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!

To X-ray or not to X-ray – that is the question, but what is the answer?

Guidelines and protocols are in place for a reason. Based on years and years of experience and collated data and individual opinions of specialists etc, these guidelines are set up to aid the budding EM physician. They are not absolute though, as I learnt the hard way (a most unenjoyable way to learn!)

56 year old female, otherwise fit and well, comes in to ED one fine morning around 7am. I was part of the night team, counting the minutes down to when the day team will arrive and I will be able to go home. I was asked by the registrar to see this patient who had turned up to be assessed in the first assessment bay; she was at that time the only patient waiting to be seen (a rare occurrence in ED). I went into the makeshift cubicle (which basically meant drew the curtains around myself and the patient’s bed) introduced myself and asked her what brought her to ED that morning. She reported she had an ongoing pain in her left ankle, that she had been to her GP for. Twice. When I asked her when it first began, I was quite disappointed to find out this had been going on for a few weeks (3 I think she said!) She had been to her GP who had told her on two separate occasions that this seemed like soft tissue injury, and she was advised pain killers. She came in today because she felt she was not improving. She was into hiking and jogging and was a very fit 60 year old. The concern for her was she was unable to pursue her rigorous exercise routines due to this pain. She denied any direct trauma to the affected limb, and reported no swelling or bruising. No previous history of any joint problems (no prior medical history, actually!) and she examined very well: no bony tenderness to medial or lateral malleolus (the inner and outer parts of the ankle); she was able to put weight on it, as evidenced by the fact that she had walked into the department of her own accord without any support (and without a limp!); she had full range of motion except some difficulty in everting her foot, which reproduced the pain. There were no wounds or bruises or swellings, and full power and normal reflexes ended my examination, along with palpable pulses, good capillary refill distally and no neurological deficit. I advised her to continue taking pain relief and to seek a physiotherapist because she may have injured her muscles or a tendon/ligament and may require some specific exercises. She then suggested I x-ray it, and I explained to her why I thought it didn’t warrant an x-ray. She seemed a little less convinced but did not argue, and I sent her home. I documented everything, and thought that was the end of that.

I was called by one of my consultants a few days or weeks later, informing me that I had had a letter of complaint against me. It transpired that eventually when the pain had not gotten better over the next 10 days, despite having been seen by physiotherapy as well, the patient went private and got an x-ray done, which revealed (or so I am told) a stress fracture of the distal end of the fibula! A stress fracture! Of the fibula! The fibula is one of two long bones forming the lower part of your leg. I had never actually in my not-so-many-years of experience heard of a stress fracture involving the fibula.

My consultant was very supportive about it. She had gone through my documentation, and was quite satisfied with the plan I had made for the patient based on my assessment at that time. She agreed that based on that assessment there was no indication for the x-ray. But she taught me a few things about stress fractures that I did not know; that they are more common in the metatarsals than in the fibular end, but that in view of her age, I should have considered the possibility that she might have been osteoporotic and would be prone to fractures without any significant trauma, a detail that I had failed to factor in in my assessment of her. The experience taught me so much about how I need to remain humble in this profession that I decided to do a reflective note on it at the time and added it to my portfolio.

What have I learnt? I have a lower threshold for stress fractures in older patients, despite having no findings on examination/history suggestive of bony injury. I intend to read up on stress fractures and increase my knowledge base on the topic (and maybe blog about it in a later post!). I still intend to continue fully taking a history and doing a proper detailed examination of a patient, and then using my clinical judgement in order to decide on a plan of management for a patient.

You never know when your well-intentioned actions may be the wrong way to go, regardless of whether or not they work for the other hundreds of similar cases. So never get cocky, never get complacent, always be humble, and always, always DOCUMENT!