EM interview – my experience

So a lot of you have asked about my interview experience – I had it last year and it was my first major interview experience in the UK. I applied for the ACCS-EM post, run through training. My interview was last year, and the details are a bit sketchy, but I am putting them up here in case someone is curious about what it actually entails.

It was done in two batches on the day of interview, there was a morning batch and an afternoon batch, and I believe this was;t the only day of interviews. Mine was part of the morning batch.

(I will upload a separate post about portfolio requirements, here I am just sharing my interview experience.)

It had four stations. Presentation – Ethical scenario/clinical scenario – portfolio station – General Management etc

Each station had 2 emergency medicine consultants giving feedback, so in all 8 consultants to give you a score.

My first station – and possibly my worst one! – was the presentation station. This is where they give you a topic for presentation, the topic can be anything, it has to remotely be related to the medical field, it doesn’t have to be something clinical. You get the topic when you reach the station, after which they give you a few minutes to prepare (3 or 5 minutes, I don’t remember the exact amount of time) They take you into a separate room, you are provided with different coloured markers/pens, sheets of paper on a stand and the topic at hand. My topic was ‘Should the UK adopt a policy of implied consent for organ donation after death?’ I thought about what it meant, because it doesn’t really come to you straightaway does it, the meaning of the statement? I assumed (probably rightly) that it meant should the UK adopt a policy of implied consent where the wishes of the deceased had not been known, in cases of sudden or unexpected death, and utilise their organs without actually having their prior consent. I decided I stood against this notion, and I went ahead to try and make a presentation around it. Now here is where I hit a snag – I can say if the answer is yes or no, but to make a 5 or 7 minute presentation around it? What do I do? So I started by outlining what I wanted to speak about, first minute of introduction to what organ donation actually was, which organs could be transplanted and used by other individuals, etc. Then I tackled the actual controversial topic: yes or no. I said no, and then I gave my reasons: Patients ultimately should have a right of deciding what happens to them or their bodies, and in cases where they can not or have not expressed their wishes then their next of kin or legal guardian or court appointed person has to make the decision for them. But someone has to MAKE the decision for this to happen, it shouldn’t automatically happen, you have to take into account the deceased person’s wishes, their family’s wishes, their religious or cultural factors influencing their decisions. I think I babbled on for a while, and ultimately petered to a stop. The two consultants present in the room smiled at me. I thought that was it. But no. They had questions! The first one was pleasant, smiling – and asked me a question I do not remember even. I don’t think I knew the answer to that question but I bravely said I could look up the information if you like and come back to you with that information, but that I honestly did not know. She backed down. The second consultant, boy was he getting into a state! I realised now they were playing good cop bad cop. He questioned my opinion, asked me three times (yes, three times!) how I felt it was appropriate to let organs go to waste when the dead people couldn’t utilise them and why would I not want these to be put to good use. I kept calm and reiterated my initial stance, he even banged his hand on the table to express his displeasure at my answer. I stood my ground (what could I do, I did not want to portray one opinion from the beginning of the presentation and then back down and go for the complete opposite opinion!) He then finally smiled at me and said your time is up, you may proceed to the next station. I was shaking in my suit but I felt it could have gone worse. Atleast I got to say what I felt and wanted to say, eh?

Second station was the ethical/clinical scenario station – 2 consultants, one scenario each, but they were sat at the same table so both could give an assessment of both answers. First case was the ethical case: You are asked to see a 50 year old male in rests who comes in clutching his chest in apparent chest pain – he speaks no english and you do not speak his language. He is accompanied by his 11 year old (or 14 year old, I don’t remember the actual age) daughter who speaks both languages fluently. How do you proceed? Now having worked in the ED in the UK, I knew that it was frowned upon to use relatives/friends as interpreters, and it was preferred to use professional interpreters that the hospital may provide, or a service called ‘language line’ which you ring up and ask for whichever language professional interpreter to be put through, and you basically use him/her as the middleman as you take the history and examine the patient, all the while communicating by phone. Not the most practical solution, but one that appeases examiners, as it did this time. They were quite happy with my answer, I told them ideally I would like to use a professional interpreter, language line etc. But since this is potentially an emergency and I am aware of the time it may take to arrange an interpreter, I would atleast like to ask for patient’s known history and whether he was allergic to anything, and atleast begin the process of giving painkillers and start my assessment with his consent via his daughter. I also used the phrase ‘will ask seniors to advise me on this situation as well’ which always sits well with examiners, especially for the more junior posts. They do not want you to be a hero, they want you to be safe and utilise appropriate senior help whenever you feel the situation entails. The interviewer then asked me if there was any other avenue I could utilise for this purpose, and I remembered once having had to use one of our staff members, a registered nurse, as an interpreter. I mentioned that, which was seemingly the right answer, as they moved on to the next question: what do you think would be the problems that you may face if you do end up using the daughter as an interpreter? I mentioned she is not a professional, I won’t have any guarantee that what she is relayed to the patient an what the patient is relaying to her is not literally lost in translation. I also mentioned there would be aspects of the history that she may not be aware of, such as his medications or some malignancy that he has kept from her. She may also be very frightened and seeing her father in pain or unwell may cause her to be very distressed, and would make her even more distressed if I used her in this situation. The buzzer went off at this point and so I was asked to move on to the next examiner (sitting in the same room). The second scenario was a clinical case, the interviewer showed me an ECG – asked me to identify it (it was an SVT – atleast, I thought it was!) which I did, and then she went on to ask me how I would go about managing the patient, I kept giving her options but I felt she was probing further, and then it clicked: ask for senior help or specialist advice, which I mentioned and she let me off the hook. I stepped into a 3rd encounter:

Third station – portfolio station: Once again, two interviewers, who already had access to my portfolio (they asked us to submit our physical portfolios at the start of the interview outside the portfolio station, and before our turn came for the actual portfolio station they had already gone through the broader aspects of each portfolio). Now here I must add there were candidates who had come in with huge binders of information, one candidate had three such folders and about 7 rolls of what seemed like very large maps but were very likely poster presentations of various researches and audits he had undertaken – these served to really really unnerve candidates like me who had the thinnest portfolio! Anyway, I went in, they asked expected questions, that sounded more like mere confirmation of information I had already provided (twice- first time when I wrote it all down in my application, and second time when I handed them the portfolio with all the hard copy evidence) – still they had questions like: So you have done an ALS course, no others, correct? Yes. And you have no other degrees other than your primary medical qualification? Yes. And I see you have some feedback from medical students that you have taught. Yes. Is there any other evidence of teaching? No (because if I had, wouldn’t I have submitted it before already?!) and this went on. We discussed some bits about my CV. Some bits about my prior experience (Tell me about this 6 month volunteer post you did back in the USA, or So I see you have some experience in Oncology? Tell me more.) So just basically a general chat to gain an idea about who I am and what I have done and how I have turned into this person sitting in front of them, applying for a training post in emergency medicine, how did I get here, what roads have I travelled.

Lastly – the Fourth station – I don’t know what this station is called but they asked sort of direct and indirect abstract questions vaguely related to the practise of emergency medicine. They asked me if I knew what the term exit block meant. I didn’t, so they explained that an exit block means that patients are coming in to the emergency department, but they are not coming out of it, probably due to a shortage of beds for the admitted patients, so that the system isn’t moving forwards, and there is a jam, or a  literal block. They then asked me how I would deal with this phenomenon.  I thought about it and replied to the tune of ‘make sure it’s still a safe department, make sure everyone has adequate pain relief, comfort measures, next antibiotic doses and regular medications prescribed, if they have been waiting a while, maybe get them a more comfortable bed instead of the trolley, try to offer them something to eat if it is clinically warranted, and a cup of tea or coffee would go a long way, along with a sincere apology about the wait and an explanation that all efforts are being made to make sure things progress. There was another question which I forget, but it was once again more abstract not directly clinical medicine but more management, I think it was along the lines of if you see a colleague is drunk or intoxicated, how would you proceed (I am not sure, I may be remembering some other time this question was asked of me) but anyway, you get the gist of it.

That was it.
I went home. Or rather I went to the train station, and took 3 connecting trains back home, slept for 3 hours and went to work on a night shift. I thought I hadn’t done too well, and anyway, it was my first interview for a training post.

It was also my last. At least for the next 6 years!

ePortfolio

Everyone working in the ED should have an eportfolio. Whether you want to be an emergency physician or not, that is irrelevant. What is relevant and important is that your time is important and the time you spend (invest?) in a certain post, however long that may be, is valuable. You should be able to gain as much as you can from the experience, and not just have the experience to show for it, but should also be able to prove what your capabilities are.

What is a portfolio? It is essentially you, on paper. What you amount to, what your skill set is, what your experiences are, and what you will potentially bring to the table if they should hire you or atleast select you for an interview. So what does your CV show? Would you hire yourself if someone with your CV applied for this position?

The world is changing. It used to be that just putting on your CV that you have worked at this grand post for 3 years and 7 months, looks and sounds impressive (probably is!) but nowadays, it may not amount to anything. I have said this elsewhere as well, and I reiterate: if you have performed 500 intubations in your past experience as an anesthetic registrar, but have no formal paperwork showing your skill, proving that you are indeed capable of this feat, then you will never be considered superior or more valuable than, let’s say someone who has done 15, but is able to prove all of those with nicely signed off competencies for each one. Your CV will often be the judging point that decides whether or not someone likes you enough to consider interviewing you. If your CV doesn’t cut it, you won’t ever get a chance to come face to face with someone who you may need to impress with your skill.

So take your time, build up your CV. If you are in a non training, trust grade job; it doesn’t pay well, you are unhappy with the hours; make it a priority to get as many competencies signed off as you can. Whether there is a dislocated or fractured joint that you manipulated back into its anatomical position, or whether it is the skill of passing an IV line in an infant; whether it is asking for a colleague feedback from a nurse you have worked with, or whether it is an audit you did with a consultant, ask yourself: how does this get into my portfolio? You could just print out the findings from your audit and add it to your portfolio, but would it not look better if you were to get that same consultant who you did the audit with to sign you off and give his/her opinion regarding your role in the audit, and assess you on its various aspects? ePortfolios come with generic forms that assess all sorts of skills, including some of the ones mentioned above.  And because they are generic, they can be utilized universally. If you are competent to perform arterial blood gases in ED, and get signed off for it, and you end up in let’s say, gynaecology, the competency and skill remains the same; you can utilise evidence from your eportfolio to showcase your skill.

So don’t waste your time, your experience in any post is of value to the department you are in, but you should also make sure you tap into that value and are able to utilise that to maximise the benefits to yourself. There is no shame in asking for an assessment, or for feedback; just get their email address, most are only too happy to comply. Otherwise you will find yourself at the end of a 3 year 7 month placement, with nothing but a start and an end date to signify your progress in that post, and that is all it will ever be: a start and an end date. Make sure that does not happen to you.

Pearls of Wisdom – what I have learnt, the hard way

  • NEVER request a chest x-ray JUST to rule out rib fractures. It won’t change your management, unless the patient is short of breath or there are concerns for a pneumothorax, then request a chest x-ray to rule out PNEUMOTHORAX – but I repeat, NEVER for a rib fracture. If you put those words in the request form, that may well be the one (and only) time a radiologist will leave their dark dungeons and come out into the light, TO HUNT YOU DOWN AND KILL YOU.
  • ALWAYS have a chaperone present, or atleast offer the patient one, in cases of intimate examinations (PR, breast, pelvic and/or genitalia). Document – name of chaperone, or when the patient declines having a chaperone present, make sure to state that in the notes clearly. A chaperone is for your protection, and not for the patient’s only.
  • NEVER request x-rays for (suspected) broken toes. If it looks and sounds and feels like it is fractured, it probably is.  Before you x-ray it (which you should never do!) you will neighbour strap the affected toe to the next toe, sort of to act as a splint and reduce the pain. THAT is the management for a fractured toe. If you request an x-ray (once again, something you should never do!) you will find that it is indeed fractured, and then proceed to tell the patient that yes, it is indeed fractured but I have already buddy-taped (another name for neighbour strapping) your toe and the x-ray doesn’t really change my management. I will now run away because the radiologist is probably going to kill me now.
  • Always reduce an ankle fracture BEFORE x-raying. If it’s clinically requiring it, you won’t change the management by wasting time with x-rays; you don’t want the patient to lose their blood supply or stretch out their nerve to point of no return while they’re waiting in the x-ray department, do you?
  • NEVER discharge someone from the department on behalf of someone who has given advice over the telephone. They need to physically see the patient and make a judgement. You can ask for advice, but active management issues, and discharge from hospital on someone’s advice, doesn’t stick in a court of law. If they didn’t come down and document they saw the patient and THEN recommended this and that, then IT DID NOT HAPPEN. They will backtrack faster that a patient on furosemide will need a wee. Well, probably faster than that!
  • ANYONE presenting with abdominal pain, or loin pain, or back pain, above the age of 40-45, PLEASE CONSIDER AAA. It is never a good idea to miss anything, but it is a scary-ass thing to miss a AAA when you have been sitting on it for 3 hours.
  • LISTEN to your gut feeling.
  • Ask for advice BEFORE sending the patient home. No shame in asking for an opinion or running it by someone more experienced. But no forgiving the thing you missed that your ego didn’t allow you to question or ask someone for advice.
  • ALWAYS x-ray pelvis in elderly patients presenting with a fall, I have seen patients walking in to the department with a slight limp, found to have impacted femoral neck fractures. Specially patients with dementia or learning difficulties or any sort of cognitive impairment.
  • Be that extra bit more thorough in patient with cognitive impairment of any sort, delirium etc, they are the ones with hidden signs/symptoms that they sometimes can not express in usual ways of communication. Not every patient who is in pain will tell you (or will be able to tell you) that they are in pain. They may be agitated, or fidgety, or moaning, or distressed, or literally crying out every 2 seconds “Help me!” yet when you ask them what they require help with, they wouldn’t be able to tell you. Pay extra heed to them and be very, VERY vary of what you may miss in these cases.
  • Whenever doing bloods/putting a cannula in, always make sure you have a trolley near by or at least a comfortable chair in a private cubicle – patients have a tendency to faint/go vasovagal on you at the touch of the needle, you don’t want them to be flailing around while you have a cannula/needle in them.

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    WATCH THIS SPACE FOR FURTHER LOVELY NUGGETS OF INFORMATION THAT I HAVE GLEANED IN THE PAST. AND I HAVE LEARNT THE HARD WAY. DO NOT MAKE THE SAME MISTAKES I DID.

Advice that I wish I had when applying or even thinking about applying for EM training

Pre-alert! Boring post with an avalanche of information up ahead, kindly move on if not interested in EM as a future.

I was not always interested in EM. No, unsurprisingly, I used to be interested in surgery. I completed my medical school education in Pakistan, and actually did an elective placement in surgery at a Harvard hospital. WHILE in medical school. It doesn’t get any more committed than that.
Fast forward a few (read quite a few years!) and I found emergency medicine (or it found me, but that’s a story for another blog post – can’t put ALL my ideas in the same post now, can I? otherwise I am not going to have too much of a blog, right?). I did 3-4 years of emergency medicine as a non-training doctor back home in Pakistan, passed my PLAB exams which gave me a license to practise in the UK, and moved here to really try and get into a training post. I got into a non-training trust grade post as an ED SHO, and I have to admit, (credit where credit is due) my experiences in both the department of ED back home in Pakistan, and here where I started and got my bearings in this ED world, have quite a significant part to play in finally landing me this current training post I am in.

My advice to my peers and readers of this blog who are considering or might consider a future in EM to be their thing, is going to be severely bullet-pointed, for emphasis:

Start early. Prepare yourself. Arm yourself with as much information as possible about the program or specialty, about its general requirement and then its finer more intricate details. Look at the RCEM website, speak to college tutors and colleagues who are within the department, glean from them information about the various different pathways available, and what you need to do to get started, and also, of the many pathways available which one is best suited for your unique experiences and skill set.

– Pick a pathway that meets your requirements (or vice versa, you meeting its requirements, it’s all one happy marriage!) and set to work fulfilling the criteria for application. Now there are usually two sets of criteria for application to these posts: the mandatory, or absolutely necessary requirements, where if you apply with even one criteria missing from this list your application will go directly into a large waste bin the size of Suffolk that has accumulated many a CV since the olden days; and the lesser known and hence considered less important (but can be the difference between being offered an interview and going into the reject pile) preferable criteria, which aren’t mandatory, but if you have one or more of these, your application becomes a lot more likely to be considered over someone who say, has all the mandatory requirements but none of the additional preferred ones. Most important question? Where do you get this information. Ask around, read a blog (!) or google search ‘Person specifications for application to EM training‘ followed by the year when you will be applying, as they tweak the requirements every year. Look at the criteria now, and make a list of the things you have, and a list of things you still need to work on.

– Then decide on a timeline: is it achievable by application deadline this year? Ask yourself, is it really worth applying this time round with minimal criteria? Or can you look a bit better (atleast on paper!) next year and have a better chance? At any rate, if you have all of the mandatory criteria, it can not hurt to apply. If nothing else comes of it, then you can atleast consider it a learning experience, filling out the application and making yourself aware of the timescale and what needs to be done etc.

– Get a few things out of the way, as soon as possible. Get a National Insurance number, make sure you have at least 1 major course out of the way, ALS always helps, wherever you are applying, even if it is a non training course and I mean, come on, it should technically make you feel good about yourself and give you the confidence to handle a critical emergency, should it suddenly arise while you are let’s say standing in line at the Costa in the hospital and the woman in front of you collapses. Yes, ALS is definitely a plus to have on board, but do consider doing at least one other course – ATLS or APLS, or even the European versions of them – depending on availability, and your calendar of events for the rest of the year, your study leave and your budget. Never underestimate budget restrictions and always have that in the back of your mind. You can’t book an exam or a course or…do anything essentially if you can’t afford it. Also, make sure you are a member of medicolegal indemnity/insurance organisations like MDS or MDU.

Look at exam dates, if there is an exam requirement, make sure the exam requirement is met, atleast you should make an effort towards it (an honest effort, not just applying for an exam just so you can let someone know that yes I will be appearing for this exam, but I intend to party my free time away!) Factor in exam prep and study leave for an exam and travel and stay expenses if the exam is out of city, which it usually is. Also factor this in with your plans to participate in a course like ALS, ATLS etc, so that these don’t clash.

– Looking at the list of person specifications, you will notice that every requirement has an indication of when it is infact required by. So it will say, for example, that A is required by the time of application, and B is required by the time of interview, and C is required before the start of the program. So you can factor those elements in, and change the timeline of your requirements as needed.

Audit. Audit. Audit. Re-audit. It is so important, not just as a requirement for your application, but also for your GMC appraisal etc, and for your own growth as a physician, to participate in some form of quality improvement projects, from a minor audit to actual active research, anything that may serve to improve patient care from any aspect in the future. The topic of the audit can be relevant to your specialty, or a general one, or just any specialty actually, but what people tend to ignore is the fact that an audit is not just a tick-off-from-a-checklist-and-forget-about-it-now-that-I-am-done thing, but you should create a timeline where you spread the findings from your audit like the joy it will bring (it will not) to everyone concerned, for example your department staff, and let them know how to improve things. Keep reiterating the how-to-improve-things and keep reminding them till you achieve a little things-have-improved situation. THEN YOU RE-AUDIT THE WHOLE THING AGAIN, after a certain time period to allow for improvement, see if there is any improvement. You could re-audit it again, and again. Interviewers and the people considering your application want to see commitment to a goal, and what better way to show commitment than to keep trying to address an issue that you think is a problem and can be improved. Speak to your supervisor or any consultants, they will be glad to receive some help in some ongoing audit or you could give an idea for an audit of your own.

Get started on an e-portfolio, and started getting any and all competencies signed off as early as possible. What you do matters, and make every bit count. If you have intubated 500 patients, but can not provide any documentary proof of it, then you will be second to the person who can show signed competences of having done even 25 intubations. MAKE EVERYTHING COUNT. Read more about this here.

While this is in no way an exhaustive list – it is still a work in progress and I have still got so much to learn – but I do feel that this list forms the basis for entering into any training post, not just emergency medicine. You could embellish your CV in any way to make it better suited to a certain specialty – but these particular little things form the crux of any training application.
In the end, I would like to add a forgotten little adage: “Anything worth doing, is worth doing right.”
So make sure you do it right. Good luck!”

 

(WATCH THIS SPACE FOR MORE POINTERS, I WILL COME BACK AND EDIT THIS AND ADD SOME MORE THINGS.  THIS IS AS MUCH AS I COULD TYPE FOR NOW, DADDY DUTY CALLS. MY SON IS TRYING TO TYPE onNTHELaptopsh and canhtwriteakh anyFURTHer862mx..