Doctor Taking Notes

INTERVIEW: CLINICAL

Author: Dr George Higginbotham

Academic Foundation Doctor at North Bristol NHS Trust 

 

GENERAL APPROACH

The purpose of the interview is to gauge whether you’ll make a good clinical academic, and the clue is in the title - ‘clinical’. Aside from your skills and experience as a researcher/all-around good person, the interviewers want to see that first and foremost you’ll make a good doctor.


Of course, as with other skills, clinical assessment and management takes a good deal of practice. Certainly, you won’t be expected to know everything at this stage. You will, however, be expected to demonstrate the knowledge and thought processes of a competent and safe foundation doctor.


Primarily, this comes down to recognising some of the most common acute medical/surgical presentations that you will be called about as an FY1/FY2, initiating a sensible management plan, and escalating/handing over appropriately.


This may seem daunting, especially for those of you yet to sit final exams (as was the case for my interview). However, the key part of a competent (and confident) assessment is a methodical ABCDE approach. In this way, it’s helpful to approach this how you would approach an OSCE station of an acutely unwell patient.


The interview panel may ask you to simply talk through the scenario and your thought processes, or they may wish to role-play certain aspects of the scenario (e.g. a phone call with a nursing colleague or senior doctor).


For example, you may be given something like the scenario below:

 

SCENARIO:

You are an FY1 doctor on call. You are bleeped by a nurse, who says the following:


“Hello, I’m one of the nurses calling from ward 10. I’m worried about the man in bed 13, he seems breathless. I’ve just done his obs and he has a NEWS score of 6, what should I do?”


You may be given a couple of minutes to read through before starting the station - this is a good time to start thinking broadly about possible causes for the patient’s symptoms (e.g. causes of breathlessness could be asthma, PE, arrhythmias, anaphylaxis etc.)


It’s easy in this scenario (as in real life) to panic when the person on the other end of the phone is worried. However, you’ll be much better prepared, and have a greater understanding of the situation, if you take some time to gather information first.

 

STEP 1: GATHER INFORMATION

  •   What is the patient’s full name, date of birth, and hospital number?


Depending on your hospital’s IT system, you may be able to find out a great deal from the computer in front of you whilst you are still on the phone (e.g. recent bloods, observations, clinical notes). This is also good to have handy when it comes to escalating the patient to a senior (more on that later).


  •  What has the patient been admitted with?

This will often be provided in the question/by the person asking for help in real life, but it is essential to ask about this if not.


  •  Can you tell me the most recent set of observations in full, including what the patient is scoring for on the NEWS?

The NEWS score by itself doesn’t really tell us much about the situation without knowing how the score is made up. A patient may be scoring highly in a couple of parameters, or at lower levels across multiple parameters


Once you’ve gathered the information, it’s time to go and assess the patient.

 

TIP

There may be tasks that you can ask the nurse to perform whilst you’re on your way (e.g. in a patient with chest pain, you can ask for an ECG, which may then already be performed ready to interpret when you arrive)

 

STEP 2: ABCDE

“I’m worried this patient is acutely unwell, so I will assess them using an A to E approach”

GENERAL RULES

  •   Look, listen, feel

  •  If you find something abnormal, stay on that step to intervene before moving on

  •  After you’ve made an intervention, re-assess that step

  • Before you move on to the next step, re-assess the steps before (Note, in the interview, this will be very quick - “I’ve finished C, I would reassess A and B to make sure the patient hasn’t deteriorated... and then move on to D”

  • Escalate early! this is really important, especially if there are issues with the airway. Remember, this station is about making sure you’ll be a safe foundation doctor. In real life, a senior doctor would rather be called unnecessarily than not be called and the patient come to harm. In an interview setting, there’s nothing to lose by escalating if you’re concerned.


AIRWAY

  • Patency - if the patient is answering in full sentences, you can assume it is patent

  •  Look: oral secretions, rash, angioedema

  • Listen: stridor, gurgling

  • Feel: inspired air


If the airway is not patent - airway manoeuvres (head tilt/chin lift, jaw thrust), adjuncts (nasopharyngeal/oropharyngeal airway), call 2222/anaesthetist!

BREATHING

  •   Look:

- Effort of breathing - use of accessory muscles, pursed lips, nasal flaring

- Efficacy of breathing - O2 saturations, respiratory rate, cyanosis

  • Listen:

- Auscultate for air entry, wheeze, crepitations

  • Feel:

- Position of trachea (central), chest expansion, percussion


If absent/poor respiratory effort (e.g. RR <10), use bag valve mask


Additional adjusts to assess breathing - ABG, portable CXR

CIRCULATION

  • Pulse - rate, rhythm, character

  • Blood pressure

  • Capillary refill (centrally)

  • JVP

  • Peripheral oedema

  • ECG

  • IV access - including bloods

  • Urine output

If hypotensive, assess volume status and consider giving a fluid bolus of saline/Hartmanns (500ml, 250ml if risk of overload)

DISABILITY

  •   Consciousness: GCS (/15, broken down into E, V, M) or AVPU  

  • If GCS ≤8, the airway is not safe - contact an anaesthetist

  • Pupils - size, reactivity (light, accommodation)

  • Glucose

EXPOSURE

  • Brief top-to-toe examination - rashes, wounds, bleeding, swelling

  • Abdominal exam

  • Calves (e.g think DVT as a cause of PE)

  • Temperature

  • Bedside inspection - e.g., catheter, vomit bowl, inhaler

 

TIP

The interviewers may stop you during/following your assessment to ask further questions. This may be asking for your differential diagnoses, so try and keep these in mind whilst you talk through your assessment and think of what investigations/findings would help you to rule in/out each differential.

 

STEP 3: SBAR

This may happen at any point during your ABCDE assessment (e.g. if you’re worried about the airway), or may be the end of the ABCDE.

1.  Situation

-    Who/What/Where/When/Why
-    State who you are, and where you’re calling from
-    State what is happening, when it started, and why it started (if you know)
-    These initial points are key and will allow the person on the other side of the conversation to assess the urgency of the situation at hand, and what they should be listening out for as you continue.
-    Think - are you calling for advice? a review? to make someone aware?

 2. Background

-    Patient’s name, gender, hospital number
-    Diagnosis - what are they in hospital for?
-    Relevant past medical/surgical history (+/- relevant social history - e.g. frailty, nursing home resident)
-    Resuscitation status

3. Action

-    Communicate your objective clinical assessment of the patient, and the result of any interventions
-    Vital signs and NEWS score
-    Examination findings
-    Response to interventions (e.g., blood pressure has improved following a fluid bolus)
-    Overall clinical impression

4. Recommendation

-    Give your suspected diagnosis – you may not be 100% sure, but you can state that you’re worried the patient is deteriorating/seriously unwell and re-iterate the features that are worrying you
-    Ask for what you need – e.g review/transfer/advice
-    Ask – is there anything else you would like me to do in the meantime?

5. Response

-    Is there anything you’d like me to clarify?
-    To summarise, this is what you’d like me to do..
-    Thank them, make sure to get their name/grade for documenting in the notes

 

FINAL POINTS

 

-    BE FAMILIAR WITH INTERPRETING COMMON BEDSIDE INVESTIGATIONS – E.G., CHEST X-RAY, ABG, ECG, BLOOD TESTS (AND KNOW NORMAL

-    ALTHOUGH IT MAY SOUND CLUNKY, PRACTICE VERBALISING YOUR THOUGHT PROCESSES AS THEY HAPPEN. E.G. “THE TRACHEA IS CENTRAL, AND THERE IS GOOD BILATERAL AIR ENTRY, SO I’M LESS WORRIED THAT IT MIGHT BE A PNEUMOTHORAX’

-    IF YOU’RE NOT SURE ABOUT SOMETHING, TRY NOT TO JUST MAKE SOMETHING UP – YOU’LL COME ACROSS AS A BETTER (SAFER) DOCTOR IF YOU CAN IDENTIFY WHEN YOU’RE UNSURE, AND ESCALATE/ASK FOR HELP APPROPRIATELY, RATHER THAN CONFIDENTLY STATING AN INCORRECT (POTENTIALLY HARMFUL) MANAGEMENT PLAN.

-    PRACTICE GOING THROUGH SCENARIOS WITH FRIENDS/DOCTORS ON PLACEMENT IN REAL-TIME (JUST LIKE OSCE PRACTICE)

-    IF YOU CAN, ARRANGE A MOCK INTERVIEW WITH AN ACADEMIC DOCTOR/MENTOR, AND TREAT IT AS IF IT IS THE REAL THING – THIS WILL HELP YOU GET MORE CONFIDENT, AND IDENTIFY AREAS OF IMPROVEMENT.

GOOD LUCK!