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.

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

MRCS Courses

Enjoying watching the soccer this weekend but thought I'd give you the low down on the course I went on.

I found it super difficult to pck a course as very little info is available and because they are so expensive I felt more apprehensive about making a bad choice. AFter much debate and searching, I wittled it down to 3 course:
1) The St Thomas' 7 day course costing £1200. So ths course was highly recommended by my Reg because he said they got you to practise stations on real patients. However, as it is very popular, I couldn't get a place on he course.

2) The PASTEST MRCS revision course. Costs £799 and you also get the online revision course for free. This course is run over a weekend so its only 2 days. I didn't go as I wanted something longer. A riend went and said it was excellent. Apparently you get grilled all day as the course is mostly in OSCE format and you go around in circuits. He felt it was very useful.

3) The Royal College of Surgeons' Applied sciences for the MRCS course. This is a 5 day course at the Royal College in London and costs £1000. I went on this course and thought it was fantastic. They explained what the format of the exam would be like, taught anatomy on cadavers in small groups and gave lectures on pathology and critical care. There were also lectures and an opportunity to practise comm skills stations. I think the highlights of the course were the lectures on critical care (very comprehensive) and the anatomy demonstrations. You also get critical care viva and a physiology viva books for free. The two problems with the course is that it didn't cover clinical examination or neuroanatomy.

I don't think you need a course to pass the exam but the royal college course really helped me prepare as I was most concerned with anatomy and critical care. Much of the stuff covered on the course came up in one way or another on the course. Hope you found this useful and if you have any experiences of the other courses please share with us.

Amel

Post MRCS Part B

So I finally sat the OSCE on thursday and it was a very passable exam although I think I screwed up 2-3 of the stations and thus may lead to my failing the exam. However, results aren't till the end of June so I can still try and be mindlessly optimistic.

Anyway, for all those considering sitting the exam this winter (which will very likely include my self), I shall endeavour to give you as many tips and advise as necessary using my experiences. Over the next few weeks, I shall blog about the format of the exam, the level of detail questioning required as well as books, courses and other revision aids.

Firstly, the exam involves 18 stations in addition to two 10 minute rest stations whereby you sit by yourself in a cubicle and one twenty minute rest station separating the exam in two and during which everyone who has sat the same stations gathers and has tea. Of the 18 stations these are divided as follows:

1) Anatomy and pathology:
1x speciality anatomy station
2x generic anatomy stations
1x generic pathology station

2) Communication skills:
2x history on speciality topics
1x generic history
1x explain something to patient/relative (also has a 9 minute prep station whereby you read the notes)
1x communicate with a colleague over the phone (also has a prep station whereby you have 9 minutes to read notes and prepare)

3)Clinical skills and patient safety:
3x speciality topics- physical exam
1x generic system- physical exam
2x procedure e.g gloving/cannulation/blood cultures/excision of lesion

4)Critical care and physiology
1x manned station with imaging/results for interpretation
1x 2 manned station with a scenario and viva on critical care
1x manned station and viva on physiology and critical care

Ok so that's me done for now but watch this space for further info in the coming days and weeks.

Amel