Core Surgery Applications - Part II The Interview

So, interviews have started this week for CST and sorry this post maybe late for some of you. The interview can be split into two parts which need to be prepped for:

a) The hard portfolio
b) The actual interview

The hard portfolio is a very important way to demonstrate all your skills, achievements and also your organisation. Its upto you whether you use a lever arch file with dividers or a book. Either way there are principles that you must follow and some tips to make your book look impressive:

1. Have a contents page and ensure dividers correspond with this
2. Organise your book in logical sections
3. Avoid bunching up lots of pages in one pocket, your portfolio should read like a book so that interviewers can quickly flick through
4. Include a recent copy of your CV after the contents
5. Ensure that you add any certificates for courses as well as your MBBS certificate etc...
6. Don't forget your GMC certificate, copy of your application form and anything else they mention on the website
7. Organise printouts from your e-portfolio into CEXs in one pocket, dops in one pocket etc with the most recent and flattering first! Also don't forget the minipats/msf print outs
8. If you can print copies of presentations/posters in colour then please do to make them stand out 
9. Don't forget teaching achievements!!!
10. If you have a record of the operations you have helped in/done so far that will also be impressive. As a non trainee you can register and use the Intercollegiate Surgical curriculum Portfolio "ISCP" (www.iscp.ac.uk). I recommend this as it shows that you are already familiar with the programme that they will use for all surgical training. It is also a very nice way to display your operative rcord (if you have one). Do not worry about absolute number of surgeries as they know that not everyone has had much exposure to surgery.
11. Be comfortable and prepared to reply to any question on anything in your portfolio!!

I have included pictures of my portfolio below to give you an example of how you can set one out if you're not sure where to begin.

The next bit is the actual interview. There are many books to help you prepare, the one I recommend is "

Medical Interviews: a comprehensive guide to CT, ST and Registrar interview skills - Over 120 medical interview questions, techniques and NHS topics explained". It has lots of good examples and basically goes through how to structure answers to questions. Also, this WEBSITE has some good free content.

First of all, turn up looking smart and clean as well as early. Make sure you have brought your portfolio as well as all the necessary paperwork including photocopy of front cover of your passport, photo ID, passport pics etc... Try not have a smoke (or drink) before hand ;)

My interview (in 2011 for the London Deanery at Lions court) was split into three sections:

CLINICAL STATION: 

please note. This is the most important station and weighted the most. I had two examiners and each gave me a scenario to answer.

• The first scenario was of an elderly woman post anterior resection 1 day ago. You are called to see her as she has a low urine output. It is important with this question to say you would firstly ensure that basic ALS principles are applied by ensuring patient was stable ie ABC... Then I said I would take a history and examine the patient to look for evidence of bleeding, infection, peritonism (think anastomotic leak) etc... Then look at the obs chart and look at trends for urine, fluid balance, BP, PR, temperature as well as latest bloods esp post-op. I would ensure patient is stable and let registrar and consultant know. You need to mention what possible differentials are going through your head and how you would exclude...
• The second Scenario was of a patient who rolled over in bed and came to A+E with a fractured humerus. BE ACREFUL AND LISTEN TO QUESTION AS I APPROACHED THIS AS A TRAUMA AS THOUGHT HE FELL BUT ITS NOT! Basically, on xray he ad luscent areas. You need to say you would suspect pathological fracture and screen for malignancy through history, exam and then can possibly send off tumour markers/myeloma screen etc... make sure you show them you know which tumours metastasise to bone and how you would check for them.
• Some of my friends got asked how they would manage a kid who came in with a supraconduylar fracture (must talk about risk of neurovascular compromise if displaced) as well as abdominal tenderness after falling off tree. In both these scenarios ATLS principles are important and ensuring you tell seniors early on (the latter point goes for everything)

MANAGEMENT STATION: 

This station was a tad disorganised. I was again given two scenarios to talk through.

• The first was that one of my F1's tells me that he felt persecuted by the Consultant. You have to show that you would be understanding and caring toward your colleague but also resepctful of the right channels to pursue. You would ask them why they feel bullied. If its because they don't have enough knowledge maybe you could offer to tutor them etc. Otherwise you would encourage them to discuss with their supervisor/pastoral mentor to get advise. You would act in a supporting role. Whatever you do, don't say you would tell them to "man up" - it doesn't go down well no matter how tempting...
• The next was how would I ago about organising the rota -  snooze fest! Basically you need to balance adequate training in terms of clinic, study leave, operating time with annual leave.   I spent a lot of time talking about annual leave, THEY WERE NOT IMPRESSED!! Basically rota also needs to be EWTD compliant so other ways you can ensure people get adequate training is by using simulators etc...

PORTFOLIO STATION:

By far, this was the nicest station although it is less weighted than the others. I had a panel of 4 judges and they had looked through my portfolio before-hand (you hand it in before your other stations start) and asked questions about my teaching (including plans I had for developing this blog and website :)). I was also asked:

• What speciality I want to do and why? (I mentioned plastics and also let them know that I am aware how competitive it is by rattling off some statistics on past numbers etc)
• How will I develop my CV to increase my chances of getting a number in plastics? 
• Other people where asked: what in their CV shows a dedication and commitment to medicine, teaching, why they chose that particular deanery...

Anyway, I hope some of this is useful and I will try and get some more info on his year's interviews to help next year's applicants. Good luck and remmebr to be confident, relaxed and know your porfolio/CV.

Journal Club - November

Hi all,

I was very impressed by the response to the first journal club paper. This month, I have chosen a paper that is very clinically relevant and addresses a common problem but management is often fraught with controversy. So this month's paper is:

J Bone Joint Surg Br. 2011 Oct;93(10):1362-6.

The non-operative functional management of patients with a rupture of the tendo Achillis leads to low rates of re-rupture.

Wallace RG, Heyes GJ, Michael AL.

I will pot my assessment in a few days time and would appreciate any input from you guys. Also if you would like to suggest any papers for next month, please go ahead! I would welcome input. FINALLY, I shall be putting up some posts on core training applications soon as well as more MRCS advice...

MRCS Part B - Stations from yester year

Now please note, these stations are just to help give you an idea of what kind of topics could come up in the exam. There is no guarantee that they will come up again or even if they do the format maybe different as the exam structure has recently changed. MRCS OSCEs are designed to test your core surgical knowledge and ability. If you revise the theoretical stuff and ensure that you get experience in going to a variety of outpatient clinics as well as scrubbing in regularly in the OR then you should not have any problems.

Hope these are useful and good luck!

Clinical Skills and History Taking 

1. Examine this ladies neck I started peripherally with a thyroid status exam, but the examiner prompted me to go directly to the neck. She was an afrocarribean lady with what I thought was bilateral parotid enlargement:

Q's
• Causes of symmetrical bilateral parotid enlargement
• What is most likely cause in her (sarcoidosis)
• He asked me about other manifestations outside the neck

2. Examine this lump on a man's back: 

Large lipoma- I examined including assessing for fixity to muscle, transillumenence, draining lymph nodes etc

Q's
• What muscle was it overlying
 • What is blood supply and lymph drainage of that muscle (was Lat Dorsi)
• To describe how you would excise this lipoma
• Consent patient for procedure

 3. HISTORY: 

Very simple history for likely colorectal Ca,

Q's
• RF for colorectal ca
• Difference in presentation for IBD and colorectal ca --> why is this change in bowel habit Crohns or UC
• How you would investigate him
• Why CT pneumocolon is inferior to colonoscopy (you can biopsy with latter)

 4. CVS Exam:

Patient had AS

Q's
• Other causes of ESM --Hypertrophic cardiomyopathy
• How to investigate to see if fit for surgery- ECHO to look at EF and gradient across valve
• Any important considerations for anaesthesia? No epidural, cause hypotension which can be compensated in AS due to fixed output state

5. Hx and brief resp exam 

Completely normal exam, history of long-standing panic disorders

Q's
• Would you pass this lady in pre-assessment for an elective cholecystectomy
• What are the ASA gradings? - what would she be?
• Can you think of ways to optomise her- SSRI trial

Anatomy (3):

1. Upper limb, prosection, live patient and skeleton all in one: Rapid fire 20 questions e.g- where is the insertion of supraspinator, (demonstrate on skeleton), demonstrate pronation and supination (live pt) point out long head of biceps (pro-section)

 2. Unmanned prosection of mediastinum and thorax in saggital section. Lots of flags- just had to identify the structures - was v hard !

3. Manned station- very easy, lower GI/ Hepatobillary -prosection of bowels- asked blood supply, significance of water shed area and marginal artery of drummond. Also was given a colonoscopy picture of bowel ca and asked to identify it. Then asked dukes classification. Then hepatobillary anatomy on another prosection Skills

(2): Taking blood cultures Important points: patient was there- there were marks for interacting.

If you spoke to her, she told you she was IVDU and Hep +ve, so u had to take appropriate cautions-eye protection, and noting it on the form for the lab. Change needles before you fill bottles, and fill aerobic first. Offer to label them.
Also they had an obs chart and it said she was Pen allergic.
They said she had a new murmur, and was spiking on obs chart and asked for a differential. I said that I wld query infective endocarditis, they asked organism, I said staph, and they asked me if I want to write up Abx- I did, VANC--> she was penn allergic which was the trick of the station.

Scrubbing Self explanatory

Other stations: 

Critical Care: Definitions of sepsis, septicaemia, septic shock etc. Asked for intepretation of a HDU chart, and generally where and how to ressucitate a patient in shock, ABCDE...

Comm skills- Calming an eratic mother whose son had been in accident in playground and was on the table for an emergency splenectomy. Had to tell her risk and complications, long term e.g immunizations. and she was questioning why he was taken to surgery without consent, so u had to to know the legislation that the doc act in interest of child if no consenting adult is available in an emergency Comm skills- Discharge summary.

Information Giving- Polytrauma patient, needed to read notes in prep station and call trauma surgeon at home who is on call. He just asked questions to see if you knew the ATLS guidelines, and about management of open fractures.

Information Receiving (written stations)
ECG: AF with fast ventricular response- asked to inteprate rate/ rhythm, about reversible causes, and treatment
CT- Bilateral pleural effusions in a pancreatitic- asked about ARDS, and glasgow scoring
Erect Chest X-Ray- Perforated viscus

There and back again (almost)

Ok so massive hiatus from the blog and website, I know and I apologise profusely. Its not that IWTBAS is not a huge priority for me, but I have had a lot of work to clear. So now that I managed to get into Core Surgery in London, passed USMLE Step 1 (and revising for 2CK), finished a Plastic Surgery Observership in the USA, completed 3 audits, implemented a DVT pathway at West Middlesex University hospital, written two case reports and finished off a meta-analysis, I am READY to get back to what's important! I will be regularly updating this blog and finishing www.iwanttobeasurgeon.com. So as a treat, the next post will contain some old stations from friends who sat the exam a couple of years ago and I will also scribble a few words on Core Surgery applications. Again, let me know what you would like to see more of in this blog and also on the site. Amel

MRCS stations October 2010

MRCS Station October 2010

I will be briefly talking about the stations I had in my MRCS part B OSCEs. I will Mention them in the order I faced each station.

My first station was scrubbing. There were two examiners inside the station, and one was acting as the nurse. The description stated that you can ask the "nurse" for anything you want him/her to do. The examiners check the hands under the UV light at the end to see if you had covered all the areas during scrubbing. During the scrubbing, I was quizzed on the advantage and disadvantages of chlorhexidine and iodine, and when I would use one over the other in surgery.

Critical care: essentially the same station described by Amel. I was quizzed on TURP syndrome. As I managed to get through all the questions, the anaesetists quizzed me further on pharmacology of furosemide, and Mannitol, the mechanism of action. They also asked about the indication for intubation in a patient (all covered in Kanani's critical care vivas).

Communication skills. 10 minutes to read some notes about a patient who fell down some stairs after a drunken night out. He sustained a splenic haematoma, and the plan mentions that he needs to stay in the hospital for few days. The task is to convince the patient not to self discharge. The patient is very adamant that he wants to leave. Just had to make sure that he was not under the influence of alcohol, and has capacity to make decision. No one in my circuit managed to convince him to stay.

Pathology: scenario of a patient who presents with fever, new onset cardiac murmur, and has a previous history of rheumatic fever. The discussion was around major and minor criteria of endocarditis, most common organism, and treatment. The discussion then went onto cardiac transplants, and side effects of immunosuppression. Very straight forward station.

Critical care: scenario of a patient who was trapped under collapsed building. Discussion was around ATLS management of trauma, rhabdomyolysis, hyperkalaemia(potassium from muscle getting into the circulation).

Anatomy (specialty). Trunk and thorax. Dissection specimen of abdomen. Asked to point out stomach, duodenum, and pancreas. The different parts of stomach, blood supply. The arteries that bleed in duodenal ulcer. Parts of pancreas, blood supply, function of pancreas (exocrine and endocrine). Blood supply to the colon.

Anatomy 2. Live model present. Asked to point out tibialis anterior tendon on person. Point out Achilles tendon, Extensor Hallucis Longus, and digitorum. Dorsalis pedis and posterior tibial pulse. Show what happens when tibialis andterior and posterior contract together (inversion of the ankle). Point out where peroneus longus attaches. Nerve supply of tibialis anterior, and peroneous longus. Show me where you would test sensation of superficial and deep peroneal, and sural nerve. Demonstrate ankle and knee jerk, and the nerve roots.

Anatomy 3. Dry skeleton. Asked to point out the different parts of the humerus, and sites where nerves can be damaged. Asked what lies around the radial nerve in the radial groove (lateral and medial head of triceps). Origin and insertion of rotator cuff muscle. The examiner pointed to the ASIS and asked me what that point is called, and asked what attaches there (sartorius). Asked which nerve gets compressed around there and what is the pathology called (meralgia paraesthetica). Asked about origin and insertion of quadratus femoris.

Clinical skills: catheterisation on a plastic model (with a live patient sitting on the other side). Quizzed on what I would do if I can't get the catheter in (try bigger size, in experienced hands introducer, or SPC if still can't catheterise. Then quizzed on management of a patient who presents with abdo pain, and tachycardia.they were describing a ruptured AAA case, and how you would manage the patient.



Round 2.

Cardiovascular examination. Patient had a pacemaker. Asked about what precautions I should take; ppm check, careful use of diathermy.

Comm skills2. 10 minutes to read notes about a RTA victim with pulseless leg. Task was to call the trauma consultant to come to hospital. Quizzed about ATLS, management of open fractures, compartment syndrome.

Comm skills 3. Assess cognition of a patient awaiting elective hip replacement. Patient has AMTS of 2/10. Asked what I would do; collateral history from family, GP etc. If new, then investigate cause for confusion. Postpone surgery for now as needs investigation of confusion.

Examination 1. Knee exam of a patient with relatively new arthroscopic ports. Tender medial and lateral compartments, and patient had crutches hidden behind bed. Differential diagnosis: OA, and rheumatoid, tests I would do (weight bearing x-rays, bloods). Finally management of knee pain.

Hernia and scrotal examination: patient with bilateral inguinal hernia, and a hydrocoele. Simple question on differential diagnoses of lump in groin/scrotum, and management of hernias.

Head and neck examination. Examine a patient who has pain in submandibular region pain on eating. I performed normal neck exam, and then bimanual examination of submandibular glands, I wasn't able to feel any abnormalities, and was a but worried that i may be missing something. The examiner then said to me "I appreciate this is a normal patient...but what would you find in a patient with similar symptoms" I breathed a sigh of relief and talked about submandibular calculi. Asked about what nerves can be damaged in submandibular gland surgery, and quizzed about anatomy of parotid gland.

History. Take a history of a patient with increased urinary frequency, hesitancy, and dribbling. Basic questions on management of BPH.

Critical care 3. Scenario of a patient who had a reversal of ileostomy 3 days ago, now has abdo distension, spiking temperatures. Asked about bowel obstruction, and anastomotic leak. Differentiating true obstruction from pseudo obstruction (no bowel sounds in pseudo, and tinkling In true obstruction).

History. Patient with back pain, and numb great toe. Probable disc protrusion and compression of nerve roots. Quizzed about cauda equina, and how I would manage this patient.

Overall, very fair and straightforward exam. The examiners are generally very nice and will help you work out the answer. There are lots of staff that take you from one floor to the other, so no chance of being lost. The exam however is very long and tiring.There is a break between each 9 station where you get coffee and biscuits.