HELPING YOU

INVESTOR THROUGHISSUE
NEWSLETTER YOUR CORE SURGICAL INTERVIEW
N°3 2017
FALL 2005

Core Surg ic al
Inter vi ew Guide 6th Edition

The Guide for the Core Surgical Interview

Core Surgical Training

Core Surgical Training in the UK Ranking for your CT1 job matters. If
you get a high enough rank to be given 2
i s a t wo ye a r p ro g r a m m e or 3 of the sub-specialities of your
SECTION 1 designed to provide junior choice, or indeed the themed job of your
CLINICAL choice, then you are setting yourself up
Past stations with mock answers surgeons with general operative
with a great chance at that ST3 number.
given at interview by candidates. skills, clinical experience of both If you just scrape into core training then
Advice on how to approach the acute and ward based surgical you have to take what you are given, and
question, communicate your may not be able to do your chosen
care, and to introduce trainees to
k n o w l e d g e e f f e c t i ve l y a n d
supplementary clinical a range of sub-specialities. By the
information to make revising for end of CT2 you will have
the clinical station easy completed 24 months in surgery,
a prerequisite for progression to
SECTION 2
PORTFOLIO ST3 level.
Optimise your portfolio and
make it stand out, and impress
The structure of training varies
your interviewers. Prepare for
the new format of the portfolio throughout the country but
s t a t i o n i n c l u d i n g p re p a re d normally comprises of 4 or 6
presentation station.
month rotations. These are
Supplementary questions from
recent inter views on your themed in some deaneries such as
specialty before ST3 interviews. Clearly
portfolio with advice on how to in Manchester where a core you would be at a disadvantage to the
best answer them trainee will do around 18 months candidate above who has already got 6
months of experience and project
of one speciality and 6 months of [Link] is why we encourage all
SECTION 3
MANAGEMENT another, or varied, like in London applicants to put every effort into
The dreaded management station preparing for the interview. It may be too
where you do 4 month rotations
made simple. Past stations with late now to publish another paper, but it
in CT1 and then two 6 month is not too late to polish your interview
useful structures that you can use
rotations in CT2, one of which technique, and read up on the topics
w h e n f a c e d w i t h d i f fi c u l t
commonly asked. The Core Surgical
questions. Our authors, who all will be the sub-speciality of you Interview Guide aims to make this
previously went through the choice. process easier for you by providing a
interview take you through structure with which you can answer
common questions, and advise questions, through in depth discussion of
you on how to score maximum At the end of Core Training you the questions that we were asked over the
points apply to Speciality Training, ST3- last few years.

ST8, which leads to a

ISBN: 978-0-9576100-3-3 We aim to demystify the core surgical
Certification of Completion of application, and provide relevant advice
Training (CCT), allowing you to on how to prepare for the interview. The
stations provided here follow the actual
become a Consultant. format you will experience at interview,

CORE SURGERY INTERVIEW GUIDE [Link]

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A P P L I C AT I O N GUIDE
CONTENTS PAGE

CONTENTS 105-108 How to structure your portfolio

3 About us 109 Writing the perfect Curriculum Vitae
CLINICAL STATION 110-111 Portfolio overview
4 Introduction to the clinical station 112-113 ePortfolio
5-8 Elderly woman with a fall 114 2 minute leadership biography
9-11 Painless haematuria 115 Publications, presentations and audit
12-14 Post operative pyrexia 116-117 Teaching and audit
15-17 Wound dehiscence 119-127 Commitment to specialty
18-20 Epistaxis 128-129 Research and audit
21-24 Loin pain 130-131 How to critique a paper
25-27 Bowel obstruction I
28-31 Bowel obstruction II MANAGEMENT STATION
32-34 Burns 132 Introduction to the management station
35-36 Slipped upper femoral epiphysis 133-134 Consultant appears drunk at work
37-39 Trauma 135 Conflict Resolution
41-42 Hip dislocation 136 Dealing with colleagues
43-45 Breakdown of anastomosis 137-138 WHO checklist
46-50 Abdominal pain 139-140 Risk stratification
51-53 Projectile vomiting 141-142 NCEPOD
54-57 Difficulty urinating 143 Sterilisation
58-60 A painful leg 144 Decision making
61-63 A neck lump 145-146 Rota dispute
64-67 Shin pain 147-148 Data Protection
68-70 Penetrating trauma 149 Nurse practitioners
71-73 Post CABG complications 150 European working time directive
74-77 Swollen testicle 151 Incidence and prevalence
78-79 Paediatric hernia 152 Screening
80-82 Epigastric pain I 153-154 Medical ethics
83-85 Child with a fracture 155 Statistics
86-88 Post operative confusion 156-157 Clinical governance
89-91 Wounds and dressings 158-159 Consent
92-95 Epigastric Pain II 160 Taking the initiative
96-98 RTA 161 Revalidation
99-100 Post operative assessment 162 Cancelled theatre list

PORTFOLIO STATION 164 CONCLUSION

101-104 Introduction to the portfolio station

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ABOUT US

We are a group of surgical trainees,

working in London. We have all been
through the Core Surgical application
process, all ranking highly, and all
successful in getting our top choice
jobs.
We began writing down some of the
questions and themes that have come
up in recent years, adding advice to
those applying in the future. The
result, is the Core Surgical Interview
Guide.
It did not exist when we applied and
the only way of getting this advice
was by asking those who had gone

INTRODUCTION score, they are separated by their ahead of the competition as you
application for m score. The walk into your interview.
National Recruitment application form therefore gives the
Standardisation of the interview
All core surgical training portfolio station panel another
means that no matter where you
applications are now centralised source of information to form their
are being interviewed they should
and run by via the [Link] questions from, but does not
be testing the same skill type, be
website. This means you only have necessarily contribute to your
that decision making, clinical
to submit one application. This ranking.
judgment or academic
portal is now used for all specialty
The centralisation of the achievement. Therefore you can
applications. Important
application process aims to make it learn from people who have been
information specifically about core
fairer by standardising selection through it before you, and predict
surgical applications can be found
across deaneries. The old boys’ the type of question you will be
at [Link]
network no longer influences who asked. They change the stations
2011/12 was the first year that gets in. Today, each application e a c h ye a r, a n d d u r i n g t h e
England, Wales, Scotland and form and interview question must interviews, from day to day, but
Ireland was accessed through a be validated to show that it truly is practicing similar stations is by far
single application process. In the selecting out the best candidates. the best way to prepare for your
application form you list your interview. The panels have a
The application form is relatively
deanery preferences.  Candidates moderately sized question bank of
straight forward compared to what
are guaranteed one interview at validated questions that they vary
you will be asked at ST3 level.
their top preference deanery. If you subtly from interview to interview.
However, it allows the deaneries to
are successful you will be contacted
place you into general categories. We have included sample interview
and requested to sub-preference the
Excellent, Good, Average, and questions here. They will not be
programmes/job combinations
Below Average. Do everything you exactly the same, as the deaneries
available. Core surgery posts are
can to ensure that you are in the may change them, however, we
allocated based on your overall
‘excellent’ category on your encourage you to practice them
ranking. This is based on your
application form so that you are more than once, to place yourself a
interview score. However if two
step closer to your CT1 job.
candidates have the same interview

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THE INTERVIEW

CLINICAL

CLINICAL STATION The clinical station consists of in an organised fashion. There is no

questions in a short case format, guarantee that any interviewee will
Introduction which form the basis of a general have covered a particular specialty
The clinical station of the interview discussion around the topic. The during their training to-date. The
process can cause most angst for number of questions that you are panel will be looking for a
applicants. How can you prepare asked will depend on how quickly candidate who can give accurate
for this without revising the whole you answer the questions and and confident answers, but also
of the oxford handbook? It is worth anecdotally at least, being asked someone who can be structured
33.3% of the marks available; the many, or very complex questions, and logical in their reasoning and
same weighting as the management especially towards the end of your presentation, as well as importantly,
and portfolio stations. It is feared station, means that you have done demonstrating that they are a ‘safe’
because for some this will be one of well and the panel are trying to doctor.
the first experiences of an oral differentiate a good candidate from
In one of the author’s interviews he
clinical examination Whilst a an excellent one.
was asked about orthopaedics, a
written examination allows you to
The questions will test your clinical speciality he had no experience of.
sieve through your thoughts to
knowledge and should be scenarios Despite this he did well as he was
reach a conclusion, oral
that are commonly encountered by able to answer the questions in a
ex a m i n at i o n s p re s s u r i s e t h e
a surgical SHO on call. It is sensible structured way.
candidate into immediately
unlikely therefore that you will be
revealing those thoughts. The key The interviewers are looking for
examined on very uncommon
to this station is therefore to take a logical, structured thinkers, who
presentations, injuries or diseases.
moment, answer questions clearly will be able to cope with the
You are assessed on the structure of
and logically, and practice, practice, demands of a surgical career, rather
your answers and your clinical
practice. The course will polish than a preformed surgical registrar.
knowledge. Structured answers,
your answers to the clinical That said, practicing the clinical
even when lacking some of the
scenarios rather than teach you the stations that commonly come up
more challenging clinical details or
knowledge required so try to read should allow you to prepare. We
differentials, will mark you out as
all the cases before hand. have included some of them here.
someone who thinks logically and

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Clinical Station
An elderly woman with a fall
You are called to A&E to see an 88 year old woman who was found lying on the floor halfway down the corridor
in her nursing home. At baseline, she has a poor level of mobility, only being able to mobilise around 15 yards
with zimmerframe. She does not recall having a fall, but another resident saw her trip and fall, holding her left
hip afterwards. She currently complains of pain in this hip and on examination the hip is shortened and
externally rotated. She is in some pain at rest, and this increased on attempts at passive movement of the hip.
On your general inspection, you note that she has a pacemaker in situ.

The following radiograph was performed by A&E.

What would be your assessment of this patient’s injury and her x-

ray?

The main differential diagnosis consistent with this presentation is a

fracture of the neck of femur and although I want to see two views,
the radiograph presented is consistent with an intertrochanteric
fracture of the left femur.

Supplementary note
The history could also suggest an anterior dislocation of the hip, which could cause a restricted range of motion
and pain on passive and active movement. However, only 10% of dislocations are anterior and whilst the limb is
externally rotated, it tends not to have the same degree of external rotation as in cases of neck of femur fracture.
A posterior dislocation, which would be more commonly sustained after this type of injury, the femur would be
shortened, but internally rotated, unlike this case.

What are the risk factors of this kind of injury?

This injury seems to have been associated with minor trauma according to the collateral history, which in the
majority of cases points to someone with weakened bone. (Most hip fractures in patients with physiologically
normal bone are the result of high velocity injury). The most common bony weakness is due to osteoporosis,
followed by metastatic deposits, metabolic bone diseases such as Paget’s and osteomalacia and more rarely,
osteomyelitis.

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Clinical Station
An elderly woman with a fall

How would you manage this patient initially?

I would assess and manage this patient according to the ATLS ABCDE protocol, making patient safety my
primary concern. She should receive adequate analgesia according to the WHO pain ladder. This is likely to
include the prudent use of opiates, taking into account her age and co-morbidities. I would also ensure that my
patient was suitably fluid resuscitated using either a colloid or crystalloid solution depending on local guidelines.
At this time she should have two wide bore cannulae in situ, bearing in mind the blood losses that can occur from
a femoral fracture. The neurovascular status of the leg should be assessed and documented before any
interventions take place. I would also make this patient ‘nil by mouth’, in anticipation of a surgical intervention,
at this time I would ensure she had maintenance fluid prescribed. In the meantime, her leg should be placed in a
‘foam gutter splint’ for comfort and to reduce the risk of pressure sores. As she will have reduced mobility for a
period of time, she should have mechanical and chemical thromboprophylaxis; TED stocking and low molecular
weight heparin, unless contraindicated.

What investigations would you order for this patient and what role would they have in your management?

Important bedside investigations include a urine dip to check for signs of a urinary tract infection, which could
precipitate a fall in the elderly. I would order two views of the affected bone or joint. In this case, I would order
an AP pelvis, and a lateral right hip x-ray and full length femoral views. Pre-operative work up of this patient
would include full history and examination, importantly determining the nature of the fall (mechanical or
secondary to an underlying pathology), any co-morbidities, and the identification of any additional injuries.I
would take routine bloods and add a clotting screen and a cross match of two units of blood. Depending on the
length of time the patient was on the floor, a creatinine kinase may be indicated. I would also order an ECG and
CXR as this would help in my assessment of this patient’s anaesthetic risk and identification of underlying
pathology that may impact on their ASA classification. I would also request a pre-operative pacemaker check.

What would be the surgical management options for an intertrochanteric fracture?

I would manage this type of injury with a dynamic hip screw, followed by fluoroscopic images taken throughout
the repair to ensure the maintenance of the fracture in satisfactory reduction and proper positioning of the
fixation device.

Supplementary information
Intertrochanteric fractures are inferior to the joint capsule and lie in the plane between the greater and lesser
trochanter. Despite a reportedly acceptable rate of healing rate with conservative methods, surgical intervention
has replaced previously prevalent methods of prolonged bed rest and traction in a spica cast, each of which also
carry their own risks. Surgical intervention is now most common.

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Clinical Station
An elderly woman with a fall

What additional complications can result from intracapsular fractures of the femoral head and how would you
manage one of these injuries?

The femoral head in the adult has a retrograde blood supply with blood vessels running from the capsule and
along the femoral neck. Displacement of the femoral head and traumatic disruption of the capsule can cause a
disruption of this vasculature. This can lead to the problems of avascular necrosis of the femoral head, as well as
malunion.
Treatment options vary, depending on the age and mobility level of the patient. I would take a full patient and
collateral history concerning premorbid state and level of function. If she had limited mobility before sustaining
the fracture, I would look to perform a hemiarthroplasty. I would have a choice of cemented and uncemented
methods of securing the implant to the femoral shaft. This method would allow early mobilisation once her pain
score allowed it and I would ensure that appropriate post operative analgesia was prescribed to this end.
Functional outcome of hemiarthroplasty in patients with limited mobility tends to be satisfactory. I would ensure
that thromboprophylaxis was not forgotten, as the risk of venous thrombosis, possibly with progression to
pulmonary embolism, would be considerable.

How would your management differ in a younger, more active patient?

Intracapsular injuries in young patients would be more commonly associated with

high impact injuries such as RTA and sporting injuries. My initial management
would be to assure haemodynamic stability using an ABCD approach, with
assessment of the airway, breathing and circulation before consideration of bony
or ligamentous injury. I would proceed to open reduction and internal fixation
once the patient was cardiovascularly stable. I would also note that the incidence
of AVN in younger patients are considerable, with some studies noting rates of
up to 20% and ensure that this was explained to the patient and included on their
consent form.

Supplementary Information

You should be familiar with Garden’s classification of fractures. This is the classic method of neck of femur
fracture description, although it is becoming outdated
Type I: stable fracture with valgus impaction
Type II: Non displaced, complete fracture
Type III: Displaced fracture with maintenance of ‘end to end’ contact between the two bony fractures
Type IV: Completely displaced fracture with no contact between bony fragments
Type III and IV are associated with an increased incidence of AVN

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Clinical Station
An elderly woman with a fall

Management can be remembered easily - 1,2 screw (fixation with a

cannulated screw), 3,4 Austin Moore (or rather they will normally
require hemiarthroplasty to avoid AVN)

Sub-trochanteric fractures occur through or distal to the

trochanteric line in a transverse orientation. These are not
manageable by plate fixation, but are commonly managed with
intramedullary nailing. Rehabilitation and thrombosis prophylaxis
are as previously described.

Advice

The danger this question, where you may have some knowledge and experience, is the temptation to tell the
examiner all that you know about neck of femur fractures in general, rather than answering the question posed.
In this example, the case surrounds a plain film of an intertrochanteric fracture and the specific management of
this injury. You should answer the question you are asked and then stop. If they want more the examiner will ask
further questions. It is best to be guided by them, rather than trying to include all the knowledge you in an
answer, as you need to focus on where the points are. Examiners are generally helpful and will ask you a more
focused question if you have not scored all the points.

One strength of this answer is the appropriate exhibition of further reading of current literature, with regards to
the rates of AVN in young patients with neck of femur fractures. If you can include something similar in your
answer you will mark yourself out as one of the top candidates. Only do so if it flows naturally from your answer.
However, do not forget the importance of covering the important aspects of what you actually would do as an
SHO; a full history and examination, ensuring that the patient is haemodynamically stable, appropriate
investigations , prescription of analgesia and LMWH etc... These are equally important, give structure to your
answer, and show that you have actually been on the wards and will be a safe surgeon.

Here we have included extra information in the answers for your information. The examiner may wish to have a
more unstructured discussion about a topic, especially if it concerns his/her specialty. In this case, the examiner
is probably trying to stretch you, and it is your opportunity to distinguish yourself as an excellent, rather than just
a good candidate.

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Clinical Station
Painless Haematuria
You are asked to see a 69 year man who has been referred from his GP with painless macroscopic haematuria
with some clots. He denies urinary frequency or dysuria, but has noticed around 7kg of unintentional weight loss
over the past 4 months. He worked in a chemicals factory for 25 years, but is now retired. He has an 80 pack year
history.

What would be your differential diagnosis?

Painless haematuria in an individual of this age, and with a history of unintentional weight loss often suggests an
underlying malignancy; Frank haematuria has a 20% rate of revealing a urological malignancy. My main
differential would be bladder cancer, especially given the additional detail about the gentleman having worked in
a chemicals factory for 25 years. His history of smoking and occupational exposure to chemicals such as amines
from the textiles industry are known risk factors for transitional cell bladder cancer. Notably, 90% of bladder
cancers present with haematuria.

I would also consider renal carcinoma. This would classically be associated with loin pain +/- an abdominal
mass and I would take a more detailed history and fully examine the patient to fully assess this likelihood. There
is a possibility that this could be prostatic in origin or related to a bladder stone, but these often would be related
to microscopic, rather than macroscopic haematuria. Cystitis would also be a possible cause of this bleeding, but
was be less likely given the patient’s gender, as well as his lack of dysuria and urinary frequency.
Pain is usually associated with an inflammatory process and its absence in this case would make a renal or
bladder stone less likely and the length of the history together with weight loss point away from infection as a
cause.

How would you examine this patient?

Patient safety is my primary concern, and I would assess the patient clinically using the ABCDE protocol. I
would determine the extent of blood loss and ensure that the patient was haemodynamically stable. I would
complete with an examination to exclude abdominal and suprapubic masses and a digital rectal examination to
examine the prostate. One would also palpate for the bladder to assess for retention, as blood clots (or a tumour)
may cause an outflow obstruction. In this case a wide bore urinary catheter with the option for saline irrigation
may be indicated.

What investigations would you arrange for this patient?

I would perform a bedside urine dipstick test to confirm the presence of blood and subsequent urine microscopy
test to rule out infection. Microscopy may also identify malignant cells.
(Urine tests allow an initial assessment of the risk of urological malignancy, however overall sensitivity is less than
75% for medium and low grade tumours.)

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Clinical Station
Painless Haematuria
CT KUB, or intravenous urogram (IVU) in some hospitals, will identify the structure and function of the urinary
tract, as well as identifying stones in either ureter, while ultrasonography will allow visualisation of the renal
parenchyma.

Flexible or rigid cystoscopy under general anaesthetic currently represents the gold standard in assessment of the
structure of the bladder and would allow identification and treatment of a bleeding site, along with a biopsy or
resection if necessary for histological diagnosis.

If a tumour was identified in the urological tract, a computed tomography (CT) staging scan would be
appropriate to assess the extent of muscular invasion and any metastatic spread.

What would be the treatment if bladder cancer was identified?

It is important to involve the MDT in all cases of malignancy, and of course, all options should be discussed with
the patient. Following appropriate imaging, a transurethral excision may be carried out. CT scanning would
allow staging and identification of distant metastases, with further treatment options dependent on staging.

Supplementary information
Low grade tumours are treated by transurethral resection of bladder tumour (TURBT) followed by long term
outpatient cystoscopy screening. High grade tumours are also managed by TURBT if possible, followed by
chemotherapy, for instance single dose of intravesical chemotherapy or a weekly dose for 6 weeks after surgical
procedure. All such decisions are made after discussion between surgical and oncological teams in the uro-
oncology MDT.

Invasive bladder cancer (T1-T4) can be managed by partial or radical cystectomy with pelvic lymphadenectomy
and urinary diversion (either continent or incontinent), external beam bladder irradiation or systemic
chemotherapy. Metastatic bladder cancer (as identified by CT scan) would be primarily managed by a cisplatin
based chemotherapy regimen. It would be essential to start this as soon as possible, as untreated metastatic cancer
has a 2-year survival rate of less than 5%.

How would you decide which patients to refer to urology?

I would refer any patient above the age of 50 years presenting with microscopic haematuria or patients of any
age with frank haematuria for specialist urology opinion to exclude the possibility of urological malignancy.

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Clinical Station
Painless Haematuria
Supplementary Information

Staging of Bladder Cancer

The classical TNM system can be combined to calculate an overall cancer stage. Bladder cancers are staged from
I to IV, from least to most serious.

Stage

Stage 0a Non invasive papillary carcinoma with no invasion into bladder connective tissue or the muscle of the
(T0, N0, M0) bladder wall. No lymph node or distant spread
Stage I Carcinoma spread into the layer of connective tissue under the lining layer of the bladder but no
(T1, NO, M0) bladder invasion. No lymph nodes or distant sites.
Stage II Carcinoma spread into bladder muscle wall, but no breach of the muscular layer into fatty layer
(T2a or T2b, surrounding the bladder. No lymph nodes or distant sites
N0, M0)

Stage III Carcinoma spread through the bladder muscular wall into surrounding fatty tissue. Possible prostatic,
(T3a, T3b, uterine and vaginal spread. No pelvic or abdominal wall spread. No lymph node or distal spread.
T4a, N0, M0)

Stage IV (T4b, N0, M0): Carcinoma growth through bladder muscular wall and into the pelvic or abdominal
wall. No lymph node or distal spread.
(Any T, N1-3,M0) Carcinoma spread to nearby lymph nodes (N1-3), but no distal spread
(Any T,any N,M1) Spread to distal sites, such as lungs, liver or bone (M1)

Advice

You do not need to remember the details of the TMN classification of bladder cancer, but be aware of how if
influences management. This answer concentrates on the differential diagnosis as appropriate for the history.
When answering questions on differential diagnoses it is important to be specific, and not list every differential
you know. However, concentration on the details of the case, namely the occupational and smoking history, as
well as gender, allows you to be more specific. While cystitis is a legitimate cause of macroscopic haematuria, to
mention it before urological malignancies would show an absence of logical thinking and perhaps would signal
that if you were faced with this case as an admitting CT1 doctor, there could be some delay in initiating
necessary investigations to identify and treat malignancy.

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Clinical Station
Post operative pyrexia
You are asked to see a 67 year old with a 40 pack year smoking history and a previous diagnosis of COPD. He is
one day post repair of a strangulated, indirect, right inguino-scrotal hernia. He has a productive cough and a
temperature of between 37.9 degrees and 38.6 degrees over the past 8 hours. He is tachycardic at a rate of
110bpm and has a respiratory rate of 21 with saturations of 96%. His pain score is 5/10.

What is the most likely cause of this gentleman’s tachypnoea, pyrexia and tachycardia?

The most likely cause is a postoperative pulmonary atelectasis secondary to the accumulation of mucus secretions
in the bronchial tree. This is a risk after any intra-abdomial or thoracic surgery, where coughing will exacerbate
pain by increasing intra cavity pressures. The risk is magnified in patients with pre-existing pulmonary disease.
Pyrexia so soon after surgery is unlikely to be due to wound infection, however a pneumonia, pulmonary
embolism and DVT should be considered. In addition, other sources of infection such as a UTI, perhaps from an
indwelling catheter, cellulitis, pressure sore or other open wounds should be in one’s mind, and a comprehensive
examination would aim to identify these.

Which factors could be responsible for these complications?

Pre-operative factors include his pack year history and prior diagnosis of COPD which would contribute to
excess mucus production and collection in his bronchial tree and would reduce his functional respiratory reserve
and effective alveolar exchange surface. A smoking history also makes him more susceptible to infection.

Peri-operative factors, such as the gases used in a general anaesthetic and intubation irritate the respiratory
mucosa and increase mucus secretion from mucosal goblet cells, as well as a small amount of oedema as a post
inflammatory response to the endotracheal tube. The muscle relaxant used in general anaesthesia can reduce
post operative inspiratory effort. Being mechanically ventilated causes alveolar barotrauma, making one more
susceptible to alveolar collapse. Lying prone for the operation can result in a ventilation/perfusion mismatch,
increasing the likelihood of atelectasis. If the procedure involved laparoscopy, then the insufflation of CO2 results
in a splinting of the diaphragm and reduced ventilation to the lung bases.

Post operatively, the pain of the groin incision, lying prone, increased sedation and reduced mobility could inhibit
clearance of the accumulated secretions, increasing the likelihood of alveolar [Link] addition, the chances of
developing aspiration pneumonia, are increased. This most commonly occurs 5 days post operatively.

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Clinical Station
Post operative pyrexia
Advice
It is appropriate to group risk factors into pre-operative, operative and post operative providing a good structure
to hang your answer on. Remember: “categorise to survive!”

How would you examine this patient and how would you proceed to management?

I would start by ensuring that the patient was haemodynamically stable with assessment of the airway, breathing
and circulation following ALS principles. If the patient was speaking to me, I would consider his airway as being
patent. I would percuss and auscultate the chest and carefully inspect for use of accessory muscles, signalling
respiratory distress. I would assess the patients pulse and BP and look for a raised JVP, which could be a sign of
congestive cardiac failure secondary to an MI.

If I was worried about the patient’s current clinical state, I would contact my registrar, preferably from the
operating team, to review the patient. I would ensure that the patient had two wide more cannulae in situ, with
fluids running as necessary. I would request a chest x-ray and review the most recent blood results, including
inflammatory markers and sputum culture for the patient. I would also take an arterial blood gas (ABG) and send
blood cultures and an MSU and blood cultures. It is important to send these before starting any antibiotic
therapy.
I would monitor the patient’s saturations and if below his pre-morbid baseline in the medical notes, would start
low dose oxygen by nasal cannula, taking care of the history of COPD and the importance of not suppressing
the hypoxic drive and worsening his symptoms. In the acute setting I would prioritise satisfactory oxygenation,
but monitor for CO2 retention by repeating an ABG 30 minutes after commencing oxygen.
If I suspected pulmonary embolism was the diagnosis, I would organise a CTPA. (A d-dimer blood test would be
of limited use as a raised result may represent generalised inflammation post operatively, rather than a
thromboembolism.)

It is important to involve the respiratory physiotherapy team early in this patient’s management. Vigorous
breathing exercises and chest percussion would clear secretions. I would review his analgesia and if necessary
liaise with the pain team, as managing his pain more effectively encourages a more effective cough. This could be
managed by regular oral analgesia or patient controlled analgesia (PCA) as required. Finally, if the blood results
or cultures suggested any signs of infection, I would commence antibiotics according to local protocol, after
taking appropriate microbiology guidance.
If I were particularly concerned about his oxygenation, it may be prudent to contact the ITU outreach team or
anaesthetic registrar for advice ± review.

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Clinical Station
Post operative pyrexia
Advice

It is important to answer the question asked of you. On this occasion the question is “what is the most likely
cause of this gentleman’s symptoms”. Therefore begin your answer by saying the most likely cause and your
reasonings. You can then go on to talk about important differential diagnoses to consider, and the examiner can
stop you if this won’t score you any points.
This is a fairly typical presentation that will be managed initially by many FY1s post operatively. The difficulty in
this question is answering in a systematic manner. It is useful when asked about complications post surgery to
categorise your answer. In this case, we have used pre-operative (intrinsic to the patient him/herself), peri-
operative and post operative. This lets the examiner know that you are a logical thinker, and acts as a memory
aid. You will find that you build up a bank of these aide memoirs and that your answers become more structured,
the more you practice using them. There are more examples of these throughout this guide. Do not forget to
mention that you would contact your seniors in a situation such as this. It may sound straightforward, but it is
good practice to contact senior support early on, even if you will be managing the case mostly by yourself in the
early stages, your seniors should be aware of any concerning cases on their take. The multidisciplinary team has
become an integral part of our practice, so mention it when appropriate, including keeping the ward nurses up to
date so that they can help you hang fluids, will take more regular observations etc... It shows that you are on your
way to becoming a rounded surgeon and a good team member.
One of the key factors the examiners are looking for is a good SHO who is not only being able to manage cases
with the knowledge that you have, but also to be able to call in the help of other health care professionals when
needed and to be aware of limitations.

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Clinical Station
Abdominal pain
You are the surgical SHO on call. You are referred a 35 year old gentleman complaining of severe and
unremitting peri-umbilical pain, which started very suddenly whilst at work around 4 hours previously. He
assesses the severity as 10/10. He has felt well recently and has no history of fever, nausea, vomiting, night sweats
or change in bowel habit.

He occasionally suffers from ‘heartburn’, but this is relieved by a glass of milk before bed. He has not seen his GP
for this problem. On this occasion, a glass of milk and an antacid have not given any symptom relief. He smokes
15 cigarettes/day and consumes 10-12 pints of beer per week.

His observations are as follows: BP: 120/75 P: 115 T: 37.9 deg

What are your differential diagnoses?

Peptic ulcer disease would be my leading differential diagnosis due to his gender, smoking and alcohol history. His
previous symptoms are suggestive of gastric reflux could indicate acid hypersecretion, which would increase his
risk of peptic ulcer formation.
The acute onset of severe central abdominal pain suggests that this patient may have a perforated viscus,
secondary to peptic ulcer disease.

I would of course consider other common causes of abdominal pain in this age group such as appendicitis,
cholecystitis, nephrolithiasis, genitourinary infection or testicular torsion.

How would you proceed with this patient?

I would ensure that the patient was stable, assessing him according to the ALS ABC principles and take a history
from the patient. I would complete a full examination, focussing on the abdominal examination. Bedside tests
would include an ECG (to exclude a cardiac origin for the pain, especially with a known history of ‘heartburn’
pain), basic observations and urinalysis.

I would order blood tests including a full blood count, urea & electrolytes, liver function tests and C-Reactive
Protein. I would order an erect chest xray to exclude a perforated viscus and a plain abdominal film to look for
radiological signs of abdominal obstruction. I would take an arterial blood gas to look for a raised lactate and
consider further imaging such as a FAST (Focussed Abdominal Sonography in Trauma) scan or a CT abdomen
depending on the results of other investigations.

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Clinical Station
Abdominal pain
Explain your rationale for carrying out these investigations?

ABG Lactate – important marker of infection, particularly intraabdominal sepsis, as well as

tissue ischaemia

FBC Low Hb from a subacute or chronic GI bleed

Raised WBC in infection
U&Es Indication of renal obstruction
For baseline – especially if considering using contrast for CT
CRP Marker of inflammation/infection

LFTs Indication of biliary obstruction (raised alkaline phosphatase)

Acute hepatitis – raised ALT
Clotting Sepsis can cause deranged clotting

G&S In preparation if patient needs to go to theatre

Urinalysis Blood – UTI/nephrolithiasis
WBC – UTI/nephrolithiasis/pyelonephritis
(You are more likely to be asked about one or two tests but for the purpose of revision this table is useful)

What would you do if the patient was unable to sit up straight for the erect chest X-ray?

I would always try to get an erect CXR as it is a rapid way to visualise free air on plain film. However, if this was
not possible, a left lateral decubitus film (left side down) could be used to demonstrate free air between the liver
and lateral abdominal wall.

Your examination reveals a diffusely tense abdomen with guarding in the epigastrium. There is no renal angle
tenderness. Your x-ray has appeared on PACS.

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Clinical Station
Abdominal pain
What does the X-ray show?

This is an erect chest radiograph, in with the patient is partially

rotated. Free air is seen between the right hemi-diaphragm and
the liver. This image, in combination with the associated history
and presentation, would make a diagnosis of perforated peptic
ulcer most likely.

How would you proceed to manage this patient?

I would ask the on-call surgical registrar to review the patient as a matter of urgency, highlighting my concerns
regarding the likely diagnosis of perforated peptic ulcer and the current condition of the patient. I would put
high flow oxygen in place. I would ensure that the patient had two wide bore cannulae in situ. I would start
intravenous analgesia, based on the WHO pain ladder, starting with IV paracetamol, (in the absence of allergy).
I would start IV fluid resuscitation therapy, titrated to blood pressure, with a 500ml gelofusine fluid challenge if
the patient was clinically shocked followed by 4-6 hourly ‘normal’ saline or Hartmann’s solution if there was
satisfactory response to this challenge. I would insert a nasogastric tube to decompress the stomach and a foley
catheter to enable measurement of urine output.

I would take blood cultures before commencing broad spectrum antibiotics according to local protocol for intra
abdominal sepsis. In some cases, a central line could be necessary to assess intravascular fluid status. I would
discuss this with the surgical registrar on call. Aware that the patient could require surgical intervention, I would
make the patient ‘nil by mouth’ and ensure that a group and save blood test had been sent. After discussion with
a senior colleague, I would also discuss the patient with the anaesthetic registrar and theatre staff to alert them to
a possible impending emergency laparotomy. Should my senior think this was necessary, I would consent the
patient for the procedure (or provide the paperwork for the registrar) to ensure no delay to the operation.

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Clinical Station
Abdominal pain
Which features determine operative mortality?

Operative mortality in a patient with peptic perforation depends on four major risk factors:

• Length of time from perforation to admission

• Age
• Medical co-morbidity
• Hypovolaemia on admission

Do you know of any national or international guidelines for the management of sepsis?

The surviving sepsis campaign is a programme introduced by the European Society of Intensive Care
Medicine, aiming to increase awareness, understanding and knowledge surrounding the treatment of sepsis. Its
overarching aim is to reduce the mortality associated with sepsis by 25% (from 2009). The premise is that this can
be achieved by early recognition of septic patients, more targeted allocation of resources and setting clear goals.

These include:

• Time from A&E admission to presumptive diagnosis of severe sepsis <2 hours
• Time from A&E admission a presumptive diagnosis of severe sepsis having a lactate blood test < 4 hours
• Time from A&E admission to appropriate antibiotics less than 4 hours
• Blood cultures taken before the administration of antibiotics - to increase the likelihood of identifying an
organism and therefore appropriately targeting antibiotic prescription.
• If hypotensive or if lactate greater than 4.0mmol, immediate fluid resuscitation is started (at least 30 mL/kg
normal saline or Hartmann’s solution within one hour)

Supplementary information

Some authors have suggested that in patients with perforation, but without radiological evidence of
pneumoperitoneum, conservative management is indicated as the perforation can be assumed to have ‘sealed off ’
independently. The majority of centres advocate surgical management in cases with both peritonism and
pneumoperitoneum.

Despite strong arguments favouring nonoperative treatment of patients with perforated PUD without free air,
delaying the initiation of surgery more than 12 hours after presentation has been demonstrated to worsen
outcome. Therefore, when indicated, a laparotomy should be performed as soon as possible. The choice of
operative procedure would depend on variables such as the presence of hypovolaemic or septic shock, the degree
of peritonitis and evidence or history of chronic peptic ulceration. Laparoscopic procedures have been more

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Clinical Station
Abdominal pain
recently described. However, in the presence of significant co-morbidity or severe intra-abdominal sepsis, the
classical management is repair of the perforation with an omental (Graham) patch via upper midline laparotomy.

In patients with a prior ulcer history and without significant co-morbidity or systemic upset, a definitive ‘anti-
ulcer’ operation could be indicated to reduce recurrence rates. For a perforated duodenal ulcer (DU), this could
include a highly selective (parietal cell) vagotomy, truncal vagotomy with pyloroplasty or vagotomy with
antrectomy. In a stable patient, the ulcer would be excised and sent for frozen section analysis to exclude
malignancy.

For a benign gastric ulcer, a distal gastrectomy with either a Billroth I gastroduodenostomy or a Billroth II
gastroduodenostomy would be most appropriate. This would carry significant morbidity and not be indicated in
the acute setting.

Recurrence Rates
Any procedure that preserves vagal innervation or antral gastrin production can lead to recurrence. Recurrence
rates for various operative techniques are as follows:

• Highly selective vagotomy: 5-20 %

• Vagotomy with pyloroplasty 10-15%
• Vagotomy with antrectomy <2%

Definition of sepsis
([Link])
Documented or suspected infection with one or more of the following:

hypothermia/pyrexia core temperature <36degrees/>38.3 degrees

increased heart rate >90bpm

tachyopnoea

altered mental status

oedema or positive fluid balance >20ml/kg over 24hrs

hyperglycaemia in the absence of diabetes plasma glucose >120mg/dl

leucocytosis or leucopenia WBC >12,000/uL or <4,000/uL

raised CRP

raised procalcitonin

increased O2 requirement SvO2 >70%

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THE INTERVIEW

PORTFOLIO

PORTFOLIO STATION through the answers you gave in marks. A well structured and
Introduction the application form, through organised portfolio allows the
assessment of your portfolio and interviewer to quickly find the
through your answers to the relevant information. We provide
Your portfolio is a key piece of
interviewers questions. Compared a guide to the portfolio below,
the interview process. It is like an
to previous years there is now a which you should take time to
extended CV, a chance to
much heavier focus on the drop review. Candidates who attend
demonstrate your achievements
down questions from your our interview course will get the
during your medical school,
application. Essentially the chance to see how the portfolios
foundation years and beyond.
interview is tasked with assessing of the top ranking candidates
Surgical applications at CT1 level
the evidence you have to back up f r o m p r e v i o u s ye a r s w e r e
are increasingly competitive and those achievements. structured, and have their
you will be competing against portfolio personally assessed by
your peers who will have similar Before the start of the interview, the same candidates. There’s
aims. portfolios are collected so that the always room for improvement, so
Your portfolio station is worth interviewers can mark them if you don’t get a place on the
33.3% of the total marks for your against a standardised scoring course, make sure that you show
interview as a whole. In 2015 a sheet. This mark combined with a your portfolio to a senior surgeon,
pilot leadership skills presentation score generated from your and to a good trainee who has
was run. This is expected to be portfolio and your answers to the recently been through the
formally included in 2017. Its a questions in the station give a interview.
great opportunity to showcase total score.
yourself - as long as you are The questions asked during your
The job of the interviewer is a portfolio station are designed to
properly prepared.
difficult one as they have a very allow you to show the interviewers
The role of the portfolio station is limited amount of time to go the evidence they might not have
to assess your achievements to through your portfolio and your found themselves.
date. Assessment is threefold; task is to help them give you the

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Introduction

In 2015 a leadership presentation pilot was run. Each applicant was required to present a pre-prepared (non
powerpoint) 2 minute leadership biography This was followed by 3 minutes of questioning by the panel. In 2017
it is expected (at the time this went to press) that this pilot would become a formal part of the station for 2017.

It is essential that you know your portfolio well and can turn to the relevant section quickly. During the course,
you should be prepared to do this under pressure during both the small group sessions, and the mock interviews.

Here’s one candidates experience of the portfolio station last year.

“During my interview, there were 2 very friendly interviewers which helped calm my nerves. They had already
gone through my portfolio and marked some components on their marking sheet. One of the first questions they
asked me was ‘’I see you have attended a number of courses such as the BSS, ALS and ATLS which are very
good but why have you not done the CCrISP course?’’. Not really a question I was expecting so I have not
rehearsed an answer for this. I answered truthfully and explained how I did try to attend the course however was
let down by many institutions as core surgical trainees were given priority to attend the course:

‘’I understand the CCrISP course is a very useful course to attend for surgical trainees as it trains trainees on how
to deal with sick surgical patients efficiently which is an essential skill to have. Hence I contacted many
institutions to book a place for myself on the course however at most I was put on the waiting list as priorities
were given to core surgical trainees and I was a foundation trainee when I applied. Places were also very limited
on the CCrISP course. Although I did not manage to get myself onto the course, I have borrowed the CCrISP
manual from the hospital library which I have found very useful. I also plan on attending the course as soon as I
start my training as a core surgical trainee.’’

The interviewers responded in a very understanding manner. They said that this is a very common problem
faced by foundation doctors who are interested in attending the CCrISP course and that the college should think
of a way to overcome this. I was then asked:

‘’You have many done audits and presentations which are good. But how and what do you think you could
improve in your CV?’’

At that particular moment, as a foundation year 2 trainee who has just recently figured out what I would like to
do for the rest of my life i.e. surgery, I could think of a million ways of how to improve my CV.

I thought about the question for a while and decided to answer this question in a similar way I would talk
through my CV which is in order of the mnemonic CAMP (clinical, academic, management, personal) but
modifying my answer to suit the question at hand:

‘’There are many ways I can improve my CV. As a trainee pursuing surgery, clinically, I will try my best to spend
more time in the operating theatre to gain more experience and increase the number of my logbook entries. At
the same time I will ensure that my clinical duties in the ward are not compromised and that there is adequate
cover while I am in theatre. I will also get as many work-based assessments completed as possible with

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Other information

Other Information

Your extracurricular pursuits are valid and should form part of your portfolio. They show that you are a rounded
individual and that you recognise the importance of work life balance. Remember that this all forms part of an
interview process and that your portfolio will be read by the panel. If you have performed at a high sporting level
or achieved an impressive distinction in music or the arts, include evidence of this. This could be a certificate or a
programme from your last performance. Remember that your portfolio should look professional and that the
information that you are presenting will form part of an overall impression of what you will be like as a surgical
trainee and ultimately as a potential future colleague.

Allocate sufficient time to getting your portfolio together, it takes a lot longer than you think. Its probably best to
start by searching for all the certificates, posters and power point presentations that you wish to include, and
seeking out the inevitable missing ones. Next, put the different sections together as we have suggested, using an
old file, but one that will not cause any damage to your documents. Once a section is complete, order it with the
most impressive first. At this stage you can draft a summary sheet for the sections like publications, and a sub
contents page for the others sections. Once your portfolio is starting to look near completion, then take a trip to
WHSmiths or equivalent after calculating what you need and buy the high quality stuff. This portfolio will soon
become your most prized possession, sad but true, more valuable than your laptop, girl/boyfriend combined. You
do not want to lose it. So, keep it somewhere safe, where someone else isn’t going to pick up and drop spill tea on
etc and try to keep it in perfect condition until the big day. Photocopy everything and keep the copies in a
separate place - believe us, once you’ve spent hours tracking everything down, you’ll never want to have to do it
again!

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Portfolio Station
Commitment to Speciality

Why Surgery?

Surgical training is hard, but rewarding. It commonly will last up 8 years or more and this part of the interview is
designed to ensure that you have fully thought about your choice of a surgical career. All applicants will be keen
to convince the panel of their dedication, but what can you do to set yourself apart from other candidates? Most
of the evidence for this will come from your portfolio and it is essential that you have included all the experiences
which could show your dedication.

When answering this question it is important to both explain why you would like to be a surgeon and why you
are the ideal candidate for surgery:

Why do you want to be a surgeon?

The interviewers are looking for a well structured answer which shows dedication to speciality and motivation for
core training. It is important to give a range of reasons, with a personal example,s of why you enjoy it and why
you are suited to surgery. Your answer should be enthusiastic but focused and unique to you.

Perhaps you enjoy using your hands to make an immediate difference to peoples’ disease, or enjoy making
decisions under pressure. Surgery is fast moving when looking after acutely unwell patients in an emergency
setting, which appeals to many people. It is also allows you to look after chronic disease, where a personal
relationship is built up with your patients.

Whatever the reason you have chosen surgery, it is important to use a personal example, and if possible a
reflection/achievement related to this example. For instance here is John's answer from last year.

"I enjoy the challenge of using the practical skills I have developed, whilst I enjoy watching my consultant
carrying out larger cases, I really love performing skin biopsies myself. I can feel myself becoming more dextrous
each time, and improving my technique in small ways. Whilst this is a simple procedure, it has confirmed my love
of surgery. I enjoy seeing a patient beforehand, and explaining the operation and potential risks before carrying
out the biopsy and reviewing them afterwards. Both patients and my consultant have commented positively on
my clinical manner and on how quickly I am improving technically. I am looking forward to doing this for more
complicated procedures later in my career."

His answer is a good one as the example is generally applicable to core surgical training. It is specific and
personal and is appropriate to his current level, an F2. He also manages to mention a small achievement, a

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Commitment to Speciality

consultant's interviewing him would like to have as their trainee. He comes across as enthusiastic and
knowledgable about the need to care for patients before, during and after surgery.
He makes a strong statement at the end of his answer; “I am looking forward to doing this for more complicated
procedures later in my career." It gives a good impression to make confident statements such as this. Don’t say “if
I get into core surgical training’, say “when I get into core surgical training.”

The rest of his answer can follow a similar format:

• Reason why you want to be a surgeon

• A personal example
• Your reflection on what you / why you like it
• +/- an Achievement which positively reflects on you as a potential surgical trainee

It is a good idea to mention a variety of reasons why you want to be a surgeon. These can be research
opportunities, the fact it is challenging, the interaction with other specialties, being able to interpret images and
then do something about the surgical problem, and using advanced technology to name just a few.

You can end by mentioning the particular subspecialty you are interested in going into, "I hope to develop these
skills and then apply for ENT, a specialty that combines my passion for ...."

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Commitment to Speciality

Where do you see yourself in 10 years time?

“I would certainly hope to have completed my clinical training in 10 years time and have become a consultant.
My hope is to become a vascular surgeon. I worked on a vascular surgery firm in my first foundation year and
made a presentation to a national vascular conference during this time. I enjoy the technical nature of the work,
and enjoyed the variety in the types of operations performed, from the more lengthy and complicated bypass
procedures to the minimally invasive venous procedures, where advances are constantly being made.

I have enjoyed working in large teaching hospitals so far in my career, though I look forward to having
experiences of District General Hospitals during my training. I have an interest in teaching and have organised 2
surgical teaching courses for 3rd year students at Warwick medical school. I feel that working as a consultant at a
teaching hospital would give me more access to current teaching materials and allow me to develop this interest
further.

I have a strong interest in research. This was first developed during my BSc, where I managed to complete a
project on plasmodium falciparum, which I followed through to publication. I published the results of a surgical
audit that I completed in June on surgical complications in orthopaedic surgery and I would certainly hope to
have a breadth of research experience in 10 years time. I am interested in pursuing a PhD over the course of my
specialty training. I have discussed this with a number of my seniors who have completed their own research and
I realise that it can increases one's understanding of a subject and improve your clinical practice. I have
considered the fact that this would lengthen my training, but still think that it would be worthwhile. However, I
do not think that I would want to end up in a purely academic role as I would miss daily patient interaction.

I have played rugby at a high level throughout my school and university years and continue to play for a local
side. I am under no illusion that surgical training can be arduous with long and sometimes irregular hours.
However, I believe that having some work-life balance is essential. I would do my utmost to stay involved with my
rugby team on an occasional basis and as much as my work commitments would allow and would hope that I
would still be running out on the odd Saturday if my knees would allow it!

I was involved in an expedition to Nepal giving medical aid to deprived and remote areas on my medical elective
and am currently involved in raising funds for a charity sending medical supplies to deprived communities in
South Africa. As I become more senior, I would hope that my effectiveness in such charitable pursuits would also
increase.”

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Commitment to Speciality

What approach should be taken in answering these questions?

The difficulty of both of these questions are in their simplicity. They were among the most commonly asked
questions in recent interviews; therefore write an answer for both and learn before your interview. The easy
solution here would be to give a generic answer of for example 'I would like to be a consultant in x specialty
working in Manchester', or ‘I want to be a surgeon as I enjoy practical things’. This would be score a poor mark,
despite answering the question posed.

With this sort of question, it is useful to think of how to structure your answer. Such a wide ranging question
merits a wide ranging answer, but you must be careful that you maintain concentration on structure.

A common structure would be to divide your answer into clinical, academic and personal reasons. Candidates
are often reluctant to discuss personal aspirations in an interview, but of course these considerations will have a
bearing on your progression as a clinician and should be considered, at least briefly.

Clinical

You must show that you are aware that a core training scheme is not a specialty programme, however, at this
point, it would be appropriate to discuss your specialty aspirations, if you have one. This could be backed up by
evidence from your portfolio showing that you had given some thought to building a career focussed in that
particular direction. This could be in the form of papers, presentations or taster weeks for example.

Are there any specialties that you would like to develop? Many specialties are so sub-specialised that you may
want to be an orthopaedic surgeon, but want to have an interest in arthroscopic procedures involving the knee for
example. This sort of detail shows that you have given some though to your potential career path. If you do go
into such details, be sure that you can give adequate reasoning behind your interest if questioned more
thoroughly.

Clearly the eventual preferred destination for most clinicians is a consultant post. Would you like to work in a
large, cosmopolitan environment or a more rural destination, a DGH or teaching hospital. Whilst you may not
have thought this far ahead and your decision may change in future, such considerations show a maturity of
thinking that will set you apart from your peers. Again, make sure you can explain this answer. For example, you
may want to work in a large teaching hospital because of your experience in teaching. If you can show evidence
of a teaching course you have attended or a course you have set up for medical students in your portfolio, this will
strengthen your answer.

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Commitment to Speciality

Academic

Are you interested in research? Would you be wanting to pursue an MD or PhD in future? If so, discuss how you
think this will impact on your career and chosen specialty. Are you currently undertaking an MSC or other
further qualification? What have been your experiences of this so far and how do these experiences affect your
plans for future research involvement?

Do you have an interest in teaching? How do you plan to develop this?

Personal

Would you like to be part of a large or a smaller team? You could discuss your experiences of participating in
different types of team at this stage to show your understanding of the multidisciplinary team, but also of good
communication with seniors and other colleagues.

You could also discuss your extracurricular pursuits. If you are a keen sportsman/woman, would you hope to be
playing rugby, lacrosse or netball in 10 years time. How do you feel this would impact on your surgical career and
are there any changes that you will have to make in the intervening period to ensure a good work life balance?

Would you hope to be participating in any expeditions abroad or volunteer work? Surgery gives a lot of
opportunities abroad and if you would be keen to take advantages of these, you should make this clear. You
could again link this to past experiences on student elective or current volunteer projects. This is an opportunity
to show that you are a well qualified, but also a well rounded individual.

You also need to show good commitment to a surgical career to date. This will include your attendance at
surgical courses, such as the Basic Surgical Skills course, Advanced Trauma Life Support (ATLS), STEP Core,
STEP Foundation courses and START surgery courses. Of these, BSS and ATLS are the most favoured by the
interview panel as they are compulsory during core training, and show that you are ahead of the game already.
Course show an interest in specialty and can differentiate you from less driven candidates.

There are a number of associations for junior surgeons, which can be joined by trainees at foundation level.
These include the Association of Surgeons in Training (ASiT). This was founded in 1976 as a forum for surgical
trainees to discuss training matters and now has over 2,700 members. It arranges several courses, prizes and
awards for surgical trainees throughout the year, as well as an annual two day conference including oral and
poster presentations of delegates work. Membership of such associations goes towards highlighting an interest in

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Commitment to Speciality

Many hospitals will hold surgical teaching sessions during generic foundation year training. If you can include
documented evidence of attendance at such non compulsory sessions, this can show a dedication to higher
learning and educational achievement, both of the utmost importance for surgical trainees. Taster weeks are
another useful way for foundation year doctors to highlight their surgical interest. They can often
be  negotiated  after discussion with your educational supervisor and involve you joining another specialty of
your choice for a determined period. This will be of most benefit if you request a documentation from the
surgical consultant verifying your voluntary attendance for surgical cases, clinics and MDT meetings. It will not
only show commitment to specialty, but also organisation and good communication skills as on occasion, such
intra-firm transfers can involve delicate negotiation with senior members of both teams.

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THE INTERVIEW

MANAGEMENT

MANAGEMENT STATION the team and a willingness to ask that it will be the easiest of the
Introduction for help when necessary. three.

We include some questions asked It is important to remember that

The management station is worth
in this interview station in the last the management station holds a
33% of the marks at interview.
two years as a guide to what to third of your marks, and therefore
CT1 will see you take on more expect at your interview panel. does require revision. A good
responsibility and whilst you will answer requires familiarity with
Questions vary geographically the structure of the NHS,
be still very much in the infancy
and over time, but we hope to not complaints procedures, and
of your training, you may
only give you examples of strong ethical principles which you may
encounter more non-clinical
answers to some of these difficult not have had a reason to engage
challenges that you would have
questions, but also to help you with during your ward work in
done earlier in your practice; from
start to think about experiences FY1 and FY2.
ethical considerations, to
that you have had personally that
difficulties with colleagues and
can be used as examples. Think before you answer, patient
involvement in clinical
safety is an important starting
governance. There may be a temptation to point in answering many
exaggerate past experiences or management questions,
In this station, you will score
difficulties to try and say what you remember to say you would ask
highly by again giving confident
want the examiner to hear and to for help from more senior
and structured answers. However,
‘fit’ with the question. Don't. Your members of the team and to
these must be tempered by
answer will be much more structure your answer. These tips
knowledge of the law, pillars of
r e fl e c t i v e , c o h e r e n t a n d are the basis of success in this
medical ethics under which we
thoughtful if it is something that station.
work and must show an awareness
you have actually gone through.
of the limitations of your
capabilities as a junior member of Some people struggle to prepare
for this station and some think
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Management Station
Revalidation

What do you understand by revalidation?

Revalidation is a process by which licensed doctors are required to demonstrate to the GMC that they are up to
date and fit to practice on a regular basis. It is a means to promote and ensure continuing medical education,
standards of practice and fitness to practice. It also helps identify doctors in difficulty who require additional
support.

Since its launch in December 2012, revalidation is a legal requirement for all doctors. This revalidation process
occurs every five years, by having regular appraisals with the employer that are based on the four domains of
GMC’s Good Medical Practice (knowledge, skills and performance; safety and quality; communication,
partnership and teamwork; maintaining trust).

For trainees (StR/SpR), the responsible officer who makes the revalidation recommendation is the postgraduate
dean of the Local Education and Training Board (LETB, previously known as the deanery). This
recommendation is based on the appraisal done at the Annual Review of Competence Progression (ARCP) after
assessing the supporting evidence provided by trainees corresponding to the four domains of GMC’s Good
Medical Practice.

How would you, as a surgical trainee, provide evidence for the revalidation process?

During my surgical training, I would use the Intercollegiate Surgical Curriculum Portfolio (ISCP) to record
evidence of my ongoing training and professional development as well as feedback from 360 degree appraisals.
My responsible officer would then assess this evidence at my ARCP before making a recommendation to the
GMC.

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Management Station
Cancelled Theatre List

You are working with the Vascular Team today and you have been called by a nurse to say that the Triple A that
was planned for today has been cancelled as there are no ICU beds. This patient has been cancelled twice
previously for other reasons.

How do you proceed?

Firstly I would confirm with the theatre co-ordinator and inform my Consultant and the rest of the team
(Theatre an ward nurses, SpR, Anaesthetist etc) this was the case.
Then I would call the ICU SpR to see if there was any possible chance that another surgical patient was well
enough to be stepped down from ICU and transferred to HDU or the ward with increased clinical supervision,
thus freeing up a bed.

This is not the case and ICU tells you there are absolutely no beds free

I would go straight to the patient and explain the situation, apologizing that this has happened. If possible I
would ask my Consultant to come with me when I do this. I would re-book the patient on the next possible
theatre list and book an ICU bed at the same time, confirming it myself with the ICU staff. This would all be
done before the patient left the hospital, so they had a future date planned.

You find out that the original ICU bed had not been booked properly anyway and was a last minute request.
How could you prevent this happening again?

A patient has been cancelled on a list for the third time now, this therefore requires a DATIX (incident) form to
be written, particularly in this case. I would confirm exactly how and ICU bed should be booked and during the
next team meeting relay this information to the rest of the team. If this has happened on many occasions it may
be worth auditing this and reviewing the procedure for booking a bed.

Is there anything else you could do now that the patient has been confirmed as cancelled?

With this cancellation there leaves a lot of free time on the theatre list. I would se if there were any inpatients/
emergencies that we could bump onto our list instead, discussing with my Consultant and theatre Coordinator.

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Acknowledgements
With many thanks to all of our excellent contributors, we thank you for your time and effort.

For any future contributions, or to get involved in the core surgical interview course, please contact us at
admin@[Link]

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Conclusion
This guide aims to de-mystify the core surgical interview by giving you some hints and tips that
we would like to have had before we applied. It has been written by surgeons in the first few
years of their career. Unlike other guides out there, it is based on recent experience of the
interview. It is an essential companion to the surgical interview course, and you will be expected
to have read most of it before attending.

We recommend you start practicing these stations as soon as possible with your colleagues who
are also applying. The more practice you get the more confident you will feel and the better you
will be come interview.

We hope that you have had as much fun reading this guide as we have had writing it!

Don’t forget to visit [Link] and join us for our course. There are several
locations around the country, but it is again expected to book up quickly. Please secure your
place early to avoid disappointment

Good luck!

The (ever growing) Core Surgical Interview Team

KC Surgical Training LTD

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