SARAH CRAIG, GILES DIXON, ALICE PITI, !

SOBEL PLATI,
CATHERINE SPROSON, ANDREW VIGGARS and EILEEN WEDGE

EDITOR: HARRIET WALKER

350
Questions
for the
Preface
This book has been designed to give you a chance to familiarise yourself with
the format of questions and the frame of mind required when thinking through
clinical conundrums similar to those you will be likely to encounter in the
actual exam. The questions have been written by FYls and FY2s having just
finished medical school and scoring highly on the SJT themselves and therefore
will be based on real-life clinical encounters during the daily life of these junior
doctors. The answers and rationales have been constructed using the recom-
mendations from the General Medical Council (GMC) as to how you would
be expected to behave in the clinical environment and have been extensively
reviewed. It therefore accurately represents life as a junior doctor and high-
lights how you should be approaching these situations in your future clinical
practice as well as helping you practice for your upcoming SJT exam. Each
question has been coded according to the overriding professional domain that
the picture portrays, although in actuality there is a great deal of overlap of all
the professional attributes. lt was felt that this would be beneficial to you as a
student to help you to contemplate each area individually as you arc familiaris-
ing yourself with the subject matter. We strongly recommend that you complete
each question in a timed manner and then mark your answers after a period
of rime to help you to become used to answering them under exam conditions.
Good luck, and remember to breathe!
Harriet Walker on behalf of the author team, 2015
Contents
Preface Vil
Acknowledgements IX
Editor and Authors XI
An introduction to the situational judgement test XIII

1. Commitment to professionalism 1
Questions 1
Answers 52
2. Coping with pressure 117
Questions 117
Answers 138
3. Effective communication 165
Questions 165
Answers 197
4. Patient focus 235
Questions 235
Answers 268
5. Working effectively as part of a team 309
Questions 309
Answers 334
An Introduction to the Situational
Judgement Test
The situational judgement test (SJT) has been used by the UK Foundation
Programme Office (UKFPO) for recruitment into the foundation programme
since the 2013 round of applications. Combined with an educational perfor-
mance measure (EPM) score, this provides a mark by which candidates are
compared against each other for consideration of individual preferences for
foundation year allocation. It was designed to replace the traditional 'white-
space questions' which were heavily criticised for being influenced by an appli-
cant's creative writing skills and therefore being potentially biased. The test
itself consists of 70 questions (10 of which are pilot questions for the following
year and therefore do nor contribute to the final score) in which rhe candidate
is required to make a judgement about the correct way to behave in a particu-
lar scenario that they may reasonably encounter as a junior doctor. In this
sense, it is designed to tesr professional attributes, interpersonal and commu-
nication skills as opposed to clinical knowledge in order to ensure that a final
year medical student would be able to adequately answer the question. This is
additionally beneficial since these attributes are notoriously difficult to assess
in a written exam despite the fact rhat they are vital skills required of a doctor.
There are two different formats of questions that are used in the SJT: one in
which the student ranks a series of statements based on the desirability of the
action and the other being a multiple choice '3 of the best of 8'. Both of these
formats serve slightly different purposes with multiple choice questions being
favoured when there is more than one correct answer and ranking questions
being appropriate when comparing multiple options based on suitability. The
situations described are designed to present a moral or ethical dilemma for
which the candidate needs to judge what would be the most effective behaviour
from the options listed ro achieve the required outcome. There are five pro-
fessional domains that have been identified as being fundamental to life as a
proficient junior doctor: commitment to professionalism, coping with pressure,
effective communication, patient focus and working effectively as part of a
ream. The key documents published by rhe General Medical Council (GMC)
rhat the classification of these domains is based on are Good Medical Practice
(2013) and Tomorrow's Doctors (2009).
The main advantage of using the SJT, as opposed to an interview or the
previously utilised white-space questions, is that a national exam can be
standardised, which therefore allows for a fair and direct comparison of can-
didates. Thus, the UKFPO can perceive more easily who has an understanding
of how they should be behaving in their future role as junior clinicians. It also
allows for quicker turnaround of the marks since the moderation process is
less arduous and time-consuming. In a highly varied and complex field such
as medicine in which employees will encounter different challenges on a daily
basis, the use of a situational-based tesr also has the advantage of giving the
 xiv An Introduction to the Situational Judgement Test

candidates an insight into likely scenarios they will face in their daily job. This
means that the test is indirectly setting out a job specification that the appli-
cants can use as a framework for their future clinical practice. SJTs are also
used as part of rhe recruitment process for specialty training in general practice
and public health and may well be included in others in the future, so chis can
be viewed as a good 'practice run' for future career applications.
The major disadvantage of the exam is that there is no easy way to revise for
it apart from familiarising yourself with rhe professional domains as outlined
by the GMC and the structure of the examination in order to ensure that the
questions can be analysed efficiently and answered successfully. Due to the fact
that the hypothetical situations posed by the questions are subject co a great
deal of interpretation, there may also nor be an absolutely correct (or incor-
rect) answer; however, it is designed to ensure that the candidates consider the
problem in a logical manner based on how they envisage chat they are expected
co behave as set our in the guidelines.
The exam that you will sit will have been written based on advice from clini-
cians from FYl level through to consultancy, who will draw upon their clini-
cal experience to create a number of realistic scenarios, similar to the practice
questions that you will find in this book. Each question then goes through a
thorough review process to ensure that both the envisaged clinical situation and
subsequent answer are as accurate as possible. The exam itself lases 2 hours and
20 minutes, which when broken down by the number of questions (70) gives you
2 minutes per question. This is quire a call order and does make for a pressured
(and exhausting) exam, so it is important that you practice answering questions
with this in mind. It is also important to make sure that you remember rhar all
the information that you require will be present in the scenario; therefore, you
should not make assumptions about what might or might not be happening in
the clinical picture. Reading the key documents mentioned earlier is a good way
ro identify how best to answer the questions as this will give you an idea of how
you are expected ro behave. Remember co answer according to how you 'should'
behave and not necessarily how you 'would' behave (as these two may or may
not be mutually exclusive). The multiple choice questions are marked out of 12
(4 points per correct answer}, so you should ensure that you select 3 options;
however, if you select 4, then you will score O points in that question. The rank-
ing questions are marked according to a more intricate framework - there are
20 possible marks (4 per option) based on where you have put the particular
option compared co the mark scheme, that is in the exact same place, similar
or in a completely different location. Again, you cannot be awarded marks for
omitted answers to ensure that you do rank alJ of the options.
Editor and Authors

Editor

Harriet Walker
Core Surgical Trainee
Derriford Hospital
Plymouth, United Kingdom

Authors

Sarah Craig Catherine Sproson

Core Medical Trainee Core Surgical Trainee
Leeds Teaching Hospitals NHS Trust Sheffield Teaching Hospitals NHS
Leeds, United Kingdom Foundation Trust
Sheffield, United Kingdom
Giles Dixon
Resident Medical Officer Andrew Viggars
Palmerston North Hospital Core Medical Trainee
Mid Central District Health Board Leeds Teaching Hospitals NHS Trust
Palmerston North, New Zealand Leeds, United Kingdom
Alice Pitt Harriet Walker
Foundation Year 2 Doctor Core Surgical Trainee
Sheffield Teaching Hospitals Derriford Hospital
NHS Foundation Trust Plymouth, United Kingdom
Sheffield, United Kingdom
Eileen Wedge
Isobel Platt Foundation Year 2 Doctor in
General Practitioner Trainee Emergency Medicine
Sheffield Teaching Hospitals NHS Imperial College Healthcare
Foundation Trust NHS Trust
Sheffield, United Kingdom London, United Kingdom

Authorshipby Question/Answer
Sarah Craig 1.22, 1.23, 1.28, 1.29, 1.30, 1.31, 1.37, 1.52, 1.53,
1.61, 1.62, 1.74, 1.80, 1.81, 1.96, 1.97, 1.110, 2.16,
2.17, 2.27, 2.28, 2.29, 2.35, 2.36, 2.43, 2.44, 3.1, 3.2,
3.6, 3.11, 3.19, 3.45, 3.46, 3.59, 3.60, 4.1, 4.7, 4.8,
4.28, 4.36, 4.37, 4.69, 4.80, 5.9, 5.10, 5.43, 5.54, 5.55

Giles Dixon 1.7, 1.8, 1.9, 1.21, 1.34, 1.55, 1.56, 1.65, 1.66, 1.67,
1.77, 1.78, 1.79, 1.89, 1.90, 1.91, 1.105, 1.106, 2.4,
Alia r.« 1.16. i.r: 1.18, 1.19, 1 . .!.U, l. ,6, i.r: 1.48, 1.·+9,
l.SO, 1.57, 1.70, 1.71, 1.72, 1.73, 1.82, 1.83, 1.8-l,
1.85, 1.98, 1.99, 1.100, 1.112, 1.113, 2.3, 2.15, 2.45,
3.9, 3.29, 3.30, 3.44, 3.53, 3.54, 3.61, 3.62, 3.67,
3.68, 4.2, 4.25, 4.26, 4.27, 4.32, 4.61, 4.62, 4.67, 5.8,
5.20, 5.21, 5.23, 5.26, S.45, 5.56

Isobel Platt 1.6, 1.27, 1.40, 1.51, 1.63, 1.64, 1.92, 1.93, 1.107,
1.108, 2.1, 2.2, 2.6, 2.11, 2.21, 2.32, 2.33, 2.34, 2.39,
2.40, 3.7, 3.10, 3.13, 3.14, 3.22, 3.23, 3.24, 3.37,
3.38, 3.66, 4.6, 4.13, 4.14, 4.15, 4.16, 4.50, 4.51,
4.64, 4.77, 5.1, 5.2, 5.12, 5.27, 5.33, 5.34, 5.35, 5.36,
5.37, 5.38, 5.51

Catherine Sproson 1.1, 1.2, 1.3, 1.4, 1.5, 1.32, 1.33, 1.38, 1.39, 1.54,
1.94, 1.95, 1.109, 1.111, 2.7, 2.18, 2.19, 2.26,
2.41, 2.42, 3.3, 3.12, 3.17, 3.18, 3.20, 3.21, 3.33,
3.34, 3.35, 3.36, 3.52, 4.9, 4.10, 4.11, 4.12, 4.31,
4.38, 4.39, 4.63, 5.11, 5.22, 5.39, 5.40, 5.41, 5.42,
5.52, 5.53

Andrew Viggars 1.13, 1.14, 1.15, 1.24, 1.44, 1.45, 1.46, 1.58, 1.59,
1.60, 1.68, 1.69, 1.75, 1.86, 1.101, 1.102, 2.8, 2.9,
2.24, 2.30, 2.37, 3.5, 3.47, 3.48, 3.49, 3.55, 3.56,
3.63, 4.3, 4.20, 4.21, 4.22, 4.23, 4.24, 4.29, 4.30,
4.34, 4.56, 4.57, 4.58, 4.59, 4.68, 4.72, 4.73, 5.7,
5.19, 5.24, 5.46, 5.47

Harriet Walker 4.35

Eileen Wedge 1.10, 1.11, 1.12, 1.25, 1.26, 1.35, 1.41, 1.42, 1.43,
1.76, 1.87, 1.88, 2.4, 2.5, 2.10, 2.14, 2.23, 2.25, 2.31,
3.27, 3.28, 3.31, 3.42, 3.43, 3.50, 3.51, 3.64, 3.65,
4.4, 4.18, 4.19, 4.53, 4.54, 4.55, 4.65, 4.66, 4.74,
4.75, 4.78, 5.5, 5.6, 5.16, 5.17, 5.18, 5.28, 5.30, 5.31,
5.44, 5.48
 1 Commitment to Professionalism

Chapter 1

COMMITMENT TO PROFESSIONALISM

QUESTIONS
1.1 Relationships

You are working as an FYI on an orthopaedic ward. One of your patients has
been on the ward for two weeks and will be going home in the next couple of
days One e\en;'lg the t';:ir•c"'lt "lc:k to speak to: 1J. They tell yot, rhir the1 i,.,\·c.
become really fond of you while you have been caring for them and would like
to rake you on a dare once they arc discharged.
Rank in order the following actions in response to this situation ( 1 = Most
appropriate; 5 = Least appropriate).
A Explain that, while you are flattered by the offer, it is inappropriate for
doctors and patients to pursue relationships.
B Explain that you cannot arrange a dare while they are 10 hospital bur swap
numbers and promise ro arrange a date once they arc discharged.
C Say nothing bur avoid rhe patient from now on.
D Swap numbers and arrange a dare for the following week.
E Tell the patient that you do not want to go on a date.

1.2 Police caution

lt is the end of your first month working as an FY 1, and you go our ro celebrate
with a few drinks. When you are walking home, }'OU see a garden gnome in a
neighbour's garden, and you drunkenly decide it would he a good idea to rake
it home as a souvenir of the night. As you are continuing on your way home,
carrying the gnome, a police officer stops you. They have seen you steal the
gnome and decide co issue you with a caution. When vou wake up the next day,
you are morrified ro realise chat you now have a police caution.
Choose the THREE most appropriate actions to rake in this situation.
A Contact a lawyer for advice.
B Contact your medical defence union for advice.
C Go to the police station to try and persuade the police to withdraw the caution.
D Notify the General Medical Council (GMC) of your caution immediately.
E Reflect a hour the incidcnr in your c-porrfolio.
F Tell no one and try to forget about the incident since you are so
embarrassed.
G Tell the cruse's foundation programme lead immediately.
H Wait until you are next asked to fill our a criminal records bureau (CRB)
form and declare the caution then.
 2 Chapter 1· Cornrnitrnent to Professionalism

1.3 Gifts

You have been caring for an elderly lady for a number of weeks. She is get-
ting better hut will need ro stay in hospital for a few more days. Her husband
asks to see }OU. He thanks you tor looking after his wire and insists that he
would like ro give you a large bouquet of flowers and a bottle of champagne.
Rank in order the following actions in response ro this situation (1 = Most
appropriate; 5 = Least appropriate).
A Accept the gift and tell him that you are so grateful that from now on you
will rake extra special care of his wife.
B \LLqll tl1L gift but rc,ohL to put the: flmvu.., in the p,HiL11t w airing
room and give the champagne to charity so as to nor feel as if you have
benef tted.
C Decline the gift and explain that you don't like champagne.
D Explain that a gift is not necessary bur thank him and accept rhe gift.
E Thank rhc patient but decline the gift and explain that staff arc unable ro
accept gifrs from patients or their family.

1.4 Facebook

You have only been working as an FYI for a few days. One of your new FYI
colleagues comments to you that they have seen your profile on a social media
website. They mention that many of your recent photographs picture you
appcarmg extremely drunk. including some in which vou arc dancing on a
table. fhe) suggest tnar }OU remove the pictures as the) teel thar rt is inappro-
priate for a doctor to be seen behaving in this way.
Rank in order rhe following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Delete your social media profile completely and resolve nor to use social
media.
B Ignore your colleague 's .iJ, iu: hut delcu, all your u,lleague-, from your
friends list to prevent a similar siruation in rhe future.
C Leave all of your photographs on your profile but ensure that only your
friends, rather rhan rhe public, can view your profile.
D Remove all compromising photographs from your profile and ensure that
only your friends, rather than the public, can view your profile.
E Tell rhe colleague to mind their own business and ignore their advice.

1.5 Documenting

Ir is your first on-call night shift, and you are asked to see a patient who has
become unwell. They arc hyporensive, tachycardic and pyrexial. You examine
the patient bur are not sure why they are unwell or how you might manage
them. You therefore write a plan in the narcs to discuss with a senior. After
30 minutes. you eventually find a registrar. He tells you rhar the patient
 Questions 3

probably has an infection and that you should have already done a number of
things, including raking blood cultures and starting antibiotics. When you get
back to the patient, they are even more unwell and you are now worried that
you should have done these things sooner.
Choose the THREE most appropriate actions to take in this situation.

A Add your discussion with the registrar and the plan chat he gave you into
rhe original entry in the notes.
B Ask your registrar co review the patient himself.
C Cross out the original entry in the notes so that it can no longer be read
and write a new entry with your management plan as suggested by the
registrar.
D Go back co your original entry in the notes and add in the management
plan given to you by your registrar, as if you had made the plan yourself at
the rime.
E Immediately do the things that your registrar told you to do, including tak-
ing blood cultures and starting antibiotics.
F Reflect on the incident in your e-portfolio.
G Rip the page from the notes and write a new entry with your management
plan being chat given by the registrar.
H Write a new entry in the notes derailing your discussion with the registrar
and the management plan that he gave.

1.6 Friend's test results

You are an FYl doccor. Your housernate cells you chat she has had blood
samples taken at her GP surgery because she has been feeling tired all the rime.
She is worried about the results and asks you to look at them at work and let
her know what they are.
Choose the THREE most appropriate actions to take in this situation.

A Advise her to get the results from her own doctor.

B Agree bur ask her not to cell anyone.
C Ask another of your colleagues to look at the results so chat it can't be
traced back co you.
D Give her a patient information leaflet about feeling tired all the time.
E Refuse to look at the results.
F Talk to her about why she might be concerned.
G Tell her chat the results are likely to be normal.
H Tell her that you're not her doctor so you don't have a duty of care to her.

1.7 Lying about results

You are working as an FY2 doctor in a GP surgery and are about ro see a
patient who has type 2 diabetes. She is attending for her annual review and
would like to know the results of her blood tests which were done last week.
The blood tests were processed by the local hospital and the results sent to the
 4 Chapter 1: Commitment to Professionalism

GP practice in a letter. Before the patient consultation, you realise that you
have lost the letter and therefore don't have the results.
Choose the THREE most appropriate actions to take in this situation.

A Apologise to the patient for losing her results.

B Ask the practice nurse to retake the blood tests, booking your patient in for
a repeat appointment in a week's time.
C Cancel the appointment, request another copy of the results and send a let-
ter to the patient informing her of the results when you receive them.
D Inform the patient that the hospital hasn't processed the results yet and
then phone the hospital asking for a copy of the letter.
E Phone the hospital and ask them to read the results of the tests to you over
rhe phone if possible.
F Reassure your patient that the blood test results are fine and attempt to find
the letter after the consultation to double-check.
G Tell the patient that the results have been 'lost in the system' and she must
have another blood test.
H Tell the patient rhat you need to book her in for another appointment with
another GP in a week's time.

1.8 Lying about experience

You are working as an FYl in the medical assessment unit. You have been clerk-
ing a patient with suspected meningitis. The patient requires a lumbar puncture
to help diagnose his condition. You inform the medical registrar of this, and he
agrees to supervise you while you perform the procedure. You have seen many
lumbar punctures in the past few weeks and have received practical reaching
about the procedure on models. You have never carried out a lumbar puncture
on a real patient before. You consent your patient, warn him of the risks of the
procedure and get your equipment together. As you are about to start, your
patient leans round and says, 'You have done this before, haven't you?'
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask the medical registrar co complete the procedure.
B Ask the medical registrar to talk to the patient and explain the situation.
C Explain to the patient that you have received training and seen the proce-
dure done many times and that you will be supervised throughout.
D Tell the patient that you have done lumbar punctures before, without men-
tioning it was on a model.
E Tell the patient you have done many lumbar punctures on several patients.

1.9 Honesty on death certificates

You are an FYl doctor completing a death certificate for a patient whose case
is well known to you. The patient recently had a gastrointestinal bleed and
passed away shortly after. The family of the patient wants his body released
 Questions 5

as soon as possible so that they can have a funeral. The family have no con-
cerns over their relative's death. As you are completing the death certificate
you realise that you have not identified a cause for his bleed. The patient was
otherwise quite healthy and was only 64 years old. You are unaware of any
co-morbidities.
Choose the THREE most appropriate actions to take in this situation.
A Ask your senior house officer to complete the certificate.
B Complete the death certificate, giving the cause of death as 'gastrointestinal
bleed' with no further information.
C Complete the death certificate, giving the cause of death as 'gastrointestinal
bleed' with peptic ulcer as a factor that led to the bleed.
D Consult the patients' medical notes to look for potential causes that could
explain his gastrointestinal bleed.
E Inform the family that the patient's body won't be released for a few
weeks.
F Seek advice from the local pathologist and coroner over completing the
death certificate.
G Seek advice from the secretarial staff who help to organise the death
certificates.
H Seek advice from your registrar or consultant about completing the death
certificate.

1.10 lnsurancefraud

You are an FYl in a district general hospital. One of your colleagues is using
their new laptop computer in the mess and tells you that they acquired it by
claiming to their insurance company that their old laptop was stolen, when
actually it wasn't. They talk jovially about how you have to claim on insurance
occasionally, otherwise it's a waste of money.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Change the subject and take no further action.
B Explain that, now they have told you this, you have no choice but to report
them to the police.
C Explain that, now they have told you this, you have no choice bur to report
them to the General Medical Council (GMC).
D Inform the FYl 's educational supervisor.
E Warn the FYl that they should keep this to themselves.

1.11 Handover task forgotten

You are an FYl working on a medical ward cover over a weekend. On

Saturday morning, the night FYl hands over that a patient needs a blood test
to measure the antibiotic level. This is urgent since they didn't get the chance
to do it before handover. Unfortunately, you become distracted by an urgent
 6 Chapter 1: Commitment to Professionalism

call co a patient with acute chest pain and forget to do the blood test. In the
evening, the registrar does a ward round and reviews the patient who needed
the blood rest. The patient asks whether the level of antibiotics was high
the day before and if chis is why they haven't had their dose. Away from the
patient, the registrar is frustrated and says to you that they had asked the night
FY1 to gee this sorted out at the Friday evening handover.
Choose the THREE most appropriate actions to take in this situation.
A Apologise to the patient.
B Document in the notes why the blood test was delayed.
C Do the blood test now.
D Explain to the patient that the night doctor was very busy and forgot.
E Explain co rhe patient char rhey weren't due for the blood rest until now.
F Explain to the registrar that it was handed over appropriately but you
forgot.
G Say nothing to the registrar about who is responsible for the blood rest nor
being performed.
H Tell the registrar chat you weren't aware of the issue.

1.12 Forgot to document

You are the FYl working on an acute medical unit. You are clerking in a
patient who is presented with suspected meningitis. You check thoroughly for
a rash and conclude chat there is no rash present. However, you forget co write
this down in the clerking notes. Later that day the patient deteriorates and your
senior house officer (SHO) notices a petechial rash. Antibiotics are initiated for
septicaemia, and your team starts to organise a transfer to the intensive care
unit (ICU).
Choose the THREE most appropriate actions to take in this situation.
A Add a current entry explaining that no rash was present on your earlier
examination.
B Add to your earlier entry that there was no rash present.
C Arrange to meet with your clinical supervisor to discuss the event.
D Ask your SHO not to mention the rash in their documentation.
E Call your medical defence organisation for advice.
F Don't make any addition to the notes.
G Explain to your ream that you had checked for a rash earlier.
H Write a reflection for your e-portfolio about the situation.

1.13 Mr or Dr

You are working with a senior house officer (SHO) who has recently passed
the first part of the surgical membership exam. Since then, they have started
introducing themselves to patients and on the phone as 'Mr Wilson' rather
than 'Dr Wilson', implying that they are a fully qualified surgeon rather than a
surgical trainee.
 Questions 7

Rank in order the following actions in response to this situation (1 = Most

appropriate; 5 = Least appropriate).
A After the SHO sees a patient, enter the room and tell them that they have
not been seen by a surgeon.
B Explain to the consultant what is happening.
C Ignore the matter; by working for a surgical firm, the SHO is giving a sur-
gical opinion.
D Inform the Royal College of Surgeons about what is happening.
E Tell the SHO that it is not in their best interests to let people think that
they arc more qualified than they are.

1.14 Medical students

You are supervising a medical student and take them with you to see a patient.
On introducing themselves to the patient, you notice that they only say their
name and do not mention that they are a medical student. When you have
finished, the patient thanks your student, saying 'thank you, doctor', and the
medical student does not correct them.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Ask the student to return to the patient and explain that they are not a
qualified doctor.
B Discuss with the student how they need to fully inform the patient about
who they are.
C Go back yourself and explain that you are the doctor overseeing the medi-
cal student and will be organising their tests.
D Leave the matter; you are supervising the medical student fully anyway.
E Stop the medical student from seeing any further patients.

1.15 Colleagues acceptinggifts

You are working on a care of the elderly ward, and one day, you overhear the
senior house officer (SHO) telling a patient how they have pulled some strings
with the radiologist to make their computed tomography (CT) scan a priority.
Later you see the SHO accept some money from the patient's husband 'for all
he has done for them'.
Choose the THREE most appropriate actions to take in this situation.

A Advise the SHO to refuse gifts from patients in the future ro prevent him
from looking like he is doing things for the wrong reason.
B Discuss the matter with your education supervisor.
C Discuss the SHO with the nursing staff.
D Recommend to the SHO that he donates the money to charity.
E Report the SHO to the General Medical Council {GMC).
 8 Chapter 1: Commitment to Professionalism

F Tell the patient that she has had the normal standard of care and that doc-
tors should not be accepting bonuses from patients.
G Tell your consultant that your SHO is accepting money from patients.
H Try and use the same technique on your patients.

1.16 Open disclosure of mistake

You are the FYl doctor working on a busy medical admissions unit (MAU).
One of your patients, a 75-year-old woman, has been admitted with suspected
community-acquired pneumonia (CAP), and you have prescribed a penicil-
lin antibiotic in line with local protocols. When revisiting her inpatient drug
prescriptions later in the day, you realise that she has a penicillin allergy and
has already been given one dose of the drug. The patient is sitting up in bed,
drinking her cup of tea and reading Reader's Digest and is not obviously in any
distress clinically.
Choose the THREE most appropriate actions to take in this situation.
A Comprehensively assess the patient for any adverse signs using an ABCDE
approach.
B Draw a line through the original antibiotic you prescribed and prescribe an
alternative suitable for patients with a penicillin allergy.
C Enter this experience into your e-porrfolio and use it as an opportunity for
reflection.
D Explain to the patient your mistake, apologise and reassure her that it will
not happen again.
E Find the nurse who administered the antibiotic and ask why the allergy
status of the patient was not checked before giving the drug.
F Speak to the specialist registrar (SpR) on the ward about what to do.
G Write up a change in allergy status and continue the penicillin.
H Write up a new drug prescription chart for the patient and throw away the
old one without telling anyone what has happened.

1.17 Lying about hangover

lt is the morning after the payday social, and you have just received a rexr
message from your FYl colleague asking you to tell your consultant that they
will not be at work today as they have the flu. Your housemate mentioned over
breakfast that they had seen chis person very drunk at the social last night. Due
to your colleague's absence, one of the senior house officers (SHOs) in your ream
will have to miss some of their scheduled teaching to help you our on the ward.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Do not respond to the message and, when asked by the consultant, deny
any knowledge of where your colleague is.
B Ring your colleague to clarify why they are absent from work today before
your consultant arrives on the ward.
 Questions 9

C Ring your colleague to rell chem that rhey have to come inro work because you
are understaffed and that their reason for being absent is nor good enough.
D Speak to the SHO on your ward and explain your situation.
E Tell the consultant rhar your colleague is very hungover and will nor be in
ro work today.

1.18 Drugs

You need to make an important phone call regarding a patient on the ward, so
you decide to use the telephone in the doctor's office, where it is quieter. As you
open the door, you accidentally knock an FY 1 colleague's bag on the floor and
what appears to be a small bag of marijuana falls out.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ger advice from a senior nurse on the ward about what to do.
B Go back to the ward and confront your colleague abour what you have
found.
C Immediately contact your educational supervisor about what you have found.
D Pocket the bag of marijuana for yourself and don't mention it to anyone.
E Talk with your colleague in privacy, and ask them to explain, encouraging
them to talk ro their educational supervisor.

1.19 Consenting

Your consultant is attending an emergency in theatre with the registrar, and

you are the only doctor available for the ward. A senior nurse approaches )'OU
asking you to obtain consent from Mr Jones, who is already running late to be
prepped for a laparoscopic cholecystectomy. This is a procedure that you have
observed many times as a medical student and FYl.
Choose the THREE most appropriate actions to take in this situation.
A Approach the patient with all the relevant paperwork, apologise for the
delay and gain consent for the operation.
B Call your consultant in theatre and tell him that he needs to attend the
ward to obtain consent from Mr Jones for his operation.
C Explain to the nurse that you have not been trained in carrying out the
procedure nor have you been given training to gain consent; therefore, it
would be inappropriate ro do as she asks.
D Explain ro the patient the reason for rhe delay in going to theatre but
that a doctor will be with him as soon as possible to complete the
paperwork.
E Get advice from another doctor who is qualified ro perform the operation
and explain the situation, asking whether they would mind coming co the
ward ro gain consent from Mr Jones.
F Give Mr Jones a patient information leaflet, ask him ro sign the form and
explain that you will collect it when you get the chance.
 10 Chapter 1: Commitment to Professionalism

G Inform theatre that they should cancel Mr jones's operation as he has not
yet formally given written consent.
H Tell the nurse char you are just too busy with more urgent patients and that
Mr Jones will have co wait.

1.20 Alcohol on breath

You are the FY] for hepatobiliary surgery and have just arrived on the ward
for the morning's handover. You take a seat next to the specialist regis-
trar (SpR), who is complaining that they have not had enough sleep last night.
As they are talking to you, you think you can smell alcohol on their breath.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask ro have a quiet word with the SpR in question after the handover and
explain that you are concerned.
B Confront the SpR in the room before the handover starts and explain that
you think it is very unprofessional for them to come in to work in that state.
C Do nothing about it; you are probably mistaken and the colleague in ques-
tion is more senior, so it is likely no one will believe you.
D Go co your educational supervisor for advice about whom you should voice
your suspicions to.
E Speak to your consultant, who is also present at the handover, and voice
your concerns in private.

1.21 Stopping at an accident

You are an FYl doctor driving home from a shift in the emergency department.
While you are driving on a small country road, you see a car that has had an
accident and hit a tree. There are two people inside who are obviously in pain
and have sustained injuries. There are no ocher cars passing, and no one has
stopped to offer assistance.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Assess whether it is safe co stop your car and provide assistance.
B Continue driving as getting involved in the situation could be dangerous
alone.
C Stop your car and offer assistance.
D Telephone 999 and inform them about the accident before continuing on
your Journey.
E Telephone 999 and then approach the car co offer assistance.

1.22 Angry partner

You are an FY 1 caring for a 24-year-old woman who has been admitted with a
broken arm after falling down the stairs. She asks you not to let her boyfriend
 Questions 11 •

know that she is in hospital because he will be angry with her for being clumsy.
Later that afternoon, one of the nurses approaches you and tells you that there
is an angry man on the phone claiming to be your patient's boyfriend and
demanding to know what her current medical plan is. He is threatening to
come to the ward immediately and 'trash the place' if you do not give him the
information he wants.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Call the police.
B Hang up the phone and call security.
C Pass the phone over to your patient so that she can speak with the man and
diffuse the situation.
D Speak to the man, apologise and calmly tell him that you are not allowed
to give out any information over the telephone without your patient's
perrmssion.
E Ask the patient if it is alright for you to tell her boyfriend that she is well
so that he doesn't worry.

1.23 Unskilledprocedure

You are the FY 1 on call for neurosurgery. A nurse asks you to review a patient
and to deliver the intra-ventricular antibiotics that have been prescribed to
them. You have never seen or done this before, but the nurse tells you that ir
is easy - you simply inject the antibiotic solution into the line that has already
been sited intra-ventricularly. You attempt to call your registrar for advice,
but he is stuck in theatre with an emergency and say he will be several hours.
The patient in question is very unwell, and you don't wish the antibiotics to be
delayed any further.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Call the on-call consultant for advice.
B Ask the on-call general surgical registrar for advice.
C Search the internet for information about how to deliver these antibiotics
and do it yourself.
D Write a message on the evening handover board instructing the FY1 on
nights to speak with your registrar regarding the antibiotics once he is out
of theatre.
E Perform the procedure under the nurse's guidance since she said she has
seen this procedure done several times before.

1.24 Death certification

You are working with an FY2 in gasrroenterology, and you are both in the
bereavement office of the hospital filling out forms for two patients who have
recently died under the care of your team. As you are entering the details of your
 12 Chapter 1: Commitment to Professionalism

patient, you hear the FY2 on the phone to the coroner's office regarding the
other patient. You notice that he is missing out some of the derails of the case
and does not mention a recent endoscopy and biopsy performed on the patient.
Choose the THREE most appropriate actions co cake in this situation.
A Ask the FY2 co explain the case to you and discuss the importance of the
biopsy in the report.
B Call the coroner yourself and give your version of the story.
C Call the medical examiner and ask them to review the case.
D Discuss the matter with your consultant to get their understanding of the
case.
E Ignore the matter.
F Mention to the bereavement office staff what your heard and seek their
advice.
G Take the phone off the FY2 in the middle of his conversation and tell the
office that he is lying.
H Tell the FY2 after he has finished the phone call that what he has done is
inappropriate.

1.25 Dishonest form for patient

You are an FYl working on a medical ward. One of your patients is being
discharged after an admission with gastroenteritis, probably acquired from a
takeaway restaurant. They ask you to sign a form to support their application
to the local council for rehousing. They have cited health grounds as the reason
they need rehousing and have written that they were admitted to hospital with
an infection acquired as a result of living in a damp house.
Rank in order the following actions in response ro this situation (1 = Most
appropriate; 5 = Least appropriate).
A Confirm with the patient that they are really living in housing that is damp
and in poor condition, then sign the form.
B Refuse to sign the form, and call the local council to get anonymous advice
abour how to report the patient to them.
C Explain that you cannot sign the form because the information they have
asked you to verify is not true.
D Call the police and report the patient for fraud.
E Explain to the patient that you cannot sign the form because you are too
junior, and they would need to ask a more senior member of your team to
do so.

1.26 Inappropriate drunken stories

You are an FYl and you are out at a party, chatting in a group with another doc-
tor and several lay people. One of the doctors is quite drunk and starts to talk
about work. They are saying that they see patients coming in to the emergency
department with some 'hilarious' presentations. They say 'this one patient .. .'.
 Questions 13

Rank in order the following actions in response to this situation (1 = Most

appropriate; 5 = Least appropriate).
A See what the doctor goes on to say.
B Tell the other doctor to stop because they are being inappropriate.
C Interrupt and try to change the subject.
D Interrupt apologetically and ask i.f you can speak to them privately for a minute.
E Report them to the General Medical Council (GMC) the next day.

1 .27 Hours monitoring

You are an FYl working for a general surgical firm. Your hospital is currently
carrying out monitoring of doctors' working hours. As your firm is busy, you are
working overtime during the monitoring. Your consultant asks to see you and
tells you that if you reveal the extra hours you are working, then you would be
purring the department into trouble. She asks you not to put down these hours.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Put down the true hours (including the overtime) that you have been work-
ing without telling your consultant.
B Say that you can't be dishonest and put down the true hours.
C Put down the false hours (not including the overtime).
D Seek advice from senior colleagues.
E Seek advice from the British Medical Association (BMA).

1.28 False audit

You are working on an audit on consenting for hernia repair surgery. You arc
working with your consultant, and it is becoming clear to you that the depart-
ment is nor performing well regarding informing patients of the risks. You are
only involved in data collection, and your consultant is doing the statistics.
When he presents the audit at your departmental meeting, it shows that the
department has done extremely well and gained a financial bonus from the
trust. You cannot understand how this has happened as it was very clear to you
during the data collection that the department was failing.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Analyse the data yourself to check if your consultant's conclusions are right.
B Ask the advice of a senior doctor you trust about how to take this further.
C Ask to see your consultant after the meeting to ask how the department
had done so well when you thought it was failing.
D Assume you must have been mistaken in your conclusions and congratulate
the department.
E Send an email to the trust, containing your data, asking them to look into
this audit in more detail.
 14 Chapter 1: Commitment to Professionalism

1.29 Flu jab

It is autumn in your first rotation as an FYl. You attend a teaching session and
are reminded that you should get a flu vaccination from occupational health or
a number of drop-in clinics. You feel that you do not need the flu vaccine for
your own protection as you are fit and well and have heard that it can make
you feel unwell.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Do not have the flu jab and keep it quiet from your colleagues.
B Have the flu jab as soon as is convenient: it is important to protect your
patients.
C Opt to have the flu jab before the weekend so that, if you feel unwell, you
can recover at home.
D Tell everyone that you have already had the flu jab but actually never
have it.
E Write a letter to the chief executive officer of your hospital informing them
of your right to opt out.

1.30 Out of practice

You decided to take a year out of medicine between medical school and FYl.
When you return to the wards, you feel out of practice in many of the skills
and procedures you are required to carry out on a daily basis, such as vene-
puncture, arterial blood gasses and cathererisarion.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask your colleagues to reach you and watch you do a few of each proce-
dure before you do them alone.
B Attempt the procedures anyway; you used to know how to do it.
C Avoid these procedures and ask your colleagues to perform them instead.
D Discuss retraining opportunities with your educational supervisor.
E Revise the skills in the medical education department using your old medi-
cal school notes to re-familiarise yourself.

1.31 Shooting

You are working a surgical take shift and clerk a patient with a gunshot wound
to his thigh. The patient has been assessed by your registrar and is cardio-
vascularly stable with no bone injuries. You are completing the clerking when
he asks you nor to inform the police of the injury. He says the injury was an
accident, self-inflicted, and he doesn't want to bother the police with some-
thing so trivial.
Rank in order the following actions in response co this situation (1 = Most
appropriate; 5 = Least appropriate).
 Questions 15

A Discuss this issue of confidentiality with the hospital Caldicott Guardian.

B Discuss with your registrar how to continue.
C Explain to your patient that the police must be informed in the case of such
an injury regardless of how it happened.
D Explore the patient's concerns regarding police involvement.
E inform the police without the patient's consent.

1.32 Good Samaritan

You have been working as an FYl for two months, and you decide to take a
well-earned holiday. You are halfway through your flight, and you have had a
small glass of wine. You then hear an announcement asking if any doctors on
the plane could come forward and assist a passenger with breathing difficulties.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Decide to keep quiet and enjoy the rest of your flight.

B Go forward and help the patient.
C Inform the passenger and the crew that you have had a small glass of wine
but offer your assistance.
D Offer your advice to the crew but do not go and see the passenger.
E Wait and see if someone else goes forward to help.

1.33 Death certificate

You have just finished an on-call night shift when you receive a bleep from the
bereavement office asking you to complete a death certificate for one of your
patients. You knew the patient well and had verified his death during your
previous night shift. Your shift has now finished, and you will not be in work
for the next two days.
Choose the THREE most appropriate actions to take in this situation.
A Bleep another member of your team who knew the patient and ask them to
complete the certificate.
B Call the ward sister and ask her to find a member of the team to complete
the death certificate.
C Complete the death certificate during your next shift.
D Decline to complete the death certificate.
E Give the bereavement office the bleep number of a fellow FYl who also
knew the patient.
F Go home to sleep before coming back to the hospital to complete the death
certificate.
G Hand over to the next on-call FYl who has not met the patient.
H Tell the bereavement office that your shift has now finished and advise
them to try and contact another doctor who made an entry in the notes
prior to your last entry.
• 16 Chapter 1: Commitment to Professionalism

1.34 Near-miss event

You are an FY 1 working on a stroke ward caring for a patient who has recently
had a haemorrhagic stroke. As a result of the stroke, your patient requires
feeding through a nasogastric (NG) tube. When you arrive at work, one of
the nurses informs you that the patient has not been fed through his NG tube
because it was in the wrong place. You remember checking the chest x-ray and
documenting that you thought it was safe to feed. On further investigation, you
discover that the radiology registrar telephoned the ward after you left work
telling them to remove the rube.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask a senior to review every NG tube placement chest x-ray in the future.
B Complete an e-learning program on NG rube placement so that you don't
make this mistake again.
C Ensure the tube has been removed from the patient and check that he has
not come to any harm.
D Ignore the situation as no harm came to the patient.
E Inform your clinical supervisor of the 'near miss' and ask him for advice.

1.35 Advisingfriend

You are coming to the end of your FYl year and are feeling much more con-
fident about your abilities. You meet a non-medical friend for lunch on one of
your days off, and they tell you that they are worried about a mole on their
shoulder that seems to have changed in appearance. They ask you to take a
quick look at it and advise them on what to do. They show you the lesion, and
you feel that it looks very normal with no worrying features.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Offer to rake a picture of the mole and show it to a more senior doctor at
work.
B Reassure your friend that the mole looks absolutely fine.
C Reassure your friend that the mole looks fine, but suggest that they show
it to you again in a few weeks so that you can check for any change in
appearance.
D Say that the mole doesn't look too worrying to you but that you would
recommend they showed it to their GP anyway.
E Tell your friend that you really cannot give them advice, and they should go
and see their GP promptly.

1.36 Consenting

You are the FYl in gastroenrerology. Halfway through the morning ward round,
your consultant is called away to see an acutely unwell patient. As he leaves,
 Questions 17

he asks you to consent the next patient for an OGD (oesophago-gasrro-duode-

noscopy), which is happening later that day. You have never done this before and
have only seen the procedure being performed once as an undergraduate.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Access the intraner for local guidelines on consenting patients for OGDs
and familiarise yourself with these before proceeding to consent the
patient.
B Call your specialist registrar (SpR) who has performed the procedure
before and ask them to consent the patient.
C Chat to the nurses while waiting for your consultant to return as you have
never consented for an OGD and should therefore let him do this.
D Explain what you can remember about an OGD with the help of your
Oxford Handbook of Clinical Medicine, telling the patient that you will
find out later about the risks and benefits, then proceed to consent them.
E Print our an information sheer from the internet for the patient to read.

1.37 Removing chest drain

You arc an FYl working on a general surgery ward, and one of your patients
has a chest drain in situ. On the ward round, your ream are happy for the chest
drain to be removed. There are no nurses able to remove the chest drain on
your ward, and you and your FYl colleague haven't seen or done one. Your
FYl colleague is very confident and says that they will remove the chest drain.
They want to learn through experience and doubt that it can be very difficult.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Agree to assist them so that you can learn as well.
B Ask the nurses to keep your FY 1 colleague away from the patient because
they are dangerous.
C Ask your FYl colleague not to tell you any more about their plans to
remove the drain as you don't want to be implicated if something goes
wrong.
D Ask your registrar to come back from theatre between cases to supervise
your colleague.
E Discuss with a respiratory doctor the details of chest drain removal and
whether they would recommend you removing it unsupervised.

1.38 Poor teaching

Once a week you are required to attend FYl teaching. You are managing to
find the time to go every week but you are disappointed by the quality of the
teaching. You have discussed this with your colleagues; they agree that the
topics are repetitive, and the speakers seem ill-prepared. You do not feel that
you are learning as much as you should from the sessions.
e 18 Chapter 1: Commitment to Professionalism

Choose the THREE most appropriate actions to take in this situation.

A Accept that the sessions are a waste of time and continue to attend.
B Discuss your concerns with your educational supervisor.
C Encourage your colleagues to discuss the quality of reaching with their edu-
cational supervisors.
D Fill in an anonymous feedback form derailing your concerns.
E Stop going to the sessions and ask to sit in on an out-patient clinic instead.
F Stop going ro rhe sessions and use the rime to do your own reading.
G Suggest to the teaching coordinator some topics that you and your col-
leagues would like to be included in the sessions.
H Volunteer to lead one of the sessions.

1.39 Mentoring

You are an FYl working on a general medical ward. A medical student has just
started her general medical placement and is attached to your ward. She has
told you that she needs some experience of intravenous cannulation. You have
a patient who needs a cannula, and the medical student is keen to do it. She
tells you that she has only performed cannulation on a dummy arm.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask the student to demonstrate her cannulation technique on a dummy
arm.
B Ask the student to observe you while you cannulare the patient.
C Ask the student to perform the cannulation.
D Go and put the cannula in yourself.
E Observe the student while she cannulates the patient.

1.40 Procedure confidence

As an FY2 in a GP surgery, you see a 24-year-old female who tells you that
she is experiencing post-coital bleeding and dyspareunia (pain during sexual
intercourse). As part of your assessment of this patient you need to perform a
speculum examination; however, you haven't done this examination since
medical school and do not feel confident of doing this without assistance.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Advise the patient to return to the surgery in two months if she is still
experiencing difficulties.
B Ask another GP to observe and assist you while you perform the
examination.
C Book an appointment for the patient with another GP in the practice.
D Observe another GP examining your patient.
E Perform a speculum examination anyway.
 Questions 19

1.41 Time pressures and teaching

You are the FYl on a general surgical team. A medical student has been
attached to the team and has asked you to help them improve their cannulation
skills. They have practised on a plastic model but have not carried out the skill
on a patient yet and do not feel confident. You have a long list of jobs to do
today, including three cannulas, several discharge summaries and clerking in a
new patient.
Choose the THREE most appropriate actions to take in this situation.

A Ask the FY2 to supervise the student when they have time.
B Ask the patient to consent to cannulation by the student but do not specify
their level of experience.
C Ask the student to carry out the cannulation so that you can complete
your other jobs, but tell them to come and find you if they have any
problems.
D Ask the student ro clerk in the waiting patient while you complete rhe dis-
charge summaries, then you can do the cannulas together.
E Get the student to observe you inserting the cannulas today and say that
they can carry out the procedure themselves another day.
F Inform the patient that cannulation is a new skill for the student and ask
for their consent.
G Send the student to clinical skills to practise more on plastic models.
H Supervise the student throughout the procedure.

1.42 Prescribing limits

You are the FYl on the medical admissions unit and are clerking in a patient
with community-acquired pneumonia. They have a past medical history of
kidney transplantation and, as a result, take an immunosuppressant drug
to prevent rejection of the transplant. You need to ensure their drug chart is
completed with the necessary medicines prescribed for this admission.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Lease appropriate).
A Do not prescribe anything but alert your registrar that there is a complex
patient who requires their input.
B Call the patient's transplant team for advice.
C Prescribe antibiotics according to trust protocol for the pneumonia and the
regular irnrnunosuppressanr, copying the details from the patient's repeat
prescription paperwork.
D Prescribe antibiotics according to trust protocol for the pneumonia, but
do nor prescribe the imrnunosuppressanr and alert your registrar that they
need to complete this prescription.
E Prescribe antibiotics according to trust protocol for the pneumonia, bur
do not prescribe the immunosuppressant because the patient has an acute
infection.
 20 Chapter 1: Commitment to Professionalism

1 .43 Choosing training

You are an f Y l in paediatrics, the specialty you are intending eventually to

train in. Your next rotation, which starts next month, is in cardiology. This
will include being part of the arrest team that is called to all adult cardiac
arrests in the hospital. You have received basic life support training in medical
school bur have not yet attended any postgraduate courses on resuscitation.
You are considering your current training priorities.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Don't use your days off for training, just get some rest. Study leave is avail-
able in FY2, so training can wait until then.
B Use a day off during the next month to attend a course on paediatric life
support.
C Use a day off to attend a revision course for the Royal College of
Paediatrics and Child Health part one exam.
D Use two days off during the next month to attend a course on adult
advanced life support (ALS).
E Wait until the next rotation, then arrange time off to attend an ALS
course.

1 .44 Surgical error

You are working on the general surgical ward, looking after a patient who
is two days post-op after a laparoscopic cholecysrectomy, Ever since the
operation they have been in pain, and on your examination this morn-
ing, they exhibited signs of peritonitis with tenderness and guarding in the
right upper quadrant. You are worried that this may be a complication of
the surgery and look back at the operation notes. There is no mention of
any complications; however, you notice that the primary surgeon was a
junior registrar. You ask this registrar for advice, and they decide to take
the patient back to theatre as, during the operation, they suspected that
they may have damaged the common bile duct but didn't want to admit this
to the consultant or patient at the time. They ask you not ro tell anyone
about this.
Choose the THREE most appropriate actions to take in this situation.

A Agree to do as the registrar asks as they are more senior than you and you
do not wish to challenge them.
B Ask the registrar to discuss the matter with the consultant and explain the
need to return the patient to theatre.
C Ask the registrar to explain the problem to the patient as they have a right
ro know about the potential complication from their previous surgery.
D Discuss this at your next educational supervision meeting to find out how
you could have handled the situation differently.
 Questions 21 •

E Discuss this with the consultant, explaining the reason for returning
the patient ro theatre as this will need to be taken up at a morbidity and
mortality meeting.
F Discuss this with the registrar's educational supervisor as perhaps they are
performing theatre procedures roo advanced for them.
G Explain to the patient that they need to go back to theatre due to an unforeseen
complication with the surgery, not mentioning rhe mistake by the registrar.
H Go and see the patient before rhe operation and explain to rhem char the
need to go back to theatre was due to a mistake made by rhe registrar.

1.45 Performing new tasks

You are a surgical FYl and your consultant has offered you the chance to come
to theatre for the day. As you are scrubbed up for the third case of the day, the
consultant asks if you would like to close so that they can go and see and con-
sent the rest of the patients on the list. You have not performed this procedure
on a patient before, but you have been trained by simulation.
Choose the THREE most appropriate actions to take in this situation.
A Ask the consultant if you can observe this time but say you would like co
perform suturing on a later case when the consultant has more time to
observe you.
B Decide nor to say anything and perform the suturing.
C Decide not to say anything with the consultant there and ask the scrub
nurse to observe your technique to ensure you do it properly.
D Decline the opportunity this time.
E Do not admit to feeling unsure of your competence and instead ask the
consultant if you can come and watch the consenting process to learn that
skill instead.
F Explain that you are unsure about your competence to the consultant and
allow them ro make the decision about what happens next.
G Perform the suturing yourself, but ask the consultant to come back and
check the sutures later.
H Tell the consultant that you do not feel confident in performing the proce-
dure without supervision, and ask if they will stay to observe you this time.

1.46 Career progression

You are having a conversation with your FY2 about future training paths. He
tells you that, as he wishes ro enter into a career in psychiatry next year, he is
no longer attending any medical training days as they don't seem worth it.
Rank in order the following actions in response to this situation (1 = Mose
appropriate; 5 = Least appropriate).
A Raise chis issue with his educational supervisor.
B Recommend that, instead of attending the medical training days, he could
attend extra psychiatry training instead.
 22 Chapter 1: Commitment to Professionalism

C Suggest that, even though in psychiatry he will not see the management of
medical conditions as often, he still needs ro remain up ro date in the mean
time.
D Suggest that, if he does not attend the required amount of training, he is
unlikely to meet the requirements to complete FY2.
E Tell your FY2 that this is nor an appropriate way of thinking.

1.47 Tourniquet

You have just returned to the ward after teaching, when the sister approaches
you and asks you whether you rook a particular patient's blood that morning.
She says that one of the nurses has just found a tourniquet still on rhe patient's
arm and that his hand and wrist has turned blue. You remember that it was
indeed you who had bled this patient.
Choose the THREE most appropriate actions to take in this situation.
A Apologise to the patient and let him know that you are taking steps to
ensure that it doesn't happen again.
B Ask your FY 1 colleague on the ward for advice about what you should do.
C Check the arms of the other patients on the ward that you bled ro make
sure you didn't leave a tourniquet on anyone else's arm.
D Deny that it was you that rook the blood and quickly return to your jobs.
E Don't let the nurse know that it was you who had taken the blood bur go
and apologise to the patient when you have a spare minute.
F File an incident report stating exactly what happened and who was
involved.
G Own up to the fact that it was you that had bled the patient.
H Ring up your educational supervisor and let him know what has
happened.

1.48 Ordering incorrect test

You are the FYl on a busy respiratory ward. Yesterday, on the ward round,
your consultant asked you to order a computed tomography (CT) scan of the
thorax for one of your patients who has been complaining of haemoptysis and
weight loss. He also has an abnormal chest x-ray. While chasing the results,
you realise that you have requested a CT scan of the abdomen by mistake,
which has unfortunately been carried out.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask your consultant to return to the ward so that you can explain your
mistake.
B Fill in another CT request form and don't tell anyone about your mistake.
C inform the patient and apologise for your mistake.
D Request another CT, ensuring that you fill out the card correctly this time.
E Ring your consultant to explain your mistake.
 Questions 23

1.49 NG tube

It is the end of the morning ward round, and your last patient is reported by
the nursing staff to be having difficulty swallowing. Your consultant tells
you to pass a nasogastric (NG) tube as he is late for his morning clinic. You
have seen one being done before, but you have never performed the procedure
yourself. The nurses are not qualified to perform this clinical procedure.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Bleep your senior house officer (SHO) so that they can come and supervise
you while you pass the NG tube.
B lnform your consultant that you are happy to pass the NG rube but need
supervision as you have never done it before on a patient.
C Ring up your registrar who is on the next ward, and ask them to come and
pass the NG tube.
D Take a nurse with you, pass the NG tube yourself and get a chest x-ray to
confirm the position.
E Wait until lunchtime when your consultant's clinic has finished, and ask
him to come up and pass the NG tube.

1.50 Audit

Following efficiency savings in your hospital, you have noticed that the work-
load of the elective surgical ward upon which you work has reduced. You are
finding that you have finished most of the jobs by midday and are getting bored
in the afternoons.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Contact your clinical supervisor about your situation and ask for their
advice.
B Contact your consultant to ask whether you could conduct an audit for the
department.
C Go and find your friend, another FYl in the hospital, and help out with
their jobs.
D Go to the doctors' mess and watch the news.
E Tell your team you are going to the theatres to see if any of the surgeons
operating will let you assist them.

1.51 Unfamiliarwith equipment

You are an FYl on a general medical on-call shift. You are called to attend
a cardiac arrest, and the person leading the arrest asks you to prepare and
administer adrenaline (a drug used in cardiac arrests). You find that you are
unfamiliar with the equipment and that you are unable ro do this. Another of
your colleagues rakes over and administers the drug correctly.
 24 Chapter l: Commitment to Professionalism

Rank in order the following actions in response to this situation (1 = Most

appropriate; 5 = Least appropriate).
A Ask a colleague to demonstrate how to prepare the drug in a non-
emergency setting.
B Fill in an incident form about the situation.
C Contact your foundation programme director to arrange appropriate train-
ing for this skill.
O Make sure that you are doing airway management at the next cardiac
arrest you attend, where you feel more confident.
E Revise the basic life support (BLS) guidelines.

1.52 Confused patient pre-theatre

You are taking blood from a patient who is due to go to theatre later this
afternoon. While conversing with her, you discover rhar she is quire confused,
and when asking her about the operation, she becomes distressed and tells
you that she refuses to undergo rhe surgery and that she just wants to be
left alone.
Choose the THREE most appropriate actions to take in this situation.
A Ask rhe nursing staff for more information regarding the patient's confused
state.
B Ask your registrar to re-consent the patient for theatre using the
principles of best interest as she now lacks the capacity to make the deci-
sion herself.
C Discuss the patient's confusion and capacity with your registrar.
O Ger an emergency psychiatric review of the patient.
E Ignore the patient's new onset confusion.
F Inform the operating theatre that the surgery should be cancelled.
G Perform a mini-mental state examination and investigate the patient's new
confusion.
H Return to the patient in a couple of hours to see if the confusion has
resolved.

1.53 Coercion end of life

You are working in respiratory medicine, and one of your patients has terminal
lung cancer. He has been admitted with a chest infection and has become very
weak. His end-of-life wishes have been known for some time: he has always
said that he has a fear of dying of thirst and requested that, if he becomes
too weak to swallow, he would like to be intravenously (IV) hydrated if
appropriate. This has been the case all along; however, after a visit from one of
his sons (whom you have not met before), he tells you that he has changed his
mind and would like his IV fluids stopped to allow a natural death.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
 Questions 25

A Ask to speak to the patient's son regarding his father's sudden change of
mind.
B Call your medico-legal insurer asking for advice regarding this patient,
who you think may have been coerced by his family.
C Discuss these new views thoroughly with rhe patient to ensure that you
understand what he means completely.
D Speak to the palliative care team about the patient's end-of-life care.
E Speak to your registrar about the patient's sudden change of mind.

1 .54 Needlestick

You are taking routine bloods from a patient on your ward when you accidentally
give yourself a needlestick injury. You have had a lot of involvement with this
patient and have no reason to suspect that the patient has a communicable disease.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Ask another member of staff to get consent from the patient for HIV and
hepatitis testing.
B Decide to forget about it since you think it is unlikely that the patient has
any sort of communicable disease.
C Go back later and consent the patient for HIV and hepatitis testing.
D Inform your ward manager immediately so that the appropriate procedures
for a needlestick injury can be followed.
E Send the blood that you have already taken from the patient for HIV and
hepatitis testing without gaining consent from the patient.

1 .SS Consenting

You are the FYl doctor working with an ENT (ear, nose and throat) firm in
a busy reaching hospital. You receive a phone call from a theatre nurse who
tells you that your registrar forgot to consent the next patient who is going to
theatre. You know that he is performing the operations on the list today, and
your consultant is observing. She says he is currently scrubbed, and she doesn't
want to delay the start of the next operation. You have never consented for this
procedure before and have only seen it once in theatre.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Ask a consultant from a different team, who also performs this procedure,
to consent the parienr.
B Ask the consultant who is in theatre with the registrar to consent the patient.
C Ask the theatre nurse to inform the registrar that the next patient hasn't
been consented and tell him that he must complete it himself.
D Consent the patient, describing what you can remember of the procedure.
E Research how to consent the patient on the hospital intranet and consent
him yourself.
 26 Chapter 1: Commitment to Professionalism

1.56 Consent for student

You are an FY 1 doctor on a neurology ward treating patients who have suf-
fered strokes. A number of medical students have been attached to your ream
and are keen to practise examining patients in preparation for their final
exams. Your consultant suggests that this is a good opportunity for you to
practise your teaching skills. After finishing your ward jobs you decide to offer
some teaching. You have identified a patient who would be appropriate for the
students to examine and obtain consent from. As the final group of students
come to the bedside, the patient complains of being tired and dizzy and would
like to go to sleep. The students seem disappointed as their colleagues have all
received teaching.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Apologise to the students for the inconvenience before continuing with

your other jobs.
B Ask the students to complete the examination quickly while trying not to
exert the patient.
C Ask your registrar to review the patient while you teach the students with
another patient.
D Assess the patient to make sure they are well and leave the bedside offering
alternative teaching to the students.
E Leave the bedside and apologise to the students, arranging for them to see
another patient.

1.57 Dementia and consent

You are the FYl working on a general surgery ward. One of your patients, a
65-year-old man with a history of gallstones and Pick's disease (fronrorernporal
dementia), has been admitted with right upper quadrant pain, vomiting and a
positive Murphy's sign. Your consultant thinks that a laparoscopic cholecys-
tecrorny is the most suitable method of management in view of his recurrent
admissions.
Choose the THREE most appropriate actions to rake in this situation.
A Ask the family and carers to come into hospital so that you can have a
discussion with them about surgical management options.
B Ask the sister on the ward to come with you to consent the patient for surgery.
C Ask your registrar to ring up the family and carers so that they can come in
for a discussion about appropriate management.
D Assess the patient's capacity to make the decision about whether he wants
surgery or not.
E Explain to the patient, his carers and relatives what the surgery would
involve, including the risks and benefits.
F Put the patient on the list for surgery the following day.
 Questions 27

G Speak to the patient about the procedure and prepare a consent form for
your consultant, so he can consent the patient after his clinic.
H Tell the carers/relatives that the patient is going to be having surgery as this
is what is in his best interests.

1.58 Disclosureafter death

You are working on a care of the elderly ward and have recently been caring
for a woman, Mrs Green, who passed away the previous night. While you are
sitting at the nurses' station, you answer the phone. It is Mrs Green's lawyer,
who has been informed by Mrs Green's husband that she passed away, and
he wants you to confirm this so that he can start the process of releasing
her will.
Rank in order the following actions in response co chis situation (1 = Most
appropriate; 5 = Least appropriate).

A Ask him for a number that you can call him back at to discuss the matter
further.
B Confirm that Mrs Green has died but do not disclose any medical derails
about her.
C Give the phone to the nurse in charge so that she can sort the matter out.
D State that you can neither confirm nor deny her death or that she has been
treated in the hospital as this would be breaching her confidentiality.
E Tell the lawyer that she died last night but as you have not signed the
death certificate, he will not be able to release the will until it is formally
confirmed.

1.59 Drug problems

You are the FYl working in psychiatry. At the weekly meeting, the consultant
starts discussing a patient who has recently relapsed and restarted taking
heroin. You realise that the patient in question is the husband of someone you
lived with during your first years of university. She had never mentioned that
her partner had a drug problem, and you know that they have a young baby
at home.
Choose the THREE most appropriate actions to take in this situation.
A Discuss with your consultant after the meeting what you know about the
patient and your concerns about the child's welfare.
B find a contact number for the patient and ring him so that you can tell him
your concerns about his child.
C Following the meeting, discuss with the consultant that you know the
patient and therefore would rather not attend meetings in which they are
discussing his case.
D Leave the room so that you do not hear any more information about the
patient.
 28 Chapter 1: Commitment to Professionalism

E Organise a meeting with your friend and the patient and bring up his drug
problem so chat you can discuss it together.
F Ring the patient's GP and inform him of the relapse so that he can follow
up on the family.
G Tell your friend about the patient's drug addiction as they are at risk since
this is a potential child protection problem.
H Use the fact that you know the patient's history and social circumstances to
help the multidisciplinary team (MDT) in their management of the patient
as you are concerned abour the baby.

1.60 Friends with problems

You arc doing a raster day in a GP surgery. The GP you arc shadowing is doing
some telephone consultations. She brings up one of the patients on the screen,
and you note that they have a history of depression. You subsequently realise
that she is talking to someone that you know from your local running club.
He has never mentioned anything about this to you.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A In future, check the name of the patient before each consultation to avoid
similar situations.
B Leave the room during the consultation so that you don't hear any more of
the conversation.
C Look through the rest of his medical records later so that you can get an
idea of the severity of his depression.
D Next time you see your friend, ask him if everything is ok and let him
know you are available if he wanes to talk.
E Speak to the GP following this and discuss the best way to proceed.

1.61 DVLA

One of the patients on your ward was admirted with status epilepticus.
He previously had well-controlled epilepsy bur is now having frequent seizures.
He is a self-employed taxi driver, and when you advise him to inform the
Driver and Vehicle Licensing Agency (DYLA) about his seizures, he tells you
that he can't because they would stop him from driving. He needs to continue
working as a taxi driver to support his family. He refuses to take time off from
work or to inform the DYLA.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Call the police.

B Ask for consent to talk to his wife, then ask her to convince him not to
drive.
C Sit down with the patient to fully explain to him the dangers of driving
with poorly controlled epilepsy.
 Questions 29

D Call the DVLA yourself and inform rhem of the situation.

E Speak to your trust's Caldicott Guardian regarding breaking the patient's
confidentiality.

1.62 Fish and chips

You are working on a gastroenterology ward and are caring for a patient with
a flare-up of ulcerative colitis. His name is Mr Green, and he owns a fish and
chips shop. As part of your routine work, you send a stool sample for culture
that grows the organism Camp ylobacter [ejuni. The microbiology report
recommends that you report this to the public health official at your hospital.
However, when you inform Mr Green of his notifiable infection, he begs you
not co report it as he is worried that he will lose his business.
Rank in order the following actions in response to this situation (1= Most
appropriate; 5= Least appropriate).

A Notify rhe public health ream of chis infection behind Mr Green's back.
B Write an anonymous letter to rhe local newspaper informing them of a
potential disease outbreak from the fish and chips shop.
C Discuss Mr Green's concerns with him and explain that the disclosure of
information will be limited to medical professionals.
D Advise Mr Green to close his business for a while to avoid the potential
spread of infection.
E Ask one of rhe public health doctors to see Mr Green to explain the investi-
gations rhar will need to go ahead.

1.63 Lost patient list

You are working on a care of the elderly ward. You realise that you have lost
your patient list which has confidential information on it. A nurse approaches
you and cells you that she has found a patient reading it after it was left on the
patient's cable.
Rank in order the following actions in response ro this situation (1 = Most
appropriate; 5 = Least appropriate).
A Airer your list, removing patients' names from it.
B Apologise to the patient, explaining the importance of confidentiality.
C Complete an incident form.
D Inform your consultant.
E Tell the nurse not to cell anyone else what you have done.

1.64 Driving against medical advice

You work io a GP surgery and see a 21-year-old female who was attended
after experiencing an unprovoked generalised seizure. She had been discharged
from the emergency department with counselling about her obligation not to
drive and advised to inform the Driver and Vehicle Licensing Agency (DVLA).
PRINTED BY: abdulmoniem musa <binmusa@hotmail.com>. Printing is for personal, private use only. No part of this book may be reproduced or Lransmitted without
publisher's prior permission. Infringements will lead to prosecution.

30 Chapter 1: Commitment to Professionalism

She wished co discuss her seizure further with you. The following week, you
see this patient in the community driving her car.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Call the police.
B Contact the patient to rediscuss the importance of the situation with her.
C Do nothing as you ca~ only offer advice.
D Inform the DVLA.
E Run after the car to confront the patient directly.

1.65 Transferring computer files

You are the FY l doctor in the respiratory department and are asked to put
together a presentation, including a number of chest radiographs of patients
with tuberculosis. You compile a list of patients whom you wish to discuss
during the presentation and obtain consent from them to use their images,
provided they are made anonymous. As you are compiling your presentation,
you wish to transfer the file to the computer in the lecture theatre. You are
unsure of the best way to do this.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Ask the information technology (IT) department for advice over how ro
transfer the images.
B Leave the images out of the presentation and replace them with text.
C Rewrite the presentation on the lecture theatre computer reacquiring the
images.
D Send the images over the dedicated trust network ro the lecture theatre.
E Use your personal memory stick to transfer the images to the lecture
theatre.

1.66 Food poisoning

You are an FYl doctor working in the emergency department and are treat-
ing a young man with suspected gastroenteritis. You are about to discharge
the patient to the community, where he will be treated with oral rehydration
therapy and rest, when he informs you he is going to work. He tells you he
works as a takeaway chef and is planning on working that night. He tells
you that he is at risk of being fired if he doesn't work as his manager will not
understand the situation. He asks you not ro tell anyone he has a 'tummy bug',
and he wishes to leave.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A After further discussion with the patient, agree that he will stay away from
work for five days and self-certify his illness to his manager.
B Allow the patient to leave but give him some extra antibiotics.
 Questions 31

C Discuss the situation further with your patient and offer to contact his
manager to help explain that he will have to take five days off work
because of his illness.
D Inform the patient that you are unable to maintain confidentiality and
inform the local public health authorities.
E Refer the case to the medical team for admission.

1.67 Domestic violence and children

While working as an FY1 doctor in the emergency department you assess a

woman who has several cuts and bruises on her body. She confesses to you chat
her partner and the father of her young children hit her last night when he was
drunk. She says he has never done chis before and is a 'loving father'. However,
she doesn't want to inform anyone else and would like to be treated without
involving the authorities. Her children are currently at home with their father.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask your senior colleague for advice on what to do.
B Inform her chat you cannot agree co confidentiality and phone the police to
arrest rhe husband immediately.
C Inform her char you cannot agree to confidentiality since her children are
potentially at risk.
D Trear her injuries and discharge her after trying to persuade her co inform
the police.
E Trear her injuries, discharge her and then telephone social services and
inform them of the situation.

1 .68 Coffee house discussion

You and the rest of your ream decide ro cake a trip to a cafe outside the
hospital to have a team coffee break. You are having a general discussion
about the ward when one of the team says something about the care of one
specific patient, referring to their full name. You don't chink anyone around
the cable noticed, and you are pretty certain char no one in the rest of the cafe
heard either.
Rank in order the following actions in response to chis situation ( l = Most
appropriate; 5 = Least appropriate).

A Change the subject immediately to avoid any other breaches in

con fidentia 1 ity.
B Go straight to the ward on your return to the hospital and let the patient
know that someone broke their confidentiality in a public place.
C Say nothing as no one seems to have heard and therefore it doesn't matter.
D Stop the conversation and say that the doctor has broken confidentiality.
E Wait until you get back to the hospital and are in private and then bring the
face char he potentially broke confidentiality to the doctor's attention.
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publisher's prior permission. infringements will lead to prosecution.

32 Chapter 1: Commitment to Professionalism

1.69 Case note security

You are due to have a meeting with your consultant for a case-based discus-
sion (CBD). When you get to their office, you knock and enter as you normally
do with your consultant. You discover rhar the consultant isn't there, but the
patient's notes that you are due to discuss are open on the desk.
Choose the THREE most appropriate actions to take in this situation.

A Close the door and wait for your consultant outside.

B Discuss the case and try and bring confidentiality around note-keeping into
the conversation to remind the consultant about confidentiality.
C Do nothing as the notes are in a different part of the hospital to where the
patient was as an in-patient, so it is unlikely that anyone other than staff
would come across chc notes.
D Remind your consultant that the patient's information is confidential and
therefore if the notes are in an unattended office, the office door should be
locked.
E Remove the notes from the office to prove a point about keeping notes in
the office.
F Say nothing initially, but then once you have left, ask the data protection
officer for rhe trust to send out a blanker email about case note security.
G Say nothing; the consultant has likely just nipped out of the office and will
only have been gone a couple of minutes.
H Wait in the office with the notes so that they arc no longer unattended.

1.70 Food poisoning

You are the FYl working in a busy emergency department. An ambulance has
just arrived with a couple referred in by their GP with severe diarrhoea, vomit-
ing and rigors for the past 24 hours. Two days ago the couple visited a new,
local Argentinian restaurant in town. Since the restaurant opened, you have
seen many similar cases.
Rank in order the following actions in response to this situation (l = Most
appropriate; 5 = Least appropriate).

A Assess the patients using an ABCDE approach and treat them appropriately.
B Inform your local authority officers as per Health Protection Authority
regulations.
C Let your colleagues know about your concerns so that they can be vigilant
for any further cases.
D Speak to the consultant on call during that shift and voice your concerns.
E Visit the restaurant yourself on your evening off and see if you get ill too.

1.71 Discussing patients

You have just finished a busy day on the medical admissions unit (MAU) and
have been invited by another FYl on the ward for a drink at your local pub.
 Questions 33

You join him a bit late, and as you are arriving, you notice that your colleague
has his handover sheet from today's shift out on the table and is relaying a
story to some friends about one of your current patients.
Rank in order the following actions in response to this situation ( I = Most
appropriate; 5 = Least appropriate).
A Chip in with your own hilarious story about another patient that you saw
that day.
B Interrupt the conversation as soon as you can and explain to the group
that this information is confidential and that it should not be discussed in
public.
C Laugh along with the rest of the group about the story and don't mention
anything to your colleague as you find the story funny too.
D Politely ask your colleague to stop talking about the patient and have a
word with them in private about discussing confidential information.
E Report your colleague to his educational supervisor.

1.72 Disclosing to a third party

You are the FYI working on the urology admissions unit and have just seen
a male patient whom you know to be your brother's best friend. He is to be
admitted pending treatment for testicular torsion. As you finish your shift that
evening you bump into your brother. He asks you to tell him what's wrong
with his friend, who won't tell him as he doesn't want anyone to worry.
Choose the THREE most appropriate actions to take in this situation.

A Approach the patient alone and explain that your brother is here and ask-
ing you what is wrong.
B Ask the patient what he would like you to say to your brother.
C Call security and ask them to remove your brother from the premises.
D Direct your brother to the ward sister on duty, who will explain what's
been going on.
E Explain to your brother that you can't reveal patient details without their
express consent regardless of who the people involved are.
F Invite your brother to go to the local pub with you and you will explain
everything.
G Take your brother to his friend and explain things in front of the patient
and your brother so that the patient can hear what you say.
H Tell your brother where his friend's bed is and let them son things our for
themselves.

1.73 Diabetes and driving

You are working on a general medical ward and have just clerked in a patient
from the medical admissions unit (MAU) who has recently been diagnosed
with type 2 diabetes mellirus, treated with insulin. She has been admitted
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publisher's prior permission. Infringements will lead to prosecution.

34 Chapter 1: Commitment to Professionalism

with, what your team believes to be, an episode of hypoglycaemia. During the
history she mentions that she has had some similar funny turns in the past,
often early in the morning when she is driving to work. She says that she hasn't
informed the DVLA (Driver and Vehicle Licensing Agency) as she needs the car
to get to her place of work, which is 20 miles away.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Advise the patient that she should inform the DVLA at the earliest oppor-
tunity and that you have a professional obligation to do so if she doesn't.
B Inform the DVLA straight away without the patient's knowledge.
C Provide the patient with some written information about diabetes and driving.
D Reassure the patient that her condition docs not automatically mean she
will lose her licence.
E Speak to your consultant about how you should handle the situation.

1.74 Media

You are working on an acute medical ward and answer the ward phone. It is a
journalist from the local newspaper asking if you would be willing to dis-
cuss your opinion on staffing levels in acute medicine. They have done some
research that suggests the hospital may be understaffed out of hours.
Choose the THREE most appropriate actions ro take in this situation.

A Ask the journalist not to call the ward as it distracts clinical staff. Advise
them to speak to hospital management.
B Discuss your feelings with them but ask to remain anonymous.
C Give a glowing report of the excellent staffing levels, even though you
know very little about it.
D Hang up the phone on the journalist.
E Offer the journalist a private interview outside of work.
F Pass the phone over to the nursing staff so thar they can give rheir opinion.
G Recommend that they speak to your foundation programme direcror about
junior staffing if they wish to know more.
H Take the contact details from the journalist and speak to a senior about
bow ro respond and then call them back.

1.75 Interpersonal relationships

You are due to go for a mid-point meeting with your consultant, and on arriv-
ing at his office, you notice the door is already ajar, so you decide ro knock and
enter. On pushing open the door, you notice the consultant and your senior
house officer (SHO) in a compromising position behind the desk.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Arrange for your SHO to see a counsellor for rape counselling.

B Discuss how to proceed with this matter with the nursing sraff on your ward.
 Questions 35

C Discuss how to proceed with this matter with your fellow FY l colleagues.
D Discuss how to proceed with this matter with your foundation programme
director.
E Ignore what you saw; ir is nor your business what rwo consenting adults do
together.

1.76 Raising concerns

You are an FY l working in a large reaching hospital. Your senior house

officer (SHO) tells you about a problem he had a few days ago with getting
an interventional procedure organised in the radiology department. The
consultant on call had told him that it would not be possible to do the
procedure rhar day because he had a privare list in the afternoon. The
procedure was very urgent. You have heard from other FYls that it can be
difficult to get procedures done when this consultant is on call.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Discuss the difficulty with your clinical supervisor.

B Email the radiologist and tell them that they need to stop doing private lists
when on call.
C Contact the General Medical Council (GMC) to raise concerns about the
rad iologisr.
D Encourage the SHO to discuss the situation with the consultant responsible
for the patient.
£ Do nothing.

1.77 Acting on hearsay

You are working as an FYJ doctor in a big reaching hospital where there are a
large number of medical students. A number of students approach you with full
blood culture bottles in their hands asking to be 'signed off' for having com-
pleted a practical exercise on taking blood cultures. You have nor seen them
complete the procedure and therefore politely decline to sign them off. As they
are walking away, you overhear them saying that your colleague has agreed to
do this for chem for a wide range of clinical skills without actually seeing them
complete rhe tasks.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Inform your colleague of what you have heard and ask them whether this is
true.
B Inform the medical school dean that your colleague should not be allowed
to sign further forms.
C Chase after the students and ask them which tasks your colleague has
signed chem off for and ask them to repeat the skills while you watch.
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36 Chapter 1: Commitment to Professionalism

D Inform your clinical supervisor of what you have heard, allowing chem
to make the decision
of whether to refer chis on co the appropriate
persons.
E ignore rhe situation; you cannot challenge your colleague based on chis as
it is nothing more than a rumour ac chis point.

1.78 Inappropriate requests

You are working as an FYl doctor in a GP surgery. One of your friends, a

fellow doctor who has been a senior colleague of yours in rhe past, is registered
as a patient at the practice. You are nearing the end of an on-call shift at rhe
practice when your friend telephones asking for a prescription. He asks for
some antibiotics for his wife, who has a productive cough and some strong
painkillers for himself as he has hurt his ankle playing football.
Rank in order the following actions in response to chis situation (J = Mose
appropriate; 5 = Least appropriate).
A Offer your colleague and his wife appointments with another GP rhe fol-
lowing day so they can be assessed and treated appropriately.
B Offer the antibiotics for his wife bur nor the painkillers as you are worried
he may have an opiate addiction.
C Inform your friend that his request is inappropriate and potentially
dangerous and that you will have to inform the General Medical
Council (GMC).
D Take a history from your friend over the phone, relaying chis to your GP
trainer, who can telephone him back lacer.
E Prescribe some ibuprofen and paracetamol for your friend and tell him to
rake his wife to the local emergency department.

1.79 Newspaper cutting of colleague

You arc an FYl doctor on annual leave, and you are reading your local news-
paper. You read an article about an assault in the city centre earlier that year,
and you are shocked co see char your FYl colleague was involved and has been
charged with assault. You are unsure whether anyone else ac the hospital is
aware of chis incident as your colleague hasn't mentioned it.
Rank in order the following actions in response ro this situation (1 = Mose
appropriate; 5 = Lease appropriate).

A Approach your colleague privately asking him about the incident.

B Ignore the issue as your colleague has always been pleasant and friendly in
your experience.
C Inform the General Medical Council (GMC) immediately of the situation.
D Take the article into work and confront your colleague during the next
ward round.
E Wait and see if he is found guilty of the offence before raising the issue.
 Questions 37

1.80 Phony thank you's

It is coming to the end of your FY1 year, and you are updating your CV. You
realise that you have very little feedback from patients about your care to
incorporate, and many of your colleagues are in the same position. One of your
colleagues suggests that you all write fake thank you letters from patients for
each other so you can boost your CYs.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Report your colleague to the General Medical Council (GMC) for attempt-
ing to lie on their CY.
B Decline to be involved in writing the letters.
C Speak to your educational supervisor about how to boost your CV
honestly.
D Write and receive some fake thank you letters.
E Advise your colleagues against doing this as the GMC may rake serious
action if they were aware of this.

1.81 Sexism

You are working in general medicine with a female FY 1 colleague. You have
always been pleased with the way your consultant treats you, and you think he
is supportive and encouraging; however, you notice that he does nor behave in
the same way with your female colleague. He has attempted to joke with you in
the past about her poor career prospects because she will have children in rhe
future and often remarks to her that medicine is 'not a woman's job'.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Speak with your consultant privately ro discuss his sexist behaviour.
B Speak with another consultant in the team about your consultant's
behaviour.
C Encourage your colleague to raise this issue with the British Medical
Association (BMA).
D Advise your colleague to avoid the consultant and keep a low profile until
the end of the rotation.
E Discuss your consultant's behaviour with your educational supervisor,
including whether and how to report this issue.

1.82 Breast exam

You are clerking in a patient who is complaining of lower back pain and
intermittent paraesthesia in both her legs, when she also discloses the fact that
she has noticed a lump in her left breast, which has been there for quite a few
months. You think it is necessary to perform a breast examination in addition
to arranging an MRI of her spine.
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38 Chapter 1: Commitment to Professionalism

Rank in order rhe following actions in response to this situation (1 = Most

appropriate; 5 = Least appropriate).

A Ask the patient co remove the clothing on her top half so that you can
examine her breasts.
B Find a suitable chaperone for a breast examination.
C Don't examine the breasts during rhe clerking and leave ir for your senior
house officer (SHO) co do rhe following day.
D Document the examination, the lack of chaperone present and your findings.
E Gain consent to perform a breast examination, explaining the procedure
and the reasons why you think it is necessary.

1.83 Doctor harassing nurse

You have finished the jobs on your ward and are about to go and get some
lunch. As you pass the corridor to the doctors' office you notice one of your
fYl colleagues with his arm around a nurse, whispering in her ear. She doesn't
look comfortable with the situation, and when she secs you, she immediately
runs back co the ward.
Choose the THREE most appropriate actions to rake in this situation.

A Ask your educational supervisor in confidence for advice.

B Find an appropriate rime later in the day co ask the nurse whether she
would like co talk in private.
C Follow the nurse back ro the ward and demand char she cell you what is
going on between her and the ocher FY 1.
D Ignore the situation and walk on to gee lunch.
E Politely ask your FYl colleague what is going on and give him a chance co
explain his actions.
F Report your FY 1 colleague co his educational supervisor.
G Tell the rest of your colleagues what you saw, at the ward parry that eve-
ning, and ask what you should do.
H Tell your FY 1 colleague char his behaviour is inappropriate and that you
are going co report him.

1.84 Embarrassing colleague photos

You have just returned co work after annual leave and are catching up with
your FYl colleague. She is boasting about the fact that on New Year's Eve she
got so drunk at a parry that she ended up running along her street naked with
some friends. She then proceeds ro show you the photos on her online social
media profile.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Refuse to comment and leave the room, feeling quite sick.

B Make the other staff on the ward aware of the photos.
 Questions 39

C Suggest that she takes the photos off her online profile as she doesn't know
which coll.eagues or potential patients might be able to see them.
D Recommend that your colleague reads the guidance on the use of social
media among doctors from the General Medical Council (GMC).
E Seek advice from your senior house officer (SHO) about whether you
should say anything about her behaviour.

1.85 Patient-doctor relationship

You are working on a respiratory firm, and you have noticed that one of the
female patients on your ward has been asking a lot about your male FYI col-
league. He has spent a lot of time treating her, but you are a little concerned
that this patient may have developed a romantic attachment ro him.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Tell your colleague that he should ask the patient out for a date when she is
discharged as you suspect that she likes him.
B Voice your concerns to your colleague in private and suggest that he talks
ro the patient.
C Tell the patient that it would be unprofessional of your colleague to pursue
a relationship with a patient.
D Ask your colleague if he feels any attraction towards this particular patient.
E Tell your senior house officer (SHO) that the patient likes your colleague
and ask for advice about what ro do.

1.86 Gynaecology complaints

You are an FYl working in gynaecology. You go to see one of the post-operative
patients who needs some bloods checking. She had her procedure done under
regional anaesthetic and mentions that during the procedure she heard the consul-
tant make a comment to the registrar about her personal hygiene which upset her.
Choose rhe THREE most appropriate actions to rake in this situation.
A Ask one of the nursing staff to talk ro the patient.
B Contact the consultant and let them know what the patient heard.
C Discuss with the patient what was said and how she feels.
D Leave the matter; you weren't there, so you cannot comment.
E Mention the matter to the registrar when you next sec them.
F Raise this matter at the next team mortality and morbidity (M&M) meeting.
G Recommend that if she was upset, she should make a formal complaint.
H Tell the patient that she must be mistaken as this would not happen.

1.87 Alcohol and misdemeanours

You are an FYl working in a district general hospital. At several social events
one of your FYl colleagues has become very intoxicated, which has led to
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40 Chapter 1: Commitment to Professionalism

some inappropriate behaviour in public. They recently urinated in a side-street

and narrowly avoided being caught by the police. You arc not aware of any
instances where they have been intoxicated or hungover at work.
Choose the THREE most appropriate actions to take in this situation.

A Contact the General Medical Council (GMC).

B Discuss your concerns with the other FY ls.
C Explain to your colleague that they need to be careful about how they
behave, even outside work.
D Inform their educational supervisor of your concerns.
E Inform the programme director of your concerns.
F Keep track of how much the FYl drinks at the next social event.
G Take the FYl somewhere quiet and private to discuss the matter.
H Tell them that their recent behaviour is unacceptable.

1.88 Sexist consultant

You arc the FY 1 on a surgical ward. One of your consultants has a tendency to
make comments about female members of staff, including remarks about their
appearance. These comments sometimes include statements about the size of
their bottoms or breasts. He frequently remarks that women aren't capable of
achieving as much as men.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Speak to your educational supervisor about your concerns.

B Ignore the comments.
C Ask one of the other consultants on the ward to speak to the consultant
about his behaviour.
D Next time he makes a comment on the ward, respond by telling him that it
is inappropriate.
E Contact the General Medical Council (GMC) about his behaviour.

1.89 Inappropriate comments in mortuary

You are working as an FYl doctor in a busy teaching hospital, and you are
attending the mortuary to see one of your patients who has sadly passed away.
As you are identifying the body, you overhear a conversation between a fellow
FYl doctor and a member of the mortuary staff. You can't hear the whole
conversation, but you do hear the doctor referring to the patient as 'really fat'
and 'too big for the freezer'.
Choose the THREE most appropriate actions to take in this situation.

A Ask the mortuary staff member afterwards if he had any concerns about
the situation and discuss this with the doctor involved.
B Ask your senior colleagues for advice without mentioning your colleague's
name.
 Questions 41 •

C Complete an incident form on the situation.

D Discuss your concerns with rhe FYl suggesting that his comments were
inappropriate.
E Ignore the comments as they have not caused harm co anyone.
F Raise the situation at the weekly FY 1 teaching programme asking your col-
league co explain why he made his comments.
G Report rhe situation to the consultant in charge of rhe foundation
programme in rhe hospital.
H Write a letter to the patients' family explaining the situation and apologise
for any offence caused.

1.90 Recommending illegal substances

You are working as an FY2 doctor in a GP surgery and are seeing a patient
with motor neurone disease. She cells you chat as part of her disease she has
been experiencing severe pain in her legs. After discussing the situation further,
she tells you that she has read information online suggesting chat cannabis
could help with her pain. She wanes co know your advice on caking cannabis
for medicinal purposes.
Rank in order the following actions in response to chis situation ( L = Mose
appropriate; 5 = Lease appropriate).
A Ask the patient to book a further consultation with yourself and seek
advice from your educational supervisor in rhe meantime.
B Inform your patient rhar cannabis is illegal and refuse ro discuss rhe situa-
tion fu rrher.
C Outline the risks and benefits of cannabis, cell her rhar you have heard
of ocher patients who have beneficted from cannabis and suggest chat she
could cry it for her pain.
D Suggest that the patient shouldn't cry cannabis and offer alternative advice
and medications for her pain.
E Tell the patient you will book her into a pain control clinic and that she
should wait until then for further advice.

1.91 Smart phone pictures

You are working as an FY2 doctor in an emergency department, and you are
seeing a patient who has been involved in a road traffic accident. He has a
large laceration to rhe outside of his leg which needs to be seen by a plastic
surgeon. The plastic surgery department is located within another hospital in
the same city, and the patient will need co be transferred. You telephone the
plastic surgery registrar on call at the hospital who accepts your referral. She
rhen asks you ro cake a photo of the injury using your smart phone and send
ir as a message to rhem so char they can begin to plan the operation. You have
seen other doctors doing this, but you are unsure whether rhis is the correct
practice. The nurses inform you that rhey are going to dress the wound and ask
you to make a decision.
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42 Chapter 1: Commitment to Professionalism

Rank in order the following actions in response to chis situation (1 = Most

appropriate; 5 = Least appropriate).

A Ask the hospital photographer to take photographs urgently so that they

can be era nsfcrrcd with the patient.
B Ask the nurse not to dress the wound, leaving it open, so the plastic
surgeon can see the wound on arrival.
C Refuse to take the image and ask the nurses to dress the wound ready for
transfer.
D Take the photo and send it ro the registrar via your smart phone asking
them to delete the image immediately after they have seen it.
E Take a photo using your smart phone and email it on the secure server ro
the surgeon, then delete the photo from your phone.

1.92 Gift

You are an FYl working on a care of the elderly ward. A patient of yours is
discharged following a long hospital stay. The patient's family is extremely
happy and graceful for the care that they have received. They give you a card
expressing their thanks and a £20 note enclosed as a gift.
Rank in order the following actions in response ro this situation ( 1 = Most
appropriate; 5 = Least appropriate).

A Ask them to donate money ro your chosen chariry instead.

B Accept the card but not the gift.
C Thank them and accept the gift.
D Accept neither the card nor the gift.
E Ask the family to take you out for a meal instead.

1.93 Termination of pregnancy

While working as an FY2 in a GP surgery, a female patient attends your clinic

and says that she would like to end her pregnancy. For both religious and per-
sonal reasons, you object to termination of pregnancy (TOP).
Choose the THREE most appropriate actions ro take in this situation.

A Advise her to take alternative options, such as adoption.

B Arrange for her to see another GP at the practice who does not object to
TOP.
C Ask her to cake another week to consider her options.
D Discuss her reasons why she would like a TOP.
E Explain that TOP goes against your personal beliefs.
F Give her a patient information leaflet about TOP.
G Refuse ro refer her to a TOP service.
H Sign the abortion certificate and make the referral to TOP services.
 Questions 43

1.94 Aggressive patient

You are leaving work one evening when you see someone dressed in a hospital
gown behaving strangely in the car park. He is hitting cars, talking to himself
and being aggressive to passers-by. You see him cry to punch someone who
approaches him.
Choose the THREE most appropriate actions co rake in this situation.

A Approach the patient and attempt co calm him down.

B Ask chose nearby to help you restrain the patient.
C Call 999 and ask for police assistance.
D Call the hospital security ream.
E Call the psychiatric team co come and review the patient.
F Continue walking to your car since your shift has now finished.
G Stop ochers attempting to approach the patient.
H Tell the patient to stop damaging the cars.

1.95 Racist comments

You walk into the doctors' office and overhear two registrars making racist
comments about a consultant who works in your department. They turn to you
and ask for your opinion.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask your educational supervisor for advice.
B Explain to the registrars that you find their comments inappropriate.
C Inform the consultant about the comments that have been made.
D Offer no opinion and change the topic of conversation.
E Prim our some General Medical Council (GMC) information regard-
ing equality and diversity and pin it up in the doctors' office for future
reference.

1.96 Child protection

You are caring for a 15-year-old patient who has been admitted with a
suspected fractured elbow. You notice char over the past two years he has also
had admissions for a broken wrist, broken ribs, lacerations, burns and minor
head injuries. He confides in you that he is being bullied in school, and the
bullies are responsible for his injuries. He does not wish you to tell his parents
because they will remove him from the school, and he is just about to sir for his
exams and wants to do well enough to go to college.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Don't tell the parents: he is old enough to understand the risks of returning
to school with violent bullies and can make this decision himself.
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44 Chapter 1: Commitment to Professionalism

B Encourage him to raise this issue with his parents and offer to be there
during the conversation for moral support.
C Raise the issue with your designated doctor for child protection.
D Call the police: these are serious cases of assault and need to be reported.
E Call social services to discuss the issue with chem and request some input
from them regarding his school.

1.97 Relationships

Your rotation as an FY1 on a urology ward is drawing to a close. One of your

patients has been admitted on the ward for the entirety of your job and has
required a lot of treatment, including carheterisarion and intimate examina-
tions by yourself. You and the patient have bonded well; they are of similar age
as yourself, and you have enjoyed friendly and easy conversation with them
on the ward. When you inform them of your departure, they thank you for all
your help, pass you their phone number and ask you to call them when you are
free for a date as you are now no longer their doctor.
Choose the THREE most appropriate actions ro rake in this situation.
A Accept the phone number bur write in the notes that you have destroyed ir
and have no intentions of pursuing a personal relationship.
B Accept the phone number graciously bur never call the patient and avoid
any situation that you might run into them.
C Accept the phone number since you were hoping to write up their case for
publication and you think they are more likely to agree if you accept their
number.
D Accept rhe phone number ro save the patient's feelings but inform your
registrar of the situation and your intentions never to call.
E Accept the phone number with the intention of calling; it is difficult to meet
potential partners with your shift pattern after all.
F Reject the phone number, explaining that it is unprofessional and could get
you into a lot of trouble with the General Medical Council (GMC).
G Reject the phone number, explaining that you have enjoyed the professional
bond with the patient but that, for the protection of both them and you,
you cannot accept.
H Reject the phone number, explaining that your relationship was always
professional and that they must have been confused during their illness to
think otherwise.

1.98 Colleague missing teaching

You are an FYI attending a mandatory training day in another hospital. You
notice that your FYl colleague who works on the same ward as you is not pres-
ent despite being timetabled to be there. Between sessions, you overhear some
people saying that he wenr out drinking last night and had called them to say
that he was too hungover to attend training today.
r
Questions 45

Rank in order rhe following actions in response ro rhis siruarion (1 = Mosr

appropriate; 5 = Leasr appropriate).
A Tell rhe programme director for che day char your colleague is nor here
because he is too hungover.
B Seek advice from your friend, another FY l at rhe training day.
C Ring up your colleague for an explanation as to why he isn't at rhe
training.
D Tell everyone ar the training that he is skiving that day because he can't
handle his drink.
E Ring your colleague and say that he should rry and come in for rhe after-
noon lectures.

1.99 Prescribing error

You are in the middle of a week on call on a busy ear, nose and throat (ENT)
ward and have just arrived on the ward ro prepare the patient list for the ward
round. Your specialist registrar (SpR) approaches you and asks whether you
clerked in a woman yesterday with a sore throat. He says that she was pre-
scribed amoxicillin and has since come out in a florid rash. You remember rhar
you did see chis parienc just before you lefr lasr night, but you are sure char she
didn't have any allergies.
Rank in order rhe following actions in response ro rhis situation (1 = Mosr
appropriate; 5 = Least appropriate).

A Apologise ro the patient for your mistake and reassure them thar ir won't
happen again.
B Tell the nurses nor to continue the course of amoxicillin.
C Deny knowledge of chis patient ro your SpR bur cross our the amoxicillin
on rhe drug chart.
D Admit the mistake and ensure rhar the antibiotic is crossed off the drug
chart.
E Inform your consultant that you made an error.

1.100 Receiving a gift

You are the FYl on an endocrine ward and have been looking after a parienr
who has undergone surgery for papillary thyroid cancer. She is due ro be going
home roday, but before she leaves she hands you an envelope with a cheque and
says 'thank you for bending over backwards to make sure l received the best
care possible'.
Rank in order the following actions in response to this situation (I = Most
appropriate; 5 = Least appropriate).
A Accept the gift gracefully and share it among the team looking after her.
B Ask the patient to donate it to the hospital charity.
C Accept the money and offer to rake the patient out for a meal with rhe money.
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46 Chapter 1: Commitment to Professionalism

D Decline the money saying that you appreciate the gesture, but you are not
able to accept it.
E Accept the money and let your educational supervisor know about the gift.

1.101 Colleague's appearance

You work with an FY2 who consistently arrives at work wearing stained
clothes which don't seem to have been ironed for some time. The nursing staff
have been commenting on his appearance.
Choose the THREE most appropriate actions to take in this situation.

AAsk the sister on the ward to say something to him.

BAsk your fellow FY ls if they have noticed anything.
CDiscuss the matter further with the nursing staff.
DLeave the matter; how he chooses to dress is up to him.
ELet the consultant know the nursing staff's opinions.
FMake sure that the FY2 is well and not struggling in any way.
GSuggest to the nursing staff that, if this is something they have noticed,
they should let the fY2 know.
H Tell the FY2 that the way he dresses does not seem appropriate for a doctor.

1.102 Keeping promises

You are busy on call one evening and have a long list of jobs ro complete. You
see a patient and decide that she requires a blood test to help clarify her clinical
picture. The patient is very anxious about the results of the test and asks you if
you will let her know the results of the test as soon as they are back, which you
promise to do. However, on walking home you realise that you handed over
that task to your colleague taking over after your shift, and you are nor aware
of the result yourself.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Call the nighttime FYI and ask them to communicate the results to the
patient.
B Go and see the patient with her results first thing in the morning. Apologise
for not informing her of the results earlier and explain co her what they mean.
C Go and see the patient with the results the following day and say that they
have only just come back that morning.
D Turn back, check the results and let the patient know.
E You have handed over the job, therefore it is no longer your responsibility.

1.103 Hungover

You are the FYl working on an acute medical ward. You are out having a few
drinks with friends on a Friday night when you receive a text from a colleague
 Questions 47

reminding you that you are covering their on-call shifr the next day. You had
agreed to this several weeks before as your colleague is going to a wedding.
You have already had a bit too much alcohol and are worried that you will be
significantly hungover the next morning.
Rank in order the following actions in response to rhis situation ( l = Mosr
appropriate; 5 = Least appropriate).
A Stay our with your friends and call in sick in the morning.
B Go home immediately, have a glass of water, go to bed and go to work the
next day.
C Explain to your colleague that you forgot and can no longer work in the
morning, apologising profusely.
D Go home, have a glass of water, go ro bed and call in sick rhe next day if
you don't feel capable of working.
E Contact the resr of your fellow FY ls asking if anyone could work
tomorrow at late notice, and if nobody can then inform your colleague that
they will have to work, apologising profusely.

1.104 Train late

You are an FY1 on a medical ward, who is expected to be at work on Monday

morning. You have been away for the weekend visiting family. You decided
ro take an early train back on Monday morning because it was your father's
birthday on Sunday and you wanted to stay for dinner. Unfortunately, the train
breaks down halfway through your journey. It is unclear how long the delay is
going co be. There arc other FY ls who will also be working on the ream today.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Apologise when you arrive at the hospital and explain why you are late.
B Call the hospital and ask ro be put through ro the registrar on call for your
team, and tell them that you are sick and cannot come to work roday.
C Call the hospital and ask to be put through to the registrar on call for your
ream, and explain the situation to them.
D Email your clinical supervisor explaining the situation.
E Call one of your FY 1 colleagues and explain the situation, asking them to
relay the information at the morning handover meeting.

1.105 E-learning certificate plagiarism

You are working on your first rotation as an FYl doctor in a busy teaching
hospital. As part of your induction programme, you are required to complete a
set of e-learning modules covering various topics ranging from anticoagulation
to the use of insulin. You have completed all the modules and uploaded your
certificates ro your e-portfolio. The night before the deadline a close friend of
yours, who is also an FY] colleague in the same hospital, telephones you say-
ing that he can't complete a module covering equality and diversity because his
 48 Chapter 1: Commitment to Professionalism

laptop has broken. He asks if he can have a copy of your certificate, which he
will edit and upload to his e-portfolio. He promises that he will complete the
module in the next week and re-upload his genuine certificate.
Choose the THREE most appropriate actions to rake in this situation.
A Allow him to have a copy of your certificate as this will not affect patient
safety and ask to see his genuine certificate when he has completed the
module.
B Contact a senior colleague to ask him what you should do.
C Ignore his request and inform your friend's educational supervisor of his
attempted plagiarism.
D Reprimand your colleague for not completing the module earlier and refuse
to help him.
E Suggest that he attends work early in the morning to complete the module
before his ward round srarrs,
F Suggest that he can leave the module as you didn't learn anything useful
from ic.
G Suggest that he comes over to use your laptop to complete the module.
H Suggest that he contacts the foundation programme director asking for an
extension to the deadline.

1.106 Illegible colleague signature

You are working as an FY 1 doctor in a district general hospital and are com-
pleting your gastroenrerology rotation. While finishing your ward rounds with
the senior house officer (SHO), }'OU notice that they have nor been document-
ing their name after their entries in the medical notes. Instead, the SHO has
been entering a short, illegible signature which cannot be identified easily.
Rank in order the following actions in response co this situation (1 = Most
appropriate; 5 = Least appropriate).
A Contact human resources and ask them if they can produce a rubber stamp
that your colleague could use to document his details in the notes.
B Offer to carry out all the writing on the ward rounds.
C Suggest to your colleague that he completes his entries with his full name
and GMC number clearly legible as well as his signature.
D Suggest to your colleague that he acquires a rubber stamp with his derails
so he can clearly documenr his details in the notes.
E Write your colleague's derails in the notes after his name so that he can be
clearly idemi fied.

1.107 Diarrhoea and vomiting

You are an FYl doing a rotation in general surgery. It is the evening before a
weekend on call, and you start co develop diarrhoea and vomiting.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
 Questions 49

A Go into work bur don't carry our any tasks involving patient conracr.
B Call into work the next morning to say you won't be able to go in to work.
C Take some medication to prevent diarrhoea, such as loperamide, and go in
to work, making sure that you have excellent hand hygiene.
D Call into work in the evening, informing them that you will nor be able to
go to work the next day.
E Inform the Health Protection Agency (HPA).

1.108 Prescribing for a friend

You are an FY2, and your housemate asks you to prescribe an antibiotic for her
urinary tract infection (UTI). She has had these a few times before and usually
requires a short course of antibiotics to clear it up. Ir is Friday evening, and the
local out-of-hours centre is about to close.
Choose the THREE most appropriate actions to take in this situation.
A Advise her to drink plenty of fluids and cranberry juice.
B Gain a more thorough history of her presenting complaint.
C Give her the antibiotic prescription and inform her GP on Monday.
D Prescribe the antibiotic.
E Refuse to prescribe the antibiotic.
F Take a sample of her urine to the hospital laboratories.
G Take her to the emergency department.
H Tell her to make an appointment to see her GP on Monday.

1.109 Dress code

You have been working in a medical team for three months. You have noticed
that your fellow FY l has started wearing jeans to work. You do not feel that
she looks as smart as the rest of the team.
Rank in order the following actions in response ro this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask the ocher junior members of your ream what they think about your
colleague's clothes.
B Do nothing since she is entitled co wear what she likes to work.
C Start wearing jeans too since they are more comfortable than your smart
trousers.
D Suggest to your colleague privately that she would look smarter in some-
thing other than jeans.
E Tell your consultant that you do not chink that your colleague looks as
smart as the rest of the ream.

1.110 Other commitments

You are an FYl dedicated t0 a career in academic medicine. You have

spent the last year working on a research project that has yielded promis-
ing results. You and your supervisor wish to submit the work to a specialist
 50 Chapter 1: Commitment to Professionalism

conference for presentation. The deadline for submissions is sooner than

you thought, and you only have one day co complete rhe data analy-
sis and abstract, which you estimate will take eight hours co complete.
Unfortunately, you are working a 13-hour shift both today and tomorrow as
part of your on-call rota.
Choose the THREE most appropriate actions co rake in chis situation.
A Ask your supervisor to complete the data analysis and just do the abstract
yourself.
B Call in sick for tomorrow's shift so that you have time to do the work.
C Don't submit to the conference; your job rakes precedence.
D Go into work but turn off your bleep and sit in the doctors' office to com-
plete your work.
E Make up the rest of the data for your study and submit on time.
F Speak to your registrar about having a few hours off in the morning to
complete your work so you can work and sleep.
G Try and swap shifts last minute with another FYI on rhe same on-call rota.
H Work through the night in between your Jong shifts co gee the work
completed.

1.111 Domestic violence

You are working as an FYl in orthopaedics. You clerk in a 19-year-old woman

with a broken arm. She cells you that it was an accidental injury, but from the
bruising on her face and arms, you suspect that she may have been attacked.
When you ask her about it, she admits that her boyfriend hit her and has done
so on numerous occasions. She asks you not to tell the police because he has
promised never to do ir again.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Contact the police without informing the patient chat you are doing so.
B Encourage the patient to let you contact the police.
C Explain co the patient that you are concerned about her welfare and there-
fore intend to conracc rhe police without her consent.
D Give the patient a lea flee about a charity char supports victims of domestic
violence.
E Tell the patient that you will not contact the police without her consent.

1.112 Patient discrimination

You have just arrived on the ward and are preparing the patient list ready
for the consultant's ward round. One of the staff nurses approaches you and
wanes to ralk about the other FYl on your ward. She overheard him yesterday
making derogatory comments about one of your patients co another colleague.
She says he was saying that che patient could 'wait for his analgesia to be
 Questions 51

prescribed as he doesn't belong in this country and can wait for his rum to gee
treatment'.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Tell the nurse that she should speak directly co the fY l in question.
B Report the incident to the FYl's educational supervisor.
C Speak to your senior house officer (SHO) about the nurse's concerns and
ask for their advice.
D Speak direccly co rhe FYl in question about the nurse's concerns.
E Ask rhe patient whether he had any concerns over the treatment he received
yesterday.

1.113 Criticising collegues on hearsay

You are working on the medical admissions unit (MAU) and are at the nurses'
station chasing bloods whilst your FY 1 colleague is clerking a patient. The
patient is complaining char the doctor in accident and emergency (A&E) rook
a long time to come and sec her and then kept disappearing to answer his
phone whilst in the middle of the consultation. Your colleague apologises for
the patient's wait and then remarks chat the A&E docror 'has a reputation for
being slapdash' and that he agrees it is 'very unprofessional, and in my view, he
should be suspended'.
Choose the THREE most appropriate actions co rake in chis situation.
A Ask co speak to your colleague when he has finished the consultation.
B Ask your colleague co go back co the patient and apologise for what he has
said about the doctor in A&E.
C Don't do anything about the comments bur keep an ear our for any similar
remarks he makes about colleagues.
D Explain ro your colleague chat it is not professional co disseminate adverse
information about a colleague, especially to patients, even if it may be true.
E Interrupt the consultation to have a word with the FY] in private.
F Report the FY l ro the sister in charge.
G Speak to your educational supervisor.
H Tell the doccor in A&E chat the FYl is spreading rumours about him.
 - ------,
52 Chapter 1: Commitment to Professionalism I

ANSWERS
1.1 Relationships

A E C B D
Patients need trust in their doctors and must be able to act honestly and
openly without feeling that the doctor may see them as a potential partner.
It is therefore unacceptable to pursue a relationship with a current patient,
as in option D. Relationships with former patients are often inappropriate,
but this depends on a number of factors including the length of time elapsed
since attending the patient. In the case of option B, only a short time will
have elapsed between the patient's discharge and the start of your potential
relationship. More importantly, however, you would already be engaging in a
relationship while they remain in hospital since there is the promise of arrang-
ing a date. While option C may seem a less awkward way of dealing with the
siruation and avoids a relationship, you must not allow the patient's advances
to affect your doctor-patient relationship. If you were to feel that a patient's
advance had affected the doctor-patient relationship, then you should bring
the professional relationship to a definite end rather than simply avoiding
the patient. Option E again avoids a relationship but would risk offending
your the patient, therefore compromising the doctor-patient relationship.
Diplomatically declining the offer (A) is the best option since it is most likely to
preserve a good professional relationship.

Recommended reading
General Medical Council (2013), Explanatory guidance, in Ending Your
Professional Relationship with a Patient.
General Medical Council (2013), Explanatory guidance, in Maintaining a
Professional Boundary Between You and Your Patient.
General Medical Council (2013), Good Medical Practice, paragraphs 53, 62.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 5, Morality and decency.

1.2 Police caution

B D G
There is a legal and professional obligation to declare all criminal investiga-
tions, cautions or convictions to both the GMC and your employer without
delay (options D and G). In this case, it is unlikely that there will be any seri-
ous consequences for stealing a garden gnome; however, failing to disclose
this information may have dire consequences, even the loss of your profes-
sional registration. Since there are potentially serious consequences to this
situation, it would be prudent to seek further advice. A lawyer may be able
to give advice (A), but a medical defence union (B) is a specialist organisa-
tion and would therefore be a better first step. If you do try and overturn the
r---
Answers 53

caution (C), your first action should still be to declare the caution and seek
advice since it has already been issued to you and is unlikely to be rescinded.
Ignoring the issue (f) and delaying further action (H) are both inappropriate
since you need co act without delay. While it is important co reflect on the inci-
dent (E), this is not your immediate priority.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 68, 75.
General Medical Council (2013), Guidance on Convictions, Cautions and
Determinations.

1.3 Gifts

D B E C A
The issue of doctors accepting gifts from patients is a difficult one and often
dependent on the nature of the gift. Intimate gifts such as lingerie are clearly
inappropriate, cash gifts are generally viewed as unacceptable and expensive
gifts should either be declined or registered with your employer. Expense is
dependent on the patient's means although gifts worth in excess of £100 should
usually be declined or declared. Whatever the circumstances, the receipt of a
gift should not be seen to affect a patient's treatment. Option A is therefore the
least appropriate response. Declining gifts can also be problematic as it may
cause offence. The most appropriate response is therefore option D since it is
clear that the gift does not affect the care of the patient but it shows gratitude.
While option B avoids causing offence, the gifts were nor offered with the
intention that you should give them away. Option£ may be appropriate
although it has the potential to cause unnecessary disappointment or offence.
In the case of option C, it would be rude to decline the gift based on your dis-
like of champagne.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 80.
Medical Protection Society (2011), GP Registrar: How to be Good, pages 6-7.

1.4 Facebook

D C A B E
Doctors are entitled to a personal life; however, they must maintain a level
of professionalism. The currently accepted standards are ill defined, but the
public needs to have confidence in both the individual and the profession.
Doctors should consider that content uploaded onto social media may influence
public confidence. In this scenario, it would be prudent to remove potentially
damaging images from social media websites, and doctors are encouraged to
review their privacy settings regularly. Option D is therefore the best response.
Altering your privacy settings without removing the images (C) leaves the
potential for your images to be viewed by people who may be adversely influ-
enced, given that social media websites cannot guarantee complete privacy.
 54 Chapter 1: Commitment to Professionalism

While refraining from the use of social media (A) would remove all risk to pro-
fessional image, you should be allowed to take advantage of its benefits should
you wish to. This is therefore a valid but less favourable solution. Options B
and E may damage working relationships with your colleagues, and neither
addresses the issue of professionalism.

Recommended reading
British Medical Association (2011 ), Using Social Media: Practical and Ethical
Guidance for Doctors and Medical Students.
General Medical Council (2013), Good Medical Practice, paragraph 65.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 12, Personal conduct.

1.5 Documenting

B E H
In this situation, regardless of your worries about whether you have potentially
made a mistake or not, it is important to correct this as soon as possible. It
is therefore appropriate to carry out the recommended investigations and
treatment without delay (E). It would be prudent to ask the registrar to review
the patient with you (B) since you were initially unsure of how to manage the
patient and they have now deteriorated further. Documenting events in the
notes is a crucial parr of being a doctor, especially since the medical notes
constitute a legal document. Ir is therefore important co clearly and accurately
document what has happened in this situation (H). You should never destroy
any part of a patient's notes (G) or obscure entries within rhe notes {C).
Similarly, you should never alter a previous entry (options A and D). Option D
is actually deceptive. Option A, while preferable to option D since you would
be acknowledging that the management plan was formulated by your registrar
and adding in a true account of your discussion with him, is still factually
misleading as it will appear that this discussion took place at an earlier time.
It would be useful co reflect on this case (F), but chis is not something of
immediate importance.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 19-21.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, Chapter 6, Honesty.

1.6 Friend's test results

A E F
As a doctor you will find that friends and family will regularly confide in you
about their medical problems and ask you for information. In this scenario, you
should tell your friend that you cannot access her results for her (E), advise her
to get the results from the doctor who requested the tests (A) and talk to her
about her concerns (F). The General Medical Council (GMC) warns against
 Answers 55

treating family and close friends for many reasons, including emotional involve-
ment and thus a lack of objectivity; patients receiving care outside a practice set-
ting may not receive the same standard of care, and doctors may not feel able to
ask sensitive questions or conduct intimate examinations on friends or relatives.
You shou Id not access the results (B) or get a colleague to access them for
you (C). Both of these options would be unprofessional as you should never
access the results of patients not directly under your care. By accessing your
friend's results, you are actively getting involved in your friend's management.
Asking someone else to access them for you would be dishonest and may get
them in trouble as well. Giving her a patient information leaflet (0) may be
appropriate, but in the first instance, you should talk to her about her concerns.
Telling her that the results arc likely to be normal (G) would be inappropriate
as you have not ordered the test and you may not be completely aware of your
friend's medical history. Telling her that you don't have a duty of care to her as
you are not her doctor (H) is unnecessarily harsh; instead, it would be better to
say that she should discuss it with the doctor who ordered the tests.

Recommended reading
General Medical Council (August 2011 ), The Development of Good Medical
Practice, Treating family members.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 6, Honesty.

1.7 Lying about results

A B E
An underlying principle in our healthcare system is the need for honesty and
transparency. In this situation, if you respond with anything but honesty, it
is likely that there will be negative repercussions. Blood results are now very
rarely confirmed by letter; however, many other inter-professional communica-
tions within medicine are still done in paper form. In this scenario, you have
made an honest mistake. The most appropriate course of action is to apologise
to the patient (A) and make every effort co resolve the situation. This could
be achieved by phoning the hospital for the results (E) or asking the practice
nurse to retake the blood tests (B). Both of these options retain honesty while
protecting patient safety. Although option D could be seen as a 'white lie' that
is unlikely to harm the patient, dishonesty in any guise should be discouraged.
CancelJing the appointment and sending a letter (C) may provide the patient
with the results; however, a diabetic review requires a range of other questions
and examinations such as checking for peripheral neuropathy. Transferring the
issue to another GP (H) would be just delaying the issue and is likely to affect
your professional relationship with your colleague. Perhaps the most danger-
ous option here is to reassure your patient without knowing the results (F); you
may find it difficult to take a step back if the results are not what you expected.
The excuse of 'lost in the system' is counterproductive in all scenarios, and in
this case, it would also be a lie and is therefore inappropriate (G).
 56 Chapter 1: Commitment to Professionalism

Recommended reading
General Medical Council (2013), Good Medical Practice, Duties of a doctor.
General Medical Council (2013), Good Medical Practice, paragraphs 1, 63.

1.8 lying about experience

C B A D E
It is the nature of learning a new skill that there will always be a first time
to complete a procedure. As a foundation doctor you are allowed co perform
procedures such as lumbar punctures, pleural drains and ascitic drains, as well
as rhe core procedures required by the foundation programme curriculum, as
long as you have had the relevant teaching and training and have appropriate
supervision. When completing any procedure, you may often be asked by the
patient whether or nor you have performed it before. It is always essential to be
honest with your patient and the General Medical Council makes it very clear
that every doctor should maintain integrity and honesty with their patients and
colleagues. Option C would allow you to be honest with the patient, while also
offering chem reassurance of the fact chat you will be supervised during the
procedure and maintaining the learning opportunity for yourself. The patient
may also be reassured after an explanation from a more senior and experienced
doctor, so asking rhe medical registrar to explain the situation could also be
helpful (B). Asking the registrar to carry ouc the procedure (A) will ensure that
an experienced doctor is performing the task; however, this would remove
the opportunity for your own learning and development. Option E ranks last
because lying to your patient is completely unacceptable, and this response
would display a disregard for patient autonomy. Option D involves an omission
of the truth, which, although preferable to lying outright to the patient, is still
misleading and therefore also inappropriate.

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together, paragraphs 3, 10, 12.

1.9 Honesty on death certificates

D F H
Completing death certificates is a common task for FYl doctors and a
potentially difficult one. The death certificate is a legal document, and you
must comply with the specific rules and regulations on how they should be
completed. For the majority of certificates, the cause of death and the events
leading to the death are obvious and can be completed without discussion
with the coroner. However, in this scenario, you have no identifiable cause for
the gastrointestinal bleed in a patient who was otherwise healthy. The most
appropriate course of action would be to actively seek advice from profession-
als experienced in the area. This could be your registrar or consultant (H) or a
pathologist or coroner (F). There may also be other aspects in the patient's his-
tory that you are unaware of which could explain his gastrointestinal bleed (D).
 Answers 57

Completing rhe cause of death as gastrointestinal bleed without giving causes

or risk factors that led to the bleed (B) may not be accepted by the coroner.
This would lead to unnecessary delay for the patient's family. Completing the
death certificate dishonestly by declaring he had a peptic ulcer without investi-
gating this (C) would be wholly inappropriate. Asking your colleague to com-
plete the certificate without attempting co seek advice first (A) would be passing
off the problem onto somebody else, whereas this is something you should cry
to resolve first, and you may be able to learn from this scenario in the future.
Giving non-specific information to the family (E) would be incredibly damag-
ing during times of great distress around a death. While the secretarial staff
may offer solutions to practical problems, this is a medical issue that needs to
be sorted with professional help, so asking them here is not appropriate (G).

Recommended reading
Office for National Statistics (2010), Guidance for Doctors Completing Medical
Certificates of Cause of Death in England and Wales, section 5, How to
complete the cause of death section.

1.10 Insurance fraud

B C D A E
Insurance fraud is a criminal offence and once you are aware of it you have an
obligation to report it to the police (B) because you are bound by the profes-
sional values of being a doctor. Informing the GMC (C) is not the best option
since they are not the most appropriate body to investigate this situation from
a criminal perspective. The GMC will need to be involved, particularly if the
doctor is convicted, but the role of the police is more important at chis stage.
Telling the FYl's educational supervisor (0) is a somewhat passive way of tak-
ing action, when it is you who has heard the information. The worst options
involve not raking any action to report the doctor. Morally, the worst response
is to warn the doctor about the need to keep this a secret (E) as you are then
admitting that you recognise the illegality of what they have done and are
making yourself complicit in covering up this action. Although you are some-
what complicit as soon as you are aware, option A does not actively support
the criminal activity and is therefore preferable to option E.

Recommended reading
Medical Protection Society (2012), MPS Guide to Ethics, chapter 6, Honesty,
section: Indirect threats; chapter 12, Personal conduce, section: Morality.

1.11 Handover task forgotten

A C F
You must be honest with the registrar and accept responsibility for the delay
(F) and include an explanation of why you were distracted so that the regis-
trar fully understands the situation. It would be dishonest and unfair to your
night col.league to either actively deny that they had handed over the job (H)
 1
58 Chapter 1: Commitment to Professionalism
J

or passively allow the registrar to continue with this assumption (G). You must
also be honest and open with the patient rather than blaming your colleague
(D), which unfairly undermines the patient's trust in them. Ir would also be
dishonest to try to convince the patient that there had been no delay (E), which
could damage their trust in you. Whenever a mistake has been made, the most
important thing to do is to put it right in a timely manner (C). Although there
would be nothing wrong with documenting the events in the notes {B), and this
would be thorough and open of you, there are three more important priorities.
Documenting will nor help to correct the mistake in the way option C does,
will nor change the registrar's criticism of your undeserving colleague as F does
and will not set the patient's mind at rest, as in option A. You should always
apologise to patients for mistakes that could negatively impact their care.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 25, 55.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 6, Honesty, section: Open disclosure.

1 .12 Forgot to document

A G H
First, you should talk to your team and let them know that when you examined
the patient earlier you had checked for a rash (G), since this is an important
piece of information and will reassure the ream that it was nor missed. Ir is
viral that all medical records are contemporaneous, so you should nor go back
and alter your earlier entry in any way (B). This would he a dishonest thing to
do, even though what you are adding is truthful. Ir is a good idea to document
that you had checked for a rash and found none, which should be done in the
current place in the notes with the current time, and you can write that it is a
retrospective comment about your earlier examination (A). This is advisable
in case questions are raised later, and it is better than not recording anything
{F). The SHO should not be required to be dishonest in order to cover your
back (D), and they are likely to be unimpressed by your lack of professional-
ism if you ask this of them. Ir is very unlikely that they would agree to omit
this information from the notes because it would bring their own conduct into
question if investigated. You haven't done anything unethical or made any
major error in this scenario, you have simply forgotten to document a negative
finding that lacer turned our to be pertinent information. For the same reasons,
you do not need to seek legal advice {E) or formal support from your supervi-
sor (C). However, it would be beneficial for your learning and development to
reflect on the experience and how you will learn from it (H), to ensure your
examination documentation is thorough in the future.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 19.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 6, Honesty, section: Records.
 Answers 59

1.13 MrorDr

E B D C A
As a doctor, you should not make it appear as if you hold higher qualifications
than you do. lf someone is doing this, then they need to be made aware that
it is inappropriate for both their patients and colleagues to think that they are
talking to someone more qualified than they are. The best action therefore is to
explain this to the SHO (E) and also to make your consultant aware of the situ-
ation (B). Of the remaining options, talking to the relevant Royal College (0) is
the best as the rest involve either undermining the SHO in front of patients (A)
or leaving the SHO to practise dangerously (C).

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 66.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 6, Honesty.

1.14 Medical students

A B C E D
Despite not being part of a registered body, medical students still have to fol-
low the same rules as doctors. There is specific guidance for medical students
from the General Medical Council (GMC) about personal conduct; therefore,
the most appropriate thing to do is to ask the medical student to go back and
fully inform the patient (A). The medical student needs reminding that they
have a role in patient care and protecting patients, a big part of which involves
being truthful with the patient (B). The third best option here is to discuss the
matter with the patient yourself (C), although it would be better for the student
to do this themselves. The two worst options are E and D: to leave the patient
thinking that they have been seen by a doctor when they have not is completely
inappropriate (D), making option E a better response than D, in which you do
nothing.

Recommended reading
General Medical Council (2009), Medical Students: Professional Values and
Fitness to Practice, paragraphs 23, 24, 26 and 28.

1.15 Colleagues acceptinggifts

A B G
Accepting gifts from patients is an ethical grey area, and different people have
differing opinions. However, it is agreed that you should not accept gifts in
the form of money. Certainly, in this scenario, it sounds as though the SHO
is coercing patients a little, by making it sound as if he is doing more than he
actually is to influence patient care. Option A is correct because you should
talk to the SHO in question and try and advise him otherwise. Talking to
your supervisor (B) is also sensible as getting advice from someone with more
experience is helpful. Telling the consultant who is in charge of the patient's
 60 Chapter 1: Commitment to Professionalism

care (G) is also important. Discussing ir with the nurses is tantamount to

gossiping and is therefore best avoided (C). Giving the money to charity is,
of course, a good moral option (D), bur it does not address the root of the
problem. Immediately reporting the SHO to the GMC prior to talking ro them
(E) is also not recommended. Talking directly to the patient will leave them
distrustful of the health service and will also make them feel bad about trying
to give a gift (F). Obviously, trying similar methods to receive gifts from your
patients is not appropriate (H).

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 77-80.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 6, Honesty.

1.16 Open disclosure of mistake

A B D
This scenario assesses professionalism, particularly with regard to open and
honest disclosure of mistakes. Despite the fact that your patient is sirring
up in bed reading, option A should be one of your immediate actions as it
should be when assessing any patient. There may be clues as to her clinical
state that are only evident on closer physical examination. Option Bis also
a priority to prevent the antibiotic being given again, which could further
compromise patient safety. Although the patient may not have come to any
harm as a result of your mistake, it is important to be honest with patients
in these situations and to reassure them that it will not happen again (D).
This helps to build rapport and foster a respectful doctor-patient relation-
ship. While recording this event in your e-porrfolio is a conscientious deci-
sion, it is not an action that should be of top priority at this time. Similarly,
it is important to document what appears ro be a change in allergy status (G)
but only when you can be sure there is no delayed reaction. This informa-
tion should then be communicated to the patient's GP. Seeking advice from
a senior (F) wou Id not be incorrect; however, as an FYl doctor, you should
be competent at performing an initial assessment prior to seeking senior
assistance. For example if your patient had had an adverse reaction and
you required assistance in stabilising them, your SHO would be a suitable
help. Option E does not immediately address the problem nor does it foster
positive professional working relationships. Disposing of the evidence (H)
is dishonest, legally indefensible and does not involve assessing the patient's
present clinical state.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 16, 23,
25, 55.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 6, Honesty.
 Answers 61 e
1.17 Lying about hangover

B D C A E
This scenario requires you to act professionally as part of a team as well as to
maintain patient safety and work in the best interests of the patients. Option
B is the most appropriate initial response as it is important to maintain respect
for your colleagues and you do not know for certain that they are not suffering
from the flu. Seeking advice from another, slightly more senior colleague (D)
is often good practice if you are unsure how to act, and it is more appropriate
than option C, which is too confrontational. While it is important for an FYl to
act without delay if you believe a colleague's practice is putting patients at risk,
it is not your responsibility to reprimand colleagues for what you consider poor
professional behaviour. Option Eis the least appropriate as, at present, you have
no firm evidence that your colleague is absent due to a hangover and it does nor
help to maintain good professional relationships. Option A is also unsuitable as
you are not actively helping to provide the best care for your patients; however,
it is marginally preferable to option E since, by denying knowledge of the situa-
tion, you are not actively making unsubstantiated claims regarding a colleague.
Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 25, 35-37,
43, 59.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 11, Relating to colleagues, chapter 12: Personal conduct.
1.18 Drugs

E C A B D
The General Medical Council's Duties of a Doctor states that in situations
where you suspect that your conduct or that of a colleague may be compro-
mising patient safety, you have a duty to act without delay. In this situation,
possession of illegal substances is wrong regardless of the person's profession,
and you have a duty to be honest, trustworthy and act with integrity. Option
D is therefore the least suitable response. There is a professional dury to raise
concerns, but you should speak directly to the colleague in question in private
first to give them a chance to explain themselves and to help maintain a good
professional working relationship. Option E is therefore the most suitable
response in preference to C, while B would be inappropriate. Option C would
be suitable further down the line if the colleague in question did not rake any
further action themselves. Asking a senior nurse for advice (A) may be appro-
priate; however, they do not have a direct supervisory role and are therefore a
less suitable person to approach than your educational supervisor.
Recommended reading
General Medical Council (2009), The New Doctor, paragraphs 63, 101-102.
General Medical Council (2013), Good Medical Practice, paragraphs 35-37, 43.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 11, Relating to colleagues, page 86.
 62 Chapter 1: Commitment to Professionalism

1.19 Consenting

C D E
Informed consent is always required before any procedure, and to be quali-
fied to gain consent, you need to have had training, either in carrying out the
procedure or in gaining consent for it. As an F Yl, option C would therefore
be appropriate but option A would not. If you are unsure, getting advice from
another senior colleague would be sensible, and if someone else were avail-
able who was trained in the procedure, they could gain consent (E). You must
always make the care of your patient your first concern, so communication of
the circumstances to Mr Jones (D) is also courteous. Option His inappropri-
ate as it is neither polite nor conducive to maintaining positive professional
relationships. Although it is unfortunate that Mr Jones has been waiting, his
situation is not life-threatening and therefore attending co his problem has
to be prioritised below that of the patient currently being operated on by the
consultant (B). You must give patients information in the way they want and
can understand; however, while a patient information leaflet can be an effec-
tive way of relaying clinical information, the patient needs a conversation with
a doctor about the procedure and its risks and benefits prior to giving consent,
so option Fis therefore inappropriate. Option G may be suitable, but it is a bit
drastic in this situation.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 2, 17, 32,
35-37, 46-48, 56.

1.20 Alcoholon breath

A E D B C
As a doctor you have a duty to respond promptly and appropriately if you
think that patient safety is being compromised. It is possible that your SpR
is still under the effects of alcohol or at least not in a fit state to be making
decisions and looking after patients. Even though the drinking did not occur
in the hospital, your personal conduct outside the hospital is relevant to your
job if ir is impacting your ability to work. Option A is the best response as you
have a duty to maintain good working relationships and you have no evidence
that what you suspect is true. It gives your colleague the chance to explain,
which is courteous, and still immediately addresses a potentially serious
situation. Discussing it with a more senior colleague (options E and D) could
also be appropriate if you are unsure of what to do, and your consultant (E)
would be slightly more preferable as there are immediate issues over patient
safety. However, it is best practice to talk to the colleague in question first.
Confronting the SpR in the meeting (B) would be unprofessional, and you do
not have proof yet of your suspicions. However, your duty ultimately lies with
your patients and to do nothing could potentially lead to harm; therefore,
option C is the least appropriate response.
 Answers 63

Recommended reading
General Medical Council (2009), Tomorrow's Doctors, paragraph 133.
General Medical Council (2013 ), Good Medical Practice, Duties of a doctor.
General Medical Council (2013), Good Medical Practice, paragraph 25c.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 12: Personal conduct, page 91.

1 .21 Stoppingat an accident

A C E D B
As qualified medical professionals, doctors are likely to come across situations
outside of work where they could usefully provide assistance to individuals
who have had accidents or are suffering from a medical condition. While UK
law states that there is no legal obligation for doctors to stop at accidents, the
General Medical Council (GMC) does offer guidance. Good Medical Practice
states: 'You must offer help if emergencies arise in clinical settings or in the
community, taking account of your own safety, your competence and the avail-
ability of other options for care.' In this scenario, you have come across two
members of the public requiring urgent medical care. The best option involves
confirming your own safety first (A), but you should proceed to offer assistance
to the people in the car (C). Option E may be a sensible decision; however,
assessing the situation to acquire further derails may help the operator to assess
the urgency of the situation, so E is only the third most appropriate response.
Although you are not legally obliged to stop, GMC guidelines suggest that nor
offering assistance (B) would be inappropriate. Alerting the emergency services
but continuing on your way (D) ensures that the people involved in the acci-
dent will receive care but not offering assistance yourself would be incorrect if
it was safe to do so. Any assistance you do offer should take account of your
degree of training and other professionals available at the scene.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 26.

1 .22 Angry partner

D E C B A
The best response (D) is the one that attempts to diffuse the situation by
apologising and calmly describing that you are unable to give the man any
information as this would involve breaking confidentiality. The next best
option (E) is to revisit your patient and tell her that her boyfriend is on the
phone, clarify whether she would be happy for you to explain that she is well
so that he doesn't worry or whether she really wants you to say nothing at all.
Option C, although unfair on your patient as it would put pressure on her to
engage in a conversation that she would probably rather not have, would be the
next best choice since it attempts to address the situation directly. The question
implies that there may be some domestic abuse occurring, and your patient
may wish to shelter in the hospital and not be faced with her violent partner.
 64 Chapter 1: Commitment to Professionalism

The next best option would be to hang up the phone and call security (B), but
this would be likely to anger the man who is threatening violence against the
hospital. You have a responsibility to all of your patients on the ward, and you
need to do all you can to calm the situation down rather than risk escalating
it into a potentially dangerous situation. The least appropriate option would
be to call the police (A) as it would be difficult to explain the situation to them
without breaking the confidentiality of your patient.
Recommended reading
General Medical Council (2013), Good Medical Practice, Confidentiality,
paragraph 53.
General Medical Council (2013), Good Medical Practice, confidentiality:
reporting concerns about patients to the DVLA or DVA.

1.23 Unskilled procedure

A B D E C
This question assesses your integrity about knowing when you should not
perform a procedure that you have not been trained to implement. Unless
the situation involves life and death and doing nothing would undoubtedly
be catastrophic for the patient, you should not perform procedures that you
have not been satisfactorily trained in because you could potentially cause
serious harm. In this example, in fact it is vital to draw off the same volume
of cerebrospinal fluid (CSF) as the antibiotics so as not to cause raised intra-
cerebral pressure. If you had performed the procedure without knowing this,
the patient could have come to serious harm and be much worse off than
they would be if there was a delay in their treatment. Asking an experienced
clinician such as a consultant if they can come to assist you with the task, or
at least tell you how to perform the rask in detail, would be the safest and
best option in this case (A). Option B is the next best option; some general
surgeons will have experience from their earlier training in neurosurgery and
might be able to assist or advise. Option D to leave the job until the expert
is able to give advice and supervise, is the next best response as it is better
than performing the job yourself with potentially inadequate advice from
the internet or nursing staff. Of the two final options, option Eis better than
option C as a nurse may well have seen this procedure several times and know
exactly how you are supposed to do it, whereas information on the internet
may be much less reliable.
Recommended reading
General Medical Council (2013), Good Medical Practice, Duties of a doctor.

1.24 Death certification

A D F
Doctors have a legal obligation to tell the whole truth to protect the patients
even though they have passed away. The best thing to do, therefore, is to
discuss the matter with the FY2 himself (A), or with someone more senior and
 Answers 65

more experienced than you. ln this situation, that would be the consultant in
charge of the case (D). The other people to talk to would be those most used to
this sort of event: the bereavement office staff may be of help here (F). Calling
the coroner yourself (B) would be overstepping your role and competence as an
FYl and should not be your first move. Ignoring the matter is not acceptable
for obvious reasons (E) nor is taking the phone from the FY2 (G). Simply
telling the FY2 that he is inappropriate would only antagonise your colleague
and is therefore not a good course of action (H).

Recommended reading
General Medical Council (2013), Good Medical Practice, End of life care:
Certification, post-mortems and referral to a coroner or procurator fiscal,
paragraphs 85-87.
Office for National Statistics (2010), Guidance for Doctors Completing Medical
Certificates of Cause of Death in England and Wales, http://www.gro.gov.
uk/images/medcert_J uly _201 O.pdf.
1.25 Dishonest form for patient

C E B A D
You should never sign a document if you know chat it contains information
that is not truthful and accurate (A). However, you cannot report the patient
to the police (D) as they have not done anything criminal, so disclosing would
breach their confidentiality. The only circumstance in which you could talk
co an external agency would be to get anonymous advice (B), although this is
unlikely to be particularly helpful as your approach must be dictated by your
professional obligations. It would be best to speak to the patient directly (C) as
you may even find that they are not being intentionally deceitful and actually
believe that their housing issues are the cause of their illness. Even if they are
aware chat they are not being entirely honest, a simple explanation and refusal
from you may be enough for them ro realise that the document needs to be
honest. Option E defers the situation ro a senior member of your ream, which
is not strictly necessary, but isn't unethical either. It therefore ranks higher than
discussing with an external agency or signing the form (options B and A).

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 71.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter: Honesty, section: Misleading statements.

1.26 Inappropriatedrunkenstories

D B C E A
It seems as though the doctor is about to cell a srory that makes fun of patients,
which will undermine the medical profession in the eyes of those present. It
would not be acceptable behaviour even if the stories are anonymous as it still
breaches the crust of those patients. You should therefore interject (options
B, C and D) rather than let the doctor go on (options A and E). Reporting
 66 Chapter 1: Commitment to Professionalism

your colleague to the GMC (E) is better than simply allowing the situation to
continue (A) because it demonstrates concern, although it makes no attempt
to try and intervene at the time. If you can stop your colleague politely, this
will be best as it avoids confrontation (D). Option B will embarrass the other
doctor and may seem overdramatic to the rest of the group; however, it is a
better response than option C because it lets the doctor know that they are
being inappropriate. By simply changing the subject (C), they have not been
warned about their behaviour, so they are more likely to try to return to rhe
topic later on.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 65.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 12: Personal conduct, sections: Expectations of statutory
bodies, Alcohol.

1.27 Hours monitoring

B D E A C
As a young doctor, it is hard to question or challenge practice that seems to
be taken for granted, especially by your senior colleagues. You must remem-
ber chat you have your professionalism and integrity to uphold. The most
appropriate option is to tell the consultant that you cannot be dishonest and
put down your true working hours {B). You may feel unable to do this, so
the next most appropriate option would be option D: ro seek advice from
senior colleagues about how to handle the situation. Seeking advice from your
professional advocacy organisation such as the BMA (E) may be required, but
it would be best to talk to colleagues within your department first to voice
your concerns. Purring down the true hours without telling the consultant (A)
may be appropriate, but your consultant is likely to find out later, and this
will not stop the consultant from putting pressure on your other colleagues
in the same way in the future. Claiming you have worked the false number of
hours (C) is the most inappropriate option. Not only is this unprofessional and
dishonest, it will not help the department in the long term since it is likely that
you and your colleagues are being overworked and need more support with
staffing levels.

Recommended reading
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapters 6 and 11.

1 .28 False audit

C B A E D
The assumption in this question is that the consultant has been dishonest and
altered the results of the audit to gain financial reward from the trust. This
has patient safety implications since, instead of learning how to do better,
 Answers 67

the department thinks that it is already excellent. The best response here is
option C. You did not do the data analysis and could have made a mistake in
your assumptions that the department was failing. Option B is the next best
response: dishonesty for financial gain is a serious allegation and a senior
doctor would be able to offer advice about how to investigate this potential
case and which channels to use to escalate the issue if need be. Reanalysing
the results yourself (A) would offer you a way of testing whether your conclu-
sions are actually correct, taking into account that different statistical methods
can yield slightly different results. You would then be in a stronger position to
raise the alarm if you find your suspicions to be correct. Sharing your concerns
with the trust (E) is the next best answer; as part of whisdeblowers' protection
rights, you should be able to send named emails without fear of repercussions,
and it would be easier for them to investigate using your data if you did this.
Option D ranks last as turning a blind eye to this shows a lack of integrity
and morality.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 65-80.
NHS Employers, Raising concerns at work, http://www.
nhsemployers.org/your-workforce/retain-and-improve/
raising-concerns-at-work-whistleblowing.

1.29 Flujab

B C E A D
It is one of the General Medical Council's (GMC) recommendations that
'you should protect your patients, your colleagues and yourself by being
immunised against common serious communicable diseases where vac-
cines are available'. To decide against this advice would leave you open to
criticism from the GMC and colleagues. The best options are those that
involve you having the flu jab (options Band C). The flu jab does not give
you influenza but can cause low-grade temperatures and aching muscles
for a few days. This should not be significant enough for you to take time
off work, but you should not have to sacrifice your weekend to be unwell.
Option Bis therefore better than option C. The rest of the responses
involve not having the flu jab, so they are not ideal. Option E is the best of
those, since you are being proactive about what you believe; also contact-
ing the management of the hospital will raise awareness that staff members
may not agree with or understand the reasons behind staff vaccination,
which could alert them to the need to address this issue. Option A is
the next best response, in which you refuse the vaccination but are not
untruthful about it, as in option 0.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 28-30.
NHS Choices, Adult Flu Vaccine: Frequently Asked Questions.
 68 Chapter 1: Commitment to Professionalism

1.30 Out of practice

D A £ B C
Medical careers are varied and when rotating from job to job you will need to
be able to pick up new skills and recall old ones quickly. You will frequently
find that you have forgotten how to do some things well, and in these circum-
stances, you need to cake responsibility for your own learning and become
competent again quickly. The best way to get help is to discuss retraining
opportunities with your educational supervisor (D); by doing this, you can
set goals and they will be able to support you in reaching chem. The next best
response is option A: your colleagues who practise these skills every day arc
excellent people to learn from, and it is in their best interests that you learn
them well so chat the work can be shared. Revising the procedure privately will
help you (E), bur learning face-to-face is much more effective when working on
practical procedures than trying to remember it yourself by simulation. Option
Bis a fair response as you have learnt these procedures and performed them
in the past, so - with sensible awareness of your limitations - having a go at
a minor procedure such as cannulacion is good for your learning. Option C is
irresponsible and misses out on a vital learning opportunity as well as burden-
ing your colleagues, so it is the most inappropriate response.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 7-13.

1.31 Shooting

D B A C E
injuries secondary to the use of a dangerous weapon need to be reported to the
police. This question tackles how you balance your responsibility co protect
your patient's confidentiality and your duty of care co the public by report-
ing this serious incident. Option D is the best response; the question doesn't
contain a lot of detail as to why the patient doesn't want the accident reported,
so if you can find chis out you can better support your patient with these issues,
and you will find it easier co explain why you need to report the matter to the
police. Option Bis the next best response since, as a junior doctor, it is unlikely
that you have dealt with a situation like chis before, and some advice and input
from a senior colleague is valuable. It is also a good idea to inform senior col-
leagues as the patient may decide co leave uncreated if he feels the police will
be informed without his consent, and he could come co harm. Option A is the
next best response; each trust will have a named Caldicorr Guardian, who is
available to give advice on patient confidentiality. However, when sharing of
information is appropriate, a senior ream member should ideally be involved
first. Telling the patient that you will have to inform the police (C) is entirely
correct since, in doing so, you are being open and honest with rhe patient.
However, without knowing more information about the incident and without
knowing how much ro tell the police, this approach is likely ro distress and
worry the patient unnecessarily. Option E ranks last as you should always
 Answers 69

inform a patient if you have to break their confidentiality and explain why.
You should also discuss the amount of information that you can safely share
with a senior doctor or Caldicott Guardian to prevent sharing of unneccesary
private information.

Recommended reading
General Medical Council (2009}, Explanatory guidance, in Confidentiality:
Reporting Gunshot and Knife Wounds.
1.32 Good Samaritan

C B D E A
ln the UK a doctor has no legal obligarion to offer assistance in a communiry-
based emergency situation. However, the GMC states that, in an emergency,
you muse offer your assistance and provide a level of care that could reasonably
be expected in the situation. You should, however, be aware of the limits of
your own competence and warn rhe patient of those limits. Informing the staff
of your alcohol consumption (C) is therefore the best response in this siruarion
and preferable co simply giving your help (B). While giving the crew advice (D)
offers some assistance, you would better serve the passenger by going co assist
chem. If you wait co sec if someone else goes forward (E), the passenger may
deteriorate while you wait, which is unacceptable. Failing to volunteer in an
emergency situation (A}, unless in exceptional circumstances, is entirely inap-
propriate and may risk your professional registration.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 9.
Shepherd B, Macpherson D, Edwards C. (2006}, In-flight emergencies: Playing
the good Samaritan,Jouma/ of the Royal Society of Medicine, 99(12),
628-631.

1.33 Death certificate

A E H
According to the GMC: 'your professional responsibility does not come to an
end when a patient dies'. As such you also have responsibility to a patient's
relatives. A death certificate is important to relatives as it enables them to carry
our a funeral and achieve a sense of closure over the death of their loved one.
Death certificates should therefore be completed without unnecessary delay. In
this scenario, while your shifr has come co an end, you should still try to ensure
chat the certificate is completed. You should tell the bereavement office that
your shift has ended, bur you should also help in locating another appropriate
doctor to complete the certificate. A doctor who made an entry in the notes
prior to your last entry may be appropriate (H). You could also ask a colleague
who knew the patient to complete it (A) and/or give the bereavement office the
bleep number for an appropriate person for them to contact (E}. This is in con-
trast ro option G, which is inappropriate, since the person completing the death
certificate should have known the patient when alive. It is not the responsibility
 - l
70 Chapter 1: Commitment to Professionalism
I

of the ward sister to find a doctor, as in option B. Simply declining to com-

plete the death certificate is inappropriate as it does not offer a solution (D)
and waiting until your next shift, as in option C, would cause an unnecessary
delay. Option F would ensure that the certificate is completed in a timely man-
ner; however, you should not be required to come back to work during your
scheduled time off.

Recommended reading
General Medical Council (2010), Explanatory guidance, in Treatment and Care
Towards the End of Life: Good Practice in Decision Making, paragraphs
83-85.
1 .34 Near-miss event

C E B A D
'Near-miss' events are a valuable opportunity for learning and problem
identification. Reviewing chest x-rays for NG tube placement is a very com-
mon task for junior doctors to be asked to undertake. Feeding through an
incorrectly placed NG tube is a 'never-event' and has the potential to cause
serious harm and even death. Your first priority is to ensure that the patient
is out of danger (C). Following this, you must assess the situation and estab-
lish an action plan. The best course of action would be to seek help from a
senior colleague (E). They will be able to offer advice; it may be that all the
junior doctors in the trust require further support with the topic, in which case
training could be scheduled. Ignoring the situation (D) is the least appropriate
option as by doing so you are not preventing the issue from occurring again
in the future, and you have not ensured that your patient is safe. Asking for
a senior's opinion on NG tube placement chest x-rays in future (A) may be
appropriate in the short term; however, you must develop as a doctor and take
on a level of responsibility appropriate for your position by learning to do this
yourself. Completing a personal learning program covering NG tube placement
(B) could be an appropriate course of action; however, this would not help
identify whether chis issue was widespread or not.

Recommended reading
General Medical Council (2012), Explanatory guidance, in Raising and Acting
on Concerns about Patient Safety, paragraph 11.

1 .35 Advisingfriend

E D A C B
If you give advice to your friend you are accepting a duty of care towards
them, which makes you responsible for any investigation or treatment
that could be indicated. You should not make the decision that the mole is
benign (B) as you are very vulnerable to both ethical and legal criticism,
particularly if this is incorrect. Reassuring your friend that their lesion does
not appear worrying and asking to re-examine further down the line (C)
l Answers 71 •

is a slightly better response because you are making an attempt to further

evaluate the mole rather than simply making a one-off assessment. However,
this still leaves the duty of care entirely with you. Although it is inappro-
priate to informally get an opinion from one of your seniors (A), and this
colleague would probably be unwilling to be involved if they realised what
you were doing, at least you would be trying to ensure that you are not the
only professional who has seen the lesion. The best approach is to encourage
your friend co see their own GP (options D and E), thus declining to have a
duty of care towards them. Ir is safest not to give any opinion (E) as, if you
reassure your friend, this may make them less likely to subsequently make an
appointment to see their GP.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 16.

1.36 Consenting

A B E D C
This question highlights the importance of taking informed consent. General
Medical Council (GMC) guidance states that you should only gain consent
for procedures that you have either been trained to perform or that you have
been trained to consent for. However, as there are local guidelines available
for consenting and your consultant is unavailable, in this situation, it would
be appropriate for you to consent the patient in your consultant's absence (A).
Patient information leaflets can certainly be a useful aid to verbal explanations
but should not be used as a substitute (E). For this reason, asking your SpR to
help may be more suitable (B). While using information from a textbook can
be useful {D), it is unlikely to have all the necessary information or be as up to
dare as local policies on the inrraner. You should explain the risks and benefits
of any procedure when gaining consent, and if you are unable to do this, you
should endeavour ro find out the information before the patient consents. It
would therefore be inappropriate for the patient to sign his name before being
fully informed. Obtaining consent is a requirement for any procedure, but
in this particular case, it should be written and completed in a timely man-
ner. Option C is therefore the least appropriate response as you are nor being
proactive in completing the task that may consequently delay investigation and
future treatment.

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together.
General Medical Council (2009), Tomorrow's Doctors, paragraphs 14, 20.
General Medical Council (2013), Good Medical Practice, paragraphs 17, 32, 68.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 4: Duty of care.
 72 Chapter 1: Commitment to Professionalism
- - --- ---1

1.37 Removing chest drain

D E B C A
It is absolutely imperative that you and your colleagues practise medicine
within the boundaries of your competence to protect patient safety and to pro-
tect yourself from legal challenges if something goes wrong. The best response
here is option D; if your registrar could come back to supervise you, you
would be able to learn how to remove a chest drain and ensure that a compe-
tent doctor is present at the rime to deal with any complications. Option Eis
the next best response as, when struggling to work with a specialist piece of
equipment such as a chest drain, it is a good idea to get advice from the people
who use it the most, in this case the respiratory or cardiorhoracic team. They
would also be able to tell you if they thought that removing it unsupervised
was an appropriate thing to do. Option Bis the third best response because
although you would be showing a poor working relationship with your col-
league by asking the nursing staff to 'guard' the patient for you, the patient is
at least protected against an under-qualified doctor who could cause serious
harm. Options C and A rank last because they involve your FYl colleague
going ahead with the chest drain removal. Option C is marginally less bad than
A because you are not implicating yourself and supporting your colleague by
removing it with them; however, you would still be doing nothing co stop chem.

Recommended reading
General Medical Council (2013), Good Medical Practice, Duties of a doctor.

1.38 Poor teaching

B C G
The General Medical Council (GMC) stares that 'you must keep your knowl-
edge and skills up to dare throughout your working life'. Your education is
your own responsibility; therefore, in this scenario, you are obliged to act when
the teaching you receive does not meet your expectations. Discussing your
concerns with your educational supervisor (B) is a good response since their
role is to support your learning. Option C is also an acceptable response since
the issue is more likely to be resolved if a greater number of FYls are raising a
similar concern. If you feel that the current session topics are not useful, then a
constructive approach would be to suggest topics chat you and your colleagues
do consider useful (G). Volunteering to lead a session (H) assumes that you
will deliver a better standard of reaching and does not provide a long-term
solution. While filling in an anonymous feedback form (D) may be appropriate,
it is less likely to promote change than the previously discussed responses.
You are expected to attend the scheduled FYl teaching; therefore, avoiding
the sessions, even if you do make constructive use of the time, is inappropriate
(options E and F). Failing to address your concerns (A) is completely
inappropriate and shows a poor attitude towards your work, your colleagues
and your professional identity.
 Answers 73

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 12.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 10: Competence.
1.39 Mentoring

E B A D C
Part of a doctor's role involves teaching as well as providing adequate supervi-
sion to those who are learning. The best way for the student to practise her
skills is to learn through performing the cannulation. However, given the
student's inexperience, this should be under your supervision, as in option
E. Options A and Bare also appropriate since they too give the student an
opportunity to learn. Observing you (B), however, is a more favourable option
than practising on a dummy (A). The student has already had experience with
a dummy arm, and it is important co learn how to interact with and gain
consent from patients for procedures such as cannulation. Putting the cannula
in yourself without giving any teaching does nor fulfil your role as a teacher,
and sending an inexperienced student to cannulate alone may result in harm to
the patient. Options D and C are therefore inappropriate.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 39, 40, 42.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 10: Competence.

1.40 Procedure confidence

B D C E A
lf you do not feel completely confident in performing an examination or tech-
nique, it is useful to adopt rhe mentoring approach. This involves learning the
scientific basis for a technique, then observing a competent mentor performing
the technique and finally carrying out the technique yourself with a mentor
who can give guidance and advice while you are building up your own compe-
tence. ln this scenario, you have already successfully carried out the technique
but feel out of practice. Therefore, the most appropriate option would be to
talk through the procedure with another GP (a mentor) and then ask the GP
to observe you while you perform the examination (B). Observing another
GP performing the technique (D) may be useful if you feel that you could nor
perform the examination, but as you are simply lacking in confidence with the
technique, it is likely that you only need some assistance and support. Booking
an appointment with another GP (C) could result in a delay to the patient's
treatment and would also be a missed learning opportunity for yourself.
Performing a speculum examination without mentor supervision (E) may mean
that the patient experiences pain or that you are unable to complete the exami-
nation if you do it incorrectly. This could also damage your confidence with
this examination and impact your future practice. However, this is preferable
 74 Chapter 1: Commitment to Professionalism

to option A, which would cause diagnostic delays, and if the patient returned
to see you again, you would still have the same issues.

Recommended reading
Medical Protection Society {2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 10: Competence.

1.41 Time pressures and teaching

D F H
You should support the student to carry out cannulation. Although you
are busy, your jobs are routine, and you have a responsibility to work with
students. In addition, the student has already had teaching by simulation.
Options E and G are therefore not the most appropriate as they avoid
facilitating practical participation of the student. Option A is also avoidam,
and it is likely that the FY2 is busy roo. Handing responsibility for the student
over to rhem may be seen as unfair ream-working. It is important to inform
patients of the level of skill of the person performing a procedure if you think
that this information may affect their decision to consent. Option B is therefore
not one of the most appropriate, whereas option F is one of the best answers.
The student has not carried out the procedure before, so it is important for
them to be supervised {H), which both ensures patient safety and supports the
student to build their confidence. This makes option C inappropriate since it
is an inadequate level of supervision for rhe first attempt ar a skill. Delegating
appropriately to team members is important in managing your workload.
Asking rhe student to carry out the clerking for you prior ro doing the can-
nulas together (D) is a deal which benefits both of you, especially as clerking
is also educationally valuable for the student. Option D is therefore one of the
best options.

Recommended reading
Foundation Programme Curriculum (2012), section 1.5: Leadership; section 12:
procedures.
Medical Protection Society {2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 10: Competence, sections: Acquiring and developing new
skills, mentoring.

1.42 Prescribing limits

D A B E C
FYl doctors are not allowed to prescribe or transcribe cytotoxic or
immunosuppressant drugs. The worst response is therefore one that involves
prescribing the imrnunosuppressant {C). The best course of action is to
prescribe acute antibiotics, which is within your competence and can be done
following local protocol, and leave the prescription of the immunosuppressant
to your registrar {D). This is better than prescribing nothing {A) as there is
no reason why you shouldn't prescribe antibiotics and delaying this could
 Answers 75

be harmful. Ir would be advisable to get input from seniors within your team
before consulting another team (B), but this response is a safe one and may
be useful further down the line. Whatever you decide, you should not make
the decision to discontinue the immunosuppressant (E). This response ranks
second last because it makes no mention of alerting seniors, so the patient
could miss doses of their immunosuppressant based solely on your decision,
which would be dangerous. However, this is still safer than breaking the rules
and prescribing the immunosuppressant (C).

Recommended reading
Foundation Programme Curriculum (2012), section 7.5: Safe prescribing.
UK Foundation Programme Guidance Note on Prescribing Cytotoxic and
lmmunosuppressant Drugs. Available from: http://www.rcoa.ac.uk/sites/
defauJt/fi.les/TRG-AMRC-CHEMO.pdf.

1.43 Choosing training

D E B C A
It is important to choose training based on skills you need to develop, nor
just based on what you enjoy or find interesting. You will soon be in a posi-
tion where you need good adult resuscitation skills. The options which include
attending an ALS course therefore rank higher than options which do nor.
Option D is therefore rhe best response because it is better to be prepared
ahead of starting the job. If you wait to organise training until starting cardi-
ology (E), you will have to attend arrests prior to the course, when you may
nor be fully competent. Although your career path is focused on paediatrics,
it is not a priority at this point in terms of competence; however, option B is
better than C because it concerns resuscitation and therefore may include some
rransferrable skills. Option A is the worst option because it involves not taking
responsibility for your training needs. Sometimes it is necessary to use your
rime off for training in order to maintain your competence.

Recommended reading
General Medical Council (2011 ), The Trainee Doctor, paragraph 3 7.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 10: Competence, section: Maintaining basic standards.

1.44 Surgical error

B C E
Parr of being a competent doctor is being able to admit when you have made
a mistake, both to your colleagues and ro the patient. In this case, the mistake
was not made by you, therefore you should urge the registrar to own up to
the mistake (options B and C) rather than informing others about it yourself.
However, if the registrar does nor wish to own up to their mistake, then option
E is appropriate as the consultant should be made aware of what happened in
the theatre since the overriding responsibility for the patient lies with them,
 76 Chapter 1: Commitment to Professionalism

and the case will likely need to be brought up at a morbidity and mortality
meeting. Option A is not appropriate as someone needs to be made aware of
the mistake, particularly the patient. While discussing the case with your edu-
cational supervisor (D) would be a good idea, this will not lead to an improved
outcome for the patient. Going over the registrar's head to their supervisor (F)
is not a good idea, especially if you are questioning their abilities when you are
junior to them and were nor present at the initial operation. Options G and H
are not appropriate responses as the mistake is not yours to explain and plac-
ing blame on the registrar in front of the patient will increase the likelihood of
legal action being taken. As an FYl you are also not qualified to perform this
procedure and therefore are nor the correct person to counsel the patient on
this matter.

Recommended reading
General Medical Council (February 2013), 'Doctors make mistakes', in GMC
Student News.
Medical Protection Sociery (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 10: Competence, section: When things go wrong.

1.45 Performingnew tasks

A F H
Suturing is one of the practical competencies set out in Tomorrow's Doctors
that graduates are expected to have achieved; however, many people find it
difficult the first time they perform it in a real situation. Options H and Fare
perhaps the most appropriate responses here as they involve you admitting your
uncertainty to the consultant and either asking for supervision or allowing the
consultant to make the decision themself. Although delaying the consultant
from consenting other patients in his theatre list is not ideal, option A still
ranks in the top three as it will hopefully enable you to perform suturing at
some point in the future to improve your skills. While options D and G are
good responses in that they are unlikely to cause the patient to come to harm,
neither are in the top three because declining the opportunity will not allow
you to improve your competence and having the consultant come back to check
the sutures will delay the list. Option E also prevents the patient corning to
harm but again results in you not having the chance to improve your skills.
The two remaining responses (Band C) are not appropriate because simply
performing the sutures if you do not feel competent is unprofessional, and scrub
nurses are not trained in performing suturing and are therefore nor appropriate
supervisors.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 9, 16d.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 10: Competence, section: Maintaining competence.
 Answers 77

1.46 Career progression

D C A E B
Maintaining the required training is important for all doctors. As an FY2
doctor you will still need to gain general medical experience regardless of your
future career plans. While doctors may use their study leave days t0 attend
extra training that may help their career progression, all doctors must attend
basic training. Talking to the FY2 one-to-one is the best option here rather
than immediately going to their educational supervisor, which is why options
C and D rank higher than A. Option D ranks highest as successful completion
of all mandatory training during tbe FY2 year is important for career progres-
sion. Option C comes next as it is important to keep up to date with medicine.
Option E ranks higher than Bas, even though attending extra training is
useful, it is not appropriate to miss the core training to do this, and the FY2
should be told this.

Recommended reading
General Medical Council (June 2012), Continuing Professional Development:
Guidance for all Doctors.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 10: Competence.

1.47 Tourniquet

A F G
This question assesses your response when things go wrong ar work. Ir is
important first and foremost to own up to any mistake {G), to rake steps
to minimise further risk to the patient and then to report it through the
correct local channels. This often takes the form of an incident report (F)
which should be completed as soon as possible after the event takes place. In
addition to the formalities, you must always maintain open and trustworthy
relationships with your patients and, therefore, apologising to and reassuring
the patient is another important task that should be completed imminently
(A). Option C would nor be incorrect; however, in this situation, a colleague
has alerted you to the mistake, and it is arguably unlikely that you would
need to check other patients. While FYl colleagues can be useful sources
of some information (B), in this instance there should be no need to consult
colleagues as you should always own up to your mistakes. Denying blame
(D) is dishonest and contravenes many of the duties of a doctor, in particular
'be honest, open and act with integrity'. This behaviour could lead to further
disciplinary action. Option Eis similarly dishonest, and despite apologising
co the patient, it does nor deal with the mistake in a professional manner.
Discussing the incident with your educational supervisor {H) is certainly a
good idea in the slightly longer term; however, it is not one of the first things
you should do.
 78 Chapter 1: Commitment to Professionalism

Recommended reading
General Medical Council (2013), Good Medical Practice, Duties of a doctor.
General Medical Council (2013), Good Medical Practice, paragraphs 19, 22, 23,
25, 32, 55, 65, 68.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 10: Competence.

1 .48 Ordering incorrecttest

E D C A B
This question assesses how you deal with making mistakes in clinical practice,
in particular with regards to communication with the patient, your colleagues
and the steps you take to minimise harm. In this scenario, a CT scan may be
very helpful in providing more information about the clinical condition of the
patient; however, this should be balanced with the additional risk of radiation
exposure from another CT scan. Option Eis the most appropriate response
initially as it is important to be honest with your colleagues about mistakes,
and your consultant may wish to come and speak to the patient. You also need
to check whether they would like another CT scan to be requested. This is
possible on the phone; therefore, it is a more suitable response than option A.
Option D is the second most appropriate as it demonstrates a proactive attitude
and means that, when explaining the situation to the patient, you can reassure
them chat you are caking steps to rectify it. Option C is important as you must
be open and honest with patients; however, there are other steps to take first.
The least appropriate response would be co keep quiet about your mistake (B).
This is unprofessional and does not show honesty or respect for the patient.

Recommended reading
General Medical Council (2013), Good Medical Practice, Duties of a doctor.
General Medical Council (2013), Good Medical Practice, paragraphs 15, 16, 17,
25,31,47,49,55,65,68.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 10: Competence.

1.49 NG tube

B A C E D
Gaining competence in clinical skills through direct observation of practical
skills (OOPS) is an important part of the foundation curriculum and is neces-
sary in order to progress through your medical career. This question highlights
the balance that is required between facilitating new learning opportunities
and maintaining patient safety. Your initial response in this situation should
be option B as this ensures both of these aspects and also courteously informs
your senior that you are unhappy to work beyond the limits of your compe-
tence. The person observing needs to be trained in this skill, however, and it
may be a more junior member of the team that is most suitable. Conversely,
passing the NG tube without appropriate supervision (0) would be negligent,
 Answers 79

even if you do use a chaperone and check the position of the tube with a chest
x-ray. Asking your SHO to supervise and using this situation as a learning
experience (A) is the second best option. This is more proactive than ask-
ing your registrar to pass the NG tube (C) as you are capable of doing it but
simply need to exercise the correct precautions. This response would not only
waste a chance to expand your learning but would also unnecessarily impact
a colleague's workload. Similarly, this would be the case in option E, which
would delay patient care and fails to enact your consultant's request.

Recommended reading
General Medical Council (2009), The New Doctor, paragraphs 6, 7, 63.
General Medical Council (2009), Tomorrow's Doctors, paragraphs 6, 21.
General Medical Council (2013), Good Medical Practice, Duties of a doctor.
General Medical Council (2013), Good Medical Practice, paragraphs 9, 14.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 10: Competence.
1.50 Audit

B A E C D
This question assesses your ability to facilitate your own learning and com-
mitment to professionalism, while improving care for patients. Conducting an
audit (B) is a proactive way of trying to improve the quality of service provi-
sion in your department and is an important activity that should be completed
within your foundation years. Contacting your clinical supervisor (A) is also
sensible and perhaps more appropriate than options E and C as, by doing this,
you would still be working to benefit your team. They may also have good sug-
gestions of how you can use your time to fulfil your training needs. Assisting
in theatre can be a useful learning opportunity (E), but it would result in
neglecting your commitment to the team in which you have been assigned. It is
slightly more preferable to option C, however, in which you have not informed
your ream of your actions. Option D is inappropriate when there are many
other opportunities for you to develop your learning and contribute to improv-
ing patient care; watching the news is a worthwhile activity bur should be kept
for leisure time.

Recommended reading
General Medical Council (2009), The New Doctor, paragraphs 7, 33, 63, 116.
General Medical Council (2013), Good Medical Practice, paragraphs 9, 13, 22.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 10: Competence.
1.51 Unfamiliar with equipment

A C E D B
Once you have identified a gap in your knowledge or skill set, you should
work to set this right. In chis scenario, it is important to be proficient at this
skill for future emergency situations; therefore, you should be proactive in
 80 Chapter 1: Commitment to Professionalism

organising necessary training. The most appropriate action would there-

fore be A, asking a colleague to demonstrate the skill. Contacting your
foundation programme director to arrange teaching on this skill (C) could
result in training, but there could be a delay in arranging this teaching, and
administering adrenaline during an arrest is a simple skill that shouldn't
require structured training. Revising the BLS guidelines (E) may be useful
for your general emergency knowledge, but it would be better to seek out
practical teaching for this situation. Avoiding administering the drug in
future cardiac arrests (D) is not a professional way of dealing with a lack of
knowledge as it is important to learn and improve for the future. Filling in
an incident form (B) would be unnecessary and irrelevant as the patient has
not come to harm.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 7-9.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 10: Competence.

1.52 Confused patient pre-theatre

A C G
Patients' capacity can change and that can have an impact on the consent
they have already given for procedures. In this scenario, a capacity assessment
would need to be made to assess if rhe surgery should continue without the
patient's consent. To get more information about her confusion, asking nursing
staff is a good srarr (A) as they spend a lot more time directly with patients.
New onset confusion can be a symptom of acute illness, so you should begin
to investigate the cause appropriately, making option G an appropriate course
of action. The final appropriate response here is option C: your registrar
should be made aware of this patient's confusion and refusal to go to theatre
as chis could affect the day's list, and it would be wrong to send her to theatre
without a full capacity assessment. The inappropriate responses in this scenario
include: getting unnecessary reviews of the patient by psychiatry without
first investigating the cause yourself (D); ignoring the situation (E): sending a
patient to theatre when she refuses consent can amount to assault; cancelling
the surgery before investigating the cause for the patient's confusion and her
reasons for refusal (f), which is a bit rash; and waiting to see if the patient
improves (H). This final response involves delaying a decision, and even if the
patient does improve, your seniors should still be aware of their deterioration
as it may be more appropriate to delay the surgery until a cause for the
confusion has been found.

Recommended reading
Mental Capacity Act 2005 (2012), section I. Medical Protection Society,
Consent to Medical Treatment booklet, General advice on assessing
capacity: Fluctuating capacity.
 Answers 81 •

1.53 Coercion end of life

C D £ B A
This question deals with the complicated ethical issue of patient coercion. If you
feel that patients are behaving in a certain way because of pressures from others,
such as family members, staff, or those with a financial interest, it is your duty
to find out what the patient actually wants and to protect them from outside
influences. In this question, it seems as if the patient had decided upon an end-
of-life plan, yet, after only one meeting with an unfamiliar family member, he
changed his opinion completely. The best response is to find our what actually
happened during that meeting and ask rhe patient ro clarify his new end-of-life
wishes (C). The next best response is to speak to the palliative care team (D)
who are very experienced in end-of-life ethical issues and will be able to offer
support and advice regarding the potential coercion of this patient. Option E is
the third best response since this is a complex end of life scenario, your reg-
istrar or even consultant should be involved to ensure that the patient is fully
protected. Seeking legal advice (B) could also be considered if you believe that
the patient has been persuaded by his son to withdraw from treatment. You will
need to get some advice about how to act within the law, whether to leave this
situation alone or go against the patient's new wishes and continue to hydrate
him. However, this situation could potentially be resolved without involving
external agencies, so escalating to your immediate seniors is more appropriate at
this stage. Option A ranks last; you need to be careful when broaching the topic
of coercion with his son as this is a serious accusation. Ir would be wise to leave
this conversation to a senior doctor, if and when it becomes necessary.

Recommended reading
Mr Leslie Burke v GMC (2005), EWCA Civ 1003.

1.54 Needlestick

D A C E B
Needlestick injuries pose a difficult situation whereby you, as a doctor,
become vulnerable to potential harm from a patient, and both parties require
appropriate medical investigation and counselling. Option D is therefore the
best course of action since by reporting this to your ward manager both you
and the patient can receive the correct counselling. A risk assessment can
also be undertaken and post-exposure prophylaxis can be given if necessary.
It is always more favourable for an unexposed member of staff to approach
the patient to gain consent (A), rather than the exposed one (C), so that the
consenting doctor can remain impartial. It is inappropriate to test the patient
for communicable diseases without their consent (E), and if a positive result
were obtained, this would pose a further ethical and legal dilemma. To do
nothing is irresponsible (B) since you put your own health at risk and pose a
potential risk to your future patients if you unknowingly contract a serious
communicable disease.
 Answers 81 e
1.53 Coercion end of life

C D E B A
This question deals with the complicated ethical issue of patient coercion. If you
feel chat patients are behaving in a certain way because of pressures from others,
such as family members, staff, or those with a financial interest, it is your duty
to find out what the patient actually wants and to protect them from outside
influences. In chis question, it seems as if the patient had decided upon an end-
of-life plan, yet, after only one meeting with an unfamiliar family member, he
changed his opinion completely. The best response is to find out what actually
happened during that meeting and ask the patient to clarify his new end-of-life
wishes (C). The next best response is co speak to the palliative care team (D)
who are very experienced in end-of-life ethical issues and will be able to offer
support and advice regarding the potential coercion of this patient. Option Eis
the third best response since this is a complex end of life scenario, your reg-
istrar or even consultant should be involved to ensure that the patient is fully
protected. Seeking legal advice (B) could also be considered if you believe that
the patient has been persuaded by his son to withdraw from treatment. You will
need to get some advice about how to act within the law, whether to leave this
situation alone or go against the patient's new wishes and continue co hydrate
him. However, this situation could potentially be resolved without involving
external agencies, so escalating to your immediate seniors is more appropriate at
this stage. Option A ranks last; you need to be careful when broaching the topic
of coercion with his son as this is a serious accusation. le would be wise to leave
chis conversation to a senior doctor, if and when it becomes necessary.

Recommended reading
Mr Leslie Burke v GMC (2005), EWCA Civ 1003.

1.54 Needlestick

D A C E B
Needlestick injuries pose a difficult situation whereby you, as a doctor,
become vulnerable to potential harm from a patient, and both parties require
appropriate medical investigation and counselling. Option D is therefore the
best course of action since by reporting this to your ward manager both you
and the patient can receive the correct counselling. A risk assessment can
also be undertaken and post-exposure prophylaxis can be given if necessary.
It is always more favourable for an unexposed member of staff to approach
the patient co gain consent (A), rather than the exposed one (C), so chat the
consenting doctor can remain impartial. It is inappropriate to test the patient
for communicable diseases without their consent (E), and if a positive result
were obtained, this would pose a further ethical and legal dilemma. To do
nothing is irresponsible (B) since you put your own health at risk and pose a
potential risk to your future patients if you unknowingly contract a serious
communicable disease.
 82 Chapter 1: Commitment to Professionalism

Recommended reading
British Medical Association (2009), Consent Toolkit, Card 12: Serious
communicable diseases.
General Medical Council (2013), Good Medical Practice, paragraphs 17, 28.
Medical Protection Society (2013), MPS Factsheet: Needlestick Injuries.

1.55 Consenting

C B A E D
As your registrar will be performing the operation, it is his responsibility to
discuss the procedure with the patient and obtain consent (C}. You are neither
trained nor qualified to consent the patient yourself, so options E and D are
unsuitable; however, in chis situation, E would provide more accurate infor-
mation to the patient and therefore ranks higher. The consultant from your
team would be your second choice (B) since, although he is not performing the
procedure, he has overall responsibility for the patient. The consultant from
the other team (A) would be qualified with specific knowledge of the proposed
operation, but it would be inappropriate to disrupt his activities before your
own consultant.

Recommended reading
General Medical Council (2008), Explanatory guidance, Consent: Patients and
Doctors Making Decisions Together, paragraph 26.

1.56 Consent for student

D C E A B
As an FYl, it is common to have medical students attached to your team. While
it is part of the foundation programme curriculum to develop your teaching
skills, your priorities always lie with the patient. Although the patient has given
consent beforehand, they always have the right to withdraw the consent at any-
time. In this case the patient is complaining of feeling tired and dizzy. This could
be a symptom of progression in their illness or deterioration in their health, so a
full assessment by you is the most appropriate course of action (D). While your
registrar may need to see the patient as well (C), they will be busy with a number
of other tasks and should not be disturbed before you have assessed the patient
yourself. Completing the students' examination quickly (B) is entirely inappropri-
ate because the patient has withdrawn consent ro rake part in reaching, and this
could make them feel worse. While leaving the bedside would prevent the stu-
dents from harming the patient, this would not lead to you assessing the patient
(E). Option Eis preferable to A, however, as this would provide the students with
education and yourself with an opportunity to practise teaching; however, it
wou Id still not assess the patient, which should be your primary concern.

Recommended reading
General Medical Council (2008), Explanatory guidance, Consent: Patients and
Doctors Making Decisions Together, paragraph 9h.
 Answers 83

1.57 Dementia and consent

A D E
This question deals with the issue of a patient who may lack capacity. You
must remember that you should always assume a patient to have capacity. In
order to assess capacity, the patient needs to be able to understand, retain and
weigh up the information given to them and then also be able to communicate
a response to that information. Capacity is also decision-specific, meaning that
every time a new decision is made, capacity must be reassessed. For this reason,
in this situation, it is necessary for you to assess capacity (D) as it would be
inappropriate to assume this without an assessment, as in options F and G. If a
patient does lack capacity, it is advisable to contact those closest to the patient
so that a decision can be made in the patient's best interests. Options A and E
are also therefore the most suitable responses in this scenario. It would be inap-
propriate to simply inform the relatives/carers about the planned therapeutic
course (H) as this would not demonstrate collaborative decision-making
nor can you assume that this would be complying with the patient's wishes.
Option B is not appropriate as you (and the ward sister) are unable to consent
for a procedure that you are neither trained to carry out nor to consent for;
in addition, this assumes capacity in a patient with severe dementia. You arc
also not involving those closest to the patient, which is equally important in
difficult situations such as this. Asking a colleague to telephone the carers (C)
is unnecessary because, as an FYl, you should be able to speak to the family on
the phone, and it would be unnecessarily impacting another colleague's time.

Recommended reading
General Medical Council (2008), Explanatory guidance, Consent: Patients and
Doctors Making Decisions Together.
General Medical Council (2013), Good Medical Practice; paragraphs 17, 21, 27,
31-34, 49, 60.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 8: Patient autonomy and consent.

1.58 Disclosure after death

A D C B E
The best thing to do with phone calls from people whom you do not know
is to take a number and call them back (A) so that you can verify that they
are legitimate. In this case, you could ask which law firm they work at so
that you can ensure that the number is real; this way you can have important
conversations and be sure that they are with the correct person. Option D
is the next best course of action as by remaining neutral, you would not
accidentally disclose any confidential information. Option C is a good response
if you are unsure what to do in this setting as nurses take phone calls far more
commonly than doctors and so are often better at dealing with calls where the
identity of the caller is uncertain. Confidentiality extends beyond death and
therefore telling someone you do not know that Mrs Green died (B) would
 84 Chapter 1: Commitment to Professionalism

still be breaking her confidentiality. Option E is the worst response here as you
would be confirming that Mrs Green has died and that you are the one signing
the death certificate, therefore giving information out about both the patient
and yourself.

Recommended reading
General Medical Council (2009), Explanatory guidance, Confidentiality,
paragraphs 70, 71 and 72 {Disclosure after a patient's death).
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 9: Confidentiality.

1.59 Drug problems

A C D
In this situation, the best thing to do is to make your consultant aware of
the difficulty you have with the situation as, by knowing the couple, you
are personally involved and are at risk of breaking confidentiality, either by
accident or on purpose to protect your friend and her child. The best responses
here are therefore options A, C and D: to immediately remove yourself from
the room and subsequently share with your consultant both your concerns
and your personal difficulty with the situation. Option B is obviously a breach
of confidence and, as an FYl, it would be inappropriate for you to counsel
someone on child protection and drug rehabilitation. Discussing the situation
again is an obvious breach of confidentiality, which therefore makes options
E and G inappropriate. While informing their GP of the situation {F) is, of
course, important, there are other people in the team who could do this, and
you are much safer staying completely out of the case. The situation could be
potentially dangerous for the child, but you shouldn't immediately try and
remove the child from the father's care as this is potentially damaging for the
entire family, and a social worker would be a much better person to liaise
with the family around this. This is also the case for option H, so you should
instead give the consultant all this information {A) and then be removed from
the situation.

Recommended reading
General Medical Council (2009), Explanatory guidance, Confidentiality,
paragraphs 12 and 13.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 9: Confidentiality.

1.60 Friends with problems

A E B D C
In this scenario, the only correct way to act is not to allow your friend to
know you have found out medical information about him and to try and treat
him in exactly the same way as before. This is a difficult situation, especially
when it concerns a mental health diagnosis. Unless your friend seeks your help
 Answers 85

regarding this problem, you cannot approach the subject with him. The best
option from here on is to check all patients' names before you see their records
(A), which would prevent you from finding our personal medical derails about
them. lt would also be wise to discuss this with the GP (E) as they may have
some helpful advice for you, and it would also make them aware that you
may know other registered patients. Getting up and immediately leaving the
room (B), while appearing strange initially, could easily be explained to the GP
after the telephone consultation, and the GP is likely to be very understanding.
Offering support to your friend (D) would be a caring thing to do, but it is not
appropriate since chis would alert him that you have discovered confidential
information about him. Reading through his notes (C) is an obvious breach of
confidentiality and is the worst option in this scenario.

Recommended reading
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 9: Confidentiality.

1.61 DVLA

C B E D A
In situations where a patient might put others at serious risk of harm or
death, you can disclose their medical information ro ocher organisations in
the interests of protecting others. The responsibility for informing the DVLA
lies with the patient; however, if a patient informs you that he fully intends
to drive with a condition that could endanger the lives of others, you should
intervene. The best response here is ro sic with the patient and discuss the
reasons why you think it is safer co abstain from driving and discuss with him
his reasons for refusing (C). You could offer the advice and help of a social
worker regarding the support he could claim while out of work. The second
best response would be to talk to the patient's wife about your concerns
(B). His wife would be well placed co advise the patient from a personal
perspective, providing the patient consents to you sharing this information
with his wife. Option E is the third best response; before disclosing medical
information to others, a Caldicott Guardian can advise you on how much you
need to share, which can prevent you breaking confidentiality unnecessarily.
Every trust will have a Caldicott Guardian, whose role is to advise on the
sharing of patient information. Option D is the fourth best response since
breaking confidentiality is justified in this scenario; however, to ensure you
approach the breach appropriately and only share what is necessary, you
should discuss this with a senior, a Caldicott Guardian or your medico-legal
malpractice insurer first. Calling the police (A) ranks last since this man has
not committed a crime and may reconsider his reflex decision to continue
driving. Additionally, informing the police will distress the patient and is not
indicated at this stage. If you witnessed your patient subsequently driving
with uncontrolled epilepsy, rhar might be an appropriate point at which to
consider calling the police.
 86 Chapter 1: Commitment to Professionalism

Recommended reading
General Medical Council (2009), Confidentiality: Reporting Concerns about
Patients to the DVLA or DVA.
General Medical Council (2013), Explanatory guidance, Confidentiality,
paragraph 53.

1.62 Fish and chips

C E A D B
Some particularly infectious diseases are 'notifiable' in the UK, which means
they must be reported to a public health official. A list of these can be found
on the website of the Health Protection Agency. The General Medical Council
(GMC) views disclosures of serious infectious diseases in the interests of
public safety; therefore, this is one of the scenarios in which confidentiality
can and should be broken. The best response is to spend time with Mr Green
and explain that only medical staff and those involved in investigating the
cause of this infection will know about his illness (C). The second best
option is E, asking one of the doctors who will be directly involved in the
investigation to speak with Mr Green may alleviate some of his fears and
answer his questions about the depth and publicity of the investigation.
Informing the public health officers of his infection behind his back without
his consent (A) is the next best option in this list. You do not need Mr Green's
consent to disclose this information to the public health team, but you should
always try and gain it first. Option D should rank after this: to give Mr Green
some public health advice regarding staying off work while he is unwell is
part of being a responsible doctor. This option is similar to advising patients
with epilepsy to abstain from driving in order to protect the health of the
wider public. Mr Green's confidentiality should only be broken to those who
need to know in the public interest, so breaking it ro the general public is both
unnecessary and damaging to Mr Green's business. Option Bis therefore
ranked last.

Recommended reading
General Medical Council (2013 ), Confidentiality, Public interest: Disclosures in
the public interest.
The Health Protection Agency (2010), Health Protection Regulations.

1.63 Lost patient list

B C A D E
As an FYl doctor, confidentiality is central ro the doctor-patient relation-
ship. You should take care to avoid unintentional disclosure. Human error
unfortunately means that this cannot always be avoided. Option B is the most
appropriate course of action: you should apologise and inform the patient that
the list is confidential and ask chem not ro divulge any information from it.
Option C should be considered next. This is difficult as it may result in a
,---- Answers 87

negative effect on yourself, but you should remember chat, as a doctor, you
have a duty co put patients' interests first. It should also be noted that early
recognition of an adverse event can allow issues to be tackled and problems to
be put right. As a doctor, you should be able to reflect on events and provide
alternatives, which may avoid the same mistakes in the future. Option A is
an example of chis as ir would anonymise patient information; however, in
chis situation, this would not change the fact chat your patient has already
read your list. You may find option D useful, but it is not as important as
options B, C and A. Option Eis the least appropriate response as chis pre-
vents a concern being raised, discourages a culture of openness and would be
u n professiona I.

Recommended reading
General Medical Council (2009), Explanatory guidance, Confidentiality,
paragraphs 12, 13, 16.
General Medical Council (2012), Explanatory guidance, Raising and Acting on
Concerns about Patient Safety, paragraphs 2, 7, 9, 10, 11.

1.64 Driving against medical advice

B D E A C
Confidentiality is an important aspect of the doctor-patient relationship.
However, it is important to note char confidentiality is not absolute, and there
are a few exceptions. One such exception is disclosure in the public's best
interest. After a first generalised unprovoked seizure, the DVLA states that
the patient should have six months off driving from rhe date of rhe seizure.
The patient should be informed that, firstly, the condition may affect their
ability to drive, and secondly, it is the patient's legal responsibility to inform
the DVLA. General Medical Council (GMC) guidance states that 'if a patient
continues to drive ... you should make every reasonable effort to persuade
chem to stop'. Option B is therefore the most appropriate response. The patient
should be contacted to rediscuss their condition and the legal obligations
associated with ir. The GMC also says that you could ralk ro family, friends
or carers if rhe patient agrees. After making reasonable effort and if the
patient is still driving, you should contact rhe DVLA (D), and you should also
inform the patient char you are doing this. Option E might be perceived as
confrontational, unprofessional and beyond 'reasonable effort'. Option A is
inappropriate as iris nor the correct way of informing the authorities; however,
it is better than option C, which would be neglecting your duties as a doctor.

Recommended reading
Driver and Vehicle Licensing Agency (2013), For Medical Practitioners: At
a Glance Guide to the Current Medical Standards of Fitness to Drive,
introduction: Notification to DYLA; chapter 1: Neurological disorders.
General Medical Council (2009), Explanatory guidance, Confidentiality:
Reporting Concerns about Patients to the DVLA or the DVA.
 88 Chapter 1: Commitment to Professionalism

1.65 Transferring computer files

D A C B E
The use of hospital computer systems is common during the foundation years
and information is often transferred between devices. Patient confidentiality
must be ensured at all times and maintaining the anonymity of images and
text, while following local trust guidelines, is essential. In this case the best
way to transfer images would be to send them over the dedicated trust net-
work to the lecture theatre (0), which would ensure confidentiality. For this
reason the least appropriate response would be to transfer the images to your
personal memory stick (E). In general, this should never be done as memory
sticks can be lost and could result in a breach of confidentiality. If you were
unsure of how to transfer the images, the IT department would be willing co
offer advice (A); however, that would take valuable time that could be spent
completing other tasks. While rewriting the presentation would ensure confi-
dentiality, it would not be a good use of your time (C). Leaving the images out
of a presentation (B) would be detrimental to the learning of your colleagues
and would therefore be unsuitable.

Recommended reading
General Medical Council (2009), Explanatory guidance, Confidentiality,
paragraph 14.

1.66 Food poisoning

C A D E B
This is a difficult case because while gastroenteritis is not a notifiable disease,
your patient is a takeaway chef and could therefore potentially put the public at
risk. Agreeing with the patient after further discussion that he will stay away from
work is the best course of action (options A and C). However, the patient is clearly
anxious about keeping his job. ln this case it would be courteous and helpful for
the patient if you were to have a short discussion with his manager to inform
them of the situation (C). While legally the patient can self-certify for his illness
(A), in option C you would be responding to the patient's concerns by telephoning
his place of work, and therefore chis ranks higher. Contacting the public health
authorities (D) would be appropriate if the patient refused to stay away from work
and would ensure the safety of the public; however, this would be better left until
after attempting to tackle the problem yourself. Giving the patient some extra
antibiotics (B) would be clinically inappropriate and would still put the public
at risk if he returned to work. Option E would prevent him from going to work;
however, it would be a highly inappropriate admission for such a minor illness.

Recommended reading
General Medical Council (2009), Explanatory guidance, Confidentiality,
paragraph 39.
Health Protection Agency (2010), Health Protection (Notification) Regulations;
List of notifiable diseases.
 Answers 89

1.67 Domestic violence and children

C A B £ D
In this scenario, there are two parties involved, the patient in front of you
and the children at home. This changes the scenario because there are vulner-
able individuals at risk who may come to harm if you don't take action. The
General Medical Council's Confidentiality guidelines suggest that 'you should
usually abide by a competent adult patient's refusal to consent to disclosure,
even if their decision leaves them, but nobody else, at serious risk of harm'. In
this case, the children are potentially at risk so this can be ignored as disclosure
would be necessary co protect them from a risk of serious harm. This therefore
means that attempting co persuade the patient to inform the police herself (D),
although both polite and empathetic to the patient, ranks last as in practice, it
is unlikely to lead to this matter being brought to the attention of the appro-
priate bodies. Option C would be the first response as good communication
would hopefully build rapport with the patient at this difficult time. This is
quite a serious case, so involving senior colleagues early (A) would be appro-
priate. While treating the patient and then phoning social services (E) would
hopefully ensure the patient and her children's safety, it does not demonstrate
good communication and would be likely to harm the doctor-patient
relationship. Telephoning the police immediately (B) could help to protect
the children and would involve the patient in the process; however, further
discussion with senior colleagues would be appropriate before escalating the
situation.

Recommended reading
General Medical Council (2009), Explanatory guidance, Confidentiality,
paragraphs 51, 63.

1.68 Coffee house discussion

E D A B C
Breaking confidentiality in a situation like this is relatively easy because when
you are surrounded by your team, you can easily slip into discussing patients
and then disclose confidential information. It is important to remember other
potential breaches in this situation as well, for example leaving your list visible
for people to see. Option E is clearly the best response here as it is important
to make sure that the other doctor is aware of his mistake, but there is no
need co highlight this in front of the team in a public place (D). However, it
is better to mention the mistake in public than simply ignoring it completely
(C) or changing the subject (A) as the doctor may then not realise his error
and do it again. It is not appropriate to inform the patient (B) as it is not up
to you to point out someone else's mistake. In this scenario, it appears that no
one overheard the confidential information, so there is no need to push things
further and risk a complaint against the doctor and the team, although this is
perhaps better than saying nothing at all (C).
 90 Chapter 1: Commitment to Professionalism

Recommended reading
General Medical Council (2009), Explanatory guidance, Confidentiality,
paragraphs 12, 13.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 9: Confidentiality.

1.69 Case note security

B D F
Confidentiality is intimately related to information governance, which is what
chis case concerns. Patients' notes contain a lot of personal information and
therefore need respecting and protecting to ensure that people who are not
concerned with their care cannot look at them. Option B would be a good
response as this would discuss confidentiality in a non-confrontational way.
Reminding your consultant about the importance of confidentiality would
also be appropriate (D), bur it would need some courage to take this line with
your consultant. Suggesting that a trust-wide notice is distributed (F) would
be a good response as well since it will prompt not only your consultant but
also others within the trust to consider the confidentiality of case notes. Even
if it were true char the consultant was out of the office for a very brief rime
only (G), chis response doesn't involve doing anything about the potential
breach in confidentiality. Waiting outside the office (A) is also appropriate as
you shouldn't enter your consultant's office without permission when they are
nor there, which also means that option H is not a suitable course of action.
Assuming that no non-staff will come across the notes within the consultant's
office (C) may be true but is a very blase approach to take.

Recommended reading
General Medical Council (2009), Explanatory guidance, Confidentiality,
paragraphs 12, 13.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 9: Confidentiality.

1.70 Food poisoning

A D B C E
This question requires you to break patient confidentiality in the interests of
wider society. You must remember that food poisoning (if suspected to be
caused by a public eatery) is a notifiable disease and must be disclosed to the
relevant local health authority. ln this scenario, as an FYl, it is probably wise
to get advice from a senior with regard to notifying the relevant bodies (D);
however, the first priority should be patient care, and therefore, you need to
ensure timely, appropriate treatment is given first (A). If there is a delay in
seeking senior help, however, the next most appropriate action to take would
be to speak to the local authority yourself (B). It would also be sensible to let
 Answers 91 •

your colleagues know of the link between these cases (C), both as a matter of
courtesy and to maintain good communication within the team. Sampling the
restaurant's food (£) would be entirely inappropriate, and in this option, you
risk both yourself and others contracting and passing on an infection as you
fail to notify the authorities.

Recommended reading
General Medical Council (2013), Good Medical Practice, Duties of a doctor.
General Medical Council (2013), Good Medical Practice, paragraphs 11, 12, 22,
23, 50, 73.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 9: Confidentiality.
Public Health (Control of Disease) Act 1984, chapter 22.

1 .71 Discussing patients

D B E C A
This question focuses on the importance of maintaining patient confidentiality
both inside and outside the hospital. When you are not in your professional
capacity as a doctor, it is still your duty to maintain respect and confidentiality
for your patients. Your colleague's behaviour in this scenario is inappropriate,
both because he has written details about patients in public view and because
he is discussing them. It is therefore your duty to stop your colleague before
he reveals any more information. Option D is more appropriate than Bas it
is also necessary to remember that you should respect your colleagues and
talk to them in a polite manner. Talking to them in private would be a less
aggressive way of voicing your concerns. Reporting the FYl to his educational
supervisor (E) may be appropriate if you saw this repeatedly happen and
he appeared to disregard patient confidentiality multiple times. It is always
best to talk to your colleague first, however, before involving seniors. This is
more sensible than options C and A though, in which you are ignoring the
issue. As a doctor, your first priority should be the care and respect of your
patients. In no circumstances should you actively follow your colleague's
behaviour, as in option A, and even though in option C you are not divulging
confidential details yourself (which makes this mildly preferable to A), it would
be unprofessional to encourage this behaviour; instead, you should try and
prevent it from happening again.

Recommended reading
General Medical Council (2009), Explanatory guidance, Confidentiality.
General Medical Council (2013), Good Medical Practice, Duties of a doctor.
General Medical Council (2013), Good Medical Practice, paragraphs 20, 23, 36,
47, 50.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 9: Confidentiality.
 92 Chapter 1: Commitment to Professionalism

1.72 Disclosing to a third party

A B E
This question highlights the importance of maintaining patient confidential-
ity regardless of your personal connections with a patient. ln this scenario,
you should therefore discuss with the patient what he would be comfortable
with his relatives knowing (options A and B) and then explain politely to his
brother that you cannot divulge any information without express permis-
sion from the patient (E). As you have not had any prior instruction from the
patient to tell your brother about their admission (not to mention the fact that
your brother has said that his friend is refusing to say what is wrong), it would
be unprofessional to break this trust, as in options F and G. Similarly, asking
a colleague to do this is inappropriate as well (0). Directing your brother to
his friend (H) is not necessarily wrong as this would not break confidentiality;
however, by doing this you would also nor be explaining to your brother why
you are unable to say anything and the patient may not want to see any visi-
tors. Calling security (C) seems like an overreaction as your brother has shown
no signs of aggression, and this would be an inappropriate use of the security
ream, who may be required elsewhere.

Recommended reading
General Medical Council (2009), Explanatory guidance, Confidentiality.
General Medical Council (2013), Good Medical Practice, Duties of a Doctor.
General Medical Council (2013), Good Medical Practice, paragraphs 20, 31,
47, 50.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 9: Confidentiality.

1.73 Diabetes and driving

A D C E B
This question presents a situation in which you need to balance your profes-
sional duty to respect confidentiality with the need to protect the public. If
you are aware that a patient is driving illegally, you should do your best to
persuade them to inform the DVLA themselves (A); this would mean that you
did not need to break confidentiality. It would be unprofessional to inform the
DVLA yourself (B) without first giving the patient the opportunity to do this.
Reassuring the patient is a good idea (0) as it may help to alleviate any anxiet-
ies and hopefully help to persuade them chat honesty is the best policy, while
also showing both compassion and good communication skills. Written infor-
mation can be a helpful adjunct to this (C), but it should not be used to replace
a verbal discussion. You should also remember to provide information in a way
that the patient can understand. Obtaining advice from a senior (E) would be
appropriate if you are unsure how to handle the situation; however, a senior
house officer (SHO) or specialist registrar (SpR) is likely to be more accessible
to provide support (as would diabetes nurse specialists) and could potentially
therefore be a more practical source of advice than your consultant.
 Answers 93

Recommended reading
Diabetes UK (2009), Driving and Diabetes.
General Medical Council (2009), Explanatory guidance, Confidentiality.
General Medical Council (2013), Good Medical Practice, Duties of a doctor.
General Medical Council (2013), Good Medical Practice, paragraphs 11, 12, 23,
32,34,47,50,51, 71, 73.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 9: Confidentiality.

1.74 Media

A G H
You need to be careful how you share information with the press so as not
to be misquoted or be persuaded into giving your opinion on something you
cannot back up. As an fYl, you should not feel pressured into giving infor-
mation; if you do have concerns about the care in the hospital, it is better to
try internal reporting routes before speaking to the press. The best answers
in this scenario are those that are helpful to the journalist by directing
them to someone more senior who is able to provide more accurate and less
subjective information. This could be the hospital management (A), your
foundation programme director (G) or one of the senior clinical doctors (H).
It is important to remember that, if you are making comments in the public
realm in your capacity as a doctor, you should also declare yourself by name
and therefore remaining anonymous is not an option here (B). Lying or falsely
embellishing the real picture to the press (C) is unprofessional, and there have
been examples in the press of trusts, hospitals and staff who have augmented
reports and subsequently experienced adverse consequences. Hanging up the
phone (D) is rude and gives the journalist a poor picture of the behaviour of
staff at the hospital. Offering a private interview to the journalist (E) is risky;
if you really felt strongly about the matter, you should first seek advice from
your medico-legal insurer, your seniors and perhaps a medical union such as
the British Medical Association (BMA) about the limits of what you wish to
discuss. Deferring the call to a colleague (F) is unprofessional, discourteous
and again would give a false impression to the journalist of your opinion
regarding the matter.

Recommended reading
General Medical Council (2013), Explanatory Guidance Doctors' Use of Social
Media, paragraph 17.

1.75 Interpersonal relationships

D C B E A
This is a serious matter as the consultant is responsible for the training and
well-being of the staff working in their team, and it is therefore inappropriate
for them to be entering into sexual relationships with their junior colleagues,
especially not within the hospital grounds. The best thing therefore would
 94 Chapter 1: Commitment to Professionalism

be to report this matter to your foundation programme director and allow

them to take the matter further (D). Option C is preferable to B, as your FYl
colleagues may be able to give you more objective advice than the nursing staff
working on the ward. It should, however, be respected as a private matter, and
therefore, advice should be sought as opposed to simply gossiping about it.
Ignoring the situation {£) is better than option A, since accusing the consultant
of rape when you do not know the full story is a very serious allegation.

Recommended reading
Rughani G. (2012), When I kissed the consultant, BM} Careers. http://careers.
bmj.com/careers/advice/view-article.html?id=20007623.

1.76 Raising concerns

D A C B E
As this is an issue of patient safety, the worst choice would be to do
nothing(£). Ir would be best for the SHO ro raise their concerns themselves
(D) as you were not directly involved in the incident. Despite this, you can still
raise concerns yourself and indeed should do if you are not confident that the
SHO has done so. Your clinical supervisor, as your line manager, is the most
appropriate source of guidance (A) and can escalate the matter if necessary.
You should seek to address the issue within your organisation before going
to external bodies such as the GMC (C). However, it would be inappropriate
for you to contact the radiologist directly as this will seem confrontational,
particularly as you do not have a professional relationship with them, and your
concerns are based entirely on the reports of others (B). This option is worse
than those that involve using more formal channels ro investigate and address
the problem. However, it would still be preferable to contact the radiologist
than to do nothing (E) as it shows you are taking some action towards improv-
ing safety for future patients.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 43-44.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 11: Relating to colleagues, section: Raising concerns.
The UK Foundation Programme Curriculum (2012), section 7.1: Makes patient
safety a priority in clinical practice.

1.77 Actingon hearsay

A D C B £
Foundation doctors often spend a lot of time teaching medical students on the
wards and should be willing to do so. Additionally, medical students will often
need clinical skills and history-taking exercises to be 'signed off' by a doctor.
General Medical Council (GMC) guidelines explain that you must be honest
and objective when completing such assessments. In this case, it seems likely
that your colleague has not followed these guidelines. However, you should not
 Answers 95

act on your suspicions without first asking your colleague about what you have
heard. Option A is therefore the most appropriate course of action. Your clini-
cal supervisor will also be able to offer support as to what you should do (D).
Asking the students to repeat all of their clinical skills (C) may be purring
patient safety first, bur it would nor address the underlying issue char your col-
league is signing paperwork incorrectly. Informing the medical school dean (B),
without first addressing the issue with your colleague or supervisor, would be
inappropriate in this scenario. Conversely, ignoring rhe situation (E) could be
potentially dangerous and could lead to the students performing clinical skills
unsupervised and incorrectly.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 41 and 42.

1.78 Inappropriate requests

A D E B C
Treating friends and family should be avoided if at all possible when practis-
ing as a doctor. In chis scenario, offering an appointment for your friend and
his wife with another GP is the most appropriate response (A). This nor only
allows chem to be correctly investigated and managed bur also prevents you
from treating a friend, which could create a conflict of interest. Threatening
to inform the GMC (C) is rhe most inappropriate response in chis scenario as
your friend has not made a dangerous request, and chis is somewhat melodra-
matic and potentially inflammatory. Informing the GMC would not help the
situation and could prevent your friend and his wife from receiving necessary
treatment. Taking an accurate history and referring the case to your trainer is
another appropriate course of action (D), bur it is highly likely that they will
both need appointments to sec a GP in person regardless of whether he has a
further conversation with your trainer. Prescribing pain relief and asking him
co take his wife to the emergency department is the next best response (E) as
in doing so at least his wife will be properly assessed in person. Prescribing
antibiotics over the phone (B) is nor appropriate as you do not have enough
information to know whether the prescription is warranted (or whether the
patient has any drug allergies) without having seen and clinically assessed the
patient yourself.

Recommended reading
British Medical Association (2010), Ethical Responsibilities in Treating Doctors
Who are Patients.

1.79 Newspaper cutting of colleague

A C D E B
The GMC offers advice about openness with legal or disciplinary procedures.
GMC guidelines outline that you must inform the organisation without delay
if you have either accepted a caution, been charged with or been found guilty
 96 Chapter 1: Commitment to Professionalism

of a criminal offence. In this situation, the best course of action would be to

privately ask your colleague about the incident (A). Your colleague may have
already raised the issue with your seniors and the GMC without your knowl-
edge and approaching him privately could avoid any unnecessary distress.
Informing the GMC (C) would be the second best response as this would raise
the issue with the appropriate body, while not causing unnecessary distress
or embarrassment. Taking the article to work and confronting your colleague
on the ward round (D) would be an inappropriate way to raise your concerns.
However, waiting for a court verdict determining whether or not he is found
guilty (E) is nor in line with guidance as the GMC must be informed even if
an individual is only charged with a criminal offence. Finally, ignoring rhe
issue could be potentially dangerous and is nor in line with GMC guidance, so
option B is the least appropriate course of action.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 75.

1.80 Phony thank you's

E B C A D
Medicine is a competitive field, and doctors are always under pressure to be
the best. However, lying on your CV or fabricating qualifications or experi-
ence to gee a job is viewed very seriously by the GMC and is likely to result in
disciplinary action. The best response here is to advise your colleagues against
writing fake thank you letters (E), reminding them of the duties of a doctor to
be 'honest about your experience, qualifications and current role'. In this way,
you take steps to prevent your colleagues acting dishonestly as well as taking
a seep back from this situation yourself. The next best response is to decline
to be involved in writing the letters for each other (B), which means that you
are protecting yourself from dishonest practice. Your educational supervisor
would then be the next appropriate port of call (C) as they will be able to help
you to improve your CV honestly, although this response does little to prevent
your colleagues from potentially going ahead with their plan. Nevertheless, it is
better than jumping to conclusions and informing the GMC of their dishonest
practice (A) without any evidence since your colleagues may decide not to go
ahead with the letters. The worst response is to go along with the plan and get
involved in writing the letters yourself (D), which both goes against the guid-
ance of the GMC and means you commit professional misconduct.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 66.

1.81 Sexism

E B A C D
This scenario concerns workplace sexism and its effects on your colleagues.
It also tests your integrity since, as you are not the direct victim here, it
 Answers 97 •

would be easy to stand by and do nothing. The best response is option E,

to discuss this issue privately and outside of the clinical team with a person
who is likely to give impartial advice. Your educational supervisor would be
able to show you the correct channels if you decided to take this issue further
and how to do it tactfully. Speaking with another consultant in the team (B)
could be sensible, but there is a risk of partiality. Ideally, they should respect
and consider your point of view, but it could result in them automatically
defending their colleague. Option A, speaking directly to the consultant about
their poor conduct, may seem intimidating and outside the role of an FYl;
however, if you approached the subject carefully and respectfully, you may
find that the consultant hadn't realised that their comments were offensive,
and subsequently, they begin to treat your colleague better. Option A there-
fore ranks third. To encourage your colleague to raise this issue with the BMA
(C) is the fourth most appropriate response because although your union may
be able to give you advice on how to proceed with a complaint about sexism,
it does little to deal wirh the issue at hand, and you should attempt some
measures yourself to rectify rhe situation first. The least appropriate response is
to do nothing and advise your colleague to avoid your consultant to evade his
sexist comments (D). This shows a lack of integrity and respect for your col-
league as a doctor. By doing nothing it also implies that you are accepting this
behaviour as normal and condoning your consultant's actions.

Recommended reading
General Medical Council (2013), Good Medical Practice, Duties of a doctor.
General Medical Council (2013), Good Medical Practice, paragraphs 56-80.

1.82 Breast exam

E B D C A
This question focuses on the importance of gaining informed consent before
any type of procedure and asking whether a patient would like a chaperone
present for intimate examinations. Option E is the most appropriate initial
response as it is important that the patient understands why you wish to
examine the breasts and what it will involve. This should happen before
you find a chaperone (B), which should always be offered. Clear, accurate
documentation in medicine is vital, particularly in these types of situation
(D). If a patient declines a chaperone, it is even more important to state this.
All documentation should be done as soon as possible after the event. Leaving
this task for your SHO (C} would be unprofessional and shows a disregard for
clinical duties. However, it would not be as inappropriate as performing the
examination without informed consent or a chaperone (A).

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together.
General Medical Council (2013), Explanatory guidance, in Maintaining a
Professional Boundary Between You and Your Patient.
 98 Chapter 1: Commitment to Professionalism

General Medical Council (2013), Good Medical Practice, Duties of a doctor.

Genera] Medical Council (2013), Good Medical Practice, paragraphs 15, 17, 19,
21, 32, 36, 47, 57.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 5: Morality and decency.

1.83 Doctorharassing nurse

A B E
This situation requires a balance between maintaining respect for colleagues
and not jumping to make accusations with the duty to act if you suspect that a
colleague's behaviour may be inappropriate or jeopardising the safety of staff
or patients. In this scenario, it is therefore important that you give your col-
league a chance to explain their behaviour (E) but that you don't ignore what
potentially could be harassment (0). Reporting the FY 1 before hearing his side
of the story (options F and H) would be unfair and should only be resorted to
if there were subsequent causes for concern. You may, however, wish to speak
to a senior in confidence, and your educational supervisor would be best placed
to discuss this (A). The subject should not be shared with the other members
of your team (G) as this is unprofessional and is unlikely to help to solve the
dilemma. Offering support if the nurse wishes to talk in confidence may be a
sympathetic approach (B); however, if she does not wish to talk, you should not
force her (C).

Recommended reading
General Medical Council (2013), Explanatory guidance, in Sexual Behaviour
and Your Duty to Report Colleagues.
General Medical Council (2013), Good Medical Practice, Duties of a Doctor.
General Medical Council (2013), Good Medical Practice, paragraphs 23-25,
35-37, 59, 65, 68.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 5: Morality and decency.

1.84 Embarrassing colleaguephotos

C D E A B
This question focuses on the balance between a doctor's right to a private life
and their duty to maintain the public's respect and trust in the profession. This
is ever more important with the advent of social media. You should advise your
colleague to remove the photos from her public online profile (C) because if
they were seen by the wrong people, this could prove detrimental to her career
and the respect of the profession. She should also read the new guidance on the
use of social media (D) so that she is suitably able to maintain her professional
responsibilities alongside her right to a social life and online social interac-
tion. It may be appropriate to seek advice from a colleague if you are unsure
as to what to do (E); however, you should not spread this news among other
 Answers 99

ward staff as a means of entertainment (B}. Similarly, doing nothing would

not be conducive to upholding your professional duties nor maintaining good
working relationships (A). lf you are in a position to give advice or to support
colleagues, you should do so.

Recommended reading
General Medical Council (2012), Explanatory guidance, in Raising and Acting
on Concerns About Patient Safety.
General Medical Council (2013), Explanatory guidance, in Doctors' Use of
Social Media.
General Medical Council (2013 ), Good Medical Practice, Duties of a doctor.
General Medical Council (2013), Good Medical Practice, paragraphs 25, 34-37,
43, 59, 65.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 5: Morality and decency.
1.85 Patient-doctor relationship

D B C E A
This question deals with the relationship between doctors and their patients
and the duty to make the care of patients the first priority. A romantic relation-
ship between doctors and their patients may be seen as a breach of the natural
trust that exists in this kind of relationship, especially if the patient in question
is vulnerable. In this situation, it would be wise initially co ask your colleague
if he has any feelings cowards the patient or whether the attraction is one-sided
(D). If nor, he should be the one to talk to the patient about the reasons why
a relationship would be inappropriate (B). You should not encourage such a
relationship (A}, particularly as you have no evidence char both parties like
each other. Talking to the patient yourself (C) may be appropriate in some
situations, for example if you had good cause to believe that the patient liked
the doctor, but the doctor refused to acknowledge the situation. Regardless, it
is important to be open and honest with patients. Disclosing this information
co ocher colleagues (E) when you are unsure of the faces would be premature.
Ideally, you should talk to your colleague first and then if you have cause to
require further advice, a senior opinion may be appropriate at that stage.

Recommended reading
General Medical Council (2013), Explanatory guidance, in Ending YoHr
Professional Relationship with a Patient.
General Medical Council (2013), Explanatory guidance, in Maintaining a
Professional Boundary Between You and Your Patient.
General Medical Council (2013 ), Good Medical Practice, Duties of a doctor.
General Medical Council (2013), Good Medical Practice, paragraphs 16, 25, 31,
36,43,46-48,53,59,62,65.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 5: Morality and decency.
 1 oo Chapter l: Commitment to Professionalism

1.86 Gynaecology complaints

B C E
The most important matter here is that, if the patient was upset by an event,
those involved must apologise and explain their behaviour to the patient; most
complaints to the National Health Service (NHS) are the result of poor com-
munication. Therefore, the actions that you should take must ensure that your
consultant is aware of the problem (B) so that they can apologise personally.
You should also make sure that the registrar is aware of the problem (E) as they
too were involved and should discuss the matter with the consultant. While
you were not personally involved, as a member of the team, you can talk to the
patient and try and understand how they feel (C). Passing the issue on to one
of the nursing staff (A) is not very professional, although it may be useful to
have a member of the nursing staff present (as a chaperone) when you talk to
the patient. Leaving the matter (D) or telling the patient they are mistaken (H)
will not help to alleviate the patient's anxieties and may make matters worse.
Raising the matter at the next M&M meeting is important (F), but the matter
should be mentioned to the staff involved first. Recommending that the patient
make a complaint (G) may be appropriate if your consultant subsequently
refused to acknowledge the situation; however, they may not thank you for
recommending that a complaint be made about them before they have chance
to remedy the situation. As healthcare professionals, complaints should be
advocated only if all relevant bodies have been informed of the situation and
have neglected to take action to remedy the issues.

Recommended reading
Handling complaints poorly makes problems worse, says NHS ombudsman
(2010), BM], 341.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 5: Morality and decency.

1.87 Alcohol and misdemeanours

C D G
It is important to talk to the FYl, and this conversation should be conducted
in private to avoid embarrassing them (G). You should be kind and explain
why you are worried (C) rather than taking an accusatory approach (H). In
addition, it is important that you involve others in order to get support for
the FYl if needed and to ensure that there are no concerns over their fitness
to practice. The FYl's educational supervisor (D) is a better choice than
the foundation programme director (E) as an initial contact. You should
avoid discussing the situation with the other FYls {B) as there is no issue
here that you need to clarify with peer support, and it is more sensitive to
avoid spreading knowledge of the FYl's potential difficulties. It would be an
overreaction to contact the GMC at this stage (A). Observing them at the next
social event (F) would be irrelevant as you already know chat the FYl is getting
into trouble with their binge drinking.
 Answers 101 •

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 65.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 5: Morality and decency, section: Personal behaviour.

1.88 Sexist consultant

A C D E B
This scenario is difficult, given that it takes a fair amount of courage to chal-
lenge a senior colleague about his behaviour. The best approach would be to
get advice from your educational supervisor (A) as they can advise you from
outside the immediate clinical ream. This is a sensitive issue and their sup-
port may be important. In challenging rhe consultant's sexually inappropri-
ate behaviour, it is better for this to be done in private by a member of his
peer group (C), than in public by you as a junior (D). Option D could lead
to an escalating confrontation and have a lasting negative impact on your
working relationship. You should try to address the problem from within rhe
organisation before consulting external bodies (E), except where there are
serious concerns over fitness to practice. The behaviour of the consultant is
indecent and unacceptable as it constitutes sexual harassment, so the worst
option would be to take no action at all (B). As you are aware of these issues
regarding the consultant's behaviour, you have a responsibility to raise and
address these concerns.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 59.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter: Morality and decency, section: Employment.

1.89 Inappropriatecomments in mortuary

A B D
This situation is perhaps nor common, but it does have implications on a range
of other potential scenarios. The important factor here is ro act with discretion
and to put the comments into context. Despite the comments being inappropri-
ate, it is unlikely that any harm has been caused. However, if your colleague is
making unacceptable comments in the mortuary, this could be a sign that they
are acting unprofessionally in other situations. It is therefore important to flag
your concerns but to do this correctly and diplomatically. Discussing this with
the people who were involved (options A and D) would be most appropriate
and hopefully lead to this not happening again. Asking senior colleagues for
advice without mentioning the names of the people involved (B) could pro-
vide you with valuable advice without inadvertently escalating the situation.
Ignoring the comments would potentially let this behaviour continue without
challenge and would therefore be unsuitable (E). Reporting the situation to the
consultant in charge (G) or completing an incident form (C) would probably
be reacting excessively to a situation that could be dealc with more discretely.
 102 Chapter 1: Commitment to Professionalism

Informing the patient's family (H) would create unnecessary distress and not
be of any benefit in this scenario. Raising the comments in a large group and
implicating your colleague (F) would lead to uncalled-for conflict and distress
for your colleague.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 47, 48
and 50.

1.90 Recommending illegal substances

D A E B C
The priority in this situation is to provide help and support for your patient's
symptoms, while maintaining professional standards and practising within
the law. ln this scenario, your patient is clearly experiencing severe pain that
is not currently under adequate control. The best course of action would be
to acknowledge your patient's request for information, inform her that can-
nabis is illegal and offer more conventional alternative medications to help
with her pain (0). This option would ensure that you are not breaching the
law, while helping to control your patient's symptoms. Booking the patient
in for a further consultation (A) would delay the issue temporarily, but this
could equip you with some valuable advice and a plan from your educational
supervisor. Your educational supervisor could also offer advice on alternative
pain relief that could help your patient. Booking the patient into a specialist
pain clinic (E) could eventually help the patient with her symptoms; however,
in the primary care setting, you should attempt a wide range of medications
before referring her to secondary services. Refusing to talk about the situation
(B) ensures that you have not provided unprofessional advice, but it does not
address the patient's symptoms and offer any ways to alleviate them; therefore,
this is an inappropriate response. Advising the patient to rake illegal substances
(C), even for medicinal purposes, is not professional behaviour and should be
discouraged.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 1.

1.91 Smart phone pictures

A C E D B
This is a common scenario, where you are asked to perform a cask by a
senior doctor which may not be best practice. In this situation, the ideal
course of action would be for the hospital photographer to take the images
(A), which would ensure both that patient confidentiality is maintained and
that the images are of a suitable quality with adequate patient consent. Not
dressing a large, open wound is potentially very dangerous and could risk
introducing infection, therefore this is the least appropriate option (B). Taking
 Answers 103

a photograph of any part of a patient with or without consent on personal

photographic equipment is not advised, therefore options E and Dare both
inappropriate. However, transferring images via secure email servers (E) is
more appropriate than sending the images to a personal smart phone (D).
Refusing to cake the image may delay the operation (C), but with an appropri-
ate dressing, the patient will nor be at risk of infection, and the wound could
be assessed personally by the surgeon on arrival at the hospital.

Recommended reading
General Medical Council (2011 ), Explanacory guidance, in Making and Using
Visual and Audio Recordings of Patients, Principles.

1.92 Gift

C B D A E
The General Medical Council's (GMC) stance on this situation is perhaps sur-
prising: you may accept unsolicited goods from patients or their relatives (C) as
long as it does not affect or appear to affect the way you practise medicine, for
example your prescribing and referring practices. The guidance also states that
you should not use 'your influence to pressurise or persuade patients or their
relatives co offer gifts'. Accepting the card alone (B), however, may be appro-
priate if you feel uneasy about accepting a gift. The next best response is not
co accept either (D), but this is likely to be perceived as rude and ungrateful.
The GMC states that 'you must not put pressure on patients or their families
to make donations to other people or organisations', so option A would be
inappropriate. Asking the family to rake you out for a meal (E) would be rude
and could be perceived as not maintaining a professional boundary between
yourself and your patient and is clearly the least appropriate response.

Recommended reading
General Medical Council (2013 ), Explanatory guidance, in Financial and
Commercial Arrangements and Conflicts of Interest.
General Medical Council (2013), Good Medical Practice, paragraphs 77-80.

1.93 Terminationof pregnancy

B D E
During your time as a doctor, you may be asked to carry out or give advice
about procedures that conflict with your religious/moral beliefs. The General
Medical Council (GMC) advises that you do two things in chis situation:
'explain to patients if you have a conscientious objection' (E) and 'cell them
about their right co see another doctor' (BJ. You must make sure that they
can see another one of your colleagues soon, who can give impartial advice,
so option B is the most appropriate response. If this may cause undue delay
or is not possible, you should make the referral to a tertiary centre so that
they can have access to TOP services. In this case, you should also discuss
 104 Chapter 1: Commitment to Professionalism

the reasons why your patient wants to end her pregnancy (D), which would
show that you are not dismissing her decision. Advising her to take alterna-
tive options, such as adoption (A), is not appropriate as in doing this you
would be using your beliefs to influence her decision. Asking her ro take
another week to consider her options (C) would delay her abortion if she
should choose to go ahead with the TOP, especially if this would mean that
another colleague would have to make the referral. The Royal College of
Obstetricians and Gynaecologists (RCOG) guidelines state that 'the earlier
in pregnancy an abortion is performed, the safer it is'. Refusing to refer the
patient (G) would deny the patient her right to access abortion services.
Giving the patient written information about TOP (F) may be useful, but
in the first case, she should be given access to services and the opportunity
to discuss with a colleague without a conscientious objection ro abortion.
It is unclear in the RCOG guidance whether signing the abortion certifi-
cate (H) is covered by the 'conscientious objection' clause but not signing
the certificate is unlikely to be an issue as long as your patient has access
without delay to TOP services.

Recommended reading
British Medical Association (2007), The Law and Ethics of Abortion - BMA
Views, Parr 1: Legal considerations.
General Medical Council (2013), Good Medical Practice, paragraph 52.
Royal College of Obstetricians and Gynaecologists (2011), The Care of
Wo1nen Requesting Induced Abortion, Evidence-based Clinical Guideline
Number 7, sections 3.3, 4.3 and 4.7.

1.94 Aggressive patient

C D G
While this is not your patient and your shift has finished, you still have a
professional responsibility to ensure the safety of both the patient and the
public. It would therefore be irresponsible to continue walking to your car (F).
It is unlikely that you are going to be able to manage the situation alone, so it is
reasonable to call both the police and the hospital security (options C and D).
You do not know why the patient is behaving in such a way, so it would be
inappropriate to call the psychiatric team at this point (E), although they
may require psychiatric input in the future. You should not try to approach
the patient (A) as you risk provoking him and putting yourself at risk, and
similarly, you should not ask passers-by to help you restrain him (B). Telling
the patient to stop damaging the cars may also worsen the situation (H).
You should instead try to prevent others from approaching him (G).

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 65.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 3: Professionalism and integrity, chapter 5: Morality and
decency.
 Answers 105

1.95 Racist comments

B A E D C
Racial discrimination is unacceptable in any walk of life and should not
be tolerated. In this scenario, you should therefore make it clear to the
registrars that their behaviour is unacceptable (B). This is a difficult situation,
particularly since it involves an issue with your senior, so it would be a good
idea to ask your educational supervisor for their advice (A). Printing some
GMC guidance (E) does not properly address the problem, but it is preferable
to doing nothing (D). Informing the consultant of the comments made about
them (C) is inappropriate. Knowing about the comments will only serve to
upset or anger them and does not improve the situation.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 36, 59.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 5: Morality and decency.

1.96 Child protection

C B E D A
This question deals with the issues surrounding child protection but is com-
plicated by issues of confidentiality. The abuse outlined in the question is
severe, including burns and head injuries. Sending this patient back into such
a dangerous environment would be irresponsible, and it is your duty as a
doctor to protect children from harm. The confidentiality of children should
be respected and given the same weight as that of adults. However, Good
Medical Practice states that you should 'disclose information if this is neces-
sary to protect the child or young person, or someone else, from risk of death
or serious harm', and this is the case here. Getting advice from an expert on
how ro protect this child from danger is the best response (C). Offering sup-
port for the child while he makes the disclosure to his parents (B) is the next
best response; this keeps the parents informed and also allows you to ensure
appropriate safeguards are put in place. Option Eis the next best course of
action since social services may be able to give help and advice to this child,
but it would be best to discuss the breaking of confidentiality with a senior
Caldicott Guardian before doing so. A Caldicott Guardian is a senior person
responsible for protecting the confidentiality of patient information, and each
NHS organisation is required to have one. Calling the police {D) is a rash deci-
sion to make, and you should not jump to this conclusion without using the
proper channels of support first; however, it would be better than doing noth-
ing (A) and allowing a child to return to a knowingly violent situation which
may result in serious harm.

Recommended reading
General Medical Council (2013), 0-18 Years: Guidance for all Doctors,
paragraphs 44-52, 56-63.
 106 Chapter 1: Commitment to Professionalism

1.97 Relationships

F G H
This question raises the issue of personal relationships with patients,
particularly romantic relationships. Using your professional position to gain
a romantic relationship goes against many of the duties of a doctor. The main
issue in starting a relationship with an ex-patient is the implication that you
may have acted dishonestly during your professional relationship in order
to develop a personal one. There is also the wider implication of patients
not being able to trust their doctors if doctors view patients as potential
partners. The GMC's Good Medical Practice (2013) states: 'If a patient
pursues a sexual or improper emotional relationship with you, you should
treat them politely and considerately and try to re-establish a professional
boundary.' Accepting a phone number with the intention of developing a
relationship with this patient (E) is absolutely inappropriate as you have a
strong professional responsibility for this patient. Accepting the number with
the hope of making other personal gains, such as publications (C), is similarly
dishonest and inappropriate. Accepting the number with no intention to call
(options A, B and D) is also dishonest, as well as nor trying to re-establish a
professional boundary, and these responses are therefore inappropriate. The
only appropriate responses involve refusing the phone number (options F, G
and H). This should be done with the utmost respect and a clear explanation
of why a personal relationship cannot occur (G), bur it is still better to refuse
the number honestly and bruise the patient's feelings somewhat (F and H) than
to be dishonest with them.

Recommended reading
General Medical Council (2013), Explanatory guidance, in Maintaining a
Professional Boundary Between You and Your Patient.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 5: Morality and decency.

1.98 Colleague missing teaching

C E B A D
This question requires you to act professionally and not to judge colleagues
based on hearsay, while also remembering that you have a duty of care to your
patients. Participating in training courses is a necessary GMC requirement in
order to keep your skills up to date. Asking your colleague for an explanation
would be the most appropriate first step (C), followed by some polite advice to
come in if at all possible (E), which shows compassion for your colleague and
a genuine consideration for their learning. Seeking advice from colleagues is
good practice when dealing with professional dilemmas (B) and is more appro-
priate than telling the programme director before you have spoken to the FYl
in question (A). Spreading rumours about your colleague is unprofessional and
seeks to achieve nothing except embarrass the individual (D).
 Answers 107

Recommended reading
General Medical Council (2012), Continuing Professional Development;
Guidance for All Doctors.
General Medical Council (2013), Good Medical Practice, Duties of a doctor.
General Medical Council (2013), Good Medical Practice, paragraphs 1, 8-10,
12,24,25,36,43,59,65.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 3: Professionalism and integrity.

1.99 Prescribing error

D A B E C
Making mistakes is inevitable in medicine, and this question assesses your abil-
ity to respond to such a situation in a professional manner. It is firstly important
to own up to your mistake and to prevent any further harm to the patient by
ensuring that the drug is crossed off the drug prescription chart (D). It is then
also courteous to reassure and apologise to the patient (A). Informing the nurses
(B) is nor as important a priority as both of these actions since crossing the drug
off the prescription chart should prevent the antibiotic being given. While it
may be important to explore and reflect upon your mistake with other members
of your ream and to come up with ways to ensure it doesn't happen again (E),
chis is not a priority at the moment. Denying knowledge of the mistake (C) is
dishonest and unprofessional, even if you do prevent the antibiotic from being
subsequently administered. One should always own up to mistakes.

Recommended reading
General Medical Council (2012), Continuing Professional Development:
Guidance for all Doctors.
General Medical Council (2013), Good Medical Practice, Duties of a doctor.
General Medical Council (2013), Good Medical Practice, paragraphs 1, 16, 22,
23,25,32,36,37,55,61,65,68.
General Medical Council (2013), Good Practice in Prescribing and Managing
Medicines and Devices.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 3: Professionalism and integrity.

1.100 Receiving a gift

E A B D C
The GMC recognises that doctors are sometimes given gifts by patients as a
thank you for the care they have received. It is not inappropriate to accept these
gifts, so long as you are honest and open about it and do not let it influence the
care you provide. It is wrong, however, to ask for inducements in return for an
altered standard or programme of care. Option E is therefore most appropriate
as you are declaring the gift to your supervisor. This may well be a good course
of action as a more junior doctor. You may want to share it with the team (A)
 i
• 108 Chapter 1: Commitment to Professionalism
l

if you feel uncomfortable about keeping it to yourself, but you should declare
this to the patient. If you feel unable to accept the gift, you should politely
decline (D), but you could suggest that the hospital charity may be a more suit-
able recipient (B). Ir would be inappropriate to rake the patient out for a meal
with the money (C) as this would be breaching the professional doctor-patient
relationship and may potentially lead to a conflict of interest.

Recommended reading
General Medical Council (2013), Explanatory guidance, Financial and
Commercial Arrangements and Conflicts of Interest.
General Medical Council (2013), Explanatory guidance, Maintaining a
Professional Boundary Between You and Your Patient.
General Medical Council (2013), Good Medical Practice, Duties of a doctor.
General Medical Council (2013), Good Medical Practice, paragraphs 16, 46, 53,
56,59,62,65, 77-80.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 3: Professionalism and integrity.

1.101 Colleague's appearance

A F G
Appearance is an important part of being a doctor and ensuring that people
trust you as a professional. Ir is difficult to address these things with your col-
leagues, so you should bear in mind how you would like to be told if this were
the case for you. Therefore ensuring someone discusses the matter privately and
diplomatically with the FY2 is appropriate. Since the nursing staff are unhappy
with the situation, they or their immediate senior (the sister in charge) will be
the best placed to bring up their concerns (options A and G). The other thing to
ensure is that the FY2 doesn't have any problems at home distracting him from
his professional appearance (F). lf these responses did not solve the issue, then
it may be appropriate for you to intervene (H). The other options here involve
talking about the colleague with others (options B and C), which is not ideal
and may be seen as gossiping. Simply leaving the matter (D) is not good for your
colleague as looking unprofessional affects the trust of the doctor in the eyes of
the public. Telling the consultant about the nurses' thoughts is a possible course
of action (E), but it is a bit drastic and also isn't likely to help the situation.

Recommended reading
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 3: Professionalism and integrity.

1.102 Keeping promises

B A D C E
This scenario has to do with keeping your promises to patients. Ir is very easy
co make promises to patients and often very difficult to keep them! Option Bis
ranked the highest in this case as it involves an apology to the patient. This is
 Answers 109

always the most important thing to do when you fall short in people's expecta-
tions. In addition, you need to remember to have boundaries from letting your
work impact your private life, so it is appropriate to wait until the morning to
give the patient her results (B). For the same reason, calling the night-time FYl
(A) ranks higher than going back into work co give the patient her results (DJ
because your shift has ended. Completely dismissing the patient's concerns
and disregarding your promise (E) ranks lowest here as this is unprofessional.
However, lying to the patient co make you seem like you are keeping your
promises (C) is very inappropriate, so it must also be ranked low.

Recommended reading
General Medical Council (2013), Explanatory guidance, in Delegation and
Referral.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 3: Professionalism and integrity.
1.103 Hungover

E C D A B
If you know that you are going to be unfit for work the next day, you should
be honest about this so that alternative arrangements can be made (options
E and C). le is best for you co try to make up for your mistake by arranging
for cover so that you have not lee your colleague down (E). Option Cleaves
your colleague with the stressful job of trying to find someone else co work.
The lower ranking responses (options D and A) involve not dealing with the
problem that evening, but they at least include the proviso that you will not
work if it is not safe to do so. However, if you do not communicate this deci-
sion to the hospital until the morning, the hospital may be left with inadequate
cover, or the night FYl could have co stay until a locum can be brought in.
Option D is preferable to option A because if you do end up calling in sick, at
least you have been responsible enough to go home and try co be well for work
(D) than co give up entirely (A). The worst response is co go to work when you
are hungover (B) as this is both a risk to patient safety and likely co undermine
patients' trust in the medical profession if you look unwell or smell of alcohol.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 25.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 3: Professionalism and integrity, section: Unprofessional.

1.104 Train late

C E A D B
lf you know that you are going co be late for work, you should let your col-
leagues know chat there is a problem as soon as possible (options C and £).
This is polite and responsible and allows for them to plan around your absence.
It is better for you to follow official channels and inform the registrar (CJ
than to pass the message through one of your peers (E). Leaving it until you
 110 Chapter 1: Commitment to Professionalism

get to work to apologise in person (A) means that, until you arrive, your team
will have been left wondering whether you were coming in at all. Emailing
your supervisor is an attempt at being open about the problem (D), but you
have no idea whether they will see the message, and it is therefore useless to
the team who are expecting you. It is this ward team predominantly that you
need to apologise to, which is why option D ranks lower than option A. The
worst approach is to be dishonest and rake the day as a sick day (B) as you are
perfectly capable of working and would just be joining the team slightly later in
the morning. It is an attempt to make up an excuse and avoid criticism, which
is unprofessional and brings your integrity into question.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 68.
The UK Foundation Programme Curriculum (2012), chapter 1: Professionalism.

1.105 E-learning certificateplagiarism

E G H
£-learning is a key part of the foundation programme, with most hospital
trusts running comprehensive induction modules online. These modules must
be completed within the deadline set and not only improve personal knowledge
and skills but also help to boost patient safety. In this scenario, it is unlikely
that completing the equality and diversity module will affect your colleague's
patient care in the shorr term, but it would be unprofessional to allow him
to pass your work off as his own. The best course of action in this scenario
would be to offer your colleague several solutions to his problem without act-
ing unprofessionally yourself. Offering the use of your own laptop to a close
friend would be entirely appropriate (G), and it is good practice to offer help to
colleagues in dif ficulry. If your colleague contacted his foundation programme
director and explained the situation (H), it is probable that they would be
understanding and offer an extension to the deadline in these extenuating cir-
cumstances. While attending work out of hours should not be done regularly,
in this scenario, completing the module in your colleague's own time before
his morning commitments would also be suitable (E). Part of the specifications
of a foundation doctor is being able to judge when it is appropriate to report
incidents that may affect patient safety and when a private conversation would
suffice. In this case, contacting your colleague's educational supervisor would
be rather extreme and unlikely to help the situation (C). Similarly, contacting
a senior colleague (B) is nor necessary, when you can easily suggest solutions
to the problem yourself. Allowing a colleague to copy work or certificates (A),
regardless of their perceived importance, is poor practice and is unacceptable
under any circumstances. Reprimanding your colleague (D) wouldn't help
the situation and would be more likely to damage your relationship with him.
Equality and diversity are extremely important factors in the modern NHS,
and knowledge of NHS policy is a prerequisite for practising as a doctor in the
United Kingdom; therefore, not completing the module (F) is not an option.
 Answers 111 e
Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 56.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 3: Professionalism and integrity.

1.106 Illegible colleague signature

C D A B E
General Medical Council (GMC) guidance suggests that: 'You must be
familiar with your GMC reference number ... (and) ... make sure you are
identifiable to your patients and colleagues. All entries in medical notes must
include a date, time, signature, full name, GMC number and contact number'.
This information allows fellow healthcare professionals to easily contact
one another to discuss cases. In this scenario, your colleague has clearly nor
been documenting the necessary information. The simplest and most appro-
priate course of action is to ask your colleague to document the required
information in the notes (C). Using a rubber stamp is a quick and easy way of
documenting this, and it is offered by many NHS trusts. It is always best for
your colleagues to take responsibility for their own behaviour, and therefore,
it would be better for them to contact human resources (D) rather that you do
(A). Offering to carry out all the writing tasks on the round (B) would solve
the problem of documentation, but this would not confront the central issue
of your colleague's poor documentation, so this is the second last appropriate
option. Retrospectively documenting your colleague's details in the notes
yourself would be unacceptable (E) and therefore this response ranks last.
This is because the entry has been signed by your colleague and any additions,
regardless of their content, should be completed by your colleague. Adding to
the documentation of others without their permission is both unprofessional
and could lead to medico-legal difficulties.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 13 and 35.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 3: Professionalism and integrity, section: Unprofessional.

1.107 Diarrhoea and vomiting

D B E A C
The symptoms of acute diarrhoea and vomiting indicate an infectious gastro-
enteritis episode, for example rotavirus or norovirus. If you attend work with
these symptoms, you pose an infectious risk to hospital patients, which could
result in adverse health outcomes for your vulnerable patients or in the worst
case scenario the closing of some hospital wards, which would negatively affect
patient flow and the general efficiency of the hospital. Many, if not all, trusts
have an infection policy whereby staff are required not to attend work until
48 hours after diarrhoea and vomiting have resolved, if it is suspected to be
due to infection. Therefore, the most appropriate course of action would be
 112 Chapter 1: Commitment to Professionalism

option D: calling into work that evening t0 inform the appropriate member of
staff that you will not be able to attend work the following day. This gives the
hospital a chance t0 try and find a replacement for your working role for the
weekend; postponing the call till the next morning (B) will decrease the chance
of finding a replacement. Informing the HPA (E) is inappropriate as you have
no evidence of infectious disease; on the other hand, if symptoms continue, you
may have tO provide a srool sample to your GP or occupational health depart-
ment. Going into work and avoiding patient contact (A) is unlikely to be feasi-
ble or practical, and this would also pose an infectious risk to your colleagues.
Option C is the least appropriate option as good hand hygiene and medication
are not fail-safe measures in stopping the spread of infectious gastroenteritis.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 28.

1.108 Prescribing for a friend

B C D
Prescribing for yourself, your friends or your family is something rhar should be
avoided if at all possible. In this scenario, however, there is little other option
because not prescribing the antibiotic (E) may result in a more severe, systemic
infection. The correct answers are to gain a more thorough history (B), including
any allergies to medicines, so as to exclude anything more serious, to prescribe
the antibiotic (D) and to inform her GP on Monday (C). The General Medical
Council (GMC) states that, if you prescribe medication for someone close t0 you,
you need to make a record at the time, which includes your relationship to the
patient and why it was necessary for you tO prescribe the medication. Then you
are required to tell the patient's GP which medicines you have prescribed and any
other necessary information. Option A, advising your friend to take on lots of
fluids, is unlikely to treat the infection and may risk rhe infection becoming sys-
temic. Option F, raking a urine sample t0 the laboratory, is not the first priority
in a simple UTI, and it would be logistically difficult to chase the results. Taking
her tO the emergency department (G) is likely to result in an antibiotic prescrip-
tion but would be an unnecessary use of resources as this is neither an accident
nor an emergency. Option H, making her wait until Monday to see her GP, may
be appropriate but runs the risk of her infection becoming more systemic.

Recommended reading
General Medical Council (2013), Good Practice in Prescribing and Managing
Medicines and Devices, paragraphs 14 and 17-19.

1.109 Dress code

D B A E C
A doctor should epitomise respectability and part of this involves adhering to
a smart dress code. Dressing professionally encourages trust and respect from
both patients and colleagues. Jeans are unlikely to look smart in a hospital
 Answers 113

environment and are therefore not advisable. In this scenario, it is appropriate

to suggest to your colleague that she considers wearing something other than
jeans (D). Option B, doing nothing, is the next best response. While this does
not address your concerns, it is better than the remaining options which have
the potential to cause problems. It is, after all, your colleague's responsibility
rather than yours to maintain her own appropriate attire. You should not seek
the opinion of other team members (A) since this could be seen as gossiping
and does not improve the situation. Similarly, it is not your place to criticise
your colleague in front of your consultant (E); if the consultant has a problem
with a team member's dress, then they will deal with it of their own accord.
The most inappropriate option would be to wear jeans yourself simply because
someone else does, especially as you feel that this is an inappropriate dress
code (C).

Recommended reading
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 3: Professionalism and integrity.

1.110 Other commitments

A F G
Commitment to a specialty and an ambitious character are valuable and admi-
rable traits in a junior doctor; however, your primary commitment should be
to your current clinical job. The correct responses in this question are those
that mean your day job is covered safely. Option G, trying to swap shifts, is
sensible; swaps can frequently be made within the on-call rotas of specialties
without difficulty, although the rota coordinator should be informed of this.
Option F, asking for a few hours off, is also appropriate as your registrar will
know how busy the day is likely to be and may be able to cover your absence
safely for a couple of hours. Sharing the work with your supervisor (A) is also
an appropriate course of action as it will allow you both to have a proper
night's sleep so that you are capable of working tomorrow and able to give your
personal input into the project. Sacrificing your sleep to complete the project
and going to work tired (H) puts patient safety at risk and is therefore inap-
propriate. Calling in sick when you are well (B) is dishonest and means that the
shift is understaffed, so it is therefore unacceptable. However, while your day
job is important, you should not sacrifice important career-progressing events
without trying out other options first, so abandoning your project (C) is unsuit-
able. Turning off your bleep while at work (D) is dangerous and puts patient
safety at risk. Finally, but perhaps most importantly, it should not be forgotten
that fabricating study data (E) is dishonest, risks your professional General
Medical Council (GMC) licence and shows a complete lack of integrity.

Recommended reading
British Medical Association (updated 2013), Medical Ethics Today (3rd ed.),
chapter 21: Reducing risk, clinical error and poor performance.
General Medical Council (2013), Good Medical Practice, Duties of a doctor.
 114 Chapter 1: Commitment to Professionalism

1.111 Domestic violence

E B D C A
If a competent adult does not consent to a disclosure, you must respect their
decision even if it leaves rhem at risk of harm. This is providing that nobody
else (such as a child) is at risk of harm. You should therefore reassure the
patient that you do not intend to break her confidentiality (£). In doing so,
you may improve her trust in you and in turn promote a more open discussion
about her situation. Whilst you should not pressure the patient into consent-
ing to a disclosure, you should provide encouragement (B). Giving information
about further support, such as a charitable organisation is also appropriate (D).
Contacting the police without rhe patient's consent is a breach of confidential-
ity and particularly inappropriate if you have nor informed the patient of your
intention to do so (C, A).

Recommended reading
General Medical Council (2009), Confidentiality, paragraph 51.
1.112 Patient discrimination

A D E C B
This scenario presents a potential conflict of interests: that of ensuring that you
attempt to remain impartial and nor judge the behaviour of your colleagues
whilst ensuring the best standard of care for patients, free from the risk of dis-
crimination. Ideally in this situation, you should tell the nurse that she should
speak directly to the FYl in question (A). You should not immediately act as
a third party between the two colleagues. However, it is also important to get
both sides of the story, and therefore, it might be courteous to speak to the FYl
in person if you feel that their behaviour poses a threat to the quality of patient
care (D). Ir would be unfair to go straight to their educational supervisor with
a report based on hearsay and no actual evidence of wrongdoing, and there-
fore, option B is the least appropriate. Speaking to the patient may be a sensible
option if the nurse was very worried about the FY1 's conduct (E) and if you felt
that there was a potential case of discrimination; however, likewise, you should
encourage the nurse to act upon her concerns directly. Speaking to a senior in
confidence for advice before making any decisions (C) may be one of the last
resorts if you are really unsure how to proceed.

Recommended reading
General Medical Council (2013), Duties of a Doctor.
General Medical Council (2013), Good Medical Practice, paragraphs 23-25,
31, 35, 36, 48, 54, 56, 57, 59.
General Medical Council (2009), The New Doctor.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapters 7 and 11.
 Answers 115

1.113 Criticising collegueson hearsay

A B D
This question focuses on balancing your responsibility to raise concerns if you
believe patient safety is at risk, to maintain the public's trust in the profession
and to not judge colleagues unfairly on the basis of hearsay. In this situation, as
you have overheard his comments firsthand, it would be appropriate to speak
to your colleague about his conduct (A); however, it would be unprofessional to
interrupt the consultation (E). You have a duty to raise the issue, and monitor-
ing the situation as it evolves {C) would therefore neglect your professional
responsibility. Explaining your concerns {D) and suggesting that he apologises
to the patient, thereby maintaining good communication whilst acknowledg-
ing a mistake, would also be suitable {B). Reporting your colleague to seniors
before speaking to him and giving him the chance to rectify the situation
would be premature (options F and G). If you saw this behaviour repeated, it
may be appropriate to then speak to your supervisor for advice. Speaking to
the A&E doctor in question is not appropriate at this stage {H) as your behav-
iour would amount to adverse judgement based on hearsay, and it is not your
place to get involved.

Recommended reading
General Medical Council (2012), Raising and Acting on Concerns About
Patient Safety.
General Medical Council (2013), Duties of a Doctor: Maintaining Trust.
General Medical Council (2013), Good Medical Practice, paragraphs 24, 25,
35-37,54-56,59,61,65,68.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapters 7 and 11.
2 Coping with Pressure

Chapter 2
COPING WITH PRESSURE

QUESTIONS
2.1 Forgotten patient review

You are an FYl in general surgery. A nurse calls you to ask you to review a
patient whom she is concerned about. You agree but tell her that you are very
busy and that you'll have to come later. As you arrive into work the next day,
you realise that you completely forgot about it and have not reviewed the
patient.
Choose the THREE most appropriate actions to take in this situation.
A Apologise to the nursing staff.
B Claim that you did review the patient and that the nursing staff must have
lost the documentation.
C Create a jobs list.
D Do nothing; the nursing staff will contact you if they need you again.
E Go to the ward and check that the panenr is alright.
F Inform your consultant of your error.
G Tell the nursing staff that they should have bleeped the on-call doctor if
they were concerned.
H Write your review and time it as yesterday.

2.2 False statement

A colleague approaches you to tell you that a patient's relative has made a
complaint against her for the way that she spoke to him on the phone. You
have found her to be a hardworking, professional and polite colleague, and
you are aware of this relative and know that he is very difficult. She asks you
to make a statement to say that you were witness to her making the phone call
even though you weren't present.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Make a complaint against your colleague ro a senior.
B Make the statement that you heard the conversation.
C Refuse to make the statement.
 118 Chapter 2: Coping with Pressure

D Refuse to make the statement but offer to submit a general report about her
professional behaviour.
E Speak to the relative and tell them that their complaint is inappropriate.

2.3 Nursing pressure to refer

You are the FYl doctor working in a busy emergency department, and you
have just arrived for the morning shift. There are ten patients to see from
the night shift who are going to breach in less than 30 minutes. As you pick
up the notes before going to see the most urgent patient, the sister in charge
approaches you and says 'can you refer them to the surgeons quickly please, it's
where all rhe patients wirh abdominal pain need to be referred ro'.
Choose the THREE most appropriate actions ro rake in this sicuarion.
A Approach the patient, apologise for the delay in seeing a doctor and rake a
history and examination before referring the patient ro the surgeons.
B Document that the sister has behaved inappropriately.
C ignore the remark and go to assess the patient.
D Irnrnediately inform the consultant in charge that the sister is behaving
inapproprrarcly.
E Inform the consultant in charge that you are unlikely to be able to safely
see and refer this patient in rime because the night shift was busy, and the
patient has already been here for three and a half hours.
F Politely inform the sister in charge that you need to rake a proper history
and examine the patient before referring them to ensure the safest and most
appropriate care for char patient.
G Refer the patient to the surgeons and then quickly take a history.
H Refuse to see the patient as they are likely to breach anyway and you could
try and prevent others breaching by seeing them first instead.

2.4 Audit presentation

You are an FY l working ar a large teaching hospital. You have carried our an
audit wirh one of your FYl colleagues and have been invited to present your
findings at the large annual departmental audit afternoon. You are working
nights the week of the presentation, so you had agreed with your colleague that
she would attend and deliver the presentation so that you could go home and
rest. On the morning of the presentation she sends you a text message explain-
ing rhat she doesn't feel well and is unable to present the audit that afternoon.
Rank in order the following actions in response ro this situation (l = Most
appropriate; 5 = Least appropriate}.
A Reply to your friend that you don't feel iris fair for her to leave you in this
situation and that if she is at all able to she should come in as planned.
B Go home, and email the meeting chair saying that you are both unwell and
won't be able to give the presentation.
 Questions 119

C Go home, and if you bump inro rhe meeting chair in rhe future, say that
you had forgotten about the presentation.
D Find the meeting chair and ask if you can be moved to the end of the meet-
ing so that you can rest longer during the day.
E Keep your assigned slot for the presenrarion and ensure that you are able to
get a few hours rest either side of it.

2.5 Prioritization

You are an FYl currently working in a general medicine job. One evening you
are on call, covering all of the medical wards. You are seeing a patienr who has
a temperature and whose blood pressure has dropped. You receive a bicep from
rhe ward you are usually based on about a patient under your day ream. The
patient's family is asking to speak to a doctor for an update. You are aware
that there have been some difficulties with this family who are unhappy about
how long it is taking to reach a diagnosis for the patient.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Tell the nurse char you are on call dealing with emergencies and cannot
come to see the family.
B Ask the nurse to explain ro the family that you would be happy to speak to
them, but as you are on call, you cannot guarantee how soon you will be
free, bur they are welcome co wait if they wish.
C Ask the nurse to apologise to the family and explain that you are on call
and cannot speak ro them this evening. Suggest a rime rhe following after-
noon for a scheduled family meeting.
D Call your senior house officer (SHO) and tell them that you need them to
rake over looking after the sick patient so that you can go speak to the
family.
E Call the registrar on call and ask them to go and speak to the family.

2.6 List of jobs

You are an FYl on call over the weekend in general medicine. It is very busy,
and you have a list of tasks to complete. There is a patient who needs their
bloods checking over the weekend, a task which was handed over by a ward
doctor on Friday. A nurse has called you because they are worried about a
patient who is deteriorating rapidly. Another nurse calls you to tell you that
their patient does not understand the rationale behind a new medication that
they have started and wants to discuss it with a doctor.
Rank in order the following actions in response ro this situation (1 = Most
appropriate; 5 = Least appropriate).
A Do all the jobs as quickly as possible.
B Tell the nursing staff to bleep the on-call senior house officer (SHO).
 120 Chapter 2: Coping with Pressure

C Ask the nursing staff for more information on the patient who requires
their bloods checking and see if anyone else would be able to do this.
D See the patient who is deteriorating as soon as possible.
E Inform the nurse that speaking co patients about their new medication
which has already been started before the weekend is inappropriate and nor
an on-call job.

2.7 Seeking help

It is your first week of a job in paediatric surgery. You arc on call in the evening
when you are asked to see a boy who is bleeding heavily after a tonsillectomy.
You call your registrar who is at home, and they advise you to try conservative
treatment. You do this, but it does not stop the bleeding, and you are con-
cerned that he is losing a lot of blood and will soon become haemodynamically
unstable. When you call the registrar back and explain char you think the boy
needs to go ro theatre, they refuse to come in and review the child and instead
advise you to continue your conservative management. You do not feel experi-
enced enough to manage the patient alone and remain concerned that he needs
to go to theatre urgently.
Rank in order the following actions in response to this situation (1 Most =
appropriate; 5 = Least appropriate).

A Ask the medical registrar for help.

B Ask the on-call a naesrherist for help.
C Call the consultant and ask him to come and review the patient.
D Call the registrar back, explain the situation again and insist that he come
in and review the child.
E Continue conservative measures and wait to see if they have an effect.

2.8 Coping with pressure

You are the FYl working on a surgical unit covering patients on three dif-
ferent wards. The other FYl in your team has phoned in to let you know
that they are unwell and will be away from work for the next two days.
This has therefore left you alone on the wards to cover the jobs. There are
also two senior house officers (SHOs) on the firm: one who is working night
shifts, the ocher who is scheduled robe in theatre sessions both today and
tomorrow. You note that the other surgical team in the hospital have the
same number of patients and both FYls are present. You are struggling to
manage seeing borh unwell patients and co complete discharge letters for
patients and feel that you will need to stay late both days to complete all
the jobs.
Choose the THREE most appropriate actions to take in this situation.

A Ask the FYls on the other ream if they can help you co complete some of
your jobs.
B Ask the night FY 1 to stay late to help you clear the discharge letters.
 Questions 121 •

C Ask the SHO if rhey would be able ro leave rhearre and help you with rhe
jobs.
D Call the F Y l at home and let them know that they need ro come into work
regardless of their health.
E Call the rota coordinator and request rhar they call in a locum to help.
F Leave the discharge summaries for the night ream to complete.
G Prioritise seeing ill patients over the discharge letters.
H Stay late for the two days.

2.9 FY1 on call

You are the FYl on evening call for surgery at a districr general hospital, cover-
ing both the wards and the admission unit. You have been made aware that
there are three admissions waiting robe seen, bur you are caught up looking
after sick patients on the ward. Your registrar and senior house officer (SHO)
are in theatre, and consequently, you are not sure how to safely manage all of
these patients.
Choose the THREE most appropriate actions to take in this situation.
A Admit the waiting patients to the surgical ward as they may be unstable.
B Ask the theatre staff to get the SHO ro ring you in between their cases as
you are very busy and would appreciate their help.
C Call the admissions unit and ask the nurse in charge to perform baseline
observations on the waiting patients and let you know if any patient is
scoring on rhe 'early warning scores' system.
D Call the medical ream to sec if they could spare one of their juniors ro
help you.
E Call the ward nurses and ask if any of the day team doctors are still around
to look after their patients because you are too busy.
F Call the ward nurses and ask if any of the patients they have asked you to
see are stable and can wait a while before a review.
G Continue to see patients on the ward and see the admissions when the ward
jobs are complete.
H Go to theatre and demand the SHO be released to help you.

2.10 Coping with work

You are an FYl working on a busy surgical firm. You have been struggling
with stress and anxiety over recent weeks. You are tearful most days when you
get home from work bur so far have been managing to keep calm around your
colleagues. You do nor feel that your problems have been affecting the care of
your patients, bur they are having a negative impact on your life and relation-
ships outside of work.
Choose the THREE most appropriate actions to take in this situation.
A Arrange to meet with your educational supervisor.
B Arrange to rake annual leave as soon as possible.
• 122 Chapter 2: Coping with Pressure

C Call in sick until you feel better.

D Call the General Medical Council (GMC) for advice.
£ Discuss with your FY 1 friends outside of your team.
F Discuss with your team to let them know that you may need extra support.
G Do more regular exercise.
H Make an appointment with your GP.

2.11 Stressed and overworked

You arc an FYJ working in general surgery. It is a busy job, and a senior house
officer (SHO) whom you work with is currently off sick, so you are a team
member short. You often do nor have rime for lunch, and you feel exhausted
and stressed. You speak to your registrar who tells you rhar it is all part of the
'journey', and it will make you a better doctor in the end.
Choose the THREE most appropriate actions to cake in chis situation.
A Ask another SHO on your team co help you with your workload.
B Ensure char you are getting regular exercise.
C Have a couple of glasses of wine when you get home in the evening.
D lnform your supervising consultant.
E Make sure that you are getting regular breaks.
F See your own GP.
G Take a day off sick.
H Tell the nursing staff not to bleep you to give you a break.

2.12 On call prioritising

You are working as an FYl on a busy on-call weekend shift with the surgical
team. You have a long list of tasks ro complete and are holding the on-call
bleep. You receive two bleeps from nurses within a few minutes of each
other, each informing you of a patient who is unwell. The first patient has a
rachycardia and is experiencing some chest pain. The second patient has a low
blood pressure and is feeling dizzy. Each nurse is concerned about their patient
and wants an immediate review.
Choose the THREE most appropriate actions to rake in this situation.
A Inform the nursing staff of your situation and ask one of them to bleep the
on-call senior house officer (SHO) about their patient.
B Perform a brief review of each patient and write down a quick management
plan.
C Place both patients on your list and see them after you have completed your
other tasks.
D Place both patients on yo~r list and see them in the order the nurses
contacted you.
E Take details of both patients and their clinical condition and bleep the
on-call SHO ro ask them ro review one of the patients.
 Questions 123

F Take details of both patients and their clinical condition and make your
own assessment as to whether you can see the patients in succession.
G Take details of both patients and their clinical condition and request one
of the nurses to bleep the on-call SHO and then to get back to you if she
docsn'r receive a reply.
H Write an email to the director of surgery informing her that your workload
is too heavy at the weekend.

2.13 Escalating concerns for patient safety

You are working as an FYl in a busy reaching hospital. You have just started
your second rotation on a care of the elderly ward. Over the first few weeks,
you notice that your new ward is consistently under-staffed. The nurses
appear to be looking after roo many patients, and there arc nor enough
healthcare assistants. At lunchtime you have seen patients who are unable to
feed themselves being left without enough support to eat their food or have
a drink.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Contact your local newspaper with your concerns.
B Discuss the situation with the General Medical Council (GMC).
C Discuss with your consultant the possibility of helping at lunchtime, by
feeding patients and providing drinks yourself.
D Document your concerns in writing by completing an incident form.
E Raise your concerns with the ward manager or charge nurse.

2.14 Using guidelines

You are an FY] working on a surgical ward. One of your patients develops
palpitations, and you diagnose atrial fibrillation from the trace present on the
electrocardiogram (ECG). You realise that you don't know how to treat this
condition acutely. When you ask your registrar for advice, they say that they
are busy in theatre and that they don't know how to manage the condition
anyway. The patient's viral signs are currently stable, but you need to deter-
mine the initial steps for managing the situation.
Rank in order the following actions in response to this situation {1 = Most
appropriate; 5 = Least appropriate).
A Ask the ocher FYl on the ward for advice as you are aware that they
worked on a cardiology ward on their last rotation.
B Bleep the medical registrar on call.
C Look for a guideline on the internet from the National Institute for Health
and Care Excellence (NICE).
D Look for a trust guideline on the intranet.
E Put out a medical emergency team (MET) call.
• 124 Chapter 2: Coping with Pressure

2.15 Prescribing warfarin

You are the FY l doctor on a busy general surgical ward. Your shift was
supposed to finish two hours ago, but you have still not completed the tasks
from the morning's ward round. The sister on the ward approaches you about
a patient, recently diagnosed with atrial fibrillation, who has not had his
warfarin prescribed. Glancing at the patient's notes, you realise that he has not
had his international normalised ratio {lNR) checked today. There is no one
else available on the ward who is trained in venepuncture.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A As the INR had previously been within range, don't prescribe the warfarin.
B Pass the job over to the night medical team for them to complete.
C Prescribe the same dose that the patient received the day before as you do
not have time to check the INR again.
D Take the blood yourself, send an urgent INR request to the laboratory and
ask the night team to chase the results and prescribe the warfarin.
E Tell the nurse that you are very busy bur will ask another doctor to take the
blood and request the lN R.

2.16 Skills unsupervised

You arc reviewing a patient with a severe laceration to their head after a fall.
After a full examination, you are satisfied that their neurological status is
normal, and you ask your senior house officer (SHO) to supervise you suturing
the wound as you haven't practised chis skill since medical school. Your SHO
says they are too busy to supervise you and says that a competent FYl should
be able to suture alone. They ask you to suture the patient quickly so you can
continue with other jobs as it is very busy on the ward at the moment.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask a doctor who is working in the emergency department {ED) if they
would come and suture your patient.
B Ask an FYl colleague who has an interest in surgery and performs suturing
frequently to supervise you.
C Ask your registrar if they can supervise you
D Delegate this task to a fellow FYl colleague who is more confident
than you.
E Suture the patient to the best of your ability.

2.17 Learning from mistakes

You are having a busy day and accidentally prescribe a penicillin-based

antibiotic to a patient who reports having an allergic reaction to penicillin.
The nurse drawing up the drug checks the allergy section of the drug card and
 Questions 125

notices the reported reaction. They do nor deliver the antibiotic and contact
you to prescribe an alternative antibiotic. You are worried that this may
happen again.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Add an additional column to your handover sheet for allergies to help avoid
this situation in future.
B Discuss your workload with your consultant and the serious errors you are
making because you are so stretched.
C Fill in an incident form.
D Prescribe an alternative antibiotic and think no more of the event.
E Reflect on this event in your e-porrfolio.

2.18 Not coping

You arc having some problems in your personal life. You arc finding it difficult
to get to work on rime, and when you are at work, you find it difficult to con-
centrate on your patients. You are aware that you have been making mistakes
that you would not normally have made.
Choose the THREE most appropriate actions to take in this situation.
A Ask an FYl colleague to check your work.
8 Ask an FYl colleague to rake some of your shifts.
C Call in sick for a few days while you try to resolve the problems in your
personal life.
D Continue working but make an effort to be on time.
E Discuss your situation with your clinical supervisor.
F Go and sec your GP for help.
G Inform your consultant of your situation.
H Take some annual leave.

2.19 Mistake

You are looking after an elderly lady who has been vomiting for the past two
hours. She was admitted with an exrradural haematoma. This is your first time
looking after a patient with a head injury. You therefore do not realise chat her
continued vomiting is a sign char her condition may be deteriorating. Instead you
prescribe an anti-emetic. When your senior house officer (SHO) comes up to the
ward, he explains to you that you have made a mistake and arranges an urgent
computed romography (CT) head scan for the patient. The CT scan shows that
there has been no further bleed, and the patient is unharmed by your mistake.
Rank in order the following actions in response co chis situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask the SHO not to tell anyone about your mistake.
8 Ask your consultant to arrange a teaching session on head injuries for you
and your colleagues.
 126 Chapter 2: Coping with Pressure

C Discuss your mistake with your educational supervisor.

D Read the guidelines from rhe National Institute for Health and Care
Excellence (NICE) on rhe management of head injuries.
E Reflect on the incident in your e-porrfolio.

2.20 Failing to do arterial blood gas

You are an FY l on a very bus)' medical on-call night shift and arc asked to
see a patient who is suffering from breathlessness and a productive cough. She
has a high respiratory rate and a widespread wheeze. You notice that she has a
history of chronic obstructive pulmonary disease in her notes. As you are talk-
ing to her, she becomes increasingly drowsy. You complete your history and
examination and decide on your management plan. Part of this is to carry our
an arterial blood gas (ABG) rest. You have done several before, but unfortu-
nately, you have failed the last four attempts) ou made on previous patients.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask the on-call senior house officer (SHO) ro come and watch you perform
the procedure, giving advice on technique.
B Ask the on-call SHO to complete the ABG while you order a chest x-ray
and document your findings.
C Attempt the ABG yourself and bleep your SHO if you are unsuccessful.
D Attend the clinical skills department for further reaching on ABGs.
E Perform a venous blood gas (VBG) instead.

2.21 Challenging a senior

You arc an FY 1 in breast surgery, and you are assisting a specialist registrar
(SpR) in theatre. You notice that he has contaminated his sterile field, bur he
continues with the operation as though be has not noticed.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Inform the SpR of his mistake and suggest char he re-familiarises himself
with theatre infection control procedures.
B Ensure that the patient receives appropriate post-operative antibiotics to
lessen the risk of infection bur do not challenge rhe SpR.
C Point our to the SpR that he has contaminated his sterile field.
D Ask the theatre sister to tell the SpR.
E Make a complaint about the SpR to his consultant.

2.22 Incorrectconsent

You arc an FYl on a surgical ward and receive a phone call from a member
of the theatre nursing staff asking you to bring a patient's consent form to
 Questions 127

theatre, which has been accidentally left on the ward by the hospital porters.
You are unfamiliar with the procedure the patient is going to have but under-
stand that they will he having a general anaesthetic. The patient left the ward
with the porters 20 minutes ago, and you are informed that the patient is in
the anaesthetic room, about to have the anaesthetic. While you arc checking
that you have the correct form, you notice a section of the consent form that
has not been completed correctly. On the first page of the form the 'risks of the
procedure' section is blank. The remainder of the form has been completed and
signed by your consultant and rhe patient.
Rank in order the following actions in response ro this situation (l = Most
appropriate; 5 = Least appropriate).
A Complete the blank section on the form using your knowledge of the gen-
eral risks of operations and take the form to theatre.
B Presume the operation has no risks and walk to theatre, raking the form
with you.
C Telephone the anaesthetic room and ask the anaesthetist not to undertake
the anaesthetic until you have spoken to your consultant.
D Telephone the theatre coordinator and inform rhem to srop the operation.
£ Telephone your consultant in theatre to inform him that the consent form
has been incorrectly completed and ask him to stop the anaesthetic until
the form is completed.

2.23 Patient control of discharge summary

You arc an fYl working on an acute medical unit. You are preparing the
discharge paperwork for a patient. When you reviewed her earlier in the
day, she explained that she was under a lot of stress and struggling with her
mental health. She also mentioned that she was nor currently able to live at her
registered address so was staying with a friend. You record what she has told
you in the notes and mention these facts in her discharge letter. The patient
becomes angry, accuses you of abusing her trust and asks for the details of her
mental health and living situation to be removed from her notes and all other
paperwork.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask the senior nurse in charge to speak to the panent "' ith you, and explain
that you must record information you are aware of accurately on all medi-
cal documents.
B Call your registrar to ask for advice and support when speaking to the
patient.
C Change the discharge address back to her registered address only.
D Refuse to change anything on the discharge letter and leave.
E Remove the relevant page from her medical notes and change the address
on the discharge summary.
 128 Chapter 2: Coping with Pressure

2.24 Absent without leave (AWOL)

You are on call working with a registrar whom you have worked with before.
You find him quite difficult to work with as he does not answer his bleep
promptly, and when he does, he is very short with you and talks over you when
you try to give him patient information. You are worried that his lack of listen-
ing is compromising patient care as he does not give you enough rime to finish
telling him about sick patients.
Rank in order the following actions in response ro this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask rhe switchboard operator if there is another registrar you can talk to.
B Conclude that he is a registrar and more experienced than you, so you
should trust his judgement; if he was really worried, he would listen.
C Persist in calling the registrar because you should call for help if you are
concerned for a patient and feeling out of your depth.
D Ring the on-call consultant and ask them to come and review your
patients.
E Talk to the senior house officer (SHO) on duty with you and ask them ro
review your patients for the rest of the shift.

2.25 Bullying registrar

You are the fYl on a surgical team. You are having difficulty getting on with
one of the new registrars. You feel that they constantly undermine you in front
of other colleagues, are patronising when delegating jobs and overly critical
when you have been unable to complete all of your tasks due co a high work-
load. This problem is making you dread coming to work.
Choose the THREE most appropriate actions to cake in chis situation.
A Challenge the registrar next time they make a critical comment on the
ward.
B Contact the hospital staff counselling and conflict resolution service.
C Discuss the issue with your clinical supervisor.
D Make an appointment to see your GP.
E Talk to the registrar in private to let them know that you are upset.
F Telephone the General Medical Council (GMC) to report the registrar's
behaviour.
G Try to swap the weekend you are supposed to work on call with the
registrar.
H Warn the next group of FYls that this registrar can be a bully.

2.26 Understaffing

You are an FYl working on a busy medical ward, which you struggle ro
manage on your own when your junior colleagues are away. Your FY2 is part
time and so only works two days a week. However, during those rwo days
r Questions 129

she insists on attending optional off-sire reaching leaving you ro manage rhe
ward alone for the afternoon.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask your educational supervisor for advice.
B Discuss rhe issue with your FY2 colleague.
C Raise the issue with your consultant.
D Raise your concerns about undersraffing at the next ward meeting.
E Talk to your FYl colleagues and ask rhem to hinr ro the FY2 that she
should spend more rime on the ward.

2.27 Absent colleague

You are working in plastic surgery with another FYI who wishes ro pursue a
career in that specialty. You aspire to work in general practice. On the days
that you arc scheduled to work together on the wards, you often don't sec them
because they attend theatre to gain experience, leaving you on the ward co cope
alone. They often don't rell you where they are going or turn up for ward round
in rhe morning, assuming that you will do the work in their absence. They gee
along very well with your seniors due to their dedication to the specialty.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Speak to your clinical supervisor about how co gee fair help on the wards.
B Speak to your registrar about your colleague's lack of support on the ward.
C Speak ro your colleague about needing chem ro help om on the wards more
often.
D Keep covering for your colleague so that they can gain more experience.
E Arrange with your colleague for them to cover your shifts sometimes so
chat you can gain experience in what you would like to do.

2.28 Mean registrar

You are working as an FY 1 in general surgery at a busy teaching hospital, and

rhe job is notoriously hard work. You are managing the long hours and large
patient load ro the best of your ability, but your registrar is constantly berating
you. He expects you to know all the day's blood tests by heart, get rests done
rhe same day and have completed a mini ward round yourself before he starts
at 7 am. When you fail ar any of these tasks, he shouts at you publicly on the
ward and threatens to talk co your clinical supervisor about your incompe-
tence. His demands mean that you feel you have to come to work hours early
and stay hours late co complete all the tasks, and iris wearing you down.
Choose the THREE most appropriate actions to take in this situation.
A Call in sick for work when you become too tired.
B Discuss with your registrar ways by which you can achieve his objectives
without having ro star hours late every day.
 130 Chapter 2: Coping with Pressure

C Inform the trust of the registrar's unfair behaviour.

D Refuse to carry out your registrar's unreasonable demands and complete
the tasks that you think are appropriate.
E Speak to the British Medical Association (BMA) about how to handle
workplace bullying.
F Speak with your registrar privately to discuss your working relationship.
G Talk with your consultant about the unfair demands of your registrar.
H Work as hard as you can to achieve your registrar's demands.

2.29 Shreddingnurse

You are an FY1 working on a surgical ward. You have a challenging working
relationship with one of the nurses on your ward. She is very competent and
good at her job, but she can be very sharp and demanding of you at times and
is very critical when you make mistakes. On a busy weekend day shift, you
are working alone covering all of the surgical wards and have come to review
a sick patient. You leave your handover sheet with the day's jobs on iron the
nurses' station while you assess the patient. On your return you cannot find
your handover sheer, and chis nurse informs you char she has shredded it as iris
confidential information and should not be left lying around. You now do not
know what jobs you have left to complete.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Shout at the nurse for her inconsiderate behaviour.
B Speak to the ward sister or charge nurse about the nurse in question and
her inconsiderate actions.
C Speak privately with the nurse in question about shredding your list and
discuss your working relationship.
D Complain to your consultant about this nurse who is making your job
difficult.
E Calmly leave the ward, print out a new list and spend some time
methodically trying to remember all of your jobs that are outstanding.

2.30 Interpreters

You are the FYI on call on the admissions unit for the evening. A young
woman, looking very unwell, comes in with her sister. The patient does not
speak English, but her sister can speak some. You are quite worried about the
patient.
Choose the THREE most appropriate actions to take in this situation.
A Ask another doctor who you think speaks the same language as the patient
to see her.
B Ask her sister co ace as a translator for you.
C Ask the nurse to come and help you rake the history.
D Contact the local interpreter service and ask them to send someone in.
 Questions 131 •

E Decide ro see another parienr waiting ro be seen instead.

F Instead of taking a history, examine the patient to get a better idea of what
may be causing her clinical picture.
G Order some rests and send the patient for those while trying to find an
inrerpreter.
H Use a phone interpreter.

2.31 Demandingpatient

You arc the FY l working in a cl mica! decision unit. You have two unwell
patients on the ward. One is a middle-aged man who has suffered an acute
myocardial infarction. The ocher is an elderly woman with a urinary tract
infection causing her to be confused. However, you are called frequently
regarding another patient, a young man who has been admitted for observation
after being brought to hospital intoxicated. This patient is demanding that you
come to sec him and threatening to self-discharge if you do not.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Assess the young man and discuss his concerns.
B Prescribe initial treatment for the patient with the myocardial infarction.
C Decline to see the young man.
D Prescribe antibiotics for the patient with a urinary tract infection.
E Organise the transfer of the patient with the myocardial infarction ro a
hospital providing definitive management.

2.32 Nurse-patient breakdown

You are an FYl in general surgery doing a night shift. A nurse cells you chat
she is struggling with a demanding patient who has recently had an operation.
The patient is complaining a lot and requesting frequent doses of strong
opioids. The nurse also says that the pain is 'all in her head'. You notice that
the nurse is not attending the patient for a long time when rhe patient pushes
the button to call her. You feel that their relationship has broken down.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Speak to the lead nurse on the ward about the issue.
B Ask the patient to stop being rude and demanding.
C Decrease the patient's analgesia.
D Suggest that the nurse changes the care of the patient to another nurse.
E Leave the nurse and the patient ro resolve their issues.

2.33 Patient error

You are an FYl on a care of the elderly ward. You review a patient's chest
x-ray, which shows consolidation char is consistent with pneumonia.
 132 Chapter 2: Coping with Pressure

You inform the patient, prescribe an appropriate antibiotic and insert a

peripheral cannula. After the patient has received a dose of the antibiotic,
you realise that you have looked at the wrong patient's chest x-ray and have
therefore given the wrong patient antibiotic treatment.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Leave the patient to complete the course of anrihiorics.
B Ask your senior house officer (SHO) to inform the patient of your error and
stop the antibiotic.
C Cross the antibiotic off the prescription chart without informing the
patient.
D Fill in an incident form.
E Inform the patient of your mistake, apologise and stop the antibiotic
therapy.

2.34 Unable to get chaperone

As a male FY2 working in a GP surgery, you see a woman with dyspareunia

in your chnic. You explain that you need to Jo an examination of her external
genitalia and a vaginal examination with a chaperone present. She agrees to
the examination, hut you cannot find a member of staff who is trained to be a
chaperone. You feel uncomfortable doing the examination without a chaperone.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask her partner who is in the waiting room to be a chaperone.
B Perform the examination without a chaperone present.
C Ask her to come to see you tomorrow when you can arrange for a chaper-
one to be present.
D Make a diagnosis and treat the patient on the basis of your history.
E Ask your patient to see one of your female colleagues.

2.35 Chaperones

You are an FYl working a busy weekend night shift in an emergency depart-
ment. A young woman with known alcoholism has attended due to an episode
of bleeding per rectum. You suspect rectal varices and wish to examine the
anus and perform a digital rectal examination. The young woman smells of
alcohol and has obviously been drinking. She consents to the examination, but
when you offer her a chaperone she declines on the basis that it will rake a few
minutes to find a chaperone, and she has already been waiting to be seen for
four hours and wants to go home as soon as possible.
Rank in order the following actions in response ro this situation (1 = Most
appropriate; 5 = Least appropriate).
A Perform the examination and document fully in the notes the patient's
refusal of a chaperone.
 Questions 133

B Explain to the patient the reasons for having a chaperone present during
intimate examinations and refuse to undertake the examination until one is
present.
C Explain to the patient the reasons for having a chaperone present during
intimate examinations but that because of her long wait to be seen you will
bypass this protocol this time.
D Decide not to undertake the examination at this time.
E Ask the advice of the emergency department registrar regarding the need
for a chaperone in this case.

2.36 E-portfolio

You are working as an FYl on a busy surgical ward, and your department
is struggling with the workload since one consultant is off on long-term sick
leave. You have nor been able to meet with your clinical supervisor because of
this, and you arc finding it difficult to complete the mandatory aspects of your
FY! e-porrfolio. Every rime you approach your consultant, they say that they
are far too busy to be dealing with junior doctors' paperwork.
Rank in order rhe following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Inform your educational supervisor of this problem.
B Inform the foundation programme director at your trust and ask to switch
clinical supervisors.
C Come in to the hospital during your annual leave to try and meet with your
supervisor.
D Ask another consultant to meet with you and sign off your paperwork.
E Write a letter of complaint to the clinical lead of the department abour your
consultant's failure ro meet your educational needs.

2.37 Educational supervision

You are an FYl working on a medical ward. You arc running late one evening
and are still on the ward after the end of your shift. You have previously arranged
a meeting with your educational supcrx isor, which is due to begin in 10 minutes.
You are asked by one of the nurses on your ward to see a patient who is scoring
on rhe 'early warning scores' and whom she is quire concerned abour. You call
the on-call doctor who re1Is you they are currently with another sick patient.
Rank in order the following actions in response ro this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask rhe on-call senior house officer (SHO) to come and see the patient on
your ward when they are done.
B Call the on-call registrar and ask them to see the patient.
C Go and quickly review the patient to alleviate the nurse's worries.
D Go and perform a full review of the patient knowing it will make you late
for your meeting.
 134 Chapter 2: Coping with Pressure

E Ring your educational supervisor and let them know the situation, ask
if they can come and observe you seeing the patient as a mini-clinical
evaluation exercise (CEX).

2.38 Clerking responsibilities

You are an FYl doctor working on call in the medical assessment unit of a
teaching hospital. Your duties are to clerk patients and present them to the
medical registrar or the consultant on call. You are looking at the long list of
patients to be seen, and }'OU notice char in the few hours you have been on your
shift you have seen four patients, and your FYl colleague has only managed to
see one patient. There are many patients waiting to be seen, and you feel chat
you are under significant pressure.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate}.
A Contact the medical registrar and voice your concerns about your
colleague.
B Continue to see the patients on the list and hope your colleague can catch
up with you later on.
C Inform the medical registrar that you feel you are under too much pressure
co work through such a long list of patients.
D Offer to take over the clerking of the patient your colleague is seeing as
they are raking too long.
E Politely ask your colleague why they have only seen one patient during
the day.

2.39 Emergency in the community

You are driving to meet a friend for a meal; you haven't seen chem for a while,
and you are late. You see a person lying slumped on the pavement - you cannot
see any signs of life, and there are people crowding around looking concerned.
Rank in order rhe following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate}.
A Tell the people to call an ambulance, bur don't stop to help.
B Make a quick assessment and perform cardiopulmonary resuscitation
(CPR) if necessary, ensuring emergency services are informed.
C Do nothing as you don't have an obligation to help outside of work.
D Phone for an ambulance yourself, but don't stop to help.
E Ask if anyone there has first-aid training; if they do, phone for an ambu-
lance and then leave.

2.40 Unsafe on call

You are an FYl working a medical weekend on call. You are extremely busy
and receive many calls co see deteriorating patients. Your senior house officer
 Questions 135

(SHO) has asked you nor ro contact him in the morning as he will be doing a
post-take ward round with a consultant. You are struggling to keep up with
the workload and feel that some deteriorating patients are being left for a long
rime before a medical review. Before the weekend, you had spoken to a few of
your FYl colleagues who all feel rhar the workload is unmanageable.
Choose the THREE most appropriate actions ro take in this situation.

A Ask one of your friends who is also a docror to come in to work and
help you.
B Ask the nurses to contact you only when they are very worried about a
patient.
C Inform the medical registrar on call.
D Inform the SHO that you are not coping with the workload.
E Prioritise your workload, seeing the most unwell patients first.
F Sec all the unwell patients as quickly as possible and do nor stop for lunch.
G Speak to your consultant about your concerns after the weekend.
H Write a letter to the medical director highlighting your concerns.

2.41 Complaint

You are a male FYl working in medicine. Your educational supervisor informs
you that one of the female patients on the ward has lodged a complaint against
you. The patient had originally presented with symptoms consistent with
raised intracranial pressure. You had therefore performed fundoscopy bur had
done so in a room alone with the patient. The patient has complained that
they felt uncomfortable during the examination. Your educational supervisor
has therefore arranged for you to work on a different ward until the patient is
discharged.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Approach the patient and explain that there must have been a
misunderstanding.
B Ask a colleague to approach the patient and explain that there must have
been a misunderstanding.
C Ask the patient to drop the complaint as it may damage your career.
D Contact your medical defence organisation and seek their advice.
E Do nothing and allow rhe hospital to continue resolving the complaint.

2.42 Coroner statement

You return to your ward after a week of annual leave to find a letter waiting
for you in your letter tray. It is a letter from the coroner's office regarding a
patient who died on your ward a couple of weeks ago. The letter explains that
there are some concerns regarding the circumstances of the patient's death and
asks you to make a statement about your involvement with their care. You have
 136 Chapter 2: Coping with Pressure

never written a statement for the coroner before, and you remember little about
the patient since you only met them briefly.
Choose the THREE most appropriate actions to rake in this situation.
A Ask the nurses about their recollection of the case.
B Ask co see what another doctor involved in the case has written in their
statement.
C Consult your educational supervisor for advice regarding how ro write a
statement.
D Decide that as you only met the patient briefly, there is no need ro write a
statement.
E Locate the patient's notes, re-familiarise yourself with the case and subse-
quently write a statement.
F Put off writing the statement until you have rime to think about it properly.
G Ring a medical defence organisation for advice.
H Write the statement as soon as possible based on your memory of the case.

2.43 Angry registrar

You are an F Yl in surgery, and you are on a busy ward round. The registrar
has asked you to prescribe a medication, bur you didn't hear what dose was
required, so you ask for clarification. The registrar rums around and shouts at
you in front of the nursing staff, patients and other juniors for not listening and
being incompetent in your role on the ward round.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Loudly defend yourself: the registrar is making you look bad in front of all
of your co-workers.
B Apologise to the registrar, explaining that you wished to be careful in your
prescribing and ask him how you could better help on the ward round in
future.
C Apologise to the registrar, explaining that you wished to be careful in your
prescribing and then avoid working with that registrar in f urure.
D Apologise to the registrar, explaining that you wished to be careful in
your prescribing and ask co speak with them later ro discuss your working
relationship.
E Apologise to the registrar and then speak to your consultant about the
incident.

2.44 EWTD breach

You are an FY1 working on a busy surgical team, and you arc understaffed
because a fellow FYl is off on long-term sick leave. Although you have locum
FYls on a regular basis, they do nor know the ward or the patients, and
you and your FYl colleagues find yourself staying extra hours beyond your
contracted finishing time almost every day. When you mention this to your
 Questions 137

registrar, they say char when they were a junior, they had to work much harder
than you do and that you should just get on with it.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Continue working as normal; you will change jobs ma few months and
then things will be easier.
B Speak to your foundation programme director.
C Speak to your consultant about such extreme hours.
D Take some days off 'sick' to pay yourself back for the extra hours.
E Send an email to the chief executive officer (CEO) of your trust informing
them of the breach of hours.

2.45 Responding to colleague's request

It is a busy morning on the medical admissions unit (MAU). One of the staff
nurses approaches you and asks how long it will be before you see Mrs Clark.
She says that the patient has already been waiting two hours with a lot of pain
and she can't give any analgesia until } ou have clerked them and prescribed
their medicines.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Approach the patient anc.l apologise for their wait; explain that you are very
busy hut arc aware of them and will be with them as soon as you can.
B Explain calmly to the nurse that you are aware of the patient and will get
to them as soon as you can.
C Prescribe some morphine without seeing the patient to keep the nurse
happy.
D Make sure that you leave Mrs Clark until last on your list, just to annoy
rhe nurse.
E Ask your senior house officer (SHO) whether they have time to see
Mrs Clark.
 138 Chapter 2: Coping with Pressure

ANSWERS
2.1 Forgotten patient review

A C E
It is very easy to forget about jobs when you are busy. When you make a
mistake, you must firstly be honest and admit your error and then apolo-
gise (A). As well as acknowledging your mistake, you should try to prevent
the same incident from occurring again, which could be achieved by creating
a jobs lisr (C). You should also check that the patient is stable and not dete-
riorating (E). Claiming that you did review the patient and that the nursing
staff must have lost the documentation (B) or writing a review ..ind timing it as
yesterday (H) are both dishonest and immoral. The Medical Protection Society
(MPS) warn against altering entries in records or creating entries made after an
event. These are called non-contemporaneous records and are taken very seri-
ously by courts of law and regulatory bodies (Medical Councils and Medical
Boards). Doing nothing (D) is likely co damage your relationship with the nurs-
ing staff because they will be less likely to trust you in the future. Informing
your consultant of your error (F) is unnecessary as you should be able to resolve
this incident yourself. Telling the nursing staff that they should have bleeped
the on-call doctor if they were concerned (G) is appropriate bur less so than the
other three options because it also shifts the blame onto the nursing staff.

Recommended reading
Medical Protection Society (2012), Honesty, in MPS Guide to Ethics: A Map for
the Moral Maze, chapter 6.
2.2 False statement

DCAEB
This is a difficult scenario as you would want to support your colleague.
It would, however, be immoral to submit a fabricated and false statement (B),
so that is the least appropriate response. Your colleague is likely to be fright-
ened about the complaint and has therefore asked you to do something that is
unprofessional, without thinking about the possible implications for you; you
should refuse ro make rhe false statement bur offer ro submit a general report
about her professional behaviour to support her (0). Simply refusing to make
the statement (C) would be completely moral but is not ideal as it does nor offer
the support that your colleague requires. Making a complaint against your
colleague to a senior (A) is also less appropriate for the same reasons. Speaking
to the relative (£) is inappropriate since this is not likely to result in the relative
withdrawing the complaint, and the relative still bas a right to complain even if
you find the issue unfounded.

Recommended reading
Medical Protection Society (2012), Honesty and Personal conduct, in MPS
Guide to Ethics: A Map for the Moral Ma:::e, chapters 6 and 12.
 138 Chapter 2: Coping with Pressure

ANSWERS
2.1 Forgotten patient review

A C E
It is very easy to forget about jobs when you are busy. When you make a
mistake, you must firstly be honest and admit your error and then apolo-
gise {A). As well as acknowledging your mistake, you should try to prevent
the same incident from occurring again, which could be achieved by creating
a jobs list {C). You should also check that the patient is stable and not dete-
riorating {E). Claiming that you did review the patient and that the nursing
staff must have lost the documentation {B) or writing a review and timing it as
yesterday {H) are both dishonest and immoral. The Medical Protection Society
(MPS) warn against altering entries in records or creating entries made after an
event. These are called non-contemporaneous records and are taken very seri-
ously by courts of law and regulatory bodies (Medical Councils and Medical
Boards). Doing nothing (D) is likely to damage your relationship with the nurs-
ing staff because they will be less likely to trust you in the future. Informing
your consultant of your error {F) is unnecessary as you should be able to resolve
this incident yourself. Telling the nursing staff that they should have bleeped
the on-call doctor if they were concerned (G) is appropriate but Jess so than the
other three options because it also shifts the blame onto the nursing staff.

Recommended reading
Medical Protection Society (2012), Honesty, in MPS Guide to Ethics: A Map for
the Moral Maze, chapter 6.
2.2 False statement

DCAEB
This is a difficult scenario as you would want to support your colleague.
It would, however, be immoral to submit a fabricated and false statement (B),
so that is the least appropriate response. Your colleague is likely to be fright-
ened about the complaint and has therefore asked you to do something that is
unprofessional, without thinking about the possible implications for you; you
should refuse to make the false statement but offer to submit a general report
about her professional behaviour to support her (D). Simply refusing to make
the statement (C) would be completely moral bur is not ideal as ir does nor offer
the support that your colleague requires. Making a complaint against your
colleague to a senior (A) is also less appropriate for the same reasons. Speaking
to the relative (E) is inappropriate since this is nor likely to result in the relative
withdrawing the complaint, and the relative still has a right to complain even if
you find the issue unfounded.

Recommended reading
Medical Protection Society (2012), Honesty and Personal conduct, in MPS
Guide to Ethics: A Map for the Moral Maze, chapters 6 and 12.
 Answers 139

2.3 Nursing pressure to refer

A E F
This question assesses your ability to cope under pressure while ensuring chat
you always put the care and safety of your patients first. Sometimes in medicine,
pressures that are outside your control will affect your behaviour. However, it is
important that you deal with them in a calm, safe and professional manner. In
this scenario, you may disagree with the sister's instruction, and it is therefore
imperative that you use your communication skills to respond politely to the sister
while doing your job to the best of your ability. It would be appropriate to explain
your stance diplomatically (F), which would both show respect for your colleague
and ensure that the care and safety of the patient takes priority. Apologising to
the patient is also a courteous gesture and one that demonstrates empathy with
their situation; therefore option A would also be sensible. In situations where you
feel that patient safety is being compromised, it is important to alert your seniors,
which is why option Eis also appropriate; however, this should be done without
trying to lay blame on other colleagues without evidence (options Band D).
Options C and G, while involving an assessment and/or referral of the patient,
do not concurrently demonstrate a safe approach to assessing a sick patient and
do not show respect for your colleague. Refusing to see the patient (H) is wholly
inappropriate as this behaviour could have a negative impact on a sick patient.

Recommended reading
General Medical Council (2012), Raising and Acting on Concerns About Patient
Safety.
General Medical Council (2013), Good Medical Practice, paragraphs 15, 23, 25,
35-37, 55-57, 68.

2.4 Audit presentation

D E A B C
You have made a commitment to delivering the presentation and should therefore
endeavour to do so even though you are tired (options D and E). You have put
time and effort into the audit, and this is a valuable learning opportunity that
it would be a shame to pass up. It is sensible and reasonable to ask to move the
time to allow you to get home to rest adequately (0). Options Band Crank
lowest because they are both dishonest. You are not unwell (B), but at least in
option B, you will have informed the chair of your absence rather than just
failing to show (C). Insisting that your friend comes in is not professional: it is
likely to start an argument, and it may well be chat she really is incapacitated
(A). Nevertheless, this would be preferable to options B or C because ir does nor
involve deceit, and it attempts to ensure that the presentation is delivered.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 65-80.
The UK Foundation Programme Curriculum (2012), section 3.2: Quality and
safety improvement.
 140 Chapter 2: Coping with Pressure

2.5 Prioritization

C B A D E
Your priority when you are on call is to be available to attend emergencies on
the wards. Option C is therefore the best option because it declines politely and
makes a proactive suggestion for an alternative meeting, which will hopefully
satisfy the family. Option C is better than B because your workload is unpre-
dictable when you are on call, and you may struggle to get there and leave the
family more frustrated. Informing the nurse that you will be unable to attend
(A) is realistic but sounds somewhat rude and offers no alternative to placate
the family, which is likely to leave the nurse feeling fobbed off and stuck with
angry relatives. It is reasonable to defer the family meeting until in-hours, and
the two options chat involve other members of the on-call team therefore rank
lowest (options D and E). If you are going to take up the time of other on-call
doctors, it is better for you co ask the SHO to attend to the emergency and go
to see the family as you know them and the case already. It will use up more
time for the on-call registrar to read and find out about a patient they don't
know, and they are likely to be busy with sick patients themselves (E).

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 31-34.
The UK Foundation Programme Curriculum (2012), section 1.4: Team-working.
The UK Foundation Programme Curriculum (2012), section 8.1: Promptly
assesses the acutely ill, collapsed or unconscious patient.

2.6 List of jobs

D C B E A
Being on call is a key part of being a doctor, and your workload can be very
heavy at times. In these situations you need to be able to prioritise effectively.
The most appropriate option is D: seeing the patient who is deteriorating as
soon as possible as a quick response could prevent a critical situation. The
next most appropriate course of action would be to find out more information
about the patient requiring bloods checking and see if someone else would be
able to take the bloods, for example a phlebotomist (C). In times of increased
workload, you may need more information to effectively prioritise jobs, and
you should be able co delegate work when appropriate. Telling the nursing staff
to bleep the on-call SHO (B) is a reasonable response, but it would be prefer-
able to gather more information about the jobs required and subsequently bleep
the SHO yourself so that you have more information to hand over. It may be
true char speaking to patients about medication which has already been started
before the weekend is an inappropriate job when on call at the weekend (E),
but had you been less busy you may have been able to do this. This attitude
is also unlikely to help your working relationship with the nurse. Doing all
your jobs as quickly as possible (A) is the least appropriate action because you
should not rush reviewing unwell patients, and you are more likely to make
errors working in this way.
 Answers 141 •

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 14-16.

2.7 Seeking help

D C B A E
While challenging situations are helpful to aid your learning, you should never
feel unsupported. Help should always be available, particularly once you feel
that you have reached the limits of your competency. In this scenario, the reg-
istrar has a responsibility to aid you and a responsibility to ensure the safety of
the patient. It is therefore appropriate to insist that they come in to review the
patient (D). When seeking help, it is advisable ro work up the chain of seniority
within your ream. The consultant should therefore be your next option if the
registrar is unable or, in this case, unwilling to assist (C). There may be occa-
sions where the rest of your team are genuinely unable to attend due to other
emergencies, and you should therefore be aware of other people who may be
able to assist. In this scenario, it would be appropriate to call the anaesthetist
for help if your ream was unavailable (B). While the medical registrar (A) may
also be able to provide help, the anaesthetist is a more favourable choice since
they will likely have more experience with surgical patients. In addition, they
will ultimately be involved with the patient if or when he goes to theatre. The
least appropriate option is E: you are struggling to manage this patient alone
and you risk his condition becoming worse if you continue unaided. Even if
you have been refused help once, it is your responsibility to continue seeking
help if needed.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 14,
15c, 16d.

2.8 Coping with pressure

A C G
This is a difficult, but common scenario and most of the listed options could
in reality be considered; however, you need to determine how you can man-
age the workload to the best of your ability as an FY1. If the other team is
better staffed than you, asking them to help is appropriate (A). Asking your
SHO to help (C) is also sensible as they too are on the team and are required
to help supervise you, provided that there are enough people in theatre to
safely operate. As always when working, it is crucial to prioritise assessing ill
patients (G). Option E will already be in hand as the FYl will have to call the
rota coordinator to notify them of their absence, and they should already be
trying to improve the situation. Unfortunately, it may be likely chat you will
need to stay later than your contracted hours (H), but you should not use this
as your only management plan. The other three options are not appropriate:
asking the night team to stay out of hours is unfair and will leave them tired
for the next shift (B), calling an ill FYl into work puts patients and them at
• 142 Chapter 2: Coping with Pressure

risk (D) and discharge summaries are not a job for the night team, so it is
unfair to ask them to do this (F).

Recommended reading
Medical Protection Society (2012), Professionalism and integrity, in MPS
Guide to Ethics: A Map for the Moral Maze, chapter 3.
2.9 FYl on call

B C F
This is a difficult but common scenario which you must become adept at man-
aging. The most important thing is to ensure that all the patients are safe while
they wait for your review. Therefore, this makes options C and F both good
choices as finding our from the nursing staff if anyone is haemodynamically
unstable will help you triage which patient is sickest. Option Bis also in the top
three because, while demanding the SHO be released to help (H) is nor pro-
fessional as the SHO is likely needed in theatre, asking if the SHO could help
between cases is useful as there is usually a significant rime period at this point
where they could help you with your workload. Simply admitting the patients
and ignoring the wards (A) or vice versa (G) is not safe as you do not know
what the other patients' presenting problems are. Calling the medical team (D)
is nor appropriate, and they will likely have their own list of patients to see,
nor is option E because if you are on call our of hours, the day ream should
be able to leave on time in order to adhere with their rota as per the European
Working Time Directive.

Recommended reading
https://www.gov.uk/maximum-weekly-working-hours/overview
http://www.juniordr.com/index.php/mps-advice-centre/the-stress-factor.hrml
2.10 Coping with work

A F H
It is important to recognise rimes when you might be struggling and to seek
appropriate help through official channels. As you are managing to cope at
work, there is no immediate need for you to remove yourself from the hos-
pita I (C). While you may find it helpful to take some annual leave (B), this is
not one of the best options as it is more important to take active steps to get
more support while you are at work. Your educational supervisor is the most
important person to arrange to meet with (A). They can advise and provide
support as well as link into other sources of help. It would also be proactive
to speak to members of your team (F) as they can keep an eye on you on a
day-to-day basis and could raise any patient safety concerns if the situation
deteriorated. This is more useful than discussing with other FYls (E) because,
although peer support is valuable, they are not in a position to provide support
ro you directly on the job. You do not have any concerns abour your fitness to
practise, so you do not need to call the GMC (D). It is important to see your
GP (H) for several reasons. First, it is useful to talk ro a professional outside
 Answers 143

your work environment. Second, your GP can assess the extent of your mental
health difficulties and consider medication or talking therapies if appropriate.
Although it may well help to increase your levels of physical activity {G), this is
an adjunct to seeking help and is not as important as the three most appropri-
ate answers.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 28-30.
The UK Foundation Programme Curriculum (2012), section 3.1: Risks of
fatigue, ill health and stress.

2.11 Stressed and overworked

A D E
Coping with pressure is a necessary skill for doctors; however, it is also
important to recognise when this pressure is too much and you need help.
Unfortunately, your registrar does not seem to have understood your situation
and has nor provided you wirh helpful advice. In this case, it would be best ro
inform a more senior colleague who is approachable, such as your supervis-
ing consultant (D) or your educational supervisor. In the meantime, you need
to make sure that you are reducing your stress levels at work. Asking another
SHO to help you (A), and thereby admitting rhat you are struggling, could be
difficult but your team should be made aware of this so that changes can be
made. Making sure you are getting regular breaks (E) should also help your
performance levels and give you the chance to eat something and recuperate.
Nor only will this help your well-being, it should also improve your concentra-
tion and thereby improve patient safety.
Ensuring that you are getting regular exercise (B) is useful for some people
to de-stress, but it does not deal with the immediate problem as effectively as
options A, D and E. Having a couple of glasses of wine when you get home (C)
may be helpful as a 'one-off' but it is not a long-term solution! Seeing your GP
(F) is important if you notice that your mental health is significantly impact-
ing your life; however, hopefully that is not the case at this stage. Taking some
time off (G) may be necessary in some instances, but again this is not a long-
term resolution and the issues should be addressed before reaching this stage.
It would also leave the remaining staff in your team with even more work.
Telling the nursing staff nor to bleep you to give you a break (H) is nor a good
solution as nurses may subsequently be discouraged from contacting you in an
emergency.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 25.

2.12 On call prioritising

E F G
This is a very common scenario to be placed in while working on-call shifts.
The most important factor to consider is patient safety. You do not know the
 144 Chapter 2: Coping with Pressure

full derails about the patients who, in this scenario, could be suffering from a
myocardial infarction and sepsis respectively. The most important thing to do
is to take details about each patient as this will allow you to make an informed
decision. Option F is appropriate as, with more information, you may be able
to prioritise your workload and/or decide whether one patient needs to be
seen by one of your colleagues. Option Eis also valid as this would personally
ensure that the message has been relayed to your SHO colleague. Option G
includes a 'safety net' and is therefore advantageous. This means that if the
nurses do not get a reply from the on call SHO you will be made aware of
it and can arrange for a review yourself. This is the reason why option H is
preferable to simply asking one of the nurses to contact the SHO themselves
(A). Performing a brief review of each patient (B) may lead to inappropriate
management plans and incomplete reviews. If you feel your workload is too
heavy (H), it may be prudent to raise it with the relevant people; however,
this should be done at a time that doesn't endanger patient safety. Non-urgent
jobs can be completed in the order that they were referred to you; however,
prioritising an unwell patient should encompass a range of other factors rather
than just time (D). Option C is unacceptable as this involves prioritising non-
urgent tasks over potentially unwell patients.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 14, 15, 16.

2.13 Escalating concerns for patient safety

E D B C A
This is a difficult and very topical scenario. The Francis Inquiry Report into
the events at the Mid-Staffordshire NHS Trust between 2005 and 2009 led to
the introduction of 'duty of candour'. This requires staff to disclose informa-
tion to their employer in cases where they believe that poor care has resulted
in death or serious injury to a patient. In this scenario, while the issues may
not seem a priority, poor nutrition and hydration can ultimately lead to death
or serious injury, especially in elderly patients with multiple co-morbidities.
In practice, the best way to tackle this scenario would be first to discuss your
concerns with the ward manager or charge nurse as they may not be aware
that this has been happening (E). They may be able to find a solution, and the
problem could be rectified. However, following this, your concerns should be
documented in writing to your employer (D). There is good guidance avail-
able to advise when you should escalate the issue to higher governing bodies.
You should discuss concerns with the GMC (B) in cases where you cannot
discuss your problems Locally, or you have raised your problem locally without
success or there is immediate serious risk that must be addressed. Offering
help yourself (C) is inappropriate as you should not be taken away from your
own duties, and this would not help to solve the issue in the long term. Your
responsibility as a doctor is not to nurse your patients; this is the role of the
nursing staff, and if they are unable to provide adequate care, the issue should
 Answers 145

be raised with the appropriate higher body. The least appropriate option here
would be to contact your local newspaper directly {A}. A concern should only
be made public when you have done all you can do to deal with it within the
organisation or have good belief that patients are still at risk of harm.

Recommended reading
General Medical Council (2012), Explanatory guidance, in Raising and Acting
on Concerns About Patient Safety, paragraphs 11-17.

2.14 Using guidelines

A D C B E
In chis scenario, the patient is stable, so there is some time for you ro rry to
solve the problem yourself. The most readily available source of advice is from
your FYl colleague on the ward {A} who, given rheir previous experience,
should be able co help you with the initial steps you should take, including
whom you may need to call. It will be slightly slower to search by yourself for
guidelines that you are unfamiliar with {options D and C); however, these are
still a good source of advice. Where they are available, local guidelines {D}
are preferred over national ones {C). It is appropriate to do some investigatory
work yourself to ensure that, if necessary, you refer in the correct manner and
make prompt early decisions rather than jumping straight into calling for help
(B}. However, if you arc worried or uncomfortable with a situation, it is never
wrong to escalate to others with more experience than yourself. The patient is
not acutely unstable, so it would be entirely inappropriate to call the MET or
peri-arrest team {E).

Recommended reading
Foundation Programme Curriculum (2012), section 6.2: Evidence, guidelines,
care protocols and research.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 4, Duty of care, section: Current chinking.

2.15 Prescribing warfarin

D E B A C
This scenario requires you to act safely and in the best interests of the patient
while under pressure. Option D is the most appropriate response because
patient safety and duty of care should be your first concern, even when you
are busy. This response ensures that the patient gets the optimum dose of
their medication, but by delegating some of the job to the night staff, you are
looking after your health needs as well. Option E is the second most accept-
able response as the job would be completed; however, it is unfair to burden
colleagues with simple tasks on patients who are not their own, especially
as they may be very busy as well. Similarly, passing the job over to the night
staff (B) should result in the task being completed but after much delay, and
it is a job that the day team should be completing during their shift. The least
 146 Chapter 2: Coping with Pressure

appropriate response is option C because your actions could potentially harm

the patient. Option A is slightly more appropriate (although still not advised) as
there is less chance, given the patient's INR history, that omitting one dose will
cause harm. However, you are failing ro provide the basic standard of care that
this patient's condition requires.

Recommended reading
General Medical Council (2009), The New Doctor, paragraphs 6, 10.
General Medical Council (2013), Good Medical Practice, Duties of a doctor.
General Medical Council (2013), Good Medical Practice, paragraphs 15, 16, 45.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 4, Duty of care.
2.16 Skills unsupervised

C B A E D
Senior supervision is nor always readily available in practice on the wards
and, as an FYl, you need to determine whether you should wait for them or if
you are competent enough to undertake skills on your own. Where possible,
you should try to develop your practical skills, so getting someone to super-
vise you both protects patients and facilitates your learning. These responses
are the most highly ranked in this question. Option C is the best response
because your registrar is the next port of call if your SHO is busy and they
could even sign off a direct observation of practical skills (OOPS) section of
your e-portfolio. Option B is the next best response as your colleague who
has sutured many times before can easily show you a good technique, but it is
often better to ask a senior first. Option A is safe so it ranks third: asking an
ED doctor to suture your patient. In specialties where suturing is an unusual
skill to practise, it is common to request another doctor to attend to suturing,
and although they may not be able to attend immediately, an ED doctor is well
suited for this. The two worst responses involve suturing without confidence
and delegating the task co a colleague to get you out of the difficult situation.
If you have been taught this skill properly at medical school and had super-
vision before, you have had adequate reaching, even though you do nor feel
confident. For this reason, if you attempt suturing, you are not acting outside
your competence, and so option E ranks fourth. Passing the buck to a colleague
will nor win their favour and doesn't reflect good team-working, so option D is
the least appropriate.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 7-13,
35-38.
2.17 Learning from mistakes

C A E B D
Drug errors are common and some can be lethal. It is important to try and
learn from every mistake you make to prevent it happening again. In this
 Answers 147

question, an incident form (C) is a good way of ensuring this incident is for-
mally looked at by ward management. There may be a pattern in this mistake
that you are not aware of, and you shouldn't feel like you are 'turning your-
self in' by reporting it. Option A is the second best response: adding another
column to your handover sheet is a proactive and resourceful solution and
will help you and your FYl colleagues by having a patient's allergy status to
hand at all rimes. To achieve satisfactory sign-off for the FYl year, you need
to reflect on various situations of your choice. The aim of this being that a
dedicated period of time to think about the cause and effect of a situation
enables you to tackle it better in future. Therefore, reflecting on the event in
your e-porrfolio (E) ranks third. Option B is fourth as if the incident occurred
because you were too busy to make basic checks, it is important that rhe team
leaders are aware of it; however, it would be difficult to attribute not check-
ing a patient's allergy status solely to being too busy. Nor doing anything to
prevent the error occurring again (D) is inappropriate and so comes lase.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 22-23.

2.18 Not coping

E F G
In this scenario, you are nor maintaining your performance as an FYl, and this
may be a risk to patient safety. It is important to both recognise and act upon
chis concern. You should inform your clinical supervisor that you are strug-
gling so that they can provide the support that you need (E). Similarly, you
should make your consultant aware of the situation (G). Ir is also appropriate
to see your GP as they may be able to provide the help that you need in order
to better cope at work (F). Now chat you have recognised a problem with your
ability ro work, it would be inappropriate to continue trying to resolve the issue
(D). Taking annual leave or calling in sick (options Hand C) do nor properly
address this issue. You should not ask an FYl colleague to check your work
(A), and although it may seem like a responsible option, it is not your place to
reallocate your workload (B). This is better left to your consultant once you
have spoken to them.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 7, 13, 14,
24, 25, 28, 30.

2.19 Mistake

B D C E A
Making mistakes is an inevitabJe part of being a doctor. While we should
always strive to avoid mistakes, when they do happen, they can be used as
a valuable learning opportunity. In this instance, option B is most appropri-
ate since it enables both you and your colleagues to learn from your mistake.
 148 Chapter 2: Coping with Pressure

Reading the NICE guidelines on head injuries is also important for your own
learning (D). Discussing the event with your educational supervisor is also
appropriate (C). They may be able to help you to further analyse your actions
as well as provide advice on how you can improve your practice. You should
continually reflect on your own practice, particularly where you have identified
a weakness. Your e-porrfolio is a useful way to document those reflections (E),
and indeed all doctors are required to keep a record of their reflections. While
you would not expect your SHO to talk about your mistake extensively, he
may feel it necessary to discuss the events with a supervisor. You should respect
that decision; therefore, option A is inappropriate.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 7-15, 22.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 10, Competence.

2.20 Failing to do arterial blood gas

C A B D E
A patient with shortness of breath is a common reason for an on-call FYl to be
bleeped. Parr of your investigation plan in most cases will include an ABG, and
you will be expected to be able to perform this. It is often difficult to practise
this skill as a medical student as it is a painful procedure that patients do not
like to have to undergo. ln this scenario, though, you have clearly been compe-
tent at rhe skill in the past. Occasionally failing at various clinical skills is to
be expected when working as a doctor. le is inevitable that, with the workload
and the number of procedures you are asked to carry out you will fail at some.
In this scenario, the option that would fulfil the patient's needs and not waste
any rime would be to attempt rhe procedure yourself (C). Asking the SHO to
attend may be appropriate if you either failed to get the required blood or were
not working a busy on-call shift. The next most appropriate response would
be to ask the SHO to watch you perform the technique {A). This will inevitably
prevent your SHO from reviewing other patients, but it would mean that your
learning needs are met. Asking the SHO to perform the task themselves (B)
would ensure that the patient gets rhe test they require; however, you would
nor benefit from the potential learning opportunity. Performing a VBG (E) may
be appropriate in some situations {e.g. diabetic ketoacidosis or hyperkalaemia);
however, in this scenario, a VBG would not provide the information you
require {whether the patient is in type 2 respiratory failure or acidosis). This
makes option E the least appropriate. Attending the clinical skills department
may lead to you improving your skills and ultimately your confidence (D);
however, in this scenario, your patient has an immediate need.

Recommended reading
Foundation Programme Curriculum (2012), section 8.2: Responds to acutely
abnormal physiology.
 Answers 149

2.21 Challenginga senior

C D A B E
Challenging a senior colleague is difficult but necessary at times, especially if
patient safety is at risk. Therefore the most appropriate response is C, pointing
out to your SpR that he has contaminated his sterile field, followed by other
options that involve alerting him to his mistake. lf you do not feel confident
doing this, you could ask the theatre sister to tell the SpR (D). Informing the
SpR and suggesting that he looks at infection control guidelines (A) is unnec-
essary since it is likely to be a mistake and saying this to the SpR could be
perceived as being rude and unnecessarily abrasive. Option A, however, is pref-
erable to option B: giving the patient post-operative antibiotics and not chal-
lenging the SpR. Junior doctors should feel that they can challenge a senior,
thereby promoting a culture of openness in the NHS. Making a complaint
about the SpR to his consultant {E) would be unwarranted, unless this was an
ongoing issue, and also would not involve dealing with the current safety risk
to the patient.

Recommended reading
Medical Protection Society (2012), Competence and Relating to colleagues, in
MPS Guide to Ethics: A Map for the Moral Maze, chapters 10 and 11.

2.22 Incorrectconsent

C E D B A
This is a difficult situation for an FYl to find themselves in; however, it is
important to remember that the patient is always the first priority. The least
appropriate response is to complete the consent form yourself (A) as this
would be illegally adding information that the patient potentially has not been
informed of co a document char has already been signed by them. Without a
correctly completed consent form, the operation would nor be allowed to go
ahead; therefore, your priority is to prevent the patient from undergoing an
unnecessary general anaesthetic. Stopping rhe anaesthetist (C) is therefore the
most appropriate response as this would provide you with time to discuss the
situation with your consultant. Telephoning the consultant, who is likely co
be in theatre, would be the next course of action (El as he would be able to
arrange for the form to be completed by the patient before the anaesthetic;
however, this is less preferable than option B as it will not necessarily prevent
the patient being anaesthetised. Telephoning the theatre coordinator (D) would
not be an efficient use of time as they would have to discuss this with the
theatre staff anyway. Walking to theatre (B) is not advisable as the patient may
already have undergone the anaesthetic by the rime you arrive; in addition, it
is inappropriate as all operations and procedures have risks and patients muse
be informed of these risks beforehand. General Medical Council guidance
suggests that risks can rake a number of forms: side effects, complications or
failure of an intervention to achieve the desired aim.
 150 Chapter 2: Coping with Pressure

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together, paragraphs 28-36.

2.23 Patient controlof discharge summary

A B D C E
When a patient has become angry, it is always a good idea to get some sup-
port from a colleague. This is important for your safety and so that someone
else witnesses the proceedings. The key message in this question is that the
patient's accusation of breach of confidentiality is entirely wrong. Recording
the information patients tell you accurately is an important part of your job.
The sharing of information between professionals is vital in order to provide
high-quality care. The best two responses therefore involve explaining to the
patient that you will not change their records. A senior nurse will be more read-
ily available to help with this and will most likely be experienced in managing
conflict (A). Your registrar would be the next best choice (B). Option D respects
the principles of medical record-keeping but is confrontational and will not
repair the doctor-patient relationship. Option C is better than E because it
involves only changing a small detail on the discharge letter rather than tam-
pering with important clinical details in the medical records, which is illegal.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 50.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 9, Confidentiality, section: Maintaining patients' trust.

2.24 Absentwithout leave (AWOL)

C D E A B
It is importanr to ask for help if you think you need it, and a difficult registrar
should not put you off. lf you are concerned about the health of your patient,
then you need to be persistent with the registrar to come and see your patient
(C); such persistence will usually work, which is why this is the best response.
If you are still concerned, then you need to escalate higher than your registrar,
which would involve contacting the consultant on call (0). Talking to the SHO
and asking them to review your patients instead (E) is a good next response
as they may have more success in contacting the registrar if they too are
concerned about the patient. However, the SHO is likely also to be busy, and
therefore, they may not be happy for you to call them for the rest of the shift.
It would also be appropriate ro ensure that your patients are reviewed by physi-
cians more senior than your SHO and therefore options C and Drank higher
than E. Again, if you are acutely concerned about your patient, you need to
get the best help you can, and therefore asking the switchboard operator for
the contact details of another registrar (A) is better than pushing aside your
concerns (B); however, there is unlikely to be another registrar on call for your
specialty, especially if you are working in a district general hospital.
 Answers 151 •

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 35-38.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 11, Relating to colleagues.

2.25 Bullying registrar

B C E
The registrar's undermining behaviour is seriously affecting your working
life. It is therefore important that you seek support. The hospital counselling
service (B) can provide advice to help you cope with the situation and help
to support a dialogue between the registrar and yourself if you a re strug-
gling with this independently. At the same time as seeking help, you should
let the registrar know that you are finding your working relationship difficult
and that this is something you wish to work on together (E). Your clinical
supervisor should be aware (C) so that they can ensure you have the sup-
port you need and also because it is an issue that could have a large effect on
their clinical team if it is not addressed. Given chat the issue purely occurs at
work, you do not have to go see your GP at chis stage {D). Although this is
always a reasonable source of seeking support, there are better answers for
chis question. Furthermore, local sources of support should be accessed at
this stage rather than contacting the GMC (F) as patients are nor at risk. You
should avoid having this conversation in public and being confrontational {A)
as this can undermine patients' trust in your ream and the medical profes-
sion. Ir is not constructive co try to avoid the registrar altogether (G) and
will mean that other FYls have to spend more rime working with a senior
who they too may find stressful dealing with. Ir would be inappropriate and
unprofessional to say negative things about the registrar to their future FYls
(H) and could be seen as intentionally discrediting them or even as a way of
seeking revenge.

Recommended reading
Medical Protection Society (2012), Relating to colleagues, in MPS Guide to
Ethics: A Map for the Moral Maze, chapter 11, section, Conflict.
NHS Choices. Bullying at work. http://www.nhs.uk/Livewell/workplacehealth/
Pages/bullyingatwork.aspx.

2.26 Understaffing

B C A D E
Attending regular teaching and developing your knowledge is of obvious
importance, but your primary responsibility is always to ensure the safety of
patients you are responsible for. lo this scenario, the FY2 is continually leav-
ing the ward understaffed in order to attend optional teaching. This has the
potential to compromise patient safety. It is most appropriate to discuss your
concerns with the FY2 (B) so that she is aware and has the opportunity to act.
It would also be a good idea to discuss the issue with your consultant (C) so
e 152 Chapter 2: Coping with Pressure

that they can try to resolve the issue. Seeking advice from your educational
supervisor is appropriate (A), but it would be better to first discuss the issue
with your consultant since they have a direct responsibility over staffing within
your team. Raising the issue of understaffing at the next meeting (D) does not
directly tackle the problem in this scenario and so is less suitable. It is inappro-
priate to ask your FYl colleagues to make hints to the FY2 (E) since this is an
unprofessional approach to solving the problem.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 24,
25, 35-38.
Medical Protection Society (2012), Relating to colleagues, in MPS Guide to
Ethics: A Map for the Moral Maze, chapter 11.

2.27 Absentcolleague

C E B A D
The aim of the FYl year is to become a competent junior doctor in manag-
ing patients with both acute and chronic illnesses as well as achieving the
FYl competencies outlined in the foundation programme curriculum. In
addition to these commitments, you will work for a trust and be expected
ro perform clinical duties. If you can gain experience in ocher ways, such as
attending clinics and theatre sessions, this is of additional benefit but should
always come second to your primary commitments which rend to be ro the
patients on the ward. This scenario describes a colleague who is putting their
own personal objectives ahead of their usual jobs and expecting you to pick
up the pieces. Importantly, if two doctors are scheduled to be on the ward,
chis is because there is enough work to require two juniors. Taking on all this
work alone means that you will be seriously overworked. The best response is
option C, to speak with your colleague directly as they might nor realise how
much of a burden they are putting on you or whether you mind them being
absent. Talking together you can work our a better way of working between
you. Option E ranks second: arranging a fair amount of rime for both of you
to do something you're interested in seems reasonable as long as the wards are
always adequately and safely covered. Your registrar might not realise they
are putting you in difficulty on the wards by taking your colleague to theatre
and so speaking to them would also be appropriate (B). Once the registrar
understands the situation, in future they could check with your colleague to
make sure that the ward is quiet before allowing them into theatre. Speaking
to your clinical supervisor about how to address this situation (A) is a sensible
response, bur the wording of this option suggests that you are requesting addi-
tional help rather than help from the FYl who should be working on the ward
anyway, which is why it is ranked fourth. Option D is tbe least appropriate
response as taking on extra work can leave you dangerously overstretched, and
you shouldn't have to feel like you have to work extra hard to cover for your
colleague's absences.
 Answers 153

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 35-38.
The UK Foundation Programme Curriculum (2012).

2.28 Mean registrar

B F G
As a doctor, you will work with many different people, and some of those will
have different expectations of you and ways of working. Having said that,
the demands of the registrar detailed in this question seem unnecessary, and
his response when you don't achieve them over the top. The best responses
here involve speaking to your registrar privately to discuss how you can both
achieve your objectives together (options B and F). If your registrar doesn't
respond to your efforts to maintain a positive working relationship, you have
at least cried to deal with the problem directly and can then escalate chis issue
if nothing changes. Option G, to discuss your registrar's demands with your
consultant, is the next most appropriate response. As well as informing them
of your registrar's difficult behaviour and how his demands are forcing you
to work many hours over your contract, you could ask your consultant what
they think is really important regarding care on the wards and what should
be prioritised, and then act accordingly. The inappropriate responses in this
question include continuing to work until you burn out (options A and H). You
need to ensure chat you work healthy hours as a junior and look after yourself
ro enable you to better care for your patients; nobody works well when they
are tired. Informing the crust about your registrar's behaviour (C) is a drastic
step, so you should escalate this issue to your consultant and supervisors first.
Refusing to carry our tasks char you see as unreasonable (D) is potentially dan-
gerous. As a junior doctor, you are not yet experienced enough ro decide what
is appropriate, and you could make a serious mistake. Getting information
from your union (E) may give you some useful advice. It is perhaps worth con-
sidering; however, it is nor included among the three most appropriate options
because it doesn't involve any direct action.

Recommended reading
Carter M., et al. (July 2013), Workplace bullying in the UK NHS: A question-
naire and interview study on prevalence, impact and barriers to reporting,
BM] Open, 3.
NHS Employers guidance (April 2006), Bullying and harassment.

2.29 Shredding nurse

C B D E A
As an FYl, you will work with a large number of different people from differ-
ent specialties and seniority. It is very likely that you will find some of these
relationships challenging. Despite this, it is important to remember that we are
all working towards the same aim: helping our patients. The situation outlined
earlier sounds very frustrating, and the nurse seems to have acted hastily and
• 154 Chapter 2: Coping with Pressure

unfairly to teach you a lesson about the importance of patient confidential-

ity. The best response would be to speak to the nurse privately to explain how
difficult her hasty shredding has made the rest of your day, and to work out
a way you can prevent this happening again with a bit more tolerance of each
other (C). The second best response would be to speak to the nurse's immedi-
ate manager, the sister on the ward, about this situation and how to prevent
it happening again (B) while remembering that it is not the role of doctors to
discipline or tell nursing staff how to do their jobs. Option D ranks third as
complaining about this to your consultant isn't likely to do much to improve
your working relationship with the nurse, and as mentioned earlier, it is not the
role of doctors to discipline allied health professionals. It may, however, help
you with the rest of your day's planning as they could remind you of the most
important tasks of the day. Deciding to do nothing to help your working rela-
tionship and leaving the ward to make a new handover sheet (E) will at least
help you with the rest of the day but ignores the main issue in the scenario, and
so this option ranks fourth. The most inappropriate course of action here is
option A: shouting at anyone at work is unprofessional. You should nor need to
raise your voice to get your point across, and this could also upset patients and
further disrupt your working relationship.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 35-37.

2.30 Interpreters
A D H
In this situation, you need to put the care of the patient first. This means
you need to try and find a way to communicate with the patient. The best
ways of doing this are to see if there is another doctor available who speaks
the same language as the patient or to find an interpreter (options A, D and
H). Asking the interpreter service to send someone in may be appropriate
(D), although it depends on how unwell you think the patient is, but this
may take some time. However, phone interpreters (H) can be very helpful
in allowing you to get the history without waiting for an interpreter to be
present in person. Family members should not be used as interpreters (B),
unless it is an emergency. Taking a nurse with you (C) is not going to be
particularly helpful in this case, if they are unable to communicate with the
patient any more than yourself. Seeing another patient instead (E), when
you are clinically concerned about the patient in front of you, is not accept-
able, neither is simply examining the patient without the context of a clinical
history (F). Similarly, ordering tests blindly is not going to help your clinical
decision-making (G).

Recommended reading
BM] Careers, Medical interpreters, http://careers.bmj.com/careers/advice/view-
article.html?id=20000223.
General Medical Council (2013), Good Medical Practice, Duties of a doctor.
 Answers 155

2.31 Demanding patient

B D E A C
It is important to prioritise the patient in the most life-threatening situation
regardless of how demanding other patients may be. Myocardial infarction is
the condition requiring the most urgent treatment; therefore, you should ensure
that emergency management is prescribed to this patient first (B). Arranging
the transfer to a specialist unit(£) is also vital to ensure definitive management
of this patient and must happen in a timely fashion. However, option D, pre-
scribing antibiotics for the patient with a urinary tract infection, ranks before
option E because it is a relatively quick job, and potential sepsis in the elderly
is also a very serious condition which should be treated promptly. Although
he should be assessed (A), the young man is your lowest priority because he
is not as acutely unwell as the other two patients, and you must address their
problems in order of clinical need. Option C is the worst response because you
should not refuse to see a patient, even if their behaviour is challenging, until
you have attempted to assess the situation. It may be that there is an underly-
ing pathology that needs to be treated. There are a number of steps that can be
taken to ensure staff safety if a patient becomes aggressive, including involv-
ing security, but they should still receive care whenever possible. However, the
threat of self-discharge should not alter how you prioritise the needs of the
patients.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 9.
The UK Foundation Programme Curriculum (2012), Recognition and manage-
ment of the acutely ill patient, chapter 8.

2.32 Nurse-patient breakdown

D A E B C
Conflicts between patients and nursing staff are difficult. You must appreci-
ate the opinions of the nursing staff while also ensuring that patient care is
not compromised. ln this case, you could try to resolve the issues between the
nurse and the patient, but if you feel that their relationship has broken down
this is unlikely to work. The most appropriate response in this case is therefore
option D, to suggest that a different nurse looks after the patient. The General
Medical Council (GMC) states that a professional relationship with a patient
can be ended only when 'the breakdown of trust means that you cannot pro-
vide good clinical care to the patient'. The next most appropriate response is
speaking to the nurse in charge about the issue (A). It is a good idea to involve
the senior members of nursing staff, but this may be perceived as complain-
ing about the nurse, unless the nurse is involved in or aware of the discussion.
Doing nothing (E) would not help the situation bur does not damage the situa-
tion further and therefore ranks next. The two remaining responses, asking the
patient to stop being rude and demanding (B) and decreasing the patient's anal-
gesia (C), fail to address the conflict between the nurse and the patient and are
 156 Chapter 2: Coping with Pressure
l
likely to exacerbate the situation further. To leave a patient with Jess analgesia
following an operation is the worst course of action as this would be immoral
and would deny the patient one of their basic rights in hospital.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 57,
59 and 62.

2.33 Patient error

E B D C A
After realising that you have made a mistake relating to a patient's management
that can cause harm or distress, the General Medical Council (GMC) states that
you should do three things: put matters right if possible, apologise and explain
the situation, including the likely short-term and long-term effects. In this situa-
tion, the patient may experience side effects from the antibiotic and has unnec-
essarily been cannulated. Therefore, the most appropriate course of action
would be to inform the patient of your mistake and apologise (E). Asking your
SHO to discuss with the patient (B) is less appropriate as this is your mistake,
and you should not need senior input, but at least in doing this, the patient wilJ
receive an explanation about the abrupt changes to their management. Filling in
an incident form (D) may be useful to prevent a further incident, but this would
not deal with the current situation in hand. Stopping the antibiotic course
without informing the patient (C) would be tempting as a dose of antibiotic is
unlikely to cause the patient harm, but you should be honest to the patient to
maintain openness and trust. The least appropriate response in this question
is allowing the patient to complete the antibiotic course (A). This would be
unnecessary and may result in side effects or adverse events for the patient, for
example making them susceptible to a Clostridium difficile infection.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 55.

2.34 Unable to get chaperone

C E D B A
Chaperones are used to protect both yourself and your patient, and it is impor-
tant to offer one for any intimate examination regardless of the patient's or
your gender. Option C is therefore the most appropriate response as you should
not perform the examination without a chaperone if you feel uncomfortable
in doing so, and in this scenario, leaving the examination to the following day
will not adversely affect your patient's health. Asking your patient to see a
female GP (E) may be an appropriate response as both your female colleague
and the patient may feel more comfortable for the examination to be carried
out without a chaperone. In this case, the examination should be carried out
to obtain further clinical information, and your patient has already consented
to the examination, therefore basing your diagnosis and treatment on history
 Answers 157

alone (D) is inappropriate. Performing the examination without a chaperone

present (B) makes you vulnerable to complaints and should not be carried out
if you feel uncomfortable doing so. You may, however, examine the patient
without a chaperone if the patient did not want a chaperone and you felt com-
fortable with this, but this would require careful judgement and documenta-
tion. Asking her partner who is in the waiting room (A) is not appropriate as
a chaperone should be impartial and familiar with the intimate examination
procedure. There may also be reasons why your patient does not want her part-
ner present during the examination.

Recommended reading
General Medical Council (2013), Explanatory guidance, in Intimate
Examinations and Chaperones.

2.35 Chaperones

B £ A D C
This example deals with chaperones for intimate examinations. Chaperones
are advisable for every intimate examination as their presence protects both the
patient and the doctor. An intimate examination includes that of the breast,
genitalia and rectum. Chaperones should always be offered, even if the doctor
and patient are of the same sex. This scenario is complicated by the fact that
the patient appears ro be drunk. In situations where the patient's recall may be
clouded, such as when intoxicated, under the influence of drugs or undergo-
ing anaesthesia or sedation, it is even more important ro protect yourself from
accusations by ensuring a chaperone is present. The best responses in this case
are those that do not offer to undertake the examination without a chaperone.
Option B is the most appropriate as this placates the patient by explaining
why chaperones are so important and that you do not feel like you can con-
tinue without. Option E is the next best response as you are asking for advice.
Although, in option D, you don't perform the examination, you have not dealt
with the matter in hand and could be missing potentially serious information;
therefore, it ranks second to last. The decision about whether a chaperone is
present is ultimately up to you and the patient, and as long as this is detailed
accordingly, proceeding to do the examination without a chaperone (A) is not
necessarily wrong, although it is potentially more risky for yourself. Option C
similarly involves risk bur also means you are lying to the patient because being
rushed for time is absolutely not a reason to proceed without a chaperone;
therefore, this option is the least appropriate.

Recommended reading
General Medical Council (2013), Explanatory guidance, in Intimate
Examinations and Chaperones.
Medical Protection Society (2012), Morality and decency, section: Chaperones,
in MPS Guide to Ethics: A Map for the Moral Maze, chapter 5.
The UK Foundation Programme Curriculum (2012), section 7.2: History and
examination.
• 158 Chapter 2: Coping with Pressure
- - --- --1

2.36 E-portfolio

A C B D E
Struggling to meet the objectives of both your educational and clinical duties as
an FYl is a common problem. You have to try and work together with senior
colleagues to achieve your FY l objectives, which may well involve a degree of
compromise. The best person to talk to in this situation is your educational
supervisor (A). If the only time your consultant is free to meet with you is
during your annual leave, then you have to make allowances for this and
attend the meeting, so option C is the next best response. Remember, you must
complete your e-portfolio to pass FYl! Option Bis ranked third; if you have
persistently tried to meet with your supervisor and they refuse, this should be
reported to the foundation programme director ar your trust. Asking another
consultant to bridge the gap (D) would be a proactive way of dealing with
this problem, but you need to get this ratified with the foundation programme
director as it is not usually permitted to choose your own supervisor. Option E
would be the least appropriate course of action since writing a letter of com-
plaint wouldn't deal with the problem in hand and is likely to cause friction
between you and your supervisor.

Recommended reading
The Foundation Programme (2012), Training Descriptor and Curriculum
Matrix.
The UK Foundation Programme Curriculum (2012).

2.37 Educational supervision

E A B D C
The most important thing here is to provide the medical care that is neces-
sary to ensure patient safety while also remembering your own educational
needs. You have arranged a meeting with your supervisor; therefore, it
would be courteous to inform them that by seeing to a patient on the ward
you will be late for this. Additionally, it would be advantageous to use this
opportunity as a positive learning experience, so if your educational supervi-
sor has already allocated this time for you, then it would be appropriate to
ask them to complete a rnini-CEX form with you (E). The next most appro-
priate responses are co move up the chain of on-call physicians as you have
already finished your shift and should therefore utilise the on-call team. If
the on-call SHO is not free (A), then the next person to contact would be
the registrar (B). While it would mean that you are late for your meeting,
if the nurses are concerned about a patient and the on-call team are busy,
then you should go and see the patient yourself, but this should involve a full
review (D) which is far better than simply glancing at the patient to alleviate
the nurse's fears (C). Option D ranks higher than C as waiting for a proper
review is better than you undertaking a poor review and then not having this
followed up on.
 Answers 159

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 44-45.
Medical Protection Society (2012), Professionalism and integrity, section:
Professionalism, in MPS Guide to Ethics: A Map for the Moral Maze,
chapter 3.

2.38 Clerking responsibilities

E C B A D
Medical clerking is a very common task for junior doctors, and it is a valuable
learning opportunity as it allows you to see acutely unwell patients who require
prompt investigations and management. The complexity and severity of cases
varies from patient to patient, as does the ability of a doctor to complete their
history and examination in a certain period of time. It is expected that more
junior doctors will take longer to see a patient than more senior colleagues. In
this scenario, your colleague may have a good reason for why they have taken
a prolonged period of time to see one patient. It may be that they were seeing a
particularly unwell patient or one with a complex case, or they may be strug-
gling to make a diagnosis. In any event, approaching your colleague directly is
always the best course of action (E). The medical registrar usually has general
responsibility for newly admitted medical patients and contacting them about
the current situation would be appropriate (options A and C). However, this
would be better put in the context of voicing your concerns about your own
workload (C) rather than the performance of your FYl colleague (A), which
would both be unproductive and could damage your professional relation-
ship with your colleague. In fact, option A is less appropriate than option B,
continuing to clerk. As a clerking doctor, it is your responsibility to see patients
so continuing to clerk is important (B); however, this wouldn't provide any help
or support for your colleague who could be having difficulty. Offering to take
over your colleague's case is the least appropriate response (D) and could lead
to confusion over the casks to be completed.

Recommended reading
Medical Protection Society (2012), Professionalism and integrity, in MPS Guide
to Ethics: A Map for the Moral Maze, chapter 3.

2.39 Emergency in the community

B E D A C
The General Medical Council (GMC) states that 'you must offer help if
emergencies arise in clinical settings or in the community, taking account
of your own safety, your competence and the availability of other options
for care'. Therefore, in this scenario, the most appropriate course of action
is option B, doing an assessment and providing care as best you can until
emergency services arrive. The next best response is option E, to see if anyone
has suitable training and then leave, although first-aid training is unlikely to
• 160 Chapter 2: Coping with Pressure

be as good as your medical care since it could be outdated, or they could be

inexperienced. Phoning for an ambulance (D) would alert the medical services,
but the collapsed patient would have less chance of survival without CPR (if
it was required) while waiting for the emergency services to arrive. Telling the
crowd to call an ambulance {A) would be less appropriate as it could result in
a delay in the emergency services being aware of the situation. Doing nothing
(C) is the least appropriate response as a doctor does have a social and moral
responsibility and a duty of care to patients in emergency situations in the
community.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 26.

2.40 Unsafe on call

C E G
Part of your role as a doctor is to raise concerns when you believe that patient
care or safety is being compromised by the practices of colleagues, systems,
policies or procedures. To tackle this situation you first need to try and
improve patient safety as best you can during your on-call, and secondly you
should raise your concern through the appropriate levels after the weekend to
improve a recurring situation. The most appropriate actions during your on-
call are to inform the medical registrar {C), who is in a position to reallocate
staff to where the clinical need is, and to prioritise your casks {E) as best you
can. After the weekend, you should highlight your concerns to your consul-
tant {G), who should be able to give you advice and escalate the issue further,
should you both deem it appropriate. Asking another colleague to come in on
their day off (A) would be inappropriate as the on-call team should be able to
reallocate staff without bringing in extra people. Option B, asking the nurses
to contact you only when they are very worried about a patient, is inappropri-
ate since it could result in unwell deteriorating patients being left until a critical
point, when their further deterioration could have been prevented. However,
informing nursing staff that you are extremely busy and making them aware
that there may be a delay prior to your review would be sensible. Informing the
SHO that you are not coping (D) is unlikely to be beneficial as he has already
informed you that he is busy with the post-take ward round, and this may
only serve to increase his own stress levels. Option F, seeing all of the unwell
patients as quickly as possible and missing lunch, is both unprofessional and
dangerous. By not being thorough you may miss important diagnoses, and
breaks are vital to your working day and are known to improve productivity.
Writing a letter to the medical director (H) may be useful if you feel your con-
cerns are not being taken seriously, but in the first instance you should contact
your consultant.

Recommended reading
General Medical Council {2012), Raising and Acting on Concerns About Patient
Safety.
 Answers 161 e
2.41 Complaint

D E B A C
Doctors find themselves in potentially compromising situations on a day-to-day
basis, and it is important that you are mindful of how such situations may
be perceived by the general public. You should adequately explain to patients
what you intend to do prior to proceeding and should use chaperones for any
procedure that involves close or intimate contact. In this scenario, your inten-
tions were good, and there has been a simple misunderstanding. However, if
handled badly, this complaint could become serious, so it is important to act
with professionalism. The most appropriate response is to seek advice from
your medical defence organisation (D) as this should always be your first
action whenever any complaint is made against you. It is also prudent to allow
the hospital to deal with the complaint (E). They will work on your behalf to
resolve the situation and will notify you of any action necessary on your part.
It is completely inappropriate to ask the patient to withdraw their complaint as
this may be seen as coercion (C). Similarly, you should avoid approaching the
patient (A), even if it is to explain that there has been a misunderstanding. This
may worsen the situation or again be seen as an attempt to put pressure on the
patient. While still unfavourable, it would be better for a colleague to approach
the patient (B) rather than you since the patient may feel less uncomfortable
talking to someone other than yourself. Option B therefore ranks higher than
options A or C.

Recommended reading
General Medical Council (2013), Good Medical Practice paragraph 73.
Medical Protection Society (2012), Professionalism and integrity, in MPS Guide
to Ethics: A Map for the Moral Maze, chapter 3.
2.42 Coroner statement

C E G
You are legally required to cooperate with all formal inquiries and should do
so in a timely manner. Options D and F, which either ignore or delay this task,
are therefore inappropriate. You are also legally obliged to take reasonable
steps to ensure that the information you give is factually correct. The report
should be based on the medical records, your recollection of the case and
your usual practice. It would therefore be pertinent to re-familiarise yourself
with the case using the patient's medical notes (E). To ask the nurses about
their recollections (A) or to read what another doctor has written (B) may
inadvertently lead you to write a false account of your personal involvement,
so these are inappropriate courses of action. While giving a timely statement
is important, to write the statement quickly and purely from memory (H} may
again result in a factually incorrect statement. Writing a legal statement in
the correct manner is clearly of paramount importance. Ir would therefore be
advisable to seek advice both from your educational supervisor and a medical
defence organisation (options C and G).
 162 Chapter 2: Coping with Pressure
l
Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 71-74.
Medical Protection Society (2013), MPS Factsheet: A Guide to Writing Expert
Reports.
Medical Protection Society (2013), MPS Factsheet: Report Writing.

2.43 Angry registrar

D B E A C
As an FYl you may feel like your job is right at the bottom of the ladder, but
you are an important member of the team and a professional who should be
treated as such. Shouting at a co-worker is not acceptable behaviour, so the
best responses here both diffuse the situation immediately and take steps to
stop it happening again. The most appropriate course of action is option D; it
diffuses the situation but offers to discuss the matter in private when tempers
have cooled. Option B ranks second as, again, apologising takes the heat out
of this situation and by offering to go through the ways you can help better
on the ward round in future could improve your own working day as well as
that the rest of the team. An approach like this could result in a better work-
ing relationship. Option E ranks next: taking the matter to your consultant is a
fair approach as shouting at you in front of staff and patients is highly unpro-
fessional, and the team leader would want to be made aware. Option A is the
fourth best option as it is confrontational and will not diffuse the situation, but
it is potentially less dangerous than option C, where avoidance of your seniors
could lead to a future failure in asking for help or escalating treatment because
of your poor working relationship.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 35-38.

2.44 EWTD breach

C B E A D
The European Working Time Directive (EWTD) was put in place to protect
junior doctors from unhealthy working patterns and to protect patients from
tired doctors. The best way to raise this issue of extra hours would be within
your own team by speaking to your consultant (C). They are the head of the
clinical team and will want to know if you are struggling with your work-
load and would be able to support you by delegating senior doctors to help
with ward tasks or contacting medical staffing for a more permanent locum.
Talking to your foundation programme director (B) is the next best response as
they are there to ensure you are able to work safely and gain your foundation
competencies. They would therefore be able to offer advice on this scenario.
If this fails, then option E would be the next best course of action since con-
tacting the CEO would ensure that the issue of working hours and pressures is
seen by the management, although it would be prudent to try options C and B
first. If you feel able to do so safely, continuing to work through this difficult
 Answers 163

rota would be the next best response (A). Rotations are four months long and,
providing you are not exhausted and working safely, continuing to work extra
hours is not unsafe in itself, although it may seem unfair. Option D is clearly
inappropriate; not only is it dishonest, but taking sick days will put extra pres-
sure on the already depleted team.

Recommended reading
British Medical Association, European Working time directive.
Government legislation: Statutory Instruments 1998 No. 1833: Terms and
Conditions of Employment; The working time regulations 1998.

2.45 Responding to colleague's request

B A E D C
This question relies on your ability to maintain good communication and
respect for your colleagues whilst under pressure as well as ensuring that
you prioritise good patient care. Firstly, it is important to explain calmly and
reassure the nurse that you are aware of the patient and are simply very busy
(B). Creating an aggressive or hostile atmosphere is not professional and could
impact good patient care. Whilst the nurse may be concerned that the patient
is in pain, it would be irresponsible to prescribe analgesia before adequately
assessing the patient and taking a full history (in particular drug history and
allergy status). Option C is therefore the least appropriate, and morphine
would also not be your first line drug of choice for pain. After explaining the
situation to the nurse, it is courteous to maintain good communication with
the patient (A) as this may help to prevent any resentment or ill feeling later on.
Most patients arc very understanding but appreciate knowing what is going on.
Asking another doctor to see the patient may be appropriate, especially if you
are worried about the patient, but remember that they probably have a heavy
workload as well (E). Deliberately leaving the patient until last is petty, unpro-
fessional and likely to simply cause more unnecessary hostility between you
and your colleagues (D). More importantly, it could be detrimental to patient
care, and you should prioritise patients based on clinical need rather than your
own personal reasons.

Recommended reading
General Medical Council (2013), Duties of a Doctor: Knowledge, Skills and
Performance.
General Medical Council (2013), Good Medical Practice, paragraphs 15, 16,
32-34,35-37,46,55,56,59.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapters 7 and 11.
World Health Organisation, Pain Ladder for Adults. http://www.who.int/
ca ncer/pallia tive/painladder/en/
3 Effective Communication

Chapter 3

EFFECTIVE COMMUNICATION

QUESTIONS
3.1 Writing in the notes

You are reviewing a patient who has had an allergic reaction ro penicillin.
You treat the patient and document your history and examination in the
notes. You mention the event to your senior house officer (SHO} when you next
sec them, which is at least three hours after the event. They ask you whether
you examined their throat with a pen torch, which you did nor. You return to
the panenr ro re-examine them, and their throat looks normal. There have been
several entries in the notes since your last one, and you are unsure how to enter
th is extra in formation in the norcs.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Do not record your further examination.
B Get an extra continuanon sheer and file it our of order in the nores with
your additional findings.
C Make a new cntr y dera iling your additional cxarninarion.
D Remove that page from the notes and rewrite your entry.
E Write up your examination just underneath your last entry in the notes and
make it clear that it is written in retrospect.

3.2 Requesting tests

You are trying to order a test for a patient, which your registrar asked you to
do during the morning ward round. It is a complex radiological set of images,
and when you submit the request to radiology reception, they inform you that
you must discuss this in advance with the duty radiologist on call. You attempt
to get in contact with the duty radiologist several times over the next few hours
to discuss the request bur cannot gee through. If the request is not put in soon,
the patient will not get the investigation until next week as it is a Friday.
Choose the THREE most appropriate actions to take in this situation.
A Contact your registrar explaining the difficulties and that the imaging may
not happen today.
B Continue trying to get in contact and let the registrar know at the end of
the day whether or not the imaging happened.
C Find out who and where the radiologist is and go and see them personally.
 166 Chapter 3: Effective Communication

D Ger in touch with the consultant radiologist on call and inform them that
their registrar is unobtainable.
E Order a different set of tests for the patient, which is easier to organise.
F Put the request card in the duty radiologist's office with a note asking them
to approve it.
G Return to radiology reception mforming them that the duty radiologist has
said yes to the request.
H Speak to another radiologist with whom you get on well and ask them to
approve the request.

3.3 Knowledge

A patient on your ward is due to have a colonoscopy later in the <la)'. You are
asked to go and talk to her as she has some concerns about the procedure.
She asks you to explain the procedure anti its associated risks since she has
forgotten what has previously been said to her. You have seen a colonoscopy
once before, bur it was a long rime ago, and you remember little about it. You
cannot remember the risks.
Rank in order the following actions in response ro this situation {J = Most
appropriate; 5 = Least appropriate).
A Explain char you arc nor completely familiar with the procedure but char
you will ask someone who is to speak with her as soon as possible.
B Puc off going ro talk to her and hope that she finds someone else to speak
to in the meantime.
C So as not to damage her confidence in your abilities, give an explanation
using your knowledge of ocher similar procedures.
D Tell her as much as you can remember about the procedure.
E Tell her that you do not know enough about the procedure to be able to
discuss it with her.

3.4 Have I got cancer?

You are working as an F Y 1 doctor in a large hospital on a busy respirarory

ward. You attend a multidisciplinary ream meeting about a patient under your
care. During the discussion, it is confirmed that this patient has a diagnosis of
lung cancer. Your consultant informs you that she will talk with the patient rhar
afternoon co give him the diagnosis. When you rerurn to the ward, you are asked
by the nurses to take some routine blood tests from the same patient. When you
have finished caking the blood, the patient says. 'Have I got cancer doc?'
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Ask the registrar who is currently on the ward for advice about what you
should do.
B Inform the patient that as far as you are aware, no diagnosis has yet been
made and he should not worry.
 Questions 167

C Inform the parienr char your consulcanr wanrs ro discuss the siruarion with
him this afternoon and then find her to remind her of her promise.
D Take the patient with a senior nurse inro a side room and inform him he
has cancer.
E Tell the patient he has got cancer and tell him everything you know about
lung cancer.

3.5 Drinking with friends

You arc in a har near rhc hospital char you work in, and one of your friends
who is also a doctor has had a little bit too much to drink. A man enters the
bar and secs the group of you sitting there and comes over to talk to your
friend. While your friend does not say anything to jeopardise himself, he is
slurring his words. The man says, 'It's good to see that doctors know how to
wind down'. Your friend then hugs the man, and the man walks away. Your
friend cells you that he is a relative of one of his patienrs.
Rank in order rhc following actions in response to rhis siruarion (1 = Most
appropriate; 5 = Least appropriate).

A Excuse yourself and go to apologise ro the relative about your friend.

B Don't do anything since the relative did not seem to be upset about the
incident.
C Suggest to your friend that, the next time he sees him, he should apologise
to the relative for being drunk.
D Suggest to your friend that he go and apologise to the relative now.
E Tell your friend rhar he should nor return ro rhe bar again.

3.6 Missing notes

You are reviewing an unwell patient on the ward who you suspect may have a
chest infection. You have requested imaging and blood tests and started them
on antibiotics. You want to record your history, examination, working diagno-
sis and treatment plan in the notes, bur they have been taken off the ward for
reviewing at a multidisciplinary ream (MDT) meeting. You finish work in one
hour, and they arc unlikely to be back on the ward by then.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Enter your notes a day late when the notes are back on the ward.
B Go to handover and explain what you've done to the evening ream, so they
are aware without needing the notes.
C Seay later than your finish time to enrer your assessment when the notes are
returned.
D Write your notes on a loose sheet of paper and pin it to the ward
noticeboard.
E Write your notes on a loose sheet of paper and place it in a temporary ring
binder in the notes rack.
• 168 Chapter 3: Effective Communication

3.7 Self-discharge

You are an FY l working in general surgery. A nurse rings you from anorber
ward informing you rhar a patient of yours, who has had major colorectal
surgery earlier in the day, wishes to self-discharge.
Choose the THREE most appropriate actions to rake in this situation.
A Ask the on-call psychiatrist to assess his capacity.
B Inform the patient that if he self-discharges, he won't be provided with any
follow-up.
C Inform your specialist registrar (SpR).
D Recommend rhar he gets a friend/relative to stay with him overnight.
E Refuse ro prescribe analgesia if he self-discharges.
F Ring his sister and tell her to persuade him nor ro leave hospital.
G Talk to him, explore his reasons and let him go home if he has capacity.
H Tell the nurses that it is not your responsibility to deal with the situation.

3.8 Patient requesting full-body scan

You are an FY2 working in a GP surgery seeing your own list of patients. The
next patient on the list is a 52-year-old woman who has been to see you several
times in the lasr few weeks. Each time you have seen her, she has complained
of an array of symptoms but never has any clinical signs. You have carried out
several investigations already and have nor found a cause for her symptoms.
The patient list indicates that she has asked to see you as she would like a
'whole-body scan', which you presume is because she would like to know what
is causing her symptoms.
Choose the THREE most appropriate actions to take in this situation.
A Discuss her symptoms with your supervisor before the appointment.
B Explain the test results that you have so far and ask her if her symptoms
have changed or developed.
C Explore with the patient the reasons why she would like this scan.
D Organise a full-body magnetic resonance imaging (MRI) scan.
E Prescribe anxiolytic medications.
F Reassure her that her symptoms are not caused by anything physical.
G Refer her to the psychologist as you suspect rhar she has a functional
disorder.
H Refer the patient to one of your senior colleagues for a second opinion
before you see her.

3.9 Foreign patient

You have just returned from a period of annual leave and have been asked to
complete a discharge letter and make follow-up arrangements for a patient on
rhe ward who speaks little English. The ward sister has asked you to discharge
him as soon as possible since there is a bed shortage. The patient's family is keen
to know what is going to happen ro rhe patient when he leaves the hospital.
 Questions 169

Choose rhe THREE most appropriate actions ro rake in this situation.

A Ask for help from a doctor on another team who speaks the same language
as the patient.
B Ask your specialist registrar (SpR) to talk co the patient and his family
about follow-up while you complete the discharge letter.
C Book a translator so that you can tell the patient what follow-up plans are
in place and which medications he needs to rake and when.
D Complete the discharge letters for the patients who are leaving tomorrow
first so that you can rhen spend more time focusing on this patient.
E Explain to the ward sister that you are making this case a priority bur that
you need to ensure the patient has understood the plan for his care follow-
ing discharge.
F Get the ward sister to talk co the family and let them know what the plans
arc for this patient following discharge.
G Give the patient the discharge letter with the follow-up instructions written
on it and discharge the patient w ith his medications.
H Inform the family that you are making arrangements for a translator so
rhat the patient fully understands what will happen when he leaves the
hospital.

3.10 Suicidal patient wanting to talk

You arc an FYl doctor working on the medical assessment unit (MAU). A
patient has been admitted after an intentional overdose. The patient calls you
over and says char they want to discuss their overdose with you. The patient's
family is present.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Tell them that you will ask your senior to talk to them about it.
B Ask the family co leave.
C Find a quiet place on the ward co discuss it.
D Inform the patient that the psychiatric doctors will discuss it with them
later.
E Ask the patient if rhcy would like a nurse present.

3.11 Cancer diagnosis

One of your patients asks to speak with you to discuss the results of their
recent computed tomography (CT) scan. You know that there is a suspicious
lesion in rhe lung, which has features of malignancy and that rhe patient will
be discussed at the regional lung cancer multidisciplinary team (MDT) meet-
ing. The patient has not been informed of their suspected diagnosis and is not
aware that their chronic cough could be caused by cancer.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
• 170 Chapter 3: Effective Communication

A Ask your registrar to come with you to discuss the results with the patient.
B Refuse to speak to the patient and ask the nurses to tell the patient that you
are too junior ro interpret the scans.
C Take rhe patient into the quiet room and discuss the probability of cancer
with them.
D Tell the patient rhar the results of the scan are not back yer.
E Tell rhe parienr rhat the scan has shown a mass, bur you are nor sure of rhe
origin. Explain rhar ir will be <liscusscd at an ~lDT meeting and arrange a
meeting with your registrar tomorrow.

3.12 Referral

You are at the beginning of your shift when your consultant approaches you.
She asks you ro refer a patient to cardiology immediately so that the patient
will be seen by the cardiology team that day. You have never met rhe patient
and know very little about them.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Inform the patient of the plan to refer rhem ro cardiology and gain consent
for you ro share their information.
B Make the referral immediately.
C Read the notes before making the referral.
D Take a history and examine the patient before making the referral.
E Tell your consultant that you don't feel able to make the referral.

3.13 X-ray reporting

You are an FYl working on a care of the elderly ward. A patient is admitted
to your ward with hip pain. She has had an X-ray on admission, which was
reported as 'normal, no fracture'. However, her hip pain persists, so she is sent
for another X-ray one week later, which reveals a fracture that was also present
in the former X-ray, which was reported as normal.
Choose the THREE most appropriate actions to take in this situation.

A Inform the patient and her family that missing the fracture was the fault of
the reporting radiologist.
B Inform the patient of the situation and apologise.
C Inform the patient that she has a fracture bur omit the fact that the previ-
ous X-ray also showed a fracture.
D Make a complaint against the first reporting radiologist.
E Refer rhe patient to orthopaedic care.
F Speak to rhe reporting radiologist and ask him why he did nor see it.
G Submit an incident form.
H Write a letter to the medical director about the incident.
 Questions 171 e
3.14 Family wanting to know results

You are an FYl on a care of the elderly ward. You are approached hy the
daughter of one of your patients, and she is angry. She wants to know why her
mother has not been fully informed about her current management plan. The
patient has experienced severe headaches and a computed tomography (CT)
scan of her head has revealed a mass. Your senior specialist registrar (SpR) has
specifically asked you not co inform the patient of the results as she are very
anxious and he thinks these results would be better coming from either himself
or your consultant.
Choose the THREE most appropriate actions to take in this situation.
A Admit co the daughter that the patient has been poorly managed.
B Apologise to the daughter about the current situation.
C Ask the daughter what she understands about the current situation and
what her particular concerns are.
D Ask the patient if she would like to know the results of her scan.
E Explain that you are a junior doctor so are unable to help her with this
query.
f Inform the daughter ot the scan results but explain why you don't think the
patient should be made aware of the results at this stage.
G Organise a consulranr meeting with the family.
H Tell the patient and the daughter about the scan results.

3.15 Internet printouts

You are working as an FY2 doctor in a GP surgery, seeing a patient with type 2
diabetes. He has had poor control of his blood glucose levels for years and has
med many different medications. He is now being treated with insulin along
with a few other medications. The patient has come to see you because he has
heard of a new Jrug that Lan treat his disease. He says he heard about rr on the
television and has printed off information about the drug for you. He asks you
to read the article and prescribe the drug for him. You rend rhe article hut have
never heard of the drug before.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask the patient ro book an appointment with you in a week, allowing you
time to research the topic and discuss it with your GP supervisor.
B Ask the patient to book another appointment with a different GP.
C Discuss the medication with your GP supervisor mid-surgery to ask for
advice.
D Prescribe the medication based on the article and the mtorrnarion in the
British National Forrnulary (BNF).
E Tell the patient that the drug isn't suitable for him anti refuse to prescribe
the drug.
• 172 Chapter 3: Effective Communication

3.16 Difficult questions about cancer

You are working as an FYl doctor on an oncology ward in a large cancer unit,
and you are seeing a patient who is suffering from oesophageal cancer. He
has undergone surgery, radiotherapy and chemotherapy. You have attended a
rnulndiscrplinary ream meeting dunng which the patient's case was discussed.
During the meeting, you learnt that his cancer has metastasized, and he now
has a \Cf) poor prognosis. Your consultant came to the w ard especially to see
the patient that morning to discuss the progression of the cancer. As you are
about ro leave the ward that evening, the patient asks ro see you. He asks you
several complicated questions surrounding his disease that you do not know
the answers to.
Choose the THREE most appropriate actions co rake in chis situation.

A Answer the patient's questions ro the best of your ability.

B Apologise and explain rhat you do not know the answers to his questions.
C Ask rhe patient to wait unril the ward round on the following day when
you know your consultant will be on the ward.
D Ask the senior nurse on the ward to help answer his questions.
l:. Bleep the on-call oncology registrar and ask them to see the patient and
answer his questions.
F Offer to read our } our consulrant's entry in the notes frum the morning.
G Read the latest journal article about the disease and attempt to answer the
patient's questions.
H Telephone your consulrant and inform him of the situation.

3.17 Breaking bad news

You arc an 1-Y l work mg 111 the emergency department. A woman who has
recently been diagnosed with lung cancer presents with left-sided facial weak-
ness .• \ computed tomography (CT) scan of her head reveals a mass in the
right frontal lobe of her brain. The radiologist has reported that this is likely to
represent a metastasis, and you have referred the patient ro the on-call medi-
cal team. Your consultant advises you not to tell the patient the results of rhe
scan, but when you go to see the patient, she asks you whether her cancer has
spread.
Rank in order the following actions in response to this situation (I = Most
appropriate; 5 = Least appropriate).

A Explain co the patient that the scan was normal.

B Say that you do nor know what the scan showed.
C Tell her that an abnormality was detected, and while you can't be certain,
it is likely to be CJll('.CL
D Tell her that the scan has shown that the cancer has spread.
F Tell her that an abnormality was detected, but at this stage, you don't know
what it is.
 Questions 173

3.18 Explicitposters

The doctors' office is shared by a large group of doctors, the majority of w horn
are male. A couple of your male colleagues have put up posters of naked
women on the walk While your female colleagues have made no comments,
you have noticed that they have been using the office less and are working
elsewhere.
Rank in order the following actions 111 response to this situation (l = Most
appropriate; 5 = Least appropriate).

A Ask your male colleagues to remove the posters as you think that they are
dererri ng fem a le col leagues from using the office.
B Continue as before and enjoy the extra space in the office without your
fem a le colleagues.
C Explain to your male colleagues rhar you think the posters arc inuppropri-
ate and remove the posters yourself.
D Raise the issue with the ward manager.
E Remove the posters when no one is looking.

3.19 Consent HIV test

You arc caring for a patient with ocsophagitis. Your senior house officer (SI 10)
asks you to take blood for a human immunodeficiency (HIV) test as this is a
potential cause. You remember reading somewhere that counselling prior ro
performing an HIV rest is no longer required.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Ask one of the gcniro-urinary medicine (Clli\1) doctors ro come and

consent the patient for the rest.
B Ask your SHO to show you how to consent for the rest.
C Do not consent the patient for the test, cake the blood for the test and com-
municate the results with them afterwards.
D Have a discussion about the test with the patient to gain their consent and
record this in the notes.
E Obtain written consent from the patient.

3.20 Smoking

You are working as an FYl on a respiratory ward. You have been spending a
lor of time with a very unwell patient who is suffering from chronic obstruc-
tive pulmonary disease (COPD}. His condition is deteriorating; despite this, the
patient continues to go oft the ward to smoke. You know that his continuing
smoking is contributing to his considerable deterioration.
Rank in order the following actions in response to this situation (l = Most
appropriate; 5 = Least appropriate).
 174 Chapter 3: Effective Communication

A Do nor discuss smoking v. irh the paricnr since he should already bl! aware
of the risks.
B Explain to the patient that his smoking is contrihuring to his dereriomting
condition and you think it would be beneficial if he stopped.
C Give the patient some leaflets about stopping smoking.
D Prescribe a nicotine patch for the patient.
E Tell the patient that he must give up smoking or he will die.

3.21 Disclosure to relatives

You are looking after an elderly patient with pneumonia. Her daughter lives
abroad but has flown mer ro visit, and she asks to speak to you. She tells) ou
that she is aware of her mother's diagnosis of lung cancer and wants to know
w h.ir treatment is J\ ailahlc. You know that the patient docs nor have lung
cancer. You tell the daughter that you need to get consent from the patient to
discuss her care. When you ask rhc patient, she relic; you that she has been lying
to her daughter so that she will move back to the United Kingdom.
Choose the THREE most appropriate actions to take in this situation.
A Document the event in the patient's notes.
B Encourage the patient to he honest with her daughter.
C Inform the daughter that her mother does not have cancer.
D Reflect on the incident in your c-porrfolio.
E Talk ro the patient's daughter as if the patient did have a diagnosis of cancer.
F Tell the daughter that you are unable to discuss her mother's treatment
with her.
G Tell the patient that, if she does not tell her daughter that she does not have
cancer, you ,..·ill.
H Tell the patient that you feel uncomfortable about what she is doing and
therefore can no longer he involved with her care.

3.22 Uninformed consent

You are an FYl working in general surgery. A surgical specialist registrar (SpR)
offers you the opportunity ro witness him obtaining consent for a laparoscopic
appendicecromy. The patient signs rhe consent form, bur you feel rhar rhe
patient does nor undersrand what he has been cold as your ~pR has been using
a great deal of complex medical jargon.
Rank in order the fol km ing actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Advise the patient to make a complaint about the SpR.

B Ask another senior colleague to discuss the procedure with rhe patient
a f terw a rds.
C Away from the patient's bedside, suggest to the SpR rhar you do not think
that the patient understood his explanation.
 Questions 175

D Do norhing as you do nor want ro upset the SpR.

E Read about the complications of the procedure and go back to discuss this
with the patient.

3.23 Refusing medication

You are an FY2 working in a GP surgery. A patient comes to see you with
her husband and rells )'OU char she has had a major nosebleed two weeks after
starting aspirin, which you had initiated to reduce her risk of cardiovascular
disease. She wants to stop raking aspirin.
Choose the THREE most appropriate actions to take in this situation.

A Advise her ro find another doctor as she has nor listened ro your previous
advice.
B Ask a more senior GP colleague co discuss it further with her.
C Ask her husband ro try and convince her to continue taking aspirin.
D Discuss the reasons why she docs nor want to rake aspirin.
E Ensure that she knows the indication for commencing aspirin and the risks
of nor taking ir.
F Respect her decision.
G Seek the advice of a medical indemnity society.
H Tell her that she has co follow your advice.

3.24 Confused patient refusing antibiotics

You are an FYl working on a care of rhe elderly ward. A nurse approaches you
and cells you chat a patient is refusing her intravenous (IV) antibiotics. You go to
assess the patient and find them to he fehrile, very confused and disorientated due
co sepsis from a lower respiratory tract infection {LRTl). The patient is still refus-
ing IV antibiotics because 'it is poison' and tells you that she is in a lot of pain.
Rank in order the following actions in response to chis situation (1 = Most
appropriate; 5 = Least appropriate).

A Assess the patient's capacity to make chis decision and give the antibiotics
against her will if she lacks capacity.
B Contact the patient's husband and ask tor his consent to give the
antibiotic.
C find an oral alrernativ e for the antibiotic.
D Section the patient under the Mental Health Act.
E Tell her that you are giving her a painkiller but give her the intravenous
antibiotic instead.

3.25 Language barriers

You are the I-Y l on a busy surgical ward with many tasks ro complete. You
are required to insert a cannula and explain to an 87-year-old woman that
she requires intravenous antibiotics for a severe chest infection. The woman
• 176 Chapter 3: Effective Communication

is originally from Pakistan and doesn't speak any English. You know she has
never been in hospital before and is unfamiliar with hospital procedures.
Choose the THREE most appropriate actions ro rnke in this situation.

A Ask her daughter to translate for you at the bedside.

B Ask the in-hospital translator ro help translate the decision.
C Ask your FYl colleague, who speaks the same language as the patient, to
consent her.
D lgnore the cannula and wait for someone else to do it.
E Insert the cannula without talking co the patient.
F Provide written information in her own language about what rhe procedure
involves.
G Switch to oral antibiotics instead of intravenous.
H Use hand gestures to show what you are going ro do and see if she
u ndersta nds.

3.26 Contraception and young people

You are an l-Y2 working 111 a GP surgery, and a 15-)ear-olJ girl has come co
see you requesting contraception. She says she has been in a stable relationship
with her bo) friend, ,-..!10 is 1 Ci, for two years and would like to start having
sexual intercourse. She has investigated the different options and would like
your help in deciding which contraceptive to choose. On questioning her, she
appears to understand the situation well and is mature for her age. She says she
doesn't want her parents to be informed because they wouldn't approve. When
asked 1f she would have sexual mtercourse without contraception, she shrugs
her shoulders and says 'maybe'.
Choose the THREE most appropriate actions to rake in this siruarion.

A Ask the patient to hook an appointment wirh her mother and come ro see
you together.
B Ask your patient to book an appointment with a senior doctor, who will be
able to provide more accurate advice.
C Attempt to persuade her ro inform her parents and provide the necessary
support bur still supply contraception if she refuses.
D Document your conversation and seek advice from a senior doctor during
the consultation.
E Provide contraception only if she informs her parents.
F Provide rhe girl with condoms for contraception and ask the patient to
book an appointment in a week's time, then seek help from your educa-
tional supervisor about the correct course of action.
G Provide the girl with contraception bur inform her mother during her next
appointment.
I I Suggest that the girl should refrain from sexual intercourse until
she is of the legal age for consent and refuse to provide her with
contraception.
 Questions 177

3.27 Self-discharge

You are the FY I on a general surgical ward. A patient who was admitted with
diverticulitis is being treated with intravenous (1 V} antibiotics. They tell you
that they have had enough of being in hospital and arc leaving today. You have
no reason to believe that they lack the capacity to make this decision.
Rank in order the following actions in response to this situation (J = Most
appropriate; 5 = Least appropriate).
A Ask the patient to wait until your registrar can come to discuss their condi-
tion and the implications of going home at this stage.
B Discuss the risks of going home now, fill in a self-discharge form, and order
medication for the patient to cake home with them.
C Inform the patient that it would be unwise to go home at this stage and fill
in a self-discharge form.
D Tell the patient that they cannot leave as their treatment hasn't been completed.
E Tell the patient that thcv have the right to walk out at any rime.

3.28 Family translating

You are the FYl working on a surgical ward. An elderly woman has been admit-
ted with bowel obstrucnon. Your team go to discuss the options with her. Surgery
could be life-saving, but there is also a high risk that she could die during or soon
after the operation. The patient docs not speak, an} English. There is a group of
family members with her for rhe consulrarion, and her daughter says that she will
translarc for you. You feel rhar she i-; saying relatively little to her mother com-
pared with how much information your ream is conveying. When your registrar
asks whether the patient has any questions, the daughter says 'No', without any
interaction with her mother, and tells you that she will have the surgery.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Book the patient for surgery on tomorrow's emergency theatre list.
B Book the patient onto the theatre list, contact the hospital translator service
and arrange for a translator to attend for the surgeon's and anaesthetist's
pre-operative consultations.
C Tell the daughter that you do nor believe that she is translating accurately.
D Tell } our registrar that) ou are concerned about whether the patient is fully
informed.
E Wait until the relatives have left, call Language Line">' and use it to discuss
the situation with the patient.

3.29 Blood transfusion

You are the FY l working on a general surgery ward and are looking after
a patient with anaemia of chronic disease. After the ward round, your con-
sulranr asks ) ou ro consent the patient for i.l blooJ transfusion as her latest
 178 Chapter 3: Effective Communication

haemoglobin level \\ as 4.5 g/dl, and she is scheduled for theatre in chi: next
couple of days. As you explain the reasons for requiring a blood transfusion
along with the risks and henefirs, she tells you that her religion does nor permit
her to have the procedure and that, no matter what may happen to her, she will
not agree to it. You know her to have mental capacity.
Choose the THREE most appropriate actions to take in this situation.

A Arrange for the patient to sign ,1 proforma confirming that she docs nor
want a blood transfusion under any circumstances.
B Ask the other FY l on the ward to come with you and talk to the patient to
try and persuade her to agree to the transfusion.
C Document your conversation in the notes, explaining that she does not
want a transfusion despite the likely consequences of her severe anaemia.
D Explain the situation to your specialist registrar (SpR) and ask for their
advice.
E Ignore the patient's wishes as she is likely co die without the transfusion,
and it is in her best interests.
F Order the blood for the patient's operation anyway.
G Speak to the blood bank to get some advice.
H Tell the senior house officer (SHO) to come and talk to her to see if they
can persuade the patient to change her mind.

3.30 Blind patient

You are the FYl on a general surgical ward. Last night you clerked in a blind
patient with right upper quadrant pain and jaundice. The following morning,
after seeing the patient, your consultant asks you to discuss having a magnetic
resonance cholangiopancreatogram (MRCP) and possible laparoscopic chole-
cystectorny with the patient and says that he will come and formally consent
her for the procedure after his clinic. He tells you to look on rhc inrraner for
guidance on the procedures.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Access the local guidance on consenting for these procedures so that you
can talk to the patient.
B Ask your senior house officer (SHO) ro speak to the patient about what
these procedures involve and let her think about it.
C Print off the local guidance from the intraner and give it co the patient's
husband to read to her.
D Speak to the ward sister to see if information in braille is available to give
to the panenr.
E Tell the patient about these procedures using the local guidance and
give her husband an information leaflet to read before the consultant
returns.
 Questions 179

3.31 Refusing medication

You are the fYl on a surgical ward. While reviewing a patient's drug chart,
you notice that the nurses have been indicating that the patient is refusing to
rake their prescribed potassium supplement. Their potassium level remained
slightly low on today's blood test. You have no concerns about the patient's
capacity to make this sort of decision.
Rank in order the following actions 111 response co this situation (1 = Most
appropriate; 5 = Least appropriate).
A Prescribe potassium as an additive to their lV fluids.
B On the consultant's ward round tomorrow, bring up the fact that the
patient is ref using medications.
C Speak to the patient to find out why they are declining the medication and
discuss rhe options.
D Do nothing as the patient has a right to refuse.
E Bleep vour registrar ro let rhem know that the patient has not been getting
their potassium supplementation.

3.32 Seeking assistance to die

You are an r Y2 working in a GP surgery. A pancnt with merasranc prostate

cancer books an appointment with you. He would like advice from you about
assisted suicide.
Choose the THREE most appropriate actions to take in this situation.
A Arrange to get the patient sectioned under the Mental Health Act.
B Ensure that the patient has no unmet palliative care needs.
C Explain that you arc unable co help the patient with what he requests as ir
is illegal.
D Ger another GP to talk ro rhe patient.
E Listen to and discuss the patient's reasons for wanting to end his life.
F Refuse to engage in a conversation about this subject.
G Tell the patient that he are being selfish in wanting to die.
H Tell the patient that you are no longer able to provide care for him as he
has voiced this wish.

3.33 Ward round

You and your consultant arc doing a ward round. An elderly man has been
newly admitted, and on his clerking sheet, you both notice that he is positive
for the human immunodeficiency virus (HIV). Your consulranr draws the cur-
tains around the patient's bed and proceeds to talk loudly because the patient is
hard of hearing. He goes on to ask the patient about his HIV diagnosis, bur he
is talking so loudly that you are sure the neighbouring patients will be able ro
hear the conversation.
 180 Chapter 3: Effective Communication

Choose the THREE most appropriate actions to rake in this situation.

A Apologise to the patient on behalf of the consultant.
B Ask the patients in the neighbouring beds whether they heard any of your
conversation.
C Ignore the situation.
D Move the patient to a side room after the ward round to avoid a similar
situation in the future,
E Stop the consultant and suggest chat he continues the conversation some-
where more private.
F Suggest at the end of the ward round that the consultant offer the patient
an apology.
G Suggest to the patient chat he make a complaint against the consultant.
H Talk to the consultant about what happened at the end of the ward round.

3.34 Secret pregnancy

You are working on a general surgical ward. One of your patients needs a
computed tomography (CT) scan; however, a pregnancy rest has unexpectedly
revealed that she is pregnant. She can no longer have the CT scan because of
the pregnancy. The next day, the patient's husband asks you angrily why his
wife is still wainng for her C [ scan.
Choose the THREE most appropriate actions co rake in chis situation.
A Ask the husband to calm down.
B Ask the patient what she would like you to tell her husband.
C Discuss with the patient why she has nor told her husband char she is
pregnant.
D Encourage rhc patient to tell her husband that she is pregnant.
E Explain to the husband that the patient no longer needs the CT scan.
F Explain to the husband that you need to ask the patient's permission ro
discuss her treatment.
G Suggest that the husband discusses the CT scan with his wife as you cannot
discuss anything with him at this point.
H Tell the husband that his wife can no longer have the CT scan because she
is pregnant.

3.35 Discussion with relative

A patient was admitted to your ward with a chest infection. Two days after
her admission, she becomes more unwell and suffers a seizure. Her husband
approaches you and cells you that his wife is an alcoholic. He is worried that
her alcohol withdrawal has caused her to become more unwell while in hos-
pital. He asks you not to tell his wife about your discussion since she had not
\\ anted the hospital staff cu know about her alcohol dependence.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
 Questions 181 •

A Ask the parienr about her alcohol use without mentioning your discussion
with her husband.
B Ignore what the husband has told you since the patient has always denied
alcohol use.
C Inform rhc husband that you will need to tell the patient about vour
discussion in order to investigate whether her deterioration is related to
alcohol use.
D Tell the patient chat her husband has told you that she is an alcoholic and
ask her whether this is true.
E Treat the pauenr for alcohol withdrawal wuhour asking her whether she is
alcohol dependent.

3.36 Knife wound

You are an FYl working in the emergency department. You clerk a young
man who has been stabbed. J le says that he was attacked hut doesn't wanr the
police to know.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Lease appropriate).

A Inform the patient that you have a professional responsrbihry to tell the
police.
B Inform the police \\ irhour telling the patient that you arc going to do so.
C Refuse to treat the patient unless he consents to you informing the police.
D Respect the patient's wishes and do nor tell the police.
E Try to persuade the patient to consent to you informing the police during
his time in hospital.

3.37 Telephone conversation with relative

While working as an FY1 on a care of the elderly ward, you are asked by
a nurse to talk to a patient's son on the phone. He wants an update from a
doctor on his father's condition as he is unable to come into the hospital co
talk to you.
Choose the THREE most appropriate actions to take in this situation.

A Advise the son co speak co his father himself.

B Ask the nurse co speak to rhe relative.
C Ask the patient if he will allow the telephone conversation.
D Establish that you are talking to the son.
E Give the son a brief update on his father's condition.
F Refuse to speak to the son.
G Tell the son that you will only speak to him in person.
H Tell the son to phone the consultant's secretary to ask the consultant for
information.
 182 Chapter 3: Effective Communication

3.38 Contact tracing

You are currently working on a gynaecological ward. Results of a swab come

back on one of your patients: she has tested positive for chlamydia. Your
patient says she will take a course of antibiotics but does not want her boy-
friend to know about it.
Rank in order rhe following actions in response to this situation (1 = Most
.ippropriarc; S = Least appropriate).

A Ask a nurse to talk to the patient about it.

B Discuss rhe options wirh your consultant.
C Explore her concerns and discuss ways of informing her boyfriend.
D Inform her that it is your durj to tell her boyfriend.
E Respect her wishes and don't tell her boyfriend.

3.39 Prophylactic antibiotics

You are working as an FY2 doctor on the medical rake in a busy admissions
unir. You are treating a young man who has a headache. He has heen diag-
nosed with meningitis and has already been given antibiotics and fluids. You
inform your senior doctor, who tells you that anybody who has recently stayed
in the same house as the patient overnight will need prophylactic antibiotics.
He says that he stayed at a party last night with many of his friends and doesn't
want you to contact them because he feels embarrassed.
Choose the THREE most appropriate actions to take in this situation.

A Allow him co contact his friends to ask them if they are having similar
symptoms.
B Allow him ro lea, e rhe department when he feels better, givmg him several
packs of antibiotics ro give to his friends.
C Explore the reasons for him not wanting to disclose the information and
try to alleviate his concerns.
D Inform rhe local public health consultant, who can help to trace and treat
his friends at the party.
E Inform your consultant immediately and ask for advice on the issue.
F Refuse ro treat him if he will not reveal the identity of his friends.
G Respect his wishes and treat him without informing his friends.
H Wair to see how severe his infection is before contacting relatives.

3.40 HIV and death certificates

You arc an FYl doctor workmg in a palliative care urur and arc caring for
a patient with end-stage human immunodeficiency virus (HIV). He has a
malignancy associated with his HIV infection, and he is also suffering from
tuberculosis. Your consultant informs you that the patient is unlikely to survive
r Questions 183

for more than a couple of days. The next day, on the ward round, he asks to
discuss the possibility of him dying. He informs you that he doesn't want his
HI\' infection status to be written on his death certificate because he hasn't
told his family of his condition. He asks you to promise that you will not write
this on the cerrificare.
Choose the THREE most appropriate actions to take in this situation.

A After his death, complete the certificate b} mentioning a'\ iral infection'.
B Ask your consultant for advice before your patient passes away.
C Inform his family of his condition before he dies o;o that you can complete
the death certificate truthfully.
D Inform the patient that you will have to complete the death certificate fully,
including his diagnosis of HIV.
E Promise to omit the infection and after his death, mention only the malig-
nancy and the tuberculosis.
F Promise to omit the infection from the certificate bur after his death, com-
plete the certificate \\ ith all the information disclosed.
G Refuse to complete the certificate as you want to respect the patient's
wishes.
H Seek further information about his concerns and encourage him to tell his
family before his death.

3.41 Drug overdose

While working in the emergency department, you treat a young female patient
who has overdosed on an unknown substance. The parienr claims she has nor
taken any illicit drugs, bur she is unwell and requires treatment. She came in
after a night of drinking alcohol at a party with her friends. Her friend asks
to talk to you in privare and says that she gave the patient a recreational drug
without her knowing because she thought that she would have a 'better night
our'. The friend asks you nor co cell anyone because she might get into trouble.
The overdose can easily be treated with an antidote, and the patient will likely
make a fu II recovery.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Inform the friend that you will not be able to keep confidentiality and treat
your patient for the overdose with senior support.
B Inform the friend that you will not be able to keep confidentiality as it may
put your patient ar risk and phone rhe police after gaining the patient's
permission.
C Keep the information confidential and do not document where the infor-
mation came from while treating rhe patient.
D Phone the police and report a case of drugging.
E Refuse ro speak LO the patient's friend again on the basis of confidentiality
and dismiss her previous comments.
 184 Chapter 3: Effective Communication

3.42 Safeguarding children

You are an FYl working on a busy medical ward. A patient becomes tearful
when you go to review her one afternoon, and she discloses to you that she
is worried about going home because her partner has been very aggressive
cowards her recently. She docs not answer your questions about whether there
has been physical violence and strongly denies that there is any danger to her
mo young children bur admits chat the) arc in the house when they argue. She
asks you not to share the information she has told you.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Call your rcgistr . ir and .1.,\... them to come ;.111J take over the situation.
B Explain to the patient that you are worried about this situation, that you
have a n obligation ro record what she has told you in her medical notes,
and ask for her consent to contact social services.
C Explain to the patient that you are worried about this situation, that you
have an obligation to record what she has told you in her medical notes and
then call the safeguarding children officer for the hospital.
D Listen and offer support to the patient, and record what she tells )'OU in the
notes.
E Make a foll, formal referral to social sen ices.

3.43 Lost notes

You are the FYl on a general medical ward. The medical notes of a patient with a
complex medical history have gone missing since his transfer from another ward.
The nurses report that they have looked thoroughly for the nores. During the
ward round, you are unable to locate them, and the matter is discussed in front
of the patient at the beginning of rheir consultation. The patient is frustrated rhar
their notes arc missing and expresses a wish ro make a formal complaint.
Choose the THREE most appropriate actions to take in this situation.

A Apologise to the patient.

B Ask the patient not to complain until )'OU have had some more time to look
for the notes.
C Ask the ward clerk to start a new set of temporary notes.
D Discuss che situation with your educational supervisor.
E Explain to the patient that the porter must have left the notes somewhere.
F Fill in an incident report form.
G Go to medical records to look for the notes.
H Wait co document the outcome of the ward round until the notes are found.

3.44 Employee disclosure

You are the FYl working on orthopaedics and are looking after a 50-year-old
man who is scheduled for an operation this afternoon to mend a fractured tibia
 Questions 185

and fibula. Just before lunchtime, you receive a phone call from a man who
reports to be your patient's new employer. He wants to know how long the
patient will be in hospital and off work so that he can offer his job to someone
else. He says he doesn't have the luxury of time or money co be 'waiting around
for a disabled crnplovcc to get fit for work again'.
Choose the THREE most appropriate actions to take in chis situation.

A Ask the staff nurse to talk to the employer for you as you are about co go
for your lunch.
B Do not give the caller any information bur speak ro the patient and find our
whether he wants you co talk to his employer.
C Do nor mention what rhc patient's condition or rrcarrncnr is hut say that
they will not be able to work for a long time and that they should find an
alternative employee.
D Inform rhe caller chat he is having surgery chat atcernoon and will be our of
work for at least six weeks.
l:. Politely tell the employer that > ou cannot give an) mformauou over the
phone without the patient's permission.
F Pretend that you don't know anything about the patient and ask rhcm ro
call back at a time when you will not be on the ward.
G Seek advice from the sister in charge and ask her to come and talk to the
patient with you.
H Tell rhe caller chat it is illegal to terminate employment on the basis
of a disability and char you are going to report him to the relevant
authorities.

3.45 Child confidentiality

You are working in paediatrics, and you are caring for a five-year-old patient
named Chloe who has leukaemia. You are completing the day's jobs when a man
who says that he is Chloe's father approaches you and asks for an update on
Chloe's clinical condition. You are aware that the girl's parents are divorced and
char her mother attends the ward every day, bur you have never met her father.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Ask Chloe's mother's permission to discuss Chloe's healrh with her father.
B Invite both parents together for a rneetmg to discuss Chloe's condrrion.
C Explain chat you cannot give the man any information without proof that
he is Chloe's father.
D Ask the man to get an update from Chloe's mother rather than yourself.
E Ask him to wait while you gee a senior doctor to speak with him.

3.46 Handover sheet

You leave work in a hurry to get co the supermarket before it closes. In your
haste, you decide to leave shrcdding y our handover sheet until the morning and
 186 Chapter 3: Effective Communication

pur it safely in your bag instead. When you get home, you realise that it is no
longer in your bag and must have fallen out at the supermarket checkout. The
sheer contains a grear deal of confidential information.
Choose the THREE most appropriat e actions to cake in this situation.
A Ask your registrar for advice.
B Call the police to assist you with looking for your list.
C Call your clinical supervisor to explain what has happened.
D Ensure you never leave the hospital wich confidential patient information
agam.
1::, forget about rhe loss of the handover sheet.
F Go and speak co the patients on the ward explaining your mistake.
G Offer to Jo a teaching session on confidentiality to your FY J colleagues.
H Phone the supermarket to see if someone has handed the sheet in to cus-
tomer services.

3.47 Consultant names

You are working with a consultant on a surgical firm consisting of ten FYls.
Your consultant has nor learnt any of your names and simply refers ro you as
'boy' or 'girl' depending on the gender.
Rank in order the following actions in response to this situation ( l = Most
appropriate; 5 = Least appropriate).

A Gather all the I'Yl s together and go to discuss the mattcr w ith the consul-
tant as a group.
B 1 ct your educational supervisor know rhar your consulranr is referring ro
you in this way.
C Request your consultant to call you by your name as you find it demeaning
co be only distinguished by your gender.
D Report your consultant to the General Medical Council (GMC) for
improper conduct.
E Tell your consultant that unless he learns your name, you will nor do any
of the jobs he asks of) ou.

3.48 Degradingnursingstaff

You are about to enter the doctors' office on your ward when you hear the
senior house officer (SHO) and registrar comparing the nursing staff's physical
attributes. They are speaking loud enough that you can hear them outside the
office, which many of the nursing staff regularly walk past.
Rank in order the following actions in response to this situation (1 =
Most
=
appropriate; 5 I east appropriate).

A Enter the office and tell the SHO and registrar that you are disgusted with
their conversation and that) ou will re pore this to j our consultant.
B Enter the office loudly to make it seem as if you did not hear their
conversation.
 Questions 187

C Close the door so that no one passing by will hear the conversation.
D Remind your colleagues that the nursing staff demand more respect than to
be reduced to their physical attributes.
E Walk on by and return to the office later.

3.49 FY1 vs SpR

One evening you enter the doctors' office ro find a fellow FY l colleague in
tears. He says that his registrar had just left having told him that he was a
'useless doctor and rhe hospital would run more smoothly without him'.
He tells you that rhis is because he declined to request a computed tomography
pulmonary angiogram (CTPA) for a patient as rhe radiologist had nor thought
it was indicated.
Choose the THREE most appropriate actions to rake 10 this situation.

A Ask your colleague's educational supervisor to talk to rhe registrar.

B Comfort your fellow FY l and explain that it is nor a reflection on them if
the radiologist does nor think a scan is indicated.
C Find the registrar later in the shifr to let them know that what they said to
your colleague was inappropriate and upset them.
D Go with your colleague to find the registrar and discuss what was said.
E Phone the consulranr responsible for the team and tell them about the regis-
trar's comments.
F Say nothing: the registrar probably just needed to vent frustration at some-
one and therefore iris probably besr ro let it go.
G Suggest ro the FY 1 that he discusses how upset he was with the registrar
tomorrow when they have both had time to reflect on the situation.
I-I Volunteer to carry your colleague's bleep for rhe rest of rhe Jay so that they
can have some time to recover.

3.50 Patient concerns about GP

You are the FY l working on a medical ward. When you go to rake a blood
sample, one of your patients tells you that they are worried about how their
care was handled by their GP. The patient had , isired their GP multiple
rimes over several months before any investigations were performed. They
ask you a hour whether you think it would have made a difference if their
GP had picked up earlier that there was a serious underlying cause for their
symptoms.
Choose the THREE most appropriate actions to take in this situation.
A Agree with rhe patient that there was a delay in their diagnosis.
B Contact the General Medical Council (GMC) about the delay.
C Contact the GP ro let them know that the patient is cornplaimng about them.
D Explain that it isn't possible for you to comment on the decisions the GP
made ar the rime of their consultation.
 188 Chapter 3: Effective Communication

E Inform your registrar and consultant that the patient has these concerns.
F Listen to the patient's concerns.
G Reassure the patient that the GP c.lid everything
correctly.
H Refuse ro he involved in a conversation about another doctor's decisions.

3.51 Registrars conflicting plans

You arc the FY l working on a surgical ream. The radiology report from an
invcstigarion for a patient has suggested further imaging. However, when you
checked this earlier 10 the <lay with one of your registrars, he decided it was nor
clinically indicated. Later in the day, a different registrar docs a ward round
and declares, in front of the patient. that they need further imaging.
Rank in order the following actions in response ro this situation ( I = Most
appropriate; 5 = Least appropriate).

A Sa} nothing hut don't organise the imaging.

B Say nothing and organise the imaging.
C Tell the second registrar and the patient that the first registrar thought
imagrng was unnecessary.
D Explain ro the second registrar and the patient about the first registrar's
decision, and ask the second registrar to call them and discuss the matter
between themselves.
E Call the first registrar yourself ro let them know that their decision is being
altered.

3.52 Complaints

You go to perform venepuncrure on a patient on the ward. While you are there,
the patient tells you char he is upset about the way he was spoken ro by the
consultant on the ward round that morning. You were not on the ward round,
hut the patient explains what was said and asks if you agree char the consultant
was rude.
Choose the THREE most appropriate actions to cake in this situation.

A Advise the patient to speak to rhe consultant about these concerns.

B Agree that it sounds as if the consultant was rude.
C Apologise to the patient on behalf of the consultant.
D Decide co avoid the patient as they may complain about you too.
E Explain that you cannot comment since you were not present on the ward
round.
F Recommend that the parienr contacts the Patient Advice and Liaison
Service (PALS) to make a complaint against the consultant.
G Speak to rhe consultant yourself about the patient's concerns.
H Tell the patient that you do nor think that the consultant was rude.
 Questions 189

3.53 Consensual Dr-Dr relationship

You are an fYl, and rhe isrer on your ward approaches you after the ward
round and asks you co have a word with the other FYl on your ward. She
says that he is behaving inappropriately with your SHO while at work. You
are aware that they are in a relationship but have never witnessed this type of
behaviour yourself.
Choose the THREE most appropriate actions to take in chis situation.
A Ask other members of the ward staff if they have witnessed similar
behaviour.
B Ask the nurse whether she thinks that patient care is being compromised as
a result of their behaviour.
C Explain that you think their behaviour is fine and that if they are happy, it
docsn 't matter.
D Explain to the nurse chat you have never witnessed chis kind of behaviour.
E Say that if she has real concerns, she should speak to a more senior member
of the medical team.
F Tell the nurse that she should speak to the doctors in question.
G Tell the nurse to document her concerns formally.
H Tell your educational supervisor about the sister's concerns.

3.54 Putting arm around relative

You are the FY] on a busy colorectal firm, and the sister in charge asks for a
private talk as she says that someone has made a complaint about you. The
son-in-law of one of your patients, a woman who has just been diagnosed with
colon cancer, says that you put your arm around his wife while talking to her
yesterday, and he thought that this was inappropriate behaviour.
Rank in order the following actions in response co this situation (1 = Most
appropriate; 5 = Least appropriate).
A Explain to the nurse that you were simply comforting the woman after she
learned of ha mother's diagnosis.
B Talk to your educational supervisor about the complaint.
C Apologise to the son-in-law and explain the reasons for your behaviour and
assure him that it won't happen again.
D Tell the son-in-law that you were comforting his wife and that your behav-
iour was not inappropriate.
E Tell the nurse to explain to the son-in-law the reasons for your behaviour.

3.55 Interrupting the SpR

You are working in the genito-urinary medicine clinic and need to talk to
one of your senior colleagues. One of the nurses tells you that she thinks the
registrar is in one of the clinic rooms. You knock, and the registrar shouts
 190 Chapter 3: Effective Communication

for you to come in, but on opening the Joor, } ou discov er that the registrar is
doing cervical swabs on a lady who is in the lithotomy position. She is covered
with a sheer over her legs.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Apologise and say that you'll come back later.

B Enter rhe room and wait for the registrar to he free.
C Enter the room and ask the registrar for their advice.
D Shut the door immediately and come back later.
E Let the nurse know that she pur you in an awkward situation and that }'OU
are not happy.

3.56 Upset patient

You are an FY 1 working in oncology. One of the patients under your care has
been found to have metastases in the lungs. You walk into the bay after the
consultant has broken the news. You see that the patient is still clearly upset by
the news, and }'OU go over ro comfort them. To offer comfort and support, you
rake their hand. However, after leaving the bay, one of the nurses comes to find
you and tells you that the patient found it very inappropriate that you touched
them without their permission and would like to make a formal complaint.
Rank in order the following actions in response to this situation (1 = Most
approprrate; 5 = Least appropriate).

A Apologise to the patient immediately.

B Ask the nurse co go and explain that they were mistaken.
C Await the complaint as you feel you did nothing wrong.
D Confront the patient and tell them that you think it is unfair they arc com-
plaining about you when they are clearly just upset about the progression
of their disease.
E Take the nurse back in with you, apologise to the patient and explain that
you were trying to he comforting.

3.57 Assisted suicide

You are working as an FY2 doctor in a GP surgery when you see a patient
who has recently been diagnosed with rnoror neurone disease. Both you and
the patient know that this condition is terminal and that she has a poor life-
expectancy. She has begun to experience dcbiliraring s~ rnptoms that she feels
are humiliating and uncomfortable. She breaks down in rears during the con-
sultation and asks for your help to commit suicide. She says she has heen think-
ing about it since she received her diagnosis and would like further information
about how she might achieve this.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
 Questions 191 •

A Suggest she books an appointment with a senior GP ro discuss the issues

around assisted suicide and offer instead to focus on treating her symptoms.
B Offer to listen to her concerns and treat her S) mptoms with appropriate
medications but explain that assisted suicide is a criminal offence.
C Offer to listen ro her concerns bur explain rhar assisted suicide i" a criminal
offence and that you cannot help her.
D Prescribe the patient large doses of opiate medications and suggest that she
can make her own decisions regarding further management.
E Refer her directly to the psychiatric and palliative care teams because she
has voiced suicidal intent.

3.58 Comments on abortion

You are working as an FY2 doctor with a specialist registrar (SpR) in obstetrics
and gynaecology. You are undertaking a joint clinic and are seeing a patient
together. The SpR is leading the consultation with a l Z-year-old pregnant
woman who wishes to have a terrmnarion. She has discussed the suuanon with
the specialist nurse and now wishes to discuss this with her doctor. As you
are discussing this, the SpR informs the patient that 'abortion is wrong' and
shouldn't be done under any circumstances. The patient immediately starts to
cry and leaves the room.
Choose the THREE most appropriate actions to take in this situation.

A Ask for the patient to return tothe room and tell the SpR co apologise.
B Ask the nurse to see the patient and arrange for her to see another doctor.
C Ask the SpR ro discuss rhc case immediately with the consultant respon-
sible for the clinic.
D Discuss the situation with the consultant responsible for the clinic after the
clinic has finished.
E Discuss the situation with your educational supervisor following the clinic.
F Discuss your concerns about the situation with your Spk askmg her to
explain why she made the comments.
G Document your concerns in the notes about the consultation.
H Remain silent as the consultation was led by the SpR.

3.59 Racism

You are an FYl working on a gastroenterology ward when a nurse approaches

)'OU visibly upset. She reports that a patient in her bay has just refused to let her
rake his observations because she is black. You approach the patient to enquire
about this matter, and he repeats ro you 'I will nor be treated by a black nurse,
l have told her this already'.
Choose the THREE most appropriate actions ro take in this situation.
A Advise the nurse that she should fill in an incident form and report the
matter to her ward manager.
• 192 Chapter 3: Effective Communication

B Comfort the nurse, explain that rhe patient's bchav iour \\ ill nor be roler-
ated bur that for patient safety he must have care from nursing staff and
arrange for another nurse to care for him.
C Discharge the patient immediately from hospital bur write a letter to his GP
for follow-up care.
D Explore the patient's concerns more fully, and then approach your registrar
for advice on how to care for this patient.
E Refuse to sec the paricnr because of his unacceptable behaviour.
F Reprimand the patient for his behaviour and write a paragraph in the notes
warning other sea ff members of his racism.
G Tell the patient that he is behaving disrespectfully and that this matter will
he reported to senior doctors, nurses and ward managers. Then move the
patient into another bay to be cared for by another nurse.
H Tell the patient that, if he will not accept care from this nurse, he will get
no nursing care at all, and direct the nurses to ignore the patient all day.

3.60 Refusing treatment for children

You are working as an FY I inn paediatric emergency department. A mother

brings her one-year-old baby in for you to examine a rash on her daughter's
leg. When you inspect the rash you, recognise severe eczema with infected
areas from scratching. You plan co prescribe an antibiotic cream alongside
emollients and mild steroid cream, bur the mother refuses saying that she
doesn't believe antibiotics work, and It is better for her child's immune system
to bear rhe infection herself. She takes the prescription for the other creams and
leaves the surgery.
A Call rhe parienr's mother ar home to rry and explain the importance of this
treatment and urge her ro return.
B Call the police to recover the child and initiate antibiotic treatment.
C Discuss this matter with a senior doctor in the practice.
D Call social services to report the neglect of this child.
E Discuss the matter with another FYl who has recently completed a paedi-
atric rotation.

3.61 Inappropriatedress at work

You are the FY 1 on a busy medical ward, and one morning the sister
approaches you to voice some concerns about your fellow FY 1 colleague. She
has noticed that the FY 1 often has a bare midriff, wears bracelets and long
earrings and her knickers are often visible riding up above her skirt when she
bends over. You admit to yourself that you have also noticed that her standard
of dress is not always appropriate.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
 Questions 193

A Speak directly to the FYl in question when there is the opportunity ro

speak in private.
B Keep an eye on her clothing mer the next few days and keep a record of her
dress.
C Mention your observations and the sister's concerns to your specialist regis-
trar (SpR) and ask for advice.
D Speak to your houscrnate, another FY1 working on a different ward at the
hospital.
E Report her dress to her educational supervisor.

3.62 Late colleague

You are working the early shift on a busy medical admissions unit (MAU),
and you arc due to finish in five minutes. You ha, c chased all the im cstigarion
results for your patients and finished your job list, but it is another half an hour
before the FY 1 who is due to rake over from )'OU rums up for work. You have
noticed chat he has been late for work on repeated occasions over the past few
months.
Choose the THREE most appropriate actions to take in this situation.

A Ask the sister in charge co mention something to your colleague.

B Ask your colleague if he realises that he is late for work and if there is a
reason for it.
C Ask your other colleagues in the medical ream whether they have noticed
lateness in your FYl colleague.
D Explain to the FYl rhat ir isn't professional to repeatedly turn up lace for
work without an explanation.
E Mention your colleague's behaviour co your consultant and ask for him to
be moved into another ream.
F Speak to your educational supervisor about your observations.
G Take your colleague into the doctors' office when he arrives and speak to
him sternly about always being late.
H Write an anonymous note detailing in bold what time the shifts start and
finishes and pin it up in the doctors' office.

3.63 Registrar responsibility

While working on a medical ward, you have noticed that when you ask one
of the junior registrars to rev icw patients you arc concerned about, the) often
just give advice and don't follow this up by seeing tbe patient themselves. You
arc concerned that this means that the advice they give is not always in the
patient's best interests.
Rank in order the following actions in response ro chis situation (1 = Most
appropriate; 5 = Least appropriate).
 194 Chapter 3: Effective Communication

A Ask the registrar to come and see patients \\ irh you rather than simply ask-
ing them to do it alone.
B Raise the matter with your consultant.
C Ask other members of the ream if they have had rhe same problem.
D Ignore the registrar's advice: you have seen the patient; therefore, your plan
is superior to theirs.
E Take the registrar's advice, write the plan in the notes and state that the
registrar gave this advice.

3.64 Gift from patient

You are the FYl working on an elderly care ward. In making conversa-
tion with one of your patients, you make an admiring comment about their
watch. When they are discharged home, they approach you and give you the
watch, saying that it is a gift to show their thanks for all that you have done
for them.
R,111k in order the following actions in response ro this situation (1 = Most
appropriate; 5 = Least appropriate).
A Accept the watch, thanking the patient.
B Thank them for their kindness, but refuse the watch saying that it is impor-
tant ro them and that you want them to keep ir.
C Ensure that the patient understands that your previous comment was not
intended as a request and did nor bear any significance to how you treated
them; ask them to reconsider but accept the watch with thanks if they
insist.
D Refuse saying that it is inappropriate for them to offer you a gift.
E Accept the watch but ask the patient to keep this a secret.

3.65 Promise to family

You are an FYl working on a surgical team. One of your patients is on the
high dependency unit following major surgery. Your team is concerned that she
may be suffering from a major complication which would require returning to
theatre for further surgery, including formation of a stoma. The patient's fam-
ily ask to speak to you about her condition and what is going to happen next.
The patient is very tired and unwell but nods when you ask if she is happy for
the situation to be discussed with her family. You have several urgent jobs to
do but agree to come back and speak to them later that morning.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Call your registrar and ask rhem to come ro the ward now to speak ro the
family.
B Leave the conversation for your registrar co have during the afternoon
ward round.
 Questions 195

C Return later in the morrung and explain that you cannot discuss the derails
as you are not a surgeon.
D Return later in the morning, rake the family to a private room and explain
the nature of the suspected complication, what the surgery will involve, the
risks and the Ii kely outcomes.
E Return later in the morning, take the family to a private room and explain
that there is still some uncertainty but there is a chance further surgery will
be necessary and rhar one of your seniors will discuss this in detail with
them later on.

3.66 Interpreter

You are an FY2 in a GP surgery, and a patient who speaks very little English
attends with his friend who says char he will translate. You rake a history
about his headache, but you are worried that what you're saying is not being
fully translated, and >'OU feel like you cannot rule out a serious cause for his
headache.
Rank in order the following actions in response co this situation (1 = Most
=
appropriate; 5 Least appropriate).

A Advise his friend to bring him hack to the GP or ro emergency services if he

develops any 'red flag' symptoms.
B Book a consultation with a professional interpreter present.
C Use a telephone: interpreter service in your consultation.
D Record that you tried ro ask him about 'red flag' symptoms bur weren't
able to.
E Send the patient to the emergency department.

3.67 Breaking bad news

You are the f Y 1 working on heparobiliary surgery. One of your patients who
has previously had surgery for a cholangiocarcinoma is discussed in the rnul-
tidisciplinary team (,\,lDT) meeting in the morning, and it is confirmed that
the cancer has already spread to the liver and perironeum. That afternoon, the
patient pulls you to one side and asks, 'Did you get all the cancer out in my
operation?' You are the only doctor on rhe ward.
Rank in order the following actions in response ro this situation (1 = Most
appropriate; 5 = Least appropriate).

A Tell the patient that the MDT hasn't happened yet and that you don't know
the answer ro their question.
B Ask one of your senior colleagues when they anticipate they will be able ro
come and discuss the results with the patient.
C Explain that the more experienced doctors are not on the ward at the
moment but as soon as they have arrived, they will come and discuss the
results.
• 196 Chapter 3: Effective Communication

D Take the patient into a priv ate room and ask a nurse to come with you so
that you can discuss any concerns that the patient may have.
E Take the patient into a private room and ask a nurse ro come with you
whilst you explain that the results from the surgery have suggested that the
cancer had already spread.

3.68 Refusing antibiotics

You are the FYI working on a respiratory ward. One of your patients, Mr Splutter,
who has a history of COPD has developed an atypical pneumonia. You have
contacted microbiology who have recommended a rare combination of unusual
antibiotics, bur as you are explaining this to the patient, he says he doesn't want
any as his 'wife was in hospital with pneumonia and the drugs didn't work, she
just got more sick'.
Rank in order the following actions 111 response to this situation ( 1 = Most
appropriate; 5 = Least appropriate).
A Explain to the patient both the risks and benefits of his treatment options,
ensuring he understands why you think this regime is the best choice.
B Speak to your specialist registrar (SpR) about the situation and potential
alternative treatment options.
C Tell the nurses ro administer the antibiotics anyway and don't rell rhe
patient.
D Document the patient's decision ro refuse treatment.
E Call your consultant and ask them to come and speak to the patient.
 Answers 197

ANSWERS
3.1 Writing in the notes

C B E A D
A patient's notes are a legal document and should state the date and time
when written, be legible and signed off fully with signature, name, General
Medical Council (GMC) number and contact derails. The best way of record-
ing any new information is to make a new entry. Even if it consists of a minor
additional examination, it should be recorded chronologically, which therefore
makes option C the best response. Writing your additional examination on
another sheet and filing it can cause some confusion about the order of the
notes but will ensure that your entry is recorded accurately and fully, so option
B ranks second. Option E is potentially a risky way of making an addendum;
it is often not very obvious when notes have been added at a later date, and it
may be construed as dishonest, especially if the notes are needed at a tribunal
or an investigation. You should be very careful of this, and it is important that
you write that your comment was written in retrospect. Option A is one of the
least appropriate options: you should record all significant interactions with
patients, and if it was important enough for you to return and re-examine a
patient, the outcome should be recorded clearly. Removing pages from patient's
notes (D) is illegal. The notes are a legal document and should not intentionally
be tampered with, removed or destroyed.

Recommended reading
Medical Protection Society (January 2012), Writing good medical records, in
GP Registrar, vol. 13, Issue 1.
Medical Protection Society (April 2013), Medical Records Factsheet.

3.2 Requesting tests

A C D
Safeguards against unneccesary tests exist to protect patient safety. It can
be difficult to get tests and investigations quickly in a busy hospital, but the
safeguards (such as approval by a specialist) should not be circumvented. The
most appropriate answers include option A, which informs a senior member of
your team that the test they were expecting may not occur and gives them the
option to request another test if appropriate. Option C is also an appropriate
response as it can be much easier to reach someone if you go to see them face
to face rather than trying to call them repeatedly on the phone when they are
busy, a visit in person is harder to ignore. Although it is generally better to
contact the on-call registrar first, going directly to the consultant (D) is a valid
option if the appropriate person is unavailable and the test is urgent. Option B
demonstrates a lack of ingenuity in attempting to contact the radiologist,
and option F means the request card could potentially be lost if left on an
unattended desk. The remaining options are not appropriate due to their
 198 Chapter 3: Effective Communication

dishonesty (G) and avoidance of patient safeguards (H), while deciding to order
another set of imaging that is easier to obtain (E} is outside the competence of
an FYl and should only be done if ratified by a senior.

Recommended reading
Student BMJ (2013), Junior doctor survival guide: How to cope with on-calls,
night shifts, and everything else, BM], 21, f4014.

3.3 Knowledge

A E D B C
You must make every effort to ensure that the information you provide to
patients is accurate. You must always be honest in your communications and
work within the Limits of your knowledge. In addition, if you do not have the
appropriate knowledge or skills, it is your responsibility to find someone who
does; option A is therefore the most appropriate response. Declining to discuss
the procedure with her (E) is the next best option since it avoids being untruth-
ful; however, it does not fulfil your responsibility to provide the information.
While option D gives the patient some of the information, you may not remem-
ber important aspects of the procedure; however, the patient will wrongly
assume that you have provided all the relevant information. Ignoring the
situation (B} does not aid the patient in any way and neglects your duty of care.
Improvising based on your other medical experiences (C) is wholly inappropri-
ate since you may provide false information, and iris dishonest with regard to
your level of knowledge.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 32, 34, 68.
Medical Protection Society (2012), Honesty, in MPS Guide to Ethics: A Map
for the Moral Maze, chapter 6.

3.4 Have I got cancer?

C A D E B
As the doctor on the 'front line' on the wards, you are often faced with difficult
questions from patients and relatives, which you may not necessarily have the
competence or knowledge to answer. In this scenario, while you may know the
diagnosis, you will nor have the necessary information on hand to answer the
inevitable further questions your patient may have. Honesty and integrity is
always of the utmost importance, and this makes option B the worst response
as you should not lie or mislead your patient. Lying to the patient is not accept-
able, and in doing so you may be offering him false hope, which could be very
damaging. The best course of action would be to ask your consultant to discuss
the situation with the patient as planned (C). Failing this, your registrar is
likely to have the experience and knowledge required to speak to the patient in
the meantime (A). Informing the patient yourself, in this scenario, is completely
inappropriate. However, it should be noted that all personal and potentially
 Answers 199

distressing conversations should be performed in private with a colleague

present, which makes option D preferable to E.

Recommended reading
British Medical Association, Real Life Advice: Breaking Bad News, http://
bma.org.uk/developing-your-career/foundation-training/real-life-advice/
breaking-bad-news.

3.5 Drinkingwith friends

C B A D E
As a doctor you are, of course, allowed to enjoy a private life, but you must
remember that as a professional you are always in the public eye. You must
therefore try to remain professional in public, otherwise the medical profes-
sion risks losing the trust of the public. While embracing a relative in an
amicable manner outside the clinical situation, as in this scenario, is nor
entirely improper, it does cross the boundaries of professional conduce. The
best option here is to suggest that your friend apologises to the relative when
sober and in a professional situation (C). The next best option, however,
would be to not do anything about the situation as the relative did not seem
upset (B). This is better than risking worsening the situation. If you feel that
you need to say something, then it would be better for you to apologise to
the relative (A) as you are not drunk, than for your friend to go and do this
(0). Telling your friend nor to return to the bar would be rhe wrong response
here (E) as this would be imposing social barriers, and this is unfair on
your friend.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 55b
and 65.
Medical Protection Society (2012), Personal conduct, in MPS Guide to Ethics:
A Map for the Moral Maze, chapter 12.

3.6 Missing notes

B E D C A
All medical professionals have a duty of care to record important patient
information clearly and legibly in the notes to facilitate good handover and
informed care of patients. Notes are often taken from the wards into meet-
ings, so sometimes it is not possible for you to make entries as they happen.
In this situation, you need to make sure that the information is safely handed
over, otherwise there is no way the doctors or nurses later in the evening will
know that you have formally reviewed this patient. The best answer is option
B: informing the evening ream of your plan for this patient directly means that
they won't repeat what you have already done and that they will understand
the background if they are called to see this patient again. Writing on loose
sheets of paper is not a safe way to keep information as it can easily get lost
 200 Chapter 3: Effective Communication

but keeping them in a ring binder removes some of this risk, so option E is rhe
second-best option. Pinning notes to the ward staff noticeboard (D) is not ideal
as it is not usually a place staff would think to check, so the notes could easily
be missed. However, this response is better than having to stay on the ward for
an indeterminate time until the notes are returned (C) or failing to make any
documentation at all chat day (A).

Recommended reading
Medical Protection Society (April 2013), Medical Records Factsheet.

3.7 Self-discharge

C G D
le is important that you respect a patient's wishes, even if you deem them
foolish. In rhis scenario, you should first speak to rhe patient and assess his
capacity. lf you judge that he has capacity to make this decision, he must
not be held in hospital against his will, and he should be allowed to self-
discharge, provided he is aware that this is against medical advice (G). You
should recommend that he has someone to monitor and care for him at home
overnight (0). Your SpR should be informed about the situation as they may
also want to speak to the patient (C). Asking the on-call psychiatrist (A) to
assess his capacity would be inappropriate as this should be something you
should be able to do; however, if you find it difficult to make an assessment, it
would be appropriate to involve your seniors. Not allowing him follow-up (B)
or analgesia (£) if he self-discharges would be unacceptable in this case as he
has had major surgery and should have both to avoid complications. Ringing
his sister to ask her to persuade him not to self-discharge (F) is something
that you could suggest to the patient, but she should not be involved without
the patient agreeing to it first as this would be breaking patient confidential-
ity. Option H is unprofessional as you are part of a team responsible for the
patient's care.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 59.
Medical Protection Society (2012), Duty of care, in MPS Guide to Ethics: A
Map for the Moral Maze, chapter 4.

3.8 Patient requesting full-body scan

A B C
Working in general practice throws up challenges that are often very differ-
ent to those that you will encounter while working within a hospital. In this
scenario, your investigations and actions would very much depend upon what
symptoms she is complaining of. However, situational judgement test ques-
tions often don't include all the information you would like. In this scenario,
you must think what the most sensible course of action would be. Discussing
with the patient her symptoms and requests would be the most appropriate first
 Answers 201 •

action to take (options B and C}. This would allow you to explore her concerns
and narrow down your own differential diagnosis. You must also seek advice
from your educational supervisor when you are unsure, particularly in compli-
cated cases such as this (A). They may be able to suggest relevant further inves-
tigations, or they may suggest seeing the patient themselves to come up with a
suitable management plan. Directly referring the patient to another colleague
(H) before even seeing her would be inappropriate as you may be able to deal
with the situation yourself. Organising full-body scans of any kind are rarely
indicated, and you would not be expected to do this as an FY2 (D). Making a
diagnosis of a functional disorder may be correct; however, you do not have
enough information to do this yet (G). Reassurance can be very valuable (F);
however, it is more appropriate to rediscuss her symptoms and get the opinion
of your supervisor before making this decision to ensure you have not missed
any pathology. Prescribing anxiolytics (E) would be inappropriate without
exploring her concerns and making a formal diagnosis.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 16.

3.9 Foreign patient

C E H
This question is assessing your ability to communicate effectively with patients,
their families and also other colleagues. It is important that when patients
cannot speak English, you make every effort to provide information to them
in a way that they can understand, for example via the use of a translator (C}.
Another effective way to do this would be using patient information leaflets
written in the relevant language. You also have a duty to communicate effec-
tively with those who are close to the patient (H), especially if they are going
to have a role in caring for the patient outside of the hospital. When delivering
and making arrangements for patient care, it is also courteous ro keep your
colleagues informed of your plans; this helps to maintain good professional
relationships and will have a positive impact on the service that your patient
receives overall. Option E is therefore also appropriate. While option A may be
a suitable action to take if you cannot get hold of a translator, your colleague
is likely to be busy with their own patients; therefore, you should explore
alternative options first. Similarly, Bis less appropriate, since part of your
role as an FYl is to complete discharge letters and ensure that your senior's
plans are implemented when patients are discharged. Option F may be suit-
able, in part, when dealing with English-speaking patients; however, this case
requires additional support to ensure the patient and his family understand
rhe plans, and you should always be working in conjunction with the nursing
staff to discharge patients. Option D does not demonstrate good prioritisation;
while your reason for completing the other discharge letters first may have
merit, this patient's needs are more urgent (especially considering the need to
involve translators). Finally, ignoring the language barrier (G) is certainly not
 202 Chapter 3: Effective Communication

appropriate as patients have the right to have information presented to them

in a way that they can understand. Failure to do so could negatively impact
patient safety.

Recommended reading
General Medical Council (2009), The New Doctor, paragraph 9.
General Medical Council (2009), Tomorrow's Doctors, paragraph 15.
General Medical Council (2013), Good Medical Practice, paragraphs 32, 33.
Medical Protection Society (2012), Duty of care, in MPS Guide to Ethics: A
Map for the Moral Maze, chapter 4.

3.10 Suicidal patient wanting to talk

C E B A D
As a junior doctor you will sometimes need to have sensitive conversations
that you may not feel particularly comfortable with. In this case you do nor
know what the patient wants to discuss: for example, they may want to be
discharged, or they may be concerned about their medical health. The most
appropriate response would be option C, finding a quiet place on the ward
to talk to the patient, as the information that they disclose is likely to be
sensitive and warrants privacy. Asking the patient if they would like a nurse
present (E) is also appropriate as the nurse looking after the patient may have
built up more rapport with them and may be able to give more information.
Asking the family to leave (B) may be useful, but it would be better if you
asked the patient if they wanted to talk in private or if they would prefer their
family to be present. Simply celling them that you will ask your senior to talk
to them (A) is not appropriate at this stage as you do not know what their
concerns are; however, you could offer this after having had a conversation
with the patient. Option D, informing the patient that the psychiatric doctors
will discuss it with them later, is the least appropriate option as it would
close the conversation and could leave the patient upset or angry, especially
given the stigma that surrounds psychiatry as perceived by many members of
the public.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 31-34,
46-48.
3.11 Cancer diagnosis

A E D B C
In this situation, the bad news should be broken by a senior doctor who can
explain the suspected diagnosis and treatment options fully and accurately
answer any questions that the patient may have. A registrar is best placed
to do this, and so option A is the best response. Option Eis the next best as
you are being honest with the patient yet only giving basic information and a
basic plan. The patient may be worried after this conversation; however, by
 Answers 203

providing some information you have stayed within your competence, and your
senior can have a follow-up conversation, if needed, to explain things in more
detail. Option D is the next best answer: if you cannot break the news well,
it is best not to break it at all. Telling the patient that the results are not back
yet buys some time to ensure you can get a senior ro speak with them and will
hurt them a lot less than if you gave incomplete and incorrect information;
however, it is dishonest so should be avoided if at all possible. Avoiding speak-
ing to the patient and placing nursing staff between you (B) is unprofessional,
and if a patient wants to speak with you, you should not refuse. An important
conversation such as breaking bad news should always be between the patient
and a senior registrar or consultant. It is beyond your competency as an FYl as
you cannot answer all the questions that the patient might have, which makes
option C wholly inappropriate.

Recommended reading
Parienr.co.uk (2010), Breaking Bad News.

3.12 Referral

A D C E B
The process of referral involves the arrangement for another practitioner to
provide a service that is beyond your professional competence. Ir is important
to inform patients of any plans for referral ro other departments as well as ro
gain consent to share their information with the appropriate people (A). It is
also important, when making a referral, that you provide enough informa-
tion. This enables the healthcare professional in receipt of the referral to assess
whether it is appropriate for them to become involved in the patient's care. ln
this scenario, you need to gather the relevant information before making the
referral. While the information may be available in the notes, it is best not to
rely on the assessments made by others. It is preferable to take a history and
examine the patient yourself: option Dis therefore preferable to C. If you have
no knowledge of the patient, it may be appropriate to tell your consultant that
you are not able to make the referral (E). This would be more appropriate than
making the referral without any information about the patient (B).

Recommended reading
General Medical Council (2013), Explanatory guidance, in Delegation and
Referral, paragraphs 6, 9.

3.13 X-ray reporting

B E G
Learning from our mistakes is an integral part of the educational process
and thus improves competence. Errors should be analysed ro ascertain how
they happened to prevent reoccurrence. In this situation, you should submit
an incident form (G) to allow root cause analysis to take place. The other
most appropriate responses are to inform the patient of the situation and
 204 Chapter 3: Effective Communication

apologise (B) and refer the patient to orthopaedic care (E). The General
Medical Council (GMC) states that, in the event of a mistake relating to
patient management, you should do three things: put matters right if possible,
apologise and explain the situation, including the likely short-term and long-
term effects. Informing the patient and her family that missing the fracture is
the radiologist's fault (A) would be unprofessional and could undermine public
confidence in the profession. Option C, informing the patient bur omitting
the fact that the fracture was visible in the previous X-ray, does not involve
being completely honest and open with the patient. If the patient discovered
this at a later stage, this could also affect their trust in the medical profession.
Making a complaint about the first reporting radiologist (D) is one way of
raising concerns, but in this situation, it would be more appropriate to submit
an incident form as you cannot be absolutely sure that any blame lies with
the radiologist. Speaking to the first reporting radiologist and asking why he
did nor see the fracture (F) may be perceived as confrontational, especially
if you are not already familiar with the radiologist. Writing a letter to the
medical director (H) would raise concerns around the incident, bur the most
appropriate channel would be to submit an incident form.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 55.
Medical Protection Society (2012), Competence, in MPS Guide to Ethics: A
Map for the Moral Maze, chapter 10.

3.14 Family wanting to know results

B C G
This is a tricky scenario. As an FYI, you should not be expected to break
bad news of this nature, especially when you have been asked not to discuss
it by a senior colleague. In this situation, you should think about the patient's
autonomy and her right to know any scan results if she wishes and also confi-
dentiality as the patient may not want her daughter to know the scan results.
Therefore, you should do three things: apologise to the daughter about the
current situation (B), empathise with the daughter and discuss both what she
already knows and what she is particularly concerned about (C) and organise a
consultant meeting with the patient and her family as soon as possible (G). The
latter option would depend on whether the patient wishes to attend and, if the
patient gives consent, to lee her daughter know about rhe situation. Admitting
to the daughter that her mother has been poorly managed (A) would be unpro-
fessional even if you thought it was true and could damage her opinion of your
colleagues and even the medical profession. Asking the patient if she would like
to know the results of the scan (D) would be imperative for breaking the bad
news; however, as already established, this should be done by a more senior
colleague. Explaining that you are a junior doctor and that you cannot help
(E) would not be useful; you should instead explain that it would be better to
speak to senior colleagues and make arrangements for this to happen. Speaking
to the daughter but not informing the patient (F) is unethical, unless you
 Answers 205

have spoken to the patient first and received her permission to do so. Telling
the patient and her family the results of the scan (H) should not be done by a
junior doctor, as discussed earlier.

Recommended reading
Medical Protection Society (2012), Patient autonomy and consent; Competence,
in MPS Guide to Ethics: A Map for the Moral Maze, chapters 8; 10.

3.15 Internet printouts

A C B E D
The internet has changed access to medical information forever. Information
that used to be only available to doctors and research scientists is now acces-
sible at the click of a button. However, not all the information is genuine and
not all of it has an evidence-based rationale. Often it can be frustrating for
patients to hear that the miracle cure they have found online is no more than
an old wives' tale or a preliminary small-scale trial abroad. As a doctor, you
must be understanding of this and not dismiss your patient's concerns. In
this scenario, it is possible that the patient has found a drug that may be a
treatment option. As a junior doctor, you may lack the knowledge required
to answer all of your patient's questions. It is not a sign of incompetence or
weakness to admit that you do not know the answer and to refer to a col-
league for help. Here, discussing the case with your GP supervisor (C) could
provide a quick answer that could help to satisfy your patient. However, as
this is not an urgent issue, the preferred option would be to give yourself
the opportunity to research the topic and discuss it with your supervisor at
a more convenient time (A). Prescribing a drug you do not know anything
about (D) would be potentially very dangerous and should be avoided.
Refusing to prescribe the drug (E) would be an unhelpful response without
researching and explaining your reasoning; however, it is preferable to a blind
prescription. Booking your patient in with another GP (B) may solve your
patient's problems; however, this would not address your own learning needs
around che topic.

Recommended reading
Medical Protection Society (2012), Competence, section: Referrals, in MPS
Guide to Ethics: A Map for the Moral Maze, chapter 10.

3.16 Difficult questions about cancer

B E H
As an FYl, you are often the medical 'point of contact' for the patients
on the ward. You spend the majority of your time on the ward and see
the patients every day. This can often lead to a situation where you are
asked questions that you do not know the answers to. This is not a sign
of incompetence as you could not be expected to possess the same depth
of knowledge as a consultant at this early stage in your training. In these
 206 Chapter 3: Effective Communication

scenarios, the best course of action is honesty. The majority of patients will
respect your honesty if you admit that you cannot answer their questions,
apologise and offer ro help find them the answers. Therefore, option B
would be the best course of initial action. You must then assess how you
can help ro answer his questions and who would be the most appropriate
source of information. Technical questions about metastatic cancer should
be addressed by registrars and consultants. In this scenario, most consultants
would appreciate a courtesy phone call (H) and may suggest that you
discuss the case with the specialist registrar or even come to see the patient
themselves. If the questions were ro do with his nursing care, a senior nurse
may be an appropriate source of help (D); however, this is not the case in this
scenario. In attempting to answer his questions (options A and G), you may
inadvertently communicate some incorrect information and possibly false
hope, even if your intentions were good. Offering to read your consultant's
entry in the notes (F) is likely to cause more harm than good as the entry
hasn't been designed as a patient explanation. Finally, if these were questions
that the patient was not necessarily worried about, it could be appropriate
to delay them until the consultant ward round on the following day (C);
however, given the change in the patient's diagnosis, on balance, it would be
better to address his issues immediately.

Recommended reading
Medical Protection Society (2012), Competence, section: Referrals, in MPS
Guide to Ethics: A Map for the Moral Maze, chapter 10.

3.17 Breaking bad news

C E B D A
Breaking bad news is a difficult bur important skill that is usually left to more
senior members of the ream. However, there are situations where you are left
with no choice bur to discuss important results with patients. In this instance,
although you do nor know for certain that the brain lesion is a metastasis
of your patient's lung cancer, this is the most likely explanation. While you
could choose nor to discuss the scan results with the patient yourself, in this
instance, she has asked you outright. It would therefore be wrong to withhold
the information you have. Explaining that the scan is normal (A) is completely
inappropriate since this is untrue. Similarly, telling her that the cancer has
definitely spread (D) is also potentially untrue and would cause her undue
distress in the unlikely event that the lesion were found ro be non-cancerous.
To tell the patient that you do not know what the scan shows (B) is also dis-
honest but does not pose future repercussions, as options A and D. Option E
is a suitable response as it is true to say that there is an abnormality but that
you don't know exactly what it is. Option C, however, is the most appropri-
ate option: although you can emphasise that you have no definite answers, it
is indeed likely that this is a metastasis. A useful tool in breaking bad news
involves 'warning shots', where ideas can be introduced before definite answers
..
Answers 207

are given. This prepares the patient in advance of them receiving a definitive
diagnosis once more investigations have been performed.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 31-33.
Patient, Breaking Bad News, http://www.patient.co.uk/doctor/
breaking-bad-news.

3.18 Explicit posters

C A E D B
The doctors' office is part of the workplace and should be treated as such. It is
therefore inappropriate to display sexually explicit posters on the walls. In
this scenario, it is even more important to tackle the issue since the posters are
also making colleagues feel uncomfortable. A good first response is option C:
both explaining to your male colleagues that the posters are inappropriate
and removing them yourself. This is preferable to asking your colleagues to
remove the posters themselves (A) since by removing them yourself you are
ensuring that they are indeed removed. Taking down the posters when no one
is looking (E) does not alert your colleagues to the reason why they have been
removed, although it does still ensure that they are removed. While the ward
manager may be able to help (D), you should at least be able to attempt to solve
the situation yourself. Doing nothing (B) when the posters are obviously having
a negative impact on female colleagues is unacceptable as it shows a lack of
respect and a poor professional attitude.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 36
and 59.

3.19 Consent HIV test

D B E A C
A few years ago, it used to be routine to formally counsel patients before test-
ing them for HIV. This was because it held implications for people's health
care insurance if they had the rest as, even if it was negative, it was seen as an
admission of risky behaviour. Currently there is a big push to routinely test
people more widely and part of achieving that is to try and reduce the stigma-
tisation of the testing. Option D is the best response: you should still consent
the patient for the rest as you would for any ocher test, and you should record
your conversation in brief in the notes. An FYl should be able to do this, but
if you do not feel confident in doing so, learning from a senior can help (B).
Option E comes third; it is not necessary to obtain written consent for an HIV
test, and ir defeats the new movement to make it more routine; however, you
are getting valid consent in this way, and it is not entirely inappropriate. You
can always ask the advice and support of other medical professionals when
dealing with something outside of your comfort zone; however, consenting
 208 Chapter 3: Effective Communication

for an HIV test is something within the remit of an FY l and asking for the
attendance of another doctor outside of the department might not be appre-
ciated (A). The worst response here is option C, to not consent for the test
and 'surprise' them with the result; it doesn't show respect for the patient
and their right to provide consent, not to mention that this is also deeply
unprofessional.

Recommended reading
British HIV Association (2008), UK National Guidelines for HJ V Testing.

3.20 Smoking

B C D A E
As a doctor, it is your responsibility to promote healthy lifestyle choices and to
encourage patients to take responsibility for improving and maintaining their
own health. However, you should also respect a patient's autonomy even if
their decisions result in a risk to their health. The most appropriate response is
to discuss your concerns with the patient and encourage him to give up smok-
ing (B). Providing information leaflets is also appropriate (C), although less
favourable than option B since there is no opportunity for discussion or ques-
tions. Prescribing a nicotine patch (D) is inappropriate without prior discus-
sion with the patient about whether they wish to give up smoking. However,
this is a more favourable response than option A, which does not attempt to
address the patient's smoking. Option Eis wholly inappropriate. You should
not attempt to 'tell' a patient what to do and neither should you try to scare a
patient in order to manipulate their decisions.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs
46-49, 51.
Medical Protection Society (2012), Patient autonomy and consent, in MPS
Guide to Ethics: A Map for the Moral Maze, chapter 8.

3.21 Disclosure to relatives

A B F
While you can listen to a patient's family's concerns without the patient's
consent, you cannot disclose any information without consent. You therefore
cannot tell the patient's daughter that she doesn't have cancer (C), unless
the patient gives her consent. You should tell the daughter that you cannot
discuss her mother's case with her (F). You should never lie on behalf of a
patient (E). You can encourage the patient to be honest with her daughter
(B), but you should not coerce the patient into telling the truth (G). Similarly,
your opinion of a patient's actions should not influence the care you give
(H). It is good practice to document all conversations you have with patient's
relatives (A). This may be particularly important in this case since the
daughter may become upset that you did not disclose the truth if she were
 Answers 209

to later discover her mother's true diagnosis. While it is important to reflect

on incidents such as this (D), it is not the most appropriate response in this
scenano.

Recommended reading
General Medical Council (2009), Explanatory guidance, in Confidentiality,
paragraphs 64, 66.
Medical Protection Society (2012), Confidentiality, in MPS Guide to Ethics: A
Map for the Moral Maze, chapter 9.

3.22 Uninformedconsent

C B E D A
When obtaining consent, it is imperative to check a patient's understanding.
lf a patient does not fully understand the risk of complications, then they are
not making an informed decision and could seek legal compensation should
such a complication occur. In this scenario, you should suggest to your col-
league that you do not think that the patient fully understood (C); this may
upset your colleague, but ultimately they should know this, and it gives them
a chance to change their practice and avoid complaints and litigation. Another
good option would be to ask a senior colleague to discuss the procedure
with the patient (B) as this would enable the patient to get rhe information
required from an experienced colleague; however, this would not help your
SpR to change his practice, so it is less suitable than option C. Option E would
improve the patient's understanding; however, as a junior doctor, you are likely
to lack the necessary experience and knowledge needed to provide this infor-
mation. Doing nothing (D) would be negligent; however, advising the patient
to make a complaint about your colleague (A) would be unprofessional. As a
doctor, you should provide the correct channels for a patient if they wish to
make a complaint, but you should not suggest that a patient makes a complaint
about a colleague.

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together, paragraphs 7-11.

3.23 Refusing medication

D E F
As a doctor you should respect a patient's autonomy and their right to refuse
treatment or medication; however, you should also make sure that they have
made an informed decision. The most appropriate actions in this case are
therefore to discuss it further with the patient and empathise with her reasons
for nor wanting to take aspirin (D), to ensure that she understands the ben-
efits and the risks of aspirin (e.g. bleeding) and also the risks associated with
not taking it (E) and to respect her decision (F). Options A and H, advising
 210 Chapter 3: Effective Communication

her to find another doctor or telling her that she must take your advice, are
outdated and unprofessional as you should nor force a patient into treatments
or withdraw treatment, even if you disagree with their beliefs. Asking a senior
GP colleague to speak to your patient (B) could be helpful if you felt out of
your depth or wanted reassurance; however, this should be a situation that a
junior doctor can deal with. Asking her husband to convince her to take it (C)
would be disrespectful towards your patient and their right to make a decision.
Seeking advice from a medical indemnity society (G) would be unnecessary in
this situation.

Recommended reading
Medical Protection Society (2012), Patient autonomy and consent, in MPS
Guide to Ethics: A Map for the Moral Maze, chapter 8.

3.24 Confused patient refusing antibiotics

A C B D E
In this scenario, it is obvious that at this point in time that the patient does not
have capacity to make this decision. When a patient lacks capacity, you can give
treatment against their wish if it is in their best interests. Sepsis is potentially
life-threatening, and here the patient should be given the antibiotic against their
will, although you should remain respectful {A). Finding an oral alternative for
the antibiotic {C) may be appropriate in some cases, but IV antibiotics are more
effective in sepsis, especially when a patient is still febrile. Asking the patient's
husband for consent (B) is nor necessary but may be useful to glean the patient's
views and beliefs to decide whether you would be acting in the patient's best
interests. Getting the patient sectioned (D) is inappropriate as the confusion is
likely to resolve with treatment of the sepsis. Telling the patient that you are
giving her a painkiller but instead giving her the antibiotic {E) is deceitful and
dishonest.
Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together, paragraphs 75, 76.

3.25 Language barriers

B C F
Despite this being a relatively minor procedure, you are still required to obtain
verbal consent from the patient, so options E and H are inappropriate. Eicher
ignoring the situation {D) or changing the management plan (G) could result in
the patient receiving sub-optimal care and could potentially be dangerous. You
will need to communicate with the patient in her own language, and therefore,
options B and C would be the most appropriate as they ensure impartial com-
munication of consent. Option F is also appropriate, although less so, but it is
preferable to A because it ensures that the information relayed ro the patient is
the information you wish to communicate.
 Answers 211 e
Recommended reading
General Medical Council (2013}, Good Medical Practice, paragraph 32.
3.26 Contraceptionand young people

C D F
This question focuses on a famous case concerning consent and young people.
Ir is appropriate for a doctor to provide contraception for a child under the age
of 16 without parental consent and knowledge if:
• She is mature enough to understand the nature and implications of the
contraception.
• She cannot be persuaded to discuss the situation with her parents or allow
the doctor co do so.
• She is likely to have sexual intercourse with or without contraception.
• Her physical or mental health may suffer unless she receives contraception.
• The contraception is given in her best interests.
If a young person under the age of 16 fits these criteria, they are said to be
Gillick competent. Option C would be the best course of action to ensure she
has competence. Option D is a possibility as FY2 doctors should feel they can
approach an educational supervisor for support, and it would immediately
cackle the issue. It is also important to ensure that you have fully documented
the conversation you have had with your patient should any difficulties sub-
sequently arise with her parents. Option F, though not ideal, would provide
contraception while allowing you time to gain support and advice. Options A
and Gare inappropriate as the patient clearly does not want to inform her
parents and in so doing you would break confidentiality. Option H would
harm your doctor-patient relationship and nor solve the issue as she intends to
have sexual intercourse regardless. Option E is inappropriate as she does not
have to inform her parents if she does not wish to and should not be pressured
into doing so. Finally, asking the patient to book an appointment with a senior
doctor (B) might eventually solve the problem, but she may have unprotected
sexual intercourse in the meantime.

Recommended reading
General Medical Council (2008}, Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together, paragraphs 54-56.

3.27 Self-discharge

A B C E D
If you can convince the patient to wait, it is best for a senior to be involved
in situations of self-discharge (A). This will ensure that the risks have been
explained fully and all efforts have been made to help the patient under-
stand the importance of staying in hospital. However, you can manage the
situation yourself as an FYl and indeed you may have to if a senior is not
available at the time. You would need to have a discussion with the patient
 212 Chapter 3: Effective Communication

and complete the appropriate paperwork (B). Option Cranks lower than
B because it describes a one-way communication of the risks rather than a
two-way discussion and makes no mention of ensuring the patient gets their
medications to rake home with them, which is important for patient safety.
You cannot take a passive role in this context: telling the patient that they
are free to leave the ward is true but you must follow the necessary pro-
cesses (E). Telling the patient that they must stay (0) is the worst response
as it is both untrue and would be a complete violation of the patient's
autonomy.

Recommended reading
Medical Protection Society (2012), Patient autonomy and consent, section: Free
will, in MPS Guide to Ethics: A Map for the Moral Maze, chapter 8.
Raine T, McGinn K, Dawson J, Sanders S, Eccles S, Being a doctor:
Self-discharge, in Oxford Handbook for the Foundation Programme
(3rd edn.), chapter 1.

3.28 Family translating

E B D C A
This situation implies that you have major concerns over whether the patient
can give informed consent, so the worst response here is to ignore the issue and
just book her for theatre (A). The other four options involve different methods
of approaching the problem. Using Language Linen.r promptly but without the
family present (E) is the best response because it gives the patient an opportunity
to have the situation explained independently, without the influence of her
family, which could potentially be persuasive. Although translation is more
effective in person than via the telephone, option Bis not as good as E because
it delays the discussion until immediately before the operation. This has service
planning implications and may make the patient feel pressurised to continue
with the plan. Asking your registrar to deal with the situation (0) is a way to
raise your concerns but is passive, and you can be more proactive with the higher
ranking options. Challenging the daughter (C) is provoking confrontation, and
chis may not do much to help solve the problem. However, this is still better than
ignoring your concerns, as in option A, which is entirely inappropriate.

Recommended reading
Communication in difficult circumstances (2012), in Foundation Programme
Curriculum, Section 2.3.
General Medical Council (2013), Good Medical Practice, paragraph 32.

3.29 Blood transfusion

A C D
This question focuses on respecting patient autonomy in situations where, as a
doctor, you may not agree with the decision the patient makes. It is also impor-
tant to remember to maintain good communication with the patient and your
 Answers 213

colleagues. If the patient has capacity, you must acr according to their wishes
and remember to document accurately and clearly any conversations you have
with them, while ensuring that the patient completes any necessary paperwork.
Options A and Care therefore wise actions to take initially, while ignoring the
patient's wishes by proceeding to arrange the transfusion would be inappropri-
ate (E and F). As a less experienced doctor, it is also sensible to talk co a senior
about your conversation (D) and to see whether there is anything else that
needs to be done. This would be preferable to discussing the case with another
FYl colleague (B), who is likely not to have any more experience in these types
of situations than you. You must be satisfied that the patient is aware of the
risks of refusing treatment, but your aim should nor be to coerce them into
agreeing with you (H); instead, simply make sure that they are provided with
all of the information they need so that they can make a fully informed deci-
sion. The blood bank may be able to give you some advice about the paper-
work char needs to be completed (G), but your team should be the first pore
of call for help in dealing with these situations. You should always involve a
senior colleague.

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together.
General Medical Council (2013), Duties of a doctor, in Good Medical Practice.
General Medical Council (2013), Good Medical Practice, paragraphs 11, 14,
17, 19, 21, 31, 46-49, 54, 68, 71.
Medical Protection Society (2012), Patient autonomy and consent, in MPS
Guide to Ethics: A Map for the Moral Maze, chapter 8.

3.30 Blind patient

D E A B C
This question concerns one of the duties of a doctor: that of making sure
you give patients information in a way they can understand. This is always
important, especially when the situation involves obtaining informed con-
sent. Option D is the most appropriate initial response in this case as, in
doing this, you are showing regard for the patient's disability as well as
ensuring that she still receives the information she needs. Option E would
also be suitable (discussing the procedures with the patienr and supply-
ing the patient's husband with an information leaflet); however, it would
be courteous to the patient to provide her with the written information as
well as her husband, if possible. This would be better than simply talking
things through, as in option A, so that the patient can consolidate the verbal
conversation with written information and helps to ensure that she doesn't
forget anything important. Similarly, option Bis less appropriate, but it is
worse than option A because, in addition, you are asking one of your col-
leagues, who may be very busy, to do one of your jobs without good reason.
You may wish to ask for advice regarding giving the information, but you
 214 Chapter 3: Effective Communication

should attempt to complete the task before referring to a senior to complete it.
Option C would be the least courteous as the patient would probably not be
able to read the information herself, and you would be directly ignoring your
consultant's request by failing to discuss the procedure with the patient and
her immediate family.

Recommended reading
General Medical Council (2013), Duties of a doctor, in Good Medical Practice.
General Medical Council (2013), Good Medical Practice, paragraphs 18, 31,
32,33,46,49,51,60.
Medical Protection Society (2012), Patient autonomy and consent, in MPS
Guide to Ethics: A Map for the Moral Maze, chapter 8.

3.31 Refusing medication

C E B A D
In reality, the only correct answer here is to go and speak to the patient (C).
You need to understand their perspective and discuss the situation with them.
You do not need senior input at this stage (E); you should be able to attempt to
resolve the issue yourself, which is why option£ is less preferable to option C.
Option B is a poorer choice because it involves delaying resolving the problem
until the next day. In addition, the patient may feel embarrassed that you have
brought up the issue in front of the whole team, and this could undermine your
relationship with them. These first three options have all involved some attempt
to respond co the problem so that a solution can be found that will hopefully
lead to a mutually acceptable, effective treatment. However, options D and A
do not lead to this outcome and are therefore ranked lowest. Prescribing potas-
sium by an alternative route (A) does ensure that the low potassium doesn't go
untreated because, in extreme cases, this could have potentially fatal effects.
However, it fails to deal with the underlying issues or to involve the patient in
communication. The worst answer is to do nothing (D) as this could lead to
harm to the patient. While patients do have a right to refuse any treatments,
that doesn't mean that doctors should accept this with no further action. The
doctor and the patient should be working together to find a management plan
that is acceptable to both parties.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 2.
The UK Foundation Programme Curriculum (2012), Relationship and
Communication with Patients, chapter 2.

3.32 Seeking assistanceto die

B C E
This is a difficult situation; the General Medical Council (GMC) has produced
guidance for this issue. You should try to remain compassionate while ensuring
that you do not contravene the law by encouraging or assisting the patient to
[ Answers 215

commit suicide. Therefore, you should address a number of issues during your
consultation. Discussing your patient's reasons for wanting to end his life, while
explaining that you are unable to provide him with advice about suicide is the
best course of action (options C and E). You should also ensure that he has no
unmet palliative care needs, referring to the appropriate services that he may
require (B). Arranging to section the patient under the Mental Health Act (A)
would be inappropriate at this stage as the patient may nor have a psychiatric
disorder. Getting another GP to speak with your patient (D) could be useful as
you are likely to need support dealing with this situation; however, options B, C
and E are more important at this point in time. Telling the patient that they are
being selfish (G) would be very unsympathetic and unprofessional. Informing
the patient that you can no longer provide care (H) is incorrect; the patient has
confided in and asked you for advice, not to help them physically end their life.
Once you have established that you cannot provide the patient with this infor-
mation, you should seek other ways of improving his condition, for example
with symptom control or psychological and social support. You should listen to
and respect your patient's decisions, and for this reason, option F, refusing to
engage in a conversation about this subject, would be unsuitable.

Recommended reading
General Medical Council (2013), When a Patient Seeks Advice or Information
About Assistance to Die.

3.33 Ward round

A E F
Patients have a right to confidentiality, which is central to the trust held
between doctors and their patients. While it is inevitable that patients on a
ward will unintentionally learn information about each other, this should be
avoided wherever possible. This is particularly important when discussing
sensitive information, such as an HIV diagnosis. You should therefore stop the
consultant and suggest that he takes the patient somewhere more private (E).
This may prevent any further information from being disclosed and enable a
more open discussion between your consultant and the patient. You should
also suggest that the consultant apologises to the patient (F). It is appropriate
for you too to apologise on behalf of the consultant (A). While talking to the
consultant at the end of the ward round (H) may alert him to his mistake and
prevent a further breach of confidentiality, it does nothing to rectify the current
situation. Similarly, asking other patients whether they heard the conversation
(B) does nothing co help. Moving the patient co a side room (D) is unnecessary
and may make chem feel stigmatised. Indeed, if you act appropriately at chis
stage, there should be no similar situations in the future. Although your con-
su Ira nt has acted poorly, chis was undoubtedly unintentional. An apology to
the patient may be all that is needed to resolve the issue, so suggesting that the
patient make a complaint (G) may cause unnecessary upset. Ignoring a breach
in confidentiality (C) is inappropriate and fails your duty as a doctor.
 216 Chapter 3: Effective Communication

Recommended reading
General Medical Council (2009), Explanatory guidance, in Confidentiality,
paragraphs 6, 13.
General Medical Council (2013), Good Medical Practice, paragraph 55.

3.34 Secret pregnancy

C F G
While, in most cases, a patient is happy for their family to be fully informed
about their treatment, there are instances where this is not the case. You should
therefore be mindful when talking to relatives about what you can and can't
discuss. In this scenario, your patient has clearly felt unable at this point to
tell her husband that she is pregnant, and it is not your place to tell him. You
should therefore explain to the husband that you cannot discuss his wife's
treatment without her permission (F). It is also appropriate to ask the husband
to discuss the CT scan with his wife in the meantime (G). This gives the patient
the opportunity to tell her husband what she would like him to know. You
could discuss with the patient why she has not told her husband (C) so that you
have a better understanding of her situation and are able to offer some support
if necessary. In this scenario, you should not encourage the patient to be honest
with her husband about the pregnancy (D) as it is entirely her decision whether
to inform him or not. You should not normally lie on behalf of a patient, so
telling the husband that his wife no longer needs the scan is inappropriate (E).
Similarly, asking the patient what she wants you to tell her husband (B) is not
ideal as she may want you to lie on her behalf. Telling the husband about the
pregnancy (H) is a breach of confidentiality, so it is clearly unsuitable. Asking
the husband to calm down (A) is also inappropriate since this may further
anger him and offers no solution to the problem.

Recommended reading
General Medical Council (2009), Explanatory guidance, Confidentiality, para-
graphs 6, 64, 66.
Medical Protection Society (2012), Confidentiality, in MPS Guide to Ethics: A
Map for the Moral Maze, chapter 9.

3.35 Discussion with relative

A C D E B
While you should maintain patient confidentiality when speaking to relatives,
you can and should listen to any concerns that a relative wishes to discuss
with you. You should, however, make it clear that you may need to inform the
patient of your conversation. In this scenario, you need to speak to the patient
about her alcohol use in order to establish whether her symptoms are attrib-
utable to alcohol withdrawal. You do not necessarily have to disclose your
conversation with her husband in order to do that (A). It would not be inappro-
priate, however, to tell her about your conversation with her husband, although
you should warn him that this is your intention (C). To tell the patient about
 Answers 217

your conversation without forewarning her husband (D) is less favourable as

this may risk damaging both their relationship and the trust that the husband
has in you. You should not treat the patient for alcohol withdrawal without
establishing whether she is alcohol dependent nor should you provide treatment
without informing the patient of what it is for (E). Having said that, ignoring
the husband would fail to investigate a potentially serious condition, which is
why option B ranks last.

Recommended reading
General Medical Council (2009), Explanatory guidance, in Confidentiality,
paragraph 66.

3.36 Knife wound

A B E D C
In cases of knife or gunshot wounds, it is important co inform the police
so that they can ensure the safety of the patient, hospital staff and the
public. The police should be informed, even if the patient does not con-
sent to disclosure. However, wherever practicable, the patient should be
informed before the information is disclosed; therefore, option A is prefer-
able to B. The police should be informed as quickly as possible so that any
further harm can be prevented. Waiting for the patient to change his mind
(E), although it seems courteous, is therefore unsuitable. A decision not to
report knife or gunshot wounds is rare and should be made by the consul-
tant in charge (D). Coercing the patient into giving consent is completely
inappropriate (C).

Recommended reading
General Medical Council (2009), Explanatory guidance, in Confidentiality,
paragraphs 36-39.
General Medical Council (2009), Explanatory guidance, in Confidentiality:
Reporting Gunshot and Knife Wounds.

3.37 Telephone conversation with relative

C D E
This is a common scenario in hospital medicine. It is important, before
discussing with relatives, to confirm with the patient that they are happy
for you to speak to certain relatives (C). Without this consent, you may be
breaching confidentiality. During telephone conversations, you should try to
confirm that you are speaking co the correct person (D). You could do this
by ringing the relative on a number given to you by the patient. On occasions
when you are disclosing personal information about a patient, you should give
only the minimum necessary information (E). Options Band Hare both inap-
propriate as the son has requested to talk with a doctor, and as an FYl, you
should be able to deal with this situation. Option A is unlikely to suffice as the
son would like information from a doctor, and option F would be both rude
 218 Chapter 3: Effective Communication

and unprofessional. Having a face-to-face conversation would be preferable

in this situation; however, the son has already specified that he is unable come
into hospital (G).

Recommended reading
General Medical Council (2009), Explanatory guidance, in Confidentiality,
paragraphs 9, 64-66.

3.38 Contact tracing

C B D A E
This question assesses your ability co communicate effectively with the patient
and to know in what circumstances personal information can be disclosed
against the wishes of the patient. In this situation, you should explore your
patient's concerns and inform her of the importance of her boyfriend's treat-
ment and discuss ways of implementing it (C). This should enable your patient
to make an informed decision. Option B is the next step if the patient is still
refusing to tell her partner. This is now an issue of public safety as her boy-
friend may unknowingly infect others. Ir is important to make the consultant
aware and to implement the contact tracing protocol of the geniro-urinary
medicine (GUM) clinic. Option D is the next best response; the patient should
be informed that you may have to break confidentiality in the interest of public
safety. Option A is nor appropriate as this is shirking responsibility. Option Eis
the least appropriate course of action as the boyfriend may never find out and
unknowingly carry a chlamydia! infection, which, among other things, may
seriously damage his future health.

Recommended reading
General Medical Council (2009), Explanatory guidance, in Confidentiality,
paragraph 64.
General Medical Council (2013), Good Medical Practice, paragraphs 31, 50.

3.39 Prophylactic antibiotics

C D E
This is a difficult situation and one that is nor commonly faced. In the majority
of situations, most patients will be happy to disclose information if it will pro-
tect family and friends. Meningitis is a potentially fatal infection and should be
taken very seriously. The General Medical Council advises that a balance must
be sought between your duty of care to the patient and your duty to protect
others from serious harm. In this situation, you must inform the potential
contacts at the parry that they are at risk. The best way to do this would be
with the help and support of the patient, so option C would be most appropri-
ate. The local public health department or your consultant could also help and
offer advice in this scenario, which also makes options D and E appropriate,
especially if the patient is refusing to cooperate with your request. Allowing
him ro contact his friends himself (A) could potentially identify at-risk
 Answers 219

individuals; however, some of his friends may nor show symptoms in the early
stages of the infection. Additionally, you may run the risk of him failing to con-
tact all of the necessary people. Relying on the patient ro distribute antibiotics
ro his friends (B) is not a reliable method of providing appropriate prophylaxis
to potential contacts. Refusing to treat him (F) is a breach in your duty of
care to the patient, while respecting his wishes (G) would breach your duty
of care to the public.

Recommended reading
General Medical Council (2009), Explanatory guidance, in Confidentiality,
paragraphs 68, 69.

3.40 HIV and death certificates

B D H
The completion of death certificates is a common task for an FYl doctor.
General Medical Council (GMC) guidelines set out several siruarions where
you should disclose relevant information about a patient who has died. One
of those situations is on death certificates, which must be completed honestly
and fully. While this patient is dying from a malignancy and tuberculosis, his
HIV infection is also a key contributor to his death, and therefore, it must be
mentioned on his certificate. Option Eis therefore inappropriate. Documenting
a 'viral infection' (A) would not be completing the certificate fully so is also
inappropriate. You should be open and honest with your patient about your
duty (0), while also trying ro allay his fears (H). In a difficult situation, you
should always contact a senior for help if you are unsure about what to do (B).
Informing his family of the condition before he dies (C) would involve break-
ing patient confidentiality and is therefore inappropriate. Of the responses left,
lying to your patient is bad practice (F) and refusing to complete the certificate
(G) would ignore the issue and leave this task to a fellow colleague to deal
with, which is inappropriate.

Recommended reading
General Medical Council (2009), Explanatory guidance, in Confidentiality,
paragraph 71.

3.41 Drug overdose

A B C D E
In this type of situation, it is important nor to guarantee to a friend/relative/
partner that you will keep a conversation confidential. This is because the
information they give you may prove to be important in the treatment of your
patient (as in this case). Good communication with all parties from the outset
is key to ensuring that there is no confusion and will prevent difficult situations
from arising. Considering these points, the two most appropriate responses
are options A and B. Of the two, A is more appropriate as it deals with the
patient who currently requires treatment and involves senior support in a
 220 Chapter 3: Effective Communication

difficult situation. Refusing to speak to the patient's friend (E) could potentially
lead to sub-optimal care and the incorrect treatment, so this ranks last. Phoning
the police to report a case of drugging (D) would be inappropriate before liaising
with seniors, the patient and the friend of the patient; however, this is techni-
cally a criminal matter, so this could be considered. Keeping the source of the
information confidential and treating the patient (C) ensures immediate patient
safety; however, it may put the patient at risk in the future of a similar episode.

Recommended reading
General Medical Council (2009), Explanatory guidance, in Confidentiality,
paragraph 66.

3.42 Safeguarding children

C A B E D
As a healthcare professional, you have an ethical and legal responsibility to
take action if you become aware of children who could be at risk. You should
explain each step of what is happening to the patient, and the best person
to contact is the safeguarding officer in your hospital (C). You could defer
responsibility to your senior (A), but this is nor the best response as the patient
has disclosed to you, and you should be able to respond ro this yourself.
Referring to social services (options Band E), an external agency, is a decision
that should only be taken after seeking support from within your organisation.
Asking for consent is a problematic issue because you may need to disclose this
information to social services even if the person involved refuses their con-
sent for this. Nevertheless, option Bis better than E because it explains to the
patient and attempts to involve them in the decision, which is polite. The worst
response in this scenario is to take no action, even if you do document your
findings (D). These children are living in a house with the potential for domes-
tic abuse, and this must be investigated by the appropriate services.

Recommended reading
General Medical Council (2007), Explanatory guidance, in 0-18 Years:
Guidance for All Doctors, paragraphs 56-63.

3.43 Lost notes

A C F
The first action you should take in this situation is to apologise to the patient
(A). However, you should not seek to pin the blame on any particular member
of staff (E), especially when it is not clear how the notes were lost. You should
never try to discourage a patient from making a complaint if they wish to (B).
After speaking to the patient, you should take action to address the problem.
It is likely to take up a lot of time to search for the notes yourself in the medi-
cal records department and is unlikely to be successful (G). Involving the ward
clerk so that they can start a new temporary file (C) is appropriate, and they
will also be a valuable aid in trying to locate the originals. Using a temporary
 Answers 221 •

file is better than waiting co document (H) as you should be recording what is
happening to the patient in a thorough and timely manner to protect patient
safety. This would also minimise the risk of human error in forgetting what
has been said about the patient's management. It is important to raise this to
a higher management level as this ensures that any underlying system issues
are investigated to try to prevent future occurrence of the problem. The best
way to do this in this situation is to fill in an incident form (F). This is a better
response than talking to your educational supervisor (D) as it relates to a ward
management issue.

Recommended reading
Foundation Programme Curriculum (2012), section 2.4: Complaints.
General Medical Council (2013), Good Medical Practice, paragraph 55.

3.44 Employee disclosure

B E G
This question tests your ability to maintain patient confidentiality, specifically
for the purposes of protecting against discrimination. You should not disclose
information to third parties, as in options C and D, without the patient's per-
mission. In chis scenario, it would therefore be wise to have a conversation with
the patient about his wishes (B), and if you are unsure as to how to approach
the situation, a more experienced member of staff on the ward may be able
to help you with this (G). It would also be polite to explain to the caller in a
professional manner about your obligation to protect the patient's confidential-
ity (E), which would show good communication skills and respect for the caller
in addition to the patient. Threatening or aggressive behaviour towards the
caller (H) would simply inflame the situation and would not demonstrate good
professional behaviour. Shirking your responsibility onto another member of
the team (options A and F) is unprofessional and would show a disregard for
your professional responsibilities.

Recommended reading
Disability Discrimination Act (2005), chapter 13.
General Medical Council (2009), Explanatory guidance, in Confidentiality.
General Medical Council (2013), Duties of a doctor, in Good Medical Practice.
General Medical Council (2013), Good Medical Practice, paragraphs 31, 34,
46, 47, 50, 68.
Medical Protection Society (2012), Confidentiality, in MPS Guide to Ethics: A
Map for the Moral Maze, chapter 9.

3.45 Child confidentiality

B C D A E
According co the General Medical Council (GMC), divorce does not affect
parental responsibility, and both parents should be allowed equal access to
information about their child. The best responses establish that this man is
 222 Chapter 3: Effective Communication

definitely Chloe's father. lr is difficult when you have never met family members
before to ensure that they are who they claim to be. Option B would ensure
both parents had fair access to updates about Chloe and also seamlessly allows
you to discover if this man is Chloe's father, since his ex-partner will surely
recognise him. Option C is the next best response as validating whether this
man is Chloe's father is reasonable before discussing confidential information.
If you explain sympathetically that you need proof of his identity and that it is in
the interest of Chloe's confidentiality, most people will gladly oblige. Asking the
man to ask Chloe's mother (D) is not a very helpful response on your part, but at
least you arc avoiding a potential breach in confidentiality. However, you cannot
be sure how amicable their relationship is, so deflecting the man to Chloe's
mother may land you in the middle of a family feud. Option A is ranked fourth
because asking Chloe's mother's permission to speak to her father would ensure
that both parties know that they are each involved (avoiding an argument),
but it comes after option D because you do nor actually need the mother's
permission to discuss Chloe with her father. The least appropriate response is
Option E: asking help from seniors in complicated situations is always advised,
but an FY 1 is capable of giving simple updates to family members and shouldn't
need senior support, unless things become more complicated.

Recommended reading
General Medical Council (2007), Explanatory guidance, 0-18 Years:
Guidance for All Doctors, paragraph 55.

3.46 Handover sheet

A F H
Handover sheets are a necessity on the wards to ensure essential patient
information is always at hand. Unfortunately, they are therefore one of the
most concise summaries of an entire patient history, simply written and easily
understood by the public. You should never take sensitive patient informa-
tion home where members of the public could see it and where appropriate
disposal might not be available. In this scenario, one of the best responses is to
attempt to retrieve the lost handover sheet (H). This could recover the infor-
mation without too many people seeing it. The second best option is to ask
for the advice of someone senior, and your registrar who knows the patients
in question and the details on the handover sheet is the best person to ask for
help (A). Finally, to apologise to the patients is going to be difficult, but it is
important that you do so as it is their information that could potentially have
been made public (F). Simply ignoring the potential loss of confidential patient
information (E) is inappropriate; this is not the behaviour of an honest and
trustworthy doctor. To call the police (B) is not appropriate for the loss of one
handover sheet. The rest of the options involve you trying to prevent this hap-
pening again, which is important but doesn't retrieve the lost handover sheet.
Informing your clinical supervisor (C) could be productive as you could both
sit down and come up with ways of preventing it happening again. Option Dis
 Answers 223

a good personal learning point, although does little for the situation at hand.
Teaching other FYls about confidentiality (G) would also be a valuable learn-
ing experience, although again it does little to remedy the immediate situation.

Recommended reading
General Medical Council (2013), Protecting information, in Confidentiality,
paragraphs 12-14.

3.47 Consultantnames

C A B D E
The best response here is to go straight to the source and tell your consultant
how you feel (C). Some older, more traditional consultants may refer to you in
the same way that their seniors did them, and they simply need reminding that
this is not an appropriate way to address colleagues. The next best response is
to discuss the matter as a ream (A), followed by going to your supervisor (B).
Your consultant is not in breach of the GMC's guidelines, so reporting him
(D) is unlikely to be of any benefit to you. However, this is more appropriate
than refusing to perform any of the jobs for the consultant (E), which is both
unprofessional and would put patient safety at risk; therefore, this option has
to rank last.

Recommended reading
General Medical Council (2013), Duties of a doctor, paragraph 1.
General Medical Council (2013), Good Medical Practice, paragraph 36.
Medical Protection Society (2012), Relating to colleagues, in MPS Guide to
Ethics: A Map for the Moral Maze, chapter 11.

3.48 Degradingnursingstaff

D A B C E
Option D is the best response by far since politely reminding your colleagues
that a) they should be more respectful towards the nursing staff and b) they
are in a place where anyone could overhear their conversation are important
actions here. Option A ranks next as it involves making your colleagues aware
that their discussion should not be raking place, but it is preferable not to
be confrontational in your approach to this, which would likely make your
working situation very difficult with them and is unprofessional. Option Bis
perhaps the next best response as making it seem like you did not overhear the
conversation is likely to put an end to it, while reminding your colleagues that
others can overhear. Option C is preferable to E as, by closing the door, at least
you are attempting to make their conversation private, whereas doing nothing
(E) could result in one of the nursing staff overhearing their conversation.

Recommended reading
Medical Protection Society (2012), Respect, in MPS Guide to Ethics: A Map
for the Moral Maze, chapter 7.
 224 Chapter 3: Effective Communication

3.49 FYl vs SpR

B D G
Your colleague is upset so therefore the first thing you should do is comfort him
(B). It is important that the registrar learns how your colJeague feels and that
what he said was inappropriate, but this is best coming from the person involved
(options D and G) rather than their educational supervisor (A) or yourself (C).
However, while it is better to discuss the matter directly with the registrar,
if they do not listen, then you should escalate the matter to their consultant.
Ignoring the situation (F) is never appropriate; all doctors have bad days, but
this should nor be taken out on more junior colleagues. Offering to rake on your
colleague's duties (H), while chivalrous of you, is not going to help the situation
and will only result in further problems as you try and cover too many patients.

Recommended reading
Medical Protection Society (2012), Relating to colleagues, in MPS Guide to
Ethics: A Map for the Moral Maze, chapter 11.

3.50 Patientconcerns about GP

D E F
You should always rake the time to listen to patients' concerns (F). It would be
rude and uncaring to refuse any discussion (H). However, you must be objec-
tive when making any comment on the work of another practitioner, and in
this situation, you are not in a position to either confirm the patient's concerns
(A) or refute them (G). If you make disparaging comments about the care of
the GP, this could be seen as defamation (A). It is best to remain neutral and
explain to the patient that you do not have enough evidence to give your own
professional opinion (D). You certainly do not have enough evidence to be
concerned enough to contact the GMC at this point (B). However, you should
let your seniors know, both so that they can look into the matter further if
necessary and so that they are aware that the patient is likely to ask their opin-
ions too (E). lf you were to involve the GP in discussions about what had taken
place (C), this should be done carefully so that the patient does not feel you had
abused their trust when they confided their concerns. It should not be done in
an inflammatory or confrontational manner.

Recommended reading
Medical Protection Society (2012), Relating to colleagues, section:
Commenting upon the work of others, in MPS Guide to Ethics: A Guide
to the Moral Maze, chapter 11.

3.51 Registrars conflictingplans

D E C B A
You are in a difficult position here in the midst of poor team communication.
Nevertheless, it is important that you address the conflicting decisions (options D
 Answers 225

and E) rather than avoiding this. Option D is preferable to option E because the
patient is expecting to go for the investigation, and the last entry in the patient's
medical notes will specify that this is the plan, so there needs to be an open
discussion about it, initiated by the second registrar. By calling the first registrar
(E), you are avoiding them feeling undermined in future when they discover that
the imaging was performed, and this will hopefully lead to a discussion between
the two registrars. Option C is the next best response, and is preferable to A or B
because it raises the opposing view; however, it involves challenging the second
registrar in front of the patient, which they are likely to find embarrassing. This
conversation would be better left until away from the patient's bedside co main-
tain professionalism. To ignore the situation (options A and B) is unprofessional
and shows a lack of respect and appropriate responsibility on your part; in partic-
ular, to let the investigation remain unperformed (A) could potentially be damag-
ing to patient care if the procedure was required, so this is the worst response.

Recommended reading
Medical Protection Society (2012), Relating to colleagues, section:
Differences in opinion, in MPS Guide to Ethics: A Map for the Moral
Maze, chapter 11.

3.52 Complaints

A C E
The NHS Litigation Authority confirms char providing an apology does not
admit liability. Doctors should be prepared to apologise to a patient or relative
regardless of whether they themselves were responsible for the incident (C).
You cannot, however, comment on what may or may not have happened when
you were not present, and chis should be explained to the patient (E). It would
also be highly inappropriate to either agree or disagree with the patient's
view of the incident (options B and H). The doctor involved is best placed co
comment and you should advise the patient co raise their concerns with the
consultant directly (A). You are nor in possession of all the facts, and it would
be inappropriate for you to discuss the complaint with the consultant your-
self (G). This incident may well be resolved simply by an apology from the
consultant without the need for a formal complaint (F). Patients should be free
to make complaints about their treatment without fear that their care will be
compromised, so avoiding the patient (D) is inappropriate. In addition, per-
sonal views should not affect your relationship with the patient.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 59, 61.

3.53 Consensual Dr-Dr relationship

D E F
In this situation, you have a duty both to protect patients against any behav-
iour that may potentially compromise care and to maintain good professional
 226 Chapter 3: Effective Communication

relationships with your colleagues and not to judge based on hearsay. It would
therefore be sensible to clarify to the nurse that you had not observed this
behaviour yourself (D). The sister should speak to the doctors in question (F)
as you are not involved. If she determines that it is necessary, a more senior
member of the medical team should be involved (E). It would be unlikely that
there was a direct impact on patient safety (B); however, their behaviour may
cause discomfort to other staff and therefore impact the team's functioning.
Escalating the concerns of others when you have none yourself (H) or suggest-
ing that a formal complaint should be made (G) are inappropriate responses.
While remaining impartial, it is important to support your colleague in doing
rhe right thing, and therefore, option C would be inappropriate.

Recommended reading
General Medical Council (2013), Duties of a doctor, in Good Medical Practice.
General Medical Council (2013), Good Medical Practice, paragraphs 16, 22,
23,24,25,35-3~56,59,65,68.
Medical Protection Society (2012), Morality and decency, in MPS Guide to
Ethics: A Map for the Moral Maze, chapter 5.

3.54 Putting arm around relative

C A B E D
This question concerns good communication and the necessity to apologise ro
patients and their relatives when they are dissatisfied with your behaviour. As
a doctor, a position with social and public responsibility, purring a comforting
arm around someone may nor seem to you to be inappropriate, bur you need
to respect the fact that different cultures or religions may think diffcrenrly. It is
therefore imperative that you apologise in rhe first instance and reassure them
that this will nor happen again (C). Failing to apologise (D) would be unpro-
fessional and could lead to further action if the person in question wished to
make a formal complaint. It would also be inappropriate to ask the nurse to
speak to the relative for you (E) because it is your professional duty to speak to
the complainant in person; however, since they would still be receiving an apol-
ogy, it is therefore not as inappropriate as option D. Explaining your behaviour
to the nurse (A) is also courteous and wise so that they can support you in any
further conversations; and informing your educational supervisor (B) would
also be wise from an educational and reflective perspective. However, these
courses of action should occur after apologising to the family.

Recommended reading
General Medical Council (2013), Explanatory guidance, in Maintaining a
Professional Boundary Between You and Your Patient.
General Medical Council (2013), Duties of a doctor, in Good Medical Practice.
General Medical Council (2013), Good Medical Practice, paragraphs 31,
33-36,46-48,53,55, 61,65, 73.
Medical Protection Society (2012), Morality and decency, MPS Guide to
Ethics: A Map for the Moral Maze, chapter 5.
[ Answers 227

3.55 Interrupting the SpR

A D B C E
This scenario raises a few different issues, most of which suggest that the
registrar was not acting professionally, which puts you in a difficult position.
First, the door should be locked during intimate examinations; second, the reg-
istrar should have had a chaperone present who could have answered the door
for them and third, you should have been asked tO remain outside. The most
important thing is to make these points clear to the registrar, but you must also
apologise to the patient (A). The next best response would be to close the door
immediately and leave the patient alone (D); hopefully, the registrar would then
apologise for the interruption. Following this, the preferable response of those
remaining is to enter the room and wait (B) rather than to proceed to discuss
another patient with the registrar while the patient remains on the table (C).
The least appropriate response here is to blame the nurse incorrectly (E) as this
ill only make your working relationship difficult.

Recommended reading
Medical Protection Society (2012), Morality and decency, in MPS Guide to
Ethics: A Map for the Moral Maze, chapter 5.

3.56 Upset patient

E A B C D
This is obviously a difficult situation for the patient, and the most likely reason
for the complaint is a product of their grief reaction. However, the first thing
you must do in this scenario is apologise to the patient for any misunderstand-
ing (options E and A), although this is best done with someone else present as
a witness (E). Of the remaining options, Bis the next best as having a third
party explain the situation, while not ideal, ensures that an apology is made.
Waiting for the situation to run its course (C) is not practical but is far superior
to antagonising the patient (D).

Recommended reading
Medical Protection Society (2012), Morality and decency, in MPS Guide to
Ethics: A Map for the Moral Maze, chapter 5.

3.57 Assisted suicide

B A E C D
This is a very difficult scenario, with equally difficult responses to choose from.
Thankfully, for practitioners, there is helpful guidance available to answer
these kinds of questions. Assisted suicide is a criminal offence in the United
Kingdom, and any doctors found to be taking part in such activities would be
liable to prosecution. In this scenario, however, your patient is clearly making
a plea for help. She is experiencing severe symptoms, which are likely having
a strong effect on her mood. The General Medical Council (GMC) advises
 228 Chapter 3: Effective Communication ____ J

that doctors should be open to discuss requests from patients but should also
reiterate that this request in particular is illegal in the UK. The most important
factor in this scenario, however, is to ensure that you offer your patient help
and support for her symptoms as well as discuss her comments about suicide.
For this reason, option Bis the most appropriate response. Asking a senior col-
league to discuss the issues (A) could be appropriate, but as an FY2 doctor, you
would be expected to at least briefly discuss the issues and assist her with her
symptoms. Referring her to the psychiatric and palliative care teams (E) may be
appropriate; however, you should be attempting to manage aspects of the situ-
ation that are within your realm of competence (i.e. symptom control) initially
before making a referral. Not offering to support your patient (C) would be
inappropriate and could lead to unnecessary suffering. The most dangerous
(and potentially illegal) option would be to prescribe large doses of opiate med-
ication (D) as this could be seen as being compliant with suicide. Opiate-based
medication may have a place in this patient's care bur should be used according
to appropriate guidance from experts such as the specialist palliative care team.

Recommended reading
General Medical Practice (2013), When a Patient Seeks Advice or Information
About Assistance to Die.

3.58 Comments on abortion

B C F
This scenario deals with a number of issues that a foundation doctor may
face. First, the doctor-patient relationship portrayed in this situation is
clearly poor, and this must be addressed. Furthermore, there are also issues
about relating to colleagues as well as the moral issues surrounding abor-
tion. The SpR in this scenario is entitled to conscientiously object to provid-
ing a termination service for the patient, but the situation should have been
handled very differently. The General Medical Council (GMC) offers good
advice about how to tackle such a situation. While a doctor may object to
a particular procedure, they must provide the patient with the opportunity
to see a medical practitioner who could offer assistance. The most appropri-
ate response here would be to discuss the situation with your SpR (F) as this
would allow her to analyse the consultation and would hopefully lead to
her addressing the obvious issues. Arranging for the patient to see another
doctor (B) would ensure that the patient's needs are mer. Asking the SpR
to discuss the situation with a senior doctor immediately (C) would ensure
that you have included senior support and that the patient's needs would be
addressed before leaving the department. Discussing the situation after the
clinic (options D and E) may well be appropriate, but this does not leave the
patient with the support and advice she requires at this instance. Returning
the patient to the room without discussing the situation (A) could potentially
cause further distress and is therefore inappropriate. Documenting your
concerns would also be appropriate (G), but the priority here is to ensure that
[ Answers 229

the patient's needs are met first. Remaining silent despite having concerns (H)
is unacceptable in this scenario as this neglects the patient and would lead to
ongoing poor practice by the SpR.

Recommended reading
General Medical Council (2013), Personal Beliefs and Medical Practice.

3.59 Racism

B D G
This question deals with the issue of racism at work. Racism is not tolerated
within the NHS and faces severe disciplinary action if detected among staff. It is
more complicated when patients are racist towards staff members as despite their
behaviour, there remains a duty of care for that patient. This is a scenario that is
likely to stir strong emotions, but it is important to remain civil and professional.
There is a duty of care for any admitted patient; therefore, any option that involves
ignoring the patient or discharging them without further assessment (options C, E
and H) is inappropriate. Although it seems like avoidance of the situation, options
Band G, which involve placing the patient under the care of another nurse, are the
safest courses of action for a junior doctor to rake. Although the scenario seems
to make the patient's views quite clear, it is always a good idea to explore the
true roots of patients' concerns, and when unsure of how to take matters for-
ward, to seek senior advice; therefore, option D is also one of the best responses.
Incident reporting would be inappropriate in this case, so option A is not one of
the most appropriate responses, although it would be sensible to advise the nurse
to report this higher through nursing channels. Reprimanding patients (F) is not
the place of a junior doctor and should be avoided in all situations.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 36, 59.
Medical Protection Society (2012), Morality and decency, in MPS Guide to
Ethics: A Map for the Moral Maze, chapter 5.

3.60 Refusing treatment for children

A C E D B
This question tackles issues surrounding the protection of children. Although
this example of a skin infection may seem trivial, the implications of receiv-
ing improper treatment may lead to serious morbidity. The best response in
this question is option A. Calling the mother to properly explain the intended
treatment may calm her concerns once she is properly informed. This is within
the scope of your role as an FYl and would be both proactive and helpful.
Option C is the next best response: getting advice on the situation and how
to proceed from a senior doctor is useful in complicated scenarios, particu-
larly those involving child safety. Discussing the issue with another FYl (E)
would rank third because, although your colleague may not be able to give you
the best advice directly, they are perhaps more likely to be familiar with the
 230 Chapter 3: Effective Communication

issues surrounding child protection than you are. Option D ranks fourth: it is
difficult to understand when people make different choices for themselves and
their children to the ones rhe medical profession would advise, but this does
nor necessarily amount co neglect. Raising such a concern with social services
without concrete evidence would cause distress for the family and generate
distrust of healthcare professionals in future. Calling the police (B) would
result in similar mistrust and distress. However, in cases of life and death, and
where other routes have been exhausted, the police should be called to rescue a
child who needs ro be admitted for life-saving treatment.

Recommended reading
General Medical Council (2007), 0-18 Years: Guidance for All Doctors, para-
graphs 42-52.

3.61 Inappropriate dress at work

A C D B E
This question requires you to demonstrate good communication with staff,
while remembering the duty of a doctor to maintain a professional appearance.
lt is possible that your colleague is not aware that she is dressing inappropri-
ately; therefore, your first action should be to speak directly to her at a suitable
time (A). Speaking to a senior colleague may be helpful if you need guidance in
chis (C) and is probably more appropriate than your friend who has no super-
visory role in this situation (D). Monitoring the situation is less appropriate
(B) as you have admitted that her dress is a problem, and chis would therefore
delay addressing the issue. However, this is slightly more suitable than report-
ing her to her educational supervisor (E), which would only serve to jeopardise
your professional relationship and does not give your colleague a chance to
either explain herself or rectify the situation.

Recommended reading
General Medical Council (2007), Medical Students: Professional Behaviour
and Fitness to Practice.
General Medical Council (2012), Continuing Professional Development:
Guidance for All Doctors.
General Medical Council (2013), Duties of a doctor, in Good Medical Practice.
General Medical Council (2013), Good Medical Practice, paragraphs 24, 25,
35-37, 43, 59, 65.
Medical Protection Society (2012), Professionalism and integrity, in MPS
Guide to Ethics: A Map for the Moral Maze, chapter 3.

3.62 Late colleague

B D F
This question relies on your ability to balance maintaining a good profes-
sional relationship with colleagues with the requirement that doctors should
be reliable and punctual. You have a duty to explore and try to rectify this
 Answers 231 •

issue as you have observed on multiple occasions a lack of punctuality in your

colleague. Option A, to ask the sister to talk to him, and option H, to write
an anonymous note, are therefore not appropriate responses as this does not
involve you personally communicating the issue to your colleague. Gathering
information from other colleagues (C) is not necessary before you take action,
although you may wish to discuss the matter with someone else in the team.
You do not know, however, whether there has been a good reason for the
lateness, and therefore your first response should be to enquire as to why he is
often late (B). As a colleague you should try to help our if you can. It would be
unprofessional to exhibit aggressive behaviour (G) in any situation. Explaining
to your colleague why his behaviour isn't professional (D) would be appropri-
ate and may help him to understand why it is important that he turns up on
time for work in the future. As mentioned earlier, you may want to get advice
from a senior, and your educational supervisor is a useful point of contact, as
in option F. However, asking your consultant to move the FYl from your team
(El is not your right and nor does it help to find the reason behind why he is
often late.

Recommended reading
General Medical Council (2013), Duties of a doctor, in Good Medical
Practice.
General Medical Council (2013), Good Medical Practice, paragraphs 22, 24,
25,36-38,43,44,59,68.
Medical Protection Society (2012), Professionalism and integrity, in MPS
Guide to Ethics: A Map for the Moral Maze, chapter 3.

3.63 Registrar responsibility

A C B E D
If you ask your registrar ro review patients you are concerned about, then they
should always review them themselves and should not simply rely on your
assessment as an FYl. This is a tricky situation since you do not want to dam-
age your professional relationship or be seen to be undermining their authority.
The best way to get the registrar to review the patients directly is by going with
them to see the patient so that you can demonstrate the areas causing your
concern (A). Discussing the matter with colleagues to see if others have had a
similar experience would be useful (C), prior to discussing with your consul-
tant (B), as it would add weight to your concerns. Taking the registrar's advice
may be the right thing to do, but ensure that it is documented in the notes that
chis advice came from a senior (E). It is important to remember though char, if
you are really concerned about patient safety, you must escalate the situation as
quickly as possible to the appropriate seniors. Option D is obviously the worst
choice; you are an FYl, and thinking that your plans are preferable to that of a
registrar is both dangerous and unprofessional as you do not have their level of
experience.
 232 Chapter 3: Effective Communication

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 39-42.
Medical Protection Society (2012), Medical Records: An MPS Guide, pp. 8-10.
Medical Protection Society (2012), Professionalism and integrity, in MPS
Guide to Ethics: A Map for the Moral Maze, chapter 3.

3.64 Gift from patient

C B D A E
It is appropriate to accept small gifts from patients as long as this cannot
be seen to have affected the way you have treated them, which needs to
be clarified in this situation (C). If you have not clarified this, it would be
best to decline the watch in order to protect yourself from any accusations
of manipulating the patient or being induced to treat them differently (B).
Option Bis also a kind and compassionate way of declining, which shouldn't
have a detrimental effect on the patient's opinion of you, as opposed to
implying that the patient is being improper (0). Option D could come
across as rude but still ranks higher than options A or E. This is because
you should refuse the gift, unless you have ensured that the patient does not
consider it a deal you made for the treatment you gave them or have any other
misconceptions. Option A fails to address these questions, while option Eis
immoral as it suggests that you do feel the gift is inappropriate but want to
accept it anyway. You should always be prepared to be open and honest about
all of your interactions with patients.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 68
and 80.
Medical Protection Society (2012), Professionalism and integrity, section:
Conflicts of interest, in MPS Guide to Ethics: A Map for the Moral Maze,
chapter 3.

3.65 Promise to family

E C A D B
One of your duties of a doctor is to provide patients and relatives with the
information that they require in a way that they can understand; however, as
a junior doctor, it is often difficult to give them adequate details due to both
time pressures on the ward and a lack of clinical experience. You have made
an agreement to go back and speak to the family, so the worst option here is
to avoid the conversation altogether and leave it to the registrar who won't be
there until the afternoon (B). The family may no longer be on the ward when
the afternoon ward round takes place, leaving them feeling completely let
down by you. However, you do not have the knowledge to fully discuss the
complexities of the situation (D), so that is also an inappropriate response.
Asking the registrar to come (A) is preferable, because the family will get an
explanation from somebody more qualified, and this will take place before
 Answers 233

the time agreed. Your registrar does not need to attend the ward immediately,
however, as this is not an emergency, and you should be able to manage an
interim conversation. Meeting with the family as agreed but explaining that
you are unable to discuss things further (C) meets your agreement to speak to
them but is likely ro come across as cold, and the family may feel that you are
intentionally withholding information from rhem. It is best to explain what
you can ro the family, with an acknowledgement of the limitation of your
experience (E).

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 14.
Medical Protection Society (2012), Professionalism and Integrity, section:
Professionalism, in MPS Guide to Ethics: A Map for the Moral Maze,
chapter 3.

3.66 Interpreter

C E A B D
The General Medical Council (GMC) states that 'you should make sure that
arrangements are made, wherever possible, to meet patients' language and
communication needs'. In this scenario, these needs are not being met. In rhe
first instance, you should do everything you can to rule out a life-threatening
cause of headache. This would be best carried out by using a professional
interpreter. This needs ro be accessed immediately using a telephone interpreter
(C). Sending the patient to the emergency department (E) is the next most
appropriate response; however, they will most likely come across rhe same
barriers of communication and need the services of an interpreter. Advising
the friend to take him ro emergency services or reattend the GP if any worry-
ing symptoms occur (A), which is otherwise known as 'safety-netting', would
normally be a good course of action, bur in this scenario, you cannot be sure
that this information would be translated effectively to the patient through his
friend. Booking a consultation with a professional interpreter present (B) would
be a good approach with a non-urgent consultation, but the delay could be
potentially life-threatening in this scenario. Option D, recording that you were
unable ro rule out a sinister cause of headache, is the least appropriate option as
this would be recording the fact that you neglected your duty to your patient.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 32.

3.67 Breaking bad news

C B D E A
This is a challenging situation as it is important to remain open and honest
with your patients whist ensuring that you are not working beyond the lim-
its of your competence. As an FYl, it is not your responsibility to break bad
news such as this as it is unlikely that you will know enough ro answer further
 234 Chapter 3: Effective Communication

questions and provide reliable information about rhe future course of action
(E). However, this is slightly more preferable than lying to a patient about the
MDT (A), which is never acceptable. You should explain that the senior doc-
tors will come and discuss the results (C) as they are better placed to do this,
and it would then be sensible to speak to one of your colleagues about when
they anticipate that they will be able to attend the ward (B). In the meantime,
it may be beneficial for the patient to voice any concerns to you in private (D),
and a chaperone is often useful in these situations. You can then ensure that
the senior doctor addresses these concerns later.

Recommended reading
General Medical Council (2013), Duties of a Doctor: Communication,
Partnership and Teamwork.
General Medical Council (2013), Good Medical Practice, paragraphs 14, 16,
31-34, 46, 49, 68.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 7.
National Council for Hospice and Specialist Palliative Care Services (2003),
Breaking Bad News Regional Guidelines.

3.68 Refusing antibiotics

B A D E C
This question highlights a situation where you may need to respect a patient's
autonomy and their right to refuse treatment, even if you disagree with it.
Asking for advice from your registrar (B) is the most appropriate option in the
first instance as it is important to ensure you have all the information ready to
present ro the patient before giving them rhe opportunity to make an informed
decision. Asking for a senior's advice would be a sensible action ro rake before
speaking to the patient yourself (A). lt is probably unnecessary to bother your
consultant ar this point if the SpR is available; therefore, option B is more
appropriate than E, however it is important to keep them informed. As always,
accurate documentation is important, and after speaking to the patient and
receiving their decision, this should be your next step (D). Administering medi-
cation that a competent adult has refused is not allowed. Despite the fact that
you may think it in their best interests, you should always maintain an open
and honest relationship with patients, and therefore option C is not appropriate.

Recommended reading
General Medical Council (2010), Treatment and Care Towards the End of Life
Good Practice in Decision Making.
General Medical Council (2013), Duties of a Doctor: Communication,
Partnership and Teamwork.
General Medical Council (2013), Good Medical Practice, paragraphs 14-17,
19,21,31,46-49,68.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 7.
4 Patient Focus

Chapter 4
PATIENT FOCUS

QUESTIONS
4.1 Ordering wrong test

You are working on a busy ward and accidentally request n chest x-ray for the
incorrect patient. You notice them returning from the radiology department
before you realise your error; therefore, the wrong patient has had the scan.
Choose the THREE most appropriate actions to take in this situation.
A Apologise to the patient and arrange a meeting with your clinical supervi-
sor to find a way to prevent this from happening again.
8 Apologise to the patient and explain your error hut do not inform your
seniors of your mistake.
C Apologise to the patient for your error, look at the x-ray and inform your
seniors of your rrusta ke.
D Fill in an incident form due to the unnecessary radiation that the patient
has been exposed ro.
E Look at the x-ray to ensure that nothing is wrong and then forget all about
the event.
F Make a comment to the nurses about how this further proves that your
registrar requests too many rests.
G Pretend that the x-ray in question has never happened and order one for the
correct patient.
H Write a false entry in the notes about the patient reporrmg a cough that
justified the x-ray.

4.2 Signing sick note

You are one of the FY l doctors on urology. It is the end of a busy shift, but
you still have some jobs to complete from the morning's ward round. A patient,
who has been admitted under a different team with suspected pyelonephritis,
approaches you for a sick note as he says his doctor said he would be allowed
to go home that evening and that this is the only obstacle delaying his
discharge.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A After looking through the patient's notes co find out \\ hat his doctor
advised regarding fitness to work, provide the patient with a note in line
with these recommendations.
 236 Chapter 4: Patient Focus

B Explain ro the patient that, because you arc not familiar with his case,
you would need to look in his notes and speak to the doctor who has been
looking after him before you would he able ro sign a sick note.
C Quickly write out and sign a sick note for the patient, asking him how long
he needs it for and the derails of his admission.
D Say that you will look into it to keep rhc patient quiet, bur hurry off co can-
nulate one of your patients who has been waiting an hour already.
E Say to the patient that you are very busy ar the moment with more press-
ing jobs for your own patients and that you do not have time to be dealing
with sick notes.

4.3 End of life care

You are an FYl working in oncology. It is Friday afternoon and the computed
tomography (Cl) scan results for one of your panenrs show mulrilcvcl bowel
obstruction from metasraric cancer. Your consultant tells you that the prognosis
is now very poor; the patient is palliative, and she needs a nasogasrric (NG) tube
as she is to be nil by mouth for the foreseeable future. When you go co insert the
NG rube, the patient asks you what this means for her future. You are aware that
your consultant is planning a meeting wirh the patient and her family rhe follow-
ing morning to discuss the progression of her disease with them.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Ask the senior house officer (SHO) to go and talk to the patient instead of
yourself.
B Decline to comment and tell the patient that she must wait for the consul-
tant to talk to her.
C Explain co the patient that you don't fully undersrand the situation but that
you know that her prognosis is now much worse than previously thought.
D Tell her that she will be fine once the NG tube is in.
E Tell the patient that she only has days to weeks to live.

4.4 Discussing optionswith patient

You are an f Y I working on a surgical ward. Your consultant calls >'OU in the
afternoon and says that he has seen test results for one of his patients. The
results indicate that they need imaging of their abdomen. Your consultant tells
you to request a computed tomography (CT) scan because this will be available
sooner than other imaging modalities, even though this involves a significant
radiation exposure.
Rank in order the following actions in response co this situation (] = Most
appropriate; 5 = Least appropriate).
A Put in a request for the CT scan as your consultant has asked.
B Call your registrar and ask them co come out of theatre co discuss the scan
with the patient.
 Questions 237

C Tell the consultant that you cannot organise the scan because they have not
discussed it with the patient.
D Discuss the benefits and risks of the scan with the patient, in addition to
the benefits and risks of doing nothing.
E Inform the patient that the consultant has asked you to organise a scan,
and put in a request for it.

4.5 Imminentcardiac arrest

You are working as an f Yl and have already stayed an hour longer than your
shift finish time, in order to complete some jobs, when a nurse asks you to see a
patient urgently. This patient is well known to you because you and your learn
have been looking after her for several weeks. She is a 54-year-old woman who
was initially admitted with severe pneumonia. The nurse tells you that "he
thinks this patient may be about to have a cardiac arrest. She says the patient
still has a pulse and is breathing.
Rank in order the following actions in response to this situation (1 = Most
=
appropriate; 5 Least appropriate).

A Ask the nurse to assess the patient and call the crash team if appropriate;
then leave the ward.
B Ask the nurse to call the on-call FYl to assess the patient; then leave the
ward.
C Ask the nurse to perform a full assessment of the pancnt including a set of
observations, while you phone a member of the on-call medical team for
help.
D Immediately assess the patient with the nurse using the ABCDE approach
and call the crash team if required.
E Start CPR (cardio-pulrnonary resuscitation) at a rate of 30 compressions to
2 breaths.

4.6 Chest drain at nighttime

You are an FY1 on a quiet medical night shift. A senior house officer (SHO)
that you are working with offer~ tu assist you in performing a chest drain in a
patient with a pleural effusion. You have never inserted a chest drain before.
The patient is currently comfortable and stable; they arc not likely to deterio-
rate during the night.
Rank in order the following actions in response to this situation ( I = Most
appropriate; 5 = Least appropriate).

A Seek learning opportunities in the daytime instead.

B Suggest that the SHO speaks to the registrar about it.
C Do the procedure as learning opportunities don't arise very often.
D Ask the SHO ro do it so you can observe.
E Say that you think it should be left to the daytime staff.
 238 Chapter 4: Patient Focus

4.7 Poor equipment

You are in the urology day case centre and are asked by your senior house offi-
cer (SI-10) ro catheterise a woman before she goes for urological investigations.
There is one private room in the day case centre, bur it does not have a curtain
that can pull across the window, and there isn't a nurse available ro chaperone.
The patient is due to go down ro the urodynamics department in 15 minutes.
=
Rank in order the follow ing actions in response to this situation (1 Most
appropriate; 5 = Least appropriate}.

A Ask your SHO to come and help you catheterise and chaperone rhe panenr
in the private room.
B Call the urodyuamics department to sec if
can delay the stud> for an
}OU

hour to allow you to safely catheterise the patient.

C Catheterise the patient in the treatment room without a chaperone, using a
towel to protect her dignity.
D Send the patient down for the tests uncarheterised.
E Take the patient across onto another ward ro catheterise her, thereby
making her late for her rest.

4.8 Nurse prescribing

You are the FYl working in vascular surgery, and one of the nurses on your
ward asks you to prescribe :1 heparin infusion for a patient who has just
returned from theatre. When you arrive, the patient has already been started
on the infusion without a prescription, and when you review the operation
notes, you realise that they don't, in fact, need it at all. The nurse in question
often decides to give patients medication without checking with the medical
team first and rhen asks you co prescribe it later.
Choose the THREE most appropriate actions to take in this situation.

A Assess the patient, stop the infusion and apologise. Ask your registrar for
advice regarding raking the incident further the next time you see them.
B Connnuc with the infusion to save the nurse's embarrassment.
C Stop the infusion and bring up safe prescribing of heparin at your next
ream meeting.
D Stop the infusion and fill out an incident form.
E Stop the infusion and inform the nurse of their error.
F Stop the infusion and tell your colleagues to avoid working with this nurse.
G Stop the infusion, apologise to the patient and detail the incident in the notes.
H Stop the infusion, inform the nurse of their error and speak to the ward
matron as well as your consultant about this incident.

4.9 Staying late

You are working on a busy surgical ward. Over the last week, you have
been struggling to get all of your work done and have been going home late.
 Questions 239

Your shift has now finished, and you are ready to leave when a nurse asks you
to prescribe some analgesia for a patient who is in severe pain.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Bleep the on-call ream to hand over the patient.
B Ignore the request.
C Leave a note in the doctor's office asking the on-call ream ro prescribe the
analgesia.
D Review the patient and prescribe the analgesia.
E Tell the nurse to ask another doctor since your shift has finished.

4.10 Faulty equipment

You arc working on a cardiology ward. A patient needs an urgent clcctrocar-

diogram (ECG), but when you go to use the machine, you find that it is broken.
Choose the THREE most appropriate actions to rake in this situation.
A Complete an incident form.
B Find another machine on a neighbouring ward and perform the ECG.
C Puc a note on the machine to indicate that it is broken.
D Put the machine hack and hope that rhe next person rouse it will sort
it out.
E Report the fault to the medical equipment department.
F Report the fault to the ward manager.
G See if you can replace the machine with one from a neighbouring ward.
H Try ro fix the machine yourself.

4.11 Child protection

You arc an FY1 working in the accident and emergency department. You see
an eight-month-old baby who has been brought in by her parents. They are
concerned that she has been having difficulty breathing. You take a history and
begin to examine the baby when you notice a large bruise across her back. You
are worried that this could be a non-accidental injury.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask the parents to explain how the baby sustained the bruise.
B Ask the parents to leave the room while you continue your examination.
C Continue to examine the baby.
D Discuss your concerns with the emergency consulcanc.
E Take a picture of rhe bruise using your phone.

4.12 Abortion

A patient who has recently undergone an abortion is admitted to your

ward. She bas developed complications follow ing the abortion and requires
 240 Chapter 4: Patient Focus

in-patient care. You arc the FY 1 responsible for her ward care. Howcv er, you
have a religious objection regarding abortion.
Rank in order the following actions in response ro this situation ( l = Most
appropriate; 5 = Least appropriate).
A Ask your FY l colleague on a neighbouring ward to take over rhe care of
the pa rient.
B Avoid the patient and provide only essenria I ca re.
C Inform the patient that you are unable to care for her because you do not
agree with abortion.
D lnform the ward manager that you are unable to care for the patient and
ask them to find another doctor to care for the patient on the ward.
E Trear the patient as you would any other patient on your ward.

4.13 Sleeping tablets dementia

You are an FY 1 working on a care of the elderly ward. The daughter of an

elderly patient with advanced dementia asks you to prescribe a sleeping tablet
for her mother for when she is discharged. She is the sole carer for her mother
and says that her mother keeps her up all rughr by Irequeruly waking up and
disturbing her sleep. She is worn out and feels that she can't cope.
Rank in order the follow ing actions in response tu this situation (1 = Most
appropriate; 5 = Least appropriate).
A Advise the daughter ro put her mother 111 a residennal home.
B Prescribe the sleeping tablet and ask the patient's GP to review the
medication.
C Refuse and advise the daughter to speak to the patient's GP about increas-
ing the patient's package of care on discharge.
D Refuse bur organise a multidisciplinary ream (MDT) assessment of the
patient during her time in hospital to assess her nighttime activity and
whether she needs any more care.
E Suggest that the daughter sees her own GP to discuss her mood and
anxiety.

4.14 Group and save

You are an FYl in general surgery. You are asked to prepare a patient for
major abdominal surgery; part of this cask is ensuring that the patient has had
a blood test (group and save) to ensure that the blood bank can readily provide
blood of the patient's blood group either during or after surgery. The patient
goes into theatre, and you realise that you forgor to send a group and save
blood rest.
Rank in order the following actions in response to this situation (1 = Most
appropriate, 5 = Least appropriate).
A Complete an incident form.
B Do nothing.
 Questions 241 •

C Inform your specialisr registrar (SpR).

D Ring the operating theatre and let them know.
E Take the blood test from the patient as soon as they leave the operating
theatre.

4.15 Disruptive intravenous drug user patient

You arc an fY l in general surgery. The nurses contact you and tell you that a
patient on the ward, who is a known intravenous drug user, is disruptive, is not
engaging with trcatrnenr and keeps leaving the ward and returning seemingly
under the influence of recreational drugs. They would like you to discharge the
patient.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Contact your registrar or consultant for advice.
B Discharge the patient from hospital care.
C Signpost the patient to drug misuse and addiction services.
D Speak to the patient about their behaviour and inform them chat if it con-
tinues then they will be discharged.
E Tell the nurses that they must continue to care for the patient.

4.16 Waiter with diarrhoea

You are an FY2 in a GP surgery, and a patient comes to see you with his
uncle. The patient works for his uncle in a fast-food rcsrauranr and has been
experiencing some diarrhoea. His uncle explains that his nephew needs a
medication called loperamide co reduce diarrhoea symptoms so that he can
work in the restaurant. You are concerned that he may have an infectious cause
of diarrhoea.
Choose the THREE most appropriate actions to take in this situation.
A Advise him nor ro take loperamide at this time.
B Advise him to keep excellent hand hygiene at work.
C Ask the patient to provide a stool sample.
D Notify the Health Protection Agency (HPA).
E Prescribe the loperamide.
F Report the restaurant ro the local newspaper.
G Tell him that he must not work until the diarrhoea has stopped for
48 hours.
H Tell him char he needs to get in touch with the occupational health
department.

4.17 Hyperkalaemia and chasing blood tests

You are working as an FY2 in a GP surgery and are completing your paper-
work at the end of the day. You are reading through your documentation of a
 242 Chapter 4: Patient Focus

consulrarion w irh a 54-ycar-old male patient with diabetes, h) perrension and

chronic kidney disease. He came to see you today for an annual review and
the results of his routine blood rests. As you are completing your writing, you
notice that you missed his serum potassium result. You check the result, and it
is 6.2 mmol/L (normal range 3.5-5.0). You know that high levels of potassium
can have serious consequences. The patient seemed well during the consulta-
tion and had no complaints.
Rank in order the Iollowing actions in response to elm) situation (I = Most
appropriate; 5 = Least appropriate).
A Ask your clinical supervisor for advice.
B Assume that the sample was haemolysed as the patient was well and didn't
have an) chest pain or palpirations.
C Book urgent repeat blood tests for the patient tomorrow with an appoint-
ment to sec you .ifrcrwards ro explain the situation.
D Check all of your other consultations for the day to see if you missed any
other i mporra nt rcsu It'-.
E Telephone the patient and ask him to attend hospital for repeat blood tests
urgently.

4.18 Responsibility between teams

You are an FYl working on a surgical ward. One of your patients) in addi-
tion to their acute surgical problem, has been reviewed by the neurology ream
as they have started a new anti-epileptic drug. You know that this drug can
have serious side effects. When you look the drug up in the British National
Formulary (BNF), you find that regular blood tests should be performed to
monitor for these side effects, starting from the second day of treatment.
Choose the THREE most appropriate actions to take in this situation.
A Add instructions for drug level monitoring ro your team's daily handover
sheer.
B Call the neurology registrar to discuss the situation and get advice from
them regarding monitoring.
C Call your registrar and ask for their advice regarding appropriate
monitoring.
D Complete a request for the blood levels to be taken the next morning.
E Cross the drug off the drug chart.
f Perform the monitoring blood test now.
G Write an entry in the notes describing the monitoring required.
H Write an entry in the notes explaining that neurology are responsible for
monitoring.

4.19 Ensuring follow up

You are an f Yl working on a medical team. One of your patients has been
discharged with a plan for follow-up tests in six weeks, which arc to he
 Questions 243

organised by their GP. You realise that you have forgotten to mention this in
the discharge letter, which has been fully authorised on the computer system
and cannot be retrieved for additions.
=
Rank in order rhe following actions in response to this siruarion (1 Most
appropriate; 'i = Least approprrarc).

A Arrange the follow-up tests yourself.

B Explain to the panenr which tests rhey need, and ask them to make an
appointment with their GP in a few weeks' rime.
C Make an out-patient appointment for the patient with your consulranr to
ensure char they receive the tests.
D Telephone rhe GP surgery, and leave a message with rhe receptionist
regarding the follow-up tests.
E Write an additional letter ro the GP detailing the follow-up tests required,
and explain to the patient that they should make an appointment with rheir
GP in a few weeks' rime.

4.20 Negligence 1

You are the FYl in colorectal surgery, and one of the patients your team is
managing has developed an abscess. As part of rhe treatment, microbiology
recommended that they should be commenced on gentamicin. They are now
on day three of their treatment. At the end of the working day, you realise that
you have forgotten to check their pre-dose level, and the next dose has already
been given. You also remember that yesterday the dose had been increased.
What should you do?
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Ask the nurse why she gave the dose before you had checked the gcnrarnicin
level.
B Call the senior house officer (SHO} on call and ask their advice.
C Explam whar has happened ro the patient, apologise and ensure that you
check their levels tomorrow.
D Ring the microbiology department and ask for their adv ice.
E Tell your registrar that you had forgotten ro check the levels and ask their
advice.

4.21 Negligence 2

You are the FYl working in general medicine, and you are called in the evening
to see a patient with suspected diabetic ketoacidosis (OKA). You have never
treated a patient with OKA on your own before, but you need to initiate
treatment while awaiting help as your specialist registrar (SpR) is currently
attending an emergency in A&E resus. You think you can remember the
management steps.
 244 Chapter 4: Patient Focus

Choose the THREE most appropriate actions ro rake in this situation.

A Ask for help from your fellow FYl on call.
B Ask the advice of the wan] matron who is present at the time.
C Assess the patient using an ABCDE approach while awaiting help.
D Call your senior house officer (SHO) for help.
E Find the trust protocol online and follow it.
F Manage the patient according ro your memory of the required treatment.
G Tell the nurses you cannot manage this patient alone and therefore will
wait for the SpR to be free.
H Use the section 111 a clinical medicine handbook on treating OKA, which
you have with you, to manage the patient appropriately.

4.22 Challenging decisions

You are an FY l working on a renal team. You receive a phone call from your
consultant who is in rhe our-patient clinic and has just reviewed a patient with
chronic kidney disease, who has been feeling unwell for a number of weeks.
He would like the patient to be admitted ro the ward following the consulta-
tion, so he has dispatched the patient to the phlebotomy department for some
routine blood tests. Half an hour later, you receive another phone call from the
clinic nurse informing you that the patient and consultant have now decided
against the admission and opted instead for a follow-up clinic appointment
in one week's time. The patient has gone home. You later review the results
of the blood tests and notice that the patient's potassium level is raised at
6.4 mmol/L.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask the on-call registrar for advice.
B Ask your educational supervisor to talk to the consultant as consultant-ro-
consultant communication mar be more appropriate in situations like this.
C Call the patient at home and tell them to come in, as their blood test results
arc abnormal.
D Do nothing; the consultant has seen the blood results, and since he is their
patient, you shouldn't change their management plan.
E Ring the consultant yourself and ask them to clarify why the patient went
home.

4.23 Breaking bad news

You are the FY l in oncology and are seeing a patient with advanced loco-
regional breast cancer. Her mosr recent computed tomography (CT) of chest,
abdomen and pelvis shows that she has extensive liver metastases, which has
not yet been communicated to her. Her consultant rings the ward and says that
he is caught up in clinic ar another hospital ,111d therefore will not be able to
come and see the patient today. He asks you to discuss with her the results of
her scan.
 Questions 245

Rank in order rhe following actions in response co this situation ll = Mosr

appropriate, 5 = Least appropriate).
A Ask the FY2 to discuss the results with rhe patient as you do nor feel com-
fortable doing so.
B Ask the oncology regisrrar on call ro discuss the results with rhe parienr as
they will have a better understanding of what the findings mean.
C Inform the patient of the results but tell her you might nor be able ro
answer her questions about what this means regarding further prognosis.
D Research the prognosis and treatments of metastatic breast cancer on the
internet and use this to discuss the scan with the patient.
E Tell the consultant that this is outside of your competencies, and you do
nor feel comfortable having this discussion with the patient.

4.24 Analgesia

\X'hen you are seeing one of your outlying patients on the surgical ward, one
of the nurses comes ro ask you to prescribe some analgesia for a patient. The
patient is not under the care of your consultant, hut the nurse insists rhar this
patient has been without analgesia all night and is in a lot of pain.
Choose the THREE most appropriate actions to take in this situation.
A Ask the nurse to bleep rhe team's FYl as you don't know the patient.
B Bicep the FYl for rhar ream and lcr them know char their patient needs
analgesia.
C Perform a thorough check of the patient's notes to sec what would he the
most appropriate analgesia to prescribe.
D Prescribe a variety of analgesics as required and ask the nurse to pick the
most appropriate.
E Prescribe paracetamol as required medicine (PRN) and ask the nurse to get
a more comprehensive plan for the patient from their team later.
F Refuse to prescribe the analgesia as this is nor your patient and you know
nothing about them.
G Review the patient and take a history about the pain to prescribe the most
appropriate analgesia.
H Suggest that if the patient needs acute pain relief, then the nurse should
refer them to the acute pain team.

4.25 MRSApatient

You are rhe FYl working on a busy surgical ward. Yesterday you admitted
a 63-year-old woman into an all-female bay; she was complaining of upper
abdominal pain and vomiting. As part of her clerking, you took some bloods,
and the nurses rook swabs from her nose and groin as per local protocol. You are
now chasing her blood results and notice that, as well as having slightly deranged
liver function, her swabs have come back as merhicillin-resisrant Staphylococcus
aureus (~lRSA) positive. You Jo nor think that the nurses arc aware of this.
 246 Chapter 4: Patient Focus

Rank in order the following actions in response to this situation (1 = Most

appropriate; 5 = Least appropriate).
A Ask one of the other nurses to inform the ward sister about the i\llRSA
results as you need to contact your senior about the abnormal blood
results.
B Contact your registrar to let them know that the patient is MRSA positive
and find our what steps you should take next.
C Explain to the patient the results of the MRSA screen and let them know
that they will have to be moved into a side room.
D Immediately inform the sister on the ward of the results so that the patient
can be barrier-nursed in a side room.
E Put a plan in place regarding the deranged liver function rests (LFTs) and
let the nurses dea I with the MRSA screen as this is part of their job.

4.26 Arranging follow up

You are the FY I working on breast surgery. One of your patients is about to
be discharged after a wide local excision for a ductal carcinoma in situ. You
dunk that you remember your consultant menriorung on the warc.l round that
the patient will need a follow-up appointment in his clinic. Your colleague
completed the discharge letter for this patient, but you notice that no follow-up
arrangements have been documented.
Choose the THREE most appropriate actions ro rake in this situation.
A Ask the patient what follow-up arrangements she needs and document this
instead.
B Change the discharge letter yourself so that a clinic appointment is
arranged for the patient.
C Discuss the matter with your colleague and make sure that the details
for follow-up on the discharge letter reflect their understanding of the
situation.
D Discuss with your colleague your concerns about the follow-up
arra ngcrncnts.
E Don't voice your concerns as arrangements for this patient's discharge were
not your responsibility.
F Look in the patient's notes to double-check what the consultant said on the
ward round.
G Speak to the consultant to reiterate what follow-up arrangements the
patient needs.
H Tell your colleague to change the discharge letter as you think the consul-
tant said that the patient needed a follow-up appointment.

4.27 Antibioticguidelines

You are the FYl on a general surgical ward and are called to see a patient who
is spiking a tempera tu re of 37. 9 degrees Celsius. After assessing the patient
 Questions 247

using an ABCDE approach, you find that she is also tachypnoeic and tachy-
cardic, has oxygen saturations of 92% on air and crackles localised to the right
lung base. You suspect a hospital-acquired pneumonia and want to start anti-
biotics alongside further tests. However, the local treatment policy has recently
changed, and you can't remember rhc recommended ernpirica I treatment.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Access the local clinical guidelines on rhe inrraner and start empirical treat-
ment as recommended.
B Ask your specialist registrar (SpR) what the empirical treatment is and
prescribe according to their advice.
C Look in the Oxford Handbook of Clinical Medicine for the treatment of
pneumonia and prescribe what it suggests.
D Prescribe treatment as per the old guidelines and inform the nursing staff co
increase their frequency of observations as you will check later.
E Withhold treatment and ask the nurse co speak to microbiology for their
advice.

4.28 ABGcompetence

You arc watching your FY2 colleague rah an arterial blood gas (ABG) sample.
After a sample is collected, they leave immediately to process the sample with-
out purring pressure over the artery as per standard procedure.
Choose the THREE most appropriate actions to take in this situation.
A Ask one of the nurses co put pressure on the area.
B Ask the patient to put pressure on the area.
C Ask your FY2 colleague to come hack to put pressure on the area.
D Follow the FY2 to learn how co use the ABG analyser.
E Put pressure on the area yourself.
F Reflect on this scenario in your e-portfolio.
G Speak to the FY2's educational supervisor regarding retraining on ABG
sampling for them.
H Write in the patient's notes the incorrect way the FY2 took the sample.

4.29 Keeping up to date

You are the FY1 working for a consultant in cardiology. You have starred to
notice that, on the ward rounds, your consultant is not using the most recent
guidelines while making decisions about the management of heart failure or
hypertension. As a consequence of this, you are worried that their patients are
not receiving the best quality of care.
Rank in order the following actions in response to this situation (1 = Most
appropriate; S = Least appropriate).
A Ask your consultant to explain the management of these conditions to you
and U5C this reaching session to ask questions abour the new guidelines.
 248 Chapter 4: Patient Focus

B Discuss the matter with your senior house officer (SHO) as they arc more
experienced than you.
C Do nothing a<; you are the FYl and your consulranr probably has good
reasons for managing their patients in the way they are.
D Raise the matter with your educational supervisor at your next meeting.
E Using your knowledge of the guidelines, prescribe medications as recom-
mended instead of following your consultant's management plan.

4.30 Clinical skills

While working as an fYl on the admissions unit, you see a male patient in
acute urinary retention. After performing your baseline examination and inves-
tigations, your management plan includes catheterising the patient. You have
only performed this procedure once before as a medical student, over a year
ago, and do not feel fully confidenr performing the procedure; however, none
of the nurses on the ward are trained in male catheterisarion.
Rank in order the following actions in response to rim siruanon (1 = Most
appropriate; 5 = Least appropriate).
A Ask a member of the nursing staff to come with you to chaperone and ask
her to let you know if you start to do anything she thinks is wrong.
B Ask your senior house officer (SHO) to catheterise the patient bur go along
to chaperone and watch closely to revise the procedure.
C Ask your SHO to supervise you performing the procedure so that you feel
confident in the future.
D Call the continence nurse specialist and ask them to catheterise the patient.
E Contact the clinical skills department and arrange a revision course on
male catheterisation.

4.31 Incident reporting

During a medical on-call shift, you are called to see an elderly man who has
become increasingly unwell. When you assess him, you realise that he was
seen yesterday and started on antibiotics for pneumonia. However, when
looking at the drug chart, you see that he has not yet received any doses
of this. The doses are charred as 'drug not available'. When you ask the
nurse responsible for the patient, she tells you that the antibiotic was not
available on the ward, and the staff have been coo busy to order it from the
pharmacy. You know that the patient is deteriorating because he needs the
antibiotics.
Choose the THREE most appropriate actions to take in this situation.
A Ask the nurse to source a dose of antibiotic from another ward.
B Ask the senior house officer (SHO) to review the patient.
C Call the on-call pharmacist and ask them to provide a dose of antibiotics
immediately.
D Complete an incident form.
 Questions 249

E Prescribe the second line antibiotic for pneumonia, which is readily avail-
able on the ward.
r Report the incident to the consultant responsible for the patient.
G Report the incident to the ward manager.
11 Tell the nurse that she has endangered rhc patient hr nor ensuring char the
patient received the antibiotics.

4.32 Patient handover

You are the FY 1 doctor working on a busy general .,urger} ward, anc.l you
have starred to address your tasks following the morning ward round. You
are working quickly because you want to leave on rime char evening ro attend
a friend's birthday party. Ten minutes before you arc c.luc co leave, one of rhc
nurses asks you to assess a patient who has just fallen our of bed. She says
chat they didn't hit their head, but they arc complaining of new pam in their
right hip.
Rank in order the following actions in response to rhis situation (1 = Most
appropriate; 5 = Least appropriate).

A Assess the patient using an ABCDE approach and ask the evening team to
arrange any further investigations so that you can get to your social func-
tion on rime.
B Assess the patient using an ABCDE approach, arrange any necessary invcs-
ngarions and ensure that the evening ream arc aware of the neec.l ro chase
the results.
C Ask the nurse to put iron rhe handover board for the evening ream to be
aware of.
D Ask the nurse to arrange an x-ray of the right hip and put it on the
handover board for the evening ream to chase.
E Assess the patient using an ABCDE approach, arrange x-rays and an ECG
and wait for the results to come back before leaving rhe hospital.

4.33 Non-accidental injury

You arc working as an FY2 doctor in the emergency department of a children's

hospital. You sec Maisie, a six-month-old girl who has severe burns ro her feet
and ankles. You ask her mother how Maisie sustained her burns. She says she
was giving her a bath and didn't realise char rhe water was so hot. Maisie has
three sisters at home all under the age of ten. You are concerned this could be a
non-accidental injury.
Choose the THREE most appropriate actions to rake in this situation.

A Ask your senior registrar co rake over the case.

B Document that }'OU arc concerned about non-accidental injury hut don't
inform Maisie's mum because it may have been a genuine accident.
C inform Maisie's mum rhar, because of rhe nature of Maisie's injuries, you
will need ro discuss the case with rhe child protection ream.
 250 Chapter 4: Patient Focus

D Inform Maisie's mum that she is likely to lose access to her children.
E Inform the consultant in charge of the emergency department of your
concerns.
F Take a full history, perform a full examinarion of Maisie and start relevant
treatment.
G Telephone the police and ask them to check the temperature of the hoc
water in Maisie's house.
I I Telephone the police and inform them that several children arc at risk of
child abuse.

4.34 GP treatment final

On an FY l GP taster day, you are sitting in with a GP whom you have not mer
before. Throughout the clinic you notice that they don't fully discuss treat-
ment options with an} of their pancnrs, and most patients seem to leave quire
dissarisficd. You ask the GP,, hcrhcr he thinks that his parientv arc compliant
with rheir medrcanons, ro \\ luch he replies that nil of his patients are compliant
since they trust his judgement as a clinician. You find this a little unsettling.
Rank in order rhe following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Bring up the topic at lunchtime 111 the staff room so that you can discuss it
with other members of the practice staff in a non-threatening environment.
B Find one of the other GPs and sir in with them for rhe rest of the week as
.
vou feel that chis wav' .vou will learn more.
C lgnore the situation - at the end of the week you will no longer be working
at the practice.
D Suggest to the GP that he furrher discusses treatment options with his patients
and make a comment about how this could lead to increased compliance.
E When you finish for the day find the practice manager and suggest ro chem
that this should be raised in their next practice meeting.

4.35 Consentfor blood test

You are an FY 1 working on a care of the elderly firm. Mrs Jones, a frail,
elderly lady with known Alzheimer's disease, hypertension and atrial fibrilla-
tion, is admitted to your ward following routine monitoring by her GP of her
international normalised ratio (lNR), which was shown to be dramatically
raised. On admission she is disorientated, agitated and is wandering around the
ward. She is very unsteady on her feet, and therapy services have been unable
to find a zimmer frame for her at present. You need to rake a repeat INR, hut
she is refusing to let you take the blood sample.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask one of the nursing staff to help you return her to her bed and calm her
down so that you can take the sample.
 Questions 251

B Explain to Mrs Jones the reasons why you need to repeat the sample,
including the potential consequences of not doing so before proceeding to
rake the blood even if she still declines.
C Ask your registrar for advice and to help you assess her capacity to refuse
the blood sample.
D Leave it: you have yesterday's result from the GP so you can try to repeat
rhc sample tomorrow when she is more settled.
E Wair for a couple of hours for Mrs Jones to become more orientated to the
ward before talking to her again about raking the sample.

4.36 Jehovah's Witness

A patient you arc caring for is a jehovah's Wirness. They inform )'OU in
advance of their abdominal aortic aneurysm repair thar they do nor want to
receive blood products during the operation and that, if they bleed, they would
prefer to die naturally.
Choose the THREE most appropriate actions to rake in this situation.
A Advise the patient against surgery due to the high risk of bleeding.
B Ask the patient to contact their lawyer ro draft an advanced directive.
C Ask the patient ro fill our a refusal of blood products form.
D Ask the patient to make a donation towards the use of inrraopcrative
blood-saving machines.
E Ensure the theatre staff and the anaesthetic team are aware of this.
F Ignore the patient's statement: they might never know they've been admin-
istered blood products.
G Inform the patient's consultant of their wishes.
lI Write a message in the patient's medical norcs derailing their wishes.

4.37 Advanced directive

A patient on your ward has advanced motor neurone disease and develops
aspiration pneumonia. He has an advanced directive signed by himself, his
lawyer and his wife stating that if he becomes too unwell to swallow and aspi-
rate, he docs nor want to be rrcarcd with antibiotics. His wife tells you chat she
has changed her mind and wants you to actively treat him with antibiotics.
Rank in order the following actions in response co chis situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask your registrar ro come and speak with the patient's wife about the
advanced directive.
B Call the patient's lawyer to check rhe status and legality of the advanced
directive.
C Console the patient's wife, explaining that you cannot go against his
advanced wishes.
D Ger medico-legal advice from your medical malpractice insurer.
E Treat your patient with antibiotics.
 252 Chapter 4: Patient Focus

4.38 Refusal of treatment

An elderly patient on your ward has been recovering well following abdominal
surgery. I lowcver, she subsequently goes on to develop a severe hospital-
acquired pneumonia. While she appears ro be improving with antibiotics, she
still requires oxygcn v ia a face mask in order to maintain her saturations. You
are called to sec her because she is now refusing to keep the mask on her face,
and her saturations have become dangerously low. You explain that without the
oxygen she mar die but she continues to refuse, telling you that she wants to die.
Choose the THREE most appropriate actions to take in this situation.
A Ask your registrar to come and re, icw the patient.
B Ask ) our registrar to complete a 'do nor attempt cardiopulmonary
resuscitation' (DNACPR) form urgently.
C Assess the paricnr's capacity ro make a decision about receiving the oxygen.
D Call the crash ream.
[ Call your consultant to discuss rhe situation.
I- Contact the on-call psychiatrist for advice.
G Respect the patient's wishes and leave the oxygen off.
H Sedate rhe patient and replace the face mask.

4.39 Capacity

You arc working on a care of the elderly ward. One of your patients needs
a colonoscopy to investigate anaemia. On the ward round earlier, your
consultant had explained the procedure to the patient and asked her to sign
a consent form. Later, you are talking to the patient, and she begins to ask
you questions about the colonoscopy. She has clearly not understood or
remembered what was cxplamcd ro her earlier.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask the nursing staff whether the patient is more forgetful or confused
than she has been previously.
B Assess the patient's capacity to make the decision about whether or not to
have the colonoscopy.
C Call endoscopy and cancel the colonoscopy.
D Explain the procedure again to the patient and continue planning for the
colonoscopy.
E Inform your consultant that the patient has not understood or remembered
his explanation.

4.40 Patient unsafe at home

You are an I'Yl working on a diabetes and endocrine ward. One of your
patients has been admitted several rimes due to recurrent falls at home. He is
medically fit for discharge, but occupational therapists and physiotherapists
 Questions 253

have completed assessments which conclude that he is unsafe at home.

The patient, however, is adamant that he wants to return home.
Rank in order the following actions in response to this situation ( 1 = Most
appropriate; 5 = Least appropriate).
A Ask a psychiatrisr to assess the panenrs capaciry,
B Ask the patient's family their opinion about how he will function at home.
C Assess the patient's capacity to make the decision.
D Reduce the patient's risks of falls at home by introducing home aids and
implementing home care.
E Tell the patient char he is unable to return home as he is unsafe.

4.41 Family disagreement

You are an fYl on a care of the elderly ward. A patient wishes to he dis-
charged to her home after recovering from a urinary tract infection (UTI) that
required hospital admission. She has been seen hy occupational therapists and
physiotherapists, who have found her to be safe to be discharged home. Her
son and daughter, however, want her ro go into a nursing home as they believe
she cannot cope at home.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Advise the family that it is nor their decision.
B Advise the family char they should discuss this with your consultant.
C Inform the patient that it is best if they go into nursing care.
D Inform the therapy ream of the fa mil) 's concerns and ask them rf they wish
to carry our further assessments.
E Organise a family meeting with the rnultidisciplinary ream (MDT), with
the permission of the patient, to discuss her discharge destination.

4.42 Dementia and capacity

You are an FY I on a care of the elderly ward looking after a number of sick
patients. During a ward round, your ream decides that a patient under your
care will require a nasogasrric (NG) tube as she is not able to maintain suf-
ficient nutrition orally. The patient in question has a known diagnosis of
Alzheimer's dementia and is often confused on the ward. She has had multiple
NG rubes in the past, which she removed each time by herself. She provided
consent for the previous rubes, which you find documented in the notes. You
gather the equipment required tor the procedure and approach the patient's
bedside. As you approach, the patient says she will not have the feeding tube
because it 'feels horrible' as it is inserted.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Discuss the situation with her family and your consultant and insert the
tube if it is deemed to be in her best interests.
 254 Chapter 4: Patient Focus

B Insert rhe NG rube as she lacks capacity because of her diagnosis of dementia.
C Request a psychiatric review of the patient as she has refused feeding.
f) Return the equipment ro the store, not completing the procedure, and
document her refusal in the notes.
E Undertake a capacity assessment of the patient using clear and concise
information.

4.43 Depression and capacity

You an: the FYl on a ca rdiology ward .. \n elderly patient has been admitted
for the treatment of a probable myocardial infarction. He was brought co
hospital hy hie; daughter, who found him breathless and pale at home. He tells
you char he does nor want any further investigations as he has no interest in
life and wants to die. His daughter confirms that for the past few months, he
has been very low in mood, difficult to engage in conversation, with a poor
appetite and poor sleep.
Choose rhe THREE most appropriate actions to take in this siruarion.
A Ask the patient's daughter to speak ro him and encourage him ro accept
trearrnenr.
B Bleep your regisrra r.
C Conduct a full mental stare examination and assess his capacity to make
this decision.
D Make a referral ro liaison psychiatry.
E Start treatment with an anti-depressant.
F Tell the patient char you cannot help them ro end their life, and they there-
fore must accept the recommended rests and treatment.
G Use the Mental Capacity Act to proceed with an investigation.
H Use the Mcneal Health Act co proceed with an investigation.

4.44 Delirium and consent to investigation

You arc the FY I on a general medical ward. A patient with known dementia
has become more unwell. She is rousable but very drowsy and nor commu-
nicating at all. Normally, she is confused and agitated bur can answer basic
questions. Her oxygen saturations have dropped ro 80% on room air. Your
registrar asks you to perform an arterial blood gas (ABG) sample.
Choose the THREE most appropriate actions to take m this situation.
A Ask a nurse ro assist you by holding the patient's arm in position.
B Call rhe patient's next of kin and ask for their consent.
C Delay until later ro see if the patient becomes communicative.
D Document in rhe notes chat rhe patient did nor have capacity ro consent to
this procedure at the time.
E Document in the notes that the patient docs not have capacity to make
decisions.
F Starr the procedure hur stop if the patient becomes distressed/resists.
 Questions 255

G Talk ro the panenr and explain what you are doing throughout che
procedure.
I l Tell your registrar you cannot perform the test as the patient cannot
consent.

4.45 Child autonomy

You arc the fYl working on a paediarric ward. You have been asked to cake
blood from a 14-year-old boy to monitor his condition. When you go to speak
to him, he says that he does not want to have the blood rest because he is fed
up of needles. His mother is in the room and tells you that he is being silly and
you should go ahead.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Attempt to carry out the blood test but stop if he physically resists.
B Call your registrar and ask them to take over dealing with the situation.
C Do nor attempt the blood rest and document in the notes char the patient
refused.
D Explain to the boy why the blood test is important, but if he is definite that
he doesn't want it, do not attempt to take it.
£ Take several nurses with you to hold his arm still while you take the blood.

4.46 Withholding treatment

After finishing the ward round, one of your jobs is ro cannula re a patient who
needs intravenous (IV) antibiotics and fluids. However, as you tell her that
you have come to insert the cannula. she cells you that she docs nor want the
cannula or the antibiotics as she docs not wish co live anymore. She had been
reluctant to say this to the consultant as everyone has been so nice since she
was admitted. She asks if you could nor mention this to the consultant and just
not prescribe the antibiotics.
Choose the THREE most appropriate actions to take in this situation.
A Ask the patient if you can place the cannula and only give her the fluids to
keep her comfortable.
B Assess the patient using the Mental Capacity Act to see if she has the
capacity to make such a decision.
C Explain to the patient that you are just the FYl following the consultant's
orders. and you will have ro place rhe cannula.
D Refer the patient to rhe psychiatry team as she may be depressed.
E Tell the patient that it would be best if you ring the consultant to ask him
to come back and talk to her, and ask her if she would agree co this.
F Treat the patient under section 2 of the Mental Health Act.
G Try and find out her reasons for not wanting to live to see if there is some-
thing you can do to help.
H Use the principle of best interests co treat the patient with antibiotics.
 256 Chapter 4: Patient Focus

4.47 Questioning consent

While working an on-call shift on the surgical admissions unit, you attend
with the registrar to consent a patient for surgery. During the consent proce-
dure, your registrar doesn't mention some of the risks you think are associated
with the procedure. The pancnr signs the consent form and is due to go to
theatre later that evening.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask the: registrar, while still with the patient, about the risks you were
thinking of, in case they have slipped his mind.
B Assume that you do nor know the risks for the procedure and that the
registrar has correcdy consented the patient.
C Revise the risks of the procedure when you finish your shift ro learn them
for next time.
D Stay with the patient once the registrar has left to mention the further risks
that you think you have identified.
E Wait until you have left the patient's bedside, and then question the regis-
rra r about the risks of the procedure and suggest i h ..ir they go hack to the
patient, if indeed there are risks that have not been mentioned.

4.48 Consultant decisions

While on the surgical ward round, your consulranr is miking to a patient about
surgical management for a herniated lumbar disc. The patient asks about
acupuncture as an alternative to surgery for pain relief. They arc concerned
about surgery as a friend of theirs recently had a similar procedure and was left
with little change in their pain but experienced post-operative complications.
The patient would therefore rather avoid surgery if possible. Your consultant,
however, disregards their views saying that holistic treatments aren't effective
and will only make things worse for the patienr in the long rerm. He does not
offer any non-operative methods of treatment.
Rank in order the follow ing actions in response ro this situation (l = Most
appropriate; 5 = Least appropriate).
A Ask your consultant, after the ward round, co explain the use of alternative
treatments in cases such as this so that you can learn more about when they
should he recommended.
B Follow the consultant's plan; he is experienced and will know when treat-
ments are and are nor indicated.
C Give the patient an information leaflet regarding alternative treatment
options to read through on their own.
D Recommend to the patient that they make a complaint about their treat-
ment if they are dissatisfied with the options offered to them.
[ Talk co the consultant and suggest that rhe patient would benefit from some
further explanation as co why he feels that surgical management is prefer-
able to conservative management.
 Questions 257

4.49 Consent for children

You are working in the paediatric surgery department when you are called
to see a 15-year-old girl who was admitted for observation the previous day
with suspected early appendicitis. In the lase few hours, the nurses feel that she
has deteriorated, and you are worried that she may need ro go ro theatre. The
surgical registrar comes to review the patient and also decides that this may be
the case; however, on trymg co contact both of her parents, neither of chem are
answering their phones. Meanwhile, the patient is becoming tachycardic and
h> pocensive. The registrar feels that she needs to go to theatre immediately.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Call the patient's grandmother so chat she can give consent in the absence
of being able co contact the parents.
B Consent the patient herself as long as she has the ability to understand and
rerain the information you give ro her.
C Delay the operation as, without her parents' consent, the procedure cannot
go ahead.
D Use the principle of best interests so that your patient can be taken to the-
atre without consent.
E Write in the notes that you have unsuccessfully tried to contact the parents
and therefore the procedure cannot go ahead because you have been unable
co gain consent for it.

4.50 Coercion

You are the FYl working on a care of the elderly firm. One of your patients,
Edith, a 77-year-old woman with sub-acute bowel obstruction, asks you to
talk through her treatment options with her and her daughter-in-law. During
the consultation, the daughter-in-law does not let Edith do any of the talking.
She tells you chat she has been researching the options online and has already
talked to Edith about her options, and they have decided together that ~urgery
is the best treatment choice for her. You, however, disagree with this in view
of Edith's co-morbidities. You are worried rhar Edith i-; being coerced hr her
daughter-in-law since surgery would result in a quicker outcome but would
involve much greater risk.
Choose the THREE most appropriate actions ro take in this situation.

A Don't worry about this; as you are nor consenting Edith for theatre, it
doesn't concern you. The consultant will make the final decision.
B Explain the risks of surgical intervention and the benefits of non-operative
intervention in order to highlight that non-operative intervention would be
a better choice.
C Explain to the daughter-in-law chat she will need t0 talk to the consultant
before any treatment can be decided as they will be performing the treat-
ment and therefore must help make rhc decision.
 258 Chapter 4: Patient Focus

D Once her daughter-in-law has left, ask Edith again what her thoughts on
the situation are.
F Remind the daughter-in-law char, since she is nor Edith's next of kin, she
does not have any say in the matter, and you will not discuss it further
with her.
F State that, as the FY l , you don't fully understand the treatment options
and therefore are unable to offer advice; you can simply list the options.
G Tell the <laughter-in-law that, as Edith has ro sign the consent form, you
need to hear her opinions.
11 Tell the daughter-in-law that she is not thinking in Edith's best interests
and should not help her make the decision.

4.51 Ectopic pregnancy

You are the FY I working in the emergency department and see a 15-year-old
girl who has presented with severe right-sided abdominal pain. While tak-
ing the history, she reveals that she has had unprotected sexual intercourse
with her boyfriend, and chis morning, she noticed some vaginal bleeding and
discharge. You explain ro the patient that an ectopic pregnancy needs to be
excluded and ask her whether she would Jike you to ring her parents. She
flatly refuses saying char 'they would kick me our' if they found our she was
pregnant.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask the sister on rhc ward ro come with you ro have a longer talk with her
about why she doesn't wane her parents to know.
B Discuss the situation with your clinical supervisor.
C Keep the information confidential as you feel char the girl is competent ro
make chis decision.
D Phone her parents anyway and ask chem to come in and have a char
with you.
E Ref use to give her any more treatment until she agrees that you can tele-
phone her parents.

4.52 Coercion

A 75-year-old male patient on your ward has metastatic lung cancer. He has
been informed of the diagnosis and agrees chat the risks of an operation are nor
outweighed by the potential benefits. It is now the following day, and his son is
visiting the ward. He asks why you are doing nothing for his father, exclaim-
ing char 'he's very forgetful, he doesn't know what is best for him. He needs
the surgery and you are killing him without it.' When you go to see the patient
before the end of your shift, he says chat he wants you to arrange surgery for
him as he isn't ready to die.
 Questions 259

Rank in order the following acnons 111 response ro this situation tl = Most
appropriate; 5 = Least appropriate).
A Ask one of the nurses to come with you and talk to the son in a place of
privacy.
B Discuss with the patient why he has now changed his mind.
C Explain again to the patient why surgery wouldn't be in his best interests
but Sa) that you will ask your consultant to come and discuss it with him
at the earliest opportunity.
D Speak to your specialist registrar (SpR) about what the patient is now
saying and ask them to come with you to discuss the reasons behind his
change of decision.
E Tell the son that it would probably be best if he didn't visit his father, if he
is going to cause trouble.

4.53 Terminal diagnosis

An elderly woman has been admitted with jaundice, and investigations have
revealed that she has terminal cancer. She is profoundly deaf and finds it dif-
ficult to keep up with conversations. She has therefore given permission for her
family to be rold everything about her condition and treatment so that they
can help m explaining It to her. Her family have now been told of her terrruna l
diagnosis; however, they have asked that the patient not be told. They want to
break the news to her once she is back at home because they chink chat she is
going to be very upset and would prefer to be in a familiar environment. You
feel uncomfortable that the patient has no idea of her terminal diagnosis.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask your consultant for advice.
B Encourage the family to explain the terminal diagnosis to the patient as
soon as possible.
C Explain the terminal diagnosis to the patient.
D Let the family inform the patient of her diagnosis in their own rime.
E Tell the family that you will inform the patient of her diagnosis if they
do nor.

4.54 Cancer diagnosis disclosure

While working as an FYl in general surgery. you are approached by a patient

who is due to go for flexible sigmoidoscopy to investigate his rectal bleeding.
The patient does not want his family to know if the results show that he has
cancer as he does not want to distress them. You subsequently learn that the
patient has a rectal tumour, and the patient opts for a conservative, non-
curative approach. You arc then approached by his wife, who asks you what
the results are.
 260 Chapter 4: Patient Focus

Rank in order the following actions in response to this situation (1 = Most

appropriate; 5 = Least appropriate).
A Advise the patient's wife to discuss this with the consultant looking after
her husband.
B Advise the patient's wife to talk to her husband about it.
C Inform the patient's wife that you cannot disclose the information.
D Talk to the patient and advise him to tell his wife.
E Tell the patient's wife the diagnosis.

4.55 Relative phones ward

You arc the FY 1 working on a surgical w ard. You answer the ward telephone
because you're waiting for your registrar ro respond to their bleep. The caller
says that they are a patient's mother and asks you whether he is on this ward
and how he is doing. The patienr is a young man admitted after an accident at
work. There are no concerns about his capacity or independence.
Rank in order the following actions in response co this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask the caller ro hold, mute the phone and pass it over to the nurse in
charge.
B Ask the caller co hold while you go and speak to the patient and ask him
whether he is happy for you to speak to his mother.
C Confirm chat the patient is on the ward, reassure her chat he rs doing well
and give details of visiting hours.
D Explain politely that you cannot discuss the details of how the patient is
doing over the phone.
F. Tell the caller chat you're waiting for a call on this line, apologise and
hang up.

4.56 Giving information to relatives

You arc the FY1 on a respiratory team. One of your patients has recently been
diagnosed with lung cancer. The patient knows his diagnosis. The prognosis is
poor, and he is likely ro need a lot of care at home. During visiting hours, his
daughters approach you. They are very upset that he is still so unwell and want
to know whar is happening and why he doesn't seem to be getting better.
Choose rhe THREE most appropriate actions to take in this situation.
A Call your registrar and ask them to come explain the diagnosis ro the
daughters.
B Carefully break rhe news ro the daughters that their father has cancer.
C Explain that they will need to provide a lot of care for their father when he
leaves hospital.
D Explain co the daughters char you cannot give them information about a
patient's clinical condition unless the patient has given their permission.
E Give them a leaflet about local support groups for carers.
 Questions 261 •

1- Listen attentively to the daughters' concerns.

G Refuse to discuss the situation with them and tell them to ask their father
for information.
H Talk to the patient later that day and discuss his feelings about involving
his daughters.

4.57 Safeguarding

You are the FYl working on a busy gastroenterology ward and have a
25-ycar-old patient with learning difficulties, who has been admitted with
recurrent episodes of haematemesis. While clerking her in, you note that she
is ver y underweight, and the nurse mentions to you that her clothes were
very dirty and smelly. She still lives at home, and in the past, there have been
numerous involvements with social services, who have been concerned that her
parents are nor looking after her properly.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask the nurse in charge to ralk ro the patient.
B Call her parents and ask them to come in and have a chat with you about
her weight.
C Discuss with your clinical supervisor what action you should take, if any.
D Speak to social services about your concerns.
I: Take a nurse with you and speak to the patient about your concerns, giving
them an opportunity to say anything in confidence.

4.58 STI testing

You are working in the emergency deparrmenr when a 14-year-old boy comes
in with right-sided scrotal pain and swelling. Following your history and
examination, you suspect epididyrno-orchins, and you therefore need to ask a
sexual history and perform a screen for sexually transmitted infections (STls).
The patient has come in 'with his mother, who is very concerned for her son
and doesn't seem to want to leave him alone.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
,\ Ask his mother to go home to gee your patient some py jarnas as he is likely
to stay in hospital. Once she is gone take rhe sexual history.
B As your patient is only 14, examine him with his mother in the room
because legally she has to consent ro this.
C Send a urine sample having told your patient that it is to look for a urine
infection, and wait for the results before discussing a sexual history.
D Tell his mother that you need to ask some sensitive questions and it would
be better if she waited outside.
E Wait until your registrar has reviewed your patient and then let them make
the decision abour w hether or nor to carry our an STI screening.
 262 Chapter 4: Patient Focus

4.59 Mental health consent

You are on a rotation in psychiatry and have a psychiatry in-patient who also
has a diagnosis of lymphoma. They confide in you that they would like to stop
having active treatment for the lymphoma as iris making them feel too unwell.
1 hey arc currently under a rncnra l health section in order to be treated for their
schizophrenia.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Continue to give them mcdicanon for the lymphoma without their conscnr
as they are under mental health section and therefore you don't need their
consent.
B Stop giving them the treatment for lymphoma.
C Ask rhem to consider speaking to their haematologist a hour other options
before withdrawing treatment altogether.
D Assume that the patient must want to end their life and move them to an
increased security ward.
E Speak co your registrar about the situation.

4.60 Inappropriate images on laptop

You are an FY 1 doctor working on a busy hepatology ward and decide ro take
a break in the doctors' mess. Upon entering the mess, you find vour colleague
looking at indecent images of children on the internet. After noticing that you
have entered the room, your colleague closes the laptop and asks you not ro
tell anyone. He goes on to explain that he was researching for a presentation
on child abuse. He asks you not ro inform anyone about what you have seen
because it could be misinrcrprcted and embarrassing.
Choose the THREE most appropriate actions to take in this situation.

A Agree with your colleague and wait co see the presentation.

B Directly telephone the police and report ro them what you saw.
C Explain ro your colleague that he needs to inform his clinical supervisor
and if he does not you will have to.
D Inform the General Medical Council (GMC) of what you saw and ask for
advice.
E Inform your clinical supervisor of what you saw and ask for help with the
situation.
F Interrogate your colleague about the presentation and investigate whether
he has ever been involved m child abuse.
G Investigate whether your colleague will be working with children in the
future and rake no furrher action if he is nor.
H Offer to help your colleague with his presentation.
 Questions 263

4.61 Wrong site surgery

You are an FYI doctor, and you have been asked to assist in orthopaedic
theatres with your consultant and registrar. The next patient on the operating
list is a woman whom you have examined several rimes before. She is com-
ing to theatre for a total hip replacement. The consultant surgeon is about to
make the first incision when you realise that he is approaching the left hip.
You remember that when you examined the patient she had only complained
of problems with the right hip. Furthermore, you remember reading the pre-
operative notes documenting that the right hip is to be replaced.
Choose the THREE most appropriate actions to rake in this situation.
A Ask the consultant to operate on the right hip as you are sure that was the
one that had been troubling the patient.
B Ask the consultant to stop and discuss the issue before proceeding.
C Ask the nurse in charge to check the patient's notes.
D Ask to see the pre-operative assessment notes ro check which side should be
operated upon.
E Ask your consultant to re-examine the patient and review the X-ray images
before proceeding.
F Assume the consultant has re-examined the patient and allow him to
continue.
G Inform the specialist registrar (SpR} of your concerns.
H Inform the whole theatre staff by saying, firmly, that you have concerns
over which hip is to be operated upon and that the operation should be
stopped.

4.62 Chaperones

You are on call for colorectal surgery, and it is a particularly busy evening.
There are no nurses available to chaperone for you while you do a digital
rectal examination (DRE) on a patient presenting with constipation. The
patient says that they are happy for you to examine them and don't require a
chaperone.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate}.
A Await one of the nurses ro be free ro chaperone.
B Decline to perform the examination until someone is available to
chaperone.
C Perform the examination, documenting that the patient is happy for you to
proceed without a chaperone.
D See if a relative can come and chaperone for rhe patient instead.
E Document in the notes that you could not perform a DRE.
 264 Chapter 4: Patient Focus

4.63 End-of-life HW

You are working in the acute admissions unit (AAU), and one of the registrars
takes you with them so you can see how they discuss putting the end of life
care tool into place with patients. After the consultation, you are unsure that
the pancnt fully understood what the registrar was saying about rhc fact that
they are entering the final stages of their illness. The registrar begins to pre-
scribe the appropriate prc-crnptiv c medicines and inform the staff about the
decision. You have not met this patient before.
Rank in order the following actions in response ro this situation (1 = Most
appropriate; 5 = Least appropriate).

A Ask the nurse cu go bad. and full> explain things co the patient.
B Ask the registrar to go back and explain clearly to the patient that their
disease is likely ro lead ro death in the near future.
C Ask the registrar what they thought the patient understood by their
discussion.
D Go back into the room alone and explain to the patient again exactly what
is happening.
E Leave things as they are: the registrar rs more experienced than you at this.

4.64 Chaperone declined

You arc the FYl working on a medical ward. One of your patients is consti-
pated and needs a rectal examination for assessment of this. The patient has
the necessary mental capacity ro give consent to the examination. It is visiting
hours, and the patient has a relative present when you go to see them. You offer
for a chaperone to be present but the patient declines, saying that they will not
allow you to proceed with the exarnmarion with any additional people in the
room as they feel too embarrassed.
Choose the THREE most appropriate actions to rake in this situation.
A Agree to examine the patient alone.
B Ask a nurse to remain in the room.
C Ask the patient's relative to stay in the room.
D Call your registrar and ask them to perform the examination.
E Document in the notes that a chaperone was offered and declined.
F Do not perform the examination.
G Explain fully to the patient what you are doing as you perform the
examination.
H Explain to the patient that there must be a chaperone present.

4.65 HIV avoiding blood test

You are the medical FY 1 on call at the weekend. A newly ac.lmirred patient
urgently needs a blood test co evaluate their condition and determine
further management. You know rhar the patient is positive for the human
 Questions 265

immunodeficiency virus (HIV), and you feel very anxious about performing
the procedure in case of sustaining a needlestick injury.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Call your seruor house officer (SHO) and ask them ro rake the blood cesr.
B Record in the notes that you are declining to perform the examination due
ro personal risk.
C Carry out the blood test following standard precautions.
D Record in the notes that rhe patient declined the procedure.
E Hand over the job ro the night ream.

4.66 Unable to get a chaperone

You arc working as an FY2 doctor in a GP surgery, and you arc asked to go on
a home visit to a pregnant patient. The nurse who has triaged the call hasn't
provided you with much information on the patient, and you have nor mer her
before. The nurse does, however, inform you that she is 32 weeks pregnant
and has had some abdominal pains. When you arrive, the patient is sitting in
the living room looking quite pale. She says she has 'had some blood loss from
down below', but she can't explain how much blood there was. You perform
a simple examination and find her to be pale and slightly rachycardic. You
explain to the patient that you would like to perform a visual examination of
her, agina before deciding further management, which she agrees to. Before
you start, you realise that you don't have a chaperone. You are happy to carry
our the examination, bur you arc unsure as to your ethical obligations.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Call your educational supervisor for advice.
B Perform the examination as she could potentially he having a life-threaten-
ing vaginal bleed.
C Phone the GP surgery and ask for a colleague ro come and act as a
chaperone.
D Refuse to perform the examination and ask the patient to come into the
clinic later that afternoon for a thorough, more professional examination.
E Refuse to perform the examination and ask the patient to immediately
attend the maternity unit at the local hospital.

4.67 Drunk

You are an FY1 in an emergency department. A man is brought in, having

been found collapsed on the pavement. He is a frequent attender of the
emergency department with alcohol-related problems, and on this occasion,
he is conscious on arrival, appears drunk and is verbally abusive. A nurse tells
you that they usually put him in a side-room to 'sober up a bit' before he is
assessed.
 266 Chapter 4: Patient Focus

Choose the THREE most appropriate actions to take in this situation.

A Ask the nurse to do regular clinical observations on the patient.
B Ask the nurse to inform you when he has sobered up.
C Ask the nurses to restrain the patient while you examine him.
D Ask your senior colleague to examine the patient.
E Carry out a clinical assessment of the patient on arrival.
F Give the patient sedation.
G lnform the nurse that you cannot delay his assessment or treatment.
H Refuse the patient access to the emergency department as he is being
abusive.

4.68 Keeping promises

You arc an FY J working in paediatrics. One of your patients is nearly read)' to

be discharged, and their parents ask whether you can help them with a prob-
lem rhey have. They had made a decision for their child nor to have a vaccine
that was offered at birth but have subsequently changed their minds. You offer
to try to arrange for them to come hack to the ward for their child to have it.
After they leave, you ask your consultant who says that this is not a service the
ward can provide.
Choose rhc THREE most appropriate actions ro rake in chis situation.
A Avoid the parents on the ward.
B Call the patient's health visitor and ask them to provide the vaccine.
C Contact the pharmacist to order the vaccine.
D Do nor arrange for the vaccine to be given on the ware.I.
E Explain to the parents that vaccines should be provided in the community.
F Explain to your consulranr that you feel you have to give the vaccine now
as you have made a promise to the parents.
G Get a second opinion from a different consultant.
H Make an appointment for the patient as a ward attender.

4.69 Keeping promise to refer to dentist

It is a Friday during your FY l rotation on a busy respiratory ward. You arc

the only junior doctor looking after 16 patients. You see a patient on the ward
round who tells you that he has hroken one of his teeth, and it is causing him
to cut his tongue and lips. You make a promise co the patient co contact the
on-call maxillofacial surgeon co inform rhem of the siruarion. The patient is
otherwise stable and is receiving antibiotics for a chest infection. You com-
plete your ward round late in the day and are still completing jobs, despite
it being after rhe time you should have finished. You suddenly remember
that you have forgotten co refer your patient ro the maxillofacial surgeon for
review.
 268 Chapter 4: Patient Focus

ANSWERS
4.1 Ordering wrong test

C D A
This question deals with honesty and responsibility. You are the person who
ordered the test for the wrong patient, and now you need to take responsibil-
ity for it. Any mistake made in medicine can leave patients exposed to risks
that they needn't be. The best answers in this question involve apologising
truthfully to the patient in question and trying to prevent this from happening
again by speaking to senior staff. You shouldn't feel like bringing this mistake
to light is turning yourself in, more like actively trying to protect patients in
future. Other staff members are just as likely to make the same mistakes as
you. Options C, D and A all involve either apologising to the patient or rais-
ing the matter with senior staff, whether clinical, your supervisors or through
rhe incident form reporting system. The rest of the options do not attempt to
prevent this situation happening again. Although option B makes an attempt
to apologise to the patient, this should still be followed by you escalating your
mistake to more experienced members of the clinical team. Similarly option E
is also wrong since there is no acknowledgement of the error made despite
ensuring that the x-ray is properly reviewed, as all tests should be. The rest of
the options try and cover up the mistake by pretending it didn't happen (G),
making up a false justification for the test (H) or blaming colleagues (F), which
are all dishonest.

Recommended reading
General Medical Council (2012), Explanatory guidance, in Raising and Acting
on Concerns About Patient Safety, paragraphs 11-15.
General Medical Council (2013), Good Medical Practice, paragraph 55.

4.2 Signing sick note

B A E D C
As an FYl doctor you have a responsibility to communicate effectively with
patients, to listen and respond to their concerns but also to be honest when
signing forms or completing documentation and to take reasonable steps
to ensure that what you are writing is correct. Option B is therefore the
best response as it combines both these approaches. Option A may also be
appropriate, although it risks delaying the care of patients who are being
looked after by your team. Option E is perhaps too brusque a response, despite
your being under stress; however, it is preferable to options C and 0, which
ignore the situation and contravene General Medical Council guidance. Since
option D does not involve actively disregarding guidance on completing sick
notes but does include poor patient communication, this is more favourable
than option C.
 Answers 269

Recommended reading
General Medical Council (2009), The New Doctor, paragraph 11.
General Medical Council (2013), Good Medical Practice, paragraphs 31-34, 71.
Medical Protection Sociery (2012), Honesry, in MPS Guide to Ethics: A Map for
the Moral Maze, chapter 6.

4.3 End of life care

C B A E D
The consultant has given you enough information to give the patient an idea
of what is going to happen to them, and you are in possession of enough sur-
rounding knowledge of the patient to be able to be honest with her. Despite
this, as an FY 1, you will lack the experience in breaking bad news, so the
most appropriate course of action is to give the patient an idea of what is likely
to happen and wait until the consultant is available to have a frank discus-
sion with her (C). Of the remaining options, the safest would be to decline to
comment and await the consultant review for similar reasons (B), although
this means that the patient will be without this information over the weekend.
Option A is the next best response; if you have been caring for the patient
before, it is better for the patient to receive this information from a familiar
doctor rather than your SHO. Option Eis better than D; although you should
be honest with the patient, it is never wise to try and put a time limit on a
prognosis since, as an FYl, you do not have the knowledge to give specifics to a
patient in this way. Option D is clearly unacceptable because telling the patient
that they will be fine is a lie.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 14-16.
Medical Protection Society (2012), Honesty, in MPS Guide to Ethics: A Map for
the Moral Maze, chapter 6.

4.4 Discussing optionswith patient

D B E A C
It is important to be open and honest with patients, which includes ensur-
ing that they are aware of alternative options and are able to weigh these up
for themselves. A CT scan involves a large dose of radiation, so it is not a
procedure without risk. However, unlike consent for an operation or major
procedure, this is a procedure that you should have the competency to discuss.
Asking your registrar to do this (B), at considerable disruption ro their other
responsibilities, therefore ranks lower than doing it yourself (D). Both options
E and A, which involve proceeding to request the scan, do not involve describ-
ing the alternatives to the patient. Option E is better than option A because it
includes informing the patient of what is going on; whereas in option A, they
may be unaware that the scan has been organised until the porter arrives to
take them to the radiology department. Refusing the request on the grounds
 270 Chapter 4: Patient Focus

that your consultant has not discussed it with the patient (C) is likely to make
you unpopular and is not strictly true given that there are other methods of
ensuring the patient is aware of their options, which is why it ranks last.

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together.
Medical Protection Society (2012), Honesty, section: Consent, in MPS Guide to
Ethics: A Map for the Moral Maze. chapter 6.

4.5 Imminentcardiac arrest

D C A B E
Cardiac arrest or peri-arrest situations can be exceedingly daunting for an
FYl doctor with little experience of these scenarios. The important factor to
consider here is that the nurse is clearly very worried about the patient and
believes chat they may have a cardiac arrest soon. While there are scenarios
where you would leave duties to the on-call team outside your shift hours, this
patient quite clearly requires urgent medical attention. In this scenario, the
least appropriate option would be to commence CPR (E) as the patient needs
to be assessed further before deciding whether it is appropriate to commence
basic life support. In this case, the patient still has a pulse and is breathing, so
the most appropriate method of assessment would be the ABCDE approach
(D). If the patient does suffer a cardiac arrest, CPR should be started, and the
crash team must be called. In this scenario, it is clear that you are going to need
the support of an on-call colleague, so initially asking the nurse to perform a
full assessment (if she hasn't already) and phoning for help would be a sensible
course of action (C). Even though this situation has occurred 'out of hours', if
the patient is very unweJI, as in this case, your knowledge of her background
history and ability to immediately assess her clinical state are likely to be very
useful. Leaving the scene and handing over the task would compromise patient
safety and be unacceptable given what the nurse has told you; therefore, options
A and Bare poor choices. However, asking the nurse to make a full assessment
and escalate to the necessary persons (A) is always preferable to waiting for the
FYl on call to assess the patient, which could lead to a 5-15 minute delay.

Recommended reading
General Medical Council (2013), Duties of a doctor, in Good Medical Practice.

4.6 Chest drain at nighttime

E B A D C
As a doctor, you need to balance your educational needs with patient safety.
Inserting a chest drain is likely to be beyond your training and competence as
an FYl doctor. Doing this procedure at nighttime would be unnecessary and
places your patient under increased risk due to clinician fatigue and associated
decreased situational awareness as well as decreased staffing levels should a
 Answers 271 •

problem arise. Therefore the least appropriate option is C: doing the procedure.
The most appropriate option is E, challenging your SHO about their suggestion
that you perform the procedure. Junior doctors often find it difficult to chal-
lenge seniors, but chis should be overcome especially in scenarios where patient
safety is at risk. If your SHO refuses to acknowledge your opinion or you don't
feel comfortable in challenging their decision directly, then you should advise
the SHO to speak to their senior (B). The next most appropriate option would
be to seek similar learning opportunities in the daytime (A). Asking the SHO
to insert the chest drain while observing (D) would be putting the patient under
unnecessary risk, but this is preferable to carrying our the procedure yourself
when you have no previous experience (C).

Recommended reading
Medical Protection Society (2012), Duty of care, in MPS Guide to Ethics: A
Map for the Moral Maze, chapter 4.

4.7 Poor equipment

B E D A C
Respecting patients' dignity means that intimate examinations should be
undertaken in a private area where they cannot be overlooked by other staff or
patients. Importantly, however, you should ask the patient what their prefer-
ence is, as patients' opinions of what protects their dignity vary from person to
person. The room available in this situation is not suitable for catheterising a
patient, so you should not attempt to 'make do' with it. The best response is B:
there is a time constraint and calling the department to let them know of a
likely delay is good practice and will allow them to rearrange the patient list to
ensure everyone receives their rests today. Ensuring safe and private catheteri-
sation in a more controlled environment off the ward (E), although making the
patient late, would be appropriate since it protects their dignity, which is the
most important factor. Option D is the next best response as the urodynamics
department will be a more private area than the room available in the day case
department, and therefore, it might be necessary co send the patient down to
be catheterised in the department. The last two available options attempt to
use the inappropriate room; however, option A, with a chaperone {standard
practice), is better than option C, without.

Recommended reading
General Medical Council (2013), Explanatory guidance, in Maintaining
Boundaries: Intimate Examinations and Chaperones.
General Medical Council (2013), Good Medical Practice, paragraph 47.

4.8 Nurse prescribing

A D H
Nursing staff should never give patients regular medication without a valid
prescription. 'As required' medication is prescribed and given at the nurses'
 272 Chapter 4: Patient Focus
l
and patients' discretion but can only be given within the defined parameters of
the prescription. The options that are appropriate in this question protect the
patient immediately from an unneccesary and potentially dangerous treatment
and take steps to prevent this from happening again.
Option His appropriate as stopping the infusion and letting the heads of both
the medical and nursing team know of this serious and preventable error enables
the appropriate staff to take the relevant action. Option D is also sensible as it pro-
tects the patient immediately and ensures that the incident is looked into, although
perhaps some time after the event. Managerial and clinical staff are obliged to
look into and follow up every incident form, so this is a useful route for reporting
clinical issues. To ensure the patient's safety, it is important that you also assess
the patient for any adverse effects from the heparin infusion, as in option A. This
also involves apologising and explaining the mistake, which keeps the patient fully
informed and shows respect, and contacting your registrar, who should be able to
advise you further on how to prevent this happening again. Importantly, docu-
menting any serious prescription errors enables other medical staff to be aware
of potential adverse reactions and gives them the appropriate information to deal
with any subsequent consequences. The other responses are not ideal because,
although many of them do include stopping the infusion (C, £, F and G), they do
not prevent the situation from happening again. Continuing the infusion for the
sake of your colleague's feelings (B) is both unprofessional and unsafe.

Recommended reading
General Medical Council (2013 ), Explanatory guidance, in Good Practice in
Prescribing and Managing Medicines and Devices, paragraphs 6-13.
General Medical Council (2013), Good Medical Practice, paragraph 16.

4.9 Staying late

D A E C B
While you should not be expected to stay late on a regular basis, you still
have a duty of care to your patient, even if your shift has finished. You should
review the patient and prescribe the analgesia rather than leaving them in
pain. Option D is therefore the most appropriate response. lf you decline to
prescribe the analgesia, you have a duty to ensure that someone does. Bleeping
the on-call team yourself ensures that the job has been handed over to some-
one before you leave. Option A is therefore preferable to E, which relies upon
the nurse to hand over the task. A verbal handover is far more effective than a
written request. Leaving a note in the doctor's office risks the note never being
seen or a significant delay before it is seen and acted upon. Option C is there-
fore an unfavourable option. Ignoring the request (B) is clearly inappropriate
since the patient should not be left without analgesia.

Recommended reading
General Medical Council (2013), Duties of a doctor, in Good Medical Practice.
Medical Protection Society (2012), Duty of care, in MPS Guide to Ethics:
A Map for the Moral Maze, chapter 4.
 Answers 273

4.10 Faulty equipment

B E F
Your first duty is to your patient, and you need to ensure chat their urgent ECG
is performed, so option B should be the immediate response. You also have a
duty to ensure char any faulty equipment is repaired or replaced. Calling the
medical equipment department yourself will result in timely reporting of the
fault (E), while informing the ward manager ensures that someone will follow
up the fault and make sure that it is resolved (F). Completing an incident form
(A) is unnecessary since there has been no risk tO patient safety, and you have
taken steps to prevent any future risk. While putting a note on the machine (C)
may be useful in informing people that it is broken, it does not actively resolve
the issue. Similarly, failing to rake any steps to alert the fault to others, as in
option D, will not solve the issue, and taking the machine from another ward
(G) will just create a problem elsewhere. Trying to fix the machine yourself (H)
is potentially dangerous and not a good use of your time.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 15b, 25b.

4.11 Child protection

C A D B E
Identifying and acting upon signs of non-accidental injury early is extremely
important in the protection of children and young people. However, your first
concern in this scenario should be to complete your assessment of the child to
identify and address the underlying cause for her presenting complaint, which,
in this case, is difficulty breathing (C). Furthermore, you may go on to find
further injuries as you continue your examination. There may be a reasonable
explanation as to how the bruise occurred, and indeed any explanation should
be clearly documented. le is therefore important to ask the parents about it (A).
Any concerns about child safety must be escalated, and a good first step would
be to discuss this with the emergency consultant (D). It is usual to discuss any
concerns you may have with the parents as well and to keep them informed
about any investigations into their child's care. This is unless you feel that
informing the parents may place the child at further risk. In this instance, there
is no need to ask the parents to leave (B), and this may even be detrimental to
their future cooperation. Taking a picture of the baby on your phone is com-
pletely inappropriate. You should never take pictures of patients on your phone
as this breaches data protection (E). Photographic evidence of the bruise will be
needed but should only be obtained by a medical photographer.

Recommended reading
General Medical Council (2011 ), Explanatory guidance, in Making and Using
Visual and Audio Recordings of Patients.
General Medical Council (2012), Explanatory guidance, in Protecting Children and
Young People: The Responsibilities of all Doctors, paragraphs 2-5, 18-22.
 274 Chapter 4: Patient Focus

4.12 Abortion

E A D C B
Doctors have a right to conscientiously object to participation in abortion,
fertility treatment and withdrawal of life-sustaining treatment. However, a
doctor cannot discriminate against a group of patients, such as patients who
have had an abortion, and cannot refuse to treat the consequences of a lifestyle
choice. The patient in this scenario has made the choice to have an abortion,
and you have a duty to provide the care that she now requires (E). While ask-
ing one of your colleagues to rake over her care (A) is not the most suitable
response, it still ensures that the patient receives appropriate care. Regardless
of your beliefs, the care of your patient is your priority, and it remains your
responsibility to find a means of providing char care. Ir is therefore inappropri-
ate to ask the ward manager to find another doctor to care for the patient (D).
There is no need to cell the patient about your beliefs in this situation, and
indeed the patient may feel that she is the subject of discrimination if you were
to inform her (C). Refusing to treat the patient properly is unprofessional and
fails to fulfil your duty of care (B).

Recommended reading
British Medical Association, Expressions of doctor's beliefs, http://bma.org.uk/
practical-support-at-work/ethics/expressions-of-doctors-beliefs.
General Medical Council (2007), Explanatory guidance, in 0-18 Years: Guidance
for All Doctors, paragraph 72.
General Medical Council (2013), Good Medical Practice, paragraphs 52, 54, 59.

4.13 Sleeping tablets dementia

D C E B A
As a doctor, you will have pressure put on you by carers, relatives and other
colleagues to take specific courses of action. It is important that you keep the
patient as your main focus and make any decisions based on their best inter-
ests, while also acknowledging and respecting the opinions of your colleagues
and the patient's relatives and carers. In this scenario, you should first gather
more information during her stay in hospital (D) before prescribing any seda-
tion and see whether any more help could be offered to the patient and her
daughter. Telling the daughter to organise more care on discharge (C) would
achieve the same effect but is less appropriate than option D. The care of
the elderly department should have resources to be able to make a quick and
thorough MDT assessment, and it should also prevent the situation reaching
a crisis point if the patient was to be discharged without further help. The
daughter may need personal support from her GP (E), but the mother is the
first priority in this instance. Prescribing the patient sedatives and asking the
GP to review this (B) is inappropriate as you do not have sufficient information
to prescribe the sedative, which could have negative effects (such as sedation
during the daytime and increasing the patient's risk of falls). However, option
A is the most inappropriate response. As a doctor, you are not in a position to
 Answers 275

advise such action; you should instead offer her access to healthcare profession-
als who can further assess the patient and help the daughter to make informed
decisions.

Recommended reading
General Medical Council (2013), Explanatory guidance, in Good Practice in
Prescribing and Managing Medicines and Devices, paragraphs 14-16.

4.14 Group and save

D C E A B
This is a significant omission in a patient's treatment and could be viewed as a
breach of your duty of care. After realising that you have made a mistake relat-
ing to a patient's management that could cause harm or distress, the General
Medical Council (GMC) states that you should do three things: put matters
right if possible, apologise and explain the situation, including the likely short-
term and long-term effects. In this scenario, your priority is reducing harm to
the patient. The most appropriate thing to do would be to inform the operat-
ing theatre staff (D) as they will be able to judge the risk of continuing the
operation without readily available blood products. The operating team could
potentially delay the surgery or send off an urgent sample from the theatre.
Informing your SpR (C) would be the next most appropriate option as they
could notify the theatre; however, this is not a task that requires their seniority,
and this could cause further delays. Taking the blood test after theatre (E)
could prevent harm after surgery but would leave the patient under major risk
in the operating theatre. Completing an incident form (A) would be a good
action after the event as processes could be put in place to avoid patients being
put in this situation again. However, in the first instance, you should deal
with the immediate risk to the current patient. The least appropriate response
is doing nothing (B): this would be negligent, putting the patient at risk of
serious harm.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 55.
Medical Protection Society (2012), Duty of care, in MPS Guide to Ethics: A
Map for the Moral Maze, chapter 4.

4.15 Disruptiveintravenous drug user patient

A D C E B
This scenario relates to your duty of care to a patient and where this may
end. The patient is disruptive and taking attention away from the care of
others, which subsequently affects your duty of care to your other patients.
If the patient is taking recreational drugs, it makes surgical or medical care
extremely difficult and potentially dangerous. The most appropriate action in
this case is to seek senior input or advice from your registrar or consultant (A);
it is likely that this patient will need discharging from hospital care, but as
 276 Chapter 4: Patient Focus

an FY 1 doctor, you should not be expected to make this decision. The next
most appropriate action would be to speak to the patient about their inap-
propriate behaviour (D); however, it would be best to involve seniors in the
first instance, as the nurses require a decision. Signposting the patient to drug
misuse and addiction services (C) would be useful but is not the first priority in
this situation. Telling the nurses to continue the care of the patient (E) may be
appropriate but should be a senior decision; a clinician is within their rights to
end a professional relationship when a breakdown of trust between themselves
and the patient means that they cannot provide good clinical care. The most
inappropriate response is Bas this should be a senior-led decision, as previously
discussed.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 62.

4.16 Waiter with diarrhoea

C A G
As a doctor, you have a duty of care to your patient but also to the general
public. ln this case, you should be concerned about someone working in a
restaurant with infectious diarrhoea. The most appropriate course of action
would be to obtain a stool sample to exclude infection (C), advise the patient
not to take loperamide at this time (A) and tell him that he should not work
until the diarrhoea has stopped (G) or an infectious cause has been excluded.
Option B is a step that would reduce transmission of an infectious diarrhoea;
however, he would still pose a risk to the general public. Notifying the HPA
(D) would be a valid option if an infectious cause had been found or strongly
suspected. Reporting the restaurant to the local newspaper (F) would be very
unprofessional. Option E is inappropriate at this stage as an infectious cause
has not been ruled out, and if the patient continued to work, he could cause
an outbreak of infectious gastroenterititis, Advising him to get in touch with
occupational health (H) is unnecessary at this point as he does not have a clear
diagnosis; however, this should be considered further down the line.

Recommended reading
Medical Protection Society (2012), Duty of care, in MPS Guide to Ethics: A
Map for the Moral Maze, chapter 4.

4.17 Hyperkalaemia and chasing blood tests

E A C D B
Making mistakes is an inevitable pare of being a doctor. GPs can see up to
50 patients a day and deal with a wide range of complaints. This scenario
requires a small amount of knowledge with regard to hyperkalaemia, which
puts patients at risk of potentially fatal cardiac arrhythmias. While the blood
sample may be haemolysed (B), causing the potassium level to be falsely high,
unless this was specifically reported by the laboratory, it would not be safe to
 Answers 277

disregard what you have found. The best course of action would be to urgently
repeat the results in a safe environment, which in this case would be a hospital
(E). It would be appropriate to first discuss the patient case with the hospital
on-call medical team and explain the situation. Asking for senior advice, par-
ticularly within a primary care setting, is vital as the experience and knowl-
edge of a GP trainer will help you to decide your course of action (A). Booking
urgent blood tests for the following day (C) would cause too much delay as the
patient is in danger of a serious arrhythmia and should be seen immediately.
Rechecking your other consultations (D) may be appropriate if you think you
have missed something; however, your priority should be this patient as he is
in danger.

Recommended reading
Nyirenda MJ, Tang JI, Padfield PL, Seek! JR. (2009), Hyperkalaemia, BM], 339,
b4114.

4.18 Responsibility between teams

A D G
Now that you are aware of the need for monitoring, you have a responsibility
to ensure that this takes place, especially as the patient is primarily under
your care. You should ensure that it is easy for other members of your team to
be aware of rhe monitoring plan by adding it to your handover sheer (A), bur
you should also make a more formal record in the parienr's notes (G), where it
will also be accessible to other professionals involved in the patient's care. It is
sensible to fill in the request for the blood test now in order to ensure that it
is not forgotten or delayed the next day (D), which is particularly important
if you are not working then. It would be unhelpful and unsafe for the patient
if you were to deny any responsibility and insist that this lies with the neurol-
ogy department (H), even if you have discussed this with them (B). It would be
negligent and unsafe to alter the treatment plan simply to avoid the hassle of
monitoring (E). There is no point in performing the blood test now, when it is
not due until the next day (F); even if you are just trying to ensure it is per-
formed, the results will be difficult to interpret and act on. There is no reason
why you would need advice urgently from your registrar in this situation (C) as
you should be able to son this out yourself.

Recommended reading
Foundation Programme Curriculum (2012), Section 1.3: Continuity of care.
Medical Protection Society (2012), Duty of care, section: Acts and omissions, in
MPS Guide to Ethics: A Map for the Moral Maze, chapter 4.
4.19 Ensuring follow up

E D B A C
Although this is not an ideal situation for yourself or the patient, you should
try to communicate the additional request to the GP as per the plan made by
 278 Chapter 4: Patient Focus

your team (options E and D). It is better to do this is writing (E) rather than
by telephone (D), since this means that there is a formal record of you having
informed them and also means that the message is less likely to get lost or
misinterpreted. You have a responsibility to ensure that the necessary follow-
up takes place, and it is not fair to place this entirely on the patient (B). While
many patients are completely capable of managing their follow-up plan, not
all will be, and by doing so, you are vulnerable to criticism if they forget or
confuse your advice. Options A and Crank lowest because they alter the plan
your team has made for the patient's follow-up. There are resource availability
issues around organising the follow-up in a hospital setting rather than in
primary care. Option A is better than option C because the burden falls on you
to chase the results of the test rather than leaving your consultant to deal with
this. They are likely to be incredibly unhappy that you have used up one of
their clinic slots for a patient they did not need to see (C).

Recommended reading
Foundation Programme Curriculum (2012), Section 10.4: Discharge planning.
Medical Protection Society (2012), Duey of care, section: Scope, in MPS Guide
to Ethics: A Map for the Moral Maze, chapter 4.

4.20 Negligence 1

C E D B A
Option C is the best choice here as the patient may come to harm from your
omission. They therefore deserve a full explanation and will definitely need
their drug levels monitored the next day. This was a simple error, but such
things may be seen as negligence by the patient, and an apology can make a big
difference in how they view the mistake. While options E and Dare both good
responses, they do not include an immediate action to explain to the patient
what has happened. Option E ranks higher than option D, as you are talking
to a member of your team and someone who is directly involved in the patient's
care. Calling the SHO on call (B) may be helpful, but your team's registrar
or a member of the microbiology department is better placed to answer your
queries; therefore, it would be preferable to speak to them. Option A ranks last
as this sounds like you are blaming the nurse for your mistake, and this will
not help improve patient care. It will also not help you find out what to do next
and may create friction within the team.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 25.

4.21 Negligence 2

C D E
In this scenario, the trust would have a protocol in place and following this (E)
would give you all the advice you need for initiating treatment. In addition, it
should tell you the standard of care ro be followed. If you are really uncertain,
 Answers 279

then a call for help from someone more senior is appropriate, and the SHO
may be available even though the registrar is not (D). When seeing an acutely
ill patient, the ABCDE approach should always be used (C) as this will help
regardless of whether or not you are confident in treating the specifics of a
condition. Your memory may be right on how to treat DKA (F), but following
trust protocol is a far better way to manage this patient. Doing nothing and
waiting for the SpR (G) is not appropriate in this case and is actually negli-
gent. While the ward matron may be experienced in managing acutely unwell
patients, they should not be your first port of call as it may have been a while
since rhe last rime they saw a similar case; therefore, option B is not appropri-
ate. Your handbook may be outdated, therefore option His nor rhe best way
to manage the patient; trust protocols arc updated regularly and are a much
better resource in this case. Asking a fellow F Yl for help (A) may give you
some support, but they will also most probably have had little experience here,
so it is not one of the best responses.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 14, 18.

4.22 Challengingdecisions

A E C B D
This is a difficult scenario as there may be clinical details you are nor aware
of explaining why the consultant made the decision. However, a raised potas-
sium at this level is a medical emergency, and you should therefore act on it in
some way. Calling the on-call registrar (A) would be a good start as they can
give you advice about your next step or might be better placed to speak to the
consultant themselves. Talking ro the consultant directly (E), while sometimes
a scary prospect, would be appropriate since this will clarify all the details.
You should remember that the consultant has ultimate responsibility for the
patient's care, so calling them for advice would be the next best course of
action. Contacting the patient at home (C) would ensure immediate action;
however, it involves going over the consultant's head and is therefore not
appropriate. The remaining two responses (B and D) are the least appropriate,
as both will delay care in this emergency situation. Option Bis preferable ro
D though as this wilJ result in the matter being raised with the consultant.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 24, 25.
Medical Protection Society (2012), Duty of care, in MPS Guide to Ethics: A
Map for the Moral Maze, chapter 4.

4.23 Breaking bad news

E B A C D
The patient is under the consultant's care, and you do not have the knowledge
to give the patient an adequate understanding of what the results will mean
 280 Chapter 4: Patient Focus

for the treatment and prognosis of the patient; therefore, it is inappropriate for
you to discuss them with the patient (E). This will be a very difficult subject
for the patient, and for continuity of care, it is better that the consultant tells
the patient themselves. Option B is the next best response because, although
the registrar is not directly linked to the patient's care, they will know a lot
more about the disease and will be able to adequately counsel the patient on
the results. Option A is not ideal, but the FY2 is more experienced than you
and therefore better placed to discuss the results with the patient, if you feel
unable to. Option C is preferable to D, as it involves making the patient aware
of the limitation of your competencies, and you would not be giving the patient
any false information. Retrieving information from the internet (D) is not
always reliable or fully up to date, especially in the field of oncology where
there are often new treatments being trialled.

Recommended reading
General Medical Council (2009), Tomorrow's Doctors, paragraph 133.
General Medical Council (2013), Duties of a doctor, in Good Medical Practice.
General Medical Council (2013), Good Medical Practice, paragraph 25c.
Medical Protection Society (2012), Personal conduct, in MPS Guide to Ethics: A
Map for the Moral Maze, chapter 12, p. 91.

4.24 Analgesia

B G F
This is a difficult set of options as some of the best responses are conflicting.
Option Bis appropriate, as you are letting the correct member of the team
know chat a job needs doing and maintaining patient care. Option G is also a
good response as many doctors consider leaving a patient in pain to be inap-
propriate, and you are qualified to prescribe basic analgesia as an FYl. If you
are to prescribe analgesia, you should always review the patient first to see
if they have tried any analgesics previously and if they have any allergies or
intolerances. Option F, while it does not involve giving any pain relief, is also
appropriate since during the day, a member of the patient's team should be
available to prescribe analgesia for their patients, and this patient is not under
your care. Options A and H are not the best options here as they leave the
responsibility solely with the nurses to resolve the issue. Options C, D and E,
while resulting in the patient receiving analgesia, are not safe as they do nor
involve you actually seeing the patient. Ir should be recognised that simply
looking through a patient's notes (C) is not a replacement for seeing them.
Also, simply prescribing paracetamol (E) may not be adequate analgesia, while
prescribing a variety of analgesics (D) is not appropriate as it leaves the deci-
sion ro the nurse over what to give.

Recommended reading
General Medical Council (2010), Explanatory guidance, in Treatment and Care
Towards the End of Life: Good Practice in Decision Making.
 Answers 281 •

4.25 MRSA patient

D C A B £
This question deals with a situation in which your actions may influence the
health and safety of both your patient and the other patients and staff on the
ward. Option D is therefore the most appropriate response.You should inform
the nurse in charge in a timely manner, in case they are unaware of the results,
so that suitable safety measures can be implemented. This aims to decrease the
risk of transmission among people on the ward and contribute to maintaining
patient safety. Option C is also a courteous action to take and maintains
good patient-doctor communication; however, this should be done after the
sister has been informed so that, in the meantime, arrangements for a side
room can be underway. Option E, on the other hand, demonstrates conscious
neglect of patient care. While it may be true that the nurses arrange the
infection control measures, this shows poor communication with colleagues
and could put the health of patients and staff at risk. In matters such as this,
your registrar should not be the first person you call, and therefore, option
Bis also unsuitable; you are wasting both your time and that of your senior,
consequently delaying important patient care. Asking one of the other nurses to
contact the ward sister to organise the move of the patient while you deal with
their abnormal blood results (A) is more appropriate and may be necessary
if you couldn't find the nurse in charge and were called to a sick patient.
However, when relying on another member of staff, you cannot be sure when
or if the message was relayed.

Recommended reading
General Medical Council (2012), Explanatory guidance, in Raising and Acting
on Concerns About Patient Safety.
General Medical Council (2013), Duties of a doctor, in Good Medical Practice.
General Medical Council (2013), Good Medical Practice, paragraphs 25, 35.
Medical Protection Society (2012), Duty of care, in MPS Guide to Ethics: A
Map for the Moral Maze, chapter 4.

4.26 Arranging follow up

D F G
This question is concerned with ensuring you uphold a duty of care toward
your patients while maintaining good professional relationships. As an
FYl, it is your responsibility to ensure that discharge letters and follow-up
arrangements are in accordance with seniors' advice, and although it may not
have been your job to complete the discharge letter, you have a duty to voice
any concerns that may impact patient care. Option D is appropriate as it
shows good communication skills and humility (unlike H), which is impor-
tant, especially as you are not certain of what you remember. To change the
discharge letter yourself without discussion (B) would show a lack of respect
for your colleague, and in this scenario, you have not checked whether your
 282 Chapter 4: Patient Focus

memory of the conversation is accurate. As there is some dispute about the

information on the current discharge letter, option F is advisable; however,
you should also confirm your decision by speaking to the consultant them-
selves (G). Option C is less appropriate as your colleague may not remember
the correct information either. Asking the patient (A) is not advisable as there
is the chance that she may not correctly remember what advice the consultant
had given and may negatively affect her future care. Similarly, option E may
adversely impact her outcome and is inappropriate: ensuring that the correct
follow-up is in place for your patients after discharge is part of your remit as
an FYI.

Recommended reading
General Medical Council (2013 ), Duties of a doctor, in Good Medical Practice.
General Medical Council (2013), Good Medical Practice, paragraphs 15, 25, 35,
36, 44.
Medical Protection Society (2012), Duty of care, in MPS Guide to Ethics:
A Map for the Moral Maze, chapter 4.

4.27 Antibioticguidelines

A B D C E
This question is assessing your ability to adhere to local clinical guidelines
and remain up to date with practices in your specialty. [tis important that
this patient receives effective timely treatment, while also minimising the
risk of eliciting antibiotic resistance. Option A is the preferred response as
you are complying with the guidance that is recommended by your hospital.
Although asking for advice (B) may also be appropriate, this is informa-
tion that, as an FYl, you should at least endeavour to find yourself before
troubling other colleagues. Using the old guidelines (D) is unlikely to cause
harm to your patient and may well be effective. You are also ensuring regular
monitoring of your patient. However, this action fails to demonstrate compli-
ance with local policies. Option Eis the least advisable, as it not only dem-
onstrates a shirking of responsibility but also delays the antibiotics, a key
action in the management of sepsis. For this reason, option C is slightly more
appropriate. Although your handbook may be out of date, beginning empiri-
cal antibiotic treatment after taking cultures is more proactive than failing to
do anything.

Recommended reading
General Medical Council (2013 ), Duties of a doctor, in Good Medical Practice.
General Medical Council (2013), Good Medical Practice, paragraphs 8, 11,
16, 18.
Medical Protection Society (2012), Duty of care, in MPS Guide to Ethics: A
Map for the Moral Maze, chapter 4.
www.survivmgsepsis.org
r
I
Answers 283

4.28 ABG competence

A B E
The correct answers in this question immediately correct the error and prevent
the patient from bleeding or bruising badly. Nursing staff can often perform
this task if you need to process the sample immediately, so option A is one of
the appropriate responses. If you are confident that rhe patient themselves can
apply pressure, it can be appropriate for the patient ro do so, although you
should give rhem full instructions and check on them in a few minutes (B).
Option Eis also an appropriate response, as putting pressure on the area your-
self ensures that it is done promptly and well. The inappropriate responses are
those that involve leaving the patient bleeding, such as option C, when you go
off to call back the FY2, and option D, when you ignore the situation to learn
how to use the analyser. Options F and G involve an attempt to prevent this
situation happening again, either through personal reflection or discussing the
FY2's incompetence with their supervisor; however, neither derail an immedi-
ate response to the potentially bleeding patient. The final inappropriate answer
is H, which attempts to remove blame from you by detailing the FY2's fault in
the notes, thereby doing little in the immediate situation. This would also likely
damage your professional relationship with your colleague, so it is unsuitable.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 22-30.

4.29 Keeping up to date

D B A C E
The most appropriate response in this scenario is to discuss the matter with
someone more senior than yourself. This is perhaps best done as a reflec-
tion with your educational supervisor (D), providing that the management
plan as set out by your consultant will not lead to patients coming to harm.
Option B is the next best response as this again involves discussing the matter
with someone more senior than yourself, with more experience; however, it is
not ideal as you will not be making your thoughts about patient management
known to your consultant. While option A seems like a sensible response, the
consultant may not rake kindly to an FYl questioning their judgements, and
the reaching session may nor provide an opportunity to ask. Options C and E
are both nor appropriate; in the case of option C this leaves your concerns
unreported and is therefore nor helping the situation. Ir is better than option E,
however, since, as an FYl, you should nor be going over rhe consultant to
change management plans.

Recommended reading
General Medical Council (2012), Explanatory guidance, in Raising and Acting on
Concerns About Patient Safety, part 1, paragraphs 7, 13.
General Medical Council (2013), Good Medical Practice, paragraphs 11, 12, 13.
 284 Chapter 4: Patient Focus

4.30 Clinical skills

C B D A E
lt is important to remember that, as an FYl doctor, you should always ask for
help if you are unsure of your competencies. Option C is therefore best as you
have performed the procedure before and probably just need reassurance that
you can still do so. Option B is the next most appropriate action as this still
results in both the patient being catheterised and a learning experience for you.
Option D is the third best as, if you do not feel competent and the nurse is not
trained, it is not appropriate to try and fumble your way through the proce-
dure together (A). It should be remembered, however, char the continence nurse
should only be called in cases of difficult cathererisarion; therefore, this is not
an appropriate referral. Option E is inferior as simply booking a clinical skills
session will not help your patient in the immediate situation.

Recommended reading
General Medical Council (2009), Practical procedures for graduates, in
Tomorrow's Doctors, appendix l.
General Medical Council (2013), Good Medical Practice, paragraphs 14, 15, 16.
Medical Protection Society (2012), Competence, sections: Acquiring and
developing new skills, in MPS Guide to Ethics: A Map for the Moral Maze,
Referrals, chapter 10.

4.31 Incidentreporting

C D G
In this scenario, the patient has become increasingly unwell because he has
not received the antibiotics he needs. Your first priority should therefore be
to ensure that the antibiotics are made available as soon as possible. The best
way to do this is via the pharmacy (C) rather than taking them from another
ward (A). The antibiotics may either be unavailable or needed by other patients
on other wards. Although prescribing the readily available second line anti-
biotic may be easier (E), you should only use second line drugs once first line
agents have failed. A further priority is to ensure that this error is investigated
and addressed to ensure that it does not happen again. The best method for
incident reporting is by using an incident form (D), although you should also
inform the ward manager since they are responsible for the running of the
ward (G). Although it may be appropriate to make the consultant aware of the
incident (F), this is not an immediate priority, and they are not best placed to
deal with the problem. While the nurse should be made aware of why drugs
need to be given as prescribed (H), it is not your place to do this. The need for
further education or training will be identified and acted upon through proper
incident reporting.

Recommended reading
General Medical Council (2013), Explanatory guidance, in Good Practice in
Prescribing and Managing Medicines and Devices, paragraphs 17-19.
 Answers 285

4.32 Patient handover

B E A D C
This question tests your ability to prioritise patient care despite the potential
for conflict between work and personal commitments. As an FYl, you
should make sure that patient safety is put first while also delegating where
appropriate, so long as you can ensure a safe handover. Option C is clearly
the least sensible in this scenario as you have not responded to a colleague's
request for help and, without assessing the patient, are potentially jeopardising
patient care. Ir is also worth remembering that posting jobs on an electronic
handover system may alter the perceived urgency of addressing tasks. The
most appropriate response to this situation is to fully assess the patient (as you
would at any time of day} and ensure that any necessary investigations are
ordered (options Band£). It would be sensible to hand over the chasing of
outstanding results to the evening ream (a verbal as well as written handover is
often safest) so that you can leave work and get enough rest before your next
shift (B) and also potentially attend part of your social engagement. Waiting
for the results to come back is unnecessary (E) as long as you facilitate a safe
handover. Option A, while initially demonstrating professional behaviour by
undertaking a clinical review of the patient, lays subsequent responsibility
on your colleagues, bur it would be safer and more courteous to initiate tests
and management yourself. Option D is unprofessional because, although your
investigation may be appropriate, you should always assess a sick patient in the
same way: through history and examination first. This demonstrates a shirking
of responsibilities and is only slightly more preferable to option C because you
are initiating management (albeit blindly).

Recommended reading
General Medical Council (2009), The New Doctor, paragraph 6.
General Medical Council (2013), Good Medical Practice, paragraphs 15, 26, 35,
44,45.

4.33 Non-accidentalinjury

C E F
Child protection is a vital part of working with children and young people,
and every professional has a responsibility to raise concerns if they are
worried rhar a child may be at risk. In rhis case, iris possible rhar the child
received these injuries as a result of physical abuse. The welfare of the child
is paramount and continuing to take a history, examining the child and
treating their burns would be the first priority (F). Raising concerns with
parents can often be difficult particularly for junior staff, bur it is your
responsibility (regardless of seniority) to flag children who are potentially
at risk to the appropriate person. In this case, the most important person
to discuss your concerns with is the consultant in charge of the emergency
department (E). The consultant will have the experience and knowledge to
guide you through the relevant procedures and will likely take a central role
 286 Chapter 4: Patient Focus

in the case. In the majority of cases, it is appropriate to inform parents or

guardians if you have concerns over their child's safety (C). This transpar-
ency can avoid conflict in the future and maintains an honest relationship.
There are certain situations where not informing the parents may be appro-
priate, for example if there were concerns that this would put the child at
furrher risk; but this is not the case here. While asking for the help of a
senior doctor is not wrong, you would be expected to perform the initial his-
tory and examination in your role as a junior doctor; therefore, option A is
inappropriate. The fear of offending parents is not a reason to forgo inform-
ing them of your concerns (B), while inflammatory comments such as those
in option D are unlikely to help the situation. While the police are likely
to be involved at some stage of the investigation (options G and H), your
immediate priority involves treating the child and information gathering and
sharing, which should be done with the support of the consultant in charge
of the department.

Recommended reading
General Medical Council (2012), Explanatory guidance, in Protecting Children
and Young People: The Responsibilities of all Doctors.

4.34 GPtreatment final

D E A B C
This situation refers to giving patients the knowledge they need to make
informed and autonomous decisions about their own care. Empowering
patients in this way helps to increase compliance with treatment. This is a
difficult situation because you are not one of the members of the team in this
setting, and it is harder to interject as an outsider. However, it is important for
improved patient care that this issue is flagged, even though you do not have a
direct duty of care for the patients. Therefore, the best response here would be
to raise your concerns with the GP (D) so that you can gain further informa-
tion and understand his reasoning for the way in which the consultation was
conducted. The next best response would be to raise the issue with the practice
manager (E) so that they can investigate the matter further. Discussing the
topic informally with the practice staff {A) ranks higher than the remaining
two options, but it may be misconstrued as gossiping about the GP in ques-
tion. The worst option would be to do nothing (C) as this means that nothing
will change. Asking to learn from another GP (B) would be equally ineffective,
although, by doing this, you would at least be improving your own learning
so as to benefit patients in the future, which is why this is the fourth ranking
option.

Recommended reading
General Medical Council (2013), What to Expect from Your Doctor: A Guide
for Patients.
Medical Protection Society (2012), Patient autonomy and consent, in MPS
Guide to Ethics: A Map for the Moral Maze, chapter 8.
 Answers 287

4.35 Consent for blood test

E B A C D
This scenario poses a number of issues surrounding consent, capacity and
your duty of care to your patients as well as ensuring that you are acting in
your patients' best interests. In order to have capacity, a person must be able
to understand and retain information given to them about a course of action,
use this to weigh up their decision and then be able to communicate their
decision to the relevant practitioner. Ir is important to remember that patients
who have an established diagnosis of a cognitive deficit (such as Alzheimer's
disease) should not be assumed to lack capacity. In this scenario, a repeat blood
sample is clinically imperative, particularly if the patient is at risk of sustain-
ing a significant bleed from a fall. For this reason, omitting the repeat sample
is unacceptable and outright negligent, so option D comes last. Patients with
dementia are often disorientated, particularly in new environments, so it would
be appropriate in this situation to wait a while before attempting to assess
capacity to take the sample (E). Escalating this to your registrar would be
sensible if you were struggling with this lady's care (C); however, you should be
able to determine yourself whether your patient has the capacity, at this point
in time, to decline the blood test. Therefore, option B ranks second. Nursing
staff can be very successful in calming down agitated patients, so it would be
reasonable to ask them for help as your next course of action (A), before your
registrar who is most likely tied up with other patients.

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together, paragraph 75-76.
Mental Capacity Act (2005), chapter 9, pp. 5-6.

4.36 Jehovah's Witness

C E G
Adults can refuse any aspect of treatments if they have the capacity to do so.
One of the more common causes for refusal of treatments is religion, and
a typical example is the refusal of blood products by Jehovah's Witnesses.
Different people interpret their religion in different ways, and it is important
to assess exactly what the patient would accept and not accept well in advance
of any surgery. The correct responses here include option E: to let the theatre
staff know in advance of the patient's wishes so that they can accommodate
them and prepare alternative equipment if needed. Similarly, letting the
consultant who is performing the surgery know in advance (G) allows them
time to prepare alternative operative methods. The patient's expressed refusal
of treatment should additionally be written down, and hospitals often have
special forms for this (C); these prompt the correct questions and allow you
to go through all of the available options with the patient. It is not necessary
for the patient to get a legal document to refuse blood products (B), although
it is safer from a medico-legal point of view to get a signed and witnessed
 288 Chapter 4: Patient Focus

declaration from them. Simply documenting the patient's decision in their

medical notes (H) is not sufficient as such important details might easily be
overlooked in the notes, and they may inadvertently receive blood unwillingly.
ignoring the patient's requests and giving blood (F) can amount to grievous
bodily harm, prosecutable in the criminal courts of England, so this is entirely
unacceptable. Asking a patient to give monetary compensation for their
different beliefs (D) is unprofessional and goes against much of what the
National Health Service stands for. Finally, option A is also inappropriate; as
an FYl, advising patients on surgical options for serious conditions is beyond
your competence and is best left to more senior doctors.

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together, paragraphs 44-50.
Joint UK Blood Transfusion and Tissue Transplantation Services: www.
rransfusionguidelines.org. uk.
Mental Capacity Act 2005, Advanced decision to refuse specified medical
treatment.

4.37 Advanced directive

B D A C E
Advanced directives allow people to make decisions about their medical care
should they lack the capacity to do so in the future. Like wills, they do not
need co be signed by a lawyer, but it adds to their credibility if they are. They
should as a minimum be signed by the patient and by a witness. Relatives are
not allowed to overrule the advanced directive unless they have lasting power
of attorney (whereby the patient signs over their power for decision-making
to someone else in case of lack of capacity). The patient can overrule the
advanced directive themselves if they retain capacity. lt would be appropri-
ate in cases where there is conflict over the statements in the advanced direc-
tive to contact the lawyer who has countersigned it to check its legal validity
(B). The second best option is D, which also includes getting more help and
information, this time from a medico-legal point of view. Your malpractice
insurer is there to offer advice and guidance on the legality of complex ethical
and legal scenarios. The next best responses are to talk sympathetically with
the patient's wife (options A and C). Your registrar probably has more experi-
ence with advanced directives and should ideally speak to the patient's wife
with you (A), rather than you alone (C). The only truly inappropriate response
here is to treat the patient with antibiotics without further investigation into
the validity of the advanced directive (E). This can amount to assault. There
are some circumstances when you can challenge the validity of an advanced
directive; if treatment options have significantly improved since the directive,
which they do not specify in the document, if the person's religion has changed
to be one that forbids declining treatment or if you believe that the patient may
have been coerced or entered into the advanced directive without sound mind.
 Answers 289

Your medico-legal insurer would be able to give you advice on how to chal-
lenge an advanced directive, should you feel the need to do so.

Recommended reading
Mental Capacity Act 2005.

4.38 Refusal of treatment

C A E
Adults who have capacity have the right to refuse treatment. Any decisions
that they make must be respected, even if this may result in their death. Ir is
therefore important in this scenario to establish whether this patient has the
capacity to decide whether she wishes to receive oxygen (C). This is a difficult
situation, and assessing capacity can be difficult. It would therefore be prudent
to ask for support from someone more senior, such as your registrar and/or
your consultant (options A and E). It would be inappropriate at this stage to
complete a DNACPR form (B), given that capacity has not yet been established.
Similarly, it would be inappropriate to leave the oxygen off indefinitely (G) or
to sedate the patient against her wishes without any assessment of capacity (H).
A seemingly irrational decision is not necessarily an indication of mental
illness, so seeking advice from a psychiatrist is not necessary (F). Calling the
crash team is also unnecessary at this stage (D). The solution to the deteriora-
tion in the patient's condition is oxygen, which you are equipped to provide, if
appropriate, without the help of the crash team.

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together, paragraph 5, 43; Legal annex.

4.39 Capacity

E B A C D
In order for a patient's consent to be valid, the patient must have the capacity
to make a decision about the proposed investigation or treatment. Capacity
may fluctuate and can be affected by factors such as pain, confusion or prob-
lems with memory. In this scenario, it is important to discuss your observations
with your consultant (E). The issues surrounding capacity and consent can be
difficult and should ideally be handled by a senior. ln addition, the consultant
may have felt chat, at the time of gaining consent, the patient had the capacity
to make the decision, although she may have subsequently forgotten some of
what was discussed. Assessing the patient's capacity yourself is also a suitable
response (B). The patient may simply need some extra assistance, such as a
written explanation of the procedure to keep as a reminder. The nursing staff
should have a good insight into the patient's normal state and may be able to
give you information about whether they feel that the patient has deteriorated
(A). However, even if the patient has deteriorated, she may still have capac-
ity, which is why option B is preferable. Cancelling the colonoscopy at this
 290 Chapter 4: Patient Focus

point (C) is inappropriate since you have not assessed the patient's capacity.
To continue with the colonoscopy without addressing your concerns (0) goes
against your duty as a doctor and therefore ranks last.

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together, paragraphs 62-74.

4.40 Patient unsafe at home

C D B A E
In this scenario, your first priority should be to establish whether the patient
has capacity to make this decision (C). Regardless of whether the patient
has capacity or nor, you should try and reduce the patient's risk of falls
and contemplate whether the patient may be safe if they have increased
care and help at home (0). Getting the patient's family involved (B) would
be very useful; however, the decision ultimately rests with rhe patient and
the healthcare professionals involved in their care. Asking a psychiatrist to
assess capacity (A) should only be an option when you and your seniors have
attempted this yourself and arc not confident about reaching a decision.
Telling a patient that they are unable to return home (E) would be a depriva-
tion of their liberty and should only be carried out if they are deemed not
to have capacity, and subsequent measures to increase safety at home have
failed.

Recommended reading
Medical Protection Society (2012), Patient autonomy and consent, in MPS
Guide to Ethics: A Map for the Moral Maze, chapter 8.

4.41 Family disagreement

E D B A C
Sometimes it can be difficult to take on board the concerns and beliefs of
relatives as well as the patient. You should bear in mind that, on the whole,
they are also putting the patient's safety and well-being first. In this situation,
the most appropriate action to take would be option E. This would enable the
family to speak to all professionals concerned with their mother's care and
would give them the chance to voice their opinions and concerns. Informing
the therapy team and asking them to carry our further assessments (D) may
prove useful as they could bear in mind the family's concerns and may come to
a different conclusion. Advising the family to discuss this with your consultant
(B) would not be as useful as an MDT meeting as your consultant would be
unlikely to be able to provide information about physiotherapy and occupa-
tional therapy findings. Option A would be unhelpful and inappropriate as you
should be considerate to those close to your patient. Telling the patient to go
into nursing care (C) would be highly inappropriate, and you should not coerce
a patient into making a decision.
 Answers 291 •

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 33.

4.42 Dementia and capacity

E A C D B
Dementia is a common illness and will be seen frequently during the founda-
tion years. Patients with dementia can often be confused or disorientated.
Capacity to give consent and mental illness are therefore common problems
that are faced. The cardinal rule, which must be remembered, is outlined in
Section 1 of the Mental Capacity Act {MCA) 2005: 'a person must be assumed
to have capacity unless it is established that they lack capacity'. A diagnosis
of dementia does not mean that a patient lacks capacity to make decisions.
Furthermore, it is important to remember that capacity is decision-specific
and time-specific, making the previous consent documents in this case irrel-
evant. The best course of action would be to attempt to assess the patient's
capacity {E). This should be a skill an FYl doctor can complete, and the results
of the assessment would then be discussed with your senior colleagues before
taking further action. Discussing the situation with her family and your consul-
tant {A) would be the next most appropriate course of action. The patient may
be at risk of malnutrition, and an NG feeding tube may be in her best interests.
Requesting a psychiatric review {C) may prove to be helpful; however, a com-
petent FYl doctor should be able to carry out a capacity assessment alone.
While abandoning the procedure (D) would avoid violating the patient's rights,
it would also not help to solve her nutritional needs. The least appropriate
response would be to assume she lacks capacity {B), which is clearly contra-
dicted by the MCA.

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together, paragraph 71.
Mental Capacity Act (2005), chapter 9, pp. 5-6.

4.43 Depression and capacity

B C D
This is a complex situation that involves issues of mental illness, free will and
possibly capacity. You would not be expected to try to make any decision
yourself about the use of the law here {options G and H). Indeed, you can-
not treat medical conditions under the Mental Health Act {H) in any case,
and full assessment would be needed before using the Mental Capacity Act
(G). Option Fis inappropriate as patients must be assumed to have capacity
to make a decision until proved otherwise and making an unwise or life-
threatening decision does not indicate lack of capacity. It would be unfair
to put the responsibility on the daughter co convince her father (A). Indeed,
if she were to coerce him in any way, his consent would be invalid. Firstly,
you should carry out a full mental and physical assessment of the patient (C).
 292 Chapter 4: Patient Focus

Once you are prepared with this information, you should then refer him to
liaison psychiatry (D). Given the need to involve psychiatry, you should leave
any decision to start anti-depressant treatment to them (E). You will also need
senior support from within your ream, so your registrar should be involved (B).

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together, Part 3, paragraphs 62-76.

4.44 Delirium and consent to investigation

A D G
In this situation, ir is clear that rhe ABG is in rhe patient's best interests.
Delirium is a medical emergency and assessing the gas partial pressures and
acid-base status of rhe patient is viral. Options which involve either delaying
(C) or declining to perform the procedure (H) are not appropriate. Likewise,
abandoning the test if the patient is distressed (F) is not one of the best answers
because the results will not be obtained, and an ABC is well recognised to be
a painful test; therefore, it is inevitable that some distress will be caused. Next
of kin do not have a right to consent for patients who lack capacity to make
a decision (B); the responsibility for choosing the action in the patient's best
interests lies with the medical team. While it is not desirable to have ro restrain
the patient, this is important for both your safety and theirs during the test and
can be achieved gently and safely (A). You should document in the notes that
you performed the test without consent, why the patient was unable to consent
and why it was necessary to proceed (D). Lack of capacity is decision-specific
and time-specific, so you should never declare a patient to be globally lacking
in capacity (E). Even if you don't think the patient can understand, you should
always treat them with respect and kindness and explain what you arc doing
throughout the procedure (G).

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together, Part 3, paragraphs 62-76.
Medical Protection Society (2012), Patient autonomy and consent, section:
Capacity, The 'best interest' principle, in MPS Guide to Ethics: A Map for
the Moral Maze, chapter 8.

4.45 Child autonomy

D B C A E
If a patient initially declines a procedure, you should try ro verbally per-
suade them co provide informed consent by ensuring they understand what
is involved and the risks and benefits involved (D). It would be inappropriate
to forcefully perform the blood test in a normally developing child of this age
(E) as they should be allowed co take decisions about their care as much as is
safe. Although option A is better because it does not use physical force, it is
 Answers 293

still an attempt to perform the rest without the child's consent, and it could be
dangerous if they were to physically resist. Option C is better than A because
it is safe; however, you should try ro tackle the problem proacrively rather than
just accepting and recording the refusal. Deferring to your registrar (B) actively
ensures that the issue is dealt with but is not as good as trying to resolve it
yourself. However, if this fails, it may be reasonable to escalate, given the com-
plex capacity issues in question.

Recommended reading
General Medical Council (2007), Explanatory guidance, in 0-18 Years:
Guidance for all Doctors, paragraphs 22-41.
4.46 Withholdingtreatment

B E G
The Mental Capacity Act states that, even if this decision does not seem to
be in their best interests, patients are within their rights to refuse treatment
as long as they have the capacity to make the decision. In this case, the first
thing that you should do is assess the patient's capacity to refuse treatment
(B). Option G should also be high on your list of priorities as, by trying to find
out the reasons for refusing treatment, you may find something you can help
with. Despite the patient asking you not to tell your consultant, this is nor
something that, as an FYl, you should be dealing with alone, and therefore,
asking your consultant for help is important (E). Simply carrying on with the
cannula against the patient's wishes (C) could be seen as assault and should
not be attempted. Option D maybe necessary once you have assessed the
patient, but if she has an acute infection requiring IV antibiotics, a referral to
psychiatry will not be useful in the short term, and she may well be suffering
from delirium that will most likely resolve on treatment. Placing the cannula
purely for hydration (A) is something that can be considered if she does decline
treatment but should not be your first course of action. Neither options F nor
H should be used in this instance as, if the patient is assessed to have capacity,
it is her right to refuse treatment, and section 2 of the Meneal Health Act can
only be used for assessment and treatment of psychiatric disorders, nor for
physical disease.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 31-33.
Medical Protection Society (2012), Patient autonomy and consent, in MPS
Guide to Ethics: A Map for the Moral Maze, chapter 8.
Mental Capacity Act (2005), http://www.legislation.gov.uk/ukpga/2005/9/
section/1

4.47 Questioning consent

E A D C B
lt is crucial that the patient is fully informed about any treatment they are
consenting to. Therefore, the best response here is option E as hopefully in
 294 Chapter 4: Patient Focus

doing this, you will either learn that you were in fact mistaken, or the registrar
will be prompted to go back to the patient and add to the list of risks of the
procedure already discussed. This also avoids undermining the registrar in
front of the patient, which will not only damage your professional relationship
bur could also risk the patient losing trust in their clinical ability. While openly
challenging the registrar (A) seems confrontational, it is better than option D
since, as an FYl, you are not trained to consent people for theatre. It is better
char the registrar is reminded of their omissions in from of the patient so that
rhey can amend the consent form, than you doing this without their knowl-
edge. lf you stay behind to further consent the patient, this won't be recorded
on rhe consent form, leaving the surgeon with the possibility of legal action if
any of these risks occur. Using this as an opportunity to do further research
(C) ranks higher than ignoring your concerns (B) as, although not helping this
patient, at least you will be able to apply this knowledge to similar situations in
the future.

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together, paragraphs 47-49.
Medical Protection Society (2012), Patient autonomy and consent, in MPS
Guide to Ethics: A Map for the Moral Maze, chapter 8.

4.48 Consultant decisions

E A B C D
Option E ranks highest since consultants still need guidance as to how they
work to aid their continuing professional development. In addition, under
the General Medical Council's (GMC) consent guidance, doctors must
listen to and respect their patient's views and share all information with
patients to facilitate their decision-making. This is key to gaining informed
consent. Asking your consultant to further explain the management of the
condition to you and why he recommends surgery over other therapies to
aid your understanding (A) is good practice, but it will not help the patient
in the first instance. Option B, while potentially looking like you are not
helping the situation, is better than C and D since, in these responses, you are
overstepping your knowledge and responsibility as an FYl. This could be seen
as undermining your consultant, which has the potential to make your working
environment very difficult. In particular, suggesting that the patient makes a
complaint about your consultant (D) is wholly inappropriate.

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together, paragraphs 1, 2.
Medical Protection Society (2012), Patient autonomy and consent, in MPS
Guide to Ethics: A Map for the Moral Maze, cha peer 8.
[_ Answers 295

4.49 Consent for children

B D A E C
Consent in children is a difficult area for doctors, and it is always important
to consult more senior colleagues. In this patient, at the age of 15, she could be
deemed able to consent as long as you can prove that she is Gillick competent,
making option B the best response here. Gillick competency is a medico-legal
term that applies to treatment decisions in patients under 16 years of age. If a
minor is deemed competent to retain the necessary information and use it to
weigh up the pros and cons of a decision, they are said to be Gillick competent,
and a procedure can continue without the parents' consent. If she is deemed
to be unable to give consent, in an emergency, you can still operate on her
without her parents' consent under the principle of best interests (D). Trying
to get consent from another relative (A) is not desirable as, if they do not have
direct caring rights for the child, they are not usually allowed to consent the
patient. However, this may be the only option available to you and should be
considered if all other avenues have been exhausted. Waiting for the parents to
make contact (options C and E) is not plausible as this patient urgently needs
an operation, and it would risk further deterioration. Recording in the notes
the reasons why you could not consent the patient is important (£), but it still
leaves you doing nothing to address the underlying reason for why the patient
requires to go to theatre.

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together, paragraph 79.
Medical Protection Society (July 2012), Factsheer, in Consent - Children and
Young People.

4.50 Coercion

C D G
In this scenario, as the FYl, you can only advise Edith and her daughter-in-law
about the treatment options and alert the consultant to your concerns; you are
not in a position to make any decisions for her regarding the optimal treat-
ment. Giving basic treatment information and deferring the decisive component
of the conversation to your consultant (C) therefore encompasses all of these
things. Option G is true: Edith is the person who will sign the consent form,
therefore, ultimately the method of treatment has to be her choice. Option D
is also appropriate as this will allow you to find out Edith's ideas and concerns
without the worry of upsetting her daughter-in-law. Ignoring your analysis of
the situation (A) is unprofessional as this does not make the patient's care your
first concern and therefore goes against one of your duties as a doctor. Option
B involves only communicating the risks of one procedure and the benefits
of another. This would give a biased view of the possible treatment options,
 296 Chapter 4: Patient Focus

which, conversely is as bad as, if nor worse than, the daughter-in-law deciding
the best course of action for your patient. Options E and Hare also not appro-
priate as you risk antagonising the daughter-in-law. Option F is true in that,
as an FYl, you can only suggest treatment options; however, saying you don't
fully understand them would be lying and is therefore deceitful.

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent Guidance:
Patients and Doctors Making Decisions Together, paragraphs 41, 42.
General Medical Council (2013), Duties of a doctor, in Good Medical Practice.
Medical Protection Society (2012), Patient autonomy and consent, in MPS
Guide to Ethics: A Map for the Moral Maze, chapter 8.

4.51 Ectopic pregnancy

A C B D E
This is a question of assessing whether a patient has sufficient capacity ro make
a decision. It is generally accepted that if a person under 16 is deemed 'Gillick
competent' (i.e. able to fully rationalise the advantages and disadvantages of
a decision), then they are able to make their own decisions, and you have to
respect their right to confidentiality, provided that you do not believe them to be
at risk. In this situation, you may deem the patient co be Gillick competent, but
you should try gently to persuade her that she should tell her parents first {A).
A nurse is often a good source of non-threatening support in these situations.
If the patient still flatly refuses, maintaining confidentiality at this stage would
be acceptable too {C). It would not be wrong to discuss this situation with your
clinical supervisor {B); however, chis is an acute situation, and doing this may
delay urgent treatment and investigations. Option D would be inappropriate
if you deem her competent as this would be going against the patient's wishes;
however, at 15 years old, she is still regarded as a child in the eyes of the law, so
it would be more appropriate than refusing medical treatment (E).

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together; Legal annex.
General Medical Council (2013), Duties of a doctor, in Good Medical Practice.
General Medical Council (2013), Good Medical Practice, paragraphs 17, 31, 47,
49, 50.
Medical Protection Society (2012), Patient autonomy and consent, in MPS
Guide to Ethics: A Map for the Moral Maze, chapter 8.
Wheeler R. (2006), Gillick or Fraser? A plea for consistency over competence in
children, BM], 332, 807.
4.52 Coercion

D C B A E
While doctors are required to respect patients' autonomy, it is also impor-
tant that you ensure decisions are made of their own free will. In the case
 Answers 297

of a competent adult who changes their mind, it is necessary to explore the

reasons why. Option Dis the best response in this scenario as, in cases like
this, it is firstly important to maintain good communication within your
team, and as an FYl, it is a good idea to ask someone more senior, with
more experience of treating the patient's condition, to come with you to talk
to them. This is why option D is preferable to C; however, being party to
these discussions can be a valuable learning opportunity for junior doctors.
Option C also ensures that the patient receives the information they need and
would demonstrate good communication skills on your part, which should be
maintained at all times. As previously mentioned, it is important to explore
why he has changed his mind (B) and to ensure that it is definitely his deci-
sion, with no overt pressure or coercion from his son. Talking to the son may
be appropriate and taking a nurse with you is ofren a good idea (A); however,
your first priority should be to talk to the patient. Option E would be inap-
propriate and demonstrates both unprofessional behaviour and a lack of
respect for the son.

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together.
General Medical Council (2009), The New Doctor, paragraphs 6, 9, 10.
General Medical Council (2013), Duties of a doctor, in Good Medical Practice.
General Medical Council (2013), Good Medical Practice, paragraphs 14-17, 27,
31,33-36,44,46-49,68.
Medical Protection Society (2012), Patient autonomy and consent, in MPS
Guide to Ethics: A Map for the Moral Maze, chapter 8.

4.53 Terminal diagnosis

A B E C D
No one else can make decisions for a competent adult, unless they specifically
indicate that they do not want to be involved in their treatment. Furthermore,
you should not withhold information from patients, unless you think that
the information may cause real harm to the patient. 'Harm' should be more
than the patient becoming upset, and you should not be influenced by what
a patient's relatives ask you to do. In this scenario, the patient has a right to
know about her terminal diagnosis as soon as possible. This is a complicated
and delicate situation, however, and is probably best handled by someone
more senior, such as your consultant (A). It is also appropriate to encour-
age the family to tell the patient about her condition themselves (B). While
option E also gives the family the opportunity to tell the patient, giving them
an ultimatum risks damaging your relationship with them and would be
unprofessional. To tell the patient yourself, without consulting the patient's
family (C), is inappropriate and would certainly damage your relationship
with them. Failing to ensure that the patient is informed about her terminal
diagnosis (D) does nor fulfil your responsibility to the patient and is therefore
unacceptable.
 298 Chapter 4: Patient Focus

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together, paragraphs 13-17.

4.54 Cancer diagnosisdisclosure

C B D A E
This question relates to the underlying principles of confidentiality. If the
patient has specifically asked for this information not to be disclosed to his
family, his wishes should be kept (C). Ir would also be appropriate to advise
the wife to talk to her husband about this issue (B). Option D is less appropri-
ate as the patient has already expressed his wishes; he may, however, change
his mind if he realises that the current situation of his family not knowing
his diagnosis may be causing them more distress. Option A is not appropri-
ate as the consultant would only say the same things that you can, so passing
on a difficult situation that you can handle yourself is not ideal. It may be
unavoidable, however, if the situation escalates, and the patient's wife cannot
be placated by a conversation with you. Option E is the least appropriate
response as this involves breaching patient confidentiality against the patient's
specific wishes.

Recommended reading
General Medical Council (2009), Explanarory guidance, in Confidentiality,
paragraph 6.

4.55 Relative phones ward

B A E D C
lt is tempting to provide information in this context because the caller claims
to be a close relative and the questions asked are very basic. However, you do
not know what the patient's relationship with his mother is like and whether
he would even want her to know where he is. Ideally this dilemma would be
solved by speaking to the patient yourself and asking him how he would like
the situation to be handled (B). The next best responses involve not disclosing
any information at all. The nurse in charge would be a good person to involve
if you had concerns (A), although it would be better to handle it yourself.
Option E is quite rude and unhelpful but at least does not involve disclos-
ing any confidential information. By stating that you cannot discuss how the
patient is doing (D), you have acknowledged that he is your patient and is on
the ward, which is a fact he may nor wish to be disclosed. The worst action in
this situation is to answer the caller's questions (C) since, without the patient's
permission, this breaches their confidentiality.

Recommended reading
General Medical Council (2009), Explanatory guidance, in Confidentiality,
paragraphs 9, 64.
 Answers 299

4.56 Giving informationto relatives

D F H
The daughters must not be given any information about their father's condi-
tion without explicitly seeking his consent for chis. le would be inappropriate to
inform chem chat their father has cancer (B), even if this conversation were to
take place with a more senior doctor (A). le is also inappropriate to indicate the
level of care he will require or to assume that he would want to be cared for by
them (options C and E). However, it is rude to refuse to speak to the daughters
and would cause conflict with their father if you suggest that he has informa-
tion he has not shared with them (G). You should therefore listen politely and
attentively to their concerns (F) before explaining that you are not able to give
the information they are asking for (D). Ir would be helpful to discuss the situ-
ation with the patient to find out his wishes and offer support in disclosing the
information to them if he wanted to (H).

Recommended reading
General Medical Council {2009), Explanatory guidance, in Confidentiality,
paragraphs 6-11.
General Medical Council (2013), Good Medical Practice, paragraphs 46-48.

4.57 Safeguarding

C E D A B
This question requires you to maintain patient confidentiality in a situation
that may have safeguarding implications. You should meet your professional
duties in the context of an FYl doctor; therefore, it would be appropriate
to seek advice from a senior colleague. Your clinical supervisor would be
the best-placed person for this {C). Maintaining a trusting relationship and
open communication with the patient is very important and a skill that
is expected of all doctors; therefore, it may be wise to talk to the patient
{a competent adult) to make sure that there is nothing else she wishes to
disclose in confidence {E). If you are concerned about the welfare of one of
your patients, the General Medical Council (GMC) states that disclosing
patient information is appropriate if failing to do so may put the patient or
others at serious risk or if it is likely to help in the prevention or detection of
a serious crime. Social services may be useful if the patient is known to them
already or simply as a source of advice on further action (D). While nurses
are very good at talking to patients and it may be helpful to have them
present during difficult conversations, you should not shirk your professional
responsibility to protect your patient by passing on all responsibility to
uncover the information you need to another colleague (A). Speaking to the
parents may, in fact, put the patient at risk of more harm and you should
seek advice from senior colleagues or chose with more experience in dealing
with such manners first (B).
 300 Chapter 4: Patient Focus

Recommended reading
General Medical Council (2012), Explanatory guidance, in Protecting Children
and Young People: The Responsibility of all Doctors.
General Medical Council (2013), Duties of a doctor, in Good Medical Practice.
General Medical Council (2013), Good Medical Practice, paragraphs 12, 14, 15,
16,23,25,27,31,50, 73.
Medical Protection Society (2012), Confidentiality, in MPS Guide to Ethics: A
Map for the Moral Maze, chapter 9.

4.58 STI testing

D E A B C
This is an ethically interesting question because, although your patient is below
the age of consent, he could still be sexually active; however, you cannot make
any assumptions, so you will have to ask some difficult questions.
Option D, to ask his mother to wait outside while you take the appropriate
history, is the most suitable response as it is important to collect all the relevant
medical information, and you are unlikely to get this with his mother in the
room. Stalling until your registrar is available co review the patient (E) is a good
option if you are unhappy about asking such sensitive questions; however, the
registrar may not be happy that you left this task to them. Ignoring the patient's
autonomy and proceeding to the examination, asking the mother for consent
(B), is not appropriate when considering the Gillick principles. Even though this
is not an encounter about contraception, if you think that your patient has the
capacity to consent to sex, you should apply the same principles here, which
therefore means that your patient deserves confidentiality. Lying ro the patient
and his mother about the reason for a urine test (C) is wholly inappropriate.

Recommended reading
General Medical Council (2007), Explanatory guidance, in 0-18 Years:
Guidance for all Doctors, paragraph 42-45, 64-73.

4.59 Mental health consent

C E B D A
If patients are kept in hospital under section for treatment of a mental health
illness (section 3), this applies to treatment of the mental health illness only. As
part of their mental health illness, they are deemed not to have the capacity to
refuse treatment for their mental health illness. They may, however, have capac-
ity to make decisions about other illnesses they have. The best option is to try
and consider some other avenues of treatment as you would with any patient
who was suffering side effects from treatment. So arranging a follow-up appoint-
ment with their haematologist (C) is the best response. Seeking advice from a
senior doctor would also be appropriate (E). This is a potentially life-threatening
decision that the patient is making, so it shouldn't be made lightly. Your registrar
would probably want to speak to the patient themselves about their change of
heart. Option Bis ranked third; if a patient withdraws consent for treatment you
 Answers 301 •

cannot continue that treatment unless they are proven to lack the capacity to
make that decision, in which case it can then be given in their best interests. Until
a formal capacity assessment is made, you cannot continue to treat this patient
against their will. Thinking about the end of life and making plans regarding
end of life should not be considered suicidal ideation, so moving your patient to
a more secure ward (0) is unfair to your patient, and this option is ranked low.
The least appropriate answer is option A, which involves continuing to treat your
patient without their consent because they are under section 3. As mentioned
earlier, you cannot treat patients under section 3 against their will for anything
but their mental health disorder, unless you also have proof that they lack capac-
ity. Treating without consent a competent adult amounts to assault.

Recommended reading
General Medical Council (2013), Legal annex, Common law: Refusal of
treatment, in Consent.

4.60 Inappropriate images on laptop

B D E
This is a serious situation to be faced with, and one which raises a number
of difficult issues, the most important being concerns about your colleague's
fitness to practise. Informing your own clinical supervisor (E) will ensure that
you have the necessary support for taking steps to deal with the issue you
have come across. This is an illegal activity, so although it seems drastic, the
police should be involved (B). It would also be necessary to contact the GMC
(D) as they will be able to determine the best course of action regarding your
colleague's professional licence. The other options, while mostly sensible,
will therefore rank lower than these three, which are the most appropriate
responses. Ideally, your colleague needs to face the situation and inform his
clinical supervisor himself, but if needs be, you will have to report the issue
yourself (C). While investigation into whether your colleague will have contact
with children in the workplace might help you decide how urgent the issue is
(G), you will still have to report it regardless of whether this is likely to happen.
Agreeing with (A) or even offering to help (H) your colleague would involve
not reporting the issue, so these options are inappropriate. You may even be
implicated yourself by carrying out either of these courses of action. It is not
your place to interrogate your colleague (F), and this should be left to your
senior colleagues, the GMC and the police.

Recommended reading
General Medical Council (2013 ), Good Medical Practice, paragraph 25.

4.61 Wrong site surgery

B E H
Wrong site surgery is a National Patient Safety Agency 'never event'. In this
situation, your duty of care lies with the patient, and you should not be afraid
 302 Chapter 4: Patient Focus -1
to raise your concerns despite your consultant's seniority. Your priority in this
situation would be to postpone or delay the operation until the correct site has
been confirmed. Options B and E, asking the consultant to stop and discuss or
to review the x-rays, would allow you to delay the operation until the docu-
mentation has been checked. Option H would also be a safe option as it would
announce your concerns to the whole surgical team. Informing the SpR (G) of
your concerns would not necessarily prevent a potential wrong site surgery as
they may not relay these concerns to the consultant operating on the patient.
Although the consultant will have examined the woman before operating on
her, allowing him to continue (F) would not be appropriate if you have con-
cerns. Asking to see the pre-operative notes (D) or asking the nurse to view
the patient's notes (C) will identify the correct site for the operation, but these
responses might not delay the initial incision. Asking the consultant to operate
on the other limb without checking any documentation or images (A) is poten-
tially dangerous and is not good practice.

Recommended reading
National Patient Safety Agency, Never Events Framework 2009/10.

4.62 Chaperones

B A C E D
This situation is difficult because a DRE should be part of the examina-
tion of any patient presenting with lower abdominal pain, constipation or
a history of lower or upper gastrointestinal bleeding. Therefore, if you feel
that there is a clinical need, the examination should always be performed.
However, this examination can sometimes wait if the patient is not acutely
unwell. In this scenario, the patient is not acutely unwell, and therefore, the
examination could wait, making option B the most appropriate response to
ensure that you are practising safely. Awaiting one of the nurses to be free to
chaperone for you is sensible (A), although this may be difficult if the shift is
busy. If the patient does not wish to be chaperoned (and they are deemed to
have capacity), then you can perform the examination, but it is vital that you
make sure that this is documented clearly in the notes for legal reasons (C).
If there is no one to chaperone at all, and you do not feel comfortable per-
forming the examination, then document this clearly in the notes, and the
day team can perform the examination tomorrow (E). Relatives should not
be used as chaperones under any circumstances, so this is the least appropri-
ate response (D).

Recommended reading
General Medical Council (2013), Explanatory guidance, Intimate Examinations
and Chaperones.
Medical Protection Society (2012), Morality and decency, section: Chaperones,
in MPS Guide to Ethics: A Map for the Moral Maze, chapter 5.
[ - Answers 303

4.63 End-of-lifeHW

B C D A £
In this scenario, you need to ensure that the patient understands the full impli-
cations of their situation and that they are nor just 'being made as comfort-
able as possible'. The best thing to do therefore is to ask the registrar co go and
re-explain the situation to the patient, co make absolutely sure that they under-
stand (B). The next best response is to discuss the consultation with the registrar
(C) as this may prompt them to return to the patient. Following this, it is best if
a doctor who was present at the initial conversation re-explains the situation, so
this could be you (D), although ideally your registrar should be the one to do this
as they have more clinical experience. In addition, you must be careful that your
actions are not construed as being undermining. Asking a nurse to have this con-
versation (A) is not appropriate as the nurse should not be left to explain things
about the end of life co a patient. However, this would be better than failing to
act on your concerns (E), which would be both unprofessional and unethical.

Recommended reading
Balaban RB. (March 2000), A physician's guide to talking about end-of-life care,
Journal of General Internal Medicine, 15, 3.
4.64 Chaperone declined

A E G
It would be potentially detrimental co the patient's health to omit the examina-
tion, so you should agree to examine them alone (A) as long as you don't have a
personal objection to this. It would be against their wishes to insist on a chap-
erone being present (H). Having a nurse in the room (B) would therefore make
the experience distressing and undermine the patient's trust in you. As you
don't know the nature of the patient's relationship with the relative present, it
could cause extreme embarrassment if you asked them to observe the examina-
tion (C). The examination is important for the patient's care, so it should not
be avoided if ar all possible (F). 1t is unnecessary to ask a senior to perform
the examination instead of you (D), and it will only cause delay and is there-
fore inappropriate. It is of viral importance that you document formally that
a chaperone was offered and declined (E) in order to protect yourself against
any allegation that you intentionally examined the patient unsupervised. It is
important in all examinations or procedures to explain step-by-step what you
are doing, but this is especially the case for intimate examinations (G).

Recommended reading
General Medical Council (2013), Explanatory guidance, in Intimate
Examinations and Chaperones.
Medical Protection Society (2012), Morality and decency, section: Chaperones,
MPS Guide to Ethics: A Map for the Moral Maze, chapter 5.
The UK Foundation Programme Curriculum (2012), Section 7.2: History and
examination.
 304 Chapter 4: Patient Focus

4.65 HIV avoiding blood test

C A E B D
You should not refuse treatment to a patient on the grounds of personal risk.
The most appropriate response is therefore to carry out the procedure (C). The
next best course of action would be to ask a colleague to do this for you (A) as
that would still ensure that the patient received the test they need. However, it
is arguably selfish to expect a colleague to expose themselves to a risk that you
are unwilling to take on yourself. Handing the task over to the night team (E)
is less appropriate than option A because it will delay the test unnecessarily,
and it is also dishonest as it implies that you did not have time to carry out the
test before the end of your shift. Options B and Drank lowest because neither
make any attempt to ensure the test is performed. Documenting that you are
declining to perform the test (B) is more appropriate, however, than claiming
that the patient has refused the test (D), because the latter is dishonest and
therefore deeply unprofessional.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 10.

4.66 Unable to get a chaperone

B A C E D
This is potentially a very serious situation and one that a foundation doctor
may be faced with while working in the community. There is clear guidance
produced by the General Medical Council (GMC) about intimate examina-
tions and chaperones. The guidance suggests that a chaperone should always
be offered to the patient prior to an intimate examination. If a chaperone is
not available or if the patient doesn't want a chaperone, it is possible to delay
the examination or refer them to a more appropriate colleague. However, with
both of these courses of action, it is important to consider whether a delay
in examination could adversely affect the patient's health. In this scenario,
the patient could potentially be suffering from a severe haemorrhage and an
examination is urgently required to assess whether she needs acute hospital
admission. Therefore, as long as the patient is happy for the examination to
continue, you should do so without waiting for a chaperone (B). This situation
puts you in a difficult situation, so asking for support from an educational
supervisor (who has more experience in similar scenarios) would be the next
best response (A). Asking for a colleague to come to the patient's house (C)
would ensure the examination is carried our, but it could delay her receiving
the treatment she requires. Refusing to perform the examination and delaying
her treatment is potentially life-threatening. However, given the choice of
asking the patient to attend the clinic that afternoon (D) or immediately attend
the hospital (E), attending the hospital would ensure any necessary treatment
was available earlier.
 Answers 305

Recommended reading
General Medical Council (2013 ), Explanatory guidance, in Intimate
Examinations and Chaperones.

4.67 Drunk

A E G
In all areas of medicine, you are likely to encounter patients under the influ-
ence of alcohol or recreational substances. It is important not to discriminate
against these patients by refusing or delaying treatment. Therefore, in this
scenario, you should carry out a clinical assessment of the patient without
delay (E) and to the best of your ability. This may be difficult if the patient
continues being abusive, and you should make absolutely sure that your safety
is always considered a priority. Making sure that the patient has regular
clinical observations (A) until he is examined would also ensure that the patient
is not being discriminated against and would make sure that any deterioration,
which could indicate a serious injury or illness, is noticed. You should also
challenge the nurse's comment (G), making them aware that in doing this they
would be discriminating against the patient and informing them of the reasons
why you need to examine the patient promptly. Examining the patient when
they have sobered up (B) is unacceptable as this would delay their treatment,
which could potentially be detrimental to their clinical care. Asking the nurses
to restrain the patient (C) is unnecessary and likely to be counter-productive by
antagonising the patient. Healthcare professionals can restrain a patient with-
out capacity under common law only in an emergency situation if it is deemed
to be absolutely necessary. Asking a senior colleague to examine the patient (0)
would only be appropriate once you have tried to examine the patient yourself
and encountered difficulty. Giving the patient sedation (F) would be dangerous
before you have examined them and also unnecessary unless the patient poses
an immediate threat to others or himself. Refusing to allow the patient access
to emergency services (H) would be immoral and illegal; however, the depart-
ment would be within their rights to discharge an abusive patient once serious
pathology has been excluded.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 57 and 59.
Malone D, Friedman T. (2005), Drunken patients in the general hospital: their
care and management, Postgraduate Medical Journal, 81, 953.

4.68 Keeping promises

B D E
Your consultant has told you that the ward should not provide this service,
and you must respect this decision (D). The consultant has to consider ser-
vice planning and funding issues, which are important. Standing up to your
 306 Chapter 4: Patient Focus l

consultant (F) is likely to cause unnecessary conflict between you because there
are other solutions to this situation. Ir would also be disrespectful to your
consultant if you try to get approval from a different consultant (G) when they
have already told you not to provide the vaccine. You should not go against
their advice and arrange to give the vaccine on the ward (options C and H).
This would be unprofessional, and it is not necessary to keep your promise lit-
erally. As long as you try to make alternative arrangements for the parents (B),
you are nor letting them down. You should be honest and tell the parents the
situation (E) rather than being avoidant and leaving them feeling that you have
either forgotten or broken your promise (A).

Recommended reading
General Medical Council (2013), Duties of a doctor, in Good Medical Practice.
Medical Protection Society (2012), Professionalism and integrity, section:
Keeping promises, in MPS Guide to Ethics: A Map for the Moral Maze,
chapter 3.

4.69 Keeping promise to refer to dentist

A C E
This scenario raises a number of issues: working our of hours, referring
patients and making promises. In this scenario, although it may seem that the
patient has a fairly trivial issue, it could have great implications for his care.
Not only are necrotic teeth a potential source of infection, they are also likely
to be preventing him from earing a normal diet. The best course of action
would be to make sure that the referral is made. 1t would be appropriate for
either yourself (C) or your on-call FYl colleague (E) to make the referral. This
would ensure that your patient is reviewed and your promise has not been
broken. Apologising to the patient ensures good communication, which could
avoid any misunderstandings (A). Waiting until Monday (F) is not appropri-
ate for the clinical reasons already stated. Despite the fact that painkillers will
probably be appropriate (B), the referral to the maxillofacial surgeon is more
important as it will offer senior definitive management. Informing the patient's
dentist will also be necessary prior to discharge (H), bur the priority here is
to tackle the current issue of his broken tooth. Asking the consultant for help
(D) would be appropriate for an unwell patient or for a patient who needed
a senior review, but for day-to-day tasks this is not advised. Informing the
human resources department could be appropriate if staying beyond your paid
hours is an ongoing issue (G), but this is not the priority in this scenario.

Recommended reading
Medical Protection Society (2012), Professionalism and Integrity, section:
Keeping promises, in MPS Guide to Ethics: A Map for the Moral Maze,
chapter 3.
 Answers 307

4.70 Drunk colleague

C B A E D
Part of the General Medical Council's (GMC) fitness to practise literally deals
with physical .fitness to practise medicine. lf you are drunk or overtired, you
are not safe to be treating patients. The best response here is to try and deal
with things at source and advise your colleague to go home (C). Reporting this
incident to a senior, such as your registrar, is the next most appropriate course
of action (B). An overtired and possibly drunk FY l puts patient safety at risk,
and the team leader should be informed if one of their doctors is unfit to work.
Option A is the third best response since, if you know that something about
another doctor's practice is unsafe, it is your dury to do something about it,
even if this means going above and beyond what you are usually expected to
achieve in a day. Options that involve doing nothing are the least appropriate
in this question (options D and E); however, doing nothing and then making
the situation public on the internet (D) is worse than simply doing nothing
at all (E).

Recommended reading
General Medical Council (2009), Explanatory guidance, in Confidentiality,
Principles.
General Medical Council (2015), Declaration of fitness to practice: Guidance on
declaring health issues.
 5 Working Effectively as Part of a Team

Chapter 5
WORKING EFFECTIVELY AS PART
OF A TEAM

QUESTIONS
5.1 Extra on-calls

You are an FYl in orthopaedics. You notice that your colleague is doing many
more on-call shifts than you and the rest of your colleagues on the rota.
Rank in order the following actions in response to this situation (1 = Most
appropriate: S = l.easr appropriate).

A Alert your colleague and tell them to go and see the rota organiser.
H Do nothing.
C Tell your colleague that you can do half of their extra on-call shifts.
D Tell ) our colleague co contact the British Medical Association (BMA) to
alert chem that they are exceeding rhe European Working Time Directive
(EWTD).
E Wair until a point in your rota where you will nor be able to do many of
their extra on-calls and then inform your colleague of the unequal work-
load and offer co share their shifts.

5.2 Colleague faking illness

You are an l-Y1 in general medicine working a weekend on-call shift. Your
colleague calls in sick, so you have co cover both on-call bleeps. Consequently,
your shift is very busy. Later, you sec pictures on a social media site of your
colleague at a music festival, which you know took place on rhe weekend of
your on-call shifts.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Call in sick the next time that you do an on-call shift with your colleague.
B Confront chem about where they were over the weekend.
C Discuss the situation with your colleague's consultant.
D Do nothing: it is easier to leave it alone.
E Tell them that you won't tell anyone if they do two of your next on-call
shifts.
 310 Chapter 5: Working Effectively as Part of a Team

5.3 Colleague deleting records

You are an F Yl doctor working an on-call shift. You are reviewing several
patients on the same ward. In each of the patients' medical notes, you notice
that some of the previous entries have been erased from the notes with a
permanent pen. Jr is nor possible co read what the entries say, bur they arc all
signed by an FYl colleague of yours. The patients are stable and improving and
you identify no issues with their care.
Rank in order the following actions in response to this situation (1 = Most
appropriate: 5 = Least appropriate).
A Confront your colleague and his team during the ward round.
B ignore the entries as the) ha, c clearly been deleted.
C Inform your educational supervisor about what you have seen and ask for
advice.
D Investigate further to see whether you can decipher what has been erased
and only rake action if there is anything serious deleted.
E Speak to your colleague in private about your concerns.

5.4 Failing to escalate care

You arc: an FY2 workmg in a hospital on a medical night shift. A nurse runs up
to you and says that your FYl colleague requires your help. She tells you that he
has been dealing with an unwell patient for over an hour. She says she offered to
telephone some senior for help over half an hour ago, bur he refused help saying
'I've got everything under control'. You arrive to find your colleague attempt-
ing to insert a cannula. You briefly read through the management plan he has
written and notice several omissions. You believe that the patient is likely to he
suffering from sepsis, yet your colleague hasn't prescribed any empirical annbi-
otics. When you offer to help, your colleague refuses and asks you to leave.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Inform the medical registrar on mghts that you have concerns about the
patient.
B justify the rationale for your suggestions to the FY l and offer to discuss
the case further if required.
C Raise your concerns with your colleague's educational supervisor at a
future date.
D Submit a formal complaint to your employer after your shift about your
coJleague's rudeness.
E Tell your colleague to leave and take over the care of the patient immediately.

5.5 Registrar prescribing against protocol

You are an FYl working on a medical team. One of your patients develops an
infection. Your registrar tells you ro prescribe two antibiotics. However, you
 Questions 311 •

know from previous cases that rhe hospital anti-microbial protocol descnbes a
different treatment regimen.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Discuss the protocol with your registrar, and go ahead and prescribe
whichever option they decide on.
B Discuss rhe protocol with your registrar, and only make the prescription
yourself if the regisrrar agrees to the protocol antibiotics.
C Don't discuss your concerns with your registrar, and prescribe the anribior-
ics that they had requested.
D Don't discuss your concerns with your registrar, and prescribe the protocol
antibiotics.
E Tell your registrar that their choice is against hospital protocol and you arc
therefore nor prepared to write the prescription they have suggested.

5.6 Getting help when beyond limits of skills

Y0u are an FYl working on a medical ward at night. One of the patients has
become acutely psychotic overnight, making delusional statements and being
physically threatening towards staff, including hitting one of the nurses. Your
registrar asks you ro get psychiatric assistance immediately, prior to being
urgently called away to a cardiac arrest. However, when you bleep the on-call
psychiatrist, they decline co come see the patient until the following morning,
telling you to use an emergency holding order to keep the patient in hospital
until then, if ncccssa ry.
Choose the THREE most appropriate actions to take in this situation.
A Barricade the paticnr in their room.
B Call hospital security.
C Call the police.
D Call your consultant at home for advice.
E Fast-bleep your registrar and ask chem ro come back to rhe ward.
F Gee senior nursing support from the site manager.
G Give an injection of anti-psychotic medication to calm the patient down.
H Make sure the nurse is alright and administer first aid if required.

5.7 Sick patients

You are working on a general medical ward. One of your patients, a

45-year-old woman, has been complaining of haematemesis for the last
12 hours, vomiting small amounts of blood on a regular basis. She has no
previous history of this. You review her, and although she feels well clinically,
you notice her systolic blood pressure is only 85 mmHg, and her full blood
count shows a drop in haemoglobin by 2 g/dL in rhe last 48 hours. You feel
that she needs an endoscopy, so you contact your specialist registrar for advice,
but they disagree.
 312 Chapter 5: Working Effectively as Part of a Team

Rank in order the following actions in response to this situation (1 = Most

=
appropriate; 5 Least appropriate).

A Ask your senior house officer (SHO) who is also currenrly on the ward.
B Contact your consultant for advice and voice your concerns.
C Follow the advice of the registrar.
D Leave the matter for now but go back and review the patient in an hour to
sec if they arc still feeling well.
E Refer the patient for an upper Gl endoscopy, despite the advice of the
registrar.

5.8 Inadequate equipment

You are working a night shift covering medicine and are contacted to assess a
patient whose oxygen saturations have fallen ro 75~o. You adopt an ABCD.E
approach and decide to give the patient oxygen, take an arterial blood gas
{ABG) and some blood rests and arrange an electrocardiogram (ECG). However,
you cannot find the equipment necessary for obtaining an arterial blood sample,
and the nurses on the ward are also unable to help you locate this.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Ask a nurse to ring around other nearby wards to try and locate the equip-
ment while you stay with rhe patient.
B Ask one of your senior house officers {SHO) to stay with the patient while
you locate the ABG equipment you need.
C Contact the on-call medical registrar and explain the situation to them to
get advice.
D Decide not to do the ABG as you can't find the necessary equipment but
tell the nurses to get back in contact with you if the patient deteriorates
further.
E Go to the other wards and try to locate the ABG equipment yourself.

5.9 Leaving sick patients

It is 10 minutes until your FYl on-call shift finishes, and you are asked to see
an unwell patient who has acute chest pain and has become tachycardic and
tachypnoeic. You assess the patient and decide that they need an echocardio-
gram (ECG), a full set of bloods, an arterial blood gas {ABG) and a chest x-ray.
After your full assessment, you realise that your shift should have finished
20 minutes ago, bur your plan needs to be commenced.
Choose the THREE most appropriate actions to rake in this situation.
A Ask the clinical support workers to take the bloods and ECG while you do
the other jobs.
B Ask the nurses to pass on the message to the on-call doctors to complete
the task; then go home.
 Questions 313

C Inform the evening senior house officer (SHO) of this patient and ask them
to complete the required jobs.
D Inform the on-call registrar of this patient and ask them to complete the
required jobs.
E Inform the SHO of the patient and offer to complete the jobs if they arc
currently looking after other acutely ill patients.
F Put out a crash calJ to summon senior doctors quickly to look after this
patient; then leave.
G Stay late to complete the jobs yourself and escalate the situation if necessary.
H Write a message on the handover hoard and leave without verbally handing
over the remaining jobs.

5.10 Competence

You arc working at an ENT (car, nose and throat) firm and arc caring for a
patient who has had a severe nosebleed. The patient also has a mitral valve
replacement. and your registrar requests on the ward round char you put the
patient on prophylactic antibiotics ro protect them from bacterial cndocardiris.
You have recently read some guidance from the National Institute for Health
and Care Excellence (NICE) that recommended that antibiotics should not be
routinely used for prophylaxis in patients with prosthetic valves and should
only be used to treat suspected infection in this cohort.
Choose the THREE most appropriate actions to take in this situation.
A Ask your FY 1 colleague to prescribe the antibiotics as you don't want to
take the bla me for incorrect prescribing.
B Discuss the need for antibiotics with microbiology and act according to
their advice.
C Don't prescribe the annbiorics and neglect to tell your registrar why, to
save his embarrassment at this mistake.
D Inform the registrar of the NICE guidance during the ward round in front
of the patient.
E Mention the NICE guidance afrer the ward round and discuss with your
registrar whether the patient really needs the anribiorics.
F Prescribe the antibiotics and suggest that you have a teaching session on
anri-rnicrobials ar your next departmental meeting.
G Prescribe the antibiotics and then telephone your consultant to check if this
is the right course of acrron.
H Prescribe the antibiotics without mentioning the new guidelines to your
registrar.

5.11 Consultant advice

You are working as an FYl in the emergency department. You clerk a patient
complaining of chest pain, who has an abnormal electrocardiogram (ECG).
You are unsure of rhe exact management plan and ask a consultant for advice.
He tells you not to worrv about the ECG changes and ad, ises ~ ou to discharge
 314 Chapter 5: Working Effectively as Part of a Team

the patient. You are worried that the consultant has given y ou the wrong ad, ice
and feel that the patient needs to be admitted instead.
Rank in order rhe following actions in response to rhis siruarion ( 1 = Mosr
appropriate; 5 = Least appropriate).

A Arrange for the patient to be admitted.

B Ask another consultant for a second opinion.
C Ask a registrar for their advice.
D Discuss your concerns with the consultant.
E Ignore your worries as the consultant probably knows what he is doing.

5.12 Referral to another specialty

You are an FY l on a care of the elderly ward. One of your patients has been
confused and, therefore, has Jud J computed tomography (CT) scan of their
brain. The scan shows that your patient has bilateral subdural haernarornas,
and the report recommends seeking ,l neurosurgical opinion. Your patient is
stable. You find the neurosurgical ream intimidating, and they have rudely
rejected one of your referrals before. You do not wish to make the referral
yourself, bur your senior specialist registrar (SpR) is in clinic and your senior
house officer (SHO) is not at work today.
Rank in order the following actions in response ro this situation (1 = Most
appropriate; 5 = Least appropriate).

A Ask the evening on-call team co make the referral.

B Leave it until tomorrow ro make the referral when your seniors are on the
ward.
C Make a referral to the neurosurgical ream yourself.
D Ring your SpR 111 clinic and ask them to make the referral.
E Tell the patient char there is no treatment available, without speaking to the
neurosurgical team.

5.13 Nurse questions your competence

You are an FYl working on a busy gasrroenrerology ward and are asked to
prescribe anti-emeries for a parienr who is persistently vomiting. You rake
an appropriate history from the patient and perform a full examination. You
decide that the appropriate course of action is ro prescribe some anti-emetic
medication and give some intravenous fluids. After you have completed your
management plan, the nurse who is caring for the patient reads it and says that
she disagrees. She refuses to give rhe prescribed medications.
Choose the THREE most appropriate actions to take in this situation.
A Ask another nurse co give the medications you have prescribed.
B Ask rhe nurse what her concerns are about the prescription.
C Ask your senior house officer (SHO) t0 review your management plan.
D Change the prescription co a different anti-emetic and ask her to administer
that instead.
 Questions 315

E Complain to rhe ward sister about the nurse in quesnon.

F Explain your rationale for prescribing the medications to the nurse.
G Omir the anti-emetic and just give the intravenous fluid.
H Return to the patient and repeat your history and examination in case you
missed something.

5.14 Colleague wants to be a surgeon

You are working as an FYl on a general surgery ward wirh a fellow fYl
colleague. Your day includes completing the ward round, raking the blood tests
and completing the jobs list. Your colleague has repeatedly stressed her desire
to become a surgeon. You have discussed your career preferences several times
with her, and )'OU have said that you don't know what career path you would
like to take. After four weeks in the job, you notice your FYI colleague is
leaving the ward most days at I. j() pm to go ro theatre to practise skrn sutur-
ing. When you ask your colleague about this she says, 'I should go to theatre.
An) way, you don't w ..111t to do surgery.'
Rank in order the following actions in response ro this situation (1 = Most
appropriate; 5 = Least appropriate).
A Allow your FYI colleague to attend theatre, completing the jobs list on the
ward you rscl f.
B Ask your senior house officer (SHO) one day if they could complete the
jobs list so you can attend theatre.
C Attend theatre with your colleague.
D Inform your clinical supervisor that you are not getting to spend any time
in theatre.
E Inform your colleague that, although you are unsure of your career choice,
you would also like the opportunity to attend theatre" hilc she stay son
the ward.

5.15 Colleague not competent with ABGs

You arc working as an FYl in a busy respiratory firm. As pan of your job,
many patients require arterial blood gases (ABGs) to be done. Usually you
have five or six ABGs ro complete each day. You have noticed that your FY1
colleague always asks you ro do the ABGs while she completes other tasks.
You now feel very competent at doing ABGs. After several weeks, you overhear
your colleague saying to your senior that she doesn't like doing ABGs because
she finds them 'too hard'.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Discuss the situation with your colleague and explore her reasons for
avoiding doing ABGs.
B Discuss the situation with your colleague's educational supervisor.
C Offer to complete all of the ABGs on the ward so that your colleague
doesn't feel embarrassed.
 316 Chapter 5: Working Effectively as Part of a Team

D Offer to reach > our colleague your technique and give advice about how to
carry out the procedure.
E Refuse ro carry our any further ABGs in the hope that this will force your
colleague to develop her skills.

5.16 Training

You are the FY 1 on a busy respiratory ream. You have a long job list, including
inserting several cannulas and completing three discharge summaries. Your
registrar biceps )OU and asks if you can insert a pleural drain in a patient as
rhis needs to be done in the next few hours, and he is occupied in clinic for the
foreseeable future. You have never inserted a pleural drain before, bur you have
observed the procedure when you were a medical student. You are aware that
the FY2 on your team has carried out the procedure several times since starting
this job.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Agree char you will insert the drain if the FY2 is available co supervise you.
B Agree to insert the pleural drain and ask an experienced nurse to assist you.
C Politely request that the registrar leaves clinic to supervise you inserting the
drain.
D Refuse to insert the pleural drain and continue with your ward jobs.
E Refuse co insert the pleural drain bur offer to contact the FY2 and arrange
for rhem to carry our rhe procedure.

5.17 Registrar illness

You are rhe F Y 1 on a cardiology ream. You no rice that your specialist registrar
(SpR) seems ro be extremely rired and is having difficulty concentrating during
consultations with patients on the ward round. You are concerned that this
may affect their decision-making as well as their relationship with patients.
Choose the THREE most appropriate actions to rake in this situation.

A Approach the registrar, ask if everything is ok, explain your concerns and
suggest they discuss the matter with their clinical supervisor.
B Ask the consultant ro review all the recent decisions the registrar has made.
C Contact your consultant immediarely and explain your concerns.
D Do nothing now as no direct patient harm has occurred and observe rhe
situation from now on.
E Keep an eye on the decisions the registrar makes and discuss any concerns
wirh rhem.
1- Offer co rake over the ward round to give the registrar a break.
G Suggest that the registrar visits their GP.
H Tell the registrar that they need to go home if they aren't well enough to
work.
 Questions 317

5.18 Referring appropriately

You are the FY l on a general surgical ward. You are called by rhe nursing staff
to see a post-operative patient who is experiencmg palpitations. The nurse has
already performed an electrocardiogram (ECG), which you review when you
arrive. This shows fast atrial fibrillation. You know the treatment options for
this condition from medical school bur have not managed it before in practice.
The patienr is otherwise stable.
Rank in order the following actions in response to this situation (l = Most
appropriate; 5 = Least appropriarc).

A Bleep the intensive care outreach team and ask them to come help you with
a sick patient.
B Examine the patient fully, review the notes, then call the on-call medical
registrar, give them a summary of the c ..isc ,111d ask them to come sec the
patient.
C Examine the patient fully, review the notes and then go to theatre to speak
to your surgical registrar for advice.
D Ger your FY l colleague from the neighbouring ward to come help you
assess the patient and initiate a management plan.
E Go to the cardiology clinic to speak to the cardiology consultant for
advice.

5.19 Attendingteaching

You are the FY1 working on a general surgical ward. The job is busy, and the
day when you are due to attend your fY l reaching sessions is your consultant's
theatre day. This results in both your specialist registrar (SpR) and senior
house officer (SI JO) wanting to be in theatre as well, leaving you alone on the
ward. You know that your reaching is mandatory and that it may affect your
ability to progress from FY 1 if you do not attend the required amount of teach-
. .
mg sessions.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Ask a fellow FYl friend co give you their notes from the teaching so that
you stay up to dare.
B Ask rhe FY2 covering the neighbouring ward if they can cover for you
while you attend your teaching.
C Ask your SHO if there is any way they can help )'OU get through the jobs on
rhe ward on your teaching days before they attend the theatre session.
D Bring this matter up with the consultant and ask if there is anyway the
SHO can be let our of theatre during the hours you are meant to be in
reaching to cover the ward.
E Continue co miss the reaching sessions, and let the teaching coordinator
know char it is because you are too busy on the ward.
 318 Chapter 5: Working Effectively as Part of a Team

5.20 Thoroughclinical examination

You arc an f Y 1 working on an orthopaedic ward and have just returned from
your annual leave. You have arrived early at work co review the patient notes
ahead of the consultant ward round. The last entry in the notes for one patient
is from a physiotherapist who had noticed that the patient had a foot drop and
weakness in borh her legs. The consultant had wrirren char a full neurological
examination should be carried out followed h> a referral to the neurologist on
call. You approach your FYl colleague and ask him whether he has done this
yer. He rephes that he saw the patient quickly last night bur did nor fully exam-
ine her and that he doesn't agree with the physiotherapist's findings.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Book a magnetic resonance imaging (MRI) scan of the patient's spine w ith-
out examining them.
B Suggest that you examine the patient while your colleague joins the consul-
rant ward round and then report your findings to the consultant.
C Suggest to your colleague that you both go and examine the patient again
while the consultant does the ward round alone.
D Tell the consultant that the physiotherapist was wrong and that there is no
need for further mvcsrigarion.
E Tut under your breath and leave your FY1 colleague to do the consultant
ward round while you proceed to examine the patient.

5.21 Depressed colleague

You arc one of the doctors working on the medical admissions unit (MAU),
and over the past few weeks, you have noticed that one of your fYl colleagues
has stopped socialising with your team, has been turning up late for work and
doesn't seem to be able to concentrate. No one else seems to have noticed any
change in his behaviour, bur you suspect that something might be troubling him.
Choose the THREE most appropriate actions to rake in this situation.
A Approach your colleague when you arc alone and voice your concerns.
B Make an appointment with your educational supervisor to get some advice
on how you should handle the situation.
C Send your colleague an anonymous text message with some advice on
where to seek help for depression.
D Speak to your colleague's housernates about your concerns and tell them to
look after him.
E Speak to another FYl colleague at a different firm about your concerns.
F Suggest that your colleague speaks to his educational supervisor about any
problems he may be having that are affecting his work.
G Talk to your colleague about your observations while on the ward round so
chat your consultant knows about your worries as well.
H Tell your colleague that he isn't doing his job properly and that patient care
is hemg put ar risk as :1 result of his careless attitude.
 Questions 319

5.22 OGD consent

You are an FY 1 working on a gastrointestinal ward, and you are increasingly

being asked ro consent patients who are due co undergo an oesophago-gasrro-
duodcnoscopy (OGD). You have always declined since you know little ahour
the procedure anc.l have never seen ir performed. Your refusal has, however,
caused delays in some instances.
Rank in order rhe following actions in response co this situation (1 = Most
appropriate; 5 = Least appropriate).
A Continue to decline when asked to consent.
B Do some reading about the procedure so that you can consent in the future.
C Make your ream aware char you are not w illing co consent for chis procedure.
D Observe a colleague consenting a patient for the procedure so that you can
consent in the future.
1:. Observe a morning endoscopy lisr and discuss the risks of rhe procedure
with the endoscopist so that you can obtain informed consent from patients
in the future.

5.23 Treatmentoptions

You arc the .r YI on a medical admissions unir and have just clerked a patient
presenting with a severe flare-up of his inflammatory bowel disease. During
a team discussion, your consultant asks you to refer him to the surgeons for a
bowel resection as he feels that rhis would he more appropriate than medical
management ar this stage. looking back in rhe patient's notes, you sec that,
since his diagnosis, he has only been on steroid therapy.
Rank in order the following actions in response ro rhis siruarion (1 = Most
appropriate; 5 = Least appropriate).
A Do nor refer rhe patient or make any further management plans until you
ralk co your consultant after rhe ward round tomorrow.
B Have a discussion wirh your consultant about other medical therapies and
the patient's past drug history, anJ ask him to clarify why he thinks furrher
medical management should nor be explored firsr.
C Speak to your educational supervisor abour your concerns.
D Talk co your registrar about the consultant's decision and explain rhar you
feel he may henefir from a gasrroenterology opinion with regards ro further
medical management.
E Tell the patient char he needs ro have an operation in order ro conrrol
his disease and say that you will refer him to the general surgeons for
further care.

5.24 FY1 ward round

You are one of rhree FYls working in respiratory medicine. As a ream, you
rake it in rurns co cover the post-rake ward round each day. IIowcvcr, during
 320 Chapter 5: Working Effectively as Part of a Team

the second month of your job, you notice that one of the other FY ls regularly
seems to come up with reasons why they cannot do the ward round as often as
you and your orher colleague.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Ask your consultant ro speak to the FY 1 as you chink this behaviour is
unfair.
B Ask the other FY 1 if they too have noticed the absence.
C Discuss this with the FY l's educational supervisor.
D Do not mention it further as the current situation means that you do nor
have to cover the post-rake ward round every day.
E Speak to the FY J yourself and ensure char they are coping with their work-
load and nor struggling.

5.25 Colleague not coping with bleeps

You are working as an FYl doctor in a district general hospital on call for
medicine at the weekend. You an: covering half the hospital, and an FY l
colleague is covering the other half. Throughout the day you receive several
calls from nurses on the wards your colleague should be covering. They inform
you that they have bleeped your colleague several times, and he hasn't replied.
They say that they have several jobs that need completing on their wards.
Rank in order the following actions in response ro chis situation (l = Mme
appropriate; 5 = Least appropriate).
A Attempt ro contact your on-call FY l colleague and enquire whether he
needs further support.
B Complete an incident form and raise the issue at the next junior doctors
forum.
C Discuss the situation with the on-call medical registrar.
D Go to your colleague's wards and complete the jobs that need doing.
E Tell the nurses to continue to bleep your FYl colleague as you are not
responsible for his patients.

5.26 Working as a team

You are the FY 1 on a busy medical admissions unit, and you are finishing
off your morning jobs before you join your colleagues for lunch. As you are
leaving the ward, a nurse shouts for a doctor as one of her epileptic parienrs is
having a seizure. There is only you and two medical students on the ward.
Choose the THREE most appropriate actions to rake in chis situation.
A Ask one of the nearby support workers to record a set of observations on
the patient.
B Ask the medical students to get some oxygen and an airway adjunct in case
you need it.
 Questions 321

C Ask rhe medical students ro go and see what rhe nurse needs and ask rhem
to bleep you if they need to.
D Ask the nurse to help you protect the patient from any danger but do not
hold them down.
E Immediately go to the drug cupboard to draw up some intravenous (IV)
lorazepam.
F Obtain a history and background from the nurse before attending to the
patient.
G Pretend not to hear the call for help and continue walking to lunch.
11 Sra rr chest compressions on the patient.

5.27 Negligence

You have just started your morning shift and a colleague comes to sec you. She
is clearly agitated and cells you chat she chinks that she has accidentally pre-
scribed an antibiotic containing penicillin for a patient with a penicillin allergy
during yesterday evening's on-call shift.
Choose the THREE most appropriate actions co take in this situation.
A Advise your colleague ro review the patient immediately.
B Ensure that the antibiotic has been stopped.
C hll out an incident form.
D Offer your help in dealing with the situation.
E Review the patient yourself.
F Speak to microbiology to find a suitable alternative antibiotic.
G Tell the patient what has happened.
H Tell your colleague's consultant about the incident.

5.28 Registrar leaving patient fist

You are a surgical 1-Y l. You notice that your registrar has been leaving his
patient list lying around on the ward. On several occasions, he has left it in
a patient's bed area, and chis morning, the nursing staff informed you that a
patient had read their entry on a list left on their bedside table. They had become
upset about the fact that this information about them was so readily available.
Rank in order rhe following actions in response ro rhis situation (1 = Mose
appropriate; 5 = Least appropriate).
A Apologise to the patient and lee your registrar know about it rhe next rime
you get an opportunity to speak co him privately.
B Apologise to the patient, discuss with your fellow FYls and agree ro keep a
careful eye on the registrar to try to notice when he leaves his list around.
C Call your registrar and explain what has happened, asking him to come
back co the ward and talk to che patient.
D Discuss your concerns with your clinical supervisor.
E Put the list in question in the confidential waste bin and let the nursing
staff handle the patient's complaint.
 322 Chapter 5: Working Effectively as Part of a Team

5.29 Nurse vs SpR

You are working in the orthopaedic firm, and you notice that one of the
registrars on the ward, while friendly to you, does not interact with the nursing
staff. The nurses feel that the registrar does not listen appropriately to their
concerns and qucsnons, and he is therefore compromising patient care. They
would like you to discuss this with the registrar.
Choose the THREE most appropriate actions to take in this situation.
A Ask the nurses to communicate the details of their concerns to you so that
you can raise them appropriately with the registrar.
B Ask the ward sister to raise the issue as an advocate for the nurses.
C Discuss with the nurses the registrar who is causing a problem and how
you have noticed this also.
D Do nothing as it docs not impact you directly.
£ Let the registrar know that the nurses are unhappy with his patient care.
F Recommend to the nurses that, while you appreciate their concerns, it
would be better placed coming from them rather than through you.
G Tell the nurses that you have not noticed such a problem.
I I Tell the registrar after tomorrow 's morning trauma meeting that the nursing
staff are worried rhar he is nor listening ro their concerns about rhe patients.

5.30 Colleague's inappropriate comments

You arc the FY l working on a surgical ward. A patient has decided that they
do not wish to have surgery, even though this means they are likely ro die. One
of your FY I colleagues has been making comments such as 'Why are we even
bothering to sec them, they turned down our help' and calling the patient 'an
idiot' and 'attention-seeking'. They never mah. these comments when patients
or staff members outside the FY l team might hear them.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Discuss your concerns with other FY1 son the ward.
B Inform the foundation programme director about your concerns.
C Explain to the FY 1 that they need to respect the patient and their decision.
D Inform the FY l's educational supervisor about your concerns.
E Don't agree with the FYl bur don't say anything further.

5.31 Nurse conflict

You are the FY l working on an acute admissions unit. There is a short-

age of beds in the hospital, and the entire team is under a lot of pressure ro
discharge when possible. The medical team have decided that a young man
with pneumonia is nor well enough to go home. However, the senior nurse
approaches you anJ says rhar she feels he would be fine ro be discharged and
marks him as a planned discharge on the bed manager's board.
 Questions 323

Rank in order the following acnons in response ro rhis situation (J = Most

appropriate; 5 = Least appropriate).
A Complete the discharge paperwork for the patient.
B Change the information on the board yourself so that the patient is not
marked for discharge.
C Ask your registrar to speak to the nurse to clarify the situation.
D Explain to the nurse why the patient is not fit for discharge and ask if she
can change the information on the board.
E Do nothing.

5.32 Poor discharge summaries

You are working as an FY2 doctor on a respiratory ward and receive a phone
call from a GP. The GP reports rhar he has received a number of discharge
summaries from the ward with very little information about the patients' stay
in hospital and incorrectly prescribed medications. The discharge summaries in
question have been completed by your FYI colleague. This is not the first time
that the issue has come ro your attention as you have previously found his sum-
maries to be of poor quality.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Leasr appropriate).

A Apologise co the GP and take no further action so as not to embarrass your

colleague.
B Edit your colleague's summaries after he has completed them to amend any
mistakes.
C Inform your colleague's educational supervisor about your concerns.
D Offer ro complete all of your colleague's summaries for him.
E Offer ro help your colleague by supervising him writing a number of sum-
rnaries to improve his performance.

5.33 Colleague alcohol

You arc an FY l on a medical ward. You notice that ~ our FY l colleague often
arrives late to work and smells of scale alcohol. You feel that his performance is
being affected by this.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Inform your medical consultant.

B Advise your colleague to go to his GP.
C Inform the General Medical Council (GMC).
D Write an anonymous letter to the local newspaper about your colleague.
E Ask your colleague to give a blood sample to test his blood alcohol levels.
 324 Chapter 5: Working Effectively as Part of a Team

5.34 Colleague dispute

You arc an FY 1 working on a busy medical ward. The senior house officer
(SHO) on your team often leaves work early, meaning rhar you end up leav-
ing late. You also feel like they aren't 'pulling their own weight'. One day you
become angry and challenge your colleague directly. Now your colleague will
nor speak to you.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Leasr appropriate).

A Ask to switch medical teams.

B Agree ro divide rhe patients between you and your SHO so a s ro avoid
working together.
C Inform your registrar about the dispute and ask them to mediate.
D Apologise to your colleague and discuss your concerns.
E Relay messages in the future ro your colleague through the nursing staff.

5.35 DNACPR

You are working as an FY 1 on call over the weekend. You and a senior house
officer (SHO) review an elderlj patient who has pneumonia and multiple
co-morbidities and is deteriorating despite antibiotics and IV fluids. The
patient's son is at his hedside and says rhar he rhinks his father is dying. He
also says that his father has previously expressed a wish not to have cardiopul-
monary resuscitation (CPR). The patient is roo unwell and drowsy to discuss
CPR. Your SIIO refuses to sign a Do Not Attempt CPR (DNACPR) form as he
isn't comfortable doing so without speaking to the patient. You disagree with
your SHO and think that a DNACPR should he written.
Rank in order the following actions in response ro this situation (1 = Most
appropriate: S = Least appropriate).

A Inform the SHO's clinical supervisor about the event.

B Explain to your SHO why you disagree and suggest that he talks to a
senior about it.
C Ask the nursing staff nor to call rhc arrest ream if rhe patient arrests.
D Speak to the on-call specialist registrar (SpR) and ask them to write a
DNACPR for rhe panenr.
E Document your concerns in the notes and leave rhe patient without a
DNACPR card.

5.36 Radiologist

You are an FY1 on a general surgical job. On a post-take ward you see a
patient with symptoms and x-ray imaging that suggest bowel obstruction. Your
specialise registrar (SpR) asks you to request an abdominal computed tomogra-
phy (CT) scan by speaking ro the duty radiologist. You explain the situation to
 Questions 325

the radiologist, who rudely refuses and asks you ro 'get one of your seniors to
speak to me so that we can have a proper conversation'.
Rank in order the following actions in response to this situation (l = Most
appropriate; 5 = Least appropriate).

A lnform your registrar and ask them to call the radiologist.

B Tell the radiologist that you arc the surgical registrar.
C Reiterate the reasons why you \\ ant the scan and that your registrar has
requested it.
D Inform your clinical supervisor about the rudeness of this radiologist and
say that you would like ro make a complaint.
E Refuse to escalate to your seniors as they will say exactly the same thing as
you rsclf.

5.37 Rude colleague

You arc working as an FYl on a general surgical ward. You arc reviewing a
patient on an outlying ward when you receive a bleep from a staff nurse, on
your usual ward, asking you to review a patient that she is concerned about.
You return to review the patient and then notice that one of your FYI col-
leagues is on the ward. You ask the staff nurse why they did not approach your
colleague instead of you, to which the) reply char he is rude and patronising ro
the nursing staff.
Choose the THREE most appropriate actions ro rake 111 this situarion.

A Agree to review all the patients that the nursing staff are concerned
about.
B Ask other nursing staff if they have found your colleague's behaviour to be
a problem.
C Inform the matron about your colleague's behaviour.
D Inform your colleague's educational supervisor.
E Refuse ro get involved.
F Speak to your FYl colleague about his relationship with the nurses.
G Tell the nurse that she should discuss her issues with the FYI in question
directly.
H Turn off your bleep.

5.38 Tearful colleague

You are an FY 1 working on a busy general surgery ward. Your FYl colleague
is often tearful and is struggling to cope. She has been asking you to do a lot of
her work for the past two weeks.
Choose the THREE most appropriate actions to take in this situation.

A Advise her to see her GP.

B Ask another FYI to help you out with the workload.
C Ask your registrar ro speak ro her.
 326 Chapter 5: Working Effectively as Part of a Team

D Carry on sharing her workload and wait for her difficulties to resolve.
E Speak co her about her issues.
F Suggest rhar she finds a different profession.
G Tell her that you cannot go on sharing her workload.
H Tell her to speak to her supervisor.

5.39 Argument

You have been working on a busy surgical ward for three monrhs. You and
your fellow FYl have had a particularly busy morning looking after two
patients who have become unwell. Thar afternoon you overhear your registrar
shouting at your 1-Y l colleague because she has nor ordered a scan which they
had asked for during the morning's ward round. Your colleague is visibly upset.
Rank in order the following actions in response co this situation (1 = Most
appropriate; 5 = Least appropriate).
A Advise your colleague to discuss the altercation with her cducanonal
supervisor.
B Pretend you have nor overheard.
C Advise your colleague to tell the registrar that she was upset by what was
said.
D Ask the registrar to apologise to your colleague.
E Tell your colleague that she shouldn't rake things so personally in future.

5.40 Colleague's incompetence

You have just started work as an FYI. You notice that your FYl colleague
working on the same ward avoids performing practical procedures such as can-
nulation. You are concerned that m some instances patient treatment may have
been delayed as a result of you having to perform these procedures for them
instead.
Rank in order the following acrions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Do nothing and keep an eye on the situation to see if patient care is
compromised.
B Ask other members of staff on the ward whether they have similar
concerns.
C Speak directly to your FYI colleague about your concerns.
D Discuss rhc situation wirh rhc rcgisrrar on rhc ward.
E Suggest ro your colleague's educational supervisor that your colleague
attends remedial teaching on practical procedures such as cannulation.

5.41 Consultant kiss

You are coming to rhe end of your job on the medical admissions unit when
your consultant offers to give you some extra reaching. You arc alone in his
 Questions 327

office one evening when he leans across and tries to kiss you. You move away
and ask him to stop, which he docs immediately.
Choose the THREE most appropriate actions ro rake in this situation.

A Avoid the consultant from now on.

B Call the police and report your consultant for sexual harassment.
C Complete the remaining time in the job.
D Discuss rhe event in confidence with your educational supervisor.
E Discuss with your educational supervisor the option of moving jobs for the
remaining rime of the placement.
1- Take annual leave so that you do not have to work the remaining time in
the job.
G Tell your consultant that, while you arc Ilarrcrcd, you feel that it would be
inappropriate to pursue a relationship.
H Warn your female colleagues nor to go co rhe consulranr's office alone.

5.42 Supporting a colleague

You and an FY I colleague work rogcrher on a medical \\ ard. One <lay a week
you are both required to review the patients together on a ward round without
your consultant since she runs a clinic all day. Your consultant has suggested
that you and your colleague alternate reviewing the pancnts so that you gain
equal experience. Over the weeks, you notice that your colleague lacks confi-
dence in reviewing the patients and encourages you co sec them instead.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).
A Discuss your observations with your colleague and encourage him co try
and improve his confidence.
B Do nothing since there is no compromise in patient safety.
C Encourage your colleague to review more of the patients.
D Offer to give your colleague some teaching after work.
E Raise your concerns with your consultant.

5.43 Struggling colleague

One of your FYl colleagues has been making frequent mistakes on the ward,
such as forget ring to fill in clerking booklets full), not keeping notes up to <late
and failing to request important blood tests for patients in a timely manner.
You and your colleagues are feeling increasingly pur upon by the nursing staff,
who prefer to ask you to complete tasks because you are more reliable.
Choose the THREE most appropriate actions to rake in this situation.

A Ask medical personnel to get a locum doctor to cover the extra work you
have ro do.
B Ask the nurses to come to you first and avoid giving work to your
colleague.
 328 Chapter 5: Working Effectively as Part of a Team

C Ask your registrar ru speak with your colleague regarding remedial

train mg.
D Get the rest of your FY l colleagues rogerher so that you can raise your
grievances to your seniors as soon as possible.
E Have a private word with your colleague to ask if they arc struggling.
F Inform your colleague's educational supervisor of their incompetence.
G Keep working hard as you will change jobs on rotation soon, so you won't
have ru work with chem again.
H Offer to teach your colleague some of the basics again.

5.44 Physiotherapist date

You are an FY l working in a district general hospital. During your second

attachment, you work with a physiotherapist whom you get on well with. You
feel rhar there is a romantic spark between you. One day, you sec them in the
corridor, and they ask you if you would go on a dare with them.
Rank in order the following accions in response to chis situation (1 = Most
appropriate; 5 = Least appropriate).
A Refuse ru give an answer, and avoid the physiotherapist as much as possible
in future.
B Decline and explain to them that you can 'r date somebody > ou work with.
C Report the physiotherapist to their manager for inappropriate behaviour.
D Accept bursar rhar y ou'd want to delay the dare until you've moved on to a
new rotation.
E A1..cept and arrange for next week.

5.45 Respecting authority

You are working with another FYl on a busy respiratory ward. This week your
consultant is away on holiday, so the specialist registrar (SpR) is conducting
che daily ward rounds. You notice chat your FYJ colleague is nor coming in as
early co prepare the patient livr with you, nor is he completing his fair share of
the jobs during the day. When you raise your concerns with him that lunch-
time, he says, 'I don't agree with the decisions the SpR is making, and he isn't
the consultant, so J can't be bothered to make an effort.'
Choose the THREE most appropriate actions ro take in this situation.

A Explain to your colleague that his attitude could potentially impact

patient safety and rhar he should think about the wider iruplicarions of his
behaviour.
B Get advice from one of your FY 1 friends on another ward.
C Listen to your colleague but don't make any remarks about his comments.
D Raise your concerns about your colleague with the SpR in question.
E Speak in confidence co his educational supervisor about his attitudes.
F Suggest that he raises any issues he has with rhe SpR so that he can learn
the reasons why those decisions have hecn made.
 Questions 329

G Tactfully explain rhar, as an FY I, he should respect all staff members,

particularly those in positions of authority.
11 Tell your colleague to help you our more as you feel he is nut pulling his
weight.

5.46 Anticoagulatingpatients

You are the FYl working on a general surgical ward caring for a posr-operarive
patienr having had a bowel resection for colorectal carcinoma. As per rhe
protocol, you have prescribed prophylactic low molecular v. eight heparin for the
patient, although his dose is higher than normal as he is ohese. That evening,
the surgical registrar walks towards the ward holding rhe patient's drug card
and says loudly at the nurses' station: 'Which idiot prescribed this anticoagula-
non; do they \\ ant him to bleed out from his bowel resection"!' The nursing
staff point out that it was you.
Choose the THREE most appropriate actions to rake in this siruarion.

A Ask the registrar co perform a case-based discussion with you about the
role of posr-operanve a nricoagu Lui on.
B Ask the registrar to publicly apologise for being rude about you in front of
the ream.
C Ask the on-call haemarology registrar to come and explain ro rhe surgical
registrar why you were correct.
D Cross our your prescription and leave rhe patient wirhour anticoagulation.
E Explain to the registrar, in a voice as loud as the one he used, that you were
following the hospital protocol, so if the patient bleeds, iris not your fault.
F lnform the registrar that you were following the protocol bur that you will
change the prescription if char is what they rhink is appropriate.
G Let rhe registrar know the next day that you were upset by their publicly
calling you an idiot.
H Ring rhe consulranr and ask rheir opinion on prophylactic anticoagulation.

5.47 Punctuality

You work in a team of five FY ls. Over a period of time, you have realised that
one of your colleagues is late to work most days, which puts a lor of pressure
on you for the ward round as you have fewer people to help carry the notes,
write down the management plan and subsequently action any jobs generated.
You think your other colleagues have also noticed this.
Rank in order the following actions in response to this situation {l = Most
appropriate; 5 = Least appropriate).

A As a group, make the decision to come in earlier to get organised for the
ward round.
B As a group, organise a meeting with the FYl and explain how you think it
is unfair that they are late so often.
 330 Chapter 5: Working Effectively as Part of a Team

C Contact the FY l's educational supervisor.

D Continue as you are; it is only for four months.
E Inform rhe consultant of the problem.

5.48 Colleague not arrived for handover

You are an FYl in a small district general hospital. You are working a weekend
on call covering the surgical wards. On Saturday evening, your FY 1 colleague
who is working the night shift does not arrive for handover. The senior mem-
bers of) our team are all in the ..itre at tending an cmcrgencr case.
Choose the THREE most appropriate actions ro rake in this situation.
A Ask an FYl on another ward ro hold the surgical bleep until the FYl
arrives, in case of an emergency arising.
B Call the FY1 '<; clinical supervisor at home.
C Call your colleague co find our whether they are coming and when.
D Go home.
E Inform your seniors in theatre of the problem.
F Stay and be available for any emergency issues.
G Stay and continue with routine jobs.
H Wait in the doctors' mess for your colleague in order to give rhem a hando-
ver when they arrive.

5.49 Consultant acting unprofessionally

You arc an FY 1 working on a trauma and orthopaedics team. You arc shadow-
ing one of the consultants in his clinic as he has offered to provide you with
some teaching. Your consultant is seeing a patient who has osreoarrhriris of
his knee and would benefit from a total knee replacement. Whtie discussing
the options for his operation, your consultant suggests that the patient should
go to a local private hospital for private healthcare. To your own knowledge,
the patient had not previously mentioned wanting to have private surgery, and
you know rhar your consultant does a private clinic at the hospital rhar he
recommended.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A After rhe patient has left the room, ask your consultant why he suggested
private healthcare.
B After rhe patient ha, left the room, challenge your consultant, asking him if
there is a conflict of interest.
C Inform the patient during the consultation that )'Our consultant is acting
unprofessionally and that he may be trying to profit from the situation.
D Say nothing because your consultant didn't suggest that the patient should
necessarily attend his own clinic.
E Seek the advice of a senior colleague.
 Questions 331

5.50 Receiving and acting on feedback

You are working as an fYl doctor doing an on-call night shift. You are asked
to see a patient who is tachycardic and is feeling unwell. You assess the patient
and believe that they arc dehydrated. You documenr your findings in the notes,
take some blood tests and initiate some intravenous fluids. Two hours later,
your senior house officer (SHO) calls you to say that they have just seen the
same patienr. The SHO informs you chat your fluid prescription was wrong,
but the patient is now improving because they have 'sorted them out'. They
inform you that they have formulated a management plan and w ill review the
patient again later in the shift.
Rank in order the following actions in response to this situation (1 = Most
appropriate; 5 = Least appropriate).

A Do nothing as the patient is now stable.

B Go and sec the patient and reassess the situation.
C Make :1 note of the circumstances of the case and complete :10 e-learriing
package on intravenous fluid prescription at a further date.
D Immediately ask your SHO to provide more feedback.
E Wait until the end of the shift and ask the SI IO to prov ide }OU with some
feedback about your management of the case.

5.51 Derogatorycomments on a social media site

You are an FY 1, and an FY 1 colleague of yours has written several public

derogatory comments about nursing sraff on a social media sire. You rhink rhar
this is unprofessional and inappropriate as it may be construed as the general
opinion of the medical profession.
Rank in order the following actions in response to this situation t1 = Most
appropriate; 5 = Least appropriate).

A Confront your colleague and tell them that this is inappropriate.

B Do nothing; everyone is entitled to their own opinion.
C Inform their consultant.
D Ask a mutual friend to speak to them about it.
E Write a comment on the social media sire 111 response to one of the com-
ments, saying that you disagree with it and highlight that this is not the
general opinion of doctors.

5.52 Annual leave

Before you started work as an FYl, you booked flights for a holiday that is
scheduled for during your second FY 1 rotation. Ir is six weeks until your
planned holiday, and you submit an annual leave request. The rota coordinator
contacts you and tells you that unfortunarcly there is nor enough ward cover
for you to take your annual leave.
 332 Chapter 5: Working Effectively as Part of a Team

Rank in order the following actions in response to chis situation (1 = Most

appropriate; 5 = Least appropriate).

A Ask another FY l whether they will swap shifts to cover your ward while
you go on holiday.
B Ask the rota coordrnaror to arrange a locum co cover the w ard while you
go on holiday.
C Cancel your holiday.
D Inform the rota coordinator that, since you booked the holiday before you
started your joh, you inrend to go on the holiday even if rhc ward will he
left understaffed.
E Plan to call in sick so that you can continue with your holiday.

5.53 UTI

You arc an FYl halfway through a week of long shifts. You srart ro develop
the symptoms of a urinary tract infection (UTI). You have had similar symp-
toms before which were successfully treated with anribiorics. You do nor
have any rime off for a few days, so you will not he able to go to your GP
for a prescription.
Choose the THREE most appropriate actions to rake in this situation.
A Ask a fellow FY 1 ro write a hospital prescription for you and take it to the
hospira 1 pharmacy.
B Ask a nurse ro give you the keys co rhe medicine cupboard so that you can
take some antibiotics.
C Ask your registrar to write .111 outpatient prescription for) ou and take ir to
your local pharmacy.
D Explain your siruarion to your consultant and ask for a few hours off so
that you can attend a GP appointment.
E Swap a shift with a fellow FY l so that you can attend a GP appointment.
F Take an afternoon off as sick leave and attend a GP appointment.
G Wait until you next get a day off before attending a GP appointment.
H Write an outpatient prescription for yourself and take it ro your local
pharmacy.

5.54 Unprofessional behaviour

You are eating lunch in the doctors' mess when you overhear some FYI
colleagues laughing about one of the patients on your ward because they are
ovcrweighr. They arc making rude comments, and one of them is performing an
over-the-top impression of the patient, while the others are in firs of laughter.
Rank in order rhe following actions in response co chic; situation (l = Most
appropriate; 5 = Least appropriate}.
A Join in wirh your colleagues; chis is a private joke and means no harm.
B Ask your senior house officer (SHO) for advice on how to deal with this
siruanon.
 Questions 333

C Go over ro your colleagues and reprimand rhem for their unprofessional

behaviour.
D Speak to the individuals involved in the joke priv ately, after the incident,
about the way they discuss patients in future.
F Far your lunch and say and do nothing.

5.55 Leaving on time

You arc an FY 1 on general surgery, and you arc supposed ro be meeting your
partner for dinner after work. Your shift finishes at 6 pm, bur the evening
cover FY1 is late and has called to say that they will only arrive at 7 pm. There
are some johs left over from the day rhar you want ro hand O\'Cr.
Choose the THREE most appropriate actions to take in chis situation.
A Ask one of the senior nurses on rhe ward ro complete some of your jobs for
you so that you can leave on time.
B Call the registrar on evening cover ro complain about the lace FYl.
C Call your partner ro cell chem char you will be an hour lare.
D Continue working through the jobs until the evening cover arrives and you
can hand over the rest.
E Hand over your jobs to the evening registrar.
l- Leave at your designated time and complete the jobs tomorrow a day lace.
G Phone up the FY 1 ro do a quick handover and leave on rime.
H \X'rirc a list of all the jobs and leave ir at the nurses' station on the ward.

5.56 Discriminating against colleagues

You are rhe FYI working on a busy colorecral ward. The ward sister
approaches you and says char one of the male nurses has come to her in con-
fidence complaining that your FY1 colleague was overheard making deroga-
tory remarks a hour a nu rse 's sexua I tty. The si stcr wa nts you ro do somerh i ng
about it.
Choose the THREE most appropriate actions ro take in this situation.
A Ask the sister whether there is any evidence chat this has happened before.
B Politely e xplam char it is 1101 your place to get involved in the situation.
C Say to the sister that you have never heard your colleague make any such
remarks.
D Speak to your educational supervisor ahout the sister's concerns.
E Speak ro your senior house officer (SHO) and registrar and ask whether
rhey have ever heard your colleague make comments such as this before.
F Suggest that the sister speaks to the FY1 in question herself.
G Tell the sister that the nurse in question should speak to your colleague's
educational supervisor and make a formal complaint.
H Tell the sister that you will speak to the FYl in question for her.
 334 Chapter 5: Working Effectively as Part of a Team

ANSWERS
5.1 Extra on-calls

A D C E B
This question relates to honesty, integrity and your personal conduct. The most
appropriate answer is option A, alerting your colleague to the unfairness of
the rota and suggesting that they take matters further. Telling your colleague
to contact the BMA about their working hours (D) would be appropriate but
only after they have raised it locally with the rota organiser. Option C would
be a generous offer, but work should be shared out evenly between everyone
on the rota and should be coordinated by the rota organiser. Option E would
be dishonourable and unfair. Doing nothing (B) would be the least appropriate
response as your colleague is unfairly doing more hours (which may
subsequently adversely affect patient care) and may be unaware of this.

Recommended reading
Medical Protection Society (2012), Honesty, in MPS Guide to Ethics: A Map for
the Moral Maze, chapter 6.

5.2 Colleague faking illness

B C D A E
This scenario relates to personal conduct and your relationship with colleagues.
You must make sure that you remain level-headed and nor respond in an
equally unprofessional way. The most appropriate option would be to confront
them calmly (B) and make them aware that this is deeply unprofessional behav-
iour and cannot happen again. Telling their consultant (C) is less appropriate;
in the first instance, you should speak to your colleague yourself before involv-
ing seniors. However, you may find that this is a recurring problem or one of
many issues surrounding your colleague, in which case you should seek senior
help. Doing nothing (D) would be less appropriate as you should try to prevent
the situation from happening to either you or a colleague again. Option A
would be responding to the incident in an equally unacceptable manner and
would compromise patient safety by decreasing doctor staffing numbers.
Option Eis bribery and is therefore the least appropriate option.

Recommended reading
Medical Protection Society (2012), Chapters 6: Honesty, Chapter 11: Relating
co colleagues, in MPS Guide to Ethics: A Map for the Moral Maze.

5.3 Colleague deleting records

E C A D B
Medical records are legal documents and should not be edited in a way that
is dishonest or deceitful. To delete mistakes, a single line should be placed
 Answers 335

across the record with an explanation as to why you have made the dele-
tion and a signature. Your FYl colleague has acted incorrectly in this sce-
nario by blacking out entries in the medical notes, and you need to raise the
issue regardless of the content of the deleted notes, which is why options D
and Bare inappropriate. The only reason why option D is preferable to B is
that attempting co read the deletion may help co identify issues relevant to
patient care and allow you to minimise potential dangers to the patients you
are reviewing. The best way to raise your concerns would be in a discreet
fashion in a private setting, in order to remain professional and to avoid
embarrassment for your colleague (E). Involving senior support would be sen-
sible as they will be able to advise you appropriately (C); however, you should
attempt to speak to your colleague first to sec whether the matter could be
more easily resolved. Approaching your colleague during a ward round (A) is
overly confrontational and could lead to humiliation and a poor professional
relationship.

Recommended reading
Medical Protection Society (2012), Honesty, section: Records, in MPS Guide to
Ethics: A Map for the Moral Maze, chapter 6.

5.4 Failing to escalate care

B A E C D
Above all else, when working as a doctor, you have a duty of care to all
patients you come across. This is a difficult situation and one you may often
find yourself in when making the transition to a more senior member of the
medical ream. The best option in this scenario would be to discuss the case
with your colleague and try to explain what you think is most important for
the patient and why (B). ln doing so, you will be able to raise your concerns
while ensuring patient safety. If you believe that patient safety is at risk, you
have a duty to raise your concerns there and then. Omitting antibiotics in
a patient who is potentially suffering from sepsis could be life-threatening.
For this reason, raising your concerns after the shift is least appropriate
(C and D). However, if patient safety had been ensured first, raising your
concerns with your colleague's educational supervisor (C) may be more con-
structive than complaining to your employer about your colleague's rudeness
(0). In this scenario, if you have serious concerns about patient safety and
your colleague refuses to listen, the medical registrar should be contacted
immediately ro discuss the situation (A). Asking your colleague to leave
(E) may result in you being able to provide the care you believe the patient
requires; however, you will be losing a valuable source of information and
a pair of 'extra hands' as well as potentially damaging your professional
relationship.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 6.
 336 Chapter 5: Working Effectively as Part of a Team

5.5 Registrar prescribingagainstprotocol

B E A D C
It is important that you bring the issue to the attention of your registrar in case
they are not aware of the protocol and so that you can understand their reasoning
(options A, Band E). You are putting yourself in a potentially risky position by
prescribing out of line with local protocol as this is difficult to defend in cases that
end up in medico-legal proceedings. lt is therefore better to ask the registrar to
prescribe the antibiotics if they still wish to go against the guidelines issued by the
microbiology department (options Band E). Option E ranks lower than B because
it is likely co sound accusatory and does not facilitate further discussion. The next
most appropriate course of action would be to adhere ro your registrar's deci-
sion after discussion (A) as you may discover that there were important clinical
reasons why they recommended against the protocol antibiotics for this patient.
You should always discuss with a senior if you have concerns or questions about
a decision they are making, and this means D and Crank last. Option D involves
not being open with your registrar: going against their instructions in secret is
more likely to cause significant problems than doing it openly. Option C is the
worst course of action here because you are both prescribing against protocol and
neglecting to share your knowledge of the protocol with the registrar.

Recommended reading
Foundation Programme Curriculum (2012), Section 6.2: Evidence, guidelines,
care protocols and research; Section 7.5: Safe prescribing.
Medical Protection Society (2012), Duey of care, section: Scope, in MPS Guide
to Ethics: A Map for the Moral Maze, chapter 4.

5.6 Getting help when beyond limits of skills

B D H
The most important initial action is to check on the nurse who has been
injured (H); you now have a duty to provide care to them as well as the patient.
This relates to your obligation to provide assistance in any emergency that you
witness. With regard to the patient, you are out of your depth trying ro manage
them, and it is therefore important to get senior help. Your registrar is unavail-
able; you know that they are dealing with a more time-critical emergency, and
you should not try to pull them away from this (£). In a situation such as this,
it is appropriate to call a consultant directly for advice, even though it is out of
normal working hours (D). They are in a much more powerful position to deal
with the psychiatrist's refusal and to insist char they attend the ward to help
with the situation. Alternatively, they may decide to call in another registrar or
to attend themselves. In the meantime, you need to get hospital security to the
ward to ensure that the staff and other patients are kept safe (B). Involving the
sire manager would be a good decision (F); however, your consultant is more
likely to facilitate definitive senior medical help in this situation, and security
are well placed to protect everyone who is involved. It is unethical and illegal
to imprison a patient against their will (A) or to force treatment without their
 Answers 337 •

consent (G). Trying to give an injection in chis circumstance would be danger-

ous for everyone involved, including you.
Recommended reading
Foundation Program.me Curriculum (2012), Section 8.6: Manages acute mental
disorder and self-harm.
General Medical Council (2013), Good Medical Practice, paragraph 14.

5.7 Sick patients

A B E D C
This sounds like a patient who is clinically unwell, and while your registrar has
more experience than you, if you are uncomfortable in managing the patient,
you should always ask for help. This makes asking your SHO (A) the most
appropriate action to help you manage the patient. Going over your registrar
to contact your consultant (B) is not ideal as it may affect your relationship
with the registrar in future; however, this is the chain of command and there-
fore would be an appropriate step. Option E would be potentially difficult as
referrals from FY ls are not usually accepted without prior assessment from a
more senior doctor; however, this is the last option remaining where you are
taking immediate action, so it is therefore appropriate here. Option D, while
still maintaining care of the patient, is not ideal because leaving a potentially
unstable patient, whom you are worried about, is not advisable. Option C is
the least appropriate because, although the registrar is more qualified than you,
they have not seen the patient, and you must treat the patient in such a way
that you feel confident that you have fulfilled your duty of care.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 16b, 16d, 18.

5.8 Inadequateequipment

A B C E D
This question focuses on a situation when a patient's care may be affected as a
result of poor equipment or facilities. When presented with a hypoxic patient,
an ABG is an invaluable bedside test to further assess their clinical status. Not
doing an ABG because you cannot immediately find the equipment neces-
sary (D) would be negligent since you are denying your patient an important
investigation that will inform future management. In this situation, it would be
sensible to ask a nurse to try and locate what you need while you stay with the
patient and reassess them (A). Option B is also sensible; however, your SHO
may be busy with other cases, so it is a less favourable response than option A.
Option C is certainly important as it is wise to make your seniors aware of
sick patients; however, there are initial steps that can be taken first to get more
information for the registrar about the patient's clinical status, so this isn't the
first step. Going to another ward to try and find the ABG equipment (E) is sen-
sible; however, ideally you should not leave an acutely unwell patient without a
doctor. You should instead aim to use your colleagues effectively.
 338 Chapter 5: Working Effectively as Part of a Team

Recommended reading
General Medical Council (2009), The New Doctor, paragraph 6.
General Medical Council (2013), Good Medical Practice, paragraphs 15, 16, 18.
Medical Protection Society (2012), Duty of care, MPS Guide to Ethics: A Map
for the Moral Maze, chapter 4.

5.9 Leaving sick patients

A D E
If one of your patients becomes unwell within your scheduled working
hours, you need to assess them fully, even if this is just before your shift fin-
ishes. Ar an appropriate and safe break, you can then consider handing over
jobs to the on-call team. Option A is one of the most appropriate responses:
delegation is an important part of an FYl's job, and you will be very busy if
you do not use the support staff to help you complete your jobs. Delegating
some of the work in this scenario means that you can focus on the tasks that
only a doctor can do, which would make the rest of the management of the
patient much swifter. Option A, followed by an effective verbal handover,
would be one of the best responses. Another one of the most appropriate
responses is option D, to inform the on-call registrar if there is no one else
available to call. They may not complete the outstanding jobs, but they
would need ro be informed of this acutely unwell patient and should come
to review them as well. The third most appropriate response is option E:
informing the on-call SHO to hand over jobs is appropriate, but on-call
teams can be very busy, and you should make yourself available to stay late
to ensure they are performed timely. The inappropriate options include poor
methods of handover, such as leaving a message with the nursing staff (B)
or writing a message on the on-call message board (H) - both could lead to
misunderstandings. A handover board is appropriate for routine jobs but is
not appropriate for handing over acutely unwell patients. Option C, handing
over the jobs to the SHO, is technically an appropriate response, but offer-
ing your help to complete the jobs is more conscientious and responsible, so
option Eis preferable. Knowingly putting our a crash call for a patient who
is not peri-arrest or having a cardiac arrest (F) is dangerous and could mean
that rhe team misses a true arrest. Staying late to complete the work yourself
without considering handover (G) is an inappropriate answer as this could
lead to overwork and tiredness the next day. It is the on-call team's job to
review sick patients out of hours, and you should use them to protect your
own work/life balance.

Recommended reading
British Medical Association (2015), Safe Handover, Safe patients.
Medical Protection Society, New Doctor, vol. 3, no. 1 (2010), What drives a
good handover.
 Answers 339

5.10 Competence

B E F
Treatments and methods in medicine are constantly evolving, and if you are
aware of a new protocol for treatment, it can be useful for your own learning as
well as the whole team to discuss whether it is applicable to your field. However,
you need to consider an appropriate time to discuss new methods with seniors
so as not to undermine their knowledge in front of others. After the ward
round and away from the patient's bedside may be a good time to discuss the
new guidelines and how they may apply to your practice (E). Option B is also
appropriate: the microbiology department will be able to weigh up the different
aspects of this patient's case and will know whether the guidelines should be fol-
lowed. Although delaying learning about the new guidelines to a later teaching
session, in option F the whole team will be able to study the new guidelines in
detail and determine whether they are appropriate for clinical practice. Option
C is inappropriate as you may have misunderstood the clinical situation, and
deciding not to prescribe the antibiotics without further discussion may mean
that the patient is treated incorrectly. Bringing up the new guidelines in front of
the patient (D) undermines the registrar's treatment plan and may concern the
patient and is therefore inappropriate. Saying nothing (H) is clearly unsuitable
as it would mean that the team cannot learn from this new guidance. Option G
is also inappropriate as you should discuss the pros and cons of antibiotics with
the registrar before going straight to the consultant; they will have expected you
to do this first. Option A is the final inappropriate response in this scenario: if
you believe something that you have been asked to do is incorrect, you shouldn't
pass the blame on to somebody else and ask them to do it for you.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 11, 12,
35, 36.

5.11 Consultantadvice

D B C A E
You should never feel afraid to challenge a senior's opinion, particularly if
you think that patient safety may be compromised. Ir is most appropriate,
however, to discuss you concerns with the person in question initially (D).
They may reconsider their decision or provide a good justification for it.
It would also be appropriate to seek a second opinion from another consultant
(B). In this scenario, asking a second opinion from another consultant is more
favourable than asking advice from a registrar (C) since this may be seen as
undermining the consultant in question, and a consultant would have more
experience interpreting such rests than a registrar. You should avoid going
against a consultant's advice without first seeking a second opinion (A), but to
ignore your concern about patient safety is completely inappropriate (E).
 340 Chapter 5: Working Effectively as Part of a Team

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 24, 25.

5.12 Referral to anotherspecialty

C D A B E
As an FYl, you are expected to make telephone referrals for patients to other
colleagues and specialties. This can be a difficult technique to learn, and you
may have to speak to some challenging or intimidating colleagues. As with all
skills, the more experience you gain, the more proficient you will be. Option C
is therefore the most appropriate course of action. If you find that you are not
being listened to, you could ask your senior colleague to try themself. Ringing
your senior SpR and asking chem to make the referral from their clinic (D) is a
sensible option; however, it may prove difficult as your SpR is likely to be busy
and is unlikely to have all the relevant patient information at their disposal
in clinic. Option A is less appropriate since this is a situation chat should be
dealt with in normal working hours and by the patient's own team of doctors.
Your on-call colleagues may be extremely busy, and the referral may not be
completed due to more pressing clinical issues and a lack of relevant staff to
take the referral. Leaving the referral until tomorrow (B) would not be optimal
management for the patient and would result in a delay. However, the least
professional response would be option E as this would be negligent and is
therefore completely unacceptable.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 15-16.
Medical Protection Society (2012), Competence, MPS Guide to Ethics: A Map
for the Moral Maze, chapter 10.

5.13 Nurse questions your competence

B C F
Disagreements are an inevitable part of medicine and how to deal with them is
an important skill to learn. In this scenario, the nurse may be questioning your
competence and decision-making. The key here is to gather information from
the nurse and use that to support your decisions. Asking the nurse about her
concerns (B) and offering an explanation for your plan (F) may raise issues that
you must address or may reassure the nurse that your actions are appropriate.
If this fails to allay her fears, you should not be afraid to ask for a second
opinion (C). Often, as a junior FYl doctor, you will lack experience in dealing
with scenarios and asking for help is not a sign of incompetence. Bypassing
the nurse by asking another nurse to give the medications (A) would not
display good interpersonal skills, and you may miss an important point chat
the nurse might have been trying to make. Switching the prescription without
first discussing this with the nurse (D) would be inappropriate. Without a good
reason to change your original prescription, you should not do so. Omitting the
prescription (G) when you have assessed the patient as requiring an anti-emetic
 Answers 341 •

may lead to unnecessary suffering for the patient and is therefore inappropriate.
Complaining to the ward sister (E) is not a constructive course of action at
this stage and will impact negatively upon your professional relationship
with the nurse in question. Repeating your history and examination (H) may
be appropriate if the nurse raises an issue that you have not thought about;
however, this should only be done after discussing the situation with the nurse.

Recommended reading
General Medical Council (2012), Explanatory guidance, in Leadership and
Management for all Doctors, paragraphs 2, 6.

5.14 Colleague wants to be a surgeon

E O B A C
Attending theatre as an FYl is not an obligatory task and many FY ls struggle to
find the opportunity to do this. Operating theatres can be very valuable learn-
ing environments regardless of your future career choice (particularly for skin
suturing). In this scenario, your colleague is clearly not taking an equal share of
the workload or learning opportunities. The best course of action here would
be to politely ask your colleague if you could attend theatre (E). You have to
remember that your primary role is to look after the patients on the ward, and
you must both ensure that someone is completing that task. This is why attend-
ing theatre with your colleague and thus both of you leaving the ward would be
inappropriate (C). If your colleague does not respond to your polite approach,
the next best response would be to discuss this with your clinical supervisor (0).
They would be able to suggest an appropriate course of action. Asking your
SHO to complete the list (B) could be an appropriate response; however, not as
appropriate as options E or 0. This is because, as an FYl, you have a training
need to spend time in theatre assisting in operations. Finally, simply allowing the
situation to continue while you stay on the ward (A) is not a productive response
and would not tackle the issue of your lack of theatre experience.

Recommended reading
Foundation Programme Curriculum (2012), section 12: Procedures.

5.15 Colleague not competentwith ABGs

A O B C E
Doctors of all levels of training will have different skill sets and different
strengths and weaknesses. As a doctor, you are working as part of a team that
is responsible for providing good clinical care to your patients. The key to this
scenario is that you lack the appropriate information to take action. Therefore,
information gathering must be your priority. Option A would allow you to
approach the topic with tact and get more of an idea as to why your colleague
has been avoiding ABGs. It may be that you can offer your colleague teaching
and advice about ABGs (D) since you have had more experience, and this is a
good way for teams to help each other develop. Option A is preferable to Oas
 342 Chapter 5: Working Effectively as Part of a Team

information gathering will prevent you from causing any unnecessary offence
or embarrassment to your colleague. Refusing to carry out ABGs (E) may
result in your patients receiving suboptimal care and could be potentially dan-
gerous, making this the least appropriate response. Offering to complete all the
ABGs (C) will ensure that the patients have the correct investigations; however,
there will be times when your colleague must perform these skills on her own,
so it is vital that you help to assess her learning needs. Discussing the situation
with her educational supervisor (B) may be appropriate, but firstly you should
approach your colleague about the issue.

Recommended reading
Foundation Programme Curriculum (2012), Core procedures.

5.16 Training

C E D A B
Option C is the best initial choice. Jr is important to take opportunities to acquire
new skills. Learning skills specific to your rotation, such as pleural drainage, is
included in the foundation curriculum. Routine ward jobs should not prevent you
from doing this. The registrar is the most appropriate person to supervise a skill
of this nature, and they arc obligated to make themselves available to their train-
ees whenever possible. Options E and D arc the next best choices as they protect
patient safety. You are nor competent in this skill, so you should not carry out
the procedure without adequate supervision. Option Eis better than D because it
offers to assist the registrar in getting the procedure arranged, which is impor-
tant in building a positive working relationship. Options A and Bare the worst
responses because they involve you carrying out the pleural drain under a less
than adequate level of supervision. Option Bis the inferior of the two because,
although the nurse is experienced, she is not competent in completing the pro-
cedure herself and therefore cannot instruct you. Supervision by the FY2 (A),
though better than supervision by the nurse, is still inadequate as the FY2 has
only carried out the skill a few times. It is therefore less appropriate than refusing
to carry out the skill on the basis of protecting patient safety.

Recommended reading
Foundation Programme Curriculum (2012), section 12: procedures.
General Medical Council (2011), The Trainee Doctor, paragraphs 1.2, 1.3, 40.
General Medical Council (2013), Good Medical Practice, paragraph 9.
Medical Protection Society (2012), Competence, section: Acquiring and devel-
oping new skills, in MPS Guide to Ethics: A Map for the Moral Maze,
chapter 10.

5.17 Registrar illness

A E G
You are concerned that the SpR's competence may be affected by their
tiredness, perhaps related to physical illness or personal stress. You need to
 Answers 343

rake some action; option Dis therefore not one of the best answers. It is always
best to approach the person concerned and discuss the situation sensitively (A).
Ir would be unkind to go straight to the consultant without having spoken to
the SpR first (C), and this could undermine your future working relationship.
It would also be unproductive to 'tell off' the SpR (H), which will cause both
conflict and resentment. You must consider whether there has been any risk to
patient safety, and it is therefore a good idea to consider their past and future
decisions in case you notice any which you think are out of place (E). It would
be an overreaction, however, to ask the consultant to do this (B). While you
should be able to spot any important mistakes the registrar has made, you
are nor competent to be running a senior ward round entirely yourself, so
option Fis not appropriate. If the SpR is having problems with their health, it
is extremely important that they go to see their own GP for investigation and
support (G).

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 28.
Medical Protection Society (2012), Competence, section: Maintaining compe-
tence, MPS Guide to Ethics: A Map for the Moral Maze, chapter 10.

5.18 Referring appropriately

B C D A E
The best person to help you with the management of an acute medical
condition is the on-call medical registrar regardless of whether the patient is
admitted under medicine or surgery (B). It is likely that, if you speak to your
surgical registrar {C), they will simply advise you to bleep the medical regis-
trar. Therefore, although it is usually best to escalate within your ream first, in
this situation, it is reasonable to refer directly yourself as this will ensure the
patient receives appropriate treatment as quickly as possible. It is possible that
your FYl colleague will have more experience of the condition or may be able
to guide you on which senior to contact (0). However, this response is likely to
be slower in terms of getting definitive treatment or may lead to continuation
of the patient being managed solely by FYls without senior help. Intensive care
outreach usually consists of experienced nurses who can assist with stabilis-
ing sick patients and help with decisions about escalating to higher levels of
care. However, the patient in this scenario is said to be stable apart from their
arrhythmia, which is not the area of expertise for the outreach team; therefore,
option A is inappropriate. The worst response would be going to the cardiology
clinic because this bypasses all of the conventional processes of referral, will
delay the clinic and consequently anger the consultant (E).

Recommended reading
Foundation Programme Curriculum (2012), Section 8.1: Promptly assesses the
acutely ill, collapsed or unconscious patient.
Medical Protection Society (2012), Competence, section: Referrals, in MPS
Guide to Ethics: A Map for the Moral Maze, chapter 10.
 344 Chapter 5: Working Effectively as Part of a Team

5.19 Attendingteaching

C D B E A
Teaching as an F Yl is mandatory, and while you are allowed to miss a few
sessions due to holidays and night shifts, you do need to attend a set amount in
order to be able to complete the requirements of FYl. lt is a difficult situation
to manage if you are the only FYl on a team and the SHO is in theatre, as they
also have to attend a required amount of theatre sessions as part of their surgi-
cal training. It is best to address the situation initially with the SHO if you feel
you need help (C). Theatre lists tend to start after 9 am, once the patient has
been seen by the consultant and then been through the anaesthetic process, and
therefore they may have time to help you before the list starts. The consultant
should also be willing to aid you in attending your reaching; therefore, if you
raise the matter with them directly (D), they may be able to provide support for
you on the ward while you attend your teaching. Asking the FY2 on another
ward to help (B) may be a good idea, bur this is nor ideal as they will not know
the patients, and it places an extra burden on them. While getting the notes
from a fellow FYl (A) will enable you to keep up with what happens in the
teaching, it will not account for your absence; therefore, you still will not have
been recorded as having attended the reaching. Ir is, therefore, better to contact
the coordinator and explain your reasons for missing the teaching (E) because
they can then either assist you to be present in the future, or at the very least,
they will now have a record of why you have been absent.

Recommended reading
General Medical Council (2009), The New Doctor, paragraphs 59-67.
Medical Protection Society (2012), Competence, MPS Guide to Ethics: A Map
for the Moral Maze, chapter 10.

5.20 Thoroughclinicalexamination

B C E A D
This question requires you to show the clinical competence that is required
at FYl level: putting patient care first while maintaining good professional
relationships. If you suspect that patient safety is being compromised, you
should act without delay. Option B is therefore the most appropriate as this
ensures rhar the patient is reviewed immediately but does not hold up che
consultant's ward round, which would potentially affect the care of ocher
patients. In doing this, you are also being courteous by communicating
your idea to your FYl colleague. Options C and E are less appropriate as C
involves unnecessarily delaying the ward round, and it probably does not
require two doctors to carry out a neurological examination. Making it plain
to your colleague that you disapprove of their actions before undertaking the
neurological examination (E) may be acting in the patient's best interests, but
your behaviour is not conducive to maintaining good working relationships.
Option D is the least suitable in this instance as you have not examined the
 Answers 345

patient and therefore cannot assume that no further investigation is required;

you would be negligent if you were not proactive when you suspected that
patient care was being compromised. Organising an MRI scan (A) may be
suitable following a full neurological examination, bur it is important that you
have a clear indication when requesting tests. You should complete the plan
as documented by your consultant first and then discuss with your seniors if
needs be.

Recommended reading
General Medical Council (2009), The New Doctor, paragraphs 6, 10.
General Medical Council (2013), Duties of a doctor, in Good Medical Practice.
General Medical Council {2013), Good Medical Practice, paragraphs 7, 15, 16,
25, 35, 36, 56, 57.
Medical Protection Society (2012), Competence, in MPS Guide to Ethics: A
Map for the Moral Maze, chapter 10.

5.21 Depressed colleague

A B F
This question focuses on your responsibility to act if you suspect that you or
someone else's health may be adversely affecting patient care. It is important
to maintain healthy, supportive working relationships, while also making the
care of your patients your first concern. In this scenario, it would be wise to
talk to your colleague in a non-confrontational, private setting to see whether
they want to talk about anything that may be bothering them (A). Broaching
the subject in front of others before you are sure of what is going on {G) is not
conducive to maintaining good professional relationships and may cause both
parties embarrassment. If you are worried about your colleague and the effect
that their health may be having on patients, it would be more appropriate to
talk in confidence to your own educational supervisor {B), before you talk to
your peers (E), since your supervisor will be more experienced to handle the
issue. If an FYl is experiencing personal problems that are impacting their
work, they should contact their educational supervisor to discuss it, and this
would therefore be good advice to give to your colleague {F). While option C is
also non-confrontational, it does not proactively address the issue that may be
jeopardising patient safety. Option H would be an inappropriate way to speak
to your colleague and would not provide support for him or protection for
patients.

Recommended reading
General Medical Council (2009), The New Doctor, paragraphs 6, 10, 12.
General Medical Council (2013), Duties of a doctor, in Good Medical Practice.
General Medical Council (2013), Good Medical Practice, paragraphs 1, 24, 25,
36, 43.
Medical Protection Society {2012), Competence, in MPS Guide to Ethics: A
Map for the Moral Maze, chapter 10.
 346 Chapter 5: Working Effectively as Part of a Team

5.22 OGD consent

E C A B D
It is the responsibility of the person doing the procedure to discuss it with the
patient and gain consent. However, that person can delegate this responsibility
to someone else as long as that person is suitably qualified. The consenting doc-
tor should have observed the procedure, understand what it entails and have
a good knowledge of the risks but does not necessarily need to be qualified to
undertake the procedure. In this scenario, you could avoid delays in patient
care by raking responsibility for consenting. Ideally, you should gain the neces-
sary experience through observing the procedure and learning about its risks
(E). That said, you are nor obliged to take this responsibility, so it is also appro-
priate to inform your ream that you do nor wish to take consent for OGDs (C).
Clarifying your position with your team is preferable to simply declining when
next asked (A). While reading about the procedure may give you some of the
necessary knowledge for the consent process (B), you should have observed the
procedure in order to fully understand what is entailed. Similarly, observing
a colleague consenting assumes that they have the appropriate knowledge and
again you have not observed the procedure (0).

Recommended reading
General Medical Council (2013), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together, paragraph 26.

5.23 Treatment options

B O A C E
This question highlights the importance of providing all possible treatment
options to a patient before gaining consent. This is one criterion of fully
informed consent. It also highlights the need to maintain respect for colleagues
and to communicate professionally if you have reason to question someone
else's decision. Despite being junior, it is important to voice any concerns you
may have about patient care to your seniors. Option B is therefore the most
appropriate action to take since, by doing this, you are proactively voicing a
concern and using the experience as a learning opportunity. Similarly, it would
be appropriate to speak to your registrar (0), although your consultant should
be the first person you endeavor to talk to, if possible, as ultimately they are
in charge of the patient's care. For this reason, delaying the referral until you
can discuss this with your consultant the following day is also appropriate (A),
although this is less preferable as it would delay patient care without resolving
the situation in the meantime. Telling the patient what has been decided about
his management (E) is the least appropriate response as the patient has nor
been given information about alternative treatments, nor has he been invited
to discuss his options for future management with a specialist. Your educa-
tional supervisor can be a source of help and advice in tricky situations (C);
 Answers 347

however, it is unlikely that you would be able to discuss the matter as promptly
as necessary, and as highlighted earlier, the consultant should ideally be the
person with whom you address your concerns.

Recommended reading
General Medical Council (2008), Explanatory guidance, in Consent: Patients
and Doctors Making Decisions Together.
General Medical Council (2013), Duties of a doctor, in Good Medical Practice.
General Medical Council (2013), Good Medical Practice, paragraphs 15, 16, 24,
25,32,35,36,47,49,57,68.
Medical Protection Society (2012), Patient autonomy and consent, MPS Guide
to Ethics: A Map for the Moral Maze, chapter 8.
5.24 FY1 ward round

E B A C D
This may be a simple mistake or there may be an honest reason why the other
F Yl is not covering the ward round; however, you should make sure they are
nor struggling and should also bear in mind that it is nor fair if they are not
doing their equal share of the reams' workload. The best response therefore is
to speak to the FYl yourself and see if they are managing at work (E). The next
best response is to discuss it with your other FYl colleague (B) because, if they
have not noticed anything, it may not be a significant problem. Option A is
the next most appropriate as it would be best to talk to your ream's consultant
initially rather than their educational supervisor (C), whom you may not know.
The least appropriate response would be to ignore the situation (D) because if
it is causing you worry, then it may interfere with how you interact as a team,
and you may end up overlooking a problem if the FYI is having difficulties.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 35-37.

5.25 Colleague not copingwith bleeps

A C D B E
One of the busiest times for a junior doctor is working out of hours on the
wards. Ar weekends, nights and bank holidays, the hospital has fewer doctors
to cover the same number of patients. During these periods, teamwork becomes
incredibly important with a small number of doctors supporting rhe care of
many patients. In this scenario, discussing the situation with your FYl colleague
is the most appropriate course of action (A). This will allow you not only to iden-
tify any issues he is having but also to relay the information you have received
from the nurses. Seeking support from a senior colleague (C) may mean they
can put in measures to alleviate the pressure on your FYl colleague, so this is
the most appropriate next option. Your aim here is to solve the problem that has
arisen; asking the nurses to continue to bleep your colleague (E) doesn't assist
 348 Chapter 5: Working Effectively as Part of a Team

the situation and may cause further stress for your colleague and the nurses.
While completing the jobs for your colleague may be helpful (0), you may be
neglecting the care of the patients you are responsible for yourself. However,
assisting with jobs is more appropriate than completing an incident form (B) as
it offers a more immediate solution to the problem. Completing an incident form
may be important in the long term, bur this is nor your primary priority.

Recommended reading
General Medical Council (2012), Working with colleagues, in Leadership and
Management for Doctors.

5.26 Working as a team

A B D
This question is testing your ability to work well under pressure and ro be an
effective team player. Although you are the only doctor on the ward, there
are other members of staff and medical students around who would be able
to help. It is paramount to the success of an emergency situation that all
people involved work as a team. Options A and B are therefore sensible as the
students and support worker can be arranging help while you are clinically
assessing the patient. To prevent the patient from further harm is also impor-
tant (0) as this nor only shows leadership but also demonstrates good clini-
cal care. Commencing chesr compressions (H) is not appropriate unless you
have assessed that a patient does not have a pulse. Pretending not ro hear the
shout for help or shirking your responsibility to attend (options C and G) are
unprofessional responses and could jeopardise the patient's health and safety.
Option E should not be one of your initial responses. It may well be sensible to
ask one of the nurses to draw up some lorazepam just in case you need to use
it, but you should utilise other team members for this so that you can assess the
patient. Obtaining a background history (F) is important after the emergency
has been managed and before documentation, bur it should be secondary care
in this scenario. Additionally, you may well be able to obtain the most impor-
tant parts of the history during the process of assessing the patient.

Recommended reading
General Medical Council (2013), Duties of a doctor, in Good Medical Practice.
General Medical Council (2013), Good Medical Practice, paragraphs 15, 16, 26,
35 and 39.

5.27 Negligence

A B D
This question involves patient safety, relationships with colleagues and issues
around confidentiality. Patient safety is your first and foremost concern, so
you should make sure that rhe antibiotic has been stopped (B); the patient
also needs to be reviewed immediately. It would be best if your colleague did
this (A) as she has already mer the patient, and this would be useful for the
 Answers 349

professional development of your colleague. As your colleague has come to

you with this information, it is likely that she would like your advice and/or
help (D). Reviewing the patient yourself (E) may be necessary, but as discussed
earlier, it would be more beneficial to your colleague to do this herself. Telling
the patient yourself (G) may also be necessary; however, it would be better for
your colleague to do this. It would give your colleague the chance to explain
their actions and apologise, thus hopefully reducing the damage to their
doctor-patient relationship. Option C is not dealing with the immediate issue.
Option His nor appropriate in this isolated incident and will compromise the
trust of your colleague. Speaking to microbiology (F), while important to con-
sider further down the line, is not one of your first priorities.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 25-26.

5.28 Registrar leaving patient list

C A B D E
When you, your colleagues or patients have concerns, it is best in the first
instance to raise them with the person involved. Calling the registrar straight
away (C) gives him the opportunity to apologise for his own mistake as well as
learning from it. Delaying the discussion with the registrar (A) may mean that
the conversation never happens, and the chance for him to repair the damage
for himself is lost. Option B is also appropriate because it includes an apology
to the patient and shows a proactive effort to improve the situation. However,
it is less suitable than options C or A because it does not involve the registrar at
all. Your clinical supervisor can help with this sort of problem (D), but it may
be an overreaction to go straight to them without any prior discussion with the
registrar and is likely to damage your working relationship. The worst response
is to ignore the problem. Option E makes no attempt to address the issue and
unfairly leaves the nursing staff to handle the consequences, when this was a
mistake made by the medical team.

Recommended reading
General Medical Council (2009), Explanatory guidance, in Confidentiality,
paragraphs 12-16.

5.29 Nurse vs SpR

B F H
This is a common situation to find yourself in: where the nurses feel that
the more senior members of the team are not appropriately responding to
their concerns. Often this is because the registrars don't see a problem them-
selves and are too time pressured to explain this to the nurses. However, you
should try and improve the situation so that all team members feel valued and
listened to. Options B, F and H are therefore the best responses here as they
result in the concerns being communicated to the team in an appropriate and
 350 Chapter 5: Working Effectively as Part of a Team

non-confrontational way. It would be best if the nurses communicated this

themselves, but in your position you are well placed to help the nursing staff.
While relaying the nursing staff's concerns to the registrar (A) could result in
communication of the problem, you have no active involvement in the issue,
and it would therefore be more appropriate for the message to come directly
from the aggrieved persons. This would also avoid your registrar feeling as if
you were raking the nurses' side. To collaborate with the nurses and discuss
your opinions about individual team members (C) would not solve the prob-
lem and is unprofessional on your behalf. Ignoring the issue (D} is obviously
not appropriate here as the team needs to work together to provide optimum
patient care. Although in option E you would be making it clear that the
nursing staff are unhappy with the care delivered, this should ideally come
from the nursing staff themselves, and it does nothing to further clarify the
details of the complaint to the registrar. Option H is not appropriate as again
simply ignoring the problem will not make it disappear, but it is also untrue as
you have noticed the rift between your colleagues.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 35-37.
Medical Protection Society (2012), Relating to colleagues, in MPS Guide to
Ethics: A Map for the Moral Maze, chapter 11.

5.30 Colleague's inappropriate comments

C A D B E
This is a difficult situation since in this scenario your colleague is clearly acting
in an unprofessional manner. You should let them know that their attitude is
not appropriate, which can best be achieved with an explanation (C}. If you do
not feel confident about doing this, it could be useful to get some peer support
and analysis of the situation from the other FYls on the ward (A}. It would
be an overreaction to immediately escalate this to involve seniors (options D
and B}. But, if you were to involve seniors, the FYl's educational supervisor (D)
would be a more appropriate starting point than the programme director (B}.
The worst response in this situation would be not to take any action (E) as the
FYl is behaving inappropriately, and you have a responsibility to intervene.

Recommended reading
Medical Protection Society (2012), Respect, section: Purring patients fuse, in
MPS Guide to Ethics: A Map for the Moral Maze, chapter 7.
The UK Foundation Programme Curriculum (2012), section 2: Relationship and
communication with patients.

5.31 Nurse conflict

D C B E A
It is important here that you remember co act in the patient's best interests,
not according to what rhe nurse would like you to do. The best option is to
 Answers 351 •

engage in a discussion with the nurse (D). Option D also includes ensuring the
information on the board is changed, which is important for clarity within
the wider team. It is better to deal with the issue yourself than to involve your
seniors (C) as it is something you should be able to address successfully. Option
C is better than option B, however, because it allows discussion and opportu-
nity for the nurse to contribute her opinion rather than just overriding her (B).
Doing nothing (E} would not be constructive in this situation as there will be
confusion over the plan for the patient. However, it would be worse to com-
plete the discharge paperwork (A} as the patient is not medically fit to leave; it
is not the nurse's role to make this decision.

Recommended reading
General Medical Council (2011), Working with colleagues, in The Trainee
Doctor, paragraph 40.
General Medical Council (2013), Good Medical Practice, paragraph 41.

5.32 Poor discharge summaries

C E D B A
Writing discharge summaries is a common task for foundation year doctors.
Accurate and informative summaries help to ensure good continuity of care
and ensure good communication between healthcare professionals. In this situ-
ation, your primary focus should be to ensure patient safety. The best person
who can support your colleague is their educational supervisor (C), who can
work with the doctor to address the issues raised. Offering to help your col-
league (E) may be a short-term 'fix', but it may not ensure the quality of their
discharge summaries in the future. While option D would ensure that good-
quality discharge summaries are produced, writing the summaries yourself
would not aid your colleague's education. Similarly, editing the summaries
yourself (B) fails to address the issue with your colleague and is also a waste of
your valuable time. Apologising and taking no further action (A) will not result
in any change in your colleague's performance and will mean poor-quality
discharge summaries will continue to be produced, so option A ranks last.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 44.

5.33 Colleague alcohol

A C B E D
It is your dury as a doctor to raise a concern when patient safety or care is, or
could be, compromised. Therefore the most appropriate response in this case is
option A: you should escalate this concern quickly to the person leading your
team. If you feel that your concern is not being dealt with satisfactorily or you
do not feel you can raise it within your team, you should contact a regulatory
body such as the GMC (C). Advising your colleague to attend his GP (B) may
be useful for your colleague, but raising your concern to someone more senior
 352 Chapter 5: Working Effectively as Part of a Team

should be a priority. Option E may be helpful in gathering evidence for your

colleague's misconduct, but it is not necessary to gain proof before raising a
concern, and it may risk damaging your relationship with them. Reasonable
belief justifies raising a concern even if you are mistaken. Option D is the most
inappropriate response in this case. The GMC states that you can make a con-
cern public if you have done all you can to raise a concern through local and/or
appropriate external bodies and have good reason to believe that patients are
still at risk, provided you maintain patient confidentiality. In this situation, the
concern has not yet been raised through the primary levels. You should also
seek help and advice through external bodies {e.g., the GMC or the British
Medical Association (BMA)) before contemplating making a concern public.

Recommended reading
General Medical Council (2012), Explanatory guidance, in Raising and Acting
on Concerns About Patient Safety, paragraphs 7, 10-18.

5.34 Colleague dispute

D C A B E
The most appropriate course of action is option D: apologising and discussing
your concerns in a more controlled manner should 'clear the air' and hope-
fully allow resolution. Involving a senior (C) may be necessary to resolve the
dispute but may make you look unprofessional and a little childish. Asking to
switch medical teams {A) would not resolve your issues and is likely to make
you appear unprofessional. This is also true of option B, dividing the patients
between you, but most importantly, it may compromise patient safety and the
management of their care due to poor team communication, so this option is
ranked less favourably. Relaying messages to your colleague through the nurs-
ing staff {E) is the least appropriate response as it would be very unprofessional
and could also compromise patient safety.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 35-37.
Medical Protection Society (2012), Relating to colleagues, MPS Guide to Ethics:
A Map for the Moral Maze, chapter 11.

5.35 DNACPR

B D E A C
ln this case, it is important to balance treating a colleague with respect and
keeping your duty of care to the patient. Talking to your colleague about the
situation and suggesting that he discuss it with seniors if he is not confident
is tbe best response (B). This is a difficult situation and may need senior input
to reach a decision. Option D is therefore the next appropriate response if
your SHO does not wish to speak to the SpR themselves. Documenting your
concerns (E) may help other clinicians in reaching a decision but doesn't help
the patient and his son in the immediate situation while he is deteriorating.
 Answers 353

General Medical Council (GMC) guidance stares that decisions about CPR
should be made as early as possible. Informing the SHO's clinical supervisor
(A) is inappropriate as it is likely to damage your relationship with your col-
league and will not help in the immediate situation with your patient. Option
C is the least appropriate response as nursing staff have a legal obligation to
make an arrest call and a verbal request is not legally binding.

Recommended reading
General Medical Council (2010), Treatment and Care Towards the End of Life:
Good Practice in Decision Making, paragraphs 128-134.

5.36 Radiologist

C A D B E
This question relates to your relationship with colleagues. It can be extremely
hard to stay calm when a colleague is being rude and you feel that comments
about you are personal. In this case, your first priorities are patient safety and
duty of care to the patient, in other words ensuring that the patient undergoes
the necessary imaging. Option C is therefore the most appropriate course of
action as you may be able to give a better explanation for the rationale for the
imaging request while remaining professional. If this fails, you should then
escalate the issue to your senior (A), who will have more knowledge about
the pathology and CT scanning rationale and should also be able to use their
seniority to add more gravitas to their wishes. Ensuring that the attitude of
the radiologist is made known to your clinical supervisor (D) is appropriate
but doesn't deal with the current clinical situation. Options Band E are both
inappropriate. Option B, telling the radiologist that you are the registrar,
is outright lying and is therefore deeply unprofessional; however, option E,
refusing to escalate the issue, is worse as the patient's management, and there-
fore safety, is being compromised.

Recommended reading
Medical Protection Society (2012), Chapter 4: Oury of care; Chapter 11:
Relating to colleagues, in MPS Guide to Ethics: A Map for the
Moral Maze.

5.37 Rude colleague

B F G
When working in a large team, you will find that disagreements are very
common. As part of a team, you should do your best to help maintain
efficiency and ensure patient safety. This situation does nor appear to
compromise patient safety but does affect your workload and therefore
affects team efficiency. Ignoring the situation (E) is inappropriate as helping
to smooth over differences between colleagues is likely to increase team
productivity and better your own working environment. Turning off your
bleep (H) would be unprofessional and would leave nursing staff and
colleagues unsupported. To review all patients yourself from this point
 354 Chapter 5: Working Effectively as Part of a Team

forwards (A) is unfeasible and would result in an unbalanced and likely

unsustainable workload. Informing the ward matron (C) or your colleague's
educational supervisor (D) would both be inappropriate at this stage, before
approaching your colleague yourself.
You should discuss the issue with your colleague (F); it may be that your
colleague is not aware of how he appears to the nursing staff. On the other
hand, your colleague may be struggling in general with his work and may need
your help or even more senior support. Option B would help to gather further
information before speaking to your FYl colleague. As well as discussing
issues with your colleague, you should encourage the nurse to speak to your
colleague herself (G).

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 35-37.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 11.

5.38 Tearful colleague

E G H
This situation is nor sustainable as you cannot continue doing the workload
of one of your colleagues as well as your own. Doing so may result in burnout
and/or compromised patient safety. For this reason, option D, carrying on
sharing her work, is not appropriate. Option F, telling her to find another pro-
fession, would be unprofessional and counter-productive as this does not solve
the issue at hand. Suggesting that she seeks help from her GP (A) may be useful
advice for your colleague but does not help the immediate situation. Asking
another FYl to share your workload (B) may be helpful, but it is not a long-
term solution and does not deal with your colleague's problem. Asking your
registrar to speak to her (C) could be an action to take in the future, but in the
first instance, you should talk to your colleague yourself (E) and inform her
that the current situation is nor maintainable (G). Advising her to speak to her
supervisor (H) is a good first step in making sure that her problem is escalated
and that she receives the senior support she needs.

Recommended reading
Medical Protection Society (2012), Relating ro colleagues, in MPS Guide to
Ethics: A Map for the Moral Maze, chapter 11.

5.39 Argument

A C D B E
Disagreements are not uncommon in a busy and stressful environment
such as a hospital ward. However, they should be resolved in a professional
and respectful manner. In this scenario, the registrar has clearly behaved
poorly, and this should not be allowed to continue. You should advise your
colleague to consult with her educational supervisor (A) since they will be
 Answers 355

best placed to resolve the issue. This is preferable to encouraging the FYl
to approach the registrar herself (C) as this may result in the disagreement
escalating further. Similarly, it is preferable for you not to approach the
registrar yourself (D) since you are nor directly involved in the disagreement
and again this may escalate the problem further. Ir is inappropriate for you
ro pretend chat you have nor overheard (B) since you have a responsibility ro
act upon unacceptable behaviour by colleagues. Option E is the least accept-
able response; criticising her reaction to the disagreement will only worsen
the situation.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 35-37.
Medical Protection Society (2012), Relating to colleagues, MPS Guide to Ethics:
A Map for the Moral Maze, chapter 11.

5.40 Colleague's incompetence

C D B E A
lt is the duty of a doctor to raise and act upon concerns regarding patient
safety or compromise of care. Doing nothing (A) is therefore inappropriate.
When there is concern over a colleague's performance, it is wise to raise
these concerns with the colleague directly (C). There may be an explanation
for your colleague's behaviour, such as a lack of confidence. Your registrar
may be able to deal with the problem (D), although this is less direct than
option C. Eliciting concerns from other members of staff (B), while giving
a more detailed picture of your colleague's performance, does not solve the
problem. Option Eis an active approach; however, it risks damaging the
professional relationship with your colleague and does not explore the cause of
the situation.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 25.
Medical Protection Society (2012), Duty of care, in MPS Guide to Ethics: A
Map for the Moral Maze, chapter 4.

5.41 Consultantkiss

C D G
The General Medical Council (GMC) has not published specific guidance on
personal relationships between colleagues. While it is not recommended to
pursue such relationships, it is not prohibited. Ir is clear, however, that a good
working relationship is of paramount importance, and any personal rela-
tionships should not be allowed to jeopardise your ability ro work alongside
colleagues. In this scenario, the consultant has overstepped a boundary but has
stopped immediately when asked. You should manage the situation in a way
that allows a good professional relationship to continue. Telling the consul-
tant that you are flattered but do not want to pursue a relationship (G) makes
 -,
356 Chapter 5: Working Effectively as Part of a Team

your position clear while being polite, and you should continue to work the
remaining rime in the job (C). It would also be prudent to discuss the matter in
confidence with your educational supervisor (D) so that they are already aware
if any future problems were to arise relating to this consultant. Ar this srage,
it would be inappropriate to avoid completing the rime in your job, either by
moving jobs (E) or taking annual leave (F), since this may result in a lack of
medical cover. Similarly, you should not try to avoid the consultant (A) since
this may damage your working relationship. Warning your colleagues about the
consultant is unprofessional and risks his working relationship with them (H).
While the consultant has overstepped a professional boundary, he has not com-
mitted a crime, so reporting him to the police (B) is completely inappropriate.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 1, 34-38.
Medical Protection Society (2012), Chapter 5: Morality and decency;
Chapter 11: Relating to colleagues, in MPS Guide to Ethics: A Map for the
Moral Maze.

5.42 Supporting a colleague

A C E B D
Part of your duty as a doctor is the continual improvement and development
of your skills. You also have a responsibility to ensure that others are doing
the same. ln this scenario, your colleague is struggling to develop his skills in
patient review, and you should try to support him in tackling this problem. An
appropriate first response is therefore to discuss your observations with him
directly (A). You could also encourage him to review more of the patients rather
than asking you to do it (C). Raising your concerns with your consultant (E) is
also sensible, bur you should ideally have made some effort to resolve the issue
with your colleague directly before involving the consultant. While patient
safety is not currently compromised, it would still be inappropriate not to act
when a colleague is having difficulties in an aspect of their work (B). You should
nor offer to give your colleague extra teaching (D) since this is not your respon-
sibility, and their issue lies in a lack of confidence as opposed to knowledge.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 7, 8, 13,
35, 36, 43.
Medical Protection Society (2012), Chapter 10: Competence; chapter 11:
Relating to colleagues, in MPS Guide to Ethics: A Map for the
Moral Maze.

5.43 Strugglingcolleague

C E H
As a new FYl, starting work will be difficult, and you will make mistakes.
However, if those mistakes are serious or repeated, something needs to be
 Answers 357

done about it. ln this scenario, one of your colleagues seems to be struggling,
and this is making the job harder for the rest of you. The best responses are
those that treat your colleague respectfully and compassionately bur also lead
to remediation seeps, such as further training or extra teaching. Option C,
asking your registrar for help in chis matter, is a good response; senior
doctors should be made aware if one of their juniors is persistently making
mistakes as they can organise appropriate training and reaching sessions to
help. Option E is another appropriate response as you do not know why your
colleague isn't performing well, and it could be due to a number of factors.
By talking with them privately, you could both come up with a plan of how
to improve their skills and work together better. Option H is the third most
appropriate response: with small mistakes such as nor filling in the clerking
booklet fully, another FY l is more than capable of teaching a colleague the
correct way ro do this. Many FYls have different skills and strengths, and you
should feel confident to both teach and learn from each other as well as from
senior doctors.
Inappropriate responses include those that avoid the problem in hand,
such as asking for extra locum cover to rake over your failing FY l colleague's
tasks (A) and asking rhe nursing staff ro stop giving them things to do (B). For
option B, caking on more work yourself increases your responsibility and could
stretch you too thin, leading to more serious errors, bur it also doesn't help
your colleague improve his practice in any way. Similarly, option G burdens
you with extra work, which may be dangerous, and allows a colleague with
sub-standard skills ro progress. Getting together as a group to confront your
colleague (D) is also inappropriate as it could embarrass him. Informing
your colleague's educational supervisor of their difficulties (F) could argu-
ably be considered appropriate. Ir is a good course of action because of the
educational supervisor's responsibility to ensure that your colleague learns the
appropriate skills of an FYl; however, ro go behind your colleague's back is
underhand and shows a lack of respect. Also, since FYls do not work directly
with their educational supervisors, your colleague would surely know that
someone had privately informed the supervisor, and this will not aid their
working relationships.

Recommended reading
Medical Protection Society (2012), Relating to colleagues, section: Commenting
upon the work of others, in MPS Guide to Ethics: A Map for the Moral
Maze, chapter 11.

5.44 Physiotherapist date

D E B A C
Having a romantic relationship with a colleague is nor a problem as long as
it does nor affect patient care. In order to ensure that there is no impact on
how you act at work, it would be preferable to postpone the date until you
don't work directly together (D) rather than arranging it for next week (E).
 358 Chapter 5: Working Effectively as Part of a Team

Option E, however, is a more appropriate response than option B, turning

down the date, because you should not compromise happiness in your per-
sonal life when there is no need to. If you do turn down the physiotherapist's
offer, this should be with an answer and explanation (B), which allows you
to continue to work together in a civil and professional manner. Avoiding
dealing with the situation (A) would be both immature and potentially cause
major problems with your working relationship. This could have implications
for patient care. The least appropriate response would be to report the phys-
iotherapist to their manager (C) because they have not done anything wrong
by asking you out. Again, this option could lead to a lot of unhappiness and a
difficult working relationship.

Recommended reading
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapter 5: Morality and decency, section: Relationships.

5.45 Respecting authority

A F G
This question deals with the issue of balancing a respect for authority with
a genuine concern for patient care and new learning opportunities. If your
colleague is neglecting his duties because he doesn't agree with the SpR's
decisions, he needs to talk to the senior in question as there is the chance that
patient care and safety may be compromised as a result. Boch of these points
need to be communicated to your colleague (options F and A). It is not unrea-
sonable to ask seniors to explain their reasoning behind certain decisions;
indeed sometimes they make mistakes, and therefore, it is good to check if
you have concerns. Refusing to be proactive in response to this (C) is unpro-
fessional, impacts the team's workload and displays a lack of respect for all
your colleagues, not just those in a position of authority. Instead, you should
explain to your colleague about how respect for your colleagues works (G). It is
important that you give your colleague a chance to rectify his behaviour before
reporting him (options D and E) as this could further jeopardise professional
relationships within the team. A constructive, helpful approach would be more
appropriate than simply telling him off (H). You may wish to discuss this with
another FYI (B), but this is not as appropriate as directly addressing the situa-
tion by talking to your colleague.

Recommended reading
General Medical Council (2013), Duties of a doctor, in Good Medical Practice.
General Medical Council (2013), Good Medical Practice, paragraphs 15, 16, 22,
25,35,36,43,59,68.
Medical Protection Society (2012), Professionalism and integrity, in MPS Guide
to Ethics: A Map for the Moral Maze, chapter 3.
 Answers 359

5.46 Anticoagulatingpatients

A F G
This scenario is difficult as it puts you in an awkward position. The registrar
needs to be informed that he should not be speaking to anyone in such an
unprofessional manner, especially since he is incorrect in this case. Therefore
the best response here is to ensure chat the registrar is aware that what he said
has upset you, and this is often better left until after the event to allow the
person and yourself to calm down (G). You should also make sure that the reg-
istrar is aware that there is a protocol in place regarding anticoagulation and
find out the reasons why they do not want the patient on low molecular weight
heparin (options A and F). Getting the registrar to publicly apologise to you
would be welcomed (B), but is unlikely to happen and not necessary as long
as they do apologise to you at some point. Phoning the haematology registrar
or your consultant (options C and H) is likely only to antagonise the registrar,
so these are not good responses. If you feel that the patient should receive the
medication, you should discuss your conflicting opinion with your registrar
rather than blindly following their wishes (D). Displaying similarly unprofes-
sional behavior to the registrar (E) is only going to further anger the registrar
and is therefore best avoided.

Recommended reading
Medical Protection Society (2012), Professionalism and integrity, in MPS Guide
to Ethics: A Map for the Moral Maze, chapter 3.

5.47 Punctuality

B E C A D
The best thing to do if there is a problem with one of your colleagues is to
make them aware of the problem (B), otherwise it will go on to impair your
working relationship with them. You should, however, make sure that chis is
done tactfully so that the FYl in question doesn't feel as if you are all 'gang-
ing up' on them. If the problem is beyond what you believe you can manage
as an FYl, ensuring the consultant knows about your concerns is appropriate
(E) so that they can cake the matter further. This is better than going straight
to the FYl's educational supervisor (C), whom you may not have had interac-
tion with previously. Option A ranks higher than D because, although actively
increasing your workload to cover for another individual is not ideal, at least
in this way there is no potential risk to patient care as there is with doing
nothing.

Recommended reading
Medical Protection Society (2012), Professionalism and integrity, in MPS Guide
to Ethics: A Map for the Moral Maze, chapter 3.
 360 Chapter 5: Working Effectively as Part of a Team

5.48 Colleague not arrivedfor handover

C E F
Colleagues arriving for work late presents a frustrating but common ethical
dilemma. You should not leave rhe hospital (D) because this would mean there
would be inadequate cover and patients would not be safe. lt would also be
unsafe ro stay only ro give handover (H) and nor ro provide emergency cover
before your colleague arrives. It is also inappropriate to ask another FY 1 to
take on additional on-call responsibility while awaiting your replacement (A).
However, just because you are staying does not mean that you also need ro
continue working on non-urgent jobs (G) as you have finished your shift and
need to rest. The most important thing is that you are available in emergen-
cies (F). You should ler your seniors know thar there may be a problem (£)
because they should always be aware of who is looking after their ward
patients, and they are responsible for taking action if it becomes necessary to
bring in extra cover. It would be an overreaction and not particularly construc-
tive to call your colleague's supervisor (B). The simplest and most important
action is to contact your colleague and find our what the situation is (C); after
all they may be only a few minutes late.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 1.
Medical Protection Society (2012), Professionalism and integrity, section:
Professionalism, MPS Guide to Ethics: A Map for the Moral Maze,
chapter 3.

5.49 Consultant acting unprofessionally

A E B D C
Acting professionally includes a broad range of commitments which should be
adhered to in all medical practice. One such commitment is providing impar-
tial advice to patients. The General Medical Council (GMC) offers good advice
for these scenarios: when a doctor has a financial or commercial interest in
another healthcare provider, they should not be influenced by their interests
when treating patients. In this scenario, it is possible that your consultant is
attempting to profit from referring the patient ro private healthcare. However,
your consultant may have seen the patient numerous times, and there may have
been other conversations that you are unaware of. Therefore, the best way ro
raise your concerns would be to simply ask him in private why he suggested
private healthcare (A). Seeking the advice of a senior colleague could help as
they may have more experience and be able to suggest an appropriate course of
action (E). Challenging your consultant is an unnecessarily aggressive approach
to take here and may harm your professional relationship (B), although it is
preferable to other options because ar least the issue is raised in private with
the consultant. Doing nothing (D) may help your consultant to maintain his
relationship with his patient, but if you have concerns about a fellow profes-
sional's conduct, then you should always raise these in some way. However,
 Answers 361 •

by raising the issue while the patient is in the room (C), you may affect your
consultant's relationship with the patient without knowing all the facts that are
relevant to the situation. Option C is particularly unprofessional on your part
and therefore the most inappropriate answer here.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 75 and 76.

5.50 Receiving and acting on feedback

£ C D A B
On-call shifts can be very challenging for newly qualified doctors, but they
can also provide numerous learning opportunities. On-call shifts are usually
very busy, often with many patients requiring attention from a small team
of doctors. In this scenario, the most important thing to consider is that the
patient is now stable with an adequate management plan and a schedule for
review. After ensuring that your patient is not in danger, you should consider
how to act on the feedback you have received. So far, you have received very
little feedback that you could act upon. Waiting until the end of the shift and
then asking for further feedback (E) would ensure that you are not wasting the
valuable time of your seniors and preventing them (and yourself) from review-
ing unwell patients. Making a note of situations where there are lessons to be
learnt is a valuable way of keeping your knowledge and skills up to date, and
e-learning packages can be very useful to consolidate learning on a topic (C).
The least appropriate response here would be to re-review the patient (B) as
they have a management plan in place and a scheduled review, so this would be
an inefficient use of your time and could potentially harm other patients' care.
Doing nothing (A) would not waste time (making it preferable to option B), but
you would not receive any feedback to allow you to learn from the situation.
Immediately asking for feedback (D) would provide you with a learning oppor-
tunity, but it is not appropriate to do this during a busy on-call shift.

Recommended reading
General Medical Council (2013), Duties of a doctor, in Good Medical Practice.
General Medical Council (2013), Good Medical Practice, paragraphs 9 and 13.

5.51 Derogatorycomments on a social media site

A D E C B
This scenario relates to your own and your colleague's professionalism, and as
part of being professional, you are expected to 'uphold the reputation of the
profession, helping to maintain public confidence in it'. The most appropriate
response here is option A: confronting them and making them aware that their
behaviour is unprofessional. Asking a mutual friend to speak to chem about it
(D) may be appropriate, but it would be better for you to speak with your col-
league directly if you have an issue with their comments. Writing a response on
the social medical site (E) may harm your relationship with your colleague and
 362 Chapter 5: Working Effectively as Part of a Team

may result in an unprofessional argument on the social media site in the public
eye. Option C, informing their consultant, would be a drastic course of action
and should only be taken if you have confronted your colleague to no avail
or you perceive that there are more concerns regarding their professionalism.
Doing nothing (B) would be the least appropriate response as this would not be
upholding the reputation of the profession.

Recommended reading
Medical Protection Society (2012), Professionalism and integrity, in MPS Guide
to Ethics: A Map for the Moral Maze, chapter 3.

5.52 Annual leave

A C B D E
You should nor book a holiday without having your annual leave confirmed as
it is not uncommon for annual leave requests to be denied. The ward must have
the minimum level of staffing ar all rimes ro ensure patient safety, and most
rotas will involve periods where you are indispensible to the team. Although
you booked the holiday prior to starting work, you still have a duty to ensure
adequate staffing, and in addition, you are actually only requesting the leave
once you have been in the job some rime. The most appropriate response would
be ro try and swap shifts with a colleague so that rhe ward is covered while
you are still able take your holiday (A). The second most appropriate response,
while inconvenient, is to cancel your holiday (C) since your priority in this situ-
ation is ensuring the ward is covered. Asking the rota coordinator to arrange
locum cover (B) is inappropriate, since the hospital is not obliged to provide
external cover for annual leave. This response is preferable, however, to simply
informing the rota coordinator that you are going on holiday regardless of
whether the ward is understaffed (D). Calling sick is wholly inappropriate since
chis is dishonest, unprofessional and potentially detrimental to patient care (E).

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraph 38.

5.53 UTI

D E F
While going to work and caring for your patients is clearly a priority, your
own health is also very important. You should be registered with a GP outside
of your work or family, and you must nor rely solely on your own assess-
ment of any personal health problems. Although this may seem like a simple
urinary tract infection, you should still seek advice from your GP. In this
scenario, it would not be unreasonable to take sick leave in order to seek help
from your GP (F). Equally, you could explain to your consultant that you
need some time off to go to your GP (0). If you were able to swap a shift in
order to get time off this would also be appropriate (E). Waiting until you get
time off to seek assistance (G) may result in you becoming more unwell. It is
 Answers 363

strongly recommended that doctors do nor prescribe for themselves, family

members or friends, so options A and H are both inappropriare. In addition,
FY l doctors cannor wrire outpatient prescriptions (H). While your registrar
can write an outpatient prescription for you (C), your needs should ideally
be properly assessed by your own GP. Hospital staff should not have access
co drug treatment without the correct prescription, so option B is completely
inappropriate.

Recommended reading
General Medical Council (2013), Good Practice in Prescribing and Managing
Medicines and Devices, paragraphs 17-19.

5.54 Unprofessional behaviour

D C B E A
Doctors are rrusred members of society, and patients come to them in good
faith to be created professionally. If doctors are seen to laugh about patients,
their conditions or their behaviour, this undermines that trust. It is impor-
tant to be aware that even things said in private can easily become public,
and if you would not be willing to say something publicly, should you really
say it at all? The best response in this question is option D, speak privately
to rhe individuals after the incident. This proactively deals with rhe situation
yourself and saves embarrassment for all involved as it is likely that they didn't
mean any real harm. The next besr response is to speak to your colleagues
there and then (C); again, it is a proactive, direct approach, but it is more
confrontational. Tackling the situation in this way risks some professional
friction but will deal with the problem quickly. Asking a senior for advice
(B) ranks next. Your SHO should be able to help you decide how to tackle this
situation and whether it needs to be taken any higher. Doing nothing when you
feel like something is wrong is not a good quality in a junior doctor, so option
Eis an inappropriate response. Option A, however, is ranked last; joining in
with inappropriate behavior to make friends or because you think it is private
implicates yourself and further perpetuates the situation.

Recommended reading
General Medical Council (2013), Good Medical Practice, paragraphs 53-64.
Medical Protection Society (2012), Professionalism and integrity, in MPS Guide
to Ethics: A Map for the Moral Maze, chapter 3.

5.55 Leaving on time

C D E
With today's shift working patterns, safe and effective handover is vital to
ensure good patient care continues when you leave work. The best responses
are therefore options C, D and E, which allow for a safe handover.
Unfortunately, there may be some times when work impinges on your social
life, although this should not be the norm. Calling your partner to explain
 364 Chapter 5: Working Effectively as Part of a Team

that you will be late (C) is an appropriate response. If you are going ro hand
over any of your jobs to a doctor other than the designated one, it shou Id
be to someone who is competent and who is also on call, so the evening
registrar (E) would be appropriate. Handing over medical jobs ro someone
who is a non-medic (such as a nurse) is potentially dangerous, and there-
fore, option A is inappropriate. Writing jobs down and leaving the list with
nurses (H) or giving a quick handover via phone (G) are not safe handovers,
so these options are also inappropriate. Calling up the registrar and com-
plaining about the late FYl (B) would achieve little in this situation and is
unprofessional. The final appropriate response is option D: to maintain safe
staffing and to give an effective face-to-face handover, you need to stay on
the wards. If you are staying, you should continue to work through the jobs
that are left so as not to leave a mountain of tasks for the evening team to
complete.

Recommended reading
Junior Doctors Committee (2015), British Medical Association, Safe Handover:
Safe Patients - Guidance on Clinical Handover for Clinicians and
Managers.
Medical Protection Society (2012), Professionalism and integrity, in MPS Guide
to Ethics: A Map for the Moral Maze, chapter 3.

5.56 Discriminating against colleagues

A B F
This case presents a situation in which you should encourage the nurse and
sister to speak directly to the FYl in question (F), particularly if the sister
has reason to believe chat this behaviour has happened before (A). This
should be done before a formal complaint is made to the FYl 's educational
supervisor (G). You should not act as a third party when you have not heard
these comments, and you should not judge your colleague on the basis of
hearsay (options B, C, D, E and H).

Recommended reading
General Medical Council (2013), Duties of a Doctor.
General Medical Council (2013), Good Medical Practice, paragraphs 24, 25,
35-37, 59.
Medical Protection Society (2012), MPS Guide to Ethics: A Map for the Moral
Maze, chapters 7 and 11.
 This book provides invaluable guidance to the Situational Judgement Test, written by au-
thors who understand from personal experience that detailed explanations accompanying
each answer are the key to a successful revision aid.

This book presents over 350 ranking and multiple-choice questions, arranged by subject
groups aligned with the domains of the SJT examination, and designed specifically to
explore the readiness of candidates to face the scenarios that they will encounter as junior
doctors. A clear discussion of how the correct answer was reached and other options ruled
out for every question is given at the end of each chapter, making this book an excellent
learning aid through all stages of undergraduate studies, and particularly during revision
for the SJT examination.

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