As the end of the year approaches, our members in their final year of studies are gearing up for the SJT.
With just a few weeks to go, now's the time to make sure you know what to expect; you're well-prepared for the test's structure and how it works, and you're regularly challenging yourself with practice questions.
We've put together a selection of scenarios to prepare you for the big day. Pretend you're in an exam situation and try to answer each question within two minutes.
Be systematic about your responses. Which of the answers are clearly inappropriate? Which are the most sensible? Remember that in part one, correct placement of the best and worst answers will gain you the most points .
Part one: rank the responses in order from most appropriate, to least appropriate.
Q1) Your FY1 colleague calls in sick on Friday when you later find out that he was in fact taking a long weekend off prior to him starting nights on the Monday. What do you do?
A Speak to your clinical supervisor.
B Make the GMC aware of your colleague’s actions.
C Speak to your colleague in private about this and if it happens again, you will escalate to a consultant.
D Say and do nothing.
E Confront your colleague and mention that you will escalate to seniors if he does not cover your shift in two weeks.
Q2) You are a surgical FY1 and your registrar has asked you to obtain consent from a patient requiring an elective right hemicolectomy. You have seen the procedure done in theatre once and understand why the procedure is appropriate for the patient, but have limited experience of looking after such patients post-operatively and are anxious that you don’t know enough to explain things in the required detail.
A Ask the patient to sign the consent form without discussion.
B Discuss the operation with the patient, answering what questions you can and get them to sign the consent promising that you will get the registrar to speak to them later.
C Indicate that you don’t feel competent to obtain consent in this situation, but ask to come along and observe the process.
D Discuss the request with the registrar, indicating your concerns and ask them what they would say to the patient, and then seek consent.
E Call the responsible consultant and discuss the request.
Q3) You are at the end of your shift as an FY1 in A&E and exhausted. Your friend is cooking dinner for you and you are already late. The last patient you see is an elderly woman who is on regular anticoagulants (warfarin) following a thrombotic stroke. She has presented with a fall and is to be admitted under the orthopods. She is currently still in A&E and the orthopods are in theatre.
Just before you leave to go home, the nurse looking after her tells you that your patient has wrongly been given an additional anticoagulant as well as her regular medication.
A Verbally hand over the problem to the FY1 doctor who is taking over from you.
B Hand over by phone to the orthopaedic registrar.
C Write a detailed account of the nurse's error in the notes, advise her to report the incident to her senior and ensure that you hand over verbally to the FY1 doctor in A&E.
D Write a detailed account of the nurse's error in the notes, advise her to report the incident to her senior and ensure you hand over to the most senior person available in your team.
E Stay and deal with the clinical issues that have arisen.
Q4) You are working on a busy surgical firm with two other FY1s. You feel that you are doing more than your share of the work, frequently staying late and arriving early. You are beginning to get tired and have noticed yourself picking fault with your colleagues on the ward.
A Lose your temper on the ward in front of patients and other staff, shouting at your colleagues that they are lazy and need to start helping.
B Take your colleagues aside and explain how you are feeling and that you are worried that your performance may be affected if the situation continues.
C Tell your clinical supervisor that the other doctors are lazy and need to be brought into line.
D Carry out an audit of the tasks the others perform and their time of arrival and departure and present it to the consultant.
E Suggest that at the end of each ward round you spend 10 minutes sharing out the work and ensuring each individual knows which tasks they’re responsible for.
Q5) On her ward round your consultant states a patient needs a repeat urgent blood test in four hours, which is after your shift has ended. You go to speak to the doctor who will be covering the ward later but she says she will be too busy to do it.
A Stay to take the bloods yourself.
B Ask the patient’s nurse to bleep the doctor at the required time.
C Speak to the doctor to advise that the job is their responsibility and you’re documenting the handover in the records.
D Try and find another colleague to take the bloods.
E Tell the patient of the problem and suggest they speak to the ward manager.
Part two: choose the top 3 most appropriate responses.
Q6) It’s 11pm when a nurse sustains a needle stick injury and comes to you for help. He tells you that he does not want to make a fuss, but asks you to do some tests on the patient for blood-borne viruses the next time you do routine bloods.
A Explain to the patient what has happened and after performing a risk assessment seek their consent to undertake blood tests for Hepatitis B and C and HIV.
B Give the nurse first aid advice about how to deal with the injury and tell him you know the patient and there is no cause for concern.
C Review the notes and, if the patient would benefit from testing, add some serology for blood-borne viruses to the routine blood tests requested for tomorrow morning.
D Explain that you are too busy to take the tests but advise the nurse to attend A&E for post-exposure prophylaxis.
E Explain to the nurse that he should follow the trust protocol for managing needle stick injuries.
F Suggest that the nurse goes to occupational health to discuss his situation further first thing in office hours.
G Tell the patient you need to take some more blood for additional tests.
H Ask switchboard to contact the infectious diseases consultant immediately for advice on appropriate treatment.
Q7) You’ve been released from ward duty to attend a mandatory study day. You find the morning to be of little use and, looking at the afternoon programme, you don’t hold out much hope for that.
A Discuss with other foundation doctors whether they found it useful and if it met their learning objectives.
B Stay until the end and provide constructive comments on the feedback form.
C Leave after you have socialised after lunch and go home – it’s a waste of time.
D Return to the ward to help your colleagues.
E Tell the programme director as soon as possible that it was not an appropriate course for foundation doctors, explaining why you thought so.
F Voice your dissatisfaction with the content of the meeting so that all present can hear.
G Take the opportunity to catch up on some much-needed sleep.
H Write rude comments on the feedback form.
Q8) It’s the first week of your FY2 job on an elderly care ward. A 93-year old man arrives by ambulance from a nursing home. Shortly after, both of his adult children arrive separately in casualty, where you have been asked to review the patient by the casualty officer. The patient is confused and disorientated, incontinent and wheelchair-bound.
When you examine him you conclude that he has a chest infection that requires treating with intravenous antibiotics. Both his offspring explain that he would not wish to be admitted to hospital and that the only reason he was brought to hospital is that the nursing home manager is on leave.
The elderly care ward is full and the patient would have to be admitted to an orthopaedic ward.
A Discharge him back to the nursing home on oral antibiotics.
B Ask whether he has an advanced directive in place and establish whether it applies to the current situation.
C Make a decision in his best interests.
D Agree that his children are best placed to determine what is in his interests if he lacks the capacity.
E Ignore his children’s opinion since they do not live with him and he is not carrying a copy of an advanced directive with him.
F Having assessed him as lacking capacity to make the decision, consider his medical best interest in the absence of any additional information.
G Seek the advice of colleagues regarding his capacity to make his own decision and his medical best interests if he lacks capacity.
H Admit him to the ward without further discussion.
Q1) Answer: A C D E B
A Your colleague has clearly demonstrated that he is not taking his professional duties seriously and this issue needs to be addressed for the benefit of his future career and, more importantly, patient safety. Discussion with a senior colleague is the correct decision in order to determine the appropriate course of action. The situation may be more complex than it appears; for example, your FY1 colleague may have underlying health concerns.
C Although you have confronted your colleague, you haven’t addressed any underlying concerns about his professionalism.
B This is a probity issue and arguably could take priority over C. However, if it is a single instance, it is perhaps better addressed locally.
D is clearly not professional.
E is blackmail.
Q2) Answer: C E D B A
The medical or dental professional undertaking an investigation or providing treatment is responsible for ensuring that valid patient consent has been obtained. If this is not practicable the task can be delegated, provided that the person appointed is suitably trained and qualified, knows sufficient detail about the intervention, understands the risks and follows the principles set out in the relevant guidance.
In this situation it is unlikely that a foundation doctor will have adequate skills and knowledge, but that doesn’t mean that they can’t learn, so taking the opportunity to do so seems appropriate. Ultimately the consultant is responsible, so if the registrar leaves no option for the foundation doctor to be involved, discussing it with the consultant seems reasonable.
Q3) Answer: E D C A B
To ensure patient safety is your priority:
A handing over to the FY1 verbally might be a reasonable option (depending on other factors in the department) but it would be essential to document your handover.
B the patient needs to be assessed/treated as soon as possible and the registrar may be in theatre for hours.
C clearly documenting your handover is important. It is, however, unlikely that the FY1 is the best placed to manage this difficult situation.
D the patient is in your department and remains the responsibility of your team and the issue is not an orthopaedic problem. It would be appropriate if handing over to do so to the most senior colleague.
E this patient needs to be seen urgently and assessed by the medical team. You are aware of this situation while working, and ensuring that the patient is in safe appropriate hands before leaving to go home is the appropriate course of action in line with GMC guidance.
Q4) Answer: E B C D A
E Offers a potential solution to the problem, allowing fair sharing of the workload and clear delineation of each individual's responsibility towards patient care.
B Makes your colleagues aware of the issue and highlights that a potential patient safety concern may arise if they do not respond to the situation, however it does not provide a clear solution.
C Allows patient safety concerns to be brought to the attention of a senior, however it might raise concerns about your ability to perform as part of a team.
D May provide definitive evidence of your concerns, however patient safety issues are not immediately addressed.
A Shouting on the ward is unprofessional.
Q5) Answer: D A B C E
This question is about dealing with challenging colleagues. It would be wrong to involve a patient or their relative in any inter-professional disputes.
E is unprofessional and would not deal with the underlying issue. Similarly, the colleague’s refusal to accept the handover doesn’t justify you passing the responsibility to the nurse.
Options A and D should ensure the patient’s care is not compromised, but may add to your workload and stress levels or to that of another colleague.
You need to respect your needs for adequate rest and leisure time, but ensure the bloods get done.
Q6) Answer: F E A
Contacting occupational health is appropriate since they can enact the appropriate pathway. Most hospital trusts have a clear pathway for managing needle stick injuries. Managing the injury in the first instance would be appropriate. Most policies focus on risk assessment and testing of the patient and healthcare worker. These steps are appropriate, but only with appropriate consent.
It is inappropriate to test without consent or without the patient’s knowledge. Even where there might be a clinical basis for testing the patient, if the test has been triggered by a needle stick injury that should be explained, hence C is inappropriate.
D is inappropriate as a first step as no assessment of risk has been undertaken and it is not clear whether post-exposure prophylaxis is needed.
G Without consent, it is an assault to take blood.
H While an infectious diseases consultant is likely to give sound advice, it is not urgent and therefore not necessary to contact them out of hours.
Q7) Answer: B A E
Remember that communication skills can also relate to how you get your point of view across as a professional.
This is mandatory training – it is appropriate that you persevere with it. However, it is also a problem if important mandatory training is that poor and A,B and E will allow you to assess whether everybody else shared your view and to communicate this back to people who could make the course better.
D might seem sensible and professional, but the issue here is that the training is mandatory and thought sufficiently important for you to be released from ward commitments to attend.
C You’re just bunking off!
F, G, H are examples of an unprofessional approach, which would be open to criticism.
Remember the order does not matter and there is no negative marking; just make sure that you only pick three options.
Q8) Answer: B F G
Recognise the limits of your experience in making important life or death decisions. Make sure the patient, and their autonomy or best interests, remain your primary concern.
A You do not have sufficient evidence to support choosing an option which is not in the patient's medical best interests.
B If the patient, when capacitous, has a clear and specific advanced directive in place then discharging him to the nursing home may be the appropriate decision.
C You cannot default to a best interests decision without assessing capacity. Even when a patient is confused, they may still retain capacity to make a specific decision.
D Offspring may contribute towards an overall decision of what is in their parent's best interest when the parent lacks capacity. There is no proxy for decision-making for an adult who lacks capacity.
E By contrast, simply ignoring their input is equally inappropriate.
F If a patient lacks capacity then your duty as a doctor is to act in their best interests.
G In order to determine both whether the patient lacks capacity and to make an assessment of best interests if this is the case, it is likely to be necessary to involve senior colleagues.
H Admitting the patient without considering the complexities of the decision you are making is not appropriate given the facts of this case.