you are referring to (B) and will also further your knowledge. Contacting the gastroenterology consultant without understanding why you are calling is likely to be unproductive and frustrating for yourself and the team you are referring to (C). Asking a colleague to make the referral for you is inappropriate as you are passing work to a colleague and failing to address your own learning needs (A).

41

You are on-call on a busy late shift and covering the Stroke ward. Mrs Appleton is an inpatient with a dense hemiplegia and dysphasia. Her daughter Sally, who is a nurse in Australia, has rung the ward to enquire about the progress of her mother. You have not been involved in Mrs Appleton's care as you have just started your shift, but you are aware that she is stable. The nurse in charge of the ward confirms Sally's identity and asks you to speak with her.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Ask Sally to telephone during the daytime when the ward doctors are available
B. Tell Sally that you are unable to provide her with information about her mother's condition
C. Check the clinical notes before explaining to Sally that her mother is in a stable condition
D. Ask an available doctor, who has been involved in Mrs Appleton's care, to speak to Sally
E. Ask the nurse in charge to tell Sally that there is no-one available to speak to her at present

Answer: CDABE
Rationale: Prior to any conversation you should check the clinical notes (C) to ensure you can communicate with the relative in question and to give accurate information about the correct patient. It is also appropriate to ask a doctor who has been involved in Mrs Appleton’s care (D). As you are the on call doctor it is reasonable to ask Sally to telephone to speak to the base team for information (A) and it may not be possible to give information if you are unfamiliar with the patient or uncomfortable communicating by telephone with relative unknown to you (B). Asking the nurse in charge is a delegation of the task and risks undermining the relationship between Sally and the ward staff (E).

42

One of your patients, Miss Greenlee, confides in you that she finds one of the nurses who is caring for her to be rude and inconsiderate. Miss Greenlee tells you that she is a bit frightened of the nurse. You have not heard similar feedback about this nurse before, and find her to be approachable and friendly.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Tell Miss Greenlee that you have always found the nurse to be approachable and friendly
B.Explore these concerns with Miss Greenlee in more detail
C. Explain Miss Greenlee's concerns to the nurse involved, seeking her views on the situation
D. Inform the nurse in charge of what Miss Greenlee has told you
E. Discuss the issue with Miss Greenlee's consultant

Answer: BCDEA
Rationale: This question assesses your response to a patient who raised concerns about a member of staff and the impact on their care. It is important to gather further information before acting (B). The second most important point is to listen and act on these concerns. As you have found the nurse to be approachable and friendly which implies that the nurse would be receptive to such feedback, (C) is the most appropriate answer. It allows the nurse to address this. If you did not feel able to do this then raising the concern with the nurse in charge (D) would be the next most appropriate answer to make sure action is taken. The nursing team would be better placed to raise it with the consultant (E). Finally, to directly contradict Miss Greenlee (A) without an effective acknowledgement of her concerns or an explanation of how you plan to act on her concerns is unlikely to resolve the situation. It may also result in a formal complaint lodged in response to an issue which could have been promptly and effectively dealt with at a ward level.

43

You are working on a surgical ward. Your specialty trainee* arrives on the ward looking unkempt and you notice that he smells of alcohol. He is due to operate in one hour, and you believe that his ability to operate may be impaired.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Suggest to the specialty trainee that he looks too tired to operate
B. Ask other team members whether they think the specialty trainee is fit to operate
C. Inform your consultant of the situation
D. Contact the theatre team and ask them to prevent your specialty trainee from operating
E. Suggest to your specialty trainee that he should not operate if he is under the influence of alcohol

Answer: CEBDA
Rationale: Patient safety is at risk, and therefore this is a serious issue that must be addressed immediately. As this is a potentially delicate situation, the most appropriate course of action is to immediately raise your concerns with your consultant who is best placed to handle this situation (C). The trainee has an hour until he is due to operate and therefore telling the consultant who is overall in charge may be a better option as they could ensure appropriate cover is requested. Telling your specialty trainee that he should not operate if he is drunk is appropriate, but the confrontation may create further problems, particularly if the specialty trainee is drunk and reacts badly (E). Asking the team for their opinion may help you to decide how to further proceed, but will draw wide attention to the situation and your colleague deserves to be treated with discretion until the facts are established (B). Asking the theatre team to prevent your specialty trainee from operating would be effective but is overly dramatic. There are more appropriate and direct ways to address this situation (D). Suggesting to your senior that he appears too tired to operate does not address your concerns (A) and is therefore inappropriate as patient safety will continue to be jeopardised.

44

You are working on the Obstetrics and Gynaecology ward with another FY1 doctor, Funmilayo. You have noticed that Funmilayo often works for several hours before and after her shift. When you mention this to a nurse, she says that Funmilayo does this in order to complete tasks that are outside of her remit, to support her learning and development. Today, you see Funmilayo in the staff room at lunchtime, looking very tired.
Rank in order the appropriateness of the following actions in response to this situation (1= Most appropriate; 5= Least appropriate).
A. Suggest to Funmilayo that she should not work additional hours outside of her shift
B. Tell Funmilayo that you are concerned about how hard she is working
C. Remind Funmilayo that she should not be completing tasks that are outside of her remit, even if it is for her learning and development
D. Suggest to Funmilayo that if she is tired at work, this may have a negative impact on patient safety
E. Inform your specialty trainee* of your observations, seeking advice on how to proceed

Answer: BEDAC
Rationale: This question tests your ability to respond to the situation of a colleague who appears to be overworked and tired. (B) is the most direct and most appropriate way to raise the issue of concern for her health and allows her to directly respond or act herself. (E) involves an appropriate clinical supervisor - this is appropriate, but a less direct solution. (D) raises the important issue of patient safety but doesn't deal specifically with the impact on Funmilayo which is the focus of the situation. (A) is less appropriate as it appears that Funmilayo is already aware of this but working beyond her shift hours by choice. Finally, (C) is the least appropriate as it is not your role to supervise a fellow F1 and delineate their clinical remit.

45

You and an FY2 doctor, Max, are working within a busy emergency department. You are both treating patients separately in adjacent rooms. You have just finished an examination of your patient, Miss Poon, and she is about to leave. Through the wall, you both hear Max making loud derogatory remarks towards his patient. This behaviour is completely uncharacteristic of Max.
Choose the THREE most appropriate actions to take in this situation.
A. Apologise to Max’s patient
B. Take Max aside and ask him privately about the incident
C. Immediately inform a senior doctor
D. Reassure Miss Poon that Max is usually very professional
E. Apologise to Miss Poon for what she has heard
F. Ask Max’s patient if she would like to make a complaint
G. Inform Max that this behaviour is highly inappropriate
H. Report the incident to Max’s clinical supervisor*

Answer: BCG
Rationale: This question focuses on an event which is having an immediate impact on the quality of patient's care. It requires an immediate response to prevent harm to the patient and involves unprofessional behaviour which could have serious repercussions for Max including receiving a formal complaint or referral to the General Medical Council. The most appropriate immediate response is to take Max aside (B) and explain what you have heard, that it is highly inappropriate (G) and immediately inform a senior doctor (C). This is to ensure that the immediate assessment of the impact on the patient can be made and a plan put in place to mitigate any harm. Similarly, a senior doctor will need to speak with Max and determine what needs to happen to establish why Max has behaved this way and take steps to prevent a recurrence. Whilst it is likely that an apology will need to be made to Max's patient (A) and Mrs. Poon (E) this would likely be part of the action plan instigated by the senior doctor rather than something an FY1 would be expected to take responsibility for. Similarly, it would not be part of your job to defend Max (D) or initiate a complaints process (F). The senior doctor will need to discuss this with Max's clinical supervisor as part of a plan to prevent an occurrence and may ask for a statement of events to support this process. However, reporting the incident (H) would be the responsibility of the senior doctor rather than the FY1.

46

A very ill patient tells you one morning that she wants to discharge herself from the hospital, because she has not slept for the last three nights. She says that this is because her bed is next to the nurses’ station and the telephone is always either ringing or the staff are talking on it during the night. She tells you that the staff often seem to be chatting on the telephone rather than discussing medical matters. The patient has not been deemed ready for discharge
Choose the THREE most appropriate actions to take in this situation.
A. Offer the patient some general advice on how to sleep better at night
B. Ask the patient to tell you more about this situation and her concerns
C. Explain that telephones are only used at night by nurses for urgent issues that cannot wait until the morning
D. Document the patient’s concerns in the nursing notes
E. Inform the nursing staff that the patient is having trouble sleeping because of the noise levels at night
F. Arrange for the patient to be given some ear plugs
G. Ask the ward manager about the feasibility of moving the patient to a different bed on the ward
H. Offer to prescribe a low dose sleeping tablet

Answer: BEG
Rationale: This question assesses your ability to respond to a concern that has been raised by a patient relating to their experience of care in hospital. Simply hearing more about the situation (B) will reassure the patient that their concerns are being listened to and may lead to some mutually agreed solutions to the problem. The most practical action to take would be to inform the nursing team (E) as they may not be aware of the situation and may be able to reduce the amount of noise at night. If the situation cannot be resolved, the simple action of considering moving to another bed (G) could similarly resolve the situation. Explaining that phones are only used for urgent issues at night (C) or providing ear plugs (F) may be reasonable actions but only attenuate the issue rather than resolving the source of the problem. Documenting the problem in the nursing notes (D) may be important but won't resolve the situation. Sedation is associated with a risk of falls in hospital (H) and is an inappropriate risk to take when conservative measures (e.g. moving beds) can improve the situation.

47

One of your patients, Mr Austin, is an 85 year old man who has terminal cancer and is receiving palliative care. The team that is looking after him anticipates that he is likely to die within the next 48 hours. Mr Austin's daughter, Helen, has just arrived from New Zealand, and asks to speak to you. She demands to know why her father is no longer receiving treatment. You are aware that active treatment has been withdrawn due to the stage of Mr Austin's cancer, and the team is trying to make him as comfortable as possible
Choose the THREE most appropriate actions to take in this situation.
A. Ask Helen if she would like to speak to a more senior member of the team
B. Reassure Helen that her father is comfortable
C. Suggest to Helen that she spends some time with her father
D. Reassure Helen that the team is working hard to make her father as comfortable as possible
E. Advise Helen to make an appointment to speak to her father's consultant
F. Explain to Helen why her father's active treatment has been withdrawn
G. Inform Helen that her father does not have very long to live
H. Ask the senior nurse to come and speak to Helen

Answer: ADF
Rationale: Helen would expect to speak to a senior doctor about a decision to withdraw treatment and as a foundation doctor you should arrange this if possible (A). Asking a relative to make an appointment with the consultant in an unfamiliar situation increases their burden in a demanding situation (E). An explanation that the team are working to keep her father comfortable will help Helen understand that his care remains a priority (D). This is preferable to assuring Helen her father is comfortable (B), which is a subjective and potentially inaccurate statement. It may be necessary for you to explain why treatment has been withdrawn if Helen declines to wait for a more senior colleague (F). The decision to spend time with her father is a personal one and this type of statement should be avoided (C). If Helen asks about her father's prognosis it may be appropriate to explain that he may not have long to live but this should form part of a more detailed conversation not an initial response (G). Although the experience of the senior nurse will be valuable, it is not reasonable to ask them to convey a medical decision of withdrawal of active treatment (H).

48

An 80 year old patient, who has been on the ward for three days for treatment of a urinary tract infection, is now much improved and due to be discharged home. The patient is extremely keen to get home, where she lives alone. The patient has two daughters; the first daughter, who is present at the hospital, is keen for her mother to return home. However, her second daughter telephones the ward and leaves a message with one of the nurses to say that she is very unhappy that her mother is being discharged, as she feels that her mother is not coping at home.
Choose the THREE most appropriate actions to take in this situation.
A. Continue with the current arrangements for discharge
B. Try and find out more details about the second daughter's concerns
C. Explain to the patient that the second daughter does not want her to be discharged
D. Contact the second daughter and explain that it is her mother's right to decide whether she is discharged or not
E. Ask Occupational Therapy* to assess the patient
F. Ask the first daughter if she has any concerns about her mother being able to cope at home
G. Explain to the first daughter that she and her sister need to discuss the issue between them
H. Ask the patient if she feels that she is able to cope at home

Answer: BEH
Rationale: The first action here is to explore the daughter's concerns (B) to ensure discharge home is safe. In the event of a disagreement the OTs assessment (E) may alleviate concerns and resolve the matter. The patient's level of capacity has not been specified, but assuming good capacity, the patient's wishes must be respected wherever possible (H). Continuing with the current arrangements risks damaging the relationship with the family (A). Although a resolution within the family is desirable (G) and option (D) is correct, it risks increasing tension within the family and getting involved in the family discussion (C) may be counterproductive. The first daughter has already stated she is keen for her mother to return home (F).

49

You are working a surgical on-call shift and are due to finish at 20:00. You are preparing to hand over your remaining duties to your FY2 colleague, when you receive a bleep* from the ward at 19:55 asking you to take the history of a very sick patient, Mr Martin, who has just been admitted by his GP* and may need emergency surgery. The FY2 doctor, who you are due to hand over to, is currently in theatre with the surgical specialty trainee*. The consultant is at home.
Choose the THREE most appropriate actions to take in this situation.
A. Telephone the ward to explain that you cannot take Mr Martin’s history as you are due to finish your shift
B. Make a list of what needs to be done for handover and leave it with reception
C. Attend to Mr Martin and take his history
D. Explain to the nursing staff that the FY2 doctor and specialty trainee are currently in theatre before going home
E. Go to theatre to notify the surgical specialty trainee that Mr Martin may require emergency surgery
F. Hand over your remaining duties to the FY2 doctor
G. Wait with Mr Martin until the specialty trainee and FY2 doctor have finished in theatre
H. Telephone Mr Martin’s GP to find out the urgency of his surgery

Answer: CEF
Rationale: This question is about ensuring the care of your patient is your first priority. Therefore, as your colleagues are currently occupied in theatre, you should attend to the patient (C). It would also be very sensible to inform your team that this patient may require urgent surgery (E) so that they can prepare and organise workload. Where possible, you should be leaving work on time and handing over important, outstanding tasks is vital in this (F). Informing the ward that you cannot see the patient (A) or that the team members are busy (D) are inappropriate answers as they place the patient at risk. Making a list of tasks and leaving it with reception is also inappropriate as it does not address the concern, which is an unwell patient, and it also may be lost or not handed over (B). There is little point in waiting with the patient to hand over without at least starting to assess him (G), and the GP has already referred the patient as a surgical candidate and is unlikely to be able to comment further on the urgency of the patient's surgery (H).

50

Your FY1 doctor colleague, Roshan, has asked to speak to you in confidence. He has received feedback from his clinical supervisor* that his style of communicating with colleagues is unacceptable. You have noticed when working with Roshan that he is usually courteous, although on occasions he can be irritable and patronising with the nursing staff. Roshan is seeking your view on what he should do.
Choose the THREE most appropriate actions to take in this situation.
A. Inform Roshan that you agree with his clinical supervisor's comments
B. Advise Roshan to seek feedback from other members of the team regarding his communication skills
C. Offer to conduct some role play with Roshan so that he can practise his communication style
D. Advise Roshan to speak to his clinical supervisor about strategies for improving his communication
E. Advise Roshan to contact the foundation team to discuss the feedback
F. Advise Roshan to inform his clinical supervisor that he does not agree with the feedback
G. Advise Roshan to attend a communication skills workshop
H. Offer Roshan constructive feedback based on your past observations of him

Answer: BDH
Rationale: It would be sensible to encourage your colleague to gain feedback from a larger cohort of staff members in order for him to establish a more holistic view of his communication skills (B) as one person's opinions may not be representative of the true picture. It would also be useful to give some constructive feedback of your own observations in order to help build this more complete picture (H). If your colleague is concerned, it would always be appropriate to advise them to seek senior support to further investigate the issues (D), and developing effective strategies with a senior to overcome challenges will always be a sensible course of action. Role play (C) should only be done under supervision with a trained facilitator and therefore inappropriate to be suggested. Advising Roshan to attend a communication skills workshop (G) should only be done on the advice of a supervisor and if it has been confirmed as an issue

51

You are part of the multidisciplinary team* that has been involved with the care of a 90 year old patient, Mrs Turner, who has now been put on a palliative care pathway. You are at her bedside attending to her when her son comes into the room and insists on being able to take his mother home immediately. He tells you that he does not want her to remain on the hospital ward, and instead wants her to die at home surrounded by all of her family. Mrs Turner is awake and appears to be upset by the situation.
Choose the THREE most appropriate actions to take in this situation.
A. Ask Mrs Turner's son to try and calm down
B. Suggest to Mrs Turner's son that he come with you to a quiet room on the ward
C. Ask a senior doctor on the ward to speak to Mrs Turner's son
D. Call security to defuse the situation
E. Inform Mrs Turner that you will discuss the situation with her son
F. Try to explore with the son the rationale behind his request
G. Discuss with Mrs Turner what her preference is for where she dies
H. Advise Mrs Turner to ask her son to leave the ward until he is calmer

Answer: BFG
Rationale: This question focuses on maintaining the patient as the central focus of care in a situation which is distressing to Mrs Turner, her family and the ward team. The first priority is to acknowledge that the situation is distressing and seek to diffuse it (B, F), which in turn allows an exploration of Mrs Turner's wishes for this situation (G) which will form the basis of any subsequent discussion with her and her family. The other options are less effective initial responses. Establishing Mrs. Turner's wishes and consent to discuss the situation with her son must come before simply 'informing' (E) her that you will discuss the situation with her son. It is likely that a senior doctor will need to be involved in the discussion with Mrs Turner's son (C). This would be an action to be taken later after the immediately distressing situation is diffused. Palliative care conversations can be upsetting to patients and their families - to tell the son to 'calm down' (A) or instruct him to leave the ward until he is calmer (H) may antagonise him and doesn't acknowledge his distress adequately. Calling security would similarly be unhelpful (D) as there is no indication that Mrs Turner's son is an immediate danger to anyone and may simply cause an escalation of the situation which is already distressing to the patient.

52

A five year old patient on your ward, Caleb, has been in hospital for three days with a fever. He has not been eating or drinking normally during this time. Caleb's diagnosis is yet to be confirmed, despite ongoing investigations. You are asked by the nurse in charge to speak with Caleb's father, Mr Hamilton, about his son's progress. Mr Hamilton is angry and displaying aggressive behaviour because Caleb has not yet been diagnosed, and he says that Caleb is not getting any better. The specialty trainee* is currently in clinic and your consultant has left the ward for the day
Choose the THREE most appropriate actions to take in this situation.
A. Speak to Mr Hamilton, with the nurse in charge present, to try to explore his concerns further
B. Ask the specialty trainee to speak with Mr Hamilton upon his return from clinic
C. Ask your consultant to speak to Mr Hamilton the next time she is on the ward
D. Request that hospital security removes Mr Hamilton from the ward
E. Inform Mr Hamilton that you will not tolerate his aggressive behaviour
F. Suggest that Mr Hamilton documents his concerns in writing
G. Ask the nurse in charge to inform Mr Hamilton that you are still awaiting the results of investigations
H. Acknowledge Mr Hamilton's frustrations

Answer: ABH
Rationale: This question is testing your communication skills in a difficult situation. Whilst in a specialty like Paediatrics, it would be unusual for an F1 to find themselves in this situation, the first priority is to acknowledge Mr Hamilton's frustration (H). Not doing this would make it difficult to progress to subsequent steps to ensure resolution. The most appropriate steps here would be a chaperoned conversation with the charge nurse to gather more information on Mr Hamilton’s concerns (A). As Caleb's diagnosis is not confirmed, Mr Hamilton may have questions you are unable to answer - therefore conveying these concerns to a senior colleague as soon as they are available (B) to speak to Mr Hamilton is essential. It may be appropriate to contact the consultant if the specialty trainee was unavailable (C), however action needs to be taken on the same day and waiting to speak to the consultant the next time she is on the ward does not address the time sensitivity of the situation. Declining to talk to Mr Hamilton (G) is likely to make the situation more difficult for a colleague later. At this early stage (E) and (F) are likely to be counterproductive and may antagonise Mr Hamilton. (D) is an inappropriate initial response and is would only be appropriate if you are unable to de-escalate the situation or Mr Hamilton was a danger to others on the ward

53

You have just started an overnight on-call shift. A nurse asks you to speak to a patient, Desmond, who had a number of tests taken after being admitted this morning with acute abdominal pain. The nurse explains that Desmond is agitated, as he has not been given information about his current condition, the results from the tests or for how long he will have to stay in the hospital. You visit Desmond, who explains that he was expecting a parcel to be delivered at his house and is worried he will not be in to collect it. Desmond asks you to tell him everything you know about his condition. You are unfamiliar with his medical history and his test results, as you only started your shift two hours ago.
Choose the THREE most appropriate actions to take in this situation.
A. Suggest to Desmond that he asks the medical team to answer his questions in the morning
B. Ask Desmond whether he would like you to contact one of his neighbours so that they can collect his parcel
C. Read through Desmond’s patient notes, before answering his questions
D. Ask the nurse in charge to give you a full verbal account of Desmond’s history
E. Document Desmond's test results in his patient notes
F. Speak to your specialty trainee* about Desmond’s management
G. Listen to Desmond’s concerns
H. Reassure Desmond that he will soon be home from hospital to collect his parcel

Answer: CFG
Rationale: This assesses your response when providing information to a patient that you are not familiar with. (C) is clearly essential before trying to answer any questions. Similarly, the speciality trainee may be able to provide a synopsis of the working diagnosis and management for Desmond (F). Together with (C) this will hopefully allow answering the patient's questions. In addition to providing information, listening to Desmond (G) will demonstrate you are taking his concerns seriously and allow you to answer the specific questions he poses. This way you would have engaged in a twoway process of acknowledging the issues he raises and then providing answers. (A) delays the issue and is not an appropriate response. Similarly, (B) addresses the issue of the parcel but doesn't address his key concerns about his medical care. (D) may be helpful but you should consult documented information and a senior doctor first. The nurse in charge may only have limited information on the current status of his investigations. (E) highlights that documentation is essential but comes after you have found the results and discussed them with the patient. (H) is inappropriate as it is not based on any facts and if untrue it could be construed as unprofessional and lead to a significant complaint when it becomes clear the information is false.

54

Mr O'Brien has alcoholic cirrhosis of the liver. He is embarrassed about his condition and does not want his family to know the diagnosis. At least four members of his family visit the ward every day and on each occasion, ask you how Mr O'Brien is. On this occasion, they approach you and seem upset. They tell you that they believe that Mr O'Brien is dying of cancer and that his case is being mismanaged. They begin to get angry.
Choose the THREE most appropriate actions to take in this situation.
A. Advise the family that you will have to call security if they do not calm down
B. Ask your specialty trainee* to speak with the family
C. Ask the family why they think Mr O'Brien's case is being mismanaged
D. Ask the nursing staff to assist you in dealing with the family
E. Explain that you cannot discuss Mr O'Brien's case without his permission
F. Tell Mr O'Brien that his family thinks he is dying of cancer, asking him to clarify his condition with them
G. Reassure the family that Mr O'Brien will not die of cancer
H. Suggest to the family that they may be better speaking to Mr O'Brien about their concerns

Answer: CEH
Rationale: Mr O'Brien's privacy must be respected. It is reasonable to ask the family for the basis of their concerns and answer in a way that preserves confidentiality but reassures (C). The family members will require an explanation of Mr O'Brien's right to confidentiality (E). Mr O’Brien and his relatives may both benefit from a conversation about the family’s concerns for him (H), so suggesting to the relatives that they speak with Mr O’Brien directly is also appropriate. Telling Mr O’Brien that his family thinks he is dying of cancer is unnecessary and adds an element of coercion that is not helpful to the situation (F). You cannot reassure the family that he is not dying of cancer without discussing other diagnoses (G) and there is no reason initially to ask for senior help (B) or to put the nursing staff in a similar position (D). Advising the family members that you will call security if they do not calm down is likely to inflame the situation and is only appropriate if all other options have been explored without resolution and they pose danger on the ward (A).

55

You are on your way to take a break when you overhear an FY2 colleague, Anita, breaking bad news insensitively to the relatives of one of your patients, who has just been diagnosed with lung cancer. Anita leaves quickly. The relatives are looking extremely distressed.
Choose the THREE most appropriate actions to take in this situation.
A. Tell the nurses that the patient's relatives look extremely distressed and may need some support
B. Apologise to the patient's relatives on behalf of Anita
C. Speak to the Foundation Programme Director* about Anita's communication skills
D. Contact the hospital chaplain and ask that she comes and supports the patient and their family
E. Approach the relatives and offer them the opportunity for further discussion
F. Suggest to Anita's clinical supervisor* that she may need further training in breaking bad news to patients and relatives
G. Contact Anita and tell her that the patient and the patient's relatives are upset
H. Monitor Anita's future encounters with patients

Answer: AEG
Rationale: You have only overheard the situation and assumptions are being made, however you do have the duty to relieve any distress caused to the family. It is likely that the family will need support. Informing the nursing staff will ensure an empathetic approach in the wider team (A). You should offer to have further discussion with the family to help answer questions and alleviate their distress (E). You can apologise on behalf of the organisation for any unnecessary distress but not on behalf of your colleague without prior discussion (B). Informing Anita that the relatives are unhappy allows her to address the issue herself, apologise if necessary, and learn from the episode (G). It would not be appropriate to contact the clinical supervisor unless there is a pattern of behaviour (F). It would be the clinical supervisor's responsibility to monitor Anita's performance (H) and the Foundation Programme Director would only be involved if local resolution at the team level was not possible (C). The hospital chaplain should only be contacted after discussion with the patient or the patient's relatives (D).

56

You are working in a busy Acute Admissions Unit*. A 26 year old mother, Jodie, was recently admitted to the department with pelvic pain. Your FY1 colleague, Rohan, prescribed an oral antibiotic for Jodie. An hour later, a nurse approaches you to inform you that Jodie’s first dose of the antibiotic has been administered, but that she has just observed Jodie breastfeeding her five week old baby. You are aware that the antibiotic that has been prescribed and administered is not recommended for mothers who are breastfeeding. Rohan has now left the ward.
Choose the THREE most appropriate actions to take in this situation.
A. Seek advice from the paediatric team about the risk to Jodie’s baby
B. Request a new prescription for an appropriate antibiotic
C. Inform your consultant of what has happened
D. Apologise to Jodie, explaining what has happened
E. Advise Jodie about the hospital complaints procedure
F. Attempt to contact Rohan to inform him of his error
G. Arrange for a qualified member of staff to conduct an initial assessment of Jodie’s baby
H. Investigate how Rohan had made an error in prescribing

Answer: ABD
Rationale: It is appropriate to speak to the paediatric team (A) as they will need to advise on how best to treat the baby if necessary. This conversation may also help you in requesting a more appropriate prescription (B). You will need to have information from the paediatric team when informing the patient (D). (C) may be an appropriate option as the consultant will need to be informed, but contacting the paediatric team is more immediately relevant to addressing the situation. Another staff member e.g. the nurse shouldn't be conducting the assessment of the baby (G) - you should. (G) may seem appropriate but isn’t necessarily required once the situation has been addressed: prescription corrected, mother spoken to and advice sought regarding the baby

57

You are bleeped* to urgently attend to an 87 year old patient, Eileen, who has gone into cardiac arrest. You arrive and see that Eileen appears to be extremely frail and weak. You see no indication of a Do Not Attempt Resuscitation* (DNAR) request. A specialty trainee* also arrives and commences with the resuscitation attempt. You are concerned that resuscitation may not benefit Eileen.
Choose the THREE most appropriate actions to take in this situation.
A. Advise the nursing staff to contact Eileen's next of kin, asking them to attend the hospital
B. Ask the specialty trainee about the benefits of the resuscitation attempt
C. Ask the nursing staff involved in Eileen's care, whether there have been any DNAR discussions with the patient or her family
D. Inform the specialty trainee that you think that the resuscitation attempt would be unethical
E. Immediately contact Eileen's next of kin, asking for their views on whether resuscitation should be attempted
F. Commence with assisting the specialty trainee in the resuscitation process
G. When the resuscitation team arrives, share your concerns about the benefits of the resuscitation attempt
H. Insist that the specialty trainee delays his attempts until the full resuscitation team have arrived, and the situation can be discussed

Answer: BCF
Rationale: In this situation, it would be appropriate to quickly ascertain if any previous DNAR discussions have been held, or if the DNAR form has indeed been completed and has been filed somewhere incorrectly. Asking the nursing team on the ward is the best way to do this (C). Following this you should commence CPR with your senior as there is currently no evidence that you should not attempt resuscitation (F) and if concerned, ask them whether they think CPR is likely to be successful and in the patient's best interests (B). As there is no definite evidence of a DNAR, treatment should always be started while discussions are taking place (D, E, G) even if you consider it to be unethical. Insisting treatment is delayed (H) is inappropriate.

58

A fellow FY1, James, tells you that he is finding life as an FY1 doctor very hard. He explains that he is not sleeping well, his concentration has deteriorated, he has made a number of minor mistakes at work and he is no longer enjoying anything
Choose the THREE most appropriate actions to take in this situation.
A. Suggest that James may want to consider taking some annual leave
B. Suggest to James that he discusses his difficulties with his educational supervisor*
C. Suggest that James makes an appointment with his GP*
D. Explain to your colleagues that James may need extra support
E. Offer to assist James with some of his workload
F. Explain to James that his impaired functioning may be placing patients at risk
G. Explain to James that you are there if he needs someone to talk to or needs some support
H. Suggest to James that perhaps he should consider whether medicine is the career for him

Answer: BCF
Rationale: James should be advised to speak to his educational supervisor (B) and to see his GP (C) to ensure he receives the correct support. A tactful conversation to explain that his impaired functioning may affect patient safety is required to safeguard clinical care and to help him seek appropriate help (F). Options (G), (D) and (E) are supportive but do not address the underlying problem and you are not in a position to recommend annual leave (A) or question whether medicine is the right career for James (H)

59

You have just started a night shift on the Medical ward. You are bleeped* by a nurse to attend to an 82 year old patient, Mrs Ratnaike, who is complaining of pain. Mrs Ratnaike is crying and tells you that your FY1 doctor colleague, Haroon, was very rough when he inserted a cannula, just before he hurried away. Mrs Ratnaike says that Haroon mentioned that he was late for a social engagement, and she thinks that he was rushing to leave.
Choose the THREE most appropriate actions to take in this situation.
A. Telephone Haroon, explaining that he made Mrs Ratnaike cry
B. Apologise to Mrs Ratnaike for Haroon's behaviour
C. Advise Mrs Ratnaike of the hospital's complaints procedure
D. Explore with your FY1 doctor colleagues whether they have ever witnessed similar behaviour from Haroon
E. Ensure that Mrs Ratnaike is comfortable
F. Inform your consultant of the incident
G. The next time he is at work, inform Haroon that he made Mrs Ratnaike cry
H. Reassure Mrs Ratnaike that Haroon would not rush a medical procedure

Answer: BEG
Rationale: In this type of situation you have heard about the patient's complaint, but have not heard your colleague's side of the story. It would be sensible to apologise to the patient as you are dealing directly with the patient (B) and to check that she is now comfortable (E). Following this it would be appropriate to inform your colleague of the event the next time you see him (G) so that he may reflect on the event. Advising the patient of the hospital's complaint procedure would also be an acceptable option (C) and could well constitute the next step, however together (B), (E), and (G) comprise the most appropriate course of action. There is no need to call your colleague after he has left the hospital (A), as there is no urgency for him to know about and resolve the issue if he has already left the hospital. As this is currently a one-off event, gathering more information from your colleagues (D) or informing your consultant of the incident (F) are not yet required. You do not know whether Haroon rushed the medical procedure, so it would be unwise to advise her of this at this stage (H).

60

You are attending to a seven year old child, Aidan, whose mother has brought him to hospital because he has a high temperature. Aidan is very agitated, and is screaming and crying very loudly. As you attempt to examine him, Aidan becomes physically aggressive and tries to kick you
Choose the THREE most appropriate actions to take in this situation.
A. Explain to Aidan why you need to examine him
B. Ask Aidan's mother to help you to examine him
C. Advise Aidan's mother to bring Aidan back later when he has calmed down
D. Ask one of the nursing staff to help Aidan's mother to restrain him
E. Ask Aidan why he is upset
F. Continue to examine Aidan as best as you can
G. Tell Aidan that you will give him a sticker if he calms down
H. Tell Aidan that his behaviour is unacceptable

Answer: ABE
Rationale: This scenario describes an unwell child, who despite agitated behaviour, requires assessment. The best approach to management would be calm and engaging both mother and child. Hence, the best option would be to explain to Aiden that you need to examine him (A), and to ask his mother to help with this (B). Asking Aiden why he is upset may also be helpful and allow you to address specific concerns (E). Aiden is agitated and pyrexial and he requires urgent assessment. To send him away until he has calmed down would be inappropriate and potentially dangerous (C). Asking the nursing staff to restrain Aiden is likely to upset him more and make the situation more challenging (D). Without trying to calm Aiden down, you are unlikely to be able to examine him successfully (F). Offering stickers or treats for good behaviour may not be appropriate as it may not be a treatment style that his parents and carers appreciate (G). While the patient is unwell and upset telling him that his behaviour is unacceptable is slightly harsh, and unlikely to be productive in this situation (H).

61

You are undertaking a very busy night shift and started your only break for the evening one minute ago. A nurse approaches you to inform you that she is very concerned about a patient and wants you to see him urgently. She tells you that the patient has a fever and she suspects that he has pneumonia. When you ask for details of further observations, she cannot remember any information about the patient’s heart or breathing rate, but she notes that the patient looks very pale and unwell.
Choose the THREE most appropriate actions to take in this situation.
A. Finish your break at the time you had planned
B. Bleep* the specialty trainee* to request assistance
C. Finish your break immediately
D. Administer antibiotics to the patient to treat pneumonia
E. Ask the nurse to gather the patient’s observations
F. Ask the nurse why she suspects that the patient has pneumonia
G. Explain to the nurse why it is important to take a break during your shift
H. Assess the patient

Answer: CEH
Rationale: A common clinical situation where you must safeguard patient care despite inconvenience to yourself. You should finish your break (C) and assess the patient (H) without delay, having asked the nurse to return to the patient and take a full set of observations (E). (B) is unhelpful as your specialty trainee is likely to be busy and if you are referring a patient you should have assessed them and possess the required information for referral. (F) delays patient care and is unlikely to be useful as the nurse has already demonstrated that they have inadequate knowledge of the patient's current status.

62

You are about to start a night shift on a medical ward. During handover, Hussein, the FY1 doctor who has been working the day shift, tells you that he has nothing to hand over. When you are on the ward later that evening, a senior nurse informs you that she bleeped* Hussein several times during the day and spoke to him over the telephone about an 88 year old patient with severe chest pain. You review and treat the patient accordingly. When you discuss this incident with Hussein the next day, he states that he was never informed about this patient, and that the nurse is lying.
Choose the THREE most appropriate actions to take in this situation.
A. Inform Hussein's clinical supervisor* of the allegations that he has made about the senior nurse
B. Explain the situation to your clinical supervisor, seeking advice on how to proceed
C. Advise Hussein of the severity of his allegations, ensuring that he is aware of what he is saying
D. Inform the senior nurse that Hussein told you that she was lying about the patient with chest pain
E. Speak to the senior nurse involved, obtaining further details about the incident
F. Explore with the other nurses whether they overheard the telephone call between Hussein and the senior nurse
G. Suggest to Hussein that he talks to the senior nurse about the incident
H. Fill in a critical incident form*, documenting the incident

Answer: BCG
Rationale: This question tests your professionalism in the context where two colleagues (the senior nurse and Hussein) have each made allegations about each other professionalism. Whilst emphasizing the severity of the allegations when talking to Hussein (C), it is important to seek early senior advice (B) on how to proceed in this situation. (G) may be uncomfortable for Hussein to consider given the allegations. However, suggesting a face-to-face discussion may help resolve this situation particularly if a simple misunderstanding (e.g. a malfunctioning pager) has led each party to make allegations about the other. It is not your place as the FY1 to initiate an investigation (E, F and H) into the incidents which have occurred and similarly not your place to raise allegations on Hussain's behalf (A). Accusing the senior nurse of lying (D) is likely to be counterproductive, unprofessional and embroil you in the conflict.

63

You have been assisting in the operating theatre. Between cases you go to the coffee room where you notice a patient identification label. The label has confidential patient information written on it and it is stuck to a computer screen. The coffee room is accessible by all members of staff in the hospital. The patient, Mr Cooke, is a member of staff in your hospital who was operated on by your consultant earlier that day. You recognise the handwriting on the label as belonging to your consultant.
Choose the THREE most appropriate actions to take in this situation.
A. Remove the patient identification label from the computer screen, placing it in the confidential waste bin
B. Inform Mr Cooke that a label containing his confidential patient information was left on a computer screen in the coffee room
C. Inform your FY1 doctor colleague about the label containing confidential patient information, seeking her advice on how to proceed
D. Inform your consultant that you found the label
E. Report the incident to your clinical supervisor*
F. Complete a critical incident form*, documenting the incident
G. Inform your consultant that he has breached patient confidentiality by leaving the label on display in a public area
H. Put a line through Mr Cooke's name on the label, so that it is no longer visible

Answer: ADG
Rationale: It is important to remove the label to prevent any further breaches of confidentiality (A), and to immediately inform your consultant of what has happened (D) explaining the breach of confidentiality in order to prevent this from happening again (G). It may also be appropriate to inform the patient about the potential breach of confidentiality (B), however the most pressing tasks are (A), (D), and (G). Asking for advice from another F1 may also be acceptable (C), however there are other options that better address this case. There is no need to escalate this to your clinical supervisor at this stage (E), though if this was a recurring event it could be appropriate to seek advice from a senior. Completing a critical incident form is appropriate, but not an immediate priority (F). Placing a line through the patient's name does not address the issue with your consultant, and may not protect the patient's identity effectively (H).

64

You have been working alongside a fellow FY1 doctor, Neha, on a surgical ward for the past four weeks. Since working with Neha, you have noticed that, although she always appears to be busy and often complains about being overworked, she seems to complete far fewer tasks than you do. You think that some of the nursing team tend to avoid requesting help from Neha and instead ask you to complete the majority of the tasks. When you ask Neha about her workload, she tells you that she feels as if she “never stops” and is “always busy”.
Choose the THREE most appropriate actions to take in this situation.
A. Suggest to Neha that she needs to work more efficiently
B. Ask a fellow FY1 doctor whether they have noticed that Neha can be difficult to work with
C. Speak to your clinical supervisor* about the situation to ask for his advice
D. Ask the nursing team to distribute the tasks more equally between yourself and Neha
E. Ask the nursing team why they avoid asking Neha for her help
F. Explain to Neha that you feel that you are undertaking a disproportionate amount of the workload
G. Start to keep a record of how long Neha is spending on each of the tasks that she completes
H. Ask the senior nurse for his perspective about how the workload is being distributed

Answer: CFH
Rationale: In this situation, it is important to triangulate your view by seeking the opinions of other senior members of the team, and to sensitively discuss your concerns with the colleague in question. Therefore, approaching your clinical supervisor (C) and a senior nurse (H) to gain their opinions would be sensible. You may not be aware of certain tasks that your FY1 colleague is completing, and thus it would be wise to seek external input to validate your concerns before going further. Mentioning how you feel to your colleague would also be an appropriate course of action, and may allow you to discuss in more detail the workload and gain their perception on the division of labour (F). Telling Neha that she needs to be more efficient is very blunt, and may not actually be true (A). Similarly, before asking the nurses to distribute the workload differently, you first need to ascertain whether you are correct in your concerns about the workload. Gather more information first. Gaining external opinions is vital here, but it is more appropriate to ask your supervisor and a senior nurse than your cohort of F1s (B) or the entire nursing team (E). Keeping a record of how long it takes Neha to complete tasks will be extremely time-consuming and not a good use of your own time, it will also create an unpleasant work environment (G).

65

You are working on a surgical ward. A patient has just woken up from her anaesthetic following a laparoscopy, she has normal observations and oxygen saturation. The patient still has her drip and is drowsy. While you are reviewing her, the patient starts to become distressed and demands to go home. Her husband is in the waiting room.
Choose the THREE most appropriate actions to take in this situation.
A. Try to find out what is troubling the patient
B. Clarify the post-operative plan for the patient with the team
C. Ask a nurse to try to reassure the patient
D. Take the patient's drip down in case this is what is troubling her
E. Offer to provide the patient with some pain killers
F. Explain to the patient that she needs to stay in hospital since she has just had an operation
G. Ask a nurse to contact a senior colleague
H. Ask the patient's husband to come to the ward

Answer: ABF
Rationale: The initial action should be to exclude a reversible cause of confusion or distress and then to explore what is troubling the patient, when confident that there is no immediate action required such as administering oxygen (A). You need to know what the post-operative plan is before you can proceed further (B) and this will allow you to explain to the patient the rationale for her remaining in hospital (F). At this initial stage, there is no need for the patient's husband to be present whilst she remains drowsy (H) and the input of a senior colleague is not required (G). On further assessment, it may be necessary to offer analgesia (E) or rationalise post-operative care by taking down the drip (D) but these are not the most immediate actions. It is likely the nurse has already reassured the patient and has requested your help so delegation to the nurse is not appropriate (C).

66

Mr Siad is a psychiatric patient who has been brought onto your medical ward with a psychiatric nurse. You are aware that he was admitted to the hospital the previous week and was very disruptive and refused all treatment. Your consultant has told you to book an urgent CT* scan of his head. When you inform Mr Siad that he is booked in for a scan later that day, he tells you that he will refuse to cooperate
Choose the THREE most appropriate actions to take in this situation.
A. Inform your consultant that Mr Siad is refusing to cooperate with the CT scan
B. Delay the CT scan for 48 hours, to allow time for Mr Siad to calm down
C. Attempt to explore Mr Siad’s reasons for refusing the CT scan
D. Discuss with your consultant whether it would be appropriate to prescribe sedation for Mr Siad prior to the CT scan
E. Find out from your specialty trainee* if it would be appropriate to assess Mr Siad's capacity to refuse the CT scan
F. Politely tell Mr Siad that his disruptive behaviour is making it difficult for healthcare workers to work
G. Explain to Mr Siad about why he needs to have the CT scan
H. Ask Mr Siad if he would like a relative to come and accompany him during his stay in the hospital

Answer: CEA
Rationale: In this case it is likely that the underlying psychiatric diagnosis is central to the patient's refusal to consent but the initial act should be to exclude a more straightforward reason for the patient's reluctance (C), this may be as simple as a fear of the confined spaces in the scanner and must be excluded. Once you have excluded this, you can discuss assessing the patient's capacity with your specialty trainee (E) so that the necessary phone call to the consultant (A) is made with all the facts and allows the consultant to decide on a fully informed course of action. There is no information about the reason for the scan and therefore delaying it (B) may compromise patient safety. Prescribing sedation after discussion with the consultant (D) and asking Mr Siad about having a relative to accompany him (H) may be appropriate but shouldn’t be the first line of approach. The other three options are more appropriate. Telling Mr Siad that his behaviour is difficult (F) is inappropriate. Explaining to Mr Siad why he needs to have the CT scan (G) may not be sensible as it unclear how he may react and could have the potential to aggravate the situation

67

The consultant, Dr Scott, has asked you to write up and submit the results of a full audit cycle to a medical conference. You are aware that the audit was designed and carried out last year by Anthony, an FY2 doctor who is currently working abroad for a year. Owing to delays in the project, Anthony was unable to write up and submit the results before leaving the country. You have not been able to make contact with Anthony to request his permission to use the results of his audit, but Dr Scott has given you reassurance that you have her permission to proceed.
Choose the THREE most appropriate actions to take in this situation.
A. Write up and make the submission on Anthony’s behalf, without assuming authorship
B. Seek advice from the Medical Defence Organisation* on how to proceed
C. Continue to try to make contact with Anthony while completing the write up
D. Suggest to Dr Scott that Anthony should complete the write up and submission
E. Report Dr Scott for possible violation of ethics
F. Write up and make the submission as the first author
G. Expand on the original design and complete further work on the audit
H. Discuss your concerns about authorship with Dr Scott

Answer: CGH
Rationale: It is unethical to take credit for the work of someone else. Writing up the audit while continuing to contact Anthony is the best compromise here (C). By expanding and contributing to the audit you are contributing to the project and justifying your authorship (G) and you should explain to Dr Scott that you have misgivings about authorship (H). First authorship should be credited to Anthony (F) but you should be credited with your contribution as a co-author (A). It may cause considerable delay if Anthony is unavailable to complete the submission (D) and contacting your medical defence organisation (B) or reporting Dr Scott (E) are not appropriate without first exploring your concerns with him directly.

68

You are due to finish your day shift and hand over to a FY1 doctor, Lucie. You want to leave the hospital on time as you are meeting some of your relatives, whom you have not seen for several months. However, Lucie hasn’t arrived yet and is now ten minutes late. Lately, Lucie has not seemed to be managing her workload well and has frequently been arriving at work late. When you ask one of the nurses, Justin, if he knows when Lucie will be arriving, he tells you that he does not know, but that he is aware that Lucie has been experiencing personal problems recently
Choose the THREE most appropriate actions to take in this situation.
A. Prepare a detailed handover note for Justin to give to Lucie, ensuring that he is fully briefed on all details
B. Ensure that Lucie’s specialty trainee* is aware that her personal problems are affecting her professional conduct
C. Try to contact Lucie, to establish when she will arrive at the hospital
D. Speak to Justin, to gain more insight into Lucie’s personal problems
E. Contact another available on-call doctor, to establish whether she is willing to take your handover
F. Remain on the ward, to provide Lucie with a handover when she arrives
G. Encourage Lucie to speak to her clinical supervisor* if she is struggling with her workload
H. Ask Lucie whether she needs you to arrange cover for her shift

Answer: CEG
Rationale: In this situation, you need to ensure there is a safe handover, and encourage the colleague to seek help and advice about coping with her workload and personal issues. The first action is to contact Lucie to see if she is just a few minutes late or whether there will be a significant delay (C). Contacting another doctor who is on call to see if you can handover to them may then be appropriate (E). You should encourage Lucie to seek help from her clinical supervisor (G). If there is a clinical risk you should remain on the ward until Lucie arrives or alternative cover can be found but that would depend on the situation and nature of the cover required (F). Although a detailed handover sheet will be helpful it should not be entrusted to a third party (A) and it is not appropriate to ask Justin, the nurse, about Lucie's professional or personal issues (D). Her clinical supervisor should be involved in preference to her specialty trainee (B). If cover needs to be arranged for Lucie that should be carried out by the seniors on that shift in liaison with hospital management (H).

69

You are reviewing a patient on a stroke ward with your FY1 colleague, Jacob. The consultant, Dr Henderson, has asked that the patient's neurological status is assessed on a daily basis. You notice that without conducting any form of examination, Jacob has documented that the patient's neurological status is unchanged. When Dr Henderson later asks Jacob about the patient, he reports that the findings were unchanged.
Choose the THREE most appropriate actions to take in this situation.
A. Talk to Jacob about the importance of undertaking thorough examination
B. Document Jacob's actions in the patient's notes
C. Conduct a thorough neurological examination on the patient yourself and document the findings
D. Ask a fellow FY1 colleague if they have ever observed Jacob lie to senior staff
E. Ask Jacob why he lied to Dr Henderson
F. Remain quiet and monitor Jacob throughout the day to determine if he does inform Dr Henderson
G. Write an email to Dr Henderson informing her of Jacob’s lie
H. Speak to Dr Henderson in private to inform her of what has happened

Answer: ACH
Rationale: The priority here is patient care so you should examine the patient and document your findings (C) and then speak privately to Dr Henderson (H) about Jacob's actions. You should emphasise the importance of examination to Jacob (A) without adversely affecting your working relationship which is the likely outcome of option (E). Dr Henderson may request you to send a formal email (G). It is not your role or a fellow FY1 doctor to monitor Jacob's behaviour (F), (D), but you should speak up if you observe behaviour that puts a patient at risk. The clinical notes (B) are not the appropriate record for documenting a doctor's behaviour

70

You are asked to speak with a patient, Ms Saeed, who was admitted with an infection two days ago. Ms Saeed is very upset and tells you that she would like to make a complaint about a nurse, Russell, who she claims has not looked after her properly. When you explore this further with Ms Saeed, she tells you that she takes blood pressure medication regularly and Russell has not provided her with it since admission and that, when asked, he has not provided a reason for this
Choose the THREE most appropriate actions to take in this situation.
A. Tell Russell that Ms Saeed is unhappy with his care
B. Ask Ms Saeed whether she would like to make a formal complaint against Russell
C. Apologise to Ms Saeed on Russell's behalf
D. Raise Ms Saeed’s complaint with the nurse in charge
E. Review Ms Saeed's notes and drug chart, establishing whether there is a reason why her blood pressure medication has been withheld
F. Acknowledge Ms Saeed's concerns, explaining that you will establish why this has happened
G. Arrange for Ms Saeed to be prescribed with the appropriate blood pressure medication straight away
H. Gain an understanding of Russell's perception of his conversation with Ms Saeed

Answer: EFG
Rationale: This situation tests your ability to respond to concerns raised by a patient on the ward about another team member. The initial priority would be to acknowledge and offer to address concerns (E). Subsequently, if unable to do so, reviewing the drug chart is a reasonable next step (F). Having reviewed the notes and drugs card, if no reason for cessation of the medication can be identified, (G) will ensure that appropriate patient care is delivered in a timely manner. (A) and (D) escalate the concern raised but do not deal with Mrs Saeed’s immediate query. Whilst it may be reasonable to apologise, this should not be on someone else's behalf (C). (B) and (D) are reasonable things to consider at a later stage but are not priorities when initially dealing with the concern that has been raised. They may not be necessary if the situation is resolved promptly. Although (H) could be considered, it is not as appropriate as (E), (F) and (G) when looking to deal with the immediate situation at hand.