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How to prepare for the Mr both the clinical and the MS and the SAT part. Um So, the objectives of this uh morning session is to just remind you about the timeline and the process of the application. Um Also regarding the clinical and the professional development scenarios and to just let you know how the questions are scored in a little more detail. We're also gonna give a specific advice and tips regarding the situational judgment part. So we're gonna go through the professional development and how to approach these questions in a little more detail. And we're gonna give some preparation tips and some resources with QR codes that you can scan and you can uh probably it'll help you with your preparation and we'll also have a bit of time to answer your questions. So whatever questions you have, you can keep till the end and we'll try and answer them as best as we can. Um So just coming to the timeline. So uh the November 21st is the deadline for uh the applications for most of the specialties. I'm not 100% sure if it's the deadline for all the applications, but for CSD definitely is 21st November. So the emissary uh examination is the next step in this process. Um They haven't released the dates yet and if you go to the website, you can see that they're planning on holding it over two sessions. Um So this is not confirmed, but um they're expecting a large increase in the number of applications. So they're thinking of having one set of exam goers in January and the next set in February. So this is again, not confirmed. They said by the end of November, once the applications have gone through, they'll probably have a finalized date. Uh The next part is the interview. So in this, we're just talking about the CST interviews. So the CST interview uh portal, the interview dates are from 24th FEB to the seventh of March. Um So it's likely that the CST goes for the CST uh application. Um People who have applied for CST, the M SRA V would probably be in January, but again, we cannot confirm it at this point. So make sure you check the he and the or I website um towards the end of November to see when the dates would be. Um So this is just a reminder regarding booking the emissary. So just make sure that you're quick with the booking. Um I think I had mentioned this in the earlier session. Um The emails do get sent out, but the bookings actually opened prior to it at least last year. It did. So, um just make sure you're on the site from morning on the day of the booking. So be sure that you're checking regularly so that you can book it as soon as possible. Um Also make sure this is just to ensure that you get um location that you're comfortable with and the time that you're comfortable with and the date. Um So make sure that you keep looking. Um Another thing is uh so uh you do get professional leave for the emissary examination for all uh examination, there is uh set out professional leave that you can apply for. Uh but make sure that you're not really on nights or on long days or on difficult stressful uh days during the examination. So if you can shift around shifts, um once you get the dates to make sure that you're on normal days, if you're working, just try and do that because I think that would be really helpful uh to reduce the stress of the exam. So the exam on its own is that it's divided into the S JT and the clinical part as we all know by now. Um So the professional development part has 50 questions and these 50 questions need to be answered over 95 minutes. Um They basically assess the patient person's professional integrity, how you cope with pressure and how much uh sensitivity and empathy, empathy you have in dealing with situations. Um The scenarios, uh usually there are two types of scenarios. One is the ranking type of scenarios where you would have 4 to 5 options. It's around five usually and you have to just rank it based on what would be the best thing you can do in that situation and uh to the what would be the most inappropriate action in that uh for that question, that's the ranking type of question in the M CQ part, the questions are just you choose the three most appropriate options among around eight options. So there would be three options that would be correct to do and you just mark three that you think would be best. Again, these questions would be half, half, half of them would be the ranking top type, half of them would be the M CQ type. And uh always remember that there is no negative marking in this exam. So make sure you mark all the answers. Um don't leave any questions cause um you're not getting marked negatively. So attempt it whether you know it or not. Um So the clinical part again, it has uh 97 questions um over 75 minutes. These are the subjects that um come in them is already examined. The questions are divided among these subjects. Um The thing you need to remember is it's not uh equal distribution. There is no um The questions are not divided equally among each set. You could have, it's not a necessity, but it's a possibility that one area would have more questions. Like, II remember last time pharmacology was quite, or at least the exam I wrote Pharmacology, there was a lot of questions from Pharmac even though um it's just one of the topics. Um these are just the type of questions that come in the clinical. So it can be an investigation type of questions. So this can either be the investigation of choice in a scenario or the first investigation that you would do or like for example, the first investigation in a case that would be most appropriate. Um The second type of question is a diagnosis where you would be given a few clinical characters, some clinical um probably some pathologies and maybe an investigation, an investigation would be given to you and you would need to diagnose what the condition is based on what's given. The next one is emergencies. So that's basically what you would do in emergency scenario. Uh Drug prescriptions can be there where they ask you what is the management and uh what is the drug of choice? Um They can also be nonp prescribing management, like what surgeries or what procedure would be appropriate at that moment. Um So the clinical part, I think I had said this last time as well is again divided into two that's the single best answer type of questions. And also so the single best type of question is basically you get um, 15 to 8 option and you have to select which one would be the correct option. Um There's also the EQ type of questions where there are runs of questions and um around 3 to 4 questions would have the same options, but with different answers, again, this is also um half of half the questions would be SPS and half of them would be em QS. Um Each question uh holds the same value for mark. So make sure that you mark all the questions and don't spend too much time on one question. Um If you don't know the answer, make an educated guess and just move on, you can always mark it to come back to it later. Um If you have the time, but and very important thing to remember is that time really runs out, especially in the clinical part. So make sure you just go through the questions, you can mark it for later. If you have the time you can come back. Um Also, I would suggest do not leave a question, mark it, leave it and think you would come back to it later. You might just run out of time. So in that moment, just mark what you would think is most appropriate and move on. If you have the time, you can come back again, please do remember there's no negative marking. So answer every question. Um So the clinical part of the exam is generated from a question bank. Um, there is also around 11 trial questions. Um, the 11 trial questions, you would never know what level 11 trial questions are. If you're very lucky, 11 could be questions that you don't know and you wouldn't get marked on them at all. But if you, if you're unlucky, it could be questions that, you know, very well and other questions would be the ones that you don't know. So there's no way of knowing which 11 trial questions are. So just make sure you give your best guess for every question. So these are just some question banks. Um We're not endorsing any specific question bank. Um It's just, there's a lot of resources out there. So past medicine, New Medica, past test, there's M CQ Bank. So these are just multiple questions banks to different people suggest. So um just ask around, find out what would be best for you and use any of them. There are also a few courses. Um for example, E Medica holds a crash course, I think at the end of November, um again, we're not endorsing this. It's just available if you want to look at it. Um for the S TT part, make sure that you go through the GMC publication. So all these question banks have S TT S as well. Um But the thing is no one really knows what the correct answer for S TT is something that I was told very recently was that um two different question banks had two different answers for the same S GT. So um it's just up to you on what you want to use. Um So the M SRA examination, so we're going through the scoring. Um So the scoring is basically um there's an average score that among all the people who have written this exam and this average score would get you a point of 250 like a mark of 250. So if you were average, then you would get a 250 on clinical and 250 on S JT and that would be an average of 500. So the last year stats are basically this um in the clinical part, 76% was the average. Um So out of all the people who wrote the exam, um 76% was the average score. So half the people got above 76 half the people got below 76. And um the whoever got the 76 score got 250 whoever got above got a score above it on the professional development part, on the other hand, the average was 82% which is, I know it sounds quite high, but again, 82% was average. So people who got uh the average score at 82% got a score of 250. So that would make a total of 500. Um Your aim in this exam is basically to get how much ever higher than the average you can be. So that your score overall improves. Also remember that um you cannot really neglect a section because it's very hard to make up for one section with the other. And because you don't really know what the average of this year is going to be. Um you would just have to do well in both sections and try to get a score above average for both of them. Um And this year, the competition every year, the competition just keeps rising. So just make sure you do your best to get the high score. Um So uh there's a banding as well. So based on your score, you would be banded based uh from 1 to 4. So band one is a fail and the rest of the bands are ranked based on score. Um So in the clinical part, band two is around 55% and band four is uh about 90%. Uh the professional level band two would be around 70% and band four would be more than 90%. Um So the professional development part again, there are 50 questions. Um You have to answer this over 95 minutes. Um So this is also, there are two types of questions, there's a ranking question and the M CQ questions. So a lot of people find the M CQ questions a little easier to answer because you just need to choose three options. So if you are someone who finds the M CQ parts answered, just make sure you answer those quickly. So you have more time for the ranking options. Um The professional judgment is uh usually based on professional integrity. Um How honest you are in every situation. It's also about coping with pressure. If say your uh colleague arrived late or you have too much work. How would you deal with that situation and to um in every situation to have empathy and sensitivity? Um with regards to the patient, this could be probably a consent situation or breaking bad news or those kind of situations. Um So something you need to remember is uh the professional dilemmas, judge the level of competence at the level of an F two. and this is standardized across the UK. So avoid answering questions based on specific local knowledge that you have. Um it would be regulated by the GMC and it's across the UK. So what would, what would a trust do or what would be the best thing to do via the GMC guidelines is what you essentially need to think. So even in the S JT part, there are 50 questions and 42 questions are marked. So your, your ans you're only marked for 42 of the questions and e are just pilot questions that you don't get marked on. But again, you don't know which the EA so just you have to just give your best attempt for all 50. Um So the timing wise, each question would have around one minute 54 seconds. Um So again, like I said, usually the M CQ is a little more easier. So try and get through that a little faster and the ranking usually takes a bit more time. Again, both questions are divided half off and there's no negative marking. So please make sure that you mark all the questions. So the situational judgment test is actually used by uh many services in the UK, the civil services use it. Um They used to use it for F twos earlier um as the situational judgment test to get into training uh to get into an F two post. Um they also, so they, they use it in A V. So I think you can find the earlier uh GMC papers if you just go through it online. Um So go through the foundation program papers to see if you can find official resources, resources from the foundation program because I think that would be helpful as well. Um So something you need to remember is that in these situational judgment test type of questions, um you need to really get into the mind of the person setting the question. So and think about what they are expecting from you as an answer, do not really answer on what you would ideally or, or what you would do in the exact same situation just in a general practice, just think about what they are expecting you to answer and also go through the GMC publications and the good medical Practice guidelines. So this is something a lot of people have had told me that like you need to go through the good medical practice. Um line by line, just read it in detail because the answers would be based on those guidelines. Um Right. So these are just a few of the topics that come under each section. So in professional integrity, um one, the few things that are tested is your openness and your honesty and your willingness to admit mistakes. Um So a thing to remember is that you have to be always honest with the patient. If you make a mistake, the one of the most important thing you, you have to do is go and tell them about it and make sure they're aware. Um The next thing is to treat everyone with respect, dignity and know your professional boundaries. So remember that this is at an F two level. So it, it's not about answering what you would do in every situation. Sometimes the answer would be just to escalate it to your seniors. Um Balancing ethical tensions is another thing, quality and management of risks. Um prioritizing risks, uh being proactive and inquisitive. So this could be if, if someone's not available, you need to arrange for cover or try and find it as much as you can. Uh responsibility Um So you have a sense of responsibility as a doctor, to yourself, to others, to the population, to everyone you're treating basically and a commitment to a standard of quality of care. Um coping with pressure again, this would be um seek uh seek assistance when needed uh escalated as soon as possible. Um understand the impact of what your decisions would have on others uh how to manage stress. So, one of the questions, I think this, there was one question last time regarding um uh someone is stressed and arriving late constantly, what would you do in that situation? So it's these kind of questions, um professional demeanor, how to manage pressure, how to remain calm. Um always be self-aware again, know that you, you have limitations and sometimes you just have to escalate it um resilience to manage criticism. Well, um what would you do in bullying scenarios uh and how to manage multiple complex roles? Uh The next one we come to is empathy and sensitivity. This is basically about having a caring approach towards all patients and all colleagues. Um just to be more understanding, uh motivate others in situations, um try and understand how you can help out any situation. Um It also includes having a holistic approach to patient care, including all social psychological, emotional factors. Um It, it's, it also shows how to acknowledge and explore what the patient wants and to prioritize the patients uh wants more than everything else. Because it's his own body. So he has a right to know about his treatment and what to do with the treatment. Um It includes uh having a very patient centered approach and treating everyone as individuals in an open and not much judgmental fact. Um Right, so coming to the ranking, um so there um ranking is OK. So um the ranking is uh basically there's four or five options and you need to rank it uh from the most appropriate to the least. Um There is no tied ranks. So just, it's, it's just 1 to 5. There is nothing that's uh two answers would be correct at the same time and it's just the best correct answer. So, like I said earlier, this is a very debatable and controversial thing. Different banks, different question banks have different answers. So the best thing you can do is go through the um exam papers set by uh the hee or the official exam papers that are set and go through the good medical practice as well. So each question in this section is ranked out of 20. So if you get full marks as in you ranked each answer appropriately. Um for example, if you take a look here, um the correct answer ordered is ABCD E. So this is most appropriate to the least appropriate. And the given answer, the one that you have given is um A to E. Um And so if you get this right then you would get a total of 20 points. All right. So I'm gonna hand it over to CJ to take over this section and he will explain a bit more regarding the marking and the details of the S JT. Um I'm all right. Yeah, thank you very much. So, yeah, just to reiterate. So the ranking option. So when we're looking at the professional dilemmas questions, so you have either ranking or MC Qs as we've already discussed and doesn't matter, say there's rankings, there's four or five options. And the way to think of it is it's most to least in terms of the options, whether it's appropriateness, effectiveness important. And it's very important that you appreciate that these are separate. So it's a question of a, it's this or this or this, so not combined of separate. Now, as my said, it's very debatable, even controversial what the correct answer or the best answer is. But this is based on the JMC guidance. Now, how they mark the ranking is that if you get the correct answer as per whoever set the question, this will get you full marks. So in a five ranking options, you get 20 marks available. If you match the correct order, you get 20 marks. But subsequently, it's based on how much your answer deviates from their correct model answer. So you can think it was incorrect, but more accurately perhaps is think of it as partially correct. So you can see this big QR code that's appeared on the right. Er this leads to a er if you scan it, you can get this either an X or a Google spreadsheet, which does automate a marking for the questions. So this can be helpful for you if you're doing a mark just so you can put your answers in versus the correct answers and you can, it'll automatically score things for you. And it also has individual scorers for this to give you an appreciative of how appreciation of how things are scored, what's important and therefore crucial with the pressure dilemmas as it is with all of the M sra is to make sure you answer everything fully cannot emphasize enough ma mark an answer. Everything do not run out of time, make sure you put something down because based on the way this is marked, it's not possible to get zero. Essentially the worst you can do is get eight out of 20. So if you see at the top here, the correct answer and the given answer they match. So therefore all you get the full set of points here, even by making it essentially as far away from the correct answer as I can. So in my given answer, you can see that I put the worst an option first and I put the best option last. So those both are as far away from as possible from where they should be. So they get zero the other options are still only therefore a little bit deviated from where they ought to be. So you still score some points. So when it comes to the rankings, it's important to make sure you've answered it fully. And the other thing to bear in mind is if you think about here, if you think of this last example here where this is the correct answer, this is my given answer order. You can see that I've transposed what should be in the 2nd and 3rd position. So rather than put ABCD, I put a CBD E but I've only lost two points for that. So another important takeaway message here is that when you're doing these questions, if you're in a situation where you're not sure what to do, you don't know is this, is this better than this, you know, you're unsure, potentially, it's just better to accept it and move on because at worst, you'll lose two points if you're happy with the rest of it and there's no point agonizing or wasting time overly on this. So just this QR code, if you haven't already, you can scan it and that means you can bring up the automated scorer, we'll have it at the end as well if you want it. So for the M CQ options for dilemmas, you have eight options for a scenario and then you go select three and you get a mark four marks for each correct option that you've selected now for the M CQ, it's the most appropriate combined response. This is distinct from the ranking one where it's an either or situation. So it's option one. Is it better or worse than option two? And they're considered separately? You're not doing both, it's one or the other in M CQ, it's combined. So the three most appropriate things together and this means the options you pick should be synergistic, they should complement 11 another and reinforce one another. You should avoid contradictions because that doesn't make any sense and also avoid overlap. Uh What I mean by this is, for example, if one option says, discuss with the patient and family and the other one says discuss with the patient and family and document, it wouldn't make sense to mark both of them because one covers the other. Now, I've not seen when I've done the question, something that was that blatantly, you know, the same option. But that's the kind of thing. I mean, by avoiding overlap, you'll find that sometimes there are options which are very similar to one another. So it doesn't make sense to put both of those options down necessarily, ultimately, when you pick the three options for M CQ, when it's combined, it should be something that synergistic and it just makes sense. So if you were to forget about everything else, and you just take those three options, you that could read like a, just a response to the scenario and it would, it would make sense that they're doing what they should be doing. They're not repeating themselves, they're not contradicting themselves. So that's the way of thinking of the MC Qs. Again, there's something that will, you can just enter in, you can use that um on the spreadsheet. So in general, when preparing for any exam, so these are some tips. So this will be applicable to both know the clinical and the pressure dilemmas. You can think of there being what's your knowledge and what's your technique. So knowledge is the things that you understand. So your the clinical is the concepts, the clinical concepts you understand. And this is distinct from recall, recall is say the concepts you understand, but you don't, you could teach it to somebody else without needing the book. So it's what you really remember and then need is appre to the audience. So if it's a consultant teaching first year medical students versus the final year versus you know, sh os versus registrars, the level of knowledge they're gonna pitch is different. It's the same as you know, thinking of generic knowledge versus specialist knowledge. And again, the the important things to appreciate here are that this is at an sho level. So when we think about knowledge wise understanding you require, you shouldn't be needing to quote super specialist knowledge to answer these questions. And for professional dilemmas, you should be thinking about particularly things at limitations or what you should be doing in a scenario. There is a lot of escalation. There's all those things to consider knowledge wise. I'm not going to focus too much more on that. We'll go through some general principles for the professional dilemmas in the moment. But I appreciate that, that purpose of last week, the previous weekend and this weekend is to try and help impart some of the clinicals, the clinical paper knowledge and then reading the GMC publications and then the practice you do and then the reading up following those practice questions you do is really gonna help you develop your knowledge. That's your own study. Technique wise, you have three things, application of knowledge. It might sound simple, uh you know, silly, but we'll talk about, it's about how you think. And I'll mention that in a bit. Timing is all important in these exams. Because if you had, you know, much more time than you do, if it wasn't time pressured, then actually most people I think would find that they'd do better on these exams because it would be that much easier. Communication is not as relevant here because it's an M CQ. But the point I'd make is you answer everything. So here, knowledge wise, you need to study that yourself. Recall, it's gonna be easy if it's an M CQ. And remember in terms of the n the level of this, remember that you should be able to answer these things with sho level knowledge or the scenario in as a professional dilemma is an Shof two. So technique wise, I'm just gonna elaborate a bit more on application on to how you think and was the idea of timing. So this idea of triage for questions, communication wise, there's not really much to say, just make sure you answer everything. So technique how you think in a multiple choice that you can think of, there's three broad ways of getting your answer, you can work it out. So you can look at the question and you can select the correct answer based on thinking this is the correct answer. I've worked this out. There's a logical reason you could eliminate all the incorrect answers which leaves you by logic with what must be correct. There must be one, there's one correct answer or you could guess you can use one of these methods, you can use a combination. So the point being the system that's market, it doesn't know which way you use. So it's very important that whatever question you face you do it in the most efficient method. Sometimes it's easier to eliminate obviously incorrect things to leave you with what's correct. Um Other times it might be as I'm about to talk about and we can go about timing, sometimes it's gonna take you too long to work something out and the best you can do is eliminate something and then just guess and leave the question or it might be better just to guess that question because there's no point spending lots of time on one question and then losing time for other questions and it seems a very straightforward thing to do. But technique is very important in an exam like this where the level of knowledge is something that you probably have. So where you're going to lose out marks is where time pressure. And actually this element of technique is what's going to start differentiating people. Now, an important concept to think about application of knowledge and how you think is you may find a question and you say, I don't know this, but that's not the approach to take. What you need to focus is on what you do know. And all of you now attended, you know, these this weekend sessions and you have done your own study. So you will have had, you have have should have a broad knowledge, at least of the general topic areas that can come up. And clinical. And similarly, for professional dilemmas, you should have a hopefully a quite a broadest knowledge of those principles. So even if your immediate, you know, knee jerk reaction is, you don't know what the answer to this question is. It is possible to say certain things you do know which might allow you to eliminate things or make an educated guess. Now, the other thing about application nodule, how you think for questions is what's called guessing strategy Now the importance of guessing strategy is it just optimizes the s the statistics in your favor. So, if you were to do 100 question test, so on a subject that you know nothing about, it's answerable choice questions and every one of those 100 questions has four options. A to D, how many questions can we expect? We know nothing about it. We just have 100 questions, options A through D how many questions can we expect to get correct just by guessing? Or what's the, what's the thing? We can almost guarantee. I'll give you a second to put it in the chat if anyone wants to answer. So if you were doing 100 question test, yeah, 25%. But the important point is how do you get that? What is the strategy you're going to use? So I'm gonna pick on you and just ask, can you tell me what you would do to get that? There's a specific thing I'm looking just to get you to say, you know nothing about this topic, you just know there's 100 questions each has the answer options A to D and you're gonna get 25% on this test. But how are you going to do it? So the answer I'm looking for here is you're gonna be consistent. You're gonna put the same answer choice throughout. So not so not randomly allocate answers. So if you put the same answer choice throughout A, then you should get, or B or C or D, it doesn't matter which so long as you put the same answer just throughout, you should get 25% right. If, however, for each question, you just randomly put A or B or C or D, but there's no consistency. That's when you may well get less than 25%. And the reason for this, each individual question, the probability of getting the right answer is 25%. And if you then did 100 questions like that, it's 25% to the power 100. So you're just 25% to 25%. However, by putting the same answer choice or being consistent, what you're exploiting is essentially a test set of bias. So if I'm the person who wrote this 100 question test, each question has four options. I am going to across those 100 questions allocate roughly an even proportion of the correct answers to each of the four options. So roughly 25% of the correct answers will be a 25% would be B and so on. Now, you don't know which order that happens in. So it could be the first question, correct answer. A is correct for the first question and the 10th, 11th, 12th question and then it, you don't know where it comes up, but you do know that a quarter of the correct answer should be answering. So when you're to get I, if you're in a situation where you're guessing, in order to maximize your chances. So in this situation, you want to put the same consistent thing. Now, obviously, in this kind of exam, hopefully you're not going to be having large numbers of guesses, but the idea still holds true that and you'll see this demonstrated if you did, if you s reviewed all the questions you've guessed on, you see that if you're always consistent and you're guessing the way you guess. So, for example, the way I would, I've been taught to do this, the way I've done this is that I always guess the top most option that I've left after eliminating things, then it improves your chance of doing well. So this is the idea of guessing strategy just in an M CQ. And again, this is the idea, it's just optimizing your timing here. So when you face a question, if you decide you're going to guess, once you've done as much as you can to eliminate or say, OK, these are the options to guess from provided you're always consistent over a large number of questions. This improves your chances of getting the right answer. Now, timing wise triage is a term that we should all be familiar with. But triage of questions in an exam like this where your time pressure is very important. So the way I would advise thinking about it is if you have a time allotted per question So for example, it depends, obviously, this is something you'll determine by yourself. Um But for the, you'll divide the amount of time, divide by the number of questions, you might try to leave some time for checking. But essentially you can, you should be able to make a judgment as soon as you see a question. Is this an easy question? Because in that case, it should take you less time than you've allotted. Is it just a normal question? I'll take you exactly the amount of time that I've allotted for this or is it a hard question? Now, the reason why this is important is all the questions are work the same in terms of points, slightly different, I guess in the professional dilemmas in that rankings work slightly more than MC Qs. But even then, and the ranking questions, the five option ranking questions which are the same, they're gonna be, you know, they were both work 20 marks and certainly in the clinical paper, everything is worth the one point. So making a judgment being able to say, OK, this is easy, normal and hard is a very important skill to develop because you then decide, OK, if it's easy or normal, I will do this question because it's not going to affect the time I have left, it's not gonna take away from other things. And if it's hard making that judgment is important because at the start of the paper, for example, you don't wanna be focusing on a spring of hard questions when they could be easy marks to get at the end of the paper. But then you're gonna run out of time. So this is something that you should develop and this is why it's important to practice. Always, when you're doing these things under time conditions, after you've done the questions, it's fine to go through them, read everything you need to read, whether it's clinical or professional dilemmas. So you understand the rationale for the correct answer, but when you're doing the paper, it's always important to perhaps under time conditions so that you get a feel for how quick you are with that kind of question. And this allows you to make those kind of judgments. So in the actual exam, you can triage your questions, you can say, OK, this is easy or normal. So it's either gonna gain me time for the other questions or it's not gonna affect things. So I'll do the question or it's a hard question. So I'm going to maybe eliminate something and guess or I'm just gonna guess immediately and keep going and I can flag it and come back to it. Now, with hard questions, there's tools to think about thinking about it. It could be something that's a workable question. As in, for example, at the SAT, sometimes the scenario is very large and you look at this and you think, OK, this is the kind of question that's gonna drag me down. It's gonna take a lot of time, but I could work it out just at a glance. So I'll flag this question, I'm gonna come back to it or it could be a question. For example, in a, in a clinical, you don't have much of an idea. You can appr apply this to the principle that OK, let's focus on what I do now and try to eliminate things and then improve my odds with guessing. But those are the two kind of categories that hard questions fall into. And this is why again, it's important to consider that you have this flagging function. So optimize your technique here, you make use of that. So when you are approaching questions in your exam triage them, so think are they easy or normal? So I should do this or is it hard? Now, we've worked through some of the time. And so previous, when we were talking about this, for example, on a previous slide, we said, if you divide the 50 questions by 95 minutes, you have one minute, 54 seconds theoretically per question. But you need to do personal kind of practice on this and work out what works for you. Because obviously there is two question types in the professional learners. And it might be that you might say, OK, I think two minutes per a uh ranking question and 1.5 minutes per multiple choice question is reasonable and then it leaves you a bit of time to check hopefully at the end, but that's something you need to work up for yourself and work up. Ok? This is the time I'm gonna allot for this. This is the time I'm gonna lot for that que question type and this leaves me so much time for checking with timing. It's also just worth mentioning that it's important not to be too fast or too slow. Because if you're going too fast, then you're liable to make mistakes by just virtue of not having to spend enough time at being careless these tests. While time pressured, it should be possible again to answer the questions and the time. So if you're going too fast, you will make mistakes and you're potentially liable then to come back with lots of check in time and start talking yourself out of correct answers equally, being too slow is a big problem because then you're gonna miss questions and miss easy marks. So general preparation tips, make sure you read the questions and scenarios carefully. Don't miss things that are negator. So that so if someone put a negative word, so what's not important or those kind of things or what's the incorrect answer? Because otherwise you're gonna make mistakes. So make sure you read the questions and scenarios carefully and importantly note the keywords and phrases. These can highlight important clinical concepts or and this is more important to professional learners particularly, it can highlight the important bits that think, OK, it's this bit of GMC guidance or so this thing that you read this principle that is applicable here or is the most important issue you're not gonna need to be quoting, you know which paragraph of the G the good medical practice book that's not helpful. But if you have a rough idea of what's in their principles wise, you've read through it, you know, the rule book from which the person who's written this question is playing, you know, the kind of mindset they're in, it may be that in real life, actually, that kind of thing doesn't always work or it's not the scenario they're given is, is not what you do or something would be different. But you've read the guidance and when you go through these questions, you read them carefully, you should hopefully pick up the key issues, which means that you can then use that knowledge to get the right answer. Timing as we've elaborated on is all important. And we've given you a number of strategies by which to use for this. So it's important and then finally practice, practice is all important here because it allows you to perfect your timing. It allows you to see what share as your weekend. Now, an RG EO sometimes made when practicing for a test is that if you imagine you're sending someone a diy project, if they've got no proximate, they don't know how to use the power tools. They've never done anything diy before you set them an hour to do some kind of task. They're going to do very badly at it. Now, if they've had a few weeks to prepare, just not doing actually doy, but they've read the mails and the power tools. They know how to use the things they're using, using for this, then they'll do a bit better because at least they know how to use the drill, they know the hammer or whatever it is. They know how to do those things. If in the lead up to that task, they've actually been practicing doing other projects, not, they don't know what the project you're gonna give them is, but they've been practicing that, then they'll do even better because they're, they're practiced with using their tools in a s that's kind of scenario. And how analyzed of this is a lot of the things we talked about here. They're techniques, they're telling you tools to which to optimize your performance. But without practice, that means nothing because you shouldn't be needing to think. OK, this is the next step in the technique that is something that should come automatically. So practice is very important for this exam. Now, with professional dilemmas, specifically ma the domains that and attributes that Marriott talked about earlier, those are, are those three core components that's on the M SRA website where they've said these are the three core components and these are kind of the breakdown of it. So know those well and read, the guidance, can't emphasize that enough now approaches. So for the ranking questions, as we've, I've elaborated on before, it's the most or best option to the least or worst option. And what you're doing is assessing harm and the options are separate. So it's like all statements. So your options one through five is option one better than option five and so on. Now when you're doing this, read all the options prior for ranking and try and get an initial order. But then what you can do to help fix things as a, as a logical approach or method is you can do a comparison of options above and below. And you may have heard something called a bubble sort. So here you can see this so that there's a, there's multiple parts. So what you're trying to do is arrange the numbers in order of size. So here you take the first numbers of five and you say, is it bigger than one? Yes, it is swap it, is it bigger than four? Swap? It, is it bigger than two? Swap it, but it's not bigger than eight. So we leave it where it is. Then second part, we again take the last number and we go through now, this might seem time consuming but in a bubble. So if the numbers are already roughly in order, it makes it's very quick because you don't need to do any swaps and you immediately move on to the, the, er second or third and so on pass. And this is just a logical approach that can even help you. Because with the ranking questions, it's a either or situation you're doing option one or option two or option three or option four or option five. So you're just comparing which is better and then ranking them based on that. So that's just a way of logically approaching this. It is important of course to read all the options before and get a good starting order because then otherwise doing this approach would take a lot of time for the MC Qs, as I mentioned, it's very much the same things as earlier. It's a combined response. So with this, the three things you should work together should reinforce, they shouldn't contradict one of overlap and it just makes sense together again, this is where some of the things about how you think come into play because if you eliminate the obviously incorrect things, then that is gonna increa it's gonna make it easier. OK? So I've eliminated say three of these options. Now, working with picking three or five, you can immediately see that it's gonna be much easier because you're picking three of five. So 60% of those things you need to pick. So it's almost to eliminate two or so use the application of how you think with these questions. So I'm just gonna talk about just some general principles. So when I prepared for M Sra and I went to a course, these are some of the things they talked to me about. This is not an exhaustive list by any means. So you need to do further reading, you need to do your questions and read out the rationales for those. Again, there's no, a lot of these questions are always going to be very debatable. So there's going to be an element of, you know, I disagree with this. But ultimately just because you disagree with someone, it doesn't mean you can't get into them headspace or see things from their perspective. And that's the way to succeed at situation judgment tests. You can take the approach of, you know, this is what I would do and if you're a good doctor, you know, you should get the right answer. But it, the even better approach is to actually say, ok, this is the way that they're expecting me to think this is the way that they think and try and get that on board. So ethical principles wise, you will be familiar with this. So inefficient, non efficience, justice, and autonomy. So just when you are assessing harm and er benefits for options, you can think about this gives you almost a structure. So what are you achieving with each of these things? Sometimes scenarios might focus on a particular aspect of this. Now, confidentiality is something a big thing to think about. Uh So this is something again, that can be a key issue that's highlighted, you have the ethical obligation of confidentiality, but there's also legal elements to it. Now, the crucial thing is that obviously you can think about, er, where confident she has been vi that could be an issue that's brought up by scenario. The other thing they might present you with that you could think about is this side of, do we need to disclose confidential information? And it's either the public interest. Now, there are legal requirements where automatically there's not really a question you have to say and that's where things are notified, disease or you've got a court order. So there's a actual law in place that says you have to do this. But the challenging bit is sometimes when it comes down to your judgment as the professional, should I disclose this in the public interest? And generally speaking, you can think about this, either the ri risk of death or serious harm or prevention of serious crime. And when we think about the risk, it's to the patient but also third parties. And again, this is why sometimes it's important to note about things beside the absolute confidentiality that should always be avoided because you can't guarantee a absolute confidentiality because there may either be a direct legal requirement or if you're ma use exercising your judgment, you might find that in the public interest in this thing at this risks. You should. Now again, the classic kind of scenario that people always talk about then is this idea of someone's driving? They're not meant to be driving. Do I notify the da LA? Now that QR leads to the DV A's assessing fitness to drive. If you've never seen this before, it is quite useful day to day, we don't always need to remember the rules exactly. this has for all the medical conditions they say what the rules are. So for whether it's aneurysms, epilepsy, having had a stroke, it says exactly what the rules are from ad va point of view. So just in your day to day practice, it can be helpful for the purpose of this exam. Again, you're not going to memorize, be able to memorize all the guidance for all the conditions just as you can't remember all every paragraph of good medical practice. But it's worth going through for some of the common ones like, you know, cardiovascular events, your, you know, CVA S mis your af your, um, you know, epilepsy just quickly leave for those common really common ones just so that you've got the idea of exactly what you're meant to do. So what is meant to be disclosed and that sort of thing? Because if that person's not, you know, disclosing, then you do have a duty to disclose that. Now, when disclosing information, it's important to try and gain the consent to have that. And this is then going to come under the capacity of the consent, which is something I'll address in a second whenever you are disclosing. Ultimately, even if you've not got the agreement for it, so you're not gaining the consent, which is the best scenario, you should still try and inform that the the disclosure is happening. So already in terms of ranking options, for example, you could see that if you have to disclose information, the best ranking would probably be to try and have a discussion with them and get their consent for it. But then better than just doing it without informing them is making sure you've informed them that the disclosure is happening. And of course, you need to make sure you're documenting everything. So document the decisions, document, when you disclose, document that you talk to them about it, documenting the reasoning of why you had to disclose things. It's also though important to consider risks. And this is just because sometimes when you're disclosing confidential information, there is risk to patients or third parties. So just as when we think about that being a justification to disclose confidential information, you've had to think about the impact of the disclosure itself. So that's again, something to always think about now capacity, this is something that I'm sure everyone will have had to do make capacity assessments. Remember this capacity is the ability to make one's own decisions. It is decision specific just because someone can't consent for a surgical procedure. It doesn't mean they can't decide what they want for their dinner or to have a cup of tea. It's presumed in adults unless there's evidence otherwise. So we always work from the point, there's a presumption of capacity and what you talk about is the t what you talk the two stage test. Now, that's more recent guidance has taken away the either two stages and you typically look at these four principles for having capacity. So they have to understand the information you're presenting them for the decision, retain it long enough to make that decision. And the ba to determine the length of retention is kind of weighing up. So they need to be able to take that information and weigh it up and present you with some reasoning and then communicate that to you in terms of the weighing up, you don't need to agree with it. They just need to sow some form of reasoning that they've expressed, which isn't, you know, the sky is blue. So I'm gonna have an operation, but there's some form of reasoning. They said the things that are important to them and in terms of retention, some it's d different. So sometimes you can say, you know, they need to just retain it long enough to wear it up. But then, you know, if you go to them tomorrow, they might have again for forgotten a lot of the information. Typically with surgical procedures, it might be advisable to think about retention wise. They need to remember long enough so that if they're coming for the operation, they're gonna remember that they have given consent in all of these things, you have to support people as far as possible. So if there's a language barrier, get a translator, if they are having some kind of sensory impairment, you need to try and compensate for that as far as possible. Now, when you're doing these saves of capacity, after you've used those kind of four things, those four factors, if any one of those is lacking, they're not gonna have capacity. But then you also suggest is they impair a mind or brain to explain things. Now, in Children, we talk about this, I get it confidence. So over 16, typically, you can think they have capacity. Um You still might use a consent form too rather than one if they're under 18. But under 16, they may not have capacity and you think about gil competence. Um So Gin is the case from the eighties, which was the contraception case where doctor provided some contraception for a patient uh who was under 16, the mother objected and ultimately led to this idea that at doctor's discretion, they can do it if they judge the minor to have sufficient maturity. So this principle now is moved across a lot of, you know, other areas. So you talk about g it competence because in Children capacity for positions is an evolving thing. So it might be that someone at 14 has the ability to, to take an active part in making the decision for themselves, whether they say, you know, have their appendix out, but equally, they might not have that capacity. So it depends just as a point. So reporting sexual activity, there is GMC guidance on this, what I was taught the course I went to. So generally about ages 13 to 15, you don't usually have to report this if they're consenting. So you, you don't have to is the rule if they're under 13 hours of legal obligation, cos that's statutory rate. So that's a a legal thing. Now, from this first thing where you usually don't have to, but you usually should not report there are reasons to report. So there could be too image to consent. You can make that capacity judgment. There's some significant power differential, there's an abused position of trust, for example, teachers, that kind of thing, there's some kind of coercion and this could be for the act itself or after the fact, some they've been caused to conceal things or there's the involvement of drugs and alcohol or this per this patient is known to child protection of the police having abusive relationships. So these are just some of the principles read the guidance for that. Now, informed consent. Again, this is a typical kind of thing that can come up as a pressure dilemma for consent to be valid. It has to be informed, the patient has to have the capacity. It has to be voluntary information. I'm gonna go down in a second capacity. We've just been through and voluntary is almost self explanatory. They can't be dere supplied, there can't be undue pressure. The reason why you might think about this word undue is sometimes, for example, emergency surgery, there's not really a way of removing the pressure of that situation because sometimes the surgery is lifesaving. So if someone has a bowel perforation or they, they need an emergency laparotomy, they need it as an emergency licensing procedure and you can't really get rid of the pressure there. But you're not, you're meant to not, you, you're meant to avoid pressure as pos possible. So this is why we say no undue pressure. Now, in terms of informed consent, I'm gonna think about it from the point of view. The easy way I like to remember is if you think about a consent form one for a surgical procedure, you have the different section. So there's the name of the intended procedure, treatment or action. And essentially this means that when you're giving someone the information, you need to explain exactly what it is you're intending to do for a surgical procedure. This is the surgery, but if it was giving someone medication, it's, you know, what's the medication? Generally speaking, how does it work? So, if you're giving a BP tablets to lower your BP and if you're giving, you know, some kind of antiinflammatory, those kind of things, this is, you know, what is it intended to do or what's the intention of it with surgical procedures. It's important that the person who's consenting has an ability to explain it. So that's why it's inappropriate. If you don't know if you've not re observed this procedure, if you don't know how it's done, then you shouldn't be consenting for it because you can't answer questions, you can't explain it. Um the rules. So sometimes it's a bit um unclear generally and certainly in real world practice, you don't ask people, only people who perform the procedure to consent it otherwise sh Os could never say consent for a hip replacement or something like that. But you need to have a good knowledge in order to explain that you need to tell them what the intended benefit is. So that needs to be clear. So this is what we're hoping to achieve by this. And then you need to tell them the risks of this procedure. And I'll talk about risks a bit more on the next slide. The other thing that's important to mention is alternatives. And typically with alternatives, you think about this idea of um you know, do nothing, so do nothing. And in conservative management, these are actually sometimes different because doing nothing is not the same as conservative management, conservative management could be antibiotics versus surgery. So remember, alternatives should also be explored. Now with informed consent, the important thing to appreciate is the Montgomery case. This is the case law for this. You can read the quote there. But essentially the takeaway is that when you are thinking about risks, it has to be risk are material risk. If the patient would attach significance to it, it should be told to them. Obviously, this is a bit difficult for a doctor because it almost expects you to sometimes be a mind reader. But what it really means is that you need to have a proper conversation with this patient. Um What happened in the Montgomery case is that there was this lady who uh was not given the risks by the obstetrician being a type one diabetic for a natural pajama delivery and said that she would have opted for C section if she'd been told. And this then for superseded, what was previously in the, the case law, which is the B test from 1957 where previously, what it was like is that if you're reaching, if a responsible body of other medical professionals would agree with what you've said, then you're not negligent, at least as far as it pertains to informed consent and giving out risks. This is not the case. You have to talk about material risk. If the particular patient would attach significance to it, then it should be mentioned now with the B test, you can still almost apply the B test in terms of negligence. But there was this amendment in the nine so based on the case in the late eighties and the nine and it went to courts in the nineties. Er, the case in question was where a er child with crew who suffered deterioration pa died and the pediatric doctor in that case was refused negligence and it went to court now, ultimately, they weren't found negligent, I think. But what happened was that because there was appeals in this, the court added to as an amendment really to the, the B test that the court has to find the opinion put there to be logical, which is to say just because it's the accepted way that doctors have been doing it, you can't just use that this is the way things have always been. This is the way they've always been done. Therefore, that's why we're doing it. That's not a justification. So when the, the court is assessing, it has to be logical. But the important takeaway in this slide is the Montgomery case. When you're giving risks, you have to talk about material risks. Now, I'm not gonna go through all of these, but you can get it from the QR code. It takes you the seven principles of decision making consent by the GMC. So this idea that patients, all patients should be involved, it's an ongoing process. You need to listen to them, you need to try and find out what matters to them. And that's particularly important when thinking about material risks, you presume capacity unless otherwise. And if there's no capacity, it's about best interests. And even when there's a lack of capacity or, you know, there's a difficulty consenting, you need to try and involve them and respect their wishes. Now, personal, um beliefs is something that can come up as an issue. So sometimes your personal beliefs can conflict with what the patient wants or what they're coming to see. The typical one is termination of pregnancy. But when there were cremation forms, there was also kind of the example of you were asked to sign cremation form. You don't agree with this. You're allowed to consent con do conscientious objections to say that you don't want to give a treatment, but you need to ensure that quality of care is always provided so that the patient is assessed and treated to the best quality of care. And this can often take the form of you need to facilitate them seeing another doctor. So even if for example, the termination pregnancy one, you can say, ok, but they can see another doctor and you're not being judgmental about it, you're just giving them that opportunity to see someone else and not imposing your beliefs on them. Now, with the previous example that I mentioned to this shouldn't be an example anymore because cremation forms are no longer there. But what I was taught is if you were the only person who could sign a cremation form, er, you weren't allowed to then say you shouldn't be saying no to that, er, because you need to respect the patient's right for their beliefs. So essentially the way to think about the conflicts of personal beliefs and patient care is it shouldn't, OBJ, you shouldn't, er, obstruct the patients seeking the treatment and care that that's met some benefit to them or what they want. You shouldn't be obstructing that so often this will take to the, the form of the second opinion or seeing someone else and that will be what you'll find in the questions. Now, in terms of personal beliefs, sometimes you may have had personal experience of this in real life where patients recall consultations, it might make you uncomfortable. If you're uncomfortable, you should express it and express the pre not to be recorded, but they are allowed to do this. Your duty remains nonetheless to just continue to assess and treat them as normal action. All the things. A wise choice is to make sure you document everything from your side as well. In these scenarios, financial issues are again a common thing that can come up. Essentially, this is all about perception. So what actions you are taking, it shouldn't be perceived as encouraging or pressuring gifts. And if there's any kind of hint that this could be thought of as an abuse of trust. Again, you shouldn't be accepting things however you had to bounce. You know, when someone offers a gift, you have to bounce against rudeness. So often the rationales where you think, OK, automatically I should just, this could be perceived in the wrong way. I should just reject the gift. The problem that comes up as a rationale. And the question is, it says you're being rude by doing that. So so long as it's not encouraging or pressuring something and it's not giving an unfair advantage of altering care. And there's no abuse of trust, unsolicited gifts can be affected, accepted. Um But there are options. You've come across these some questions where you think about gifts that you shared on the team. So it's not something individual or personal or there's some kind of gift register, you can put it log it with just so that you know that everything's above board and then you can always seek advice about this of how to handle it. Now, raising concerns is something that is gonna come up again. You have a duty for patient safety and whether this be the m practice your medical practice or that with your colleagues or systems policies or procedures at the hospital, which you think are unsafe. You have a duty to raise this um the example. So for example, they changed the surgical gloves and the suture materials and they downloaded the cheaper materials where I work and people think that it's unsafe because it's lowering quality and they're raising complaints about that. Now, very important areas, any suspected, er, risk with Children. If you have any concerns with this, these should be raised and you don't need to be certain of the risk of significant harm. This is just automatically, it should be escalated. Normally you thought to discuss with the parents, but you have to bear in mind that there could be an increased risk of harm. So in those kind of scenarios, assess that and maybe that might make the option to discuss with the parents inappropriate, always should be thinking about escalating to the designated kind of child safety, gardening or the lead clinician for that patient's care. And very important is to document everything. Essentially the name of the game raising concerns because you're thinking at an sho level is going to be escalation of some form. So all you need to really do is, you know, pick who you're escalating to in a lot of these scenarios. Now, incident forms is another thing that often comes up. Certainly, if there's events that lead to actual harm, you need to fill the incident forms. But sometimes and in real life, you'll see this when they're in is we don't always fill them, the pressure dilemmas will expect you to do so. So last couple of things, so we have end of life care. So it goes without saying it should be the same quality as any other. And we have this idea of sometimes a presumption in favor of prolonging life. But also there has to be discussion. So maybe of you may have seen some of the respect form. So you have this thing quality of life versus er prolonging life. So those are conversations to be had. Now D A CPR is sometimes a controversial issue. Now, there's a case from 2014 called the Tracy case. And essentially it makes there be a legal duty to involve or consult the patients. That's the family before putting one of these in place. And this case, what happened was there was a patient with lung cancer who'd come in with a car crash and the hospital team would just put DNA CPR in place and the patient's family complained it got it retracted. But then after further consultation, it was put back in place. And from all that, there were appeals and processes and essentially the the legal details put in place that believing that the information causes distress is not a reason enough not to inform or discuss with the patient. It can be exceptions where you say there's a convincing reason to displace this right. So there is exceptions. It's not an absolute thing, but generally speaking, there is a legal duty to always involve the patient and family in the consultation. And there has to be exceptional circumstances not to do that. It should be noted though the right, there's not a right to CPR CPR like any other medical treatment, it's based on your clinical assessment. So that remains a medical decision. The legal duty is to have the discussion, the consultation. Um this would have been covered before, but when people have advanced er or they have valid advanced directives, these are binding. So you these advanced, these valid advanced refusals, those are binding. So you need to be aware of that. So hopefully, I know we've gone a little bit over and I think our next speak of theology should hopefully be around. Um We've given you a reminder of the overview of the time and process and some things for clinical and dilemmas. Um We've given you some sort of bits of advice and we hope gone to answer some questions. We might, what we might do is do the urology talk first and we can do another question session later. Um Are the blocks with time for SAT and separated? No, you can't go back. So what happens, er, is that you do your S JT first? Uh as II, remember I did the S JT first and then that ended and then you went on. So it's two separate blocks. Um I don't remember you have to read the Test Center regulations. I don't know if you get a break in between. Um I would perhaps, you know, being able to have the marathon of not going for a break. There's, I don't know if that you get one, at least a proper one where you walk around or anything. We're just gonna see if our next speaker has arrived. Yeah, next speaker is here. So I'm just gonna invite them to the stage. Um, yeah, you'll get a fight, you'll get, um, so what we'll do now is we'll just take a little break. We're gonna get our next speaker set up and we should be back in a few minutes. So if you just take two minutes to walk around, get a drink, do whatever you need to do and we'll be back at.