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LondonAFP Applicationsand Interviews Dr. Areeb Mian Academic Surgery (AFY1) CambridgeContent • London Application + Selection process • Interviews – Clinical, Academic, and Personal Overview• Academic foundation programme (AFP) or Specialised foundation programme (SFP)? • ‘Academic’ changed to ‘Specialised’WhyapplyfortheAFP? • Dedicated time to do research • Develop your research/teaching skills • Great for building up your CV and portfolio • Opportunity to set yourself up for future research jobs • Avoid the SJT factor • Welcome break to focus on other things Applicationprocess • Apply at the same time as the normal Foundation Programme through oriel • You can apply for two separate Academic Units of Application (AUoA) • (Longlisting), Shortlisting, Interviews, Offers, Cascade • 48 hours to accept AFP offer in January • If you accept – you are withdrawn from the national foundation application pool • Still have to ‘pass’ the SJT AcademicUnitofApplications(AUoAs)vsFPDeaneries • 15 AUoAS across the UK vs 20 Foundation Programme Deaneries • e.g. London and Kent, Surrey & Sussex = 1 AUoA • e.g. Cambridge = 1 AUoA • Can apply for 2 AUoAsStats https://foundationprogramme.nhs.uk/res ources/reports/LondonAFPApplicationTimeline Applications open (8 of September) nd Applications close (22 of September) Applicants informed of shortlist score (13 October) Applicants invited to interview (26 October) Initial offers made via Oriel (12th January 2022)LondonAFPprogrammesRankingpreferences • Think carefully about what jobs you rank as you may end up with job you don’t want • Be aware of the cascade system LondonLonglisting–Decilecutoffs? Year Decile cut off score 2019 40 2018 39 2017 38 2016 42 NO longlisting using EPM (decile) scores this year! https://london.hee.nhs.uk/recruitment/medical-foundation Londonchangesthisyear https://london.hee.nhs.uk/recruitment/medical-foundationLondonShortlisting/ScoringLondonShortlisting/ScoringLondonShortlisting/ScoringFinalscoreWhitespacequestions No WSQs for London Harry will discuss these in his talk FAQaboutAFP/SFA https://foundationprogramme.nhs.uk/faqs/academic- foundation-programme-faqs/ https://london.hee.nhs.uk/recruitment/medical-foundationSummaryofApplicationProcess Apply to up to 2 AUoAs alongside FP application Rank preferences within AUoAs Shortlisting Interviews Offers (48 hours to accept/decline) in January If accepted: Withdrawn from foundation programme application If declined: Return to normal foundation programme applicationTipstoboostyourapplication(youngeryears) • Presentations • Publications • Prizes (medical school, conferences, competitions) • Teaching/Leadership experience • Intercalated BScClinical and Academic AFPINTERVIEWSOVERVIEWInterviewsOverview • Every AUoA interview structure will be unique • Common mixture of features including • Clinical • Academic • Personal • Ethics & Professionalism • November to January • Often two separate interview stations (can be combined or more) • May have option to choose or are automatically allocated a slot • Start preparing after applications submitted Beneficial for future applications – CST, IMT, GP etc. Cambridgeinterview • 25 minutes • Clinical case discussion and academic interview with same panel • 3 person panel • Neurosurgeon, radiologist, layperson • Medical emergency + Ethics discussion • Academic – • Discussed my research, methods, results, translatability to clinical practice • Personal questions CambridgeInterview “What do you hope to achieve through the AFP?” “Imagine you are being interviewed by a BBC journalist, please explain the results of a research project you were involved in” “How would you design a study to investigate the effects of anticoagulants in vascular trauma patients?” “Have you contacted a supervisor? What will your project involve?” “Please describe an interesting clinical trial you would design if given the chance.” “Stem cells seem to be talked about a lot in the media, where do you see the future application of such research?” “What statistic would you use to measure the effect of X on Y?” LondonInterview • Registration and identity checks 10 minutes • Review of abstract and clinical scenario 14 minutes • Panel 1 interview (academic) 10 minutes • Panel 2 interview (clinical) 10 minutes • Typical format = CLINICAL: 3x emergencies or 1x long case discussion + ACADEMIC: Motivation questions + 1x abstract critical appraisal ClinicalInterview • Be confident • Prepare answers to common questions • Deal with problems as they arise • Have a structure to guide your reasoning and management • GOAL is to demonstrate you are a safe F1 who can prioritise patients through sound clinical reasoning • Large overlap with acute care station in finals • Practice Practice Practice Examplescenario You are the on-call surgical FY1 and have been bleeped about the following patients: Patient 1 – 85 year old lady is two days post-operative for left lower zone lobectomy. She is dyspnoeic, pyrexial and has a saturation of 88%. Her son approaches the ward staff to express his dissatisfaction with his mother’s care. He wants her to be discharged immediately. Patient 2 – Nurse tells you a police officer is asking to speak to you about a trauma patient’s injuries. Your consultant is in theatre, and your registrar is taking a referral in A&E. Patient 3 – A known epileptic patient on the ward is having a seizureTypicalstructure CLINICAL SCENARIO 1. Patient who is critically unwell 2. Patient on their way to becoming critically unwell 3. Patient thinking about becoming unwell AND/OR Ethics scenario Approachingtheclinicalinterview Most often clinical scenario(s) with acutely unwell patient(s) 3. Assessing an acutely 1. Find out more 2. Prioritise unwell patient or 4 . Safety net Ethical scenario Approachingtheclinicalinterview • B-ABCDE-HSGD • Before you get to the patient • ABCDE • History (AMPLE) • Senior advice • Review local guidelines • Document Beforeyougotothepatient Assessment Intervention 1. Find out: patient’s name, hospital ID, 1. If acutely deteriorating à 2222 peri- location +/- brief hx (SBAR handover) arrest/arrest call. 2. Observations: SO2, HR, BP, RR, T +/- ECG) 3. Gather: notes, drug charts and fluid charts 4. If multiple patients, inform the nurse you are seeing another sick patient but to carry out 15 min obs inform you or your senior to any sudden deterioration Safety is my absolute priority. I would inform a senior as soon as possible that there are potentially X unwell patients and would ask if another member of the team can see the other patient. Airway A – “ I would like to assess the patency of the patient’s airway” Assessment Intervention 1. Vocalising? à assume airway is 1. If concerned about airway, establish patent a patent airway using 2. Added sounds? – sounds • Airway Manoeuvres - Head Tilt suggestive of obstruction(stridor, Chin Lift, Jaw thrust snoring, gurgling) • Airway adjuncts 3. Examine the oral cavity – for loose nasopharyngeal objects/denture • oropharyngeal airway 4. Protect Cervical spine if an injury is • Call anaesthetist if airway is possible (e.g. trauma patients) compromised, 2222 -> Intubation & Ventilation 2. Suction of secretions/blood – wide- bore suction under direct vision 3. Removal of foreign body Breathing B –“I would like to examine the respiratory system using a look, listen and feel approach” Assessment Intervention 1) Look – chest expansion, tracheal 1. Sit the patient up deviation, chest wall deformities, 2. If concerns about breathing/low sats respiratory effort • 15L high flow 02 through non 2) Listen – air entry (equal?) and rebreathe mask* additional sounds • *88-92% sats for chronic 3) Feel – expansion and percusion retainers (equal?), position of the trachea • If poor or absent respiratory effort (central/deviated) à use a bag valve mask 4) Obs: O2 sats, RR 3. If no respiratory effort --> call arrest team (2222) Consider: • ABG • CXR Circulation C –“I would like to assess the patient’s circulatory status” Assessment Intervention 1) Look: pallor, cyanosis, and 1) Investigations distended neck veins (JVP) • Gain IV access (2 wide bore 2) Feel: cannulae in ACF) – send • Peripheral & Central Pulse bloods if time allows (which Rate, Rhythm and character ones and why) • CRT <2seconds • 12 lead ECG (dynamic 3) Listen - Heart Sounds changes) 4) Obs: HR, BP, UO • Catheterise 2) Actions • Consider fluid challenge – 500 vs 250ml (HF) over 15 mins 3) If NO CARDIAC OUTPUT à Call arrest team/2222 Disability “I would like to assess the patient’s neurological function Assessment Intervention 1) Level of consciousness - GCS / 1) Correct blood sugar AVPU 2) If overdose - antidotes 2) Pupils equal & reactive to light 3) If unresponsive or GCS </= 8 à 3) Gross neurological deficit? - Tone Call anaesthetist (airway risk) 4) Blood Glucose 5) Obs: Temperature • Consider: • CT Head Exposure Assessment Intervention 1) Skin 1) Treat as appropriate 2) Wounds 3) Calves – tenderness/swelling 4) Abdo exam 5) PR 6) Surgical site 7) Cover patient with blanket History,Senior,Guidelines,Document • H – History (AMPLE) • Allergies • Medications • PMH/ PSH • Last meal • Events leading up to illness • S – Senior input – Who can you escalate to? • Your SHO/SpR/Cons • Med/Surgical SpR • Major Haemorrhage protocol • CCOT • MET CALL/Peri-arrest • Crash call • G – Review local guidelines • D – Document Approachingtheclinicalinterview • B-ABCDE-HSGD • Before you get to the patient • ABCDE • History (AMPLE) • Senior advice • Review local Guidelines • Document • Goal is to demonstrate you are a safe f1 PossibleScenarios(notanexhaustivelist) • Shock • Endocrinology • Hypovolaemic shock • Pneumonia • DKA • Haemorrhagic shock • Pleural effusion • Hypoglycaemia coma • Anaphylactic shock • Pulmonary embolism • Adrenal failure • Septic Shock • Deep vein thrombosis • Thyrotoxic crisis • Cardiogenic (unlikely) • Myxoedema • Neurology • Neurogenic (unlikely) • Head injury • Renal • Cardiology • Meningitis • Acute kidney injury • ACS – STEMI • Subarachnoid haemorrhage • Renal Colic • ACS – NSTEMI • Stroke • UTI • Narrow complex tachycardia • Status epilepticus • Broad complex tachycardia • Delirium • Other • Syncope/ collapse • Sepsis • Atrial fibrillation • Hyperkalaemia • Severe pulmonary oedema • Gastroenterology/Surgery • Hypokalaemia • Cardiac Arrest • AA/AAA/Dissection • Acute GI bleeding • Blood transfusion and blood • Acute appendicitis products reactions • Infective endocarditis • Acute cholecystitis • Poisoning • Respiratory • Acute pancreatitis • Alcohol • Confusion • Acute severe asthma • Intestinal ischemia • Acute exacerbation of COPD • Post op fever – anastomotic • Pneumothorax leak etc • Bowel obstruction Academicinterview • Format will vary for each AUoA • Some, if not all of the following may be covered • Motivation for AFP • Previous research experience and research interests • Understanding of research • Critical Appraisal • STRUCTURE, STRUCTURE STRUCTURE • PRACTICE, PRACICE, PRACTICE Academicinterview • Why do you want to do an AFP? Why did you apply to this AUoA? What do you hope to achieve through AFP? Why are you a suitable candidate? • Must demonstrate • Understanding of self – motivation, interests, and career goals • Understanding of AFP – how will AFP enable you to reach your goals • CAMP – useful structure to answer this question • Clinical – particular specialities or clinical experiences offered by certain AFPs • Academic – opportunities to enhance your research or teaching skills • Management – developing leadership skills and positions of responsibility • Personal – location/other Academicinterview • Other questions • Tell us about a paper you read recently that interested you • If you had X amount of money, describe a research project you would design • Other personal questions include • Tell us about your research/teaching/leadership experience • Tell us about your research interests • Tell us about a time you dealt with conflict • STAR framework • Situation, task, action, results • Overlap with WSQs – know your answers Academicinterview–CriticalAppraisal • London – you will be given an abstract to prep with a clinical case in about 14 minutes • Structure is critical!!!!! • Assessing your ability to • Summarise • Critique and analyze • Identify sources of bias • Most often an RCT • Can be interviewer or interviewee ledNEJM, Nature, Lancet, Annals, BMJ Criticalappraisalinanutshell • INTERNAL VALIDITY (BIAS ASSESSMENT) = How well do the observed results represent the truth and are not due to methodological errors (aka biases) • EXTERNAL VALIDITY = GENERALISABILITYCriticalAppraisalStructuredApproach QR PICOK RAMBOS RP FEC • QR = question and relevance • PICOK = summary of the study (population, intervention, controls, outcomes, key findings) • RAMBOS = internal validity (recruitment, allocation, maintenance, baseline, blinding, outcomes, statistical analyses) • RP = external validity (resources, populations) • FEC= Funding, ethics, conclusion From Dr Maddy Ardissino’s LectureQuestionandRelevance+Summary–QRPICOK • What was the research Question? • Why was it Relevant? • Large number of patients with the disease • High mortality • Poor QALY • Population • Intervention • Control • Outcomes • Primary • Secondary • Key findings Studydesign • What was the research design? • Was the design appropriate to answer the question? Hierarchy of evidence • Pros and Cons of different study types InternalValidity -RAMBOS • Recruitment • Blinding • Consecutive • What level? • Multicentre • Outcome adjudication blinding? • Allocation • Outcome • Randomised or non • Clinical or surrogate? Composite? randomised • Designed a priori? • How was it done? • Follow up period/completeness • Simple, block, • Clinical vs statistical significance cluster • Statistics • Allocation blinded vs open • Power/Type 2 error label • Statistical models used • Maintenance • Effect size • Drop out rate? • Statistic used - Relative risk/Odds • Treatment outside equal? ratio/Hazard ratio and why? • Intention to treat analysis or • Sensitivity/Specificity Per protocol analysis? • ARR/RRR • Number needed to treat (1/ARR) • Number needed to harm (NNH) • p-values (alpha, type 1 error) ExternalValidity(RP) • Resource availability • Specialised equipment? Available throughout the world? • Cost effectiveness (on patent?) QALYs – Quality adjusted life years that treatment will bring (used by NICE to determine funding of therapies) • Population representativeness • Population (Inclusion/Exclusion criteria) - Are the patients in the study similar to the target population? • Age, gender, BMI, height, ethnicity, lifestyle • E.g. bias against older people and those with comorbidities • Other medications • More/less ill than patients you see • More/different level of attention during study than you could ever give in real life • Smoking, alcohol, other drugs • Intervention • Acceptable for pts? Frequent follow-ups? • Control • Placebo or gold standard • Outcomes • Clinical outcomes significant? • Recruitment • Mode of recruitment? - recruitment bias - more likely to get patients who are enthusiastic to apply, not representative of real life • Primary or secondary care Funding,ethics,conclusion(FEC) • Funding • Funded or non funded? – conflicts of interest? • Pharmacological/University/Research institute? • Conflicts of interest? • Pharma company funding does NOT mean that it is a bad study Funding,ethics,conclusion(FEC) • Ethics (Declaration of Helsinki) • Population – informed consent? • Intervention – Clinical equipoise? • Control – gold standard or placebo • Outcomes • Safety outcomes? Risks/side effects? • Data safety monitoring board – power to stop the study early if harmful • Type of study - Are some participants being given an inferior treatment? • Pillars of medical ethics: • Beneficence = clinical equipoise • Non-maleficence - interim analysis, safety outcomes, plcaebo, data safety monitoring board, protocol in place to stop study if it goes bad- declaration of helnski • Justice - expensive drug, research is for the good of society and will benefit all • Autonomy - Consent, capacity, voluntary, informed, free to withdraw • Good Clinical Practice (GCP) is the international ethical, scientific and practical standard to which all clinical research is conducted.Funding,ethics,conclusion(FEC) • Conclusion • In conclusion, this is a … that showed … resulted in ….. • Its main strengths are…... However, it is also limited by ..… and …… • Considering the effect size observed and the importance of the research question, I would consider incorporating elements of this study in my clinical practice. However, ideally the treatment of patients should never be based off one study. Meta-analsysis or systematic review should be carried out to make a definitive conclusionCriticalAppraisalStructuredApproach QR PICOK RAMBOS RP FEC • QR = question and relevance • PICOK = summary of the study (population, intervention, controls, outcomes, key findings) • RAMBOS = internal validity (recruitment, allocation, maintenance, baseline, blinding, outcomes, statistical analyses) • RP = external validity (resources, populations) • FEC= Funding, ethics, conclusion Generalinterviewtips • Be able to summarise your projects, presentations, teaching/leadership experiences in a few sentences • Use examples + Create a bank of examples • Practice applying to different questions • Do not rehearse answers, prepare points for common themes • Why AFP? • Why this university/hospital? • Leadership/management/teaching experience • Structure • STAR, CAMP • Reflect • Revise the common medical emergencies for the clinical component of the interview • Revise critical appraisal for the academic component of the interview Preparingforinterviews • Step 1 • Oxford handbook of clinical medicine – emergencies section • How to read a paper (first half) • Step 2 • Practice questions, clinical scenarios, and critically appraising abstracts • Step 3 • Practice with friends, contact previous AFP applicants • Feedback and improveAPPLYFOR THEAFPTips • Read relevant prospectus • Plan, write and iterate white space questions early • Learn emergencies (finals) • Look at useful resources • Speak to current/previous AFP’s • Not a waste of time, useful for finals Resources • Clinical • Oxford handbook of clinical medicine - emergencies section • Academic • How to read a paper by Trisha Greenhlagh • The Doctor’s Guide to Critical Appraisal by Gosall Narinder Kaur and Gurpal Singh Gosall • Medical interviews by Oliver Picard et al • Previous/Current AFP doctorsThanksforlistening Dr. Areeb Mian Academic Surgery (AFY1) Cambridge areeb.mian15@imperial.ac.uk