http://sjt.foundationprogramme.nhs.uk.A number of different assessments will occur during clinical school, which may be formative (i.e. largely for the student’s benefit in terms of learning and reflection), summative (a minimum mark is required to progress through the course, and could count towards your final grade), or may even contribute to job applications. The purpose of this section is to outline the different clinical assessments you may face during your clinical attachments and at the end of clinical school.
It is common at the end of a clinical attachment to be asked to present a patient you have encountered. You should expect to spend ~5 min presenting and perhaps 10 min discussing the issues raised. Your examiner is likely to be a consultant or registrar.
Some important tips include the following:
• Keep it brief! Imagine you are on a post-take ward round where there are 20 patients to be seen in a morning. Include pertinent information only (including important negatives) and state it succinctly.
• Start with some medical background if it is immediately relevant to the current admission; breathlessness 4 weeks after a CABG raises a very particular list of differential diagnoses to be considered compared to breathlessness in someone with no PMHx.
• Also add some social detail early on if this is likely to have a major impact on the patient’s management: ‘This is a 92-year-old lady from a nursing home with end-stage dementia …’
• After describing the patient’s history and your examination findings, list the differential diagnoses, perhaps with a brief comment about which are the likeliest, or the most important to exclude.
• You should then propose a management plan (remember that management includes investigations and treatment). Include some detail about which would be the most discriminating tests, or what you would be looking for in each case.
• Summarize the case with one or two sentences: ‘To conclude, this is a 64-year-old man who presents with right upper quadrant pain and fever. The most likely cause is gallstones and I would investigate him further with an ultrasound of the biliary tree.’
• Be prepared for questions about the differential diagnoses, the value of different investigations (e.g. V/Q scan vs CTPA in possible PE), and risks/benefits of different treatments.
• What learning points or issues has this case raised?
You may also be asked to compile a portfolio of written case presentations, in which case you should use the same format as in medical note keeping with a brief section at the end discussing relevant issues.
OSCEs test clinical examination, practical skills, and communication skills, usually in 10 min ‘stations’ around which you rotate in turn. You could be asked to dipstick urine, perform a cognitive assessment, or certify death in the same sitting. Although a somewhat artificial environment, the OSCE reflects the multitasking and varied nature of life as a junior doctor.
Some important points to remember include the following:
• Behave as you would in real life, by washing your hands, introducing yourself to the patient, and asking permission before acting.
• Ensure patient dignity, only exposing them after seeking permission and checking with the examiner that it is necessary. Be mindful that the patient may see 20 medical students that morning and may be fatigued.
• Time keeping is also very important. If you have only 7 min to perform a neurological examination of the lower limbs, you need to be mindful of this and ensure you cover all aspects in this time. This will require practice!
• Do not be disheartened by a bad station. As soon as the bell rings, you should move on to the next task and forget what has passed. The next examiner will not know what has just happened and you can start afresh and make a good impression.
• A critical point to remember is that OSCEs are scored using a very prescriptive mark sheet. There is little allowance for the examiner’s subjective impression of performance (as there would be in real life). If you are not seen to wash your hands or to state that you are looking for scleral jaundice, then the mark will not be awarded. State the obvious!
• The mark sheets may well be based on whatever learning materials have been made available to you. If you have been given a suggested routine for BP taking, it would be unwise to do much differently in the exam. Read and learn the routines!
• Remember the most vital traits in a new doctor are patient safety and appropriate respect/concern for the patient. These values are likely to be reflected in mark schemes.
• OSCEs provide a robust (and quantitative) assessment of all-round performance in clinical school. As a result, they often contribute significantly to the final mark. It is well worth putting in the time to practise these routines in advance.
Some examples of OSCE stations include:
Some medical schools use learning portfolios as a method of gathering evidence about your performance at medical school through work-based assessments (WBAs) or supervised learning events (SLEs). The assessments are often based on those that will be used in your graduate training and beyond, e.g. mini-clinical evaluation exercises (Mini-CEX), case-based discussions (CBDs), direct observation of procedural skills (DOPS), and multisource feedback (MSF). The assessor will usually be a doctor in the team to which you are currently attached.
A focused encounter such as assessing a patient’s airway or performing an abdominal examination.
The student chooses a case for discussion, starts with a brief presentation, and then explores the issues raised.
Sometimes known as a 360o appraisal or mini-peer assessment tool (mini-PAT). The student selects a number of colleagues (doctors, nurses, healthcare assistants, physiotherapists, and administrative staff) to complete a form describing their performance, attitude, team work, and professionalism.
There are a set of procedures where you need to demonstrate competency under supervision (cannulation, catheterization, peak flow, etc.)
Assessment of teaching and/or making a presentation, and to develop skills in preparation and scene-setting, delivery of material, subject knowledge, and ability to answer questions.
All assessments are done electronically through an e-learning website. If the assessor is not there in person to sign you off, you can generate an e-ticket to be sent to the assessor’s email address to be signed off later. This is an opportunity for both of you to highlight your strengths and weaknesses as well as an action plan to continue your professional development.
The SJT is an essential requirement in the final year of clinical schools nationwide, and the score is considered in ranking Foundation Year applications. It is worth getting right! Further information can be found at http://sjt.foundationprogramme.nhs.uk.
The SJT tests attitudes, priorities, and professional behaviour, replicating as best it can the nuances and thought processes involved in making clinical decisions. You are asked to rank answers, e.g. in order of the most to least appropriate, or to select three appropriate responses from a list of eight.
Example questions are shown in Box 48.1.
Box 48.1 Example situational judgement tests
You are just finishing a busy shift on the Acute Assessment Unit (AAU). Your FY1 colleague who is due to replace you for the evening shift leaves a message with the nurse in charge that she will be 15–30 min late. There is only a 30-min overlap between your timetables to handover to your colleague. You need to leave on time as you have a social engagement to attend with your partner.
(1= most appropriate; 5= least appropriate.)
A. Make a list of the patients under your care on the AAU, detailing their outstanding issues, and leave this on the doctor's office noticeboard when your shift ends and then leave at the end of your shift.
B. Quickly go around each of the patients on the AAU, leaving an entry in the notes highlighting the major outstanding issues relating to each patient and then leave at the end of your shift.
C. Make a list of patients and outstanding investigations to give to your colleague as soon as she arrives.
D. Ask your registrar if you can leave a list of your patients and their outstanding issues with him to give to your colleague when she arrives and then leave at the end of your shift.
E. Leave a message for your partner explaining that you will be 30 min late.
Clearly this question is assessing professionalism and prioritizing clinical responsibilities over social concerns. It emphasizes the importance of face-to-face verbal handover rather than written notes. Although handing over jobs to your registrar may seem inappropriate, in the interest of patient safety it is preferable to leaving notes in this instance.
You review a patient on the surgical ward who has had an appendicectomy done earlier on the day. You write a prescription for strong painkillers. The staff nurse challenges your decision and refuses to give the medication to the patient.
A. Instruct the nurse to give the medication to the patient.
B. Discuss with the nurse why she disagrees with the prescription.
C. Ask a senior colleague for advice.
D. Complete a clinical incident form.
E. Cancel the prescription on the nurse's advice.
F. Arrange to speak to the nurse later to discuss your working relationship.
G. Write in the medical notes that the nurse has declined to give the medication.
The aim here is to assess your ability to interact effectively with colleagues in challenging situations, and also to recognize your limitations and accept your decisions being questioned.
Reproduced from http://sjt.foundationprogramme.nhs.uk/sample.
There are plenty of examples and a rich question bank available from Metcalfe D, Dev H (2018). Situational Judgement Test, 3rd ed. Oxford: Oxford University Press.