GIVING & RECEIVING INFORMATION SCENARIO –

REFERRING A PATIENT TO A SPECIALIST

Instructions for candidate:

You are the on-call surgical CT2 who has just received a handover about a patient in
the hospital. Your registrar has asked you to contact the consultant cardiothoracic
surgeon at the regional centre to discuss this patient and arrange transfer if
appropriate.

Hospital/case notes:

A 24-year-old fireman was brought in by ambulance following a road traffic collision

(RTC). He was travelling at 40 mph and hit a wall face-on. He was wearing a seatbelt
at the time but has complained of severe chest pain since the incident. He had a
Glasgow coma scale (GCS) score of 13 in the ambulance, but it is now at 15. His
abdomen is soft. There are no bony injuries.

Observations on arrival:
• Heart rate: 110 bpm
• Blood pressure: 100/60 mmhg
• Respiratory rate: 30 breaths/min
• Oxygen saturation: 95% (on room air).

Bloods:
• Hb: 9 g/dl (90 g/l)
• Platelets: 300 × 109/l
• White cell count: 14 × 109/l
• Na+: 138 mmol/l
• K+: 4.5 mmol/l
• Urea 8 mmol/l
• Creatinine: 140 μmol/l.

Arterial blood gas on air (FiO2 60%):

• pa(O2): 18 kPA
• pa(CO2): 4.2 kPa
• Bicarbonate: 11 mmol/l
• Lactate: 12 mmol/l.

Examination findings:
• Chest radiograph: widened mediastinum, small right-sided pneumothorax and
bilateral pleural effusions.
• CT: verbal report (formal awaited): small right pnemuohaemothorax and small
left haemothorax. No cardiac tamponade, but dissection of thoracic aorta
extending to the aortic arch. No active extravasation; no cardiac tamponade.
 GIVING & RECEIVING INFORMATION SCENARIO –
REFERRING A PATIENT TO A SPECIALIST

Instructions for colleague:

You are a cardiothoracic consultant at a tertiary centre. You routinely accept

referrals from other hospitals but would normally expect a consultant or registrar
level hand-over. You are not impressed that a CT2 is calling to make a referral
about a potentially critical patient.

Interaction:

• This conversation will be via a telephone conversation.

• You are extremely busy and are having to take time out of your schedule to
take this phone call. You are allowed to be angry and rude during the
conversation.
• You do not have to agree with the CT2’s comments or management plan,
but you should be prepared to explain all your reasoning.
 GIVING & RECEIVING INFORMATION SCENARIO –
CONSENTING AND PREPARING FOR HERNIA SURGERY

Instructions for actor:

You are the wife of a 54-year-old man with severe learning difficulties. You know
that your husband requires emergency surgery, but believe that he cannot
understand the need for the operation and the nature of the operation (including
risks and complications) himself. You will enquire as to the nature of the disease
and its treatment, and also ascertain how it will affect his future quality of life.

Interaction:

• The FY2 should include you in the conversation as much as possible and tell
you all the risks and benefits of surgery, however you will not make the
decision. It is the surgeon’s responsibility to make a decision in the best
interests of your husband.
• At the end of the discussion, your permission should be sought to obtain a
signature, so ensure that you have asked the FY2 any questions you have
about the process or the procedure.
 GIVING & RECECEIVING INFORMATION SCENARIO –
CONSENTING AND PREPARING FOR HERNIA SURGERY

Instructions for candidate:

You are the surgical FY2 on call. You are asked to see a 54-year-old man with a
‘painful, tender, firm lump in the right groin’. When you go to assess the patient, you
learn that he has quite severe learning difficulties. Examination of the groin reveals
an irreducible hernia in the right groin. There is a scar over the groin already. His wife
is present and confirms that he had a hernia in the right groin operated on over 10
years ago. She is his next of kin.

Hospital/case notes:

• Ensure that you are familiar with the operation enough to consent the patient.
• It is important, as in this case, you have examined and marked the patient
yourself.
• The issue here is that the patient cannot give informed consent himself: this
can be ascertained with a mini-mental test, and if time allows, assessment by
an independent mental capacity advocate (IMCA).
• His wife cannot provide consent for him either.
• In the UK, no adult can provide consent for another adult to undergo medical
treatment.
• However, his wife should of course be involved in the discussion as much as
possible, and the consenting process can still include her in this way, ie she
should be told the risks and benefits of the surgery.
• This case will need to be discussed with a senior.
• Suggest that a Consent Form 4 is utilised.
• A patient is considered to be competent to consent if they can understand
the information they are given, retain the information they are given, and
weigh up the risks and benefits of the treatment.
• A Consent Form 4 is when the clinician goes ahead and consents a patient for
medical treatment or surgery if they feel the patient is not competent to
consent, and receiving the treatment is in their best interests.
• The wife should not make this decision: it is the surgeon who needs to make
the decision in the best interests of the patient. The wife should still be
included in the discussion, and she may add her signature to the consent
form.
• It is advisable that a second opinion for these types of consent is sought. This
can come in the form of a discussion between colleagues within the surgical
team, ie the surgical registrar and the surgical consultant agreeing that a
Consent Form 4 is necessary.
 GIVING & RECEIVING INFORMATION SCENARIO –
CONSENTING & PREPARING FOR HERNIA SURGERY

Instructions for examiner:

You are the examiner for this station, in which the candidate is expected to communicate,
empathise and sympathise with the patient. Good communication is vital to becoming a
good surgeon. The candidate is expected to elicit the appropriate ideas, concerns and
expectations from the patient, deliver key information to the wife (actor) and check
understanding within the nine minutes allowed. If you feel the candidate is not performing
the station correctly, you may invite them to re-read the brief available in the station.

In this station the candidate is communicating with the wife of a patient with learning needs
who requires an emergency operation. The candidate must elicit what the wife understands
has happened, explain the nature of the problem, the need for surgery, the need for a
consent form and the process this will involve. It is important the candidate explains why a
Consent Form 4 is being used and offers senior review if necessary. You should assess the
candidate against the suggested structure given below:

Starting the discussion:

• Candidates will begin by introducing themselves to the patient and his wife and

mention which team he is under. They will ascertain her relation to him and inform her

of what needs to be done in this meeting.

• They should inform his wife that she should feel free to interrupt if she has any

questions or needs clarification.

Explain the need for surgery:

• Candidates must assess her understanding of what his current problem is and agree

or correct this.

• They should explain in easy terms what a hernia is.

• They should inform the patient and his wife that there is concern that this may involve

strangulated bowel, and thus it needs an operation soon.

• They should explain the alternatives to surgery, but in this case, as the bowel is

potentially involved, a non-operative approach may cause significant deterioration.

• In this case, this is a recurrent hernia.

Explain why a Consent Form 4 is required:

• ‘In order to perform surgery, we have to ensure it is in the patient’s best interests.

After weighing up the benefits and risks, in this particular case, it is.’

• Candidates should explain that the consent form is a simple document that records

that a conversation has taken place, but they would like to take the opportunity to

talk to the patient and his wife through the operation.

Explain the operation:

• Requirement for general anaesthesia: the anaesthetist will come and assess the

patient shortly.

• The operative details should be brief and easy to understand.

• An incision is made over the hernia (in this case, over the previous scar).

• Dissection is carried out until the defect in the muscle is reached.

• Scarring is anticipated because of the previous operation: this makes surgery more

challenging.

• Once the defect is identified, it is repaired with sutures and usually a mesh.

• The wound is then closed up. The operation normally takes 45 minutes, but can be

longer.

Explain the risks/complications:

• Ideally, candidates will complete these on the consent form as they explain them.

• They should identify the main risks and ensure the patient (wife in this case)

understands them.

• Complications specific to this case would include: recurrence, chronic pain,

bleeding/haematoma (which may require further intervention), or requirement for

orchidectomy, laparotomy or intestinal resection.

• It must be explained that these are generally uncommon.

Explain alternatives to surgery:

• In this case, as strangulation is suspected, there are no practical alternatives.

Comment on long-term issues:

• Candidates should make clear that they do not anticipate any issues.

• Prior to discharge, candidates will ensure that the patient has returned to his baseline

capacity.

• If there are any concerns in the future, candidates should make clear that they would

be happy to address them.

Summarise the conversation:

• They must ensure the wife understands all the pertinent points and clarify any

misunderstanding.

• They should directly ask if she has any further questions.

• They should organise a time update her after surgery.

 • They must ask permission to obtain her signature on the consent form to indicate a

conversation has taken place.

Examiner mark sheet:

Domain Marks
Communication 0–4
Uses appropriate opening/introductions and establishes purpose of the
interview.
Uses technical/non-technical language appropriately, accurately and with
fluency.
Confirms that there is common understanding.
Uses appropriate body language and eye contact.
Demonstrates clarity and focus in communication.
Demonstrates active listening towards others.
Demonstrates empathy and responds appropriately to relative’s concerns
and questions.
Reviews understanding and summarises appropriately.
Adequate closure of interview.
Professionalism 0–4
Plans ahead, offers sensible future plan post-surgery.
Explains the procedure accurately and clearly.
Checks understanding of the consent process and re-explains as necessary.
Explains why a Consent Form 4 is appropriate.
Offers a second opinion if relative asks.
Acknowledges fears of surgery.
Offers other support networks/agencies.
Is sympathetic to the mood of a distressed relative and acknowledges this.
Offers further resources as necessary.

Examiner overall assessment

Fail Borderline Pass

 GIVING & RECEIVING INFORMATION SCENARIO –
CONSENTING FOR SURGERY

Instructions for actor:

You are Mrs Sanky, a 55-year-old woman with severe arthritis. You are having an
elective total hip replacement in 2 weeks’ time.

Interaction:

• This will be a face to face conversation with the candidate.

• You are worried about the risks of the procedure, so you should make this
clear to the candidate. Ensure that you ask any questions you may have, as
it is the responsibility of the candidate to fully explain the procedure and the
next steps to be taken.
 GIVING & RECEIVING INFORMATION SCENARIO –
CONSENTING FOR SURGERY

Instructions for candidate:

You are in clinic. Please consent Mrs Sanky for her hip operation. She is a 55-year-old
woman with severe arthritis and she is having an elective total hip replacement in
two weeks' time.

Hospital/case notes:

Focus on:
• explaining the process leading to surgery
• the indications for intervention
• operation details
• risks, complications, and alternatives
• recovery process
• easing her anxiety.
 GIVING & RECEIVING INFORMATION SCENARIO –
CONSENTING FOR SURGERY

Instructions for examiner:

You are the examiner for this station, in which the candidate is expected to communicate,
empathise and sympathise with the patient. Good communication is vital to becoming a
good surgeon. The candidate is expected to elicit the appropriate ideas, concerns and
expectations from the patient, deliver key information to the patient and check
understanding within the nine minutes allowed. If you feel the candidate is not performing
the station correctly you may invite them to re-read the brief available in the station.

In this station the candidate is communicating with a patient due to have an elective hip
replacement. It is important the candidate discusses the indications for surgery, the
alternatives, the general risks of surgery and specific risks of this type of surgery. The
candidate should check for understanding throughout and offer information and follow up at
the end. You should assess the candidate against the suggested structure given below:

Starting the discussion:

• Candidates will begin by introducing themselves and informing her of the consultant

in charge of her care.

• They should ensure she is comfortable.

• They should encourage her to interrupt and ask questions if necessary, and outline

what they will explain to her in this consultation.

Explain the disease process:

• Candidates must gain an understanding of what the patient understands so far and

elucidate what her main symptoms are.

• This information should be used to explain why she is suffering from these symptoms

(in this case, degeneration of hip joint).

• Candidates should explain that the operation is mostly done under general

anaesthesia, but she will meet an anaesthetist who will explain this process in more

detail prior to the operation.

Explain and consent her for the procedure:

• It is helpful to draw a diagram if it can be done quickly and if stationery is available.

This should be kept brief, succinct and in easily understandable language. For

example: ‘The hip is a ‘ball and socket joint’ and allows for a great deal of movement

when we walk and run and for weight bearing. A hip replacement is an operation that

allows for the damaged hip bone to be replaced with an artificial ball and socket that

undertakes the functioning of the natural joint’.

• It requires a long incision around the hip joint and upper leg.

• Dissection is performed until the bone is reached.

• The arthritic bone is excised and replaced with metal work which restores anatomy

and function.

• The wound is then closed up.

• The operation normally takes two hours or so.

Explain alternatives to this procedure:

• losing weight

• reducing strenuous exercise

• physiotherapy and gentle exercises

• medical treatment, eg anti-inflammatory drugs

• using walking aids, eg crutches or a stick.

Risks and complications:

• It is sensible for candidates to complete this section on the consent form (if required)

as the risks and complications are explained to the patient.

• They should start by reassuring the patient that this is a relatively common operation,

and that it is normally safely performed.

• For specific risks, they should mention actions taken to mitigate them.

• General risks: bleeding (may require re-intervention), infection, DVT/PE (use of

heparin, TED stocking to minimise this), CVS risks.

• Specific risks: neurovascular injury (may require more extensive surgery), chronic

pain, failure of prosthesis (requiring revision), dislocation, bone injury during operation

(senior surgeon will be leading the operation).

• These risks, including postoperative mortality, are very rare.

Explain what to expect after surgery:

• There will be pain postoperatively, but this can be well controlled with pain killers.

• Over the course of the first few days, she will receive physiotherapy to assist her

mobilisation.

• Candidates must reassure her that she will only be discharged once she is ready.

• They should then mention that, if necessary, occupational therapists will assess her to

ensure her transition to home is smooth.

• She will be assessed in clinic after surgery to ensure that her long-term recovery is

progressing as planned.

Summarise:

• Candidates need to ask her if there are any points that she would like re-explaining or

if she has any questions.

• They should offer an information leaflet.

• They should nform her that she will have the opportunity to meet the team again

prior to surgery if she thinks of anything else.

• Candidates should re-iterate that the intention of the operation is to alleviate her

symptoms and restore her mobility.

• If she is happy to sign the consent form they should ensure that she is given a copy.
Examiner mark scheme:

Domain Marks
Communication 0–4
Uses appropriate opening/introductions and establishes purpose of the
interview.
Uses technical/non-technical language appropriately, accurately and with
fluency.
Confirms that there is common understanding.
Uses appropriate body language and eye contact.
Demonstrates clarity and focus in communication.
Demonstrates active listening towards others.
Gives adequate time for questions and concerns.
Reviews understanding and summarises appropriately.
Adequate closure of interview.
Professionalism 0–4
Plans ahead, offers sensible future plan post-surgery.
Explains the procedure accurately and clearly.
Checks understanding of the consent process and re-explains as necessary.
Explains the operation risks in general.
Explains the risks specific to this surgery.
Offers a second opinion if asked.
Acknowledges fears of surgery.
Offers other support networks/agencies.
Offers realistic post-surgical plan.
Offers further resources as necessary.

Examiner overall assessment

Fail Borderline Pass

 GIVING & RECEIVING INFORMATION SCENARIO –
DISCHARGE AGAINST MEDICAL ADVICE

Instructions for actor:

You are an 18-year-old man who was admitted to the Surgical Ward yesterday after
being involved in a car accident. You were slowing down when the driver in front
stopped abruptly, and you drove into the back of the car. You presented to the
Emergency Department because of abdominal pain. You had a CT scan, and were
told that there is a ‘blood clot’ in your spleen. You were advised that you would need
to stay in hospital for at least three days for observation. You have an important job
interview to attend tomorrow for your dream job, and you need to catch a train this
evening. You feel well and do not have any pain. You do not understand why you
need to be confined to a hospital for three days and want to know what the risks
are. You are happy to accept the risks involved for discharge today.

Interaction:

• Unlike other stations, this conversation will definitely take place face-to-face.
• The candidate will try to emphasise the serious nature of your splenic injury
and the need to keep you under observation.
• You will however continue to insist on self-discharge, so the candidate should
begin assessing your capacity.
 GIVING & RECEIVING INFORMATION SCENARIO –
DISCHARGE AGAINST MEDICAL ADVICE

Instructions for candidate:

You are the on-call core surgical trainee in General Surgery. You have been asked by
the ward sister to speak to an 18-year-old man with a traumatic splenic haematoma
who wants to self-discharge.

Hospital/case notes:

• An 18-year-old man presented to the Emergency Department yesterday,

following a road traffic accident. He was a restrained driver who collided with
a stationary car while slowing at a junction. Although he was asymptomatic at
the scene, he had experienced left-sided abdominal pain a few hours later.
• A chest X-ray did not show any evidence of pneumo- or haemothorax. CT
abdomen with contrast revealed a grade I subcapsular haematoma of the
spleen. No other injuries were identified.
• He was managed conservatively and admitted for close monitoring and
observation. He was to remain in hospital for at least three days prior to
discharge. Although grade I injuries are less severe and may not require
surgical intervention, patients may present with delayed splenic rupture
and haemoperitoneum, which can be fatal.
 GIVING & RECEIVING INFORMATION SCENARIO –
DISCHARGE AGAINST MEDICAL ADVICE

Instructions for examiner:

You are the examiner for this station, in which the candidate is expected to communicate,
empathise and sympathise with the patient. Good communication is vital to becoming a
good surgeon. The candidate is expected to elicit the appropriate ideas, concerns and
expectations from the patient, deliver key information and check understanding within the
nine minutes allowed. If you feel the candidate is not performing the station correctly you
may invite them to re-read the brief available in the station.

In this station the candidate has been asked to speak to an 18-year-old man with a traumatic
splenic haematoma who wants to self-discharge. The patient sustained grade I injuries
following a road traffic collision. If there is disagreement in this conversation, then it is vital
this is dealt with professionally. There is no set guide for these discussions as they often rely
on the candidate’s responses, but you should assess the candidate against the suggested
structure given below:

Preparation:
• The candidate should ensure a suitable setting for the discussion – a quiet room, if
possible; hand over bleep to a suitably qualified colleague to avoid disruptions during
the discussion; and have a nurse/sister to sit in with them.
• Ask if the patient would like another friend or a relative to be present.
• Be fully aware of the particular situation: look up case notes, relevant scans, research,
etc.

Framework for communication:

• The candidate should introduce themselves (name, role, shake hands).
• Smile and look friendly, with an open-body language.
• The candidate should make sure they are at the same level – if the patient is sitting do
not stand over them.
• If the candidate is sitting at a desk, they should sit themselves and the patient on two
chairs at a corner, so the desk does not come between them.
• The candidate should explain the purpose of the consultation and their role within the
team.
• Use open questions to explore the patient’s understanding of what has happened so
far.
• What are their concerns, and why do they want to self-discharge (idea, concerns,
expectations)?
• Use active listening skills and empathise where possible.
• Try not to interrupt until the patient has finished their story.
• Do not argue.
• Summarising is a good technique: it establishes understanding to avoid
miscommunication and provides reassurance to the patient that the candidate is
listening to what they have to say. It also allows them to mention any other point they
may have forgotten to state. Refer to the Calgary–Cambridge guide to
communication.
Dealing with self-discharge:
• The candidate should summarise the patient’s side of the story, and highlight the key
issues raised. Check if there was anything else they needed to mention.
• Explain the clinical and imaging findings.
• Emphasise the serious nature of the splenic injury.
• Emphasise the need for close observation in a hospital setting due to the risk of
deterioration.
• Emphasise that there is a possibility of re-bleeding in the next few days, which could
be fatal, especially if not in hospital – the worst-case scenario may be death.
• Empathise with their situation regarding needing to attend their interview, but explain
that the risk to life must be taken into consideration and travelling long distances with
such an injury would not be advisable.
• The candidate should then present their points in a methodical manner and be
prepared to repeat them.
• Do not be confrontational.

Assessment of capacity:
The issue is to decide whether this patient has the capacity to make a decision regarding
self-discharge. To assess his capacity, the following need to be established:

• The patient can understand/comprehend the information provided to him by the

clinician/candidate.
• The patient can retain the information – a person should be able to retain the
information given for long enough to make the decision.
• The patient can use that information in making the decision – a person should be able
to weigh up the pros and cons of making the decision.
• The patient can communicate their decision.
• Capacity is time and context specific. If the decision is unclear, a second opinion
should be sought and capacity rechecked at another time.
Examiner mark sheet:

Domain Marks
Communication 0–4
Uses appropriate opening/introductions and establishes purpose of the
interview.
Uses technical/non-technical language appropriately, accurately and with
fluency.
Confirms that there is common understanding.
Has a good manner (and/or appropriate body language and eye contact).
Demonstrates clarity and focus in communication.
Reviews understanding and summarises appropriately.
Adequate closure of interview.
Professionalism 0–4
Does not fabricate clinical information.
Allows time for patient to ask questions/make point.
Is respectful.
Offers further support.
Does not raise voice/argue with patient.

Examiner overall assessment

Fail Borderline Pass

 GIVING & RECEIVING INFORMATION SCENARIO –
DO NOT ATTEMPT RESUSCITATION (DNAR) DECISIONS

Instructions for actor:

You are the daughter of the patient in question, a 69-year-old woman. You do not
live far from your mother and visit her once a week to help with shopping and
errands, so you have a strong bond. Your mother is a widow and prior to
admission she has lived on her own, in her own home, with carers visiting once a
day. Last week your mother underwent an emergency laparotomy
and Hartmann’s procedure for large bowel obstruction secondary to sigmoid
tumour. There was also a liver lesion, which has yet to be characterised. Your
mother developed hospital-acquired pneumonia postoperatively. It is now day four
and you are requesting that a DNAR order is put on your mother’s chart. Your
mother’s health has been steadily deteriorating over the last 4–5 years, and you
feel her quality of life is now very poor.

Interaction:

• This will be a two-way conversation, as the ST3 will want to understand why
you feel this way and you will be expected to explain.
• While you will have a say in the process, it remains a clinical decision as to
whether a DNAR is appropriate in this case.
 GIVING & RECEIVING INFORMATION SCENARIO –
DO NOT ATTEMPT RESUSCITATION (DNAR) DECISIONS

Instructions for candidate:

You are the ST3 in general surgery. A patient’s daughter has requested to see you.
Last week her 69-year-old mother, Mrs B, underwent an emergency laparotomy
and Hartmann’s procedure for large bowel obstruction secondary to sigmoid
tumour. At surgery, there was also a liver lesion, which has yet to be characterised.
She developed hospital-acquired pneumonia postoperatively. She is in
the ITU, intubated and ventilated, with increasing inotropic requirements. It is now
day four and the daughter is requesting that a DNAR order is put on her mother’s
chart.

Hospital/case notes:

Prior to the meeting you should:

• Ensure a suitable setting for the discussion (quiet room, tissues, turn off bleep
or mobile phone, etc).
• Ask if the daughter would like a friend or another relative to be present.
• Ask members of the nursing team and/or ITU team if they can attend too.
• Be fully aware of the particular situation and the patient’s current condition
and prognosis.
 GIVING & RECEIVING INFORMATION SCENARIO –
DO NOT ATTEMPT RESUSCITATION (DNAR) DECISION

Instructions for examiner:

You are the examiner for this station, in which the candidate is expected to communicate,
empathise and sympathise with the patient/relative. Good communication is vital to
becoming a good surgeon. The candidate is expected to elicit the appropriate ideas,
concerns and expectations from the relative, deliver key information to the relative and
check understanding within the nine minutes allowed. If you feel the candidate is not
performing the station correctly you may invite them to re-read the brief available in the
station.

In this station the candidate has been asked to discuss a DNAR with the daughter of an
unwell ITU patient. It is important that this is a two-way discussion – there is no set way the
candidate should approach this, but active listening and open questions are key. It is
important to elicit what the patient’s views on DNAR would have been and what the current
quality of life is at the moment. The candidate should also explain that although relatives may
have a say and should be involved in such discussions, they cannot request clinically
inappropriate treatment, nor decline clinically appropriate treatment. You should assess the
candidate against the suggested structure given below:

Starting the discussion:

• Candidates will begin by introducing themselves to the daughter and mentioning the

senior clinician in charge of her mother’s care.

• They should ensure she is comfortable.

• They should outline the purpose of the meeting.

Establish what is understood:

• Candidates should explore the reason why the patient’s daughter wanted this

discussion. They should take the opportunity to determine her pre-operative quality

of life. Most importantly, they must ascertain if the patient had made any official

requests for DNAR or end-of-life care, or had made any such wishes informally.

• The opportunity to highlight her current condition should be taken. She does appear

to be deteriorating and is requiring increasing organ support. Also, there is a distinct

possibility of metastatic cancer (although results are yet awaited) for which she

would most likely not be a candidate for further oncological treatment.

• Candidates should explore her understanding of what DNAR means, to ensure her

perceptions are correct. They must explain the fact that DNAR only refers to CPR

provision, and not active care.

 • The possibility of a cardiac arrest will need to be discussed, which would be quite

reasonable in her current state. Candidates should explain the outcome of such action

(low recovery of spontaneous circulation, likelihood of cerebral injury, rib fractures,

and an unpleasant way to end one’s life). However, they should also mention that

these factors are unpredictable, and some patients, albeit a small proportion, do make

a recovery.

• Candidates need to explain that the final decision rests with the senior clinician in

charge of her care, but in this case there is agreement that CPR would not be in her

best interests and that it is unlikely to be successful.

• Candidates need to inform her that they will update their seniors and, if all are in

agreement, then they will ensure a DNAR status is recorded. They must inform her

that if the patient’s condition dramatically improves, this can be reversed: it is not a

permanent judgement and will be reviewed periodically.

• They should re-iterate that this discussion was specifically concerning DNAR, rather

than withdrawal of care. This may also need to be discussed in due course, if her

mother’s condition does not improve.

Summarise:

• Candidates should ask if she has any further questions, or if she would like to meet

again to discuss the issue, given that this is a very difficult time for her and her family.

• They must ensure a clear consensus is achieved.

Examiner mark sheet:

Domain Marks
Communication 0–4
Uses appropriate opening/introductions and establishes purpose of the interview.
Uses technical/non-technical language appropriately, accurately and with fluency.
Confirms that there is common understanding.
Uses appropriate body language and eye contact.
Demonstrates clarity and focus in communication.
Demonstrates active listening towards others.
Demonstrates empathy and responds appropriately to relative’s concerns and
questions.
Reviews understanding and summarises appropriately.
Adequate closure of interview.
Professionalism 0–4
Does not offer unrealistic outcomes or expectations.
Does not pressurise relative into talking when silent.
Acknowledges fears and offers realistic hope.
Discusses DNAR and the concept of ceilings of care.
Offers to reconvene with the relative if she needs time to think.
Offers other support networks/agencies.
Is sympathetic and empathetic to the mood of a relative of a seriously sick patient.

Examiner overall assessment

Fail Borderline Pass

 GIVING & RECEIVING INFORMATION SCENARIO –
REFERRING A PATIENT TO A SPECIALIST

Instructions for Examiner:

You are the examiner for this station, in which the candidate is expected to communicate,
demonstrate professionalism and get their point across to a specialist without fabrication.
Good communication is vital to becoming a good surgeon. The candidate is expected to
deliver key information, respond to questions appropriately and summarise why the referral
is clinically appropriate to the colleague within the nine minutes allowed. If you feel the
candidate is not performing the station correctly you may invite them to re-read the brief
available in the station.

In this station the candidate has been asked to discuss an urgent cardiothoracic referral with
the on-call cardiothoracic consultant. They have been briefed to be annoyed at the grade of
referring doctor, so it is imperative the candidate placates this in a professional way. It is
important that this is a two-way discussion – the candidate should recognise that they are
talking to a senior clinician and respond appropriately. If there is disagreement, then it is vital
this is dealt with professionally. There is no set guide for these discussions as they often rely
on the candidate’s responses, but you should assess the candidate against the suggested
structure given below:

Introduction:

• First, candidates must confirm who they are speaking to is the correct person.

• They should introduce themselves clearly and the team/consultant in charge of the

patient’s care.

• They should state their purpose for calling (both advice and the possibility of a

transfer).

• They should enquire if it is a good time to talk (in case the consultant is in the midst

of managing an unwell patient, or in a public space).

• They must remember to explain why they are contacting the unit

(registrar/consultant is busy elsewhere managing the patient at present or scrubbed

in theatre and they have taken the initiative).

Provide relevant information:

• Candidates should give a very concise and relevant history: a 24-year-old man in A&E

resuscitation who has been involved in an RTC. He was in shock at the scene, and

although responsive to immediate resuscitation, his vitals remain labile.

• They outline the immediate life-threatening (and reason for transfer) injuries as

reported on the CT: possible traumatic dissection, no active bleeding, etc.

• They inform the consultant that the scans have been transferred to his hospital

synchronously.

• Then, they can convey his observations and injuries in an ABC approach. For example:

airway self-ventilating, talkative, no injuries, breathing – saturations were 80% on air at

 scene, currently 95%, however his pa(O2) is 18 kPa on 60% oxygen. This should be

continued until they have given a full account of their findings.

• Candidates should outline their interventions, including important negatives. For

example, he is not intubated, and he has a right intercostal drain with 50 ml of

bloodstained fluid. His is receiving his second unit of packed red cells, and has had 1 g

of tranexamic acid.

Outline reason for transfer:

• Candidates should start by asking the consultant’s expert opinion if there is anything

else they should be doing for the patient right now.

• The patient has been assessed by the trauma team, including the candidate’s seniors,

and the consensus is that he requires specialist care urgently.

• This will be because of his current injuries and/or the need for immediate specialist

intervention in case of acute deterioration.

Listen ‘actively’ to the colleague’s advice:

• The consultant may suggest further interventions prior to transfer (eg left-sided chest

drain).

• He will either agree or disagree with the candidate’s request; they should therefore

listen carefully to any reason and respond accordingly. However, they must always

remain polite.

• They should volunteer any appropriate information at this stage: for example, there is

a critical care ambulance on standby as well an anaesthetic registrar escort.

Confirm plan:

• If the consultant agrees the need for transfer, candidates should thank them and

inform them that they will orchestrate matters at their end and keep the consultant

posted of any changes.

• They should exchange contact details and the location where the patient should

arrive.

• If the consultant does not agree, candidates should politely enquire the exact reasons,

so they can relay the information to their seniors. Again, it should be indicated that a

consensus does need to be reached, and so candidates should inform the consultant

that they will need to liaise again very soon, or involve a more senior colleague. They

must ensure that a time frame to re-discuss is assigned and ask (politely) for the

consultant’s name, as their senior may want to speak to them directly.

 • If there are clinical questions the consultant has raised, candidates should answer

them if able to do so, as this may change their mind.

Examiner mark sheet:

Domain Marks
Communication 0–4
Uses appropriate opening/introductions and establishes purpose of the
interview.
Uses technical/non-technical language appropriately, accurately and with
fluency.
Confirms that there is common understanding.
Uses appropriate body language and eye contact (and or good telephone
manner).
Demonstrates clarity and focus in communication.
Reviews understanding and summarises appropriately.
Adequate closure of interview.
Professionalism 0–4
Does not fabricate results or clinical information.
Allows time for clinician to ask questions/make point.
Is respectful/offers further senior input.
Clearly identifies grade of referring doctor.
Does not raise voice/argue with senior clinician.

Examiner overall assessment

Fail Borderline Pass

 GIVING & RECEIVING INFORMATION SCENARIO –
REFERRING A PATIENT TO ITU

Instructions for candidate:

Mr Choi is a 56-year-old man who presented with symptoms of a perforated caecum

confirmed on CT imaging. He is unwell and will need an emergency laparotomy,
which has been arranged. His past medical history includes chronic renal failure, a
myocardial infarction two years ago and hypertension. You have 10 minutes to
prepare, after which you should discuss this patient with the ITU registrar on call to
get advice on management and arrange an HDU bed postoperatively.

Hospital/case notes:

You must have all pertinent details that an ITU doctor will want to know about this
patient:
• past medical history
• current condition (including present and proposed treatment)
• latest test results (blood tests, arterial blood gas (ABG), CT results)
• you must also have valid clinical reasons for wanting the patient to be
transferred to ITU/HDU
• saying that your senior has asked for a bed is not a valid reason
• due to bed shortages, transferring patients to ITU/HDU simply for closer
monitoring also may not be appropriate.
 GIVING & RECEIVING INFORMATION SCENARIO –
REFERRING A PATIENT TO ITU

Instructions for colleague:

You are the ITU registrar and are currently very busy running the ITU. However,
there is genuine reason to admit this patient to ITU following his surgery, for close
monitoring and for likely organ support. The patient in question is a 56-year-old
man who has been sent for an emergency laparotomy after presenting with a
perforate caecum. You really feel that someone more senior should be discussing
this case with you. In the latter part of the conversation, you realise that there may
not be any beds available.

Interaction:

• This will most likely be a telephone conversation, but may also be face to
face.
• For the purpose of this station, you should agree that this patient requires
an ITU bed, however no beds are available.
• It is then the responsibility of the candidate, to discuss with you any suitable
strategies to overcome this.
 GIVING & RECEIVING INFORMATION SCENARIO –
REFERRING A PATIENT TO ITU

Instructions for examiner:

You are the examiner for this station, in which the candidate is expected to communicate,
demonstrate professionalism and get their point across to the ITU consultant without
fabrication. Good communication is vital to becoming a good surgeon. The candidate is
expected to deliver key information, respond to questions appropriately and summarise why
the referral is clinically appropriate to the colleague, within the nine minutes allowed. If you
feel the candidate is not performing the station correctly you may invite them to re-read the
brief available in the station.

In this station the candidate has been asked to discuss an urgent ITU referral with the on-call
ITU consultant. They have been briefed that there is no bed available, so it is imperative the
candidate explores ways of overcoming this in a professional way. It is important that this is a
two-way discussion – the candidate should recognise that they are talking to a senior
clinician and respond appropriately. If there is disagreement, then it is vital this is dealt with
professionally. There is no set guide for these discussions as they often rely on the
candidate’s responses, but you should assess the candidate against the suggested structure
given below:

Introduction:

• Candidates will begin by introducing themselves clearly.

• They will state the team/consultant in charge of the patient’s care.

• They will state their purpose for calling (requirement for ITU bed).

• They must enquire if it is a good time to talk (in case the consultant is in the midst of

managing an unwell patient, or in a public space).

Provide relevant information:

• Background: 56-year-old man admitted three hours ago with peritonism and

confirmed to have a ruptured appendicitis. Currently in A&E resuscitation area.

Candidates should provide past medical history, with relevant dates and

interventions.

• Current state: unwell, hypotensive and tachycardic with a high temperature. He was

shocked at presentation, but is responding to IV fluids and antibiotics. His CT scan

confirms the diagnosis and there are no other adverse features. Highlight blood

results and blood gas analysis. Outline further management: catheter inserted

because of poor urinary output.

• Future plan: he is going to theatre imminently for a laparotomy and may require

extensive bowel resection. Candidates should expect gross faecal contamination, and

a worsening of his septic shock during the operation. He will be resuscitated further in

the anaesthetic room.

 • Reasons for ITU/HDU bed: the consultant surgeon and anaesthetist are sufficiently

worried about his current state and his recent cardiac history. Although fluid

responsive, his vitals remain labile. Surgery will be extensive. He will require close

invasive monitoring, possibly organ support (eg inotropes) and may require repeat

surgery. Furthermore, the anaesthetist may keep him intubated following surgery,

dependent on how it progresses.

Listen ‘actively’ to the senior colleague’s advice:

• The ITU doctor may suggest further interventions prior/during surgery (eg repeat

blood gas).

• They will either agree or disagree with the request: candidates should listen carefully

to any reason and respond accordingly. However, they must always remain polite.

Confirm plan:

• If the ITU doctor agrees the need for a bed, candidates should thank them, inform

them that they will let theatres know and keep ITU posted of any changes during and

immediately after the operation. Candidates will also get the theatre team to give

updates regarding timings once the operation is underway and an assessment has

been made.

• Contact details should be exchanged.

• If the ITU doctor does not agree, candidates should politely enquire the exact reasons,

so they can relay the information to their seniors. Again, it should be indicated that a

consensus does need to be reached, and so candidates should inform them that they

will need to liaise again very soon, or involve a more senior colleague. A time frame to

re-discuss needs to be assigned, and candidates should ask (politely) for their name

as the senior may want to speak to them directly.

• If there are clinical questions that they raise, candidates should answer them if able to

do so, as this may change their mind.

Examiner mark sheet:

Domain Marks
Communication 0–4
Uses appropriate opening/introductions and establishes purpose of the
interview.
Uses technical/non-technical language appropriately, accurately and with
fluency.
Confirms that there is common understanding.
Uses a good telephone manner (and/or appropriate body language and eye
contact).
Demonstrates clarity and focus in communication.
Reviews understanding and summarises appropriately.
Adequate closure of interview.
Professionalism 0–4
Does not fabricate results or clinical information.
Allows time for clinician to ask questions/make point.
Is respectful/offers further senior input.
Clearly identifies grade of referring doctor.
Does not raise voice/argue with senior clinician.

Examiner overall assessment

Fail Borderline Pass

 GIVING & RECEIVING INFORMATION SCENARIO –
PRESENTING A PATIENT WITH POLYTRAUMA TO YOUR CONSULTANT

Instructions for candidate:

You are the on-call orthopaedic registrar and have just finished undertaking the
secondary survey of a trauma call patient. They have a contaminated open fracture
and you feel they need urgent surgery today. You call to discuss the case with your
consultant who is running today's trauma list.

Hospital/case notes:

A 43-year-old quad biker has been in a crash at a farmyard; he is brought in with an

obvious left-sided compound tibial fracture and significant pain, and the wound has
been in the mud. He is orientated, there was a delay for the paramedics to bring him
to the hospital and there were no other injured individuals. The patient has a history
of hypothyroidism on levothyroxine with an allergy to penicillin, but is otherwise well.
He ate four hours ago and has not had anything to drink since then. He works as an
accountant, does not smoke or drink alcohol, and there is a family history of type 2
diabetes mellitus (T2DM).

Observations on arrival:
• Heart rate: 100 bpm
• Blood pressure: 140/80 mmhg
• Respiratory rate: 24 breaths/min
• Oxygen saturation: 96%.

Bloods:
• Hb: 12 g/dl (120 g/l)
• Platelets: 458 × 109/l
• White cell count: 8 × 109/l
• Na+: 140 mmol/l
+
• K : 3.8 mmol/l
• Urea: 5 mmol/l
• Creatinine: 80 μmol/l.

Examination findings (primary survey):

• Speaking: airway clear, C-spine immobilised.
• There is some bruising across left side of chest but equal air entry, no surgical
emphysema, no difference in percussion note.
• There is some ooze of blood from the fracture site.
• Glasgow Coma Score (GCS) 15, pupils equal and reactive to light.
• On log roll some tenderness over back, weak dorsalis pedis and posterior
tibial pulses but present, gross contamination of fracture.

Imaging findings:
• CT traumagram (including leg): no significant injury, incidental left-sided
adrenal adenoma may require further characterisation later, right-sided renal
cyst; comminuted fracture left tibia, major vessels intact.
 GIVING & RECEIVING INFORMATION SCENARIO –
PRESENTING A PATIENT WITH POLYTRAUMA TO YOUR CONSULTANT

Instructions for colleague:

You are the orthopaedic consultant and are on call in a busy trauma list that was
already full from this morning's trauma meeting. Unfortunately, there have been
several technically demanding cases and the list is running late. There is limited
capacity to undertake additional work and the list is only staffed until 1700 h. It is
currently 1500 h.

Interaction:

• In the exam this conversation may take place in person or over the phone. In
this example, this will be a telephone conversation.
• This conversation will test the candidate’s negotiation and presentation
skills.
• As the orthopaedic consultant, you are already very busy. You are very
stressed and may be rude during the conversation.
• The orthopaedic registrar strongly believes the patient requires urgent
surgery, so will be trying to communicate all the key facts to you, as to why
this patient should be added to the trauma list.
 GIVING & RECEIVING INFORMATION SCENARIO –
PRESENTING A PATIENT WITH POLYTRAUMA TO YOUR CONSULTANT

Instructions for examiner:

You are the examiner for this station, in which the candidate is expected to communicate,
demonstrate professionalism and get their point across to their consultant without
fabrication. Good communication is vital to becoming a good surgeon. The candidate is
expected to deliver key information, respond to questions appropriately and summarise why
the referral is clinically appropriate to the colleague within the nine minutes allowed. If you
feel the candidate is not performing the station correctly you may invite them to re-read the
brief available in the station.

In this station the candidate has been asked to discuss an urgent orthopaedic patient with
the on-call orthopaedic consultant. They have been briefed to be annoyed at the grade of
referring doctor, so it is imperative the candidate placates this in a professional way. It is
important that this is a two-way discussion – the candidate should recognise that they are
talking to a senior clinician and respond appropriately. If there is disagreement, then it is vital
this is dealt with professionally. The skill is being able to pick out the important facts in the
first nine minutes with the notes, then communicate them succinctly. Candidates should
remember ATLS (advanced trauma life support) principles: for critical cases like this, the
ABC approach is a useful method to hand over severe injuries. There is no set guide for
these discussions as they often rely on the candidate’s responses, but you should assess the
candidate against the suggested structure given below:

When presenting patients to seniors, a simple approach is to use the ‘SBAR’ mnemonic:

• situation

• background

• assessment

• recommendation.

Situation:

• Basic patient information including name.

• He has come in as a major trauma call, with details of the mechanism of injury.

• He has a contaminated open fracture.

• The patient will need to go to theatre.

Background:

• co-morbidities

• additional information on mechanism if

necessary.
Assessment:

• Candidates should give an abridged presentation of relevant findings from ATLS

primary survey, ie haemodynamic status and other major injuries.

• They should also give an assessment of the fracture: that it is open and

contaminated, or that distally the blood supply to the foot may be compromised.

• Then they should resent important points from CT findings, ie findings in lower limb

and that no other abnormality has been found.

Recommendation:

• Basic initial management of open fracture in

the resuscitation area.

• The patient should be prepared for theatre.

• A secondary survey should be undertaken.

Candidates must listen actively to their colleague’s advice; the colleague may well interrupt
their presentation and make it difficult for them. They should actively listen patiently and
discuss their concerns openly.

Key initial management points to make for this compound fracture:

• Initial management as per ATLS.

• Candidates must ensure limb status is documented prior to manipulation or surgery.

• There should be haemorrhage control through direct pressure or, as a last resort,

tourniquet application.

• Wounds should be handled to: remove gross contaminants, photograph for record,

seal from the environment.

• The wounds have not been provisionally cleaned either by exploration or by

irrigation.

• Limb splintage is the most appropriate means of immobilisation in A&E, provisional

external fixators have not been applied.

• IV antibiotics and tetanus prophylaxis should be given.

• There should be two orthogonal views of the tibia, and radiographic assessment

should include knee and ankle.

 Examiner mark sheet:

Domain Marks

Communication 0-4
Uses appropriate opening/introductions and establishes purpose of the interview.
Uses technical/non-technical language appropriately, accurately and with fluency.
Confirms that there is common understanding.
Demonstrates a good telephone manner (or appropriate body language and eye contact).
Demonstrates clarity and focus in communication.
Reviews understanding and summarises appropriately.
Adequate closure of interview.

Professionalism 0-4
Does not fabricate results or clinical information.
Allows time for clinician to ask questions/make point.
Is respectful of senior input.
Clearly identifies grade of referring Dr.
Does not raise voice/argue with senior clinician.

Examiner overall assessment

Fail Borderline Pass

 GIVING & RECEIVING INFORMATION SCENARIO –
REQUESTING A COMPLEX CT

Instructions for candidate:

You are the on-call surgical CT2 who has just assessed a patient in A&E with your
consultant. He thinks the patient may have Boerhaave syndrome. It is almost 1700 h
and your consultant has now asked you to speak to a senior radiologist, to organise
an urgent CT with oral and IV contrast.

Hospital/case notes:

• Presentation: a 56-year-old man, who is a known alcoholic, presents with

severe upper abdominal and chest pain. He has been vomiting for the last 24
hours. He is septic, but responsive to fluids.
• Examination: there is upper abdominal tenderness; no mass; crepitus in the
neck.
• Bloods: blood test results are awaited.
• Chest X-ray: no pneumoperitoneum or pneumomediastinum; left-sided pleural
effusion.
 GIVING & RECEIVING INFORMATION SCENARIO –
REQUESTING A COMPLEX CT

Instructions for colleague:

You are a senior consultant radiologist. It is almost 1700 h and your shift is coming
to an end. Suddenly, a CT2 runs in requesting a CT scan which you know will take
some time to set up and complete. You are not so eager to hang around.

Interaction:

• In the exam, this conversation could take place face to face or over the
telephone, so be prepared for both methods of interaction.
• As it is late in the day, you are less likely to want to fully engage in this
conversation with a CT2.
• You do not have to agree with the CT2’s comments or management plan,
but you should be prepared to explain all your reasoning.
 GIVING & RECEIVING INFORMATION SCENARIO –
REQUESTING A COMPLEX CT

Instructions for examiner:

You are the examiner for this station, in which the candidate is expected to communicate,
demonstrate professionalism and get their point across to a senior radiologist without
fabrication. Good communication is vital to becoming a good surgeon. The candidate is
expected to deliver key information, respond to questions appropriately and summarise why
the scan is urgent to the colleague within the nine minutes allowed. If you feel the candidate
is not performing the station correctly you may invite them to re-read the brief available in
the station.

In this station the candidate has been asked to discuss an urgent CT scan request with the
on-call radiologist. The radiologist is coming to the end of his shift and he is eager to go
home. It is important that this is a two-way discussion, and the candidate should recognise
that they are talking to a senior clinician and respond appropriately. If there is disagreement,
then it is vital this is dealt with professionally. There is no set guide for these discussions as
they often rely on the candidate’s responses, but you should assess the candidate against the
suggested structure given below:

Introduction:

• The candidate introduces themselves clearly.

• States the team/consultant in charge of the patient’s care.
• States their purpose for speaking to the radiologist (requirement for urgent CT scan
with oral and IV contrast).
• Shows empathy that it is quite late in the day, but it is regarding a patient their
consultant has seen and they are significantly worried about.

Provide relevant information:

• Candidates must be succinct, but unlike communicating with patients and carers, here
they can use more technical language. They should use a structured system for
handing over clinical information and keep it relevant to the situation (securing a CT
scan).
• Background: 56-year-old man with alcohol excess admitted one hour ago with severe
vomiting for 24 hours, presenting with severe upper abdominal pain, and crepitus
around the neck. Chest X-ray confirms a large left pleural effusion. Currently in A&E
resuscitation area.
• Candidates state their suspected diagnosis clearly.
• Current state: unwell; hypotensive and tachycardic with a high temperature. He was
shocked at presentation but is responding to IV fluids and antibiotics.
• The renal function is not yet back, so candidates can attempt to obtain a point of care
creatinine test and discuss with ITU to ensure they are happy to haemofiltrate the
patient if necessary or wait for the biochemistry results to come back.
• In this particular case, candidates give details relevant to the radiology department
including important negatives: he is not inebriated at present and is fully compliant
with instructions (Glasgow Coma Scale (GCS) score of 15) and he is able to swallow.
ECG is normal. He has IV access.
• Candidates should explain what they want and why: ‘My consultant strongly suspects
he has a Boerhaave syndrome, and given how unwell he is, we wish to confirm the
diagnosis’.
• If the diagnosis is confirmed, the patient will require urgent transfer to the regional
upper GI unit and they will need a CT scan prior to transfer (ie obtaining the scan
affects his management).
• Reasons for urgency: candidates must explain they know it is late in the day, but
given how unwell the patient is and the seriousness of the suspected diagnosis, they
need to be scanned urgently.
Listen ‘actively’ to the colleague’s advice:

• Colleagues will either agree or disagree with the request: candidates must listen
carefully to any reason and respond accordingly. However, they must always remain
polite.
• They should volunteer helpful information to further increase successful outcome.
• In this case, examples would be: ‘I have informed the porters to bring him to the CT
scanner and updated the radiographer who is ready’. ‘I have prescribed oral
gastrografin and nurses are ready to administer it.’ ‘I will stay with the patient during
the scan’ (ie no waiting for an escort).
• ‘My consultant will come to see you as soon as the scan is done to have a look at the
images together with you.’

Confirm plan:

• If the radiologist agrees, then candidates must thank them and confirm that they will
get things moving immediately.
• Contact details should be exchanged.
• If the radiologist does not agree, candidates should politely enquire the exact reasons,
so they can relay the information to their seniors. Again, it should be indicated that a
consensus does need to be reached, and so candidates should inform them that they
will need to liaise again very soon, or involve a more senior colleague. A time frame to
re-discuss needs to be assigned, and candidates should ask (politely) for their name
as the senior may want to speak to them directly.
Examiner mark sheet:

Domain Marks
Communication 0–4
Uses appropriate opening/introductions and establishes purpose of the interview.
Uses technical/non-technical language appropriately, accurately and with fluency.
Confirms that there is common understanding.
Uses appropriate body language and eye contact (and or good telephone
manner).
Demonstrates clarity and focus in communication.
Reviews understanding and summarises appropriately.
Adequate closure of interview.
Professionalism 0–4
Does not fabricate results or clinical information.
Allows time for clinician to ask questions/make point.
Is respectful/offers further senior input.
Clearly identifies grade of referring doctor.

Examiner overall assessment

Fail Borderline Pass

 GIVING & RECEIVING INFORMATION SCENARIO –
SPEAKING TO A DIFFICULT JUNIOR COLLEAGUE

Instructions for candidate:

You are a CT2 and one of the FY1 doctors has been attending the hospital late,
without prior warning, on a regular basis. This is being commented on by several
members of the team. Clinically, he is good, but you have also discovered from your
other FY1 that he often leaves work early without telling anyone. You have decided
to speak to him about this.

Hospital/case notes:

Communicating with a colleague in this scenario is challenging, as there is a risk that

you are creating a problem where there is none. So, you must approach the
conversation very delicately, and ensure that you give your FY1 an opportunity to
explain his side of the story. After all, there may be very good reasons that explain
his behaviour. During this conversation you must:

• identify the problem and highlight his strengths too

• understand the problem from everyone’s perspective
• highlight the possible outcomes from this
• develop a strategy to overcome and resolve this issue
• organise a further meeting to re-evaluate progress.
 GIVING & RECEIVING INFORMATION SCENARIO –
SPEAKING TO A DIFFICULT JUNIOR COLLEAGUE

Instructions for colleague:

You are an FY1 doctor who lives very far away from the hospital, and it takes you
around two hours a day to commute each way. As a result, you often arrive late,
especially if there are train delays. As it takes so long to get home, you try to leave
work early, but only if your jobs are completed. As a result of the travelling, you are
tired most of the time, and are getting quite fed up with work.

Interaction:

• Unlike other communication scenarios, this will definitely be a face to face

conversation in the exam.
• You are not expecting this conversation and may not know what it is about,
while the CT2 is naturally concerned about you and your wellbeing.
 GIVING & RECEIVING INFORMATION SCENARIO –
SPEAKING TO A DIFFICULT JUNIOR COLLEAGUE

Instructions for examiner:

You are the examiner for this station, in which the candidate is expected to communicate,
empathise and sympathise with the junior colleague – then address the key points of
concern, formulate an agreed action plan and agree to review at a future time point. At no
point should the conversation become hostile. Good communication is vital to becoming a
good surgeon. If you feel the candidate is not performing the station correctly you may invite
them to re-read the brief available in the station.

In this station the candidate has been asked to speak with an FY1 doctor who has regularly
been attending the hospital late and without prior warning. It is important that this
conversation is approached delicately, and that the candidate gives the FY1 an opportunity
to explain himself – there may be a good reason to explain this behaviour. You should assess
the candidate against the suggested structure given below:

Set the scene:

• Candidates should explain, politely, why they want to speak to him.

• They clearly explain the specific reasons, so that he understands their concerns.

• They highlight that they are not reprimanding him, or reporting him, but rather they

want to understand his point of view.

• They make clear that they wish to reach an agreement by the end of the

conversation.

Explore the areas of concerns in more detail:

• The concerns should be made clearly so that the FY1 is aware of the problem that

others perceive.

• Candidates should explain how they have come to know about these issues through

their own observations, and what other colleagues have mentioned (without naming

names).

• Candidates indicate that as others are picking up on this issue, it may escalate to a

conversation with the consultant, or, even worse, may result in failure to achieve

completion of FY1 training.

• Without making it too formal, candidates can mention that punctuality and reliability

are key parts of the profession, GMC guidelines, and integral to good team-work.

• It should be underlined how important he is to the functioning of the team, and hence

his absence makes a difference to everyone else.

Ask him about his thoughts on this issue:

• Candidates can give prompts to achieve this.

• They should listen closely, and in a non-judgmental manner.

• They should understand his side of the story. He is trying very hard, but the long

commute is taking its toll on his work.

• Does he perceive there to be a problem? If not, then candidates must explain that

others do see it as a problem, so he is aware that the matter will escalate with

potentially serious consequences.

Find a solution together:

• Candidates should openly discuss ideas about how one could make it easier for him.

• In this case, these would include: simply notifying a colleague if he is running late or

when he wants to leave early; assisting him in finding local accommodation, or

organising an on-call room on certain days; working with the rest of the team to

ensure he and his fellow FY1s are taking their half-days off so that he can get some

extra rest.

Make arrangements to meet again:

• Candidates should summarise the consensus that has been agreed.

• They should plan to meet again at a specified interval.

• Candidates must ask him to contact them at any time if there is anything he wants to

discuss.

• He must be reassured that this conversation will be kept private.

• Candidates will reiterate that they simply want to help him, and do not want this

matter to escalate any further.

 Examiner mark sheet:

Domain Marks
Communication 0–4
Uses appropriate opening/introductions and establishes purpose of the
interview.
Uses technical/non-technical language appropriately, accurately and with
fluency.
Confirms that there is common understanding.
Uses appropriate body language and eye contact.
Demonstrates clarity and focus in communication.
Demonstrates active listening towards others.
Reviews understanding and summarises appropriately.
Adequate closure of interview.
Professionalism 0–4
Offers sensible solutions.
Offers to reconvene at specified time interval.
Offers support if needed.
Reassures colleague that conversation will be kept private.
Is sympathetic to the junior colleague.

Examiner overall assessment

Fail Borderline Pass

 GIVING & RECEIVING INFORMATION SCENARIO –
SPEAKING TO AN ANGRY RELATIVE

Instructions for actor:

You are the mother of an 8-year-old girl. Three days ago, you rushed your daughter
to the Emergency Department because of her high fever, vomiting and severe
tummy pain. You were told that your daughter may have appendicitis and that an
operation was required. The daughter went on to have the operation later that
evening. You were told that the operation was a success and the appendix was
removed. You were told that your daughter needed to stay in hospital for IV
antibiotics because of severe infection. Today, you noticed your daughter to be a lot
worse and more drowsy. Your daughter was then admitted to the ITU because her
infection was getting worse and she had an ‘abscess’. One of the nurses there said
that the operation was not thorough enough and that is why she was so unwell. You
are angry that your daughter’s care has been compromised due to a failure on the
part of the surgeon and you want some answers as to why this happened. You also
want to know how her treatment is going to change from here onwards.

Interaction:

• Unlike other stations, this conversation must take place face-to-face.

• You may lose your temper in the conversation – it is the responsibility of the
candidate to remain calm.
• You want to know all the details as to why your daughter’s care was
compromised but be mindful that the candidate is not the surgeon
responsible. There may be questions they cannot answer, so you should push
them on how they will resolve these.
 GIVING & RECEIVING INFORMATION SCENARIO –
SPEAKING TO AN ANGRY RELATIVE

Instructions for candidate:

You are the general surgical SHO. You have been asked to speak to the mother of an
8-year-old girl who has been admitted to ITU due to severe sepsis, three days after
an emergency laparoscopic appendicectomy. The girl’s mother is angry that her
daughter’s care has been compromised due to a mistake in the operation.

Hospital/case notes:

• An 8-year-old girl presented three days ago with severe right iliac fossa pain
and fever. She was taken to theatre that evening for a laparoscopic
appendicectomy by the on-call ST3.
• Operative notes describe a perforated appendix with pus and faecal
contamination in the pelvis. A standard appendicectomy was performed.
• She continued to receive IV antibiotics postoperatively due to the extent of
the infection but earlier today, her clinical status deteriorated with worsening
pain, rigors and high inflammatory markers. An abscess was suspected and
confirmed on imaging. Due to the severity of her sepsis, she was admitted to
the Paediatric Intensive Care Unit.
• At handover, the ST3 who performed the operation remarked that he forgot
to wash out the pelvis.
• A plan has been made to request ultrasound-guided drainage of this abscess.
 GIVING & RECEIVING INFORMATION SCENARIO –
SPEAKING TO AN ANGRY RELATIVE

Instructions for examiner:

You are the examiner for this station, in which the candidate is expected to demonstrate
professionalism while communicating and empathising with the relative in question. Good
communication is vital to becoming a good surgeon. Nine minutes are allowed for this
station. If you feel the candidate is not performing the station correctly you may invite them
to re-read the brief available in the station.

In this station the candidate is communicating with an angry relative; the mother of an 8-
year-old girl who has been admitted to ITU due to severe sepsis, three days after an
emergency laparoscopic appendicectomy. The girl’s mother is angry that her daughter’s care
has been compromised due to a mistake in the operation. If there is disagreement, then it is
vital this is dealt with professionally. There is no set guide for these discussions as they often
rely on the candidate’s responses, but you should assess the candidate against the
suggested structure given below:

Preparation:
• The candidate should ensure a suitable setting for the discussion: a quiet room if
possible, hand over bleep to a colleague, and a nurse to sit in with them.
• Ask if the mother would like another friend or relative to be present.
• Be fully aware of the particular situation: look up operative notes, ITU notes etc.

Framework for communication:

• The candidate should introduce themselves.
• Smile and look friendly, with open body language.
• The candidate should make sure they are at the same level – if the relative is sitting
do not stand over them.
• If the candidate is sitting at a desk, they should sit themselves and the relative on two
chairs at a corner, so the desk does not come between them.
• The candidate should say what they had to do with the case and what they are here
for. They must confirm that they are speaking to the mother of the child.
• Use open questions to explore their impression of what has happened so far.
• What are their concerns and what has upset them?
• Use active listening skills and empathise where possible.
• Try not to interrupt until the patient has finished their story.
• Do not argue.

Communicating with an angry relative:

• The candidate should summarise the mother’s side of the story and highlight the key
issues raised. Check if there was anything else they needed to mention.
• Apologise for any perceived miscommunication or lack of care.
• Clarify each issue one by one in a calm manner.
• Explain the intraoperative findings of perforated appendicitis. Explain that the
procedure involves washout to remove as much contamination as possible.
• The candidate should explain that their colleague omitted to do this and that they will
find out why this happened. The candidate should not try to hide this mistake or gloss
over it. They should not take responsibility for others’ actions as they cannot know
what the thought process was intra-operatively.
• Explain the reason for ITU admission and the plan going forward, ie drainage of
abscess.
• Present all points in a methodical manner and be prepared to repeat them.
• Do not be confrontational.
Finishing the conversation:
• The candidate should summarise the key points.
• Ask the mother if they have any questions: candidates must answer those they can,
but must be honest. If they do not know the answer, the candidate should either point
the relative in the right direction or find out and inform them.
• Repetition may be required.
• The candidate should outline the actions they will be taking, ie organising follow-
up/physiotherapy.
• Offer a point of contact: either the consultant’s secretary or a specialist nurse, if
applicable.
• Direct them to PALS (patient advice and liaison service) if they wish to make a formal
complaint. PALS offers confidential advice, support and information on health-related
matters.
• The candidate should ensure that they have offered apologies for any deficiencies in
their daughter’s care.
Examiner mark sheet:

Domain Marks
Communication 0–4
Uses appropriate opening/introductions and establishes purpose of the
interview.
Uses technical/non-technical language appropriately, accurately and with
fluency.
Confirms that there is common understanding.
Has a good manner (and/or appropriate body language and eye contact).
Demonstrates clarity and focus in communication.
Reviews understanding and summarises appropriately.
Adequate closure of interview.
Professionalism 0–4
Does not fabricate clinical information.
Allows time for patient to ask questions/make point.
Is respectful.
Offers further support.
Does not raise voice/argue with patient.

Examiner overall assessment

Fail Borderline Pass

 GIVING & RECEIVING INFORMATION SCENARIO –
SPEAKING WITH AN ANGRY PATIENT

Instructions for actor:

You are a 30-year-old man who works in a warehouse with a young family to
support. You have been suffering from low back pain and shooting pains down your
right leg for the last two weeks. You saw your GP who told you to ‘take it easy’. You
felt like the GP was not interested. Your symptoms subsequently worsened as you
continued to work. You were then admitted to the Surgical Assessment Unit
(SAU) where a junior doctor saw you briefly and said that you needed ‘a scan’
because your ‘nerves might be compressed’. You subsequently had an MRI scan. The
consultant saw you this morning and told you to go home before rushing off. You
are angry that nobody has bothered to inform you of the MRI findings. You are
scared that you might become paralysed and worry about how you will provide for
your family.

Interaction:

• Unlike other stations, this conversation must take place face-to-face.

• The candidate is expected to clarify all your queries and explain the MRI
findings to you, so you may push them on this if you feel they are not
performing adequately.
• Remember to ask the candidate about next steps and follow-ups after this
conversation.
 GIVING & RECEIVING INFORMATION SCENARIO –
SPEAKING WITH AN ANGRY PATIENT

Instructions for candidate:

You are the on-call core surgical trainee working on the Surgical Assessment Unit
(SAU) today. The nurse in charge has asked you to speak to a patient with sciatica
who is being discharged with a view to a neurosurgical follow-up. However, they
report that the patient is angry and says that nobody has spoken to him today and
he feels like nothing is being done. You saw him this morning on the consultant post-
take ward round when the plan for discharge was made.

Hospital/case notes:

• The patient is a 30-year-old man who presented to SAU with a 2-week history
of worsening low back pain and associated sciatica in the right leg. He had
initially seen his GP who had advised rest and analgesia. As his symptoms
worsened, he attended the Emergency Department and was then admitted
to SAU. He underwent an MRI this morning which showed a moderately sized
L4–5 disc herniation on the right. There was no evidence of cauda equina
compression. His case was discussed with the local neurosurgical unit who
advised outpatient referral to the spinal clinic, analgesia and physiotherapy.
• He was subsequently seen by the on-call orthopaedic consultant on the post-
take ward round and informed of the neurosurgical plan. The consultant was
in a rush as he needed to start the trauma list, so he hurried off to see the
next patient.
 GIVING & RECEIVING INFORMATION SCENARIO –
SPEAKING WITH AN ANGRY PATIENT

Instructions for examiner:

You are the examiner for this station, in which the candidate is expected to demonstrate
professionalism while communicating and empathising with the patient in question. Good
communication is vital to becoming a good surgeon. Nine minutes are allowed for this
station. If you feel the candidate is not performing the station correctly, you may invite them
to re-read the brief available in the station.

In this station the candidate is communicating with an angry patient with sciatica who is
being discharged with a view to a neurosurgical follow-up. The patient is angry as he says
that nobody has spoken to him today and he feels like nothing is being done. If there is
disagreement, then it is vital this is dealt with professionally. There is no set guide for these
discussions as they often rely on the candidate’s responses, but you should assess the
candidate against the suggested structure given below:

Preparation:
• The candidate should ensure a suitable setting for the discussion: a quiet room if
possible, hand over bleep to a colleague, and a nurse to sit in with them.
• Ask if the patient would like another friend or relative to be present.
• Be fully aware of the particular situation: look up past medical history etc.

Framework for communication:

• The candidate should introduce themselves to the patient.
• Smile and look friendly, with open body language.
• The candidate should make sure they are at the same level – if the patient is sitting do
not stand over them.
• If the candidate is sitting at a desk, they should sit themselves and the patient on two
chairs at a corner, so the desk does not come between them.
• The candidate makes clear what they had to do with the case and what they are here
for.
• Use open questions to explore their impression of what has happened so far.
• What are the patient’s concerns and what has upset them?
• Use active listening skills and empathise where possible.
• Try not to interrupt until the patient has finished their story.
• Do not argue.

Communicating with an angry patient:

• The candidate should summarise the patient’s story and highlight the key issues he
raised. Check if there was anything else they needed to mention.
• Apologise for any perceived miscommunication or lack of care.
• Clarify each issue one by one in a calm manner.
• Explain the findings of the MRI scan using lay terms.
• Inform him of the neurosurgical plan. Explain that the consultant had a theatre list to
start and apologise for the abruptness of the consultation.
• Present all points in a methodical manner and be prepared to repeat them to ensure
the patient understands.
• Do not be confrontational.
Finishing the conversation:
• The candidate should summarise the key points.
• Ask the patient if they have any questions – candidates must answer those they can
but must be honest. If they do not know the answer, the candidate should either point
the patient in the right direction or find out and inform them.
• Repetition may be required.
• The candidate should outline the actions they will be taking, ie organising follow-
up/physiotherapy.
• Offer a point of contact: either the consultant’s secretary or a specialist nurse, if
applicable.
• Direct them to PALS (patient advice and liaison service) if they wish to make a formal
complaint. PALS offers confidential advice, support and information on health-related
matters.
• The candidate ensures that they have offered apologies for any deficiencies in the
patient’s care.
Examiner mark sheet:

Domain Marks
Communication 0–4
Uses appropriate opening/introductions and establishes purpose of the
interview.
Uses technical/non-technical language appropriately, accurately and with
fluency.
Confirms that there is common understanding.
Has a good manner (and/or appropriate body language and eye contact).
Demonstrates clarity and focus in communication.
Reviews understanding and summarises appropriately.
Adequate closure of interview.
Professionalism 0–4
Does not fabricate clinical information.
Allows time for patient to ask questions/make point.
Is respectful.
Offers further support.
Does not raise voice/argue with patient.

Examiner overall assessment

Fail Borderline Pass

 GIVING & RECEIVING INFORMATION SCENARIO –
BREAKING BAD NEWS

Instructions for actor:

You are the mother who was expecting Billy home from school in the afternoon,
but he did not return. You understand that there has been an accident but do not
know how severe his injuries are, or that he has been rushed to theatre. You are
very anxious to find out what has happened and who is to blame for the accident.
You are distraught to hear that your son has been critically injured and your main
concern is that he may die. You want to know when you can see him, what are his
chances of survival and what are the long-term implications?

Interaction:

• This discussion will need to take place in a suitable setting – somewhere

quiet, where tissues and support are available.
• You may want other relatives and/or friends to be present for the
conversation.
• As Billy is currently undergoing surgery, this poses difficult circumstances
for the interaction. You will primarily want to know if your son is going to
survive, however, the candidate must be honest and explain that details like
this will not be clear until after surgery.
 GIVING & RECEIVING INFORMATION SCENARIO –
BREAKING BAD NEWS

Instructions for candidate:

The on-call surgical registrar has asked you to go down to the Emergency
Department to talk to the mother of a 12-year-old boy who was brought in by
ambulance one hour ago, having been involved in a road traffic accident. The boy is
currently in theatre with multiple abdominal injuries, including a splenic rupture. You
need to convey the information to the mother and answer any questions she may
have.

Hospital/case notes:

• A 12-year-old boy was brought in by ambulance.

• He was unstable at presentation; there was immediate resuscitation.
• FAST scan was performed, showing free fluid in the abdomen.
• He was immediately taken to theatre where a consultant surgeon was present.
• The operation was started: splenic rupture was confirmed; other viscera need
to be fully inspected for injuries.
• He required an intraoperative blood transfusion.
 GIVING & RECEIVING INFORMATION SCENARIO –
BREAKING BAD NEWS

Instructions for examiner:

You are the examiner for this station, in which the candidate is expected to communicate,
empathise and sympathise with the patient. Good communication is vital to becoming a
good surgeon. The candidate is expected to elicit the appropriate ideas, concerns and
expectations from the patient’s mother, deliver key information to them and check
understanding within the nine minutes allowed. If you feel the candidate is not performing
the station correctly you may invite them to re-read the brief available in the station.

In this station the candidate is communicating with the mother of a sick child. The candidate
will need to ensure the mother understands what has happened, explain the serious nature of
the problem, elicit the mother’s ideas, concerns and expectations, and offer a sensible future
management strategy that allows the mother to plan ahead. You should assess the candidate
against the suggested structure given below:

Starting the discussion:

• Candidates should start by introducing themselves and mention that they are part of

the team managing Billy.

• They should ask the mother if she wants anyone else to be present.

• They will ensure she is sitting down.

Determine what she understands and would like to know:

• The mother should be asked directly what she knows so far.

• Candidates should assess this information and base what they tell her according to

her level of understanding.

• They must remain empathetic.

Give her information in a structured manner:

• They should give a warning shot, for example ‘I've got some bad news’ and leave a

short pause.

• They should start with confirming her understanding that Billy is currently in a critical

condition: he is presently undergoing major surgery.

• They must break the bad news sensitively (in small easy to understand blocks).
Candidates should describe the events briefly and chronologically:

• ‘Billy was brought in after sustaining a road traffic accident.’ They must be honest

about scanty details.

• ‘He was very unwell when he arrived at hospital and needed to be rushed to theatre.’

• ‘Significant injuries were suspected at the time, and hence the decision to operate

was mandated immediately.’

• ‘He is presently undergoing abdominal surgery by very experienced clinicians.’

• ‘At present, it is known that the spleen is injured, requiring surgery, and this injury

necessitated a blood transfusion.’

• ‘As yet, an assessment of other injuries, if present, is being made.’

• ‘Billy’s condition is stabilising now that he is being actively managed.’

Candidates must volunteer further information:

• ‘At present, we do not know the true extent of his injuries, but as soon as we have

finished the operation, we will update her.’

• ‘Billy is likely to go to ITU after surgery where he can be monitored more closely.’

• ‘You will be able to see him after the operation.’

• If she enquires about Billy’s long-term outcome, candidates must be honest and

inform her:
o ‘We cannot determine this just yet until we have completed the operation.’
o ‘Over the course of the next few hours we will be able to obtain a clearer
picture.’
o ‘However, we will keep you regularly updated on his progress.’
o The need for further treatment and rehabilitation will be dictated by how he
progresses.
o Candidates should explain the risks of surgery and anaesthetic.
o If asked directly, they should explain the long-term complications of
splenectomy, ie lifelong antibiotics.

Summarise the conversation:

• Candidates should ask if she has any further questions at this stage.

• They should check understanding/clarify misunderstandings.

• They should acknowledge that this is a lot of information to take in and this is a most

difficult time for her.

• Thus, candidates should organise to meet again in 2–3 hours when there will be more

information.

• They should try to ensure that someone will be with her.

• They should offer realistic hope.

• They will offer their sympathy to her.

Examiner mark sheet:

Domain Marks
Communication 0–4
Uses appropriate opening/introductions and establishes purpose of the
interview.
Uses technical/non-technical language appropriately, accurately and with
fluency.
Uses ‘warning shot’ technique to soften blow.
Confirms that there is common understanding.
Uses appropriate body language and eye contact.
Demonstrates clarity and focus in communication.
Demonstrates active listening towards others.
Demonstrates empathy and responds appropriately to relative’s concerns
and questions.
Reviews understanding and summarises appropriately.
Adequate closure of interview.
Professionalism 0–4
Plans ahead, offers sensible future plan post-surgery.
Does not pressurise relative into talking when silent.
Acknowledges fears and offers realistic hope.
Offers to reconvene with the relative when more information becomes
available.
Offers other support networks/agencies.
Is sympathetic to the mood of a distressed mother and acknowledges this.

Examiner overall assessment

Fail Borderline Pass