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IMT Interviews Station 1 - Application and Suitability Dr Anahita Sharma, Dr Jake Kennedy, & Dr Anush ShashidharaStructure of this subsection Give of yourview suitability to be achievements to an IM trainee, 2 date which are 4 including most relevant to clarifying minutes your application minutes questions on to be an IM achievements trainee and applicationScoring § Station 1 is scored by the 2 interviewers out of 5 possible marks, with the marks being combined and then weighted to make part of your total IMT interview score. § There are 2 separate scores within station 1: § Application and achievements (medical school and post-graduate) – weighted at x1.6 = 16 marks § Suitability for IMT – weighted at x1.6 = 16 marks § When adjusted for weighting – 32/60 points available from this section = 53% total IMT score! § Remember – your communication is assessed across all 3 stations – 12 marks (20%)Planning THINK ABOUT YOUR APPLICATION YOU ONLY HAVE 2 MINUTES – BE AND QUALITIES THAT ARE FOCUSED IN YOUR SELECTION. TRANSFERABLE TO AN IMT NO AIDS/RESOURCES ALLOWED.Things to focus on - presentation Academic – exams e.g. honours at medical school? MRCP part 1? Prizes? Research and publications – Case reports/original research? Leadership and teamwork – Local, regional or national roles both within and outside of medicine QIP and presentations – think back to medical school! Teaching – local, regional or national teaching – have evidence! How to maximise your selected achievements Credit will be given to achievements which demonstrate skills transferable to being an IM trainee; these achievements do not necessarily need to have been gained in physician-related activity. Examples Junior doctor’s mess lead – During my FY1, I became lead for X hospital’s junior doctor’s mess, involving coordination of social events and maintenance of the mess’ food supply. I performed this leadership role alongside my clinical work duties. This demonstrates my leadership and organisational skills, that I think are integral to the success of an IM trainee. Teaching – During my FY1, I became involved in facilitating the delivery of a 12 week teaching programme to medical students rotating through the department. I facilitated creation of the teaching content, alongside delivering this content. This demonstrates my teaching and communication skills, which I believe are essential in fulfilling my role as a doctor and will be transferable to my practice as an IM trainee. Note – These statements enable the interviewers to ask follow-up questions. For example, “Why do you think leadership is important as an IM trainee?” Think about managing the acute take – taking responsibility for overseeing junior members of staff alongside prioritising your own clinical workload. 2 minutes – be focused and highlight the pertinent details that maximise your ability to demonstrate skill transference to the examiner.Structuring answers § By domain e.g. clinical, academic, leadership/management/QIP, personal 4 minutes of questioning – variable! What can you evidence as commitment to IMT training? - Have you sat MRCP part 1? – Demonstrates commitment to a career as a physician - Conferences/extracurricular events – Importance of continual professional development - QIP or research projects you have participated in - Presentations - Where do you see yourself in 5 years? How do you manage stress? - Very important to consider when burnout is rife within healthcare – you could be asked why stress management is important. - What coping strategies have you adopted to decompress? 4 minutes of questioning – variable! What qualities can you demonstrate that are essential to being an IM trainee - Leadership and teamwork skills and experience – have examples! - Prioritisation skills - Teaching skills/qualifications and experience - Communication – think of an example of an emergency situation requiring SBAR or a breaking bad news scenario - Presentations Tell me about a QIP/audit you have been involved in - Did you adopt a leadership role here throughout the PDSA cycles? - What were the difficulties associated with e.g. date collection/change idea implementation? What will you take forward into IM training? - Why is QIP important in healthcare? Key points - Be selective in your achievements - cover 4/5 achievements with examples e.g. teamwork within the 2 minute period - ALWAYS link back to the IM trainee personal specification – the examiners want to award you the marks!IMT Interviews Station 2 - The Clinical ScenarioStructure of this subsection Review Questions Handover 3 the 8 about the 1 of the minutes Clinical minutes Clinical minute Clinical Scenario Scenario ScenarioScoring § The clinical scenario is scored by the 2 interviewers out of 5 possible marks, with the marks being combined and then weighted to make part of your total IMT interview score. § There are 2 separate scores: § Investigations/diagnosis/management – weighted at 1.2x § Patient Handover – weighted at 0.8x § When adjusted for weighting there are a possible of 20 points available from this section (12 for Ix/Dx/Mx, 8 for Handover) § This section is therefore the most valuable being worth ¼ of the total interviewPlanning SCENARIO TEND TO BE QUITE SHORT MTIME” WILL ACTUALLY BE MENTAL – EXPECT A FEW SENTENCES PREPARATION TIMEThings to consider What further information would you like to gather? What next steps/further investigations would you like? Your differential diagnosis Possible interventions treatments Holistics: how to go about communicating with the patient, colleagues and any relatives that may be present Example Scenario You are called to see a 19-year-old boy who has been brought into A&E by ambulance. He is known to have epilepsy and was brought in after having a seizure. He is having a another seizure in majors.1. How will you assess this patient? § An A-to-E assessment is critical in the assessment of this patient – it will help us identify any critical pathologies and manage them as we go along, with the structured approach ensuring that nothing is missed § It would also be useful to get help at this stage – involving the MDT to help complete tasks as you complete your assessment will ensure prompt treatment § Communication here is key and it is important to keep those around you aware of your progress through your assessment Airway • Maintaining own? Facial oedema, added upper airway noises Breathing •RR/Sats/ABG/CXR if indicated, treat with oxygen + meds if neededusultate, measure • Look for pallor and signs of shock, feel for pulses and oedema, auscultate heart, Circulation measure HR/BP, gain access and take bloods, treat if underlying cause identified Disability • GCS, check blood glucose, pupil reactions Everything else • in case of seizure, any obvious injuries 2. What are the possible causes of this man’s seizures? Unprovoked Provoked Epilepsy Psychogenic Vascular Toxic Infectious Metabolic Focal Generalised NonAttackptic Strokes Bleeds Drugs Alcohol Encephalitis Hypoglycaemia Hyponatraemia Hypernatraemia Uraemia Hypoxia Hypocalcaemia Bedside • Examination – neurological – signs of meningism, fundoscopy •activities over last few days, last known seizure may need to be collateral 3. How Bloods would you • FBC – infection markers further • U&Es and Bone profile – metabolic abnormalities + uraemia investigate • Gas – lactate Specialist this patient? •causeider brain imaging if concerned about intracranial • Consider LP if concerned about meningitis/encephalitis Identify the underlying cause and treat reversible Identify factors – hypoglycaemia, hypoxia and metabolic abnormalities Call Call for help – a team will be needed to provide the 4. How will appropriate level of care for this patient you manage this patient? Check the patient has been brought in seizing– often PR if diazepam or buccal midazolam Start Start the clock – if the seizure does not self terminate within 5 minutes, start a benzodiazepine Status epilepticus is defined as a seizure that fails to self terminate within 5 minutes 5. What do First line management of status epilepticus is a benzodiazepine: you PR Diazepam Buccal Midazolam IV Lorazepam understand Another dose of these can be given if there is no improvement within 5 minutes of the by status first dose, at this point it would be important to consider airway support epilepticus? If convulsive status epilepticus does not respond to 2 doses of a benzodiazepine, give any of the following medicines intravenously as a second-line treatment: levetiracetam phenytoin sodium valproate6. How is refractory status managed? § If the patient continues to seize despite 2 doses of benzodiazepine and a second-line anti-epileptic drug – this is considered refractory status - consider the following third-line options under expert guidance: • phenobarbital or • general anaesthesia7. What are the complications of status epilepticus? Cardiac Cerebral Rhabdomyolysis Respiratory arrythmias and damage and Renal failure Sudden death arrest Failure8. What is important to tell a patient who is presenting with seizures for the first time? § A single seizure is not diagnostic of epilepsy – epilepsy is defined as having two or more unprovoked seizures § The patient must inform the DVLA and stop driving – they may be able to drive if they remain seizure free for the next 6 months9. Would you start anti-epileptic medication after a single seizure episode? § 1 in 20 people will have a seizure at some point in their life – most will never have another § Starting a patient on an AED after a single seizure may result in thinking that it has prevented seizures that would never have happened § Often, if these patients have no adverse effects on an AED - they will choose to remain on an AED if they remain seizure free § Short answer - no Example Handover S – This is a 19 year old male who was brought in via ambulance with seizures. B – This gentleman was admitted after having a seizure, and was found to have a second seizure whilst in A&E. He is known to have a background of epilepsy with no other past medical history noted. A - (based on the info obtained during discussion with examiner)– The first seizure was reported to have lasted 2 minutes, and was self-terminating. The second seizure lasted for 90 seconds and was also self-terminating. I have performed an A-E assessment. The patient is tachycardic, hypertensive and saturating 93% on 15L oxygen. I have taken routine bloods, including a VBG and capillary glucose. R – If this gentleman has another seizure lasting >5 minutes, I would recommend seeking the hospital status epilepticus guidelines, and treating with an IV benzodiazepine. I would also recommend putting out a 2222 Medical Emergency call to ensure support for the individual’s airway from senior personnel.IMT Interviews Station 3 - Ethical, professionalism and governance questionStructure of this subsection A single question focusing on one or more Up to 5 areas (moral, ethical, minutes legal). Guide your answer by GMC Good Medical PracticeScoring § Station 3 is scored by the two interviewers out of 5 possible marks, with the marks being combined and then weighted to make part of your total IMT interview score. § Scoring for station 3: § Weighted at x1.6 = total 16 marks § When adjusted for weighting – 16/60 points available from this section = 27% total IMT score! § Remember – your communication is assessed across all 3 stations – 12 marks (20%)Planning REVIEW GMC GOOD MEDICAL 5 MINUTES – SCENARIO WILL PRACTICE BE GIVEN ON COMPLETION OF STATION 2Key pointers Patient safety – always a priority! What are the issues raised? E.g. Issues surrounding confidentiality and patient harm Autonomy; Beneficence; Non-maleficence and justiceics principles: be resolved locally before escalating to a consultant/senior?he issue What extra information gathering would be beneficial for to fix this problem? E.g. Clarification of patient concerns5 principles: • Assume capacity • Take practical steps to ensure it e.g. hearing aids, written communication, involvement of primary caregivers/relatives • The least restrictive option should always be used • Unwise decisions do not mean a patient lacks capacity •interestsmergency context, always act in a patient’s best If struggling to ascertain: Capacity • Involve other professionals e.g. SALT to assist decision- making *always decision-specific! • Seek advice from primary caregivers/relatives • Seek advice from mental health or legal team If deemed to lack capacity: • Ascertain if LPA or advanced directive available • Seek informed statements from carers or IMCA if no one to represent patient • Act in patient’s best interests Consent § 3 principles: 1. Patient must have capacity 2. Informed (this is an ongoing process and should be initiated early) and the patient should be presented with material risks they would want to be aware of during the consent process (Montgomery case) as well as the alternatives, including the scenario in which treatment/procedure is not performed 3. Free from coercion § If aged <16 years – assume Gillick competence § Can be overruled (including parental responsibility) if patient refuses treatment, if in their best interests Most patients understand expect information will be shared with the direct care team Principles: • Use the minimum appropriate necessary information • Share information relevant to direct care Confidentiality • Tell patient about disclosures they may not expect • Support patients to access their information When to breach? • Patient consents e.g. explicit consent for purposes other than direct care or local audit; • If patient lacks capacity and sharing information is to their benefit; • Disclosure is required by law; • Disclosure is in the public interest e.g. serious harm, safeguarding, communicable diseaseEnd-of-life care decisions Patients are approaching the ‘end of life’ when they are likely to die within the next 12 months; this includes those whose death is expected to be imminent as well as those with: • Advanced, progressive and incurable disease • General frailty and co-existing conditions • Risk of dying from a sudden acute crisis in their condition • Life-threatening acute conditions caused by sudden catastrophic events Treatments may only serve to prolong the dying process and cause unnecessary distress e.g. CPR, ventilation, antibiotics, dialysis, NIV and clinically assisted nutrition/hydration Palliative care can be provided at any stage of a patient’s illness How to maximise your points Governance – rules that govern the stepwise process through which an activity should be undertaken. Hence, GMC Good Medical Practice is key here! Example Driving post-seizure: You are an FY2 in GP and a patient who was previously admitted to A&E last week with a seizure attends for a follow-up. You suspect the patient may have driven themself. – Raises issue of sensitively communicating with the individual. For example, ascertaining the information the individual received surrounding driving post-seizure is important. This also raises the topic of public safety – DVLA guidance can be sought. In addition, what would you do if the individual refused to stop driving? This raises the issue of confidentiality. Inebriated colleague: You are the FY1 in General Medicine and your IMT 2 has arrived on the ward, slurring their speech and is making inappropriate remarks towards the nursing staff– Patient safety. Nursing staff wellbeing. How would you escalate and to whom? How would you support this individual? E.g. offering support to liaise with alcohol cessation service? Colleague’s social media: You are the FY1 on Geriatric Medicine and notice that a fellow FY1 colleague has posted on Twitter a joke about a patient who had been delirious during your shift.– Patient identifiable information (confidentiality breached). What would your immediate action be? How would you approach your colleague and what would you recommend they do? Demonstrate empathy and adopt a non-confrontational stance. What are the GMC guidance on social media use amongst doctors? Other considerations - Gillick competence - Safeguarding/child protection - Late colleagues - Mistakes in clinical practice - Clinical staff self-administering ward medication - Incorrect patient discharge - Unequal workload distribution amongst colleagues