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What is CAMP?
- For background and motivation questions:
What is STAR?
- For 'give an example' questions:
What is SPIES?
- For questions on difficult colleagues:
- Seek info
- Patient Safety
Take me through your CV?
- C - Foundation - neuro, India, Core med - neuro
- Managed complex neuro patients on ward
- Stepped up into registrar role and have done multiple days holding acute referrals phone
- Substantial experience receiving thrombolysis patients in a Hyperacute stroke centre, working independently overnight and to a strict time pressure,
- Proficient in LP and all other clinical procedures
- A - BSC with hons, Brain – labproject + cowrote article, Teaching
- M - Teaching, Audit, LNC, Rota managing
- Independence + team work
- Opportunities for research
- Funtional symptoms not only neuro problem
- 2 things from doctor – only achieved in clinical neurology
- Stuff I have done already
Biggest change to neuro over past 10years?
- Scheduled -> unscheduled care
- Not pure neuro – changes in stroke
- 24 hour holistic service
- BIG PAPERS THAT CHANGED THIS
Why not train somewhere else?
Other regions also look interesting but none are quite as upfront about supporting and encouraging academic pursuits.
What is your Biggest Achievement?
What do you like least about neurology?
neuro is good but bad system
- I welcome all the challenges that patients, their pathology, their relatives and their behaviour present...
- System is stretched. Bed pressures. Pressure to discharge complex patients early and risk patient safety.
- Pressure comes from senior nurses and i often find that it is easily dealt with by communicating early and effectively with the ward team to create clear plans with thresholds and avoiding the same topic over and over again.
What have you done outside scheduled activities to show interest?
- Med school - SSC in india, research in alzheimers
- Foundation - conference-> acute neurology course, Neurology book club, Audit viral encep
- CMT - case series for TBM, conferences
Where do you see yourself in 10 years?
- Consultant post
- Unsure of DGHtertiary preference
- Special interest in neuroimmunoneuropsych and hope to be able to lead clinical research.
- Still very keen to continue teaching and develop abilities by taking courses.
- In addition, this year out has been about starting a project in india that aims to change health education policy in order to address the vast health inequalities. Its at a very young stage at the moment but hopefully in 10 years i will still be able to oversee this project as it develops.
What skills do you need to improve?
- C -More functional neuro
- A - Failed RCT - more experience in the clinical trials
Give an example of a situation where you showed empathy?
Encephalitis EMPATHY patient
- Bleep, privacy
- Ensured confidentiality
- Tone of voice
- Gave time and remained silent.
- He clearly felt relieved to confide in some one
- Non-verbal cues
- Mirroring and pace
Give an example of when you had to defend your own beliefs regarding the treatment of a patient?
HiNTS exam VS MRI pt
- Patient known to have vascular risk factors presented with acute vertigo, heard about it at handover,
- Consultant pushing for MRI and wanting to keep patient in hospital for 3 days and on high dose oral anticoag.
- I had recently read about HiNTS
- After handover Discussed the possibility of preventing a prolonged hospital stay with a bedside test in 15 mins.
- Consultant said it wouldnt make a difference as he would not be happy discharging the patient until he had MR confirmation.
- I explained that the study found that the bedside test was more sensitive than MR in the early stages of a PCI and i would be happy to find the paper so he could confirm my interpretation.
- Soon the cons was very interested in doing the exam and allowed me to do it with his supervision and we confirmed that the patient did infact have peripheral vertigo.
- Having seen this work so well i was keen to share the information with the rest of the department and presented at the next journal club.
A situation where you failed to communicate appropriately?
Telling Jr Dr to fast track discharge pt
- S - Fastrack apper work for palliative patient
- T - delegated to Jr Doc - they then came to me a few days later asking for help to complete it.
- A - This delayed patients discharge which they were very upset about. This was my mistake – I did not communicate effectively with my colleague and check that they knew which forms to complete, how to do so and where to send them – assumed they already knew. I had to be honest with pt and family and apologise for my error.
- R - This taught me to be very explicit with my colleagues and to double check full understanding of what I am asking of them. I no longer assume that they already know, in order to prevent delay in patient care or discharge.
Informed consent from a patient in a vulnerable situation?
18 week pregnant miscarriage
- Gynae triage as an f2
- 18 week pregnant – PV bleeding and pain.
- USS showed no fetal HB and had miscarried.
- Surgical management of miscarriage – needed consent
- Lady was very tearful distressed and more worried about her husband's response.
- She was not in a frame of mind that would allow her to take in the information necessary.
- Slow down, give time, offered that we could delay the conversation. She was keen on this.
- Resolution – discussed with my registrar and explained that we could not get reliably informed consent for at least a few hours – agreed to delay the procedure till the following day.
- Later that evening I went back to take consent. I frequently checked her understanding and took time to answer her question.
What makes you a good team player?
- Approachable + supportive e.g…
- Adaptive and take initiative to try and solve problems e.g…
- Enthusiastic e.g…
Recent example of when you played an important role in a team?
- Case of PM
- Co-ordinated input for a very sick gentleman in the middle of the night and managed to get the right people to talk to each other and come to a senior level decision.
- Also supported the hospital-at-night team whilst decisions were being made it my priority to advocate for the patients right to full level care until a decision was made.
Example where you failed to act as a good team player?
Do you work better on your own or as part of a team?
Team overall + individual tasks
I enjoy working as part of a team. Interacting with people, forming relationships and supporting each other is a far more convivial environment in which to learn and work. Ive shown this in the past as i have assembled teams to deliver teaching courses and maintained good relationships which in turn led to better teaching environemts.
I work better when im enjoying my work and for that reason i would say i work better in a team. But a lot of the jobs that i carry out within teams are individual tasks. Such as running a GP clinic list or organising the ward round. Teams i have worked with have given me lots of positive feedback on the initiative i take to do these individual tasks whilst being a team player and making sure that everybody is in the loop and informed of any developments.
What makes you a good leader?
- Approachable and supportive – nurses in GRH and cannulation
- Adaptable and initiative – Podcasts in SFS
- Enthusiasm + motivation – very important in teams especially when you are trying to steer towards a goal that you have set.
An example where you showed leadership?
Nurses in GRH and cannulation
- Busy surgical attachment lot of our workload was taking bloods due to an understaffed phlebotomy service.
- Nurses all said they wanted to help but didnt have appropriate training.
- I discussed with senior nurses how to go about getting training they kindly agreed to organise a formallly taught clinical skills session for the junior nurses.
- After the formal teaching i encouraged the other junior doctors on the firm to delegate blood taking to the nurses so that they could get more experience under their supervision.
- Resulted in substantial decrease of our workload by evening it out across appropriately trained staff. Aided in team cohesion.
- I saw an area in which our ward was not working efficiently and communicated with various people to encourage our staff to increase its skill set. By setting aims and delegating appropriately i was able to help our team work more effectively.
Difference between mangement and leadership?
- Leadership is having a vision and leading a team towards that vision with good communication and enthusiasm.
- Management is directing the people and resources in a group to achieve the vision that has been set.
An example where a new and different approach to a patient of yours proved beneficial?
Secret bulimic lady
27 year old lady ex-alcoholic with recently diagnosed cardiomyopathy presented with incidental hypokalemia. 3 admission for this in the past 6 months and she was fed up that the doctors couldnt find the cause. Took a full history, voluntereed no new information. After looking at notes + bloods again i went back to discuss the diagnostic difficulty and involved her in the process. Pt now volunteered that she was bulimic but had not been able to tell anyone and really wanted help. K+ corrected, we referred her to the eating disorders clinic and the patient was. On discharge,, the lady me for not judging and being open and approachable.
Creative thinking to solve a problem at work?
- NK case from OBGYN:
- Atypical pneumonia after giving birth
- Situation - Atypical pneumonia, prolonged hosp stay post Csection. Resp advised to move her onto their ward. Obs didnt want anything to do with her. Mother and baby were going to be separated
- Task - I had to do a job, read through her notes and on speaking to her found that she was very anxious and depressed about the whole thing. Separating mother and baby = very poor idea.
- Action - I spoke to my obs cons to hear her thoughts and communicated that this was the only ward mother and baby could be together could we keep her here and convince resp to keep her as an outlier with regular review. Also spoke to resp team and they were happy to.
- Result - For the next 2 weeks mom and son got to stay together and maintain a bond. She got regular reviews and was well on discharge. I had to demonstrate initiative and confidence in going against the plans of 2 consultants but by providing an alternative and highlighting the minor disadvantages with my plan we managed to keep all parties happy.
A mistake you have made?
- Fast track referral – ultimately my fault for not checking understanding.
- Learnt to check understanding of colleagues when sharing workload.
- I now ensure that junior colleagues talk me through how it is they will execute the task before giving them to independence to do it themselves.
A situation where you showed professional integrity?
Whilstle blowing Chandra
- Whistle blowing on medical registrar who I did not feel was safe on the acute medical rota.
- Felt underpressure as this was a senior colleague
- But my responsibility lies with the patients and patient safety
- Escalated the situation – consultants thanked me for coming forward.
- Maintained integrity by remaining professional towards the colleague whilst the investigation was ongoing.
- Despite being uncomfortable about whistleblowing I deemed it in the patients’ best interests to come forward.
What are the advsdisadvs of admitting when mistakes are made?
- Gets sorted quicker
- You know your area of weakness and can work towards fixing it
- People trust you because you are honest
- Matters are generally resolved with less conflict due to the honety
- Suedstruck offfired
- Patients + colleagues lose trust in you
How do you organise your workload?
Professional vs personal work load
There are constraints on how one can organize workload – so after completing a thorough ward round I ensure that I sit down with my colleagues and create a pooled list of jobs which we then prioritise in a time sensitive manner (sending off diagnostic and investigative tests early). We then work through these list in a collaborative manner which avoids duplication and also ensures we have done the jobs nice and early. This allows for free hours in the day which are often used to complete longer term administration but can be taken up by ward emergencies or late consultant ward rounds.
On a more personal level, making time for audit or teaching is very important to me and I do this by setting aside dedicated hours outside of 9-5. I have found that if I don't earmark these hours they can easily disappear and now ensure that each week I predetermine these slots.
How do you handle stress?
- Acute stress
- Busier you are the more you have to stop
Outside of work
- Longer term stress of many hours or persistently busy take
- Sharing burdens is very important and i insist on team breaks and team lunches whenever possible. good for team morale
Squash, Cycling, drums and band. Cooking
How do you recognise that you are stressed?
Flit and think about all the jobs i have to do rather than doing any one of them. Which is why i always bear in mind that the busier you are the more you have to stop. Assess which job is most important to do next. Do that one and then reasssess.
Example of a stressfull situation?
2 locum docs on over weekend nights and i had to take a leading role.
Holistic approach in managing a patient?
83 year old previously fit, presenting with #humerus. Son at home with parkinsons for whom she was carer and very worried.
Describe a time you had to deal with a sceptical patient?
- Man thinks he has tumour, but had SUNCT
- S - GP placement, man in 60s presenting with headache. Sounded like a neuralgiform headache and had no red flags. Offered appropriate treatment and onward referral to neuro. Man very concerned that it was a brain tumor, wanted a scan.
- i went through signs and symptoms one would expect using a leafelt from a validated website to support my points.
- He had read about how doctors miss tumors when they present with strange symptoms. Still wasnt happy with my answer.
- Wanted a scan, i said i would discuss it with seniors and call him by the end of the day.
- Seniors felt it warranted onward referral and a CT so i called him back and told him i had done all the following.
- He got his CT which was clear and a diagnosis of neuralgiform headache along with appropriate treatment.
- The benefit of allaying anxiety outweighed the risk of radiation and whether it was an aproprate use of resources is an interesting point of debate but in this situation of a man who was skeptical it was useful to delay the decision and get a second opinion from seniors to inform management.
Explain a time when you had to support a colleague with a work-related problem.
A close friend and housemate who was finding clinical work very difficult for many reasons. Although she enjoyed being a medical student, the decision-making and risk-management that clinical work entails was very difficult for her. She was exquisitely stressed and even when she did her psych attachment which was her long term career goal, she despised it.
I outlined to her that her reasons for not enjoying work were going to be present in every clinical job and she should either consider non-clinical work such as public health, research or a more drastic career change and leave medicine altogether.
Reassured her that her degree was very valuable and would get her interviews in most places.
Many long conversations and exploring options she has decided to take a year away from clinical work and explore other career opportunites. Currently applying to ...
What skills or personal attribute do you possess that will make you a good trainee?
Communicate well, work well with others, and use team appropriately to get work done. tabs show this
Empathic and supportive not only towards patients but colleagues too and eager to volunteer to help.
Interested and enthusiastic about science and the way hospitals work. Always asking questions and making time to answer them through audits and reviews.
- Address complex issues think laterally and find a solution whilst seeking help if required.
- Structured and thorough way.
- Endeavored to gain early experience in this by offering to hold the neurology bleep
- Communicate well
- Empathic and supportive
- Interested and enthusisatic
- Very able to work under pressure
- Interested, enthusisatic therefore take on too much.
- TCD in ICP paper
Tell us about your teaching experience?
- SFS – P2P teaching small interactive groups + podcasts
- Acute neurology – small interactive group, f1s and f2s
- CMT interview course – national course I organized and delivered to help prepare CMT candidates
- BEST – Formal bedside teaching that has been included into the QMUL curriculum
Why do you enjoy teaching?
- I like getting excited about interesting things and get personal satisfaction when others 'get' some thing and get excited too.
- Reinforces knowledge.
You have been asked to organise a weekly education meeting for your colleagues - how do you approach this task?
- What? – curriculum
- Logisitics – where? How many? Time?
- Weekly – who can attend? Who takes over when your not there?
- FEEDBACK – participants and presenters
Tell us about feedback you have had as a teacher...
- Positive – enthusiastic, interesting, relevant
- Negative – respond quick e.g. handouts
- Quick to act on – e.g. current Queen Mary teaching – timings (doodle), organization
Tell us about a bad teaching experience you have had?
Teaching with interpreter in India.
- Area centre in Gudalur
- Trying to teach through an interpreter
- Pride in communicative ability and ability to get a point across but felt as if lost all of that due to the filter of non-clinical interpretation.
- It made me realize that sometimes you are not the right person for the job. Just because I wrote the handbook does not mean I was the right person to deliver it to this audience. I changed tactics and found a clinical colleague from my hospital who could help translate and get the salient points across in a way I trusted was being received well.
Which methods of teaching do you know?
- Small groups
- See1 Do1 Teach1
- Powerpoint slideslectures
What are the qualities of a good teacher?
- Respects students and is never patronising
- Facilitates and is positive and encouraging
- Right tool for the right job and the right person – its about looking at the content and thinking of the best way to sell that content.
- Promote enthusiasm
- These are platonic ideas of an ideal teacher and each of us has more of one quality than another
- So I think the last quality that may be the most important is a teacher that seeks to improve themselves with formal feedback to augment how they teach.
What is clinical audit?
A process of reviewing the current practice against set standards. Analyzing whether we meet it. If not, then exploring why not. Knowing why not, attempting to achieve standards by changing the way we practice. Then checking the change has achieved set standards.
Why are audits important?
- We work in systems that have incessant pressures to become more and more efficient, Audit is a rigorous and reliable way to search for areas where those efficiency savings can be made and then do something about it.
- Mantain quality of care, as any concientious practioner should want to
- They are good way to learn how hospitals work outside of the immediate clinical arena and how those working systems are malleable if you have the evidence.
What are the problems assoc with audits?
- Problems with carrying out an audit:
- Selecting patients
- Clunky old systems
- Coding issues
- Retrospective so some data missing.
- Problems with audits as hospital do them:
- Audits docs wanna do over audits the hospital needs doing.
Tell us about your research experience...
- Alz D paper in BRAIN
- Weed RCT
Difference between audit and research?
- Audit = comparing current practice against set standards
- Research = Finding out new knowledge
Why is research important?
- -Important to who?
- Patients = New therapies and management
- Doctors = EBM should underlie EVERYTHING we do - partaking in research helps understand how it is carried out and also helps discern the good from the bad.
- Although we can improve our current standards by repeatedly doing quality improvement and aduit, we will never push past that ceiling of care without new knowledge on which to found new guidelines.
Trusts = improves reputation
Do you think that all trainees should do research?
- Need to be dedicated
- Other trainees have other ways of appraising evidence
- Absolutely not.
- Research is very very expensive. Not only in money but also in time and human resources.
- It is also very important that it is done very thoroughly and to answer a specific question as well as it can.
- The best way to achieve this is to have a select number of people doing research because they have a great passion for it and a keen to dedicate the time and energy that is required to answer a question well. I know from my own experience that research at times can be very tedious and very very frustrating. I spent the best part of 6 months counting red dots through a microscope. It requires the individual to be very dedicated.
- Time, money and resources are limited and its probably best that we funnel them to those that are keen and capable rather than everyone.
- Often people say that research teaches you how to appraise evidence but I think there are other ways for trainess who don't take part in research to become proficient at this such as journal clubs, relevant courses and conferences.
What is research governance?
A set of rules set out by a DoH document that set boundaries on how research should be carried out. Much like clinical governance dictates how patient care should be carried out.
- Sets out ethical boundaries:
- getting approval, maintaining patient dignity, getting their consent, risk benefit analyses.
Scientific boundaries: Not duplicating work,
Information boundaries: maintain anonimity, Make publicly available whether published or not, open to critical review by publishers.
Health and safety bpundaries
Financial boundaries: To pay people damaged by research (i.e. researchers).
What is EBM?
Using the best available evidence along with your clinical judgement to inform clinical actions and decisions, bearing in mind the patients values.
What are the different levels of evidence available?
- Ia Systematic Review of RCTs
- Ib One or more RCT
- IIa One well designed study without randomisation
- IIb Cohort studies
III Descriptive studies, case-control, correlation studies, case series.
IV Expert opinon
Why does a clinician need to take account of their own clinical expertise in EBM?
The evidence needs to be applied correctly. Age group, race, comorbidities,. If they apply great. If they dont you need to take into account the risks and communicate your thinking with the patient and come to a decision together.
What is clinical governance?
Umbrella term – pillars of CARE(ISP)
A quality assurance process that maintains and improves standards of care and holds the NHS accountable to the public.
- Clinical effectiveness - EBM approach, implementing guidelines, changing practice as necessary.
- Audit -
- Risk management - learning from mistakes, report incidents, blame free culture.
- Education and training - Courses, exams, WBAs, Appraisals
- IT systems - keep updated and confidential
- Staff manangement
- Patient involvment - satisfaction questionairres
How do you critically analyse a paper?
- I - Introduction
- Suddenly - Sample selection
- Realised - Randomisation
- I - Intervention
- Orally - outcomes
- Fucked - Follow up
- Saddams - Stats 1 - chance and power
- Son - Stats 2 - precision analysis
- Randy - Results
- Cunt - Conclusion
Who is responisble for clinical governance in your trust?
The trust board + execs - put systems inplace to make sure the culture at work is focused on the 7 pillars of clinical governance.
All of the staff are responsible in making sure the ethos of clinical governance permeates everyday work. From junior doctors, to ward clerks, to cleaners and the Pals service.
Whats the difference between a standard, a guideline and a protocol?
Standard = a defined level of quality
Guideline = a framework that assists clinicians in making decisions. To be applied with clinical judgement.
Protocol = step-by-step approach to dealing with a certain situation that must be followed exactly. Sepsis6 for example.
Consultant comes on ward drunk?
- P - get consultant away from patient areas quickly and sensitively. If that doesnt work, use another senior (nurseregcons) if that doesnt work then last resort = security.
- I - Needs to go home, could help organise transportation, make sure he doesnt drive. Speak to other cons colleagues and organise cover in the short term.
- E - will need to inform his senior consultant colleagueclinical director and ask whether this will be escalated.
- S - Support team until matter is resolved. Volunteer to take on extra duties etc.
What will the clinical director do once you tell him about drunk cons.?
- S - Info from you and his other colleagues
- P - Will need to decide whether cons is suspended for a while or its a one off event with a clear trigger and has been sorted.
- I - Provide cover if not coming back to work. Look into reasons for behaviour
- E - WIll discuss it with medical director + cheif execs and decide whether to just warn or suspend and report to GMC
- S - There are underlying causes and clinical director should work with the cons to address these either changing working schedules or insisting on getting outside help.
What is professionalism?
- Various levels (essentially mirror the growth of a doctor)
- Basic - appearance, punctual, honesty
- Knowing - Guidelines, protocols, patients
- Judgement - Having knowledge and applying it in areas of uncertainty.
- Probity - knowing limits, when you are outside those limits, knowing where to go for advice and being honest and apologising when you have over stepped the boundary
So I see you like teaching, how will it influence neurology?
- -neuro patients
- -neuro services - improved referrals and triaging process
Do you want to do research?
Yes in functional neuro
Absolutely, i have a growing passion for functional neurology and i feel we are only starting to probe our preconceptions about these tremendously common disorders. Functional illness pervade every specialty in medicine but i feel it is within neurology that the problem is being approached in a progressive and scientific manner. It is a field i want to further our knowledge of and this can only be done through research. The aspect of functional illness that i find most interesting is the exploration of 'agency' in the illness ad I think Mark Edwards work so far has been the most interesting and has opened up an avenue that was until now unknown to us. It is something i intend to explore in a different manner.
In 5 years – how will you be working?
- -Clinical 3 parts - IP, OP + FNS
- -Teaching - students and GPs/referrals
- -Service provision + audit
Where do you see yourself in 10 years time?
- -Say what you hope to have achieved
- -Clinical 3 parts - IP, OP + FNS
- -Teaching - students and GPs/referrals
- -Service provision + audit
- In 10 years i would hope i am in my early years as a consultant. I am flexible about whether this will be in a DGH or Tertiary environment as what i have in mind can be achieved in either place. I would like my Clinical time to be divided into 3 parts
- General neurology care of inpatients with ward rounds,
- General neurology care of outpatients in clinics
- Development and delivery of a service catered to Functional neurology patients. During my registrar years i will aim to get exposure to services that already exist around the country and see how one can implement such a service.
- I would want teaching to be the main thrust of my academic time - i’d like to develop courses within the hospital i work in to cater for every level of student or doctor that rotates through our hospital so that we churn out physicians and doctors that are more confident in their ability to manage neurological patients to deliver a higher level of care from the point of admission. I’d also like to take this teaching out of the hospital and offer training and support for GPs in the local area to empower them to create effective systems that can filter referrals to local neurology services.
- Managerially i believe a lot of my time will be occupied in delivering the Functional neurology service i have already mentioned - there will be various areas of the service that will need constant updating with regular audits to asses implementation.
How will neurology change i the next 10 years?
- More shift towards unscheduled care
- Increase delivery of care in community and near patients home
- Loss of the hub and spoke model with increased services such as neurophys available at DGHs
- Shift toward Registrars assisting with Gen med on calls.