Smashing the Core

Surgical Training
Interview
Smashing the Core Surgical Training Interview is a crucial roadmap through the
highly competitive world of surgery, written by previous Core Surgical
Training National Recruitment panel members. It provides a realistic
understanding of what is expected on the interview day and how best to
prepare for it.
This book provides advice on how to maximise your time as a medical
student and foundation year doctor in preparing for the Core Surgical
Training (CST) interview process. It covers all aspects of the interview,
including how to prepare the portfolio, virtual interview etiquette, and post-
interview considerations.
This book contains the following:

• More than 30 clinical scenarios and more than 15 management

­scenarios with model answers
• Model frameworks for structuring answers
• Information covering real-life struggles, including how to maximise
opportunities as a medical student, how to publish, and how to decide
whether to take an F3 year
• Insights into the diverse world of modern surgery, including women
in surgery, LGBTQ issues, dyslexia and neurodiversity, and challenges
faced by ethnic minorities
• A framework for international medical graduates planning surgical
careers

This is the perfect preparation guide for any medical student or junior doctor
with a serious desire to launch a career in surgery in the United Kingdom by
smashing the CST interviews.
Smashing the Core
Surgical Training
Interview
A Holistic Guide to
Becoming A Surgeon

Edited by
Anokha Oomman Joseph and
Janso Padickakudi Joseph
First edition published 2024
by CRC Press
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and by CRC Press
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Library of Congress Cataloging‑in‑Publication Data
Names: Joseph, Anokha, editor. | Joseph, Janso, editor.
Title: Smashing the Core Surgical Training interview : a holistic guide to becoming a surgeon /
edited by Anokha Joseph and Janso Joseph.
Description: First edition. | Boca Raton : CRC Press, 2023. | Includes bibliographical references and index.
Identifiers: LCCN 2023009109 | ISBN 9781032388434 (paperback) | ISBN 9781032395913 (hardcover) |
ISBN 9781003350422 (ebook)
Subjects: MESH: General Surgery—education | Education, Medical, Graduate | I­ nterviews as Topic |
Job Application | United Kingdom
Classification: LCC RD37 | NLM WO 18 | DDC 617.0071—dc23/eng/20230612
LC record available at [Link]
ISBN: 978-1-032-39591-3 (hbk)
ISBN: 978-1-032-38843-4 (pbk)
ISBN: 978-1-003-35042-2 (ebk)
DOI: 10.1201/9781003350422
Typeset in Palatino
by Apex CoVantage, LLC
 To Dr Susmita Oomman, Thomas Oomman,
Omana Padickakudi and Ouseph Padickakudi, our parents,
for your unwavering love and support. Thank you.

And to Kimaya and Sitara, our daughters. You

give our lives meaning and purpose.
Contents
Foreword by Fiona Myint��������������������������������������������������������������������������������xi
Foreword by Roy Phitayakorn��������������������������������������������������������������������� xiii
Acknowledgements�����������������������������������������������������������������������������������������xv
Editors������������������������������������������������������������������������������������������������������������� xvii
List of Contributors�����������������������������������������������������������������������������������������xix

Introduction��������������������������������������������������������������������������������� 1
Anokha Oomman Joseph and Janso Padickakudi Joseph

Chapter 1 Application Process for Core Surgical Training������������������� 3

Stefanos Gkaliamoutsas

Chapter 2 Multi-Speciality Recruitment Assessment (MSRA)������������ 9

Sushrut Oomman

Chapter 3 Preparing Your Surgical Portfolio����������������������������������������� 13

Sharukh Jamal Zuberi, Virginia Haoyu Sun, Anokha
Oomman Joseph, and Janso Padickakudi Joseph

Chapter 4 How to Publish�������������������������������������������������������������������������� 35

Alan Askari

Chapter 5 Mastering the Presentation����������������������������������������������������� 43

Humayun Razzaq and Janso Padickakudi Joseph

Chapter 6 How to Structure Your Answers: Clinical��������������������������� 45

Anokha Oomman Joseph and Janso Padickakudi Joseph

Chapter 7 How to Structure Your Answers: Management������������������ 51

Anokha Oomman Joseph and Janso Padickakudi Joseph

Chapter 8 Virtual Interview Etiquette���������������������������������������������������� 57

Viswa Rajalingam and Janso Padickakudi Joseph

vii
viii Contents

Chapter 9 Clinical Scenarios��������������������������������������������������������������������� 61

William Rea, Sharukh Jamal Zuberi, Muhammad Salik,
Gopikanthan Manoharan, Gargi Pandey, Goran Ameer
Ahmed, Joshua Gaetos, Anokha Oomman Joseph, and
Janso Padickakudi Joseph

Chapter 10 Management Scenarios���������������������������������������������������������� 121

William Rea, Saarah Ebrahim, Hari Nageswaran,
Humayun Razzaq, Anokha Oomman Joseph, and
Janso Padickakudi Joseph

Chapter 11 Post-Interview Job Preferencing������������������������������������������ 145

Stefanos Gkaliamoutsas and Alex Meredith-Hardy

Chapter 12 Life as a Core Surgical Trainee��������������������������������������������� 149

Haseem Raja and Janso Padickakudi Joseph

Chapter 13 The Challenges of Life as a Core Surgical Trainee���������� 153

Gargi Pandey and Janso Padickakudi Joseph

Chapter 14 To F3 or Not to F3��������������������������������������������������������������������� 157

Alex Meredith-Hardy, Gargi Pandey, Anokha Oomman
Joseph, and Janso Padickakudi Joseph

Chapter 15 Medical Students – Planning a Career in Surgery����������� 167

Rose Kurian Thomas

Chapter 16 Women in Surgery������������������������������������������������������������������ 179

Sharlini Sathananthan and Anokha Oomman Joseph

Chapter 17 International Medical Graduates – Planning

to a Move to the UK���������������������������������������������������������������� 191
Muhammad Talha, Muhammad Salik, and Anokha Oomman
Joseph

Chapter 18 International Medical Graduates – Planning

a Career in Surgery����������������������������������������������������������������� 199
Muhammad Salik, Muhammad Talha, and Anokha Oomman
Joseph

Chapter 19 Dyslexia and Neurodiversity������������������������������������������������ 203

Carol Leather
Contents ix

Chapter 20 Out in Surgery – LGBTQ Issues������������������������������������������ 221

Mustafa Khanbhai

Chapter 21 Getting into Core Surgical Training as an Ethnic

Minority������������������������������������������������������������������������������������ 227
Tolu Ekong, Temitope Ajala-Agbo, and Eniola Salau

Index................................................................................................................. 235
Foreword
I am pleased to have been asked to write a foreword for this useful book.
Surgery is a rewarding and worthwhile career that allows us to help
and heal our patients while, for many of us, satisfying a desire to spend
time, using practical skills or creating tangible innovations. This book has
been written to help those taking the step up from medical student or
foundation doctor to the first rungs on a surgical career ladder.
For most this is an exciting prospect, and I actively encourage it.
However, having been a previous Training Programme Director for Core
Surgery I am well aware of the bureaucratic and emotional hurdles that
some young doctors face when transitioning from foundation trainee to
core surgery trainee. There can be a minefield of information to absorb
and digest. We all come from different backgrounds, and with varying
levels of career foundation and support. For equitable access to training,
I recognize that some will need more guidance than others.
I am delighted to see that, in addition to some very useful hints and tips
on starting a career in surgery, this book touches on topics for which there
is often little signposting. In particular, there is guidance for those indi-
viduals who may see themselves as being perceived as different from the
mainstream. All credit to the authors for bringing these issues together in
one source. We need to embrace diversity in surgery. It must be understood
that people who come from different backgrounds and with different char-
acteristics may present themselves in a different way to that which we may
be accustomed to seeing, but this does not mean that they will not perform
well if given the opportunity. It is diversity that brings a breadth of quali-
ties to surgical practice and helps to build a stronger, more compassionate,
innovative, and progressive profession. Without change, we cannot evolve.
I encourage all readers of this book to strive to be their best doctor,
their best surgeon, and above all, their best self.

Professor Fiona Myint

Consultant Vascular Surgeon

Vice President of the Royal College of Surgeons of England

xi
Foreword
Dear Readers,
It is my absolute pleasure to write a foreword for this book enti-
tled, ‘Smashing the Core Surgical Training Interview: A Holistic Guide
to Becoming A Surgeon,’ edited by Miss Anokha Oomman Joseph and
Mr Janso Padickakudi Joseph. The editors have put together a wonderful
group of surgical educators to write this practical and easy to read book
that is filled with useful pearls for prospective surgical training appli-
cants. Although the book is clearly focused on training programs in the
United Kingdom, I think that many of the chapters contain general prin-
ciples that can be applied by students around the world.
I also want to congratulate the authors and editors on writing this
important book as it directly addresses feelings of imposter syndrome
and stereotype threat. Now more than ever, the world needs well-trained
surgeons who reflect their larger communities and will support their
patients’ needs and decision-making to have productive and healthy lives.
I hope that you enjoy reading this book and apply its knowledge to
your own journey of achieving surgical excellence!

Roy Phitayakorn, MD MHPE FACS

General and Endocrine Surgery

Vice Chair of Education, Massachusetts General Hospital
Department of Surgery
Associate Professor of Surgery, Harvard Medical School

xiii
Acknowledgements
Thank you to the incredible authors who have contributed to this book.
Each of your contributions has been rooted in your lived experience of
working in surgery; this is exactly why the wisdom you share is so power-
ful. This book will help to close the information gap to allow candidates
to succeed in securing a coveted Core Surgical Training (CST) number,
regardless of their background.
We would like to acknowledge ACE Medicine and Surgery for its con-
tribution to this book. ACE Medicine and Surgery’s vision of empowering
surgical aspirants with the knowledge and skills to smash CST interviews
matches the mission of this book. We are grateful for an incredible part-
nership, rooted in deep friendship.
Thank you to Health Education England and the chair of the Core
Surgery Training and Advisory Committee, JCST for clarifying that, since
this book contains no reproductions of interview material, it is permis-
sible to print.

xv
xvi Acknowledgements
Editors
Anokha Oomman Joseph is an oncoplastic breast trainee who has com-
pleted her surgical training at the London Deanery with her final years
of training at St Bartholomew’s Hospital and The Royal London Hospital.
She has completed a masters in medical education from Cardiff
University. She has an extensive teaching portfolio. She is a tutor for the
MSc in surgical sciences at the University of Edinburgh. She has previously
been an associate lecturer at Anglia Ruskin Medical School.
She is a graduate, with distinction, of the Surgical Leadership Program
at Harvard Medical School. She has previously been a panel member for
the National Recruitment for Core Surgical Training.

Janso Padickakudi Joseph is a minimally invasive and bariatric fellow at

Beth Israel Deaconess Medical Center, Harvard Medical School (BIDMC/
HMS), USA. He was a resident at Johns Hopkins Hospital, USA. He gained
his CCT in general surgery from the East of England Deanery. He was
awarded a Queen’s Medal for Service for his work during the Ebola
epidemic in West Africa.
He has completed a masters in surgical education from Imperial College
London. He is currently the course lead for advanced surgical communication
skills at BIDMC/HMS. He has previously been a panel member for National
Recruitment for Core Surgical Training.

xvii
Contributors
Mr Goran Ameer Ahmed Dr Stefanos Gkaliamoutsas
Locum Consultant Oncoplastic Core Surgical Trainee
Breast Surgeon East Lancashire Hospitals NHS Trust
Frimley Health NHS Foundation
Mr Mustafa Khanbhai
Trust
General Surgery Registrar
Frimley Park Hospital
St Bartholomew’s Hospital
Dr Temitope Ajala-Agbo London Deanery
Surgical Trainee
Tønsberg Hospital Miss Rose Kurian Thomas
Vestfold Hospitals Trust, Norway Medical Student
Imperial College London
Mr Alan Askari
Post CCT Bariatric / Upper GI Fellow Dr Carol Leather
Bedfordshire Hospitals NHS Trust Dyslexia Consultant
Royal College of Surgeons Independent Dyslexia Consultants,
London, UK
Miss Saarah Ebrahim
Core Surgical Trainee Mr Gopikanthan Manoharan
Bedfordshire Hospitals NHS Trust Post CCT Upper Limb Fellow
East of England Deanery Robert Jones Agnes Hunt
Orthopaedic Hospital
Mrs Tolu Ekong Royal College of Surgeons
General Surgery Registrar
East and North Hertfordshire Dr Alex Meredith-Hardy
NHS Trust Core Surgical Trainee
East of England Deanery Torbay and South Devon NHS
Foundation Trust
Mr Joshua Gaetos
Cardiothoracic Surgery Junior Mr Hari Nageswaran
Fellow Consultant Upper GI Surgery
Barts Health NHS Trust Aneurin Bevan University Health
St Bartholomew’s Hospital Board

xix
xx Contributors

Dr Sushrut Oomman Ms Eniola Salau

Histopathology Registrar Core Surgical Trainee
University Hospital of Wales East and North Hertfordshire
Health Education and NHS Trust
Improvement Wales East of England Deanery
Miss Gargi Pandey Dr Muhammad Salik
Core Surgical Trainee Core Surgical Trainee
Barts Health NHS Trust Aberdeen Royal Infirmary,
London Deanery NHS Grampian
East of Scotland Deanery
Mr Haseem Raja
ENT Registrar Miss Sharlini Sathananthan
University Hospitals Coventry & General Surgery Registrar
Warwickshire East and North Hertfordshire
West Midlands Deanery NHS Trust
East of England Deanery
Mr Viswa Rajalingam
Colorectal Surgery Miss Virginia Haoyu Sun
Dudley Group Foundation Trust Medical Student
Harvard Medical School
Mr Humayun Razzaq
Core Surgical Trainee Dr Muhammad Talha
Aneurin Bevan University Health Surgical Clinical Fellow
Board Nottingham University Hospitals
Health Education and NHS Trust
Improvement Wales East Midlands
Mr William Rea Mr Sharukh Jamal Zuberi
General Surgery Registrar Core Surgical Trainee
The Royal London Hospital Chelsea and Westminster NHS
Barts Health NHS Trust Foundation Trust
Introduction
Anokha Oomman Joseph and Janso Padickakudi Joseph

So you want to be a surgeon? You have made a great choice! A career in

surgery is demanding, challenging, and incredibly rewarding. As sur-
geons, we are privileged to serve people when they are at their most
vulnerable. The satisfaction of being able to make a direct difference in a
patient’s health outcome with your own hands is immeasurable.
In this book, we aim to demystify the process of becoming a surgeon
in the United Kingdom. We want to empower you with the knowledge
and skills to make these first steps and enter Core Surgical Training (CST).
We will give you specific advice on how to prepare for the interview, both
in terms of maximising your portfolio and how to approach questions
systematically.
This book is particularly aimed at medical students and junior doc-
tors who think they do not have what it takes to become a surgeon. Maybe
you have internalised some common stereotypes of what being a surgeon
is like and believe that you do not fit the mould. We have included specific
chapters for women in surgery, international medical graduates, medical
students, neurodiverse candidates, and LGBTQ candidates. There is space
for you to be exactly the way you are in surgery.
We are recent general surgery graduates of the UK surgical training
programme. We were interviewers for the national CST interviews and
therefore have a thorough understanding of the application process. We
also hold a master’s in medical/surgical education. Our wonderful team
of authors consists of 25 committed individuals who have lived experi-
ence of the issues and challenges they write about. We hope that our col-
lective experience will help you in your career as you make the first steps
towards becoming a surgeon.

DOI: 10.1201/9781003350422-1 1
chapter one

Application Process for

Core Surgical Training
Stefanos Gkaliamoutsas

Introduction
Recruitment for Core Surgical Training (CST) is a national process conducted
by Health Education England (HEE) London and Kent, Surrey and Sussex
(LaKSS) via the Oriel online application portal. There are several key dates
throughout the recruitment cycle which are important to bear in mind as late
submissions are not accepted. The following table is adapted from the appli-
cation timeline presented in the 2023 Core Surgical Training Supplementary
Applicant Handbook.1 This can be used as a rough guide, although there
is a slight annual variation to the application timeline, and it is, therefore,
important to read the relevant Core Surgical Training Supplementary
Applicant Handbook1 when it is uploaded to Oriel, usually in late October
or early November every year. For example, the recent addition of the Multi-
Speciality Recruitment Assessment (MSRA) exam as part of the shortlist-
ing process and as a component of a candidate’s total application score has
resulted in some significant changes to the application timeline.

The Application Process1

Activity Date
Job adverts appear on Oriel By early November
Application window From early November to early
December
Invitations to MSRA By Mid-December
MSRA dates 2-week window in January
Evidence upload dates 10-day window from late January
to early February
MSRA and verified self-assessment Mid-February
score released
Interview invitations sent Mid-February
(continued)

DOI: 10.1201/9781003350422-2 3
4 Smashing the Core Surgical Training Interview

(Continued)
Activity Date
Interview Dates 2-week window in March
Preferencing Dates 3-week window in March
(overlaps with interview dates)
Initial offers made Late March
Hold deadline Early April
Upgrade deadline Mid-April
Interview scores and feedback released Early May

Applying on Oriel
Registering for an Oriel account is a very straightforward process, which
you should do by October of the year prior to your expected CST start date
(e.g. an applicant aiming to start a CST job in August 2024 should have
made an Oriel account by October 2023).2 Job adverts typically appear in
early November for posts starting in August of the following year, with
applications opening soon thereafter and remaining open for about one
month. Having an Oriel account will allow you to apply for multiple spe-
cialities, should you choose to do so.
The application requires you to provide personal information, such as
contact details, evidence of the right to work in the UK, and equality and
diversity information. Furthermore, you must declare your employment
and training history (including justification for any employment gaps of
four weeks or more in the three years prior to the post’s start date). You
must provide details of three referees who have supervised your work
over the preceding two years. Last but not least, you are required to com-
plete a self-assessment of your portfolio for which you will be awarded
points. You must ensure that you have the required evidence for any
claimed achievements, as you will be required to submit this further
down the application process. Once you have submitted your application,
you are not able to make any further amendments, so it is a good idea to
go through it a few times to correct any mistakes you may have made.
Be careful not to overestimate or underestimate your points (you need to
have the required evidence to back up your self-assessment scores).

MSRA
A substantial recent change to recruitment is the addition of the Multi-
Speciality Recruitment Assessment (MSRA) exam, which all longlisted
applicants (i.e. applicants who are eligible for a CST post per the published
Person Specification3) are required to take and which will form 10% of the
application score. If the MSRA remains part of the recruitment process for
Chapter one: Application Process for Core Surgical Training 5

future cycles, then it is likely that invitations to the MSRA will continue
to be sent in December, and the exam will be taken in a two-week period
in January. The MSRA Applicant Guide should be referred to for more
information on booking and sitting the exam.4

Uploading Evidence
The evidence upload portal opens in late January and closes in early
February. Evidence needs to be collated and uploaded as one document
using the Core Surgical Training Self-Assessment Portfolio Proforma5. The
Core Surgical Training Self-Assessment Scoring Guidance for Candidates
document,6 which is updated annually, details exactly what is acceptable
evidence for each category. Do not deviate from this as there is very little
flexibility in this regard. Please read the Portfolio chapter for further guid-
ance. It would be a shame to lose out on points for things that you have
accomplished because of unacceptable evidence!
MSRA results and verified self-assessment scores are released in mid-
February, and the top-scoring applicants on MSRA will have their self-
assessment scores verified and be invited to interview. Applicants have
72 hours to submit any appeals against their verified scores, and if doing
so, must explain why they feel their verified score is incorrect based solely
on the evidence that has already been submitted. You will not be allowed
to resubmit evidence, once again emphasising the importance of getting
this right the first time!

Booking an Interview Slot

You will receive an email from Oriel with instructions on how to book your
interview slot via your Oriel account. Interview slots are booked on a first-
come-first-served basis. Previous applicants have often argued whether it
is beneficial to book an interview early or late in the interview window.
There is no clear advantage to either option; ultimately, the applicants who
are better prepared are the ones who will give themselves the best chance
of being offered a CST job! In terms of the time of day, anecdotally a mid-
morning slot is the most advantageous as the examiners will be fresh and
will have had time to calibrate their scoring with the first couple of trainees.

The CST Interview

Interviews are conducted over a two-week window in March. These are
virtual and are held over Microsoft Teams with a panel usually consisting of
two consultant interviewers and a lay observer, and occasionally additional
administrative staff may also be present. In its current format, the interview
lasts 20 minutes and is split into a ten-minute Management section and a
6 Smashing the Core Surgical Training Interview

ten-minute Clinical section. Within the ten-minute Management section,

you will be asked to give a three-minute pre-prepared presentation on a
topic, often relating to leadership in surgery. The topic will be emailed to
you around the same time that interview invites are sent out. Following
this, the interviewers will question you on this presentation for two min-
utes. This is then followed by a management scenario question, with five
minutes allocated to answering the question. The ten-minute Clinical sec-
tion consists of two five-minute clinical scenario questions.
Given that the interview makes up 60% of your final application score,
it is very important to prepare thoroughly for this. The amount of time
that one would need to prepare adequately for these interviews varies
depending on the amount of pre-existing surgical knowledge and inter-
view experience that you possess. Someone who has recently passed
their MRCS Part A, for example, may only require a few weeks to feel
adequately prepared, whereas someone who has not sat a surgical exam
recently or had a recent surgical job may feel more comfortable with two
to three months of preparation. Our advice would be to start preparing at
least two months in advance. The first month should be spent on gather-
ing relevant resources and revising common surgical topics.
With one month to go before the interview, the focus should shift
to mock interview practice. Practising regularly under conditions that
resemble those of the actual interview with a group of applicants should
be prioritised. It is worth enquiring whether senior registrars or consul-
tants at one’s trust would be willing to set up mock interview sessions, as
these clinicians often have experience with interviewing themselves and
can be invaluable sources of information and feedback. While a lot of time
will be spent revising the possible content of the interview, do not under-
estimate the importance of good interview techniques.

Ranking CST Jobs

You will be asked to rank jobs during the three-week preferencing win-
dow in March, during which you will also be informed of your total appli-
cation score, which consists of the MSRA (10%), verified self-­assessment
score (30%), and interview score (60%) ranking and whether you are
appointable to a CST post.
Offers are released in late March, and you will have 48 hours to make
a decision. You can respond to the offer in the following ways:

1. Accept.
2. Accept with upgrades. If you chose this, you may receive an offer for
a job higher on your preference list should it become available later.
3. Reject. If you chose this, you will not receive any other CST offers in
this recruitment round.
Chapter one: Application Process for Core Surgical Training 7

4. Hold. If the offer is not accepted before the hold deadline, it is auto-
matically rejected.
5. Hold with upgrades. If you chose this, you may receive an offer for
a job higher on your preference list should it become available later.
An offer that is not accepted before the hold deadline will be auto-
matically declined.

If you choose to accept or hold with upgrades, you have the option to
change your preferences by reordering them or adding/removing certain
jobs, should you wish to. Be very careful when doing this, as you need
to make sure you would be happier receiving one of the other jobs you
have ranked above the one you have been allocated. Remember that if you
are offered a different programme and are not happy with it, you cannot
request your previously allocated programme back.

Accepting an Offer
If you are offered a job and choose to accept it, then you have come to the
end of the CST application process. You will then be contacted by your
new employer in due course with further instructions. Congratulations
and good luck with the start of your surgical training!

References/Key Documents
1. CST Supplementary Applicant Handbook 2023. [Link]
Web/PermaLink/Vacancy/F1906CDC. *
2. Oriel Applicant User Guide. [Link]
Bank. **
3. Person Specification 2023; Core Surgical Training – CT1. [Link]
[Link]/portals/1/Content/Person%20Specifications/Core%20
Surgical%20Training/CORE%20SURGICAL%20TRAINING%20-%20
CT1%202023%[Link]. ***
4. MSRA Applicant Guide 2023–24. [Link]
Link/Vacancy/F1906CDC. *
5. Self-Assessment Portfolio Proforma. [Link]
PermaLink/Vacancy/F1906CDC. *
6. 2023 Self-Assessment Guidance for Candidates. [Link]
Web/PermaLink/Vacancy/F1906CDC. *
•  *These can be found on Oriel within the “Documents” tab of the
“LaKSS – Core Surgical Training – CT1, LAT1, ST1” vacancy by following
the link.
• **This can be found in the Resource Bank on Oriel by following the link
• ***This can be found on the HEE website under Speciality training >
Recruitment > Person specifications > Core Surgical Training or by
­following the link.
chapter two

Multi-Speciality Recruitment
Assessment (MSRA)
Sushrut Oomman

In line with other medical specialities in the United Kingdom (UK), it

has been announced that from 2023, the Multi-Speciality Recruitment
Assessment (MSRA) will also be used for recruitment into Core Surgical
Training (CST) (1).
The MSRA is a timed, computer-based exam carried out at a test cen-
tre. It is designed to assess competence at the level of a foundation doctor.
It is a test already being used in other specialities, such as clinical radiol-
ogy, obstetrics and gynaecology, ophthalmology, core psychiatry training,
and general practice (2). Therefore, MSRA questions cover an extensive
range of topics.

What Is the MSRA Used For?

The results from your MSRA will be used to create a shortlist. Only the
top 1,200 applicants will be invited to interview. In addition to this, your
result will contribute to 10% of your final interview score. The rest of the
score will be from your portfolio (30%) and clinical and management sta-
tions (60%). Your final score will determine your rank and, in turn, affect
which job you are offered.

How to Take the MSRA

The MSRA is held between January and February at Pearson Vue test cen-
tres in the UK. In situations where the candidate is affected by coronavi-
rus, you may be eligible to take MSRA remotely using Pearson’s OnVUE
delivery system. This remote testing is not available for any other issue
that is not related to coronavirus.
For those applying from outside the UK, local testing centres can be
used. You will be sent an invite in early December to book a slot if fol-
lowing the submission of a completed application you are deemed to be
eligible.

DOI: 10.1201/9781003350422-3 9
10 Smashing the Core Surgical Training Interview

Format of the MSRA

The MSRA has two parts: (1) Professional Dilemmas (PD) and (2) Clinical
Problem-Solving (CPS).

Part 1 – Professional Dilemmas

The Professional Dilemmas (PD) section tests the candidate’s ability to
make the most appropriate decisions at the level of a second-year foun-
dation doctor in complex and challenging situations. Every scenario is
reviewed by subject matter experts (SMEs) to ensure that the content does
not contain UK-specific procedures and policies that would disadvantage
candidates such as international medical graduates. There are 50 ques-
tions to answer in 95 minutes. These are situational judgement test (SJT)
questions. There is no negative marking, so you should attempt every
question.
There are three main domains that are covered in the Professional
Dilemmas paper:

1. Professional integrity
2. Coping with pressure
3. Empathy and sensitivity

The core themes covered within these domains include professional con-
duct, interactions with patients, interactions with colleagues, staffing
issues, prioritisation, managing workload, acting with integrity, and deal-
ing with difficult situations in the most empathetic and sensitive manner.
There is no assessment of clinical knowledge.
The possible answers listed in the question will all be realistic. The
response to the scenario is compared to how close they are to the expert
group’s response to each question. The closer your answer is to the perfect
answer, the higher your score.
The paper utilises two types of question formats. The first is the
‘ranking’ questions, where you will be faced with four or five possible
actions, which you need to rank in order of the most appropriate to the
least appropriate (1 = most appropriate, 5 = least appropriate). These are
not chronological but discrete actions.
The other type of question is the ‘multiple best answer’ where you will
be presented with eight options, and you will be asked to choose three of
the most appropriate actions. These three appropriate actions when taken
together should be able to fully resolve the situation.
In both these types of questions, there will be a mixture of good,
acceptable, and poor responses to the situation, as judged by the SMEs.
These questions do not include responses that are totally implausible.
Chapter two: Multi-Speciality Recruitment Assessment (MSRA) 11

Part 2 – Clinical Problem-Solving

In the Clinical Problem-Solving (CPS) section, each question presents a
clinical scenario which requires the selection of the most appropriate diag-
nosis, investigation, prescribing, and management for the patient. The test
covers a broad range of topics, such as medicine, paediatrics, surgery, and
reproductive medicine, to name a few, and is based on the clinical practice
of an FY2. Seventy-five minutes are allocated to answer 97 questions. This
paper consists of MCQs (multiple choice questions) and EMQs (extended
matching questions) (2).

MSRA Paper Number of Number of Questions Test Time

Questions Contributing to Final Score
Professional 50 scenarios 42 (8 pilot questions) 95 minutes
Dilemmas (PD)
Clinical Problem- 97 questions 86 (11 pilot questions) 75 minutes
Solving (CPS)

How to Prepare for the MSRA

As the MSRA score will be used for shortlisting, it is the gateway into
securing an interview. You should therefore treat it as a priority. You
should allocate four to six months of revision for it. This is easier said
than done given your clinical commitments and other activities for CV
building which you may have going on.
There are many resources available to aid in preparation for the
MSRA, which include Passmedicine, Pastest, MCQ Bank, eMedica Online
Revision, ARORA Medical Education, Medibuddy, and OnExamination.
Once you have chosen the resource you plan to use, you should go through
each topic systematically and spend time reading up on topics that you
are weak in. Practice MCQs regularly in your revision period and towards
the end of your preparation go through a few MSRA mock papers in a
timed setting.

References
1. Overview of Core Surgery Training | Medical Education Hub [Internet].
[cited 2022 Nov 28]. Available from: [Link]
training-recruitment/medical-specialty-training/surgery/core-surgery/
overview-of-core-surgery-training/applying-for-core-training#allocation15
2. Taking the MSRA | Medical Education Hub [Internet]. [cited 2022 Nov 28].
Available from: [Link]
medical-specialty-training/multi-specialty-recruitment-assessment-msra/
taking-the-msra/overview-of-the-msra
chapter three

Preparing Your Surgical Portfolio

Sharukh Jamal Zuberi, Virginia Haoyu Sun, Anokha
Oomman Joseph, and Janso Padickakudi Joseph

Disclaimer: Chapter is based on requirements for the 2022 round of CST application.

In this chapter, you will learn how to collect evidence, structure, and pres-
ent your portfolio to obtain maximum marks. Every year Core Surgical
Training (CST) becomes more and more competitive. Therefore, every
point matters. A single point can determine whether you are shortlisted,
appointable, or receive an offer. It is crucial that you start collecting rel-
evant evidence for your portfolio as early as possible; it can take longer
than expected to locate and organise the required proof to present your
achievements.
Before the COVID-19 pandemic, all interviews were held face-to-face.
Candidates were asked to bring a physical portfolio to the interview.
During the interview, examiners would review and verify each piece of
evidence against the assessment criteria. In this previously interactive sta-
tion, examiners had the opportunity to question candidates on any unclear
evidence. This gave candidates the chance to corroborate any ambiguous
evidence. Since 2021, the portfolio assessment and interview have been
moved online. The portfolio review now occurs without the candidate
present. This emphasises the importance of meticulous preparation and
presentation of your portfolio. You need to ensure that there are no gaps
in your evidence that the examiners can question. Examiners are review-
ing many portfolios a day, and it is therefore crucial for your evidence to
be clear, concise, and meticulously aligned with portfolio instructions.

What Is Your Portfolio Used For?

As part of the Oriel application form, you will be asked to provide a port-
folio self-assessment score. Your self-assessment score is used to short-
list the top-scoring ~1,300 candidates. These shortlisted candidates will
then be invited to upload evidence of their achievements to the evidence
upload portal.

DOI: 10.1201/9781003350422-4 13
14 Smashing the Core Surgical Training Interview

Each piece of evidence you upload will be reviewed by trained asses-

sors. They will verify that you have claimed the correct number of points.
They can change your score if they feel your evidence merits a differ-
ent score from your self-assessment. This process produces your verified
evidence score. After the evidence verification process is complete, the
highest-scoring ~1,200 applicants are invited to attend a remote interview.
A combination of your verified evidence score and interview score is
used to determine your final total score and ranking (CST-Supplementary
Applicant Handbook 2022).

When to Start Gathering Evidence

The earlier you start the better. If you have not yet started, the time is
now! Candidates who are considering a career in surgery should familia-
rise themselves with the self-assessment scoring guidance as soon as pos-
sible. Looking at this document during medical school or at the start of the
foundation programme can help you to focus your academic efforts dur-
ing these key years. This long-sighted approach gives you the best oppor-
tunity to achieve near-full marks. If you are unsure if you want to pursue
surgery, you should still collect evidence as a lot of the generic domains
such as audits, and teaching experience that is required in surgery over-
laps with other specialities.

Which Type of Evidence to Gather

Although each year the criteria for the portfolio change slightly, the broad
principles remain the same. Your evidence needs to be exceptionally
clear and precise. There is little margin for error. Examiners will not be
handing you marks. We advise that you follow the self-assessment scor-
ing guidance with precision. Any achievements declared must have been
undertaken after commencing your medical or first undergraduate degree
(achievements from school or before university are excluded). Once you
have your portfolio together, ask a senior surgical registrar or consultant
to review it. Your evidence should mirror the guidance word for word.
Do not use patient-identifiable data. This includes, for example, thank-you
cards or letters from patients. Hospital numbers are also an example of
patient-identifiable data.

Top Ten Tips for Portfolio Preparation

1. Aim for excellence. Aim to pick up the top marks in each category; if
you aim high, you will pick up some points on the way. Avoid zero
points in any category. Every point matters.
Chapter three: Preparing Your Surgical Portfolio 15

2. Start portfolio preparation early.

3. Consider the effort-to-glory ratio. Be selective about the projects you
engage with. Pick those which will get you the most marks without
consuming your whole time/effort.
4. Use your time wisely. Consider which points are achievable in the
timeframe you have left. In each domain, weigh up the time taken
to reach top marks and if your time should be spent more wisely
elsewhere.
5. Work smart. For example, in the publication domain, in the 2022
marking, the top mark (6) is awarded to the first author’s original
research. However, 4 marks are awarded to a first author of a case
report or editorial letter, which may be more realistic for you to
complete.
6. Use your network. Work with peers. Speak to current core train-
ees. Get advice from seniors. Your network will be a rich source of
invaluable tips.
7. Be honest. If your score is significantly different compared to the
assessor’s score, your probity may be questioned. This can have sig-
nificant ramifications.
8. Follow the instructions word for word. Upload your documents with
the exact wording contained in the instructions. A single, succinct,
complete document is best if possible.
9. Be strategic. You can only use an achievement to score points in a sin-
gle domain. Therefore, you should use the breadth of your achieve-
ments to gain the highest points across all domains.
10. Enjoy the process. Putting your portfolio together will summarise all
the hard work you have put into becoming a surgeon. Be proud of
your achievements.

Layout
Laying out your portfolio in a structured, precise manner is key to obtain-
ing maximum points. We recommend uploading your evidence for each
domain in a single PDF file. The first page should act as a summary
page, clearly informing the examiner where you are claiming points. On
this summary page, you should highlight the scoring criteria, your self-­
assessment score, and the description of evidence in your portfolio.
Many candidates upload a single piece of evidence per domain. If
you have one clear piece of evidence of which you are 100% certain that
it fulfils the top criteria, then upload this. This is the most powerful for
examiners. However, if there may be even an inkling of uncertainty in
interpretation, you should upload more than one piece of evidence per
16 Smashing the Core Surgical Training Interview

domain within the same PDF. You should ensure that you list and present
all pieces of evidence in the same order. You should highlight your name/
key wording in the pieces of evidence.

Commitment to Speciality
MRCS Part A Examination
MRCS Part A is the first of two surgical exams, which you need to pass
before you apply to become an ST3 in a surgical speciality. Passing the
MRCS Part A is imperative for successful CST applicants. Previously can-
didates could gain points by simply booking the exam, but now a pass
mark is required. You should aim to sit the MRCS Part A at the end of FY1
or at the start of FY2. By sitting and passing this exam you score 4 valuable
points. Your knowledge will be fresh coming out of final year exams in
medical school, so we recommend capitalising on this.
The two things you need to think about before signing up to take this
exam are time and money. You can take it as soon as you become an FY1
doctor. Using your precious annual leave to revise is no fun, and the last
thing you want is to fail on your first attempt. The exam has a low pass
rate (35%) and merits adequate preparation. If you have a rotation with
no/minimal out-of-hours commitment, like GP or psychiatry, we recom-
mend using this four-month block to revise. Throughout the year there
are three annual sittings for the MRCS Part A exam – January, April, and
September.
Some useful resources to consider include the following:

1. eMRCS
2. TeachMeAnatomy
3. TeachMeSurgery
4. ATLS, 10th edition
5. Netter’s Atlas of Human Anatomy
6. Pastest

Attendance at Surgical Courses

Surgical courses are an excellent way to increase your knowledge and
skill base in surgery. Some courses are mandatory for your progression
as a surgeon and may be required for ST3 applications down the line. One
challenge many candidates face is the cost of many courses. Unfortunately,
there is very little room to manoeuvre here. You should consider these
courses as a professional investment. See what resources are available to
you in your deanery; some deaneries run free or discounted courses for
Chapter three: Preparing Your Surgical Portfolio 17

Figure 3.1 MRCS Part A – pass.

their trainees. Make sure you are aware of your study budget entitlements
and apply for funds appropriately.
Any surgical-themed course organised or accredited by one of the
Royal Colleges of Surgeons, an international/national surgical organisa-
tion, or a deanery will be accepted. Alternatively, any surgically themed
course with evidence of CPD accreditation will also be accepted. Non-
accredited or undergraduate medical school society-organised courses
will not be accepted. Courses that teach foundation-programme-level
skills (e.g. catherisation) will not count for points.
18 Smashing the Core Surgical Training Interview

When looking for courses, consider the offerings of all Royal Colleges
of Surgeons (England, Edinburgh, Glasgow, and Ireland), trainee organ-
isations (e.g. ASiT, BOTA, AOT), or trainee wings of national organisations
(e.g. the Mammary Fold, Roux Group, Duke’s Club).
Basic Surgical Skills and Advanced Trauma Life Support are par-
ticularly useful courses, conferring real-life knowledge and skills for the
interview. Beware that these courses are extremely popular and can book
out more than six months in advance.

Examples of Surgical Where to Book Price (Approx.) Length

Courses
Basic Surgical Skills Royal College of £670.50 2 days
(Intercollegiate BSS) Surgeons England
Advanced Trauma Royal College of £749.00 2 days
Life Support (ATLS) Surgeons England
Care of the Critically Royal College of £799.00 2 days
Ill Surgical Patient Surgeons England
(CCrISP)
Systematic Training Royal College of £139.50 1 day
in Acute Illness Surgeons England
Recognition and
Treatment (START)
Future Surgeons: Key Royal College of £110 1 day
Skill Surgeons
Edinburgh
Surgical Skills for Royal College of £99 1 day
Students and Health Surgeons England
Professionals
ASIT Preparing for a [Link] Free for members Online
Career in Surgery
Course
Foundation Skills in [Link] Free for members 1 day
Surgery Course
So you Want to Be a Rouleaux Club Free Flexible, online
Vascular Surgeon
Surgical Skills BMJ Free Flexible, online

Operative Experience
All candidates should create an account on [Link], the pan-surgi-
cal electronic logbook for the UK and Ireland. You should log the cases
that you are involved with contemporaneously as you progress in the year.
Chapter three: Preparing Your Surgical Portfolio 19

Figure 3.2 Attendance at a surgical course.

This will ensure that you do not miss cases off your logbook. The top
candidates will start doing this from medical school onwards. Your aim
during the foundation programme should be to be involved in 40 cases
or more for the top marks. Your involvement needs to be ‘assisting’ or
‘supervised trainer scrubbed’; ‘observed’ will not count for points. If
you only have one three-month surgical block in your foundation pro-
gramme, you will need to participate in more than 13 cases a month. This
may be difficult to achieve with your prescribed rotas. You may need
to find opportunities to increase your surgical case volume. You should
identify elective lists without coverage and offer to staff these. You should
seek opportunities on the emergency list. We recommend involving your
rota coordinator before the start of your rotation and discussing your aim
for operative experience. You should position yourself in your group of
foundation programme doctors as the ‘go-to’ person if help is needed in
theatre. Many other foundation doctors will have no interest in perform-
ing this role.
The evidence for this section of the portfolio should be a consolida-
tion report from [Link]. The summary sheet needs to be signed
20 Smashing the Core Surgical Training Interview

and validated by a consultant, including their full name and GMC

number. No patient-identifiable data (including hospital numbers)
should be uploaded.

Figure 3.3 Operative Experience Logbook – part 1.

Chapter three: Preparing Your Surgical Portfolio 21

Figure 3.4 Operative Experience Logbook – part 2.

Attendance at Surgical Conferences

Surgical conferences are a chance for you to increase your knowledge, con-
nect with the surgical community, and showcase your work. You should
attend three conferences to score the maximum marks. Many conferences
are available for free or with discounted rates for medical students and/
or junior doctors. You can attend these virtually or in person, with the
virtual option often offering a significant discount. Single webinars will
not count towards points. You should request a conference attendance cer-
tificate straight after the event and store this safely.
Examples of a few organisations that have conferences include the
following. It is ideal to submit a piece of work to these conferences and
combine this with attendance.

• ASiT
• Royal College of Surgeons
22 Smashing the Core Surgical Training Interview

• Association of Surgeons of Great Britain and Ireland (ASGBI)

• Association of Upper Gastrointestinal Surgery of Great Britain and
Ireland (AUGIS)
• Royal Society of Medicine
• ENTUK
• ACE Medicine
• British Orthopaedic Association
• British Association of Plastic Reconstructive and Aesthetic Surgeons
(BAPRAS)
• British Association of Urological surgeons (BAUS)
• Society of British Neurological Surgeons
• Vascular Society

Figure 3.5 Surgical conference attendance.

Chapter three: Preparing Your Surgical Portfolio 23

Surgical Experience
If you have a surgical placement during your foundation programme,
you will score full marks in this section. As you are interested in surgery,
it is imperative that you rotate through a surgical block to consolidate
your interest. At the end of your rotation, you should obtain a signed let-
ter from your educational supervisor on official letterhead, including the
name of the placement, hospital, and the dates undertaken. Alternatively,
you can obtain full marks in this section if you have completed a four-
week surgical elective during medical school. If you do not have a surgi-
cal rotation you must arrange for a five-day taster week in surgery. These
days can be non-consecutive. Double-check the guidelines for the exact
wording and requirements required for these letters. You may need to
pre-draft them for your supervisors to sign to make sure they are worded
appropriately.

Figure 3.6 Surgical placement letter.

24 Smashing the Core Surgical Training Interview

Figure 3.7 Surgical elective letter.

Postgraduate Degrees and Qualifications

In previous years, additional postgraduate degrees were considered for
points. This has been removed for the 2023 intake.
This was a section that many candidates struggled in. Compared to
all the other sections, this part of the portfolio required the most invest-
ment of time and money. If you intercalate during medical school this can
be used for points. You should pursue additional qualifications only if you
are truly interested in the subject. During the foundation programme,
there are part-time master’s degrees (e.g. University of Edinburgh/Royal
College of Surgeons of Edinburgh MSc in Surgical Sciences) that can
Chapter three: Preparing Your Surgical Portfolio 25

Figure 3.8 PhD certificate.

be commenced. This course will also help you to prepare for the MRCS
examination.

Prizes/Awards
This domain rewards candidates who have demonstrated excellence in
their training. During medical school, you may be able to pick up one of
the yearly prizes for various subjects.
In the context of Core Surgical Training, the prizes that are being con-
sidered relate to outstanding work that has been submitted to a medical
meeting. Every audit, quality improvement project, and piece of research
can be turned into an abstract and submitted to a conference. National
meetings score the highest points, with regional meetings scoring fewer
points. You should aim to submit your work to national meetings.
Keeping up with select organisations through mailing lists or sub-
scribing to social media updates will alert you to opportunities, such as
conferences, essay prizes, and other awards.
26 Smashing the Core Surgical Training Interview

Figure 3.9 Prize certificate.

Quality Improvement/Clinical Audit

Leading a surgically themed audit or QI project that demonstrates change
is a high-yield activity that can propel your marks significantly. Achieving
full marks in this section can be reached by working smart. During foun-
dation training, you must complete an audit each year. Many audit proj-
ects can come your way. It is up to you to select wisely.
Key principles to bear in mind when selecting an audit:

• Who are the registrars and consultants involved in the project? Are
they known to have completed audits previously and have they pub-
lished work consistently before?
• Is this a closed-loop audit – i.e. will there be a first cycle where a
problem is identified and an intervention is made followed by a
cycle second?
• What is the time frame? Ideally, you want to pick a project that you
can finish quickly. Examples of such topics are VTE prophylaxis,
antibiotic prescription, operation note standard, WHO surgical
safety checklist, ward round documentation, or quality of handover.
• You do not want to be spending too long on this. You must aim to
complete the audit loop cycle in less than six months.

Be careful when wording your evidence. Make sure it matches the specifi-
cation word for word so there is no confusion for the examiners. In previ-
ous years, this has meant including the words ‘lead’, ‘surgically themed
closed-loop audit’, and ‘demonstrated positive change’.
Chapter three: Preparing Your Surgical Portfolio 27

Figure 3.10 Audit confirmation letter.

Teaching Experience
This section is designed to show off your teaching experience and has
a big weighting. This section gives you the second most points in your
portfolio. It can be a challenge to show it off accurately, and therefore, you
should ensure you obtain feedback forms from students whilst also get-
ting a letter signed by the consultant confirming involvement in design-
ing and organising a teaching programme.
28 Smashing the Core Surgical Training Interview

Figure 3.11 Teaching confirmation letter.

We advise being smart in this section. Many candidates who have not
organised teaching at the university level end up spending a lot of time
during foundation training organising an elaborate teaching programme
which may not finish in time for the application deadline.

Training in Teaching
This section is where you will show off any training in teaching you have
had. However, it can be quite a challenging section to complete.
Chapter three: Preparing Your Surgical Portfolio 29

Figure 3.12 MEd degree certificate.

Many candidates will score 1 point in this section by attending the

Oxford Medical – Teach the Teacher Course for Doctors, which is a two-
day interactive course available both virtually and in person for £399.
Some students may opt to do a teaching-specific postgraduate quali-
fication, such as a PG Cert or PG Diploma. However, these options are
time-consuming and expensive. Moreover, if you are completing this dur-
ing your FY3 year, the odds are that you will not complete it before the
application deadline. Candidates need to weigh up if their time can be
spent more wisely for two additional points.

Presentations
Here you should include evidence of any poster or oral presentations at
international, national, and local conferences. When submitting abstracts
to conferences, you should always aim for national conferences. Poster
presentations are more achievable compared to oral presentations.
Typically, abstracts are derived from original research and audits.
Each hospital tends to have research fellows or surgical trainees with
research experience. Our advice is to contact these individuals early and
express your interest. At the same time, inform them why you want to
get involved in research. All surgical trainees know the importance of
presentations on your CV.
30 Smashing the Core Surgical Training Interview

Figure 3.13 Oral presentation letter.

A common surgical conference to aim for is ASiT as they accept a high

number of abstracts.

Publications
Publications are very challenging to achieve and becoming first author
of original research that is published in a PubMed ID journal can
be time-consuming. We advise students to get involved in original
Chapter three: Preparing Your Surgical Portfolio 31

research as first author; however, there is no guarantee that this work

will be finished in time for the application deadline. Always clarify
whether you will be a named author on the projects or not at the
beginning.
A more achievable and realistic target is case reports and editorial let-
ters, which are only 2 points less than a first-author publication.
A case report is a detailed report of the symptoms, signs, diagnosis,
treatment, and follow-up of an individual patient. These are less time-
consuming and have a greater chance of being published. The best way to
get a case report is to ask your surgical seniors. Surgery is always evolv-
ing, and unexpected events can happen all the time with the on-call team
or whilst in elective theatre. By being keen and asking around, you are
bound to find a case that can be written up. Unfortunately, many journals
now require a fee to publish case reports.
Another avenue is writing a letter to a medical journal where
researchers read original papers and write a short 400-word essay as a
response.

Figure 3.14 Publication acceptance.

32 Smashing the Core Surgical Training Interview

Leadership and Management

Many candidates have had a leadership role in some capacity whilst at
university or during their foundation training. Remember that the lead-
ership role in this section is not confined to the medical profession or
medical societies. Non-medical examples may include charity, youth
organisations, and sports, to name a few.

Figure 3.15 Leadership and management letter.

Chapter three: Preparing Your Surgical Portfolio 33

The key area in which individuals struggle is how they can demon-
strate a positive impact. The way to showcase to the examiner that you
have had a positive impact is by clearly writing a few sentences in the
letter which confirm your appointment of what you have achieved during
your tenure and how this led to a positive impact.
Those candidates who do not have a leadership role or want to aim for
a national role can do so by applying to any national medical or surgical
committee. Each committee has committee members at different levels.
An appropriate and achievable role to apply for is Foundation Year Rep.
We advise you to follow several national organisations on Twitter and
keep an eye on when they send out applications. The more you apply, the
more chance you have of getting accepted.

Conclusion
The CST self-assessment criteria are daunting to look at in the very begin-
ning. However, as you familiarise yourself with the requirements you
can build a plan for each domain. Breaking the work up into chunks can
make the task more manageable; scoring points in each area is achievable.
Candidates should start to work on their portfolio early, work in teams,
tackle their weaker areas first, and maximise the effort-to-glory ratio.
Year after year, the overarching domains have remained broadly the
same; however, the requirements within each domain can slightly differ.
Each year the requirements get released a month before the application
deadline, meaning there is not enough time to react to these changes. For
example, in 2021, you get maximum points for a surgically themed closed-
loop QI project; however, previously in 2020, the QI project could be in any
speciality. The more experience and evidence you gain over the years, the
more likely you are to have built a portfolio that is high-scoring despite
the yearly changes.
Many candidates find it difficult to get evidence back from their consul-
tants who are often very busy. You should take a proactive approach here.
Draft a document for the consultant which matches the self-­assessment
criteria word for word. The consultant has the option of changing the
wording. By facilitating the consultant’s job, you can ensure that the evi-
dence is fit-for-purpose and returned in a timely manner.
You should aim to score points in all domains. However, you should
prioritise maximising points in sections that have the highest weight
and are most achievable. This includes sections like Commitment to
Speciality (20 marks), Teaching Experience (10 marks), QI Project (8 marks),
Leadership (8 marks), and Poster/Oral Presentations (6 marks).
This chapter provides you with the necessary information and tools
to score highly in the portfolio section. Candidates will still need to put
in the time and effort to receive the required evidence. Work in a smart,
34 Smashing the Core Surgical Training Interview

methodical fashion with aim and purpose. We wish you success in your
application!

Case Study: Sharukh Jamal Zuberi

I am a core surgical trainee based in London. I graduated from Imperial
College School of Medicine in 2019. During medical school, I intercalated
with a BSc in management from Imperial College Business School (first
class honours). I completed foundation training in the Essex, Bedfordshire,
and Hertfordshire Deanery from 2019 to 2021. During my second year of
foundation training, I applied for Core Surgical Training with a modest
portfolio score of 48/72. Unfortunately, after the interview stage, I was
unsuccessful.
Instead of shying away, I used this year to become more focused on
my application. I took up the role of clinical teaching fellow at the Royal
Surrey County Hospital and completed a postgraduate certificate in medi-
cal education from the University of Surrey. This setback spurred me to
become even more focused towards my goal of becoming a surgeon.
I achieved membership in the Royal College of Surgeons of England in
2021 and reapplied for CST with a strong portfolio score of 67/72. Having
achieved full marks in my interview, I was ranked second in the country
during the 2022 round of CST applicants.
I am in a unique position of experiencing the very lows and highs
of the application process, having applied twice for CST. In this chapter,
you have read many of the tips and tricks for the portfolio section that
I employed successfully.

Reference
1. ht t ps://coresurg [Link]/w p-content/uploads/2021/11/CST-
[Link]
chapter four

How to Publish
Alan Askari

There are a few things that terrify surgical trainees more than the pros-
pect of writing and publishing a scientific paper. At the heart of this dread
is a series of misconceptions. The most inhibiting of these is that carrying
out academic projects and publishing papers are inherent traits that some
lucky chosen few are born with, rather than a skill that can be learnt by
anyone. I hope that this chapter will dispel some of those myths and dem-
onstrate that writing and publishing scientific manuscripts is a skill that
is learnt over time, like any other in surgical practice, and is not one that is
particularly difficult to learn. This chapter will focus on how to organise
yourself to write scientific papers and move on to getting them published
in a timely manner. At the end of the chapter, there is a template for your
writing endeavours.

Myths
The preconception that writing papers is only for ‘academics’ in surgery
is so pervasive that it has led to many trainees developing a fixed rather
than a growth mindset. Many trainees only write the minimum papers
require to graduate from surgical training. Over the years, I have heard
many reasons that people ‘cannot write a paper’. Here are my top five
favourite myths:

1. Writing papers is hard/takes a long time: Whilst it is true that writing a

scientific paper requires the dedication of time and effort (like any
other new skill we learn), it is important to remember that it is not a
particularly long learning curve. Maintaining momentum is the sin‑
gle most important factor in successfully completing a project. Many
projects fall into the academic graveyard and are never completed
for the simple reason that participants do not persevere to get over
the last few hurdles despite investing weeks and months of work
into it.

DOI: 10.1201/9781003350422-5 35
36 Smashing the Core Surgical Training Interview

2. I’m naturally no good at writing papers: Strictly speaking, this is abso-

lutely true, but guess what? No one is naturally good at writing
papers! It is a skill that we learn and develop. Yes, some people may
have more ability and will be quicker on the learning curve, but no
one is ‘naturally gifted’ in writing a paper any more than they are at
driving a car or playing the violin. They learn over time and so can
you.
3. I’m not a native English speaker/writer: Whether we like it or not,
English is the lingua franca of academic writing. Whilst native
English speakers may find it easier to overcome their learning curve,
anyone can be trained to write an academic paper. Some of the best
manuscripts I have seen written have not been written by native
English speakers.
4. I can’t write ‘scientifically’: The idea that a good article must be lengthy
and requires complicated writing to make it seem credible is quite
frankly preposterous. Quite the opposite is true – the most well-
written academic papers are those in which the authors can deliver
the key ideas and message of their project in a style and format that
can be easily understood. As one of my all-time heroes, US physicist
Richard Feynman, once said, ‘If you cannot explain something to a
first-year student, you don’t know it well enough’.
5. Only high-impact factor journals publish well-written papers: Impact fac-
tor, h-index, and all other metrics of measuring academic output have
their own controversies. The medical literature is full of examples
of how even the highest-impact journals can publish articles which
have turned out to be incorrect or in some cases, even worse, out-
right fraudulent. Equally, some of the best, most practice-­changing
papers have been published in relatively lower-impact journals hav-
ing been rejected by the ‘big hitters’.

The Recipe
Now that we have successfully dispelled all these myths and fixed ideas,
it’s time to get into a growth mindset. The remainder of this short chapter
will focus on a step-by-step cookbook that will have you writing in no
time. Let us assume that you have completed your project, i.e. you have
collected all your data, you know what outcomes you are investigating
and now the time has come to write it up and submit it to a journal. Here
are 10 easy steps that will help you get there quickly:

1. Have a template: Never, ever, ever write up an academic paper start-

ing from a blank document. It is the most demoralising and painful
experience you can have in academia and the surest way of putting
Chapter four: How to Publish 37

you off writing it altogether. Instead, create a template that is filled

with sub-headings and bullet points that you can use for every
paper. That way, when you come to write a paper, all you need to do
is write around the bullet points that you have written, and before
you know it, half the paper is written for you. My first session of
writing a paper is only this – populating my template with bullet
points, ideas, and short notes. I then leave it and come back to it at a
later date to fill in those bullet points.
2. Clarify what you want to convey: This cannot be overstated enough;
have a clear understanding, in very simple everyday language, of
the message you want to convey. The simpler the language, the more
direct, the better. Avoid the use of colloquialisms and unnecessary
words. Remember, in science complicated does not mean better.
3. Work in bursts: It is very difficult, if not impossible, to write a man-
uscript from start to finish in one sitting. This is one of the main
areas where people go wrong. They feel like they need to clear an
entire weekend of their lives to dedicate to writing the manuscript.
Inevitably this is not possible. Surgical training, work duties, part-
ners, family, children, and life in general will have other plans for
you. As a result, that weekend where you were going to ‘just write’
never comes. The project runs out of steam, months go by, and that
blank document that was going to be a paper just sits there on your
laptop. Be realistic. Work in bursts. Have a way of scheduling time
to write just two to three paragraphs a week. Before you know it, in
a month you have a paper!
4. Maintain momentum: This is the mother of all project killers. We have
all been there. Over a coffee break after a ward round, a group of
clinicians gather round, and someone will pipe up with ‘It would be
really interesting to look at . . .’ or ‘We have some data we collected,
we just need someone to write it up . . .’ And just like that, a project
is born to applause and fireworks. Two months later, nothing has
moved forward. Avoid this like the plague; at that very same meet-
ing, write out who the project members are and who will do what
and by when. Assign responsibility and realistic deadlines to each
team member and hold them to account. Make them buy the coffee
each time until they do not deliver; they will either stop drinking
coffee with you, or you will get the project done. Either way, you
will know where you stand. There are no rewards for half-finished
projects. To quote everyone’s favourite vertically challenged, green
sage, ‘Do or do not. There is no try’.
5. Re-draft: Accept that more than one draft is necessary. Therefore,
selecting collaborators for your team is of vital importance. Different
people will have different perspectives on your work. It is very easy
38 Smashing the Core Surgical Training Interview

to develop tunnel vision when you are writing a manuscript from

start to finish.
6. Use technology wisely: Never work with 12 different tabs open,
including your favourite animals doing cute activities on YouTube.
Close all non-essential programs, remove your phone to another
room, and set an allocated time to write your two to three para-
graphs in that one sitting. Emailing your fellow collaborators, the
14th re-draft (23 drafts is my personal record – I am still recovering
from that trauma) is a terrible idea. Use cloud-based documents,
such as Google Drive, Dropbox, or Box, so that everyone is work-
ing from a single document and all changes made can be seen by
everyone in real time.
7. Use a reference manager: I remain convinced that those who do refer-
ences manually must hate not only themselves but all living beings in
the universe. Otherwise, why would they want to introduce so much
suffering into the world? It takes hours to do references including
every dash, dot, full stop, bracket, italic, boldface, and who knows
what else to a particular journal’s liking. Then what happens? Your
consultant, attending, senior author, or professor decides actually
the International Journal of Occult Mythological Medicine would be a
better fit for your paper than the World Journal of Occult Mythological
Medicine. Of course, they both have completely different referencing
formats. There goes the weekend. Use a reference manager. There
are many different ones out there. Many are free, and some require
a subscription or a small fee. Examples are EndNote, Zotero, and
Mendeley. It does not take long at all to learn how to use them, and
it will save you hours of time and months of psychological therapy.
8. Select your target journal: Different journals have different interests,
and they have specific readerships to cater to. Think carefully about
whether your paper is something that this journal is interested in.
Have they previously published similar papers? Optimism is a very
nice trait, and far be it for me to discourage it, but sending your
n = 15 patients who had wound complications after appendicitis to
Nature is unlikely to yield favourable results.
9. Respond to reviewers: Once you do get a journal that is interested in
your manuscript and asks you to make minor amendments or to
respond to reviewer comments, get started on it early. Reply to each
specific point raised by the reviewers in a different colour and high-
light the changes in the manuscript to make it easy for the editor to
identify.
10. Be resilient: Nineteen – yep, 19 – that is my record number of rejec-
tions for a single paper before it finally got accepted somewhere.
Accept that not every journal or reviewer will like what you write.
Chapter four: How to Publish 39

Accept that reviewer 2 (it is always reviewer 2) will come up with

some ridiculous comment that will make you question if the edi-
tor sent them your paper or someone else’s. Take the good points
and the advice, and make the changes that you and your fellow
authors think are reasonable and send them to the next journal on
the hit list.
40 Smashing the Core Surgical Training Interview

[Title of Manuscript]
Full Names of Authors

Author Titles and Affiliations

• Relevant medical degrees of each author
• Hospitals/universities each author is affiliated with

Corresponding Author
Name and email of the corresponding author

Conflict of Interest and Funding

The authors declare no conflict of interest, and no funding has been
obtained for the purposes of this study.

Author Contribution
• Report how each author contributed to the study (e.g. ‘The study was
conceptualised by AA and AB. Data collection was performed by
AA, AC, and AD. The manuscript was written by AA and AE and
edited for scientific content by AE and AF’).
Chapter four: How to Publish 41

Abstract (200–300 words)

Introduction (1–2 lines)
• Line 1 (brief background of the main condition): Diabetes is a com-
mon chronic condition affecting millions of people worldwide.
• Line 2: The main aim of this study is to determine the efficacy of
metformin in treating type 2 diabetes.

Methods (1–2 lines)

• Line 1: A systematic review and meta-analysis were conducted using
PubMed, Google Scholar, and OVID.
• Line 2: The PRISMA checklist was used, and Forest plots were gen-
erated to demonstrate the difference between the two groups.

Results (3–4 lines)

• Lines 1–2: Main demographics: A total of xxx articles/patients were
included in this study, of which xxx% were female; the median age
was xxx years (IQR yy-zz).
• Lines 3–4: Main findings: Patients who underwent treatment xxx
were 35% more likely to . . .

Conclusion (1–2 lines)

• Line 1: Treatment xxx is associated with xxx in patients with xxx.
• Line 2: The recommendations of this study are . . . Further work is
required to clarify whether this is . . .
42 Smashing the Core Surgical Training Interview

Introduction (2–3 paragraphs)

• Paragraph 1: Opening paragraph about the health condition/
situation.
• Paragraph 2: Brief background on what others have reported on this
specific issue.
• Paragraph 3: Explain why research in this area is important. The last
sentence should lay out what the aim of the study is.

Methods (2–3 paragraphs)

• Paragraph 1: The duration of the study (e.g. ‘from January to
May 2015’) and inclusion criteria.
• Paragraph 2: Ethical approval (if required), variables collected, and
statistical analysis.

Results (3–4 paragraphs)

• Outline the key findings of the study with reference to tables and
figures.

Discussion (6–8 paragraphs)

• Paragraph 1: The first line must state the main findings of the study.
• Paragraphs 2–6: The main discussion points in relation to findings of
other studies.
• Paragraph 7: Main limitations of the current study.
• Paragraph 8: Summary of the paper, conclusion, and future work
needed.

References
• Check journal referencing format and use referencing software,
such as Mendeley, EndNote, ReadCube Papers, [Link], Zotero,
and Article Galaxy Enterprise.

Tables and Figures

• Label all tables and figures.
• Limit the number of tables and figures to a maximum of five to six in
total.
• Ensure tables and figures are referred to in the text and there are no
contradictions.
chapter five

Mastering the Presentation

Humayun Razzaq and Janso Padickakudi Joseph

During this highly predictable part of the interview, you will need to give
a short presentation about a predefined topic and answer questions for a
couple of minutes. Invariably, the topic relates to a broad aspect of surgery,
such as leadership, teamwork, or communication, and how this relates to
being a core surgical trainee (CST). If you come prepared, you can score
full marks on this aspect with ease.

Understand Definitions
Read and re-read the topic for your presentation and ensure you under-
stand all the questions’ components. When you are preparing your
answer, be sure to address every part of the stem.
Imagine the topic is leadership. Make sure that you understand the
definition of leadership inside out. This does not just involve the diction-
ary definition. Read about different ways and models to conceptualise
leadership. Ask yourself the definition from a multitude of angles. For
example, you should be able to answer what are the attributes of a good
leader, what makes a bad leader, and what the difference is between lead-
ership and management.

Use Your Own Experience

Now that you understand the definition, delve deep into your lived experi-
ence, and dig up the most pertinent examples that show how you demon-
strate these attributes. Your examples can certainly come from medicine.
However, they are often more memorable and powerful if they come from
outside of medicine. Make sure that you chose an example of something
reasonably recent. And make sure that it is an example that you are pas-
sionate about. This is also the time to showcase your uniqueness, and
diversity in thought will be appreciated here. Imagine the situation from
an interviewer’s point of view. Interviewers will be hearing presentation
after presentation about an individual leading a trauma team or leading a

DOI: 10.1201/9781003350422-6 43
44 Smashing the Core Surgical Training Interview

quality improvement project. Of course, these can be effective and inter-

esting. However, you will catch the interviewer’s imagination if you pres-
ent an example that is outside the box.

Relate Your Experience Back to CST

Once you have picked one or two examples to speak about, make sure that
you flesh out what attribute you are trying to present. If the attribute is,
for example, the ability to delegate, then make sure that you tie this back
in with life as a CST. This will show the interviewer that you understand
the realities of being a CST. You must complete this step, as otherwise you
have just told an interesting story without demonstrating why this makes
you an outstanding candidate to become a surgeon.

Practise, Practise, Practise

When narrating the experience, it is important that it showcases your
ability to communicate effectively. There is a lot of emphasis on devel-
oping and consolidating communication skills in CST. You should aim
to make no more than three points during your presentation, as it will
be too unwieldy otherwise. Use top-down communication, which means
setting the scene first (‘In my presentation, I am going to speak about X,
Y, and Z’) and then delving deeper into each. That way, the interviewer
has a roadmap of where your presentation is going. Make sure that you
have a strong concluding sentence to avoid an awkward silence at the end.
Practise in front of the mirror, to your colleagues, to your friends and fam-
ily. Try your presentation on someone outside of medicine. This will give
you valuable insights. For full marks, your presentation should be well-
rehearsed, delivered without notes, and precisely timed.
chapter six

How to Structure Your Answers

Clinical
Anokha Oomman Joseph and Janso Padickakudi Joseph

Having a logical, robust structure to your answer will allow you to pres-
ent yourself as an organised, trustworthy core surgical trainee (CST).
Although there is no one right way to deliver an answer, we present a scaf-
fold on which you can build during your practice sessions. You should aim
to deliver your answer in one go, without interruption by your assessor.
If you answer all the points on the scoresheet through your unprompted
answer, you will score maximum points.
The example scenario that we will use is as follows:

You are the core surgical trainee on the trauma team. You are asked to attend
to a major trauma. The patient is a 27-year-old male driver of a car that has
crashed. He is complaining of intense abdominal pain. He is haemodynami‑
cally unstable.

Step 1: Identify the problem, and mention possible outcomes.

• Usually, the stem of the question relates to one obvious disease
pathology. Very occasionally, there may be two competing diagno-
ses. You should start by stating this clearly. Your second sentence
should mention possible outcomes – usually either a scan or an
intervention. By starting the case in this way, you focus the exam-
iner’s mind and let them know that you understand the big issues
and decisions at hand.
• In this scenario, I am concerned that the patient is acutely unwell and has
a possible life-threatening intra-abdominal injury, such as bleeding from
the liver or spleen. They may be in haemorrhagic shock. I am considering
whether the patient is stable enough for a scan or whether they may need to
go to theatre immediately for a damage-control laparotomy.

DOI: 10.1201/9781003350422-7 45
46 Smashing the Core Surgical Training Interview

Step 2: Alert the appropriate team.

• If you are dealing with an unwell patient, you need to make sure
to alert the correct team. Sometimes it will be entirely appropriate
for you to make an initial assessment independently. If the patient
is severely unwell, you will want to alert the medical emergency
response team, the trauma team, or your registrar very early. There
is a fine balance here between working autonomously to the level of
a trustworthy CST or being seen as either too cautious or overconfi-
dent. The key is to appear competent, confident, and safe.
• In a haemodynamically unstable trauma patient with a potential for signifi‑
cant injuries, I need the help of the entire trauma team. I would ensure a
trauma call has been put out, with all associated specialities in attendance,
including general surgery, A&E, and orthopaedics. Given the severity of
this patient’s presentation, I would alert my registrar immediately.

Step 2: Use an assessment framework to make an initial assessment.

• Whenever you are assessing an unwell patient, you should use a
framework. In an acutely unwell patient, you should use the CCrISP
model. In a trauma scenario, you should use the ATLS model. In
either case, you will perform an A–E assessment of the patient ini-
tially, then look at basic investigations or documentation. The extent
to how detailed your description of the A–E assessment will depend
on the acuity of the patient. If you have a trauma patient who is short
of breath, you want to describe the airway and breathing assessment
sequentially, in great detail. Conversely, if you have a post-operative
patient who is septic, A and B will not be as relevant, and you can
skim over these. The key is to make a sensible, holistic assessment of
the patient.
• I would attend to this patient immediately using the ATLS approach.
I would ensure that their c-spine is secured with three-point immobili‑
sation. I would make an assessment of their airway by speaking to the
patient. I would introduce myself and ask them their name. If they are able
to respond, I would move on to B. I would listen to their lungs to ensure
equal air entry bilaterally. I would assess their respiratory rate and oxygen
saturation. I would check for significant injuries to the chest wall. I would
deal with any life-threatening findings such as a tension pneumothorax at
this stage. In C, I would obtain the patient’s heart rate and blood pressure.
If they are hypotensive and tachycardic, I would be concerned about haem‑
orrhagic shock from intra-abdominal bleeding. I would ensure the patient
has two large-bore peripheral IV lines, with blood specimens sent off at the
same time, including an FBC, U&E, LFTs, coagulation screen, X-match
for four units, and VBG. I would activate the major haemorrhage protocol.
Chapter six: How to Structure Your Answers 47

Given how unwell the patient is, I would give them two units of O-negative
blood and see how they respond. Given that I believe they are having intra-
abdominal bleeding, I would also examine their abdomen at this stage to see
if they are peritonitic. To complete my primary survey, I would proceed to
D by examining GCS, temperature, and pupils. For E, I would examine long
bones and perform a log roll with rectal examination.

Step 3: Speak about the history and physical examination.

• State what aspects of the history and physical examination you find
relevant. For example, in a trauma patient, you want to understand
the mechanism of injury through a focused history. You will also
want to localise any pain they are experiencing. Physical examina-
tion should be described, with a couple of potential findings. In the
example, you have already performed most of the physical exami-
nation during the detailed A–E assessment. Here you will need to
be creative about potential findings and outcomes, as the examiners
will not give you any further clinical information.
• Once my primary survey is complete and I have addressed any life-threat‑
ening complications, I would ask the patient for a focused history, includ‑
ing an AMPLE history (allergies, medications, medical history, last meal,
events). At this stage, if the patient is not responding to resuscitation and
has a peritonitic abdomen, I would be concerned about life-threatening
intra-­abdominal bleeding. If they are responsive to resuscitation, we may
have time for further investigations.

Step 4: Speak about investigations.

• Here you will want to discuss any investigations that can either
help you make a diagnosis or a decision. You have already sent off
blood tests in your A–E assessment, but you may also want to con-
sider microbiology (e.g. blood cultures in a septic patient), diagnostic
radiology (e.g. FAST scan at bedside, x-rays, ultrasound, or CT scan),
interventional tests (e.g. interventional radiology, interventional
endoscopy), or operative management (i.e. straight to theatre).
• In this scenario, the patient is haemodynamically unstable. If they do not
respond to resuscitation, then I would ask A&E to perform a FAST scan at
the bedside. This will confirm if there is free fluid in the abdomen. This is
a surgical emergency and will need to go to theatre for a damage-control
laparotomy. However, if they respond well to the resuscitation and are no
longer tachycardic and hypotensive, I would consider whether to get a scan.
This would take the form of a triple-phase CT of the chest/abdomen/pelvis.
This scan will localise the injury and potential source of bleeding.
48 Smashing the Core Surgical Training Interview

Step 5: Escalate/involve.
• Now that you have made a full assessment of the patient, you want
to escalate their care appropriately. This includes escalating up and
down within your own team. Involve your foundation doctors and
any physician associates on your team, and delegate tasks to them.
Escalate early to your registrar and the consultant on-call. You also
want to escalate across to other medical specialities (e.g. medicine,
anaesthesia, paediatrics, or interventional radiology) as appropri-
ate to the case. You may want to involve other teams (e.g. intensive
care, critical care outreach, or theatres). Finally, consider members
of the wider healthcare team that require involvement, including
nurses, radiographers, porters, the theatre coordinator, or the site
manager.
• When managing this patient, I would utilise my entire team. I would ask
my FY1 to perform specific tasks during the assessment and resuscitation,
such as running the VBG and communicating the result back to me. I would
escalate early to my registrar and even directly to my consultant in this life-­
threatening scenario, especially if I think the patient needs an emergency
laparotomy. I would want to involve other specialities early, including radi‑
ology, ICU, or anaesthesia. In addition, I will need to liaise with nursing
staff or the theatre team if I thought the patient needed to go to theatre
immediately. If the patient needed to go for a scan, I would alert the radiog‑
raphers and porters as to the urgency of the scan. I may also want to discuss
scan findings with interventional radiology. All the while, I would ensure

Figure 6.1 Clinical escalation pathway.

Chapter six: How to Structure Your Answers 49

that there is a member of staff assigned to document this patient’s progress

contemporaneously, and I would write notes as soon as the patient’s urgent
needs are met.

Step 6: Keep the patient at the centre of care.

• If you can keep the patient at the centre of care while you discuss
this scenario, you will demonstrate your real-life empathy. This will
set you apart from most candidates. Always consider whether there
are wider social issues that you be leading to this presentation – for
example, is a trauma an accident, a self-harm attempt, or an assault?
Are there safeguarding issues to consider? Is any long-term follow-
up required?
• Throughout all of this, I would keep the patient at the centre of care and,
if possible, involve their family. I appreciate that this is a high-stakes, life-
threatening situation and that this can be scary or stressful for the patient.
I would ensure that their symptoms, especially pain, are adequately con‑
trolled using medications. I would also speak directly to the patient, explain‑
ing every step of the way, addressing them by name, and making eye contact
with them, as it must be frightening for so many things to be happening at
once while in the supine position. I would involve the patient’s next of kin
and keep them informed. If the patent needs to go to theatre immediately,
I would consent them if I felt comfortable or, alternatively, fill out a consent
form 4 if the patient was not in a state to consent.
chapter seven

How to Structure Your Answers

Management
Anokha Oomman Joseph and Janso Padickakudi Joseph

Like in the clinical scenario, you should have a logical, robust structure to
your management scenario answer. For most questions, you can use the
SPIES framework (seek more information, patient safety, initiative, esca-
late, support) to deliver your answer. If you can bring in empathy and per-
sonal experience, this will show that you are truly ready to become a CST.
Again, you should aim to deliver your entire answer in one go, without
the need for prompts.
The example scenario that we will use is as follows:

You are the new core surgical trainee on urology in a tertiary centre. The job
is known to be busy. There are four unfilled posts on an eight-person junior
surgical rota. You find that you are being asked to cover on-calls regularly.
How would you approach this situation?

Step 1: Identify and name the problems.

• Once you read the scenario, take a deep breath and think. Try to
distil the issues into the two or three most important management
problems. You will not be able to speak about all facets of the prob-
lem, so focus on the key issues. Here you want to use big-picture
buzzwords, such as ‘patient safety’, ‘professionalism’, ‘training’, or
‘workforce planning’.
• The key management issues are the distribution of work, patient safety, and
my own training needs. I would approach this situation with an open mind
as on-calls are often an excellent learning opportunity, both in terms of
managing patients and exposure to theatre.

DOI: 10.1201/9781003350422-8 51
52 Smashing the Core Surgical Training Interview

Step 2: Seek more information (S).

• State how you would approach this situation and gain the maximum
amount of information. Make sure that you consider your viewpoint
and those of others. Be sure not to be accusatory or biased in your
assessment, and approach the problem with a growth mindset – i.e.
that there are important things to learn, even in a difficult situation.
• As a first step, I would review the rota to determine if my suspicions are cor‑
rect. I would see how many on-calls I have been covering and whether this
has impacted other aspects of my learning. I would also assess if there have
been other adjustments made because of the increased on-call frequency,
such as dedicated theatre days or compensatory days off. I would review
my logbook and workplace-based assessments and evaluate whether I am on
track to achieving the required competencies.
• I would initiate a discussion with the three other junior doctors on the rota.
I would ask about how they are managing their duties and weekly schedule,
including time on the ward, clinics, and theatre. Perhaps there are other
trainees who have previously been on this rotation. I can approach them to
find out if this has been a recurring issue.

Step 3: Consider the impact on patient safety (P).

• Everything we do in clinical medicine eventually leads back to
patients. You need to centre your response to reflect that you under-
stand that the patient is the centre of everything we do as clinicians,
be that providing clinical care, teaching, or research. We recommend
that you address patient safety directly.
• My main concern is the potential impact that staffing shortages can have
on patient safety. I would consider the impact of the staff shortage on the
provision of services, both elective and emergency.

Step 4: Take initiative (I).

• You should present yourself as a thoughtful, proactive team player.
You should aim to make a positive contribution to whatever difficult
situation is being presented to you. In a management scenario, this
may take the form of an audit to further understand the situation.
• At this point, I would consider auditing the rotas over a period of a few weeks
to assimilate evidence of my concerns. I would seek out as many training
opportunities in my current situation until things have been resolved.
Chapter seven: How to Structure Your Answers 53

Figure 7.1 Management escalation pathway: clinical issues.

Step 5: Escalate (E).

• With the evidence in hand, you will want to escalate your concerns.
Usually, this takes the shape of three routes of escalation: clinical,
training, or professional. Make sure you mention every step and
stop if your concern is resolved.
• The clinical escalation pathway for management scenarios is as fol-
lows: registrar → consultant in charge of case → clinical supervi-
sor → clinical director → divisional director → chief medical officer
(CMO). You will also want to submit a Datix report (Figure 7.1).
• The training escalation pathway for management scenarios is as fol-
lows: At the local level, it involves the registrar → educational super-
visor → Royal College tutor → director of medical education. You
may also want to involve the rota coordinator and guardian of safe
working. At the deanery level, it involves the trainee representative →
54 Smashing the Core Surgical Training Interview

Figure 7.2 Management escalation pathway: training issues.

training programme director → head of the school of surgery → post-

graduate dean. If the issues persist, you would escalate to the General
Medical Council or the Royal College of Surgeons (Figure 7.2).
• The professionalism escalation pathway for management scenarios
is as follows: registrar → educational supervisor → clinical director
→ divisional director → chief medical officer → chief executive offi-
cer. Depending on the circumstance, you may also need to involve
the deanery, as detailed. In extreme circumstances, if your concerns
remain unresolved, you will want to escalate to external organisa-
tions, including the BMA, the GMC, the Royal College of Surgeons,
or your defence union (Figure 7.3).
• I would escalate my concerns to my educational supervisor, my clinical
supervisor, and the rota coordinator. I would try to proactively suggest solu‑
tions that have been discussed with the other junior doctors. Perhaps the
fair distribution of on-calls and increased support of other training require‑
ments are required. Perhaps foundation-year doctors or registrars are able
to cover some of the duties. Maybe locum doctors might need to be recruited.
The department should also consider why there are four vacant positions
and how these can be filled.
Chapter seven: How to Structure Your Answers 55

Figure 7.3 Management escalation pathway: professionalism issues.

• If my concerns are unresolved, I would escalate them to my trainee repre‑

sentative or the Royal College tutor. If my training is being impacted signifi‑
cantly, I would involve my training program director. The clinical director
for the department, director of medical education, and the guardian of safe
working may also need to be involved. The British Medical Association may
also be consulted, especially to ensure that the rota is compliant with the
European Working Time Directive.

Step 6: Support (S).

• You need to show empathy and concern for your colleagues, even in
a scenario where you may be feeling attacked. You can demonstrate
your understanding of complex situations – for example, by saying
that you may not be able to provide support directly – but support
may be available.
• As all of this occurs, I would offer support to my fellow junior doctors, who
may be struggling with the intensity of the workload. I would aim to man‑
age this situation in a calm and professional manner.
56 Smashing the Core Surgical Training Interview

Step 7: Final considerations.

• In closing your management scenario, you want to make any final
considerations. If you have not yet done an audit on the subject mat-
ter, this may your chance to say it. An audit will not be appropriate
in every case. You will also want to present yourself as a thoughtful
future CST and want to include reflection as part of your answer. If
the scenario involves harm to a patient, you will want to apologise to
the patient and direct them to the Patient Advice and Liaison Service
(PALS). You will want to enter a Datix report and discuss the case
at the morbidity and mortality meeting. The situation might need a
root cause analysis. If you are facing a never-event, this will require
a serious incident report and central reporting. You, or a member of
the team, will need to inform the patient using duty of candour.
chapter eight

Virtual Interview Etiquette

Viswa Rajalingam and Janso Padickakudi Joseph

Introduction
Since the COVID-19 pandemic, there has been a seismic shift in the adop-
tion of video-conferencing tools. What started out of necessity has now
become a convenience. Video-conferencing applications, such as Zoom
and Microsoft Teams, have become ubiquitous in almost every industry,
with medicine and surgery being no exception. Core surgical training
interviews are now web-based and seem set to be so for the foreseeable
future. Understanding and mastering these applications is essential to
allow you to communicate clearly and effectively and present your best
self to the panellists. Before you even think of joining your first video call,
you must ensure that you are appropriately set up. Most of our communi-
cation is nonverbal, so you must be seen and heard well.

The Setup
Stable Internet
Make sure that you have a stable, fast internet connection for the inter-
view. A superfast broadband connection plugged into your device is far
better than relying on a mobile hotspot. The availability of the internet or
WiFi signal strength may determine where you conduct your interview,
whether it is in your home, a friend/relative’s home, your hospital, or your
university. Prior to connecting, disable/hold off any major system updates
to the operating system, applications, or games as they will consume sig-
nificant bandwidth. Make sure that no one else in the household is down-
loading a large amount of data at the same time.

Conferencing Etiquette
You need a quiet, private room where you will be undisturbed for the
duration of your interview. If required, book a conference room at your
hospital or university. Prior to joining the virtual interview room, you will
be joining the holding room, and this is your opportunity for a final check

DOI: 10.1201/9781003350422-9 57
58 Smashing the Core Surgical Training Interview

of your video and audio transmission. Dress professionally for the occa-
sion, just as you would for an in-person interview. You can keep a glass of
water nearby but avoid drinking anything else. Canned drinks should be
avoided as they can be misinterpreted as alcoholic beverages. Do not eat
or chew gum during the interview.

Lighting
Choose a well-lit room, preferably with a light source behind the screen/
monitor and behind the camera. This light source should ideally be white
and preferably cold so as to not make you sweat. A white natural light
LED bulb is perfect for this.
Avoid having the light source behind you as you will present your
silhouette to the panellists. Having the light source on one side of you will
create shadows on the opposite half of your face. This will make it hard for
interviewers to see your expressions and may be distracting.

Background
A plain white or off-white background is the perfect backdrop for the
video interview. Failing that, choose a wall with a neutral colour. Avoid
having a window or any strong colours that may distract from you or,
even worse, colours that may blend you into the background.
Avoid having a busy background, especially with pictures, paintings,
or bookshelves. If you want to add some colour, then a simple houseplant
will do. If you are adding props, be mindful of how the picture is framed;
you do not want plants sticking out of your head!
Be aware that colours may come through differently on camera. This
is especially the case on lower-quality webcams, such as those built into
laptops. Some webcams may not have a wide colour range and suffer from
poor colour reproduction. Therefore, it is worth checking with a preview
on whichever application you are using to make sure that you can be seen
clearly. Lighting can also have a big effect on colour representation on
camera, so it is worth ensuring that lighting is set up beforehand.

Equipment
Whilst it is not necessary to have audio-visual equipment that would
rival the BBC, investing in a good-quality webcam and having a clear mic
available will serve you well beyond just the interview.
Laptop webcams are what most people are going to use. If you are
using one, you must make sure the lighting is adequate as these web-
cams typically have the smallest of sensors. These sensors struggle in
low-light conditions and the subsequent software correction can result in
Chapter eight: Virtual Interview Etiquette 59

poor image quality and colour reproduction. A dedicated webcam usu-

ally results in a much-improved picture quality and can be used in future
presentations and conferencing. These devices can come with additional
features, such as superior image processing and adjustable field of view,
as well as privacy features. With the sky being the limit, it is important
not to get too carried away. Typically, a 1080p or 2K webcam with good
low-light performance should suffice. Adjustable field of view is a bonus
as it allows you to frame yourself perfectly in the resultant video output.
Choosing a good microphone is important so that the interviewers
can hear your voice clearly and without unwanted interference. Whilst
software noise cancelling has improved dramatically in recent years, hav-
ing high-quality input will ensure that your voice will sound as natural as
possible without any unwanted cut-outs and noise. Using earphones with
a clip-on mic attachment is a perfectly adequate option that will sound
better than a standard laptop-embedded mic. A dedicated headset is a
better option but try and find one that is not too bulky or horribly over-
sized. Alternatively, a dedicated mic on a stand is a good if not slightly
overkill option, but it has the advantage of being more versatile if you
were to use it in future projects or video lectures. If you do go down the
dedicated mic route, choose one that has good software support with a
USB connection and an auto-levelling function. Companies like RØDE,
Marantz, and Shure all produce consumer and prosumer mics for this
purpose.

Camera Positioning
The ideal camera position is as close as possible to eye level, directly in
front of you. Ideally, you should be looking into the camera whilst answer-
ing questions but still have the video feed in your peripheral vision so that
you can respond to visual cues and mirror body language.
It is best to avoid having the camera positioned too high that you have
to look up and also has the effect of making to appear smaller than you
are. Position it too low and you might give panellists a good view up your
nose and make it difficult for them to read your facial expressions.

Microphone Positioning
The ideal position of the microphone depends on which one you intend to
use. If you are using a built-in mic on a laptop or a tablet, you have little
choice in this matter. However, there are things you can do to improve the
quality of your audio transmission. Make sure that the mic opening is not
blocked with debris. Gently blow or clean the opening, taking care not to
damage the mic inside. If you must, use compressed air, then hold it at
least eight inches away to ensure that the pressure from the can does not
60 Smashing the Core Surgical Training Interview

damage the diaphragm of the mic. These mics are also incredibly sensi-
tive, so avoid placing anything (e.g. paper, flashcards) on them as they will
pick up the rustle if you move them during the interview.
If you are using a clip-on mic, it is best clipped between the top but-
tons of a shirt or anywhere on your clothing where it is not likely to rustle
against your clothing as you talk.
A headset mic is best adjusted close to your mouth and away from
your nose so that it does not pick up breath sounds.
A dedicated dynamic mic or condenser mic should be either on a table
stand or on an adjustable boom. It is possible to keep the mic out of view
by keeping it either above or below you and out of the frame of the camera.
These mics are designed to pick up voices and have excellent sound isola-
tion characteristics. They work best when pointed at you and typically can
be adjusted to either a near or far setting depending on your setup.

Seating Position
Adjusting your seating so that you are close as possible to eye level with
the camera is important for the reasons discussed earlier. Furthermore,
it is important to consider what tics and movements you are likely to do
when answering questions. Ideally, you need to sit upright and comfort-
ably. If you are someone who is likely to swivel or rock in the chair when
stressed or answering questions, it is important to have a chair without
those functions as it will be very distracting to the panellists.

Application Settings
When setting up the video-conferencing application, make sure you have
an account with your work or NHS email. If you have a profile picture,
make sure it is appropriate for the occasion. Take time to go through your
video and audio settings to make sure that the video is clear, focused,
and appropriately zoomed in. Where available, hardware acceleration
should be turned on, and depending on the type of mic and the level of
background noise, you can adjust noise suppression settings to get a clear
natural audio transmission. If you are unsure, these settings are best left
on auto.
chapter nine

Clinical Scenarios
William Rea, Sharukh Jamal Zuberi, Muhammad Salik,
Gopikanthan Manoharan, Gargi Pandey, Goran Ameer
Ahmed, Joshua Gaetos, Anokha Oomman Joseph, and
Janso Padickakudi Joseph

General Surgery
Clinical Scenario 1: Post-Operative Desaturation
You are asked to see a 59-year-old gentleman on the ward, day 4 post-­
laparotomy for ischaemic bowel. He has a saturation of 84% on 2 litres of
oxygen and a respiratory rate of 30. How would you approach this patient?

Based on the information provided, I am concerned about a potential

post-operative respiratory complication, with pulmonary embolism or a
respiratory tract infection following major surgery being my primary dif-
ferentials. I would attend to this patient immediately and ask the nurse to
call the outreach team.
I would assess the patient in a systematic way based on the CCrISP
principles. In view of the recent pandemic, I would make sure I take rel-
evant PPE precautions. I would talk to the patient to ensure the patency
of his airway. I would put him on 15 litres of high-flow oxygen via a non-
rebreather mask with a reservoir bag and attach him to a pulse oximeter.
I would initially aim for a saturation of 92% and above. If the patient is
verbally responsive, I would move on to assessing breathing and start
with adequate exposure. If not, he would require airway adjuncts.
I would inspect for central cyanosis, bilateral chest movement, use
of any accessory muscles, and any intercostal recessions and look for
any distended neck veins. I would palpate to confirm the tracheal posi-
tion and percuss the thorax to look for any hyper-resonance or dullness.
I would auscultate the chest anteriorly and posteriorly in a sitting position
to ascertain air entry and breath sounds. I would also listen to the heart
sounds. Simultaneously, I would keep an eye on the pulse oximeter to see
saturation on 15 litres of high-flow oxygen. I would check the patient’s lat-
est COVID-19 swab status. I recognise at this point that this patient needs
an ABG and a chest x-ray.

DOI: 10.1201/9781003350422-10 61
62 Smashing the Core Surgical Training Interview

I would move on to circulation to complete the assessment. I would check

the central and peripheral capillary refill, feel the extremities, and ask for
the patient’s blood pressure and pulse rate. As this is a post-op inpatient, he
might already have a Foley catheter, and I would ask for hourly output in
the last 24 hours. I would ensure this patient has peripheral venous access in
the form of two large-bore IV cannulas. I would draw blood and send for a full
blood count, urea and electrolytes, liver function test, c-reactive protein, bone
profile, and blood cultures if the patient is febrile. I would request an ECG. If
the patient has tachyarrhythmia, this might require specialist management.
As part of disability, I would then calculate the patient’s GCS and
check the blood glucose and temperature. Following that, I would expose
and examine the patient’s abdomen, including the removal of any dress-
ings to carefully inspect the wound and examine his calves.
I would go through this patient’s medical history to see if he has any
background of, for example, COPD, asthma, congestive cardiac failure,
or any other cardiorespiratory pathologies. I would read the op-note to
see the findings and specifics of the procedure done four days ago and
whether any specific instructions were given. I would go through the
patient’s medication chart to see if he is on any bronchodilators/steroid
inhalers and if he has had his relevant thromboembolic prophylaxis pre-
scribed and administered, and I would see if he is on any other relevant
medications. I would see the latest ward round notes to see if there were
any specific concerns. I would calculate the Wells score.
With all this information, I would escalate to my registrar and poten-
tially the consultant surgeon. I might require the help of the medical out-
reach team as the patient might be having a life-threatening pathology
and might require a higher level of care. I might need to call the ITU team.
During this situation, I would delegate some tasks, such as running the
ABG, to my FY1. Based on the patient’s initial response to treatment and
assessment, he might need a CTPA to exclude a pulmonary embolus. If
this were my top differential, I would start therapeutic anticoagulation
with low-molecular-weight heparin. Alternatively, if the patient is septic
and I suspect hospital-acquired pneumonia, I would start sepsis 6 and
antibiotics. If there is any concern over the patient’s abdominal examina-
tion, I would include a CT for the abdomen/pelvis.
I would be mindful of the distress the patient is in and would update
him as much as practically possible and involve family or next of kin at an
appropriate time.

• Probes
• What are your immediate concerns?
• What information would you gather while assessing the patient?
Chapter nine: Clinical Scenarios 63

• What investigations would you consider in such a patient?

• How would you escalate this patient?
• Positive markers
• Appreciates the urgency of the situation and attends to the
patient immediately
• Assesses using a structured approach based on CCrISP principles
• Keeps reassessing after intervening
• Is mindful of the current pandemic situation
• Requests initial investigations, including a CXR and ABG
• Escalates appropriately (e.g. outreach, registrar)
• Goes through relevant PMH/operation notes/medications
• Negative markers
• Does not attend immediately
• Uses an unstructured approach
• Does not get appropriate investigations, such as ABG/CXR
• Does not see the response to intervention
• Fails to escalate to outreach and registrar

Clinical Scenario 2: Upper GI Bleed

You are the core surgical trainee on-call at a district teaching hospital. You
are asked to see a 76-year-old alcoholic gentleman on the gastroenterology
ward with haematemesis. He is hypotensive and tachycardic. How would
you approach this patient?

I am concerned this patient is in hypovolaemic (haemorrhagic) shock

owing to an upper gastrointestinal bleed secondary to oesophageal vari-
ces. My priorities would be to resuscitate, evaluate, and escalate appropri-
ately. I would attend to this patient immediately and ask for an updated
set of observations. If concerned about the vitals, I would request the ward
team to put out a medical emergency call. I would also escalate this to
my registrar early. This patient might require an emergency therapeutic
endoscopy.
I would approach the assessment and management of the patient
according to the CCrISP protocol. I would start with an A–E assessment.
I would assess his airway by speaking to him and by looking and lis-
tening for any additional airway sounds signalling airway obstruction
or bodily fluids in the oropharynx. If the patient is speaking, that indi-
cates a patent airway, in which case I would move on. However, if there
are abnormal airway sounds, I would use the wall-mounted suction to
remove any liquid obstruction and insert an airway adjunct if required
(either an oropharyngeal or nasopharyngeal airway).
64 Smashing the Core Surgical Training Interview

I would then move on to assess his breathing, looking for any signs of
respiratory distress or cyanosis. I would feel for his chest expansion and
would listen to his lung fields for any abnormal breath sounds. I would
request to know his respiratory rate and oxygen saturation. If the patient
is hypoxic or tachypnoeic, I would request a chest x-ray and arterial blood
gas analysis, as well as ensuring high-flow oxygen administration to max-
imise oxygen absorption and delivery.
Assessing his circulation, I would look for signs of shock by looking
for pallor, clamminess, and decreased consciousness level, which could
indicate poor perfusion of the tissues. I would also feel for a central and
peripheral pulse to determine its presence, character, volume, rate, and
rhythm. I would auscultate the precordium to assess the presence of any
diminished or additional heart sounds. I would measure the patient’s cap-
illary refill time centrally, blood pressure, and heart rate. I might request
an ECG if I am concerned about an arrhythmia.
The patient would require two large-bore IV cannulas, as well as hav-
ing a set of baseline blood specimens for full blood count, urea and elec-
trolytes, liver function tests, clotting, and two group and save samples for
cross-matching. If an ABG was not performed earlier, a VBG should be
taken at this point to assess the haemoglobin and lactate levels.
I would then assess his neurological function by calculating his
Glasgow coma score (GCS) and requesting a blood glucose measurement.
Finally, I would expose the patient, examine his abdomen, and perform a
PR examination to look for any melaena.
I would also look at the patient’s notes to find out about his medical
history, in particular whether he is known to have oesophageal varices,
given the history of alcohol abuse. Another differential is a bleeding pep-
tic ulcer or malignancy. I would also want to see his drug chart to ensure
he is not on any blood-thinning agents.
If my assessment confirms haemorrhagic shock secondary to an upper
gastrointestinal bleed, my clinical priorities would be to ensure ongoing
tissue perfusion, arranging a place of safety, and arranging therapeutic
intervention.
I would resuscitate with blood transfusion, initially O-negative
packed red blood cells, followed by type-specific cross-matched blood
and possibly other blood products if indicated. I would activate the mas-
sive transfusion protocol.
At this stage, I am also considering my clinical team. If I have any
FY1, I might delegate some tasks, including running the ABG or liaising
with blood transfusion services to them. I hope my registrar has become
available to assist with the care of this patient. A senior decision-maker
is required at this stage, so if my registrar is not reachable, I would esca-
late this directly to my consultant. Therapeutic intervention with an
Chapter nine: Clinical Scenarios 65

oesophagogastroduodenoscopy (OGD) is indicated urgently if the patient

does not respond to the resuscitation and continues to have ongoing upper
GI bleeding. This patient should ideally be moved to a high-dependency
unit or intensive care unit bed with the capability of invasive blood pres-
sure monitoring.
In order to facilitate this, I would liaise with the blood transfusion lab-
oratory, haematologist on-call, intensive care doctor, outreach team, and
gastroenterologist on-call. This patient might possibly require a general
anaesthetic to facilitate the OGD, so after discussion with the gastroen-
terologist, a call to the theatre coordinator and anaesthetist on-call might
also be needed.
The patient and his family must be kept informed at all times, and
I would keep the patient at the centre of care. The ward staff might also
need some support after a very visual and emotive event, and I would
explore if they were interested in a debriefing exercise after the event.

• Probes
• What are your priorities?
• What is your differential diagnosis?
• What other information would you gather?
• Who will be required to aid with the management of this patient?
• Positive markers
• Attends to the patient immediately
• Performs A–E assessment along with a clinical note and chart
review
• Recognises patient is in hypovolaemic shock and manages
appropriately
• Performs appropriate, timely escalation
• Negative markers
• Fails to recognise a critically unwell patient
• Passes responsibility to the medical team
• Uses an unstructured approach to patient assessment

Clinical Scenario 3: Pancreatitis

You are the core surgical trainee on-call at a district general hospital. You
are asked to see a 43-year-old patient in A&E with acute abdominal pain.
Their amylase is 4000. You note they have a medical history of diabetes. How
would you approach this patient?

Given the history and amylase value, this patient almost certainly has
acute pancreatitis. I would attend to the patient urgently. My priority is to
exclude systemic complications of acute pancreatitis, such as acute kidney
66 Smashing the Core Surgical Training Interview

injury, ARDS, and multi-organ failure. The patient would require admis-
sion to hospital, and I would consider what level of care they require.
I would do a quick A–E assessment using the CCrISP principles.
If the patient is haemodynamically stable, I would take a history, with
specific questions to establish the underlying cause of their pancreati-
tis. I would specifically ask about a history of gallstones and alcohol
use. I would also assess their medical history, their regular medica-
tions (including any new medications), and their allergies. I would
then examine the patient, performing respiratory, cardiovascular, and
abdominal examinations. The respiratory examination would be look-
ing for any evidence of pleural effusion or acute respiratory distress
syndrome. The cardiovascular examination would be looking for evi-
dence of intravascular depletion or dehydration. And the abdominal
examination would be assessing for jaundice or evidence of retroperi-
toneal haemorrhage.
I would then review all available blood results and any relevant previ-
ous investigations. I want to see an FBC, U&E, LFTs, CRP, clotting, amy-
lase/lipase, and an ABG. I would determine the Glasgow-Imrie score. If
I am concerned about complicated pancreatitis, I would arrange a CT scan
to determine if there is any necrosis or peripancreatic collections. If there
are no previously conducted ultrasound scans, I would request this to
exclude gallstones. If there is jaundice present, the patient might require
an MRCP or ERCP.
Once I have assessed the patient, I would make use of the full team.
I might delegate some tasks to the FY1 – for example, calculating the
Glasgow-Imrie score. I would alert my registrar and inform them about
my assessment and management of the patient. If the patient is sick, with
multi-organ involvement, I would involve my registrar early.
In terms of management, the patient would need a strict fluid input
and output chart with urinary catheterisation. The patient could continue
oral intake but might need supplementation with aggressive IV fluids.
I would not start antibiotics unless there was a clear source of infection
as pancreatitis with cholangitis. Given this patient’s history of diabetes,
close monitoring of blood sugars is indicated. The patient could continue
their regular diabetic medication. However, depending on how much
oral intake they are able to tolerate, their blood glucose levels are likely
to be variable. A variable rate insulin infusion (a sliding scale) might be
required if the blood sugar levels are abnormal. The patient would also
require a drug chart with their regular medications, analgesia, a VTE risk
assessment with low-molecular-weight heparin, and anti-embolic stock-
ings prescribed. They might also require antiemetics, antispasmodics,
and PPIs in the PRN section.
Chapter nine: Clinical Scenarios 67

If the patient had an acute kidney injury or had signs of ARDS, I would
contact the outreach team and speak to the ITU registrar for consideration
of this patient to be managed in a level 2 setting like HDU. If the patient
had necrotising pancreatitis CT and associated conditions causing organ
failure, I would discuss this patient with the local HPB team on-call.
At all times, I would keep the patient at the centre of care. I would
explain the need for multiple investigations and the seriousness of their
condition to them. If the patient had gallstone pancreatitis in particular,
I would use visual aids to explain this to them.

• Probes
• What is the likely diagnosis?
• What are the most common causes of pancreatitis?
• What would your priorities be during the assessment of the
patient?
• How would you assess severity of pancreatitis?
• Positive markers
• Has a systematic approach to patient assessment
• Considers complications of pancreatitis
• Orders appropriate investigations
• Escalates to the registrar and consultant appropriately
• Negative markers
• Prescribes simple analgesia only
• Does not consider the aetiology of pancreatitis
• Does not consider possible complications of pancreatitis
• Does not escalate appropriately
• Does not consider a higher level of care

Clinical Scenario 4: Post-Operative Fever

You are the core surgical trainee on colorectal surgery. You see a 37-year-old
gentleman on the ward round. He is two days post–right hemicolectomy for
malignancy. He has a temperature of 38.1°C. How would you approach this
patient?

In a patient with a low-grade fever post-operatively, I would be con-

cerned about an infection. The most significant source of this is an anas-
tomotic leak. However, given that patient is only day 2 post-op, I would
also be considering other sources of infection, such as intra-abdominal
collection, chest infection, urinary tract infection, and skin infection of
the operative wound. I would also consider DVT/PE as a non-infective
source of post-op fever.
68 Smashing the Core Surgical Training Interview

I would review the patient’s observations and most recent blood tests,
as well as the operation note and anaesthetic chart. I would also make
note of the patient’s comorbidities, particularly issues that could contrib-
ute to immunosuppression or wound breakdown, such as diabetes or tak-
ing steroids.
I would assess this patient according to the CCrISP protocol. I would
ensure his airway is patent and self-maintained. I would then look at his
breathing, feel for any asymmetrical chest movement or crepitus in the
chest wall, auscultate the chest for any abnormal breath sounds, and mea-
sure the respiratory rate and oxygen saturation levels. If he is hypoxic or
tachypnoeic, then I would start oxygen supplementation.
I would then move to assess his circulation, looking for any signs
of hypotension or impaired perfusion. I would feel for his central and
peripheral pulses for rate, rhythm, character, and volume. I would aus-
cultate the precordium for abnormal heart sounds and then measure his
heart rate, blood pressure, capillary refill time, and temperature.
I would cannulate the patient and send off a full set of blood spec-
imens. I would then assess his consciousness using the Glasgow coma
scale and request a blood glucose measurement.
I would fully expose the patient and examine him to attempt to deter-
mine the source of the infection. Given the patient’s history, there are mul-
tiple possible sources: respiratory, urinary, skin (either cellulitis, phlebitis,
or surgical incision), or intra-abdominal. I would take down any dressings
to inspect the wounds, review drain content and volume, and palpate the
abdomen to determine any evidence of peritonism suggesting an intra-
abdominal source. The patient is likely to be catheterised, so a urine dip is
likely to be positive, so I would ask the nursing team to send off a sample
for culture and sensitivity. I would also examine the calves to ensure there
is no DVT. I would also look at any peripheral or central lines.
A chest x-ray would be indicated if a respiratory source is suspected.
Though an anastomotic leak on day 2 is unusual, it remains the most con-
cerning source of infection. If I was concerned about an anastomotic leak,
I would request a CT scan to confirm this. If I suspect a DVT, I would
calculate a Wells score and obtain a venous Doppler. If I found an infected
line, I would remove it.
I would also review the patient’s drug chart and see if he is on immu-
nosuppressants or antibiotics. I would also look at the operative note to
see if there was any complication during the surgery.
Following my assessment and management plan, I would then con-
tact the responsible registrar or consultant and present the patient to them
with a summary of what treatments and investigations I have initiated.
I would ask my FY1 to help with documentation and make sure the blood
work is drawn.
Chapter nine: Clinical Scenarios 69

If the CT revealed an anastomotic leak, then the patient would require

a return to theatre to take down the anastomosis, wash out the abdomen,
and most likely form a stoma as a second anastomosis would be at an
unacceptably high risk of breakdown.

• Probes
• What are the causes of post-op fever?
• How would you investigate the source of infection?
• What are the non-infective causes of fever?
• Positive markers
• Uses a systematic assessment
• Considers the sources of infection
• Considers investigative methods
• Negative markers
• Fixates on anastomotic leak
• Does not consider different causes of post-operative fever

Clinical Scenario 5: Wound Dehiscence

You are the core surgical trainee on general surgery. On the ward round you
see 55-year-old gentleman, day 5 post–emergency laparotomy, for perforated
diverticular disease. The patient is complaining of discomfort in the abdomen,
and there is copious pink fluid discharging from the wound.

In this scenario, given the post-operative timing, the pink fluid makes me
concerned the patient is at risk of wound dehiscence resulting in a burst
abdomen. Other differentials include wound infection or infected seroma.
I would assess this patient according to the CCRISP protocol. I would
ensure the patient was speaking to me and had a patent airway.
I would then look at his breathing, feel for any asymmetrical chest
movement, auscultate for any abnormal breath sounds, and measure the
respiratory rate and oxygen saturation levels. If he is hypoxic or tachy-
pnoeic, I would then request the nursing staff to administer oxygen.
Then I would move to assess his circulation, looking for any signs
of hypotension or impaired perfusion. I would feel for his central and
peripheral pulses for rate, rhythm, character, and volume. I would aus-
cultate the precordium for abnormal heart sounds and then measure his
heart rate, blood pressure, capillary refill time, and temperature. If he is
hypotensive, I would administer a fluid bolus of crystalloid, after which
I would reassess to see if there had been any improvement.
If he is tachycardic, I would request an ECG to rule out tachyarrhyth-
mia. If he is febrile, then he would need blood cultures and antibiotic
administration. The presence of fever makes the diagnosis of infection
70 Smashing the Core Surgical Training Interview

highly likely, given the patient’s history, and should trigger the initiation
of the sepsis 6 bundle.
I would then assess his consciousness using the Glasgow coma scale,
and also request a blood glucose measurement.
I would then examine the abdomen more closely. I would take down
the abdominal dressing and inspect the laparotomy wound, looking for
surrounding erythema, induration, swelling, fluctuance, necrosis, tender-
ness, crepitus, and discharge.
If there is discharge, I would note the volume and character of
­discharge – is it serous, purulent, or bloody? If the discharge is coming
from the laparotomy wound with no other signs of infection, I would be
concerned that this patient is about to have a wound dehiscence resulting
in a burst abdomen, which could be very alarming for the patient and the
staff.
If abdominal wound dehiscence is already present, I would cover the
wound with warm saline-soaked swabs after pushing the back bowel
into the abdomen. I would have more saline swabs ready at the bedside.
I would escalate this to my registrar immediately. I would involve the
ward sister so that I have an extra pair of hands with me. I would also con-
tact the anaesthetic team and the theatre coordinator and book the patient
and acquire consent from him for an urgent return to theatre for closure
of the laparotomy wound.
Alternatively, if I found that this patient has a seroma or wound infec-
tion, I might take out some stitches or staples and start antibiotics.

• Probes
• What is your differential diagnosis?
• What are your priorities?
• What other information would you gather?
• Who else would you like to involve in this patient’s care?
• Positive markers
• Considers malignancy as the most likely diagnosis
• Constructs a reasonable differential diagnosis
• Requests appropriate investigations
• Escalates to the registrar or consultant appropriately
• Has a structured approach to patient assessment
• Recognises that the pink fluid is the classic sign seen before a
burst abdomen
• Negative markers
• Uses an unstructured approach to patient assessment
• Does not involve the wider healthcare team
• Does not consider differentials more serious than a wound
infection
• Does not escalate
Chapter nine: Clinical Scenarios 71

Clinical Scenario 6: Trauma

You are asked to see a 29-year-old patient following a road traffic accident.
He had to be extracted from the car. He seems to be in significant pain and is
clutching his abdomen. How would you approach this patient?

I am concerned that this patient has significant intra-abdominal injuries

following the road traffic accident. This could be due to a viscus perfo-
ration or internal bleeding. Depending on the patient’s haemodynamic
stability, he might require a scan or might need to go directly to theatre.
I would attend to this patient immediately after putting out a trauma
call. I would approach the patient using an ATLS approach. I would ensure
the patient’s c-spine is secured with three-point immobilisation. I would
assess the airway by first speaking to him. I would ensure high-flow oxy-
gen is being administered. If he verbally responds, indicating a patent and
self-maintained airway, I would move on to assess his breathing.
I would look for bilateral chest rising, bilateral chest sounds, and a
central trachea. I would palpate for chest wall tenderness and surgical
emphysema and auscultate the chest for breath sounds in all regions.
I would then measure the oxygen saturation and respiratory rate.
If the airway is intact, I would then move on to circulation and
haemorrhage. I would assess the patient’s heart rate, blood pressure,
and c­ apillary refill time. I would inspect and palpate the patient’s abdo-
men, then look for symmetry of the ASIS bilaterally and palpate the long
bones. I am doing this in C because I am looking for a source of bleed-
ing. I would also look around the patient for any evidence of external
haemorrhage.
I would ensure that bilateral large-bore access is gained. At the same
time, I would take blood specimens for venous blood gas, FBC, U&E, LFTs,
and cross-match. If the patient is hypotensive and tachycardic, he might
benefit from a blood transfusion. If there is an ultrasound-trained mem-
ber of the trauma team present, a FAST scan could be used to determine
the presence of intra-abdominal fluid.
For disability, I would calculate his GCS and assess for pupillary reac-
tion to light. I would then expose the patient, fully examine him, perform
a log roll, and digital rectal examination.
As I am concerned that this patient has significant intra-abdominal
injuries, I would be quick to escalate this to my registrar and consul-
tant. The anaesthetic team should already be in attendance as part of the
trauma team.
Depending on the patient’s response to initial resuscitation and the
results of his FAST scan, we might decide to perform a CT for the abdo-
men and pelvis if he is stable. Alternatively, we might have to go directly
to theatres for an exploratory trauma laparotomy if the patient is unstable.
72 Smashing the Core Surgical Training Interview

This decision-making requires communication with A&E, nursing staff,

radiology, blood transfusion, and theatre teams. Given the urgency of the
situation, a second CEPOD theatre might need to be opened up.
I appreciate that this is a stressful time for the patient. I would keep
him at the centre of care. I would explain what is happening to him in a
timely manner. I would ensure that he has adequate analgesia. If he could
consent to surgery, then I would do this. However, in this trauma situa-
tion, he might require a consent form 4. I would update his next of kin.

• Probes
• What is your differential diagnosis?
• What are your priorities?
• What other information would you gather?
• Who else would you like to involve in this patient’s care?
• Positive markers
• Understands ATLS structure
• Takes a multidisciplinary approach to the trauma patient
• Knows when not to consider a CT
• Escalates appropriately
• Negative markers
• Performs an unstructured examination
• Does not escalate
• Fails to involve other members of the trauma team
• Wants a CT in an unstable patient

Clinical Scenario 7: C. difficile Infection

You are the core surgical trainee. You are asked to see a 65-year-old lady who
has been treated for diverticulitis with several courses of antibiotics. She now
presents with abdominal pain and diarrhoea. How would you approach this
patient?

I am concerned this patient has C. difficile colitis secondary to overgrowth

following repeated antibiotic courses. My other differentials include
diverticulitis or complications of diverticulitis, such as a diverticular per-
foration or abscess.
Given the history of diarrhoea, the patient should be seen in a side
room with the required isolation precautions. I would approach her
using a CCrISP approach. I would take a full history, enquiring about her
abdominal pain and taking note of what antibiotic she has received, in
how many courses, and in what time frame.
I would also ask about the patient’s diverticular disease, how often she
gets flares, if she has had any investigations, and if she has had any com-
plications from her diverticulitis. I would ask about her medical history
Chapter nine: Clinical Scenarios 73

and drug history, including allergies. I would also ask if this patient has
ever had a colonoscopy and, if so, how long ago.
I would then examine this patient. If I feel the patient is extremely
unwell, I would use an A–E approach.
Speaking to the patient and receiving a response would ensure her
airway is patent and self-maintained. I would then look at her breathing,
feel for any asymmetrical chest movement, auscultate the chest for any
abnormal breath sounds, and measure the respiratory rate and oxygen
saturation levels. If she is hypoxic or tachypnoeic, I would then request
the clinic staff to locate an oxygen cylinder to administer oxygen.
Then I would move to assess the patient’s circulation, looking for any
signs of hypotension or impaired perfusion. I would feel for her central
and peripheral pulses for rate, rhythm, character, and volume. I would
auscultate the precordium for abnormal heart sounds and then measure
her heart rate, blood pressure, capillary refill time, and temperature.
If the patient is hypotensive, I would administer a fluid bolus of
crystalloid, after which I would reassess to see if there had been any
improvement. If she is tachycardic, I would request an ECG to rule out
tachyarrhythmia. If she is febrile, then she would need blood cultures and
antibiotic administration.
I would then assess the patient’s consciousness using the Glasgow
coma scale and also request a blood glucose measurement.
I would then assess the abdomen more closely. I would inspect, pal-
pate, percuss, and auscultate the abdomen to determine the location of
pain, its severity, and the presence of any peritoneal irritation.
Following history taking and examination, I would review any
investigations available and review any notes available – either from this
admission or previous documentation. My priority with the assessment
would be to exclude an acute abdomen.
I would send for blood tests, including FBC, U&E, LFTs, CRP, and
group and save. If I am clinically concerned about C. difficile colitis, then
I would ask for a stool sample to be sent to microbiology for toxin gene
(PCR) and glutamate dehydrogenase EIA (GDH). If this is positive, then
we would need to do a toxin enzyme immunoassay (EIA). If this also
comes back as positive, then the patient likely has C. difficile, and this
needs mandatory reporting. Trust policy on isolation, enhanced nursing
care, and cleaning protocol would need to be followed.
If I am concerned about the complication of diverticular disease, such
as a perforation or abscess, then I would obtain a CT for the abdomen/
pelvis.
Depending on the severity of the C. difficile colitis, if it is a moderately
severe disease, I would commence oral metronidazole, and if it is a very
severe disease, the patient would need IV vancomycin per the trust pro-
tocol. I would speak to my registrar about the patient’s case. In particular,
I would enquire about where the patient should be admitted to – medicine
74 Smashing the Core Surgical Training Interview

or surgery. I would speak to nursing and bed management to facilitate

admission.
I would keep the patient at the centre of care at all times, communicat-
ing my findings and planning with her. Given her recurrent episodes of
diverticulitis, we might also need to consider a long-term plan for her in
terms of surgical resection. I would ensure that this patient has an appro-
priate follow-up in the colorectal clinic to discuss this.

• Probes
• What is your differential diagnosis?
• What are your priorities?
• What other information would you gather?
• Who else would you like to involve in this patient’s care?
• Positive markers
• Considers more than one differential
• Approaches the case in a systematic manner
• Escalates appropriately
• Negative markers
• Uses an unstructured approach
• Focuses on a single diagnosis
• Ignores or fails to take into account previous attacks of
diverticulitis

Clinical Scenario 8: Post-Operative Breast Haematoma

You are asked to see a 54-year-old on the general surgery ward, day 2 post-­
mastectomy. The patient has 300 ml of blood in her drain. She is on apixaban,
which was restarted earlier today. How would you approach this patient?

I would review the patient immediately. I am concerned the patient is

bleeding from her mastectomy wound. She might require a return to
theatre.
I would initially assess using the CCrISP algorithm. I would make
sure patient’s airway and breathing are intact by talking to the patient.
I would check patient’s observations and haemodynamic state by mea-
suring oxygen saturation, heart rate, blood pressure, and capillary refill.
I would make sure the patient has two large-bore IV lines.
I would give patient high-flow oxygen initially. If the patient is hypo-
tensive and tachycardic I would start 20 ml/kg warm crystalloids stat.
I would take an ABG to check for lactate, Hb and base deficit. I would also
take blood for G&S, FBC, U&E, clotting, and LFTs.
Depending on the shock state, if she is in stage 3 or 4 haemorrhagic
shock, I would activate the major haemorrhage protocol.
Chapter nine: Clinical Scenarios 75

I would expose the patient to examine her wound for evidence of

haematoma, such as bruising and tense swelling of the mastectomy site.
I would examine the drain content.
I would review the notes, in particular the operative note. I would see
if there were any concerns over haemostasis.
If there is evidence of active bleeding, I would call my registrar and
inform the consultant in charge of the patient because she might need to
go back to theatre to control bleeding. At this stage, I do not think there
is a role for additional investigations, such as an ultrasound scan of the
breast.
In the meantime, although there is no direct reversal agent for apixa-
ban, I would call the haematologist on-call to discuss the case and deter-
mine the need for plasma or prothrombin complex concentrate (Beriplex).
While seniors are on the way, I would apply a pressure dressing to tam-
ponade any active bleeding. I would alert the anaesthetic team, theatres,
and nursing staff that this patient needs to go back to theatre urgently.
I would explain the situation to the patient and provide her with anal-
gesia and reassurance. I would prepare the consent forms for my registrar.
I would update the next of kin and document in the notes.

• Probes
• What are your priorities?
• What other information would you gather?
• What investigations would you do?
• How would you escalate this patient’s care?
• Positive markers
• Recognises that the patient is actively bleeding and this is a sur-
gical emergency
• Recognises that this requires a team-based approach
• Assesses the patient with a structured A–E approach
• Requests appropriate investigations (e.g. group and screen, FBC,
coagulation panel) and anticipates the need for immediate blood
transfusion and correcting pre-existing coagulopathy
• Escalates to the registrar or consultant appropriately
• Negative markers
• Does not attend immediately and recognise the situation as a
surgical emergency
• Fails to include other members of the surgical team (anaesthe-
tists, theatre nurses, etc.)
• Uses an unstructured approach to patient assessment
• Does not anticipate the need for immediate blood transfusion
and correcting pre-existing coagulopathy
• Does not escalate patient care appropriately
76 Smashing the Core Surgical Training Interview

Clinical Scenario 9: Inflammatory Bowel Disease

You are asked to see a 38-year-old gentleman on the gastroenterology ward
with inflammatory bowel disease who is complaining of abdominal pain. He
has been on steroids for ten days for treatment of a flare. How would you
approach this patient?

I would attend to this patient as soon as possible. As I am on my way to

see the patient, I would think of the differential diagnoses of bowel per-
foration, toxic megacolon, and acute severe (fulminant) colitis. The patient
might require operative intervention.
I would assess the patient using the CCrISP algorithm. I would make
sure the airway and breathing are intact by checking to the patient is able
to talk and checking breath sounds, respiratory rate, and oxygen satura-
tion. I would check the circulatory status by checking heart rate, blood
pressure, and urine output. I would make sure the patient has two wide-
bore IV lines.
I would give high-flow oxygen to start with and start 20 ml/kg crys-
talloids stat. If I suspect sepsis, I would make sure the sepsis 6 bundle
measures are carried out. I would give oxygen, IV antibiotics, and fluids,
take specimens for lactate and blood culture, and measure the patient’s
urine output.
I would then examine the patient in general for signs of dehydration,
pallor, and jaundice. I would examine the patient’s abdomen to check for
tenderness, distension, peritonism, scars, and hernial orifices. I would
also check bowel sounds and do a PR exam to check for blood, mucus,
and any rectal mass.
I would examine the patient’s charts for observations, the fluid bal-
ance chart, and the Bristol stool chart for frequency and consistency of
stool. I would also go through the patient’s history and background medi-
cal issues. I would check the patient’s latest blood tests paying, particular
attention to WCC, CRP, and lactate levels. I would get a new set of blood
and take an ABG.
I would keep the patient nil by mouth and arrange for an urgent CT
AP with IV contrast.
At this stage, I would escalate to my registrar or consultant. I might
need to discuss this with the on-call radiologist to make sure that they
understand the urgency of the scan. I would liaise directly with the
radiographers to make sure that the patient gets an early slot. I would also
discuss the patient’s care with the medical team to see if there are any
treatment alternatives, such as escalation to biologics.
Depending on the assessment and CT findings, the patient might
need ongoing conservative management or urgent surgery in the form of
Chapter nine: Clinical Scenarios 77

subtotal colectomy if the colitis is acutely severe. I would keep the patient
at the centre of care, involving him in the decision-making. I would
ensure that he has adequate analgesia and symptomatic control of nausea
or fever. If the patient does have a perforation or flare of IBD unresponsive
to medical management, he would need surgical intervention. After dis-
cussion with my seniors, I would prepare a consent form for the patient,
inform the anaesthetic team and theatre coordinator, and book the patient
for a laparotomy.

• Probes
• What are your priorities?
• What other information would you gather?
• What investigations would you do?
• How would you escalate this patient’s care?
• Positive markers
• Recognises that the patient has IBD unresponsive to medical
therapy
• Recognises that this requires a team-based approach
• Assesses the patient with a structured A–E approach
• Requests appropriate investigations, including CT scan
• Escalates to the registrar or consultant appropriately
• Negative markers
• Does not attend immediately and recognise the situation as a
surgical emergency
• Fails to include other members of the team (gastroenterologists,
radiologists, theatre team, etc.)
• Uses an unstructured approach to patient assessment
• Does not escalate patient care appropriately

Clinical Scenario 10: Trauma

You are the core surgical trainee on trauma. You are asked to see a 25-year-
old who presents to A&E with a penetrating knife injury to the right upper
abdomen. How would you approach this patient?

I am concerned that this patient has intra-abdominal injuries follow-

ing their knife injury. I would be specifically worried that there might
be damage to the liver, gallbladder, hepatic triad, duodenum, head of
pancreas, or IVC. However, I also need to consider the possibility of a
trans-compartmental injury, with possible diaphragmatic injury causing
a haemopneumothorax or haemopericardium.
78 Smashing the Core Surgical Training Interview

I would attend to this patient immediately and would activate the

trauma team. I would approach the patient using ATLS principles. I would
ensure the patient’s c-spine is secured with three-point immobilisation.
I would assess the airway by first speaking to them. I would ensure
high-flow oxygen is being administered. If they verbally respond, indicat-
ing a patent and self-maintained airway, I would move on to assess their
breathing. I would look for bilateral chest rising, bilateral chest sounds,
and a central trachea. I would palpate for chest wall tenderness and surgi-
cal emphysema and auscultate the chest for breath sounds in all regions.
I would then measure the oxygen saturation and respiratory rate.
If the airway is intact, I would then move on to circulation and haem-
orrhage. I would assess the patient’s heart rate, blood pressure, and capil-
lary refill time. I would inspect and palpate the patient’s abdomen, look
for symmetry of the ASIS bilaterally, then palpate the long bones. I would
also look around the patient for any evidence of external haemorrhage.
I would ensure that bilateral large-bore access is gained. At the same
time, I would take blood for venous blood gas, FBC, U&E, LFTs, and cross-
match. If the patient is hypotensive and tachycardic, I would transfuse blood.
If there is an ultrasound-trained member of the trauma team present,
a FAST scan could be used to determine the presence of intra-abdominal
fluid in Morrison’s pouch. This would also assess for potential diaphrag-
matic injury if there were haemothorax or pneumothorax on the lung
windows and also exclude a haemopericardium.
For disability, I would calculate the GCS and assess for pupillary reac-
tion to light. As I am concerned that this patient has intra-abdominal inju-
ries, I would be quick to escalate this to my registrar and consultant as
they are likely to require a laparotomy.
Depending on the patient’s response to initial resuscitation and the
results of the FAST scan, we might decide to perform a CT scan or alter-
natively go directly to theatres for a laparotomy. This decision-making
would require communication with A&E, nursing staff, radiology, blood
transfusion, and theatre teams.
I would also ensure that I explain what is happening to the patient
and liaise with the family.

• Probes
• What are your concerns?
• Who will need to be informed?
• What investigations would you like to perform?
• Positive markers
• Uses a systematic approach
• Recognises the possibility of trans-compartmental injuries
• Considers either scans or theatres, depending on how stable the
patient is
Chapter nine: Clinical Scenarios 79

• Negative markers
• Uses an unstructured examination
• Does not involve other specialities or colleagues

Clinical Scenario 11: Acute Cholecystitis

You are asked to see a 62-year-old gentleman on the ward with acute chole‑
cystitis. He has been on antibiotics for five days. He is complaining of severe
abdominal pain over the last few hours and is now spiking a temperature.

In this scenario, I am concerned this patient has a complication from cho-

lecystitis like gallbladder perforation, new onset cholangitis, or an unre-
lated abdominal catastrophe like perforated DU.
I would examine the patient immediately as I am concerned he has
sepsis. I would assess using the CCrISP algorithm. I would assess his air-
way first by speaking to him. I would ensure he is on high-flow oxygen.
If he responds, I would move on to assess his breathing. I would look
for bilateral chest rising, bilateral chest sounds, and a central trachea.
If his airway is intact, I would move on to circulation. I would assess
the patient’s heart rate, blood pressure, and capillary refill time. I would
ensure that bilateral large-bore access is gained. I would take blood spec-
imens for blood gas, FBC, U&E, LFTs, clotting profile, and cross-match.
For disability, I would calculate his GCS and obtain a temperature and
blood glucose. I would make sure the patient has adequate analgesia on
board.
Given the scenario, I am concerned the patient has sepsis, and hence,
I would initiate the sepsis 6 bundle. I would take blood cultures, measure
lactate on the ABG, measure urine output, and give the patient oxygen,
IV fluids, and IV antibiotics. I would also request a COVID-19 swab test.
If unstable, initially, I would start IV crystalloids at 20 ml/kg. I would
give a second bolus if the patient is still hypotensive after the first one.
I would be cautious with fluid resuscitation in a patient with a history
of heart disease to avoid volume overload. I would aim to maintain his
mean arterial pressure (MAP) equal and above 65, and if this is not
achievable with fluids, I would contact ITU to assess the patient to con-
sider vasopressors.
After initial assessment and management, I would review the patient’s
notes and check drug charts. I would let my registrar know, but I would
arrange for an urgent CT abdomen and pelvis to get a definitive diagnosis.
In the meantime, I would escalate to second-line antibiotics after checking
trust microbiology guidelines and the patient’s allergies.
Depending on the CT scan, the patient’s ongoing management might
include emergency surgical intervention if the patient has a perforated
duodenal ulcer or a perforated gallbladder, or it might include emergency
80 Smashing the Core Surgical Training Interview

gallbladder drainage by interventional radiology if the patient has a gall-

bladder empyema.
I would discuss this patient with the ITU registrar and transfer this
patient to the high-dependency unit for more frequent monitoring and
support. I would explain the scan findings and the plan to the patient.

• Probes
• What is your diagnosis?
• How would you manage this patient?
• Positive markers
• Assesses the patient with a structured A–E approach
• Requests appropriate investigations
• Recognises the need for monitoring in HDU
• Negative markers
• Uses an unstructured approach to patient assessment
• Does not escalate appropriately

Clinical Scenario 12: Ectopic Pregnancy

You are the core surgical trainee. You see a 37-year-old Jehovah’s Witness
patient with right iliac fossa pain. She is haemodynamically unstable. How
would you approach this patient?

In this scenario, I am concerned that the cause of the haemodynamic insta-

bility and right iliac fossa pain is either due to hypovolemic shock from a
ruptured ectopic pregnancy or septic shock from a perforated appendix.
The patient might also have had another abdominal catastrophe.
I would attend to this patient immediately. I would assess this patient
using the CCrISP algorithm. First, I would speak to the patient and make
sure her airway is intact. At the same time, I would give high-flow oxy-
gen via a non-rebreather face mask. I would assess the adequacy of the
patient’s breathing by looking for chest expansion, checking for the tra-
cheal position, listening to breath sounds, and oxygen saturation. At the
same time, I would make sure two large IV lines are in place and she
is working. I would do blood gas, FBC, U&E, LFTs, clotting profile, and
cross-match.
I would check the patient’s circulation by checking her heart rate,
blood pressure, and capillary refill time. I would start with 1 litre (20 ml/
kg) of warm crystalloids stat.
I would also perform a general and abdominal examination to estab-
lish a differential diagnosis. If the patient is showing signs of sepsis, like
fever, warm peripheries, and flushed face, I would initiate the sepsis 6
Chapter nine: Clinical Scenarios 81

bundle to manage her initially. This involves giving IV fluids to maintain

a MAP of 65 or more, stat IV antibiotics, and high-flow oxygen. Before the
antibiotics, I would take blood specimens for culture and sensitivity, and
I would also check the patient’s lactate and insert a urinary catheter to
assess urine output.
If, however, on initial assessment, the patient is looking pale, tachy-
cardic, hypotensive, and with prolonged capillary refill time, I would be
concerned about internal bleeding and hypovolemic shock. I would esca-
late this to my registrar and consultant as this is a tricky situation, given
the patient is a Jehovah’s Witness. If stable enough after initial resuscita-
tion, I would take a quick history and review medical notes. I would also
check her capacity and check her beliefs regarding blood transfusion.
If not compos mentis, I would check for any documented advance
decisions made by the patient. If any doubt about the validity of advance
directives, I would act in the patient’s best interest and start the transfu-
sion. If the patient clearly has the capacity and refuses transfusion or has
a valid advance decision stating refusal, I would explain the consequences
of not having the blood transfusion. I would also check her beliefs regard-
ing autologous transfusion and plan for a cell saver to be used in theatre if
the patient goes on to have emergency surgery.
Depending on the results of tests and her initial response, the patient
might need to have imaging or go to theatre immediately. I would liaise
with the anaesthetist, the theatre coordinator, and the ITU registrar. If
there are signs of ruptured ectopic pregnancy, like vaginal bleeding, posi-
tive pregnancy test, and haemorrhagic shock, I would alert the gynaecolo-
gists immediately.
I would make sure to document my management and discussion with
the patient at the earliest possible chance.

• Probes
• What is your differential diagnosis?
• How would you manage this patient?
• Would you transfuse blood?
• Positive markers
• Assesses the patient with a structured A–E approach
• Recognises patient is a Jehovah’s Witness
• Recognises the need to escalate early to the registrar and
consultant
• Negative markers
• Uses an unstructured approach to patient assessment
• Does not involve other teams
• Transfuses blood without considering the patient’s wishes
82 Smashing the Core Surgical Training Interview

Clinical Scenario 13: Bowel Obstruction

You are the core surgical trainee. A 56-year-old presents with a three-day
history of vomiting and abdominal pain. He has a history of emergency lapa‑
rotomy for an internal hernia. He is a type 2 diabetic on insulin.

In this scenario, I am concerned the patient has intestinal obstruction

secondary to adhesions from his previous surgery. Other differentials
include acute pancreatitis and diabetic ketoacidosis.
I would review the patient immediately. I would assess using the
CCrISP algorithm. I would speak to the patient and make sure his air-
way is intact. At the same time, I would give high-flow oxygen via a
non-rebreather face mask. I would assess the adequacy of the patient’s
breathing by looking for chest expansion, checking for the tracheal posi-
tion, listening to breath sounds and oxygen saturation. I would assess the
patient’s heart rate, blood pressure and capillary refill time.
At the same time, I would make sure two large IV lines are inserted,
and I would request an arterial blood gas, FBC, U&E, LFTs, amylase,
and cross-match. I would check the patient’s GCS and blood glucose
levels.
I would expose and perform an abdominal examination. I would
check for hydration, jaundice, abdominal distension, scars, peri-
tonism, and bowel sounds. I would do a PR exam at the earliest
convenience.
I would arrange for abdominal x-rays in the first instance. If this shows
signs of bowel obstruction, I would make sure he is nursed at 45 degrees
or more and ensure an NG tube is inserted as soon as possible to prevent
aspiration of gastric contents. I would also insert a urinary catheter and
check his urine output. I would ensure a fluid balance chart is followed
by measuring all input and output. I would inform and escalate to my
registrar once I have initiated a management plan.
Doing all this in a timely manner is labour-intensive, and according
to the clinical urgency, I would need help from nursing staff and other
members of the emergency team, like the outreach team and foundation
doctors.
After initial assessment and management, I would get a CT scan of
the abdomen and pelvis for a definitive diagnosis. If the obstruction is
secondary to adhesions, the patient could be conservatively managed for
up to 48 hours. However, if the obstruction does not resolve in this period,
the patient would need to be taken to theatre for an emergency laparot-
omy and adhesiolysis.
I would update the patient and his family about his condition and
document in the notes.
Chapter nine: Clinical Scenarios 83

• Probes
• What is your diagnosis?
• How would you manage this patient?
• Does this patient need to go to theatre?
• Positive markers
• Applies appropriate management of bowel obstruction
• Uses appropriate investigation
• Negative markers
• Uses an unstructured approach to patient assessment
• Does not consider a conservative approach initially

Clinical Scenario 14: Hernia

You are the core surgical trainee on-call at a central teaching hospital. You are
asked to see a 75-year-old lady in A&E who has swelling in her groin, vomits,
and has abdominal pain.

Given the patient’s age and history, I am concerned this patient has an
obstructed hernia; my priority would be to exclude a strangulated her-
nia. Given her gender, this is likely to be a femoral hernia; however, an
obstructed inguinal hernia is the most likely diagnosis as it is the most
common type of hernia.
I would attend to the patient urgently and do a quick A–E assessment
using the CCrISP principles.
I would take a history, with specific questions to establish if the patient
has an inguinal/femoral hernia. I would ask questions to establish if the
hernia is just incarcerated or if there are symptoms to suggest obstruction
and possibly ischaemia of the bowel within the hernia sac. I would ask
about symptoms of bowel obstruction, such as abdominal pain, vomiting,
failure to pass flatus, or open bowels.
I would ask about her medical history, medications, and allergies.
I would examine the patient, performing an abdominal examination,
looking to elicit any peritonism. I would then assess the swelling in the
groin, firstly to establish if it is a hernia, and then to see if it is an inguinal
or femoral hernia, and then to assess if it is incarcerated or strangulated.
I would then review all available blood results and any previous rel-
evant investigations, such as a CT for the abdomen and pelvis or USS for
the groin, to see if the patient has a hernia.
I would check if the patient’s x-ray of the abdomen in A&E shows
dilated small bowel loops suggesting an obstruction. I would check the
lactate levels to assess if there are signs of ischaemia.
If the AXR confirms dilated small bowel loops, this suggests an
obstructed hernia. The patient would need a nasogastric tube and IV fluids.
84 Smashing the Core Surgical Training Interview

The patient would need to be nil by mouth. I would insert a catheter to

monitor the urine output.
The patient needs to go to theatre for a repair of hernia +/− bowel
resection +/− laparotomy. I would ensure that the patient gets an
urgent senior surgical review by the on-call surgical registrar. I would
then discuss this with the on-call anaesthetist and inform the theatre
coordinator. I would speak to the bed manager to inform them of the
admission.
I would explain the need for an operation to the patient and ask con-
sent from her for theatre.

• Probes
• What is the diagnosis?
• Does this patient need a CT for the abdomen?
• Can she be managed conservatively?
• When will you plan for theatre?
• Positive markers
• Uses A–E assessment along with previous imaging and chart
review
• Understands the importance of assessing if the patient has a
strangulated hernia
• Arranges appropriate investigations and plans for theatre
• Appropriately escalates
• Negative markers
• Fails to recognise the risk of a strangulated hernia
• Does not work up the patient appropriately

Clinical Scenario 15: Anastomotic Leak

You are the core surgical trainee on-call at a district general hospital. You are
asked to prescribe a sleeping tablet for an agitated patient. The patient is a
67-year-old lady, day 5 post–laparoscopic anterior resection for rectal cancer.

Given the history, I am concerned this patient has an anastomotic leak,

causing an infection that led to delirium. There could be other causes of
sepsis, such as a chest infection or wound infection; however, given it has
been five days since an anterior resection, my priority would be to exclude
an anastomotic leak.
I would ask the ward nurse to do an urgent set of observations so that
I have the most recent observations.
I would review the most recent blood tests, as well as the operation
note and anaesthetic chart. I would also make note of the patient’s comor-
bidities, particularly issues that could contribute to immunosuppression
that might another factor in developing an anastomotic leak.
Chapter nine: Clinical Scenarios 85

I would assess this patient according to the CCRISP protocol. I would

ensure the airway is patent and self-maintained. I would then assess her
breathing, feel for any asymmetrical chest movement, auscultate the chest
for any abnormal breath sounds, and measure the respiratory rate and
oxygen saturation levels. If she is hypoxic or tachypnoeic, then I would
start oxygen supplementation.
I would then move to assess her circulation, looking for any signs
of hypotension or impaired perfusion. I would feel for her central and
peripheral pulses for rate, rhythm, character, and volume. I would aus-
cultate the precordium for abnormal heart sounds and then measure her
heart rate, blood pressure, capillary refill time, and temperature.
I would cannulate the patient and request for FBC, U&E, LFTs, amy-
lase, clotting profile, and cross-match. I would also do blood gas and mea-
sure the lactate. I would then assess her consciousness using the Glasgow
coma scale and request a blood glucose measurement.
I would fully expose the patient and examine her to attempt to deter-
mine the source of the infection. Given the patient’s history, there are mul-
tiple possible sources: respiratory, urinary, wound, or intra-abdominal.
I would inspect any dressings to inspect the wounds, review drain con-
tent and volume, and examine the abdomen to determine any evidence of
peritonism suggesting an intra-abdominal source.
I would also review the patient’s drug chart and see if he is on immu-
nosuppressants or antibiotics. I would also look at the operative note to
see if there was any complication during the surgery.
If there are signs of abdominal peritonism and the patient is stable,
I would arrange a CT for the abdomen and pelvis after a discussion with
my registrar.
If I was concerned about sepsis, I would initiate the sepsis 6 bundle
and ensure that lactate, urine output monitoring, and blood cultures have
been sent off. I would also ensure the patient is given IV fluids, IV antibi-
otics, and oxygen supplementation.
I would also request a urine dip for culture and sensitivity and order
a chest x-ray to rule out other sources of infection. However, at day 5, an
anastomotic leak is the most concerning source of infection.
Depending on the CT findings, the patient might likely need to be
taken back to theatre for an emergency laparotomy and end colostomy.
I would speak to the patient and explain the findings of the scan and ask
for consent. I would inform the anaesthetist and the theatre coordinator
and speak to the ITU registrar as the patient would need an HDU bed in
the post-operative setting.

• Probes
• What is the diagnosis?
• Can she be managed conservatively?
• Does she need a CT for the abdomen and pelvis
86 Smashing the Core Surgical Training Interview

• Positive markers
• Uses A–E assessment along with the assessment of operation
notes and chart review
• Understands the importance of excluding underlying causes of
delirium, such as sepsis from an anastomotic leak.
• Appropriately escalates
• Negative markers
• Gives the patient sedatives without excluding causes for delirium
• Does not work up the patient appropriately
• Does not escalate

Urology
Clinical Scenario 16: Haematuria
You are the core surgical trainee in urology. A 65-year-old woman presents
with a three-week history of painless, frank haematuria. Her medical history
is significant for hypertension. She has a 40-pack-year history of smoking.
How would you approach this patient?

I am concerned that this patient might have cancer of the urinary tract,
given her history of significant smoking and persistent painless haema-
turia. Pertaining to this, I am also mindful that the patient could develop
clot retention from significant haematuria. I would make sure to rule out
benign conditions, such as UTIs and renal stones as a cause of haematuria.
The patient might or might not require admission to the hospital, based
on my assessment.
I would approach the patient using a CCrISP approach and do an A–E
assessment. If she is hemodynamically stable, then I would proceed by
taking a detailed history. I would start by exploring the history of haema-
turia in detail, asking about volume, colour, and clots. I would ask about
any associated urinary symptoms, such as dysuria, frequent urination, or
pneumaturia. I would ask about pain. I would ask about any recent weight
loss or night sweats to assess for B-symptoms related to cancers. I would
ask about any history of UTIs, renal stones, or any other urinary prob-
lems. On examination, I am particularly looking for any obvious abnor-
mal masses in the suprapubic region and the renal angle. I would examine
the patient using a chaperone.
In terms of investigations, I would request for FBC, U&E, CRP, and
clotting profile to assess the patient for anaemia, any signs of infection,
and any indication of renal dysfunction. I would also send a cross-match
to ensure that blood could be given if required.
Chapter nine: Clinical Scenarios 87

In terms of microbiological investigations, I would review the urine

dip to rule out any infection. If it is nitrite or leucocyte positive, I would
ask for it to be sent for MC&S. At this stage, I am concerned that the
patient has an underlying malignancy. I think she would need an urgent
outpatient CT scan on a two-week wait pathway. She would also require
a flexible cystoscopy with biopsy. If she has a significant clot burden and
is at risk for clot retention, I would arrange for admission to the hospital,
placement of a three-way catheter, and irrigation with normal saline. If
I think her presentation is more suggestive of renal colic, I would arrange
for a CT KUB.
Once I have assessed this patient, I would involve my registrar or con-
sultant to determine whether she should be managed as an inpatient or
outpatient. Although the diagnosis of malignancy is not yet confirmed,
I would alert the outpatient urology nurses to keep an eye out for her
investigations. She might need to be added to a multidisciplinary team
meeting for discussion.
Throughout all of this, I understand that this might be a difficult and
stressful situation for the patient and her family. I would keep the patient
at the centre of care, communicating with her sensitively. Breaking bad
news of a cancer diagnosis is a very sensitive conversation, and it is best to
wait for confirmation of the diagnosis before making any statements such
as this. I would discuss the timing of this conversation with my registrar
and consultant.

• Probes
• What is your differential diagnosis?
• What are your priorities?
• What other information would you gather?
• Who else would you like to involve in this patient’s care?
• Positive markers
• Considers malignancy as the most likely diagnosis
• Constructs a reasonable differential diagnosis
• Requests appropriate investigations
• Escalates to the registrar or consultant appropriately
• Has a structured approach to patient assessment
• Negative markers
• Has an unstructured approach to patient assessment
• Does not involve the wider healthcare team
• Breaks bad news without adequate information
• Does not consider inpatient versus outpatient management
88 Smashing the Core Surgical Training Interview

Clinical Scenario 17: Renal Colic

You are the core surgical trainee on urology. A 65-year-old gentleman pres‑
ents to A&E with severe right-sided flank pain. His urine dip is positive for
blood +++. How will you approach this patient?

From the information at hand, the patient appears to be having renal colic.
I would attend to the patient early and make sure the patient is comfort-
able as renal colic is a very painful condition. I would liaise with my A&E
colleagues and make sure the patient is prescribed appropriate analgesia
and is comfortable while waiting to be seen. The patient could also have
obstructive uropathy causing sepsis. Although less likely, this could also
represent a ruptured AAA, which is a surgical emergency.
On arrival, I would ask the patient and make sure he is comfortable
and pain-free. If not, I would review the analgesia on the drug charts and
prescribe more if appropriate. If the patient is unwell, I would follow an
A–E approach using the CCrISP protocol. However, if the patient is stable,
I would proceed to take a detailed history and examination. I would then
ask about the pain, in particular asking about the onset, duration, and
character. I would enquire about any associated urinary problems and any
history of renal stones. Specifically, I would also ask about risk factors for
AAA, such as cardiovascular disease and any previous aortic ultrasounds.
Using a chaperone, I would perform a full abdominal examination, in par-
ticular looking for renal angle tenderness or a palpable AAA. I am also
looking to see if the patient is displaying signs of sepsis, such as tachycar-
dia or fever.
I would request relevant investigations, which would include FBC,
U&E, LFTs, CRP, and amylase. The urine dip has already been inspected
and shows +++ blood. If the patient is septic, I would also get blood cul-
tures. Based on a diagnosis of presumed renal colic, I would organise a
CT KUB non-contrast in consultation with my registrar. If I am in any
doubt about the diagnosis, a CT of the abdomen/pelvis or a CT angiogram
might be other options.
If I am concerned that the patient is septic with obstructive pyelone-
phritis, I would initiate sepsis 6. This includes starting high-flow oxygen,
IV fluids, and IV antibiotics, and I would take blood cultures, check lac-
tate, and monitor urine output.
The eventual management for this patient depends on his clinical
situation and the results of his CT scan. If he has a small renal stone and
well-controlled pain, he might be managed as an outpatient. If he has an
obstructing stone causing sepsis, he would require admission and decom-
pression, either with a retrograde stent or nephrostomy. If the patient had
an alternative diagnosis, such as a ruptured AAA, this would require
emergency specialist management by the vascular surgery team.
Chapter nine: Clinical Scenarios 89

Throughout this patient’s assessment, I am cognizant of the team that

I work within. If I had an FY1, I might delegate specific tasks to them,
such as taking blood specimens or placing a catheter. I would escalate to
my registrar or consultant based on clinical urgency. I would also involve
nursing and speak to radiology for advice.
Throughout all this, I would keep the patient at the centre of care and
make sure I communicate my thinking process and findings with him.

• Probes
• What is your differential diagnosis?
• What are your priorities?
• What other information would you gather?
• Who else would you like to involve in this patient’s care?
• Positive markers
• Considers renal colic as the most likely diagnosis
• Constructs a reasonable differential diagnosis
• Requests appropriate investigations
• Escalates to the registrar or consultant appropriately
• Has a structured approach to patient assessment
• Negative markers
• Has an unstructured approach to patient assessment
• Does not involve the wider healthcare team
• Does not offer early analgesia
• Does not escalate patient care

Clinical Scenario 18: Paraphimosis

You are the core surgical trainee on urology. You are asked to see a 56-year-
old gentleman as a ward referral. He is POD#2 after a sigmoid colectomy. He
still has a urinary catheter, which is draining clear urine. He complains of
intense pain in his penis. How will you approach this patient?

Penile pain in a post-op patient with a properly functioning catheter would

make me consider paraphimosis. Other possibilities include irritation from
the catheter or urinary tract infection. This might require reduction, cathe-
ter removal/exchange, or antibiotics, depending on my patient assessment.
I would approach the patient using an A–E approach, using the CCrISP
algorithm. In the absence of acute haemodynamic concerns, I would pro-
ceed to take a focused urological history and examination. I would ask
about the nature of the pain, its onset, and any aggravating or relieving
factors. I would ask for associated symptoms, such as dysuria or haematu-
ria. I would examine his penis, with a chaperone present, to see if he has
a paraphimosis or if there is blood at the urethral meatus. I would also
examine the output of the catheter to see if the urine is cloudy or bloody.
90 Smashing the Core Surgical Training Interview

I would review the patient’s notes and blood work. In particular,

I would look at the operative note to see why the catheter was placed,
if the foreskin was replaced, and whether there are any reasons (such
as injury to the bladder intra-operatively) that would mean the catheter
should stay in place.
If I think the patient does indeed have paraphimosis, I would pre-
scribe adequate analgesia. I know that paraphimosis could be reduced at
the bedside by applying gentle pressure to the swollen foreskin along the
penile shaft for a few minutes to reduce oedema and then replacing the
foreskin in its place. Hypertonic solutions, such as 50% dextrose, could be
applied topically to osmotically reduce oedema. This could also be per-
formed using a penile block. At this point in my training, I do not feel
comfortable performing this procedure independently, so I would alert
my registrar so that we could perform this together. If this is not success-
ful at the bedside, the patient might need to go to theatre for a reduction
+/− dorsal slit under general anaesthesia. This would involve coordina-
tion with theatres and the anaesthetic team. If I think the patient has a
urinary tract infection, I would consider catheter exchange/removal and
antibiotics.
Finally, this is an event in which the patient has come to harm. I would
submit a Datix form and discuss this case at morbidity and mortality for
the whole team to learn lessons from this adverse event. I would also dis-
cuss this with the patient, using the duty of candour rules.

• Probes
• What is your differential diagnosis?
• What other information would you gather?
• When would you escalate this patient’s care?
• If you find that the patient has paraphimosis, how would you
proceed?
• Positive markers
• Considers paraphimosis as the most likely diagnosis
• Constructs a reasonable differential diagnosis
• Escalates to the registrar or consultant appropriately
• Has a structured approach to patient assessment
• Understands own limitations
• Negative markers
• Does not consider paraphimosis
• Does not consider whether the urinary catheter needs to stay in
place
• Has an unstructured approach to patient assessment
• Does not review analgesia
• Does not escalate patient care
Chapter nine: Clinical Scenarios 91

Clinical Scenario 19: Urinary Retention

You are the core surgical trainee on urology. A 57-year-old gentleman pres‑
ents to A&E with the inability to pass urine for the past 12 hours. He is now
in significant discomfort. He is otherwise fit and well. How will you approach
this patient?

The patient appears to be in urinary retention. I would ask A&E to do a

bladder scan to confirm this diagnosis. The patient might require a cath-
eter and possible admission for monitoring of fluid fluxes. Another differ-
ential is hypovolaemia with resultant low urinary output, with the pain
being caused by an alternative intra-abdominal pathology.
I would assess the patient using the CCrISP guidelines. Once I am
satisfied with the A–E assessment and I have confirmed that the patient is
hemodynamically stable, I would proceed to assess for acute urine reten-
tion. I would take a detailed history and specifically ask about any uri-
nary tract symptoms, such as dysuria or frequent urination. I would try
to establish if the patient has pre-existing prostatic symptoms, such as
dribbling. On examination, I would feel for a distended, palpable, tender
bladder and try to exclude any other cause for acute abdominal pain. With
a chaperone present, I would also perform a digital rectal examination to
assess the prostrate for enlargement.
In terms of investigations, I would get an FBC, CRP, U&E, LFTs, amylase,
and PSA. This would enable me to assess renal function and other causes of
abdominal pain. The bladder scan would show me if there indeed is reten-
tion. If the bladder scan shows >500 ml of urine, I would catheterise the
patient. Concomitantly, I would send a urine dip and send urine for MCS.
I would escalate to my registrar if I am unable to catheterise the patient
as I do not want to cause traumatic urethral injury through multiple
attempts. The patient might require a supra-public catheter or a flexible
cystoscopy-assisted catheter insertion over a guide wire. I could not per-
form these procedures currently but would be interested to learn from my
seniors. I would also discuss with my senior if an ultrasound KUB would
be of value for this patient. Depending on the patient’s clinical status, we
might be able to manage this in an outpatient setting, in which case I would
liaise with the urology clinic to arrange for follow-up in the TWOC clinic.
Alternatively, I might need to liaise with nursing and bed management to
get a bed for this patient if the patient is being admitted as an inpatient.
I would keep the patient at the centre of care, especially as having a
catheter might be uncomfortable for him.

• Probes
• What is your diagnosis?
• What other information would you gather?
92 Smashing the Core Surgical Training Interview

• How would you escalate this patient’s care?

• If you fail to catheterise the patient, what other options would
you consider?
• Positive markers
• Considers urinary retention as the most likely diagnosis
• Constructs a reasonable differential diagnosis
• Escalates to the registrar or consultant appropriately
• Has a structured approach to patient assessment
• Understands own limitations
• Negative markers
• Does not attend to the patient and delegates management to A&E
• Has an unstructured approach to patient assessment
• Does not escalate patient care
• Is not aware of other options if urethral catheterisation fails

Clinical Scenario 20: Testicular Torsion

You are the core surgical trainee on urology. A 12-year-old boy presents with
a four-hour history of sudden, severe left testicular pain. The pain started
while he was playing volleyball. How will you approach this patient?

Given the age and presentation, I am concerned about testicular torsion,

which is a surgical emergency. The other differential is testicular trauma.
As such, my priority would be to quickly assess the patient, and if I am
suspecting testicular torsion, then I would urgently escalate to my regis-
trar since the patient needs to go to theatre for scrotal exploration within
six hours of the onset of pain.
I would assess this patient immediately using the CCrISP algorithm.
If he has haemodynamically stable, I would take a focused history and
examination. I would specifically ask about the onset of pain and timing.
I would ask about any associated trauma or swelling. I would ask about
pre-existing lumps or bumps. On examination, I would use a chaperone
and ask for permission for a genital examination. Specifically, I would
look for a tender, high-riding testicle with the absence of a cremasteric
reflex.
Testicular torsion is a clinical diagnosis and requires no further inves-
tigations. A urine dip might be helpful to exclude a UTI or epidydimo-
orchitis. If I found a scrotal haematoma on the background of trauma,
I might request an ultrasound of the scrotum. I would make this deci-
sion in close collaboration with my registrar or consultant, whom I would
involve early in this case.
If the patient needs to go to theatre, then I would communicate this
with the theatre staff, on-call anaesthetist, and A&E. This might also require
Chapter nine: Clinical Scenarios 93

communication with other surgical specialities who share CEPOD theatres

as the case order might need to change. Sometimes a second theatre might
need to be opened up. If I feel competent, I would consent the patient for
scrotal exploration and mark the correct side with a permanent marker.
I am conscious that this is a stressful, high-stakes situation. The
patient and his family might be concerned about the viability of the tes-
ticle, and I would do my utmost to keep them at the centre of our care and
informed every step of the way.

• Probes
• What are your priorities?
• What other information would you gather?
• How would you escalate this patient’s care?
• If the patient required an emergency scrotal exploration, whom
would you need to inform?
• Positive markers
• Appreciates the urgency of the situation and attends to the
patient immediately
• Recognises that this requires a team-based approach
• Escalates to the registrar or consultant appropriately
• Books patient for theatre and discusses with theatre team and
anaesthesia
• Negative markers
• Does not attend immediately
• Uses an unstructured approach to patient assessment
• Does not escalate patient care
• Fails to book the patient for theatre properly
• Does not recognise testicular torsion or its urgency

ENT
Clinical Scenario 21: Neck Mass
You are the ENT SHO asked to review a 40-year-old lady who has presented
to A&E with a neck mass. She complains of a two-month history of ‘tightness’
in her neck. She denies pain or breathlessness but feels that over the previous
fortnight, she can feel a more palpable mass on the front of her neck.

Neck masses encompass a broad range of differentials, both benign and

malignant. I am concerned that this patient might have a thyroid, parathy-
roid, or lymphatic malignancy. Benign diagnoses could include thyroid or
parathyroid masses, infection, Graves’ disease, Hashimoto’s thyroiditis,
and lymphadenopathy secondary to an infection. With a rapid increase
94 Smashing the Core Surgical Training Interview

in size, I would attend to the patient urgently, particularly to ensure her

airway is secure.
I would assess the patient using the CCrISP algorithm. If she was hae-
modynamically stable, I would undertake a thorough and detailed his-
tory with focused questions about thyroid/parathyroid imbalance, such
as weight loss or gain, heat or cold intolerance, diarrhoea or constipation,
excessive sweating, tremors, lethargy, palpitations, visual disturbance,
and menstrual irregularities. I would specifically ask about any red flag
symptoms, including unintentional weight loss, loss of appetite, night
sweats, difficult or painful swallowing, and voice change/hoarseness.
I would ask about any fever, localised pain, and any swallowing diffi-
culties. I would then inquire about the patient’s smoking status, use of
alcohol and any other illicit drugs, and radiation exposure and also gather
information about her family history with a focus on any autoimmune,
thyroid/parathyroid, and endocrine pathologies.
I would then get a full set of observations and review them, with
emphasis on pulse rate, blood pressure, and temperature. I would then
carefully examine the patient. This would include a quick general physi-
cal exam followed by a thorough examination of the neck swelling from
behind. The examination would involve careful inspection to ascertain
the position, size, symmetry, extent, and shape of the swelling followed
by palpation to ascertain firmness, regularity, mobility, and tenderness, as
well as tracheal position. I would then ask the patient to stick her tongue
out, followed by swallowing, and look for any associated movement of
the swelling, I would also auscultate the mass for any bruits and check
for any neck vein distention. I would finish the examination by looking
for common signs associated with thyroid pathology, such as exophthal-
mos, lid lag, tremors, pretibial myxoedema, and loss of lateral eyebrows.
I would keep a broad differential while assessing the patient in case my
differential changes, such as a vascular lesion or muscular mass.
This patient needs blood tests, including FBC, U&E, LFTs, bone pro-
file, thyroid functions tests (including T3, free T4, and TSH), and parathy-
roid hormone levels. With the blood tests available, I would discuss this
patient with my on-call registrar.
If the patient has a thyroid emergency, such as thyroid storm, I would
start oxygen, IV fluids, and paracetamol. I would liaise with the medical
registrar on-call regarding starting beta blockers and anti-thyroid medi-
cations. This patient might require a higher level of care, in which case
I would liaise with the HDU team.
Alternatively, if the patient is not acutely unwell and does not require
hospital admission, I would arrange for an urgent two-week-wait ultra-
sound of her neck +/− FNA. I would alert the outpatient ENT team to keep
an eye on this result and make arrangements for the patient’s results to be
reviewed in a timely manner.
Chapter nine: Clinical Scenarios 95

I would explain the management plan to the patient and answer any
questions she might have.

• Probes
• What are your immediate concerns?
• What are your differentials?
• What other information would you gather?
• How would you escalate this patient’s care?
• Positive markers
• Takes thorough and focused history
• Considers benign and malignant causes for presentation
• Considers conditions requiring hospital admission
• Requests relevant investigations (TFTs, bone profile)
• Recognises the need for USS and FNAC
• Negative markers
• Uses an unstructured approach
• Fails to rule out emergency conditions
• Does not take a focused history
• Is not mindful of malignancy
• Does not request appropriate blood tests
• Fails to involve senior

Clinical Scenario 22: Bleeding Post-Thyroidectomy

You are the core surgical trainee on-call at a tertiary teaching hospital. You
are asked to see a 41-year-old lady in theatre recovery for dyspnoea. She is
freshly post-hemithyroidectomy for a thyroid nodule. Her left neck is grossly
swollen. How would you approach this patient?

I am most concerned this patient might be suffering from a post-­operative

haematoma, causing airway obstruction, though unilateral laryngeal
nerve injury is also a differential. I would advise the recovery staff to
apply high-flow oxygen and obtain a full set of observations. I would
attend to the patient immediately, and if the operating surgeon were still
present, I would inform them as well.
I would evaluate the patient using a CCrISP approach. On immediate
assessment, I would assess for patency of the airway by speaking to the
patient. I would listen for the patient’s upper airway sounds, listening
for stridor, hoarseness, or ‘breathy’ sounds. I would also inspect the neck,
assessing for any swelling, bruising, leaking staple lines, and tracheal
deviation. Were there any of these findings, I would inform my senior
immediately as this is a surgical emergency. In extremis and in the absence
of immediate available help, I would take a systematic approach to open
the wound at the bedside, by exposing skin, cutting sutures, opening
96 Smashing the Core Surgical Training Interview

the skin, opening superficial and deep layers of muscle, evacuating the
haematoma, and packing the wound. This would relieve pressure on the
trachea causing airway obstruction. I would then re-evaluate the airway
and proceed to do the A–E assessment. If the clinical acuity of the patient
allows, I would also read the operative note to determine if there has been
any concern over haemostasis.
After the procedure, the patient would need an immediate return to
theatre for haemostasis, so early contact with the on-call anaesthetist, spe-
cifically informing them of airway compromise and potentially distorted
anatomy, would allow them to prepare their theatre and airway equip-
ment to allow safe intubation. The operating surgeon or the on-call ENT/
general/endocrine surgeon (depending on the provision of these speciali-
ties at the local site) would need to be informed of their assistance in the
operation. Post-operatively, the patient might require a high-dependency
unit or intensive care unit bed, so liaison with the critical care team would
aid post-operative destination planning.
Given this was an unplanned return to theatre, there has to be a duty
of candour discussion with the patient post-operatively. The patient
also needs to be discussed in the departmental morbidity and mortality
meeting.

• Probes
• What are your priorities?
• What are your differentials for post-surgical dyspnoea?
• When will you involve your seniors?
• Positive markers
• Attends to the patient immediately
• Recognises this is a life-threatening emergency
• Suggests opening of the surgical wound to evacuate the
haematoma
• Considers forward destination beyond initial management
• Negative markers
• Does not attend immediately
• Has an unstructured approach
• Does not escalate
• Fails to consider definitive management

Clinical Scenario 23: Epistaxis

You are the core-surgical trainee and are called to see a 50-year-old man with
a background of hypertension and atrial fibrillation on ramipril and warfa‑
rin. He presents to ED with active epistaxis from the left nostril. How would
you proceed?
Chapter nine: Clinical Scenarios 97

The most common causes of epistaxis include trauma, hypertension,

or secondary to drugs such as anticoagulants or antiplatelets. I would
enquire about when the bleeding started, and how much blood he has
lost. I would also ask if there was any history of recurrent epistaxis, bruis-
ing, or bleeding from elsewhere.
I would immediately go and see the patient and assess him using the
ABCDE approach. I would assess the airway by speaking to the patient. If
they were speaking in clear full sentences, I would give 15 litre of oxygen
via a non-rebreathe mask and move onto breathing.
The priority in this patient is to arrest the bleeding and ensure he is
haemodynamically stable. I would assess his pulse, cap refill, and blood
pressure. I would ask for help with IV access with a large bore cannula
and simultaneously take blood including VBG, FBC, U&E, LFT, CRP,
group and screen, and clotting.
I would then start fluid resuscitation and ask for help from one of the
nursing staff to apply pressure to the soft part of the nose of the patient
for 15 minutes while they were sitting forward. If this does not arrest the
bleed, I would then proceed to pack the nose with either an absorbable
pack or a rapid rhino which could apply haemostatic pressure.
I would consider warfarin reversal if the bleeding restarts and discuss
this patient with haematology.
I would escalate this patient to the registrar on call, as the patient may
need to be taken to theatre for cauterisation of the bleed, if the bleeding
does not stop with packing.
Once the bleeding has stopped, the nasal pack would stay in situ for at
least 24 hours prior to removal and consideration of discharge.
I would ensure I speak to the patient and their family to ensure they
are informed of the management and answer any questions they may have.

• Probes
• What further information do you need?
• What tests do you require?
• Will you reverse the warfarin?
• Positive markers
• Assess using ABCDE approach
• Needs IV access as a matter of urgency
• Requests appropriate initial investigations including G&S and
FBC
• If ongoing bleeding should be escalated and prepared for theatre
• Negative markers
• Does not prioritise this patient
• Unstructured approach
• Does not escalate patient
98 Smashing the Core Surgical Training Interview

Clinical Scenario 24: Peritonsillar Abscess

You are a core surgical trainee and are called to see a 30-year-old women with
a history of tonsillitis presented to the emergency department. On this occa‑
sion, she cannot speak properly and has been unable to swallow any tablets or
eat food due to the pain. You are asked to come and assess the patient to rule
out a peritonsillar abscess.

In this scenario, I am concerned this patient has a peritonsillar abscess.

I would assess her using an ABCDE approach. First, I would speak to
the patient to assess her airway status. If she cannot speak to me in full
sentences, I will conduct a airway assessment before moving on. I would
do this by examining the oral cavity, to assess the tonsils for any obvious
peritonsillar swelling or deviation of the uvula. If this is present, then the
most important treatment to secure the airway is aspiration of the abscess
to remove pus and create more space. I will consider escalating to the
anaesthetic team early if my patient needs airway support.
I would then move on to assess breathing and circulation. I would
assess the pulse rate and blood pressure and secure IV access for further
treatment. I would take blood including VBG, FBC, U&E, LFT, CRP, and
clotting. I would start fluid resuscitation, intravenous antibiotics, and give
a stat dose of steroid to help reduce swelling.
I would ensure that the patient has a full range of neck movements as
it is important to ensure there are no signs of a deep neck space infection.
I will also check the patient’s GCS.
After completing my examination, I would admit the patient for IV
fluids, regular IV antibiotics, and steroids. I would escalate the patient to
the registrar on call in case further aspiration or incision and drainage of
the abscess is required.
I would speak to the patient and their family to ensure they are
informed of the management and answer any questions they may have.
Once the patient can eat and drink and swallow tablets they can be
discharged to complete a course of oral antibiotics.

• Probes
• What is the priority for this patient?
• What is the most important treatment?
• Positive markers
• Assess using ABCDE approach
• Airway is assessed appropriately
• Peritonsillar abscess is aspirated
• Negative markers
• Does not rule out deep neck space infection
• Does not start on IV antibiotics
• Does not escalate patient
Chapter nine: Clinical Scenarios 99

Plastics
Clinical Scenario 25: Necrotising Fasciitis
You are the SHO on-call for plastics and have been asked to see a 35-year-
old female IVDU who presents three days after injecting heroin into her
right wrist. She has severe pain around the injection site. The pain has been
getting worse with increased erythema, redness, and tracking up the arm.
She is febrile, tachycardic, and hypotensive. How would you approach this
patient?

I am the SHO on-call for plastics and have been asked to see a 35-year-old
intravenous drug user who is presenting with pain in her wrist. She is
potentially showing signs of septic shock. Given how sick she is, I would
inform my registrar of the referral. Over the phone, I would ask the ED
to initiate the sepsis 6 protocol. My current differentials are necrotising
fasciitis, complicated cellulitis, abscess, or a foreign body like a needle in
the forearm. She might require theatre.
I would approach the patient using the CCrISP protocol. If the patient
could speak to me, her airways are patent. I would then want to know
her respiratory rate and oxygen saturation and ensure she was on high-
flow oxygen if clinically indicated. I would assess breathing by inspect-
ing if the patient is in respiratory distress. I would feel for any signs of
tracheal deviation and unequal chest expansion and percuss the lungs
bilaterally. I would then auscultate the lungs anteriorly and posteriorly
to assess for equal air entry. If the airway is intact, I would move on to
circulation. I would assess the patient’s heart rate, blood pressure, and
fluid status. I would ensure that the patient has two large-bore cannulas
inserted where I would take an FBC, U&E, CRP, LFTS, coagulation screen,
and group and save. I would take an ABG to assess the patient’s lactate
level. In addition, I would commence the sepsis 6 protocol by taking blood
cultures, monitoring the urine output, administering fluids and antibiot-
ics, taking the patient’s lactate level, and giving oxygen if needed. Finally,
in circulation, I would ensure an ECG is done as the patient is tachycardic.
If circulation is now stable, I would move on to disability by assessing
the patient’s GCS, blood glucose levels from my ABG, and temperature.
Lastly, I would expose the patient appropriately, assessing her from head
to toe but focusing on the right arm.
On the right arm, I would inspect for signs of erythema, abscesses,
open wounds, and track marks. At this point, I would mark out the
patient’s erythema. I would feel for any signs of crepitus, warmth, and ten-
derness and assess how soft or firm the compartments are. As I am most
concerned about necrotising fasciitis, I would perform the sweep test and
look for signs of discoloured water. This completes my A–E assessment.
At this point, I would ensure that my registrar is aware of the situation
100 Smashing the Core Surgical Training Interview

and take a focused history. I might also consider an x-ray of the forearm if
I am concerned about a retained foreign object, such as a needle.
If the patient has necrotising fasciitis, then she requires definitive
management with operative debridement. As the SHO, I would prepare
the patient for theatre by ensuring that the patient is nil by mouth and
has been booked onto the CEPOD list and that the on-call anaesthetist is
aware. I would ensure that antibiotics are started after discussion with
microbiology. The first-line treatment for necrotising fasciitis in my unit
is benzylpenicillin with clindamycin. Furthermore, I would inform the
ITU/HDU about this patient as she might go there post-operatively for
inotropic or vasopressor support.
I appreciate that this must be a stressful situation for the patient, and
I would update her and her next of kin about the urgency and severity of
the situation.

• Probes
• What is your differential diagnosis?
• How would you escalate this patient’s care?
• What features in this presentation make you think about sepsis?
• What definitive care would you offer this patient?
• Positive markers
• Appreciates the urgency of the situation and attends to the
patient immediately
• Considers life-threatening diagnoses, such as necrotising fasciitis
• Recognises that seniors should be involved early
• Assesses the patient with a structured approach
• Negative markers
• Does not consider the life-threatening condition early on
• Uses an unstructured approach
• Escalates at the end of the scenario rather than early
• Does not recognise septic shock

Clinical Scenario 26: Burns

You are the SHO on plastics. You have been asked to see a 26-year-old male
who presents to A&E via ambulance with partial-thickness burns to his face,
trunk, and left arm following a house fire in an enclosed space. How would
you approach this patient?

I am concerned that this patient has had extensive burns following a

house fire. The burns to the face could lead to inhalation injuries and a
compromised airway. The trunk burns, if circumferential, could contrib-
ute to respiratory distress. In any trauma call, I would also be concerned
about other traumatic injuries. I would attend to this patient immediately.
Chapter nine: Clinical Scenarios 101

I would put out a trauma call immediately. I would inform my registrar

of this situation.
I would approach the patient using an ATLS approach. I would ensure
that his c-spine is secured with three-point immobilisation. I would assess
her airway by first speaking to him and starting high-flow oxygen. At the
same time, I would look for any signs of soot inhalation around the nos-
trils and mouth, as well as any signs of stridor. If the patient has signs of
airway compromise, this could require intubation, and I would alert the
anaesthetic team immediately.
At breathing, I would want to know the patient’s respiratory rate and
oxygen saturation. I would look for signs of respiratory distress, paying
particular attention to the patient’s chest to check for circumferential
burns. If this is the case, the patient might need an escharotomy. Next,
I would feel if the trachea is central, check for equal chest expansion ante-
riorly and posteriorly, and percuss the lungs. I would then auscultate to
hear for equal breath sounds bilaterally. I would ask my FY1 to obtain an
ABG and also use this sample to obtain carboxyhaemoglobin levels.
If the airway is intact, I would move on to circulation, with my main
concern here being fluid resuscitation and any signs of haemorrhage from
the five main areas from concomitant trauma. I would want to know the
patient’s heart rate and blood pressure. I would assess the patient’s fluid
status and insert two large-bore cannulas. I would send for a full blood
count, U&E, LFTs, CK, and cross-match. I would start 1 litre of Hartman’s
stat and insert a urinary catheter to monitor fluid output. If circulation is
stable, I would move on to disability by assessing the patient’s GCS, blood
glucose, and temperature.
Lastly, I would expose the patient from head to toe, looking for any
additional injuries. I would ask the nursing staff to completely remove the
patient’s clothing to stop the burning process whilst preventing overex-
posure and hypothermia.
This completes my primary survey. My secondary survey would
involve calculating the total body surface area (TBSA) burnt using
Wallace’s rule of nines and calculating how much fluids to give over a
24-hour period using the Parkland formula.
My immediate investigations would have been done in the primary sur-
vey. At this point, I would want to inform my registrar who would be part
of the trauma call and my consultant. If the main issues only relate to burns,
this patient should be transferred to a specialised burn unit, and I would
facilitate this. I might need to involve anaesthetics for airway control, gen-
eral surgery if I find any other life-threatening injuries, and orthopaedics for
orthopaedic injuries. Depending on my assessment, the patient might also
require further investigations, such as a trauma CT scan.
During all of this, I would keep the patient at the centre of care.
I would ensure that he is receiving adequate analgesia as burns could be
102 Smashing the Core Surgical Training Interview

very painful. If possible, I would also explore the circumstances around

the burn and consider whether this is an accident, self-harm attempt, or
assault.

• Probes
• In a burn patient who has had both facial and trunk burns, what
additional pathologies are you most worried about?
• How would you escalate this patient’s care?
• Who else would you involve in this patient’s care?
• Positive markers
• Appreciates the urgency of the situation and attends to the
patient immediately
• Puts out a trauma call immediately and involves the plastics
team
• Recognises that seniors should be involved early
• Assesses the patient using a structured ATLS approach
• Is aware of when to fluid-resuscitate a patient
• Mentions Parkland formula for fluid resuscitation
• Mentions Wallace’s rule of nines to estimate burn severity
• Negative markers
• Does not attend immediately
• Uses an unstructured approach to patient assessment
• Fails to include other members of the trauma team
• Does not escalate patient care
• Does not recognise the patient might have suffered inhalation
injuries or circumferential burns
• Does not initiate fluid resuscitation

Clinical Scenario 27: Dog Bite

You are the SHO on-call for plastics, and you are asked to see a 53-year-old
female dogwalker who got bit on the palmar surface of her right index finger
this morning. She comes into the ED complaining of swelling and stiffness of
the right index finger. How would you approach this patient?

I am concerned that this patient has had a dog bite, which could lead to an
infection, such as a deep space infection or a flexor sheath infection. I am
also concerned about the potential for neurovascular and bone injuries.
I would assess the patient following the CCrISP protocol. If the patient
is speaking to me, her airway is patent, and I am happy to move on to
breathing. In breathing, I want to know the patient’s respiratory rate and
oxygen saturation and if clinically indicated I would start her on 15 litres
of oxygen with a non-rebreather mask. I would assess her breathing by
Chapter nine: Clinical Scenarios 103

looking to see if she is in respiratory distress. I would then feel her trachea
and check for equal chest expansion bilaterally followed by auscultation.
If breathing is stable, I would move on to circulation. Here, I would want
to know the patient’s heart rate, blood pressure, and temperature. I would
assess her fluid status and insert a large-bore cannula. I would take an
FBC, U&E, CRP, LFTs, coagulation screen, VBG, and group and save. If the
patient shows any signs of sepsis, I would instigate the septic 6 protocol of
taking blood cultures, monitoring the urinary output, administering flu-
ids, starting broad-spectrum antibiotics, measuring the lactate level, and
starting oxygen. If circulation is stable, I would assess the patient’s dis-
ability by checking her GCS, blood sugar levels, and temperature. I would
expose the patient, focusing my examination on her hand.
On examination, I would be looking for any signs of puncture
wounds, swelling, erythema, pus, discharge, and if the finger is in a fixed
flexed position. I would then feel if the hand is hot and assess areas of
tenderness, especially along the flexor sheath. This would be followed by
a neurovascular examination, which would involve assessing the hand’s
function.
Following my CCrISP assessment, I would take a focused history
regarding hand dominance, time of onset, and any medical history lead-
ing to poor wound healing, such as the presence of diabetes or taking ste-
roids. An x-ray of the hand in two views would be needed to ensure there
are no underlying fractures. Once I have all this information, I would
escalate to my registrar about my findings.
To manage this patient effectively, she would need to be admitted into
the hospital for intravenous antibiotics and formal washout and debride-
ment in theatre. As the SHO, I would facilitate this process by informing
the on-call anaesthetist, booking on the CEPOD list, and ensuring all the
relevant blood specimens have been sent. If I feel confident, I would get
consent from the patient and mark her. I would also inform the on-call
consultant.
I appreciate that this might be a stressful situation for the patient, and
I would keep her informed every step of the way.

• Probes
• What are your differentials?
• Which structures are you most concerned about being damaged?
• What further investigations would you request?
• Positive markers
• Appreciates the urgency of the situation and attends to the
patient immediately
• Escalates appropriately
• Assesses the patient with a structured approach
104 Smashing the Core Surgical Training Interview

• Negative markers
• Does not admit the patient
• Uses an unstructured approach
• Fails to escalate care
• Does not coordinate emergency washout

Orthopaedics
Clinical Scenario 28: Hip Fracture
You are the core surgical trainee on-call for orthopaedics. You have been asked
by A&E to see a 92-year-old lady who had a fall at home. She was on the floor
for five hours before being found. She is in A&E with an externally rotated
leg.

In this scenario, I am concerned about a fractured neck of femur. She

might also have acute kidney injury secondary to rhabdomyolysis, given
her prolonged lying on the floor. Additionally, I am also concerned about
hypothermia, given this patient’s age and prolonged lying. She might
require operative intervention for her hip fracture.
This is a trauma patient who should be treated using an ATLS
approach. However, given the nature of the referral, it is possible that A&E
might already have performed a primary survey and possibly cleared the
c-spine. If this was the case, then I would proceed to review the patient’s
observations and available investigations, as well as the A&E clerking.
I would also make note of the patient’s comorbidities and drug history.
I would take a full history from the patient herself, finding out the
mechanism of the fall – was it mechanical or non-mechanical? I would
want to know of any preceding symptoms, such as chest pain, shortness
of breath, or neurological symptoms that might explain the cause of her
fall. I would ask about the location of her pain and discomfort.
I would then examine the patient. I would speak to her, and receiv-
ing a response would ensure her airway is patent and self-maintained.
I would then look at her breathing and feel for any asymmetrical chest
movement or crepitus in the chest wall, auscultating the chest for any
abnormal breath sounds, measuring the respiratory rate and oxygen satu-
ration levels. If she is hypoxic or tachypnoeic, then I would start oxygen
supplementation.
I would move to assess the patient’s circulation, looking for any signs
of hypotension or impaired perfusion. I would feel for her central and
peripheral pulses for rate, rhythm, character, and volume. I would aus-
cultate the precordium for abnormal heart sounds and then measure her
heart rate, blood pressure, capillary refill time, and temperature. I would
request an ECG to exclude an arrhythmia as the cause of her fall.
Chapter nine: Clinical Scenarios 105

I would cannulate her, to take baseline blood tests such as FBC, U&E,
LFTs, clotting, and two group and save samples. This is because this patient
is highly likely to require an operation for her neck of femur fracture, so
knowing her clotting function is within normal limits is important, and
she might require a transfusion (either pre-operatively to optimise or post-
operatively due to blood loss). She should also have no food for six hours
and no clear fluids for two hours pre-operatively so the cannula would
allow administration of medications during her n ­ il-by-mouth period. She
should also have a CK to assess for rhabdomyolysis.
I would then assess the patient’s consciousness using the Glasgow
coma scale and also request a blood glucose measurement.
I would fully expose the patient and examine her fully, including a
dedicated musculoskeletal examination of the affected hip and any other
joints that might have been injured. I would also assess the neurovascular
status of any affected limbs.
After the full examination, I would determine if any further investi-
gations are required in addition to the blood tests requested. If no imag-
ing has been completed, then a plain x-ray of the pelvis, affected hip, and
femur would be required, as well as any other injured limbs. If urine or
chest infection could be considered the cause of the patient’s fall, then a
urine dip and chest x-ray would be indicated.
If the fractured neck of femur is confirmed, then the patient would benefit
from a fascia iliaca block for pain relief before definitive fixation of her fracture.
Given the prolonged lying, I am concerned about an acute kidney
injury. This could be secondary to rhabdomyolysis. The treatment for this
is usually intravenous fluids.
Once I have made an assessment, I would involve my registrar or con-
sultant. I think the patient would require definitive treatment of her frac-
ture, and this would need to be coordinated. I would escalate across to other
specialities, such as the renal registrar and medical registrar, to get advice
for the AKI and potentially to treat any cardiac or neurological causes for
the patient’s fall. I would inform the ITU registrar after discussion with the
renal/medical team in case the patient needs haemofiltration prior to sur-
gery. I would also inform the anaesthetic registrar and the theatre coordina-
tor as this patient would need surgical fixation. Finally, I would involve the
orthogeriatric team as this patient would need their input.
I would then document my findings and management plan and com-
plete a drug chart including the patient’s regular medications, analgesia,
VTE prophylaxis, and intravenous fluids. If the registrar is happy for me
to ask consent from the patient, then I would discuss the operation with
the patient, complete the consent form, mark the affected side, and book
her on the next available trauma list.
I understand that this is a stressful situation for the patient. I would
call the patient’s family and inform them of the plan. Given the patient’s
106 Smashing the Core Surgical Training Interview

advanced age, if she has carers, they need to be informed. Given that the
patient lay for a long time before being found, it is also possible that the
patient has safeguarding issues and might not be able to manage at home
any longer going forward.

• Probes
• What is your differential diagnosis?
• What are your priorities?
• What other information would you gather?
• Who else would you like to involve in this patient’s care?
• Positive markers
• Recognises the risk of AKI and rhabdomyolysis
• Manages analgesia appropriately
• Involves appropriate specialities
• Negative markers
• Requests A&E to do the x-ray and re-refer if fractured
• Fails to understand the importance of managing the AKI prior to
surgery

Clinical Scenario 29: Cauda Equina Syndrome

You are the core surgical trainee on orthopaedics. You are asked to review a
32-year-old male manual worker in A&E. He complains of a two-day history
of lumbar back pain and bilateral leg pain. Since this morning, he has had dif‑
ficulty passing urine and an altered sensation in his perineum. How would
you manage this patient?

I am concerned that this patient has a spinal emergency like cauda equina
syndrome. He has back and leg pain with difficulty passing urine and
altered sensation in his perineum. I would review this patient urgently. He
would likely require an urgent MRI and possibly spinal decompression.
I would examine this patient using a CCrISP approach, doing an ini-
tial A–E assessment and reading the A&E notes. Then I would obtain a
detailed history of the back/leg pain and inquire about any incontinence
and altered perianal sensation. I would ask about recent trauma. I would
enquire about medical history, medications, and allergies.
After providing adequate analgesia, I would perform a complete
neurological examination of the lower limbs. This exam would include
straight leg raise to test sciatic stretch. I would test for tone, sensation, and
power in the lower limbs. For sensation, I would assess light touch and
pin prick. I would assess the patient’s lower-limb reflexes, including knee
jerk, ankle jerk, and Babinski. I would perform a PR exam with a chaper-
one. I would test for tone and sensation – again light and pinprick. I would
ask for a pre-void and post-void bladder scan.
Chapter nine: Clinical Scenarios 107

I would gain IV access and obtain initial blood tests (FBC, U&E, CRP,
and ESR). Since I am concerned about cauda equina, I would ask radiology
for an urgent MRI scan.
I would inform my registrar of my findings. Pending the results of the
MRI, I might also need to involve anaesthetics and the theatre team.
I would explain the potential diagnosis and management plan to the
patient. Cauda equina syndrome is the compression of the cauda equina
nerve roots that leads to the development of back or leg pain, lower-limb
neurological deficit, saddle anaesthesia, and bladder or bowel dysfunc-
tion. The urinary incontinence is from overflow due to retention. The
patient should be kept nil by mouth until a final read is available on the
MRI. Surgical intervention in the form of emergency spinal decompres-
sion would be required.

• Probes
• What are your concerns with this patient?
• How would examine this patient?
• How would you further investigate this patient?
• How would you escalate this patient’s care?
• Positive markers
• Appreciates the urgency of the situation
• Performs a neurological examination, including PR
• Organises an urgent MRI scan
• Asks for a pre- and post-void bladder scan
• Escalates appropriately
• Negative markers
• Does not attend to the patient urgently
• Has an unstructured approach to examination
• Uses inappropriate or inadequate investigations
• Does not escalate urgently

Clinical Scenario 30: Shoulder Dislocation

You are the core surgical trainee for orthopaedics. You attend to an 18-year-
old rugby player in A&E who was tackled and fell onto his right shoulder.
He experienced immediate pain and is unable to move his shoulder despite
analgesia. How would you approach this patient?

Considering the mechanism of injury and the patient’s inability to move

his shoulder, I suspect a shoulder dislocation. A dislocated joint is an
orthopaedic emergency and needs early, safe reduction.
I would approach this patient using an ATLS approach. Given the
nature of this referral, I would presume that A&E has already done a
primary survey and perhaps cleared the c-spine. However, I would still
108 Smashing the Core Surgical Training Interview

perform a quick A–E assessment to exclude any other concomitant life-

threatening injuries. If the patient is haemodynamically stable with an
isolated complaint, then I would focus on the shoulder.
I would first provide this patient with adequate analgesia and then
obtain a brief history of the mechanism of injury and any previous frac-
tures or dislocations to this shoulder. My examination would include not-
ing the position of the arm – abducted and externally rotated if anterior
dislocation and internally rotated if posterior dislocation. I would per-
form a neurovascular assessment of the affected limb and compare it to
the contralateral side. I found focus my neurological examination on the
affected limb, looking at tone, power, sensation, and reflexes. The exam-
ination would be limited in some aspects by the inability to move the
shoulder. I would assess the vascular status by feeling for distal pulses
and measuring capillary refill time.
An urgent x-ray is required for confirmation of the diagnosis and
to also ascertain if a concurrent fracture has been sustained. The x-rays
should include two orthogonal views. Dislocations could be anterior or
posterior. Anterior dislocations constitute the majority of shoulder dis-
locations. Posterior dislocations could often be initially missed. When
reviewing x-rays, I would look for the ‘light bulb’ sign, which indicates
posterior dislocation.
At this stage, I would escalate this patient’s care to my registrar. If a
simple dislocation is found, then closed reduction in A&E using adequate
analgesia should be attempted. Multiple attempts at reduction should be
avoided as this could lead to fractures and neurovascular injuries. The
manoeuvre for reduction is the traction-countertraction method.
Once the joint is reduced, neurovascular assessment and x-ray must
be repeated. A referral to the physiotherapy team is important.
In the case of an irreducible dislocation or if there is a concomitant
fracture, this patient would require urgent manipulation under anaesthe-
sia in theatre. Hence, the patient should be nil by mouth. I would prepare
the consent form for my registrar and mark the appropriate side. I would
also involve my consultant, the anaesthetist, and theatre team. The patient
should be aware of the risk of requiring and open surgical reduction for
dislocations that fail closed procedure.
Throughout this process, I would keep the patient at the centre of care.
I would communicate our decision-making to him and make sure he is
involved in all decision-making. I realise that performing a closed reduc-
tion in A&E could be traumatic for the patient, and I would do my utmost
to make sure he is reassured and receives adequate analgesia or sedation.

• Probes
• What are your concerns with this patient?
• How would you examine this patient?
• How would you investigate this patient?
Chapter nine: Clinical Scenarios 109

• Positive markers
• Provides adequate analgesia
• Performs a neurovascular examination
• Obtains basic imaging (x-ray)
• Escalates patient care to the registrar appropriately
• Negative markers
• Does not appreciate the variety and complexity of potential
injuries
• Does not provide adequate analgesia
• Proceeds with manipulation without initial imaging
• Does not escalate patient care

Clinical Scenario 31: Compartment Syndrome

You are the core surgical trainee for orthopaedics. A 27-year-old male cyclist
sustained a closed right tibial fracture. He has been admitted for overnight
analgesia and tibial intramedullary nailing the following morning. He is
tachycardic and in severe pain in his right leg. How would you approach this
patient?

I am concerned that this patient has compartment syndrome following

tibial fracture. This is an orthopaedic emergency, and I would attend this
patient immediately.
I would review the patient using a CCrISP approach. I would per-
form a quick A–E assessment of the patient. If there are no life-threatening
issues, I would proceed to focus on the affected limb.
I would review the observation chart, paying attention to the pain
score and review the drug chart for analgesia taken so far. If inadequate
analgesia has been administered, then I would proceed to prescribe some
urgently. Otherwise, I would take down any bandages or split any back
slab that has been applied and elevate the limb. I would proceed to exam-
ine the affected limb. I would do a full neurovascular and musculoskel-
etal examination. In particular, I am looking for pain out of proportion on
passive stretch. This would indicate compartment syndrome, which is a
clinical diagnosis. From a neurological point of view, altered sensation or
paraesthesia could indicate nerve damage. From a vascular point of view,
lack of a peripheral pulse and paralysis are late findings and carry a very
poor prognosis. I do not think that any further investigations are war-
ranted at this point.
I would immediately escalate to the orthopaedic registrar or con-
sultant. I would also make the patient nil by mouth, gain adequate IV
access, take initial blood specimens (FBC, U&E, coagulation screen, and
group and save), and prescribe IV fluids. I would consent and mark the
patient after explaining the diagnosis and management to the patient.
110 Smashing the Core Surgical Training Interview

The anaesthetist and theatre team must also be alerted. Rarely, in some
instances, when the diagnosis is unclear, compartment pressures could
be measured on the ward. However, more usually, treatment for compart-
ment syndrome is emergency fasciotomy in theatre.

• Probes
• What further information would you require?
• Are there any immediate actions to be taken?
• How would his care be escalated?
• Positive markers
• Attends to the patient immediately after recognising the risk of
compartment syndrome
• Reviews analgesia received since admission
• Removes any constricting casts or bandages and elevates the
limb
• Performs pertinent examination
• Escalates patient care urgently
• Negative markers
• Does not immediately attend to the patient
• Does not recognise the risk of compartment syndrome
immediately
• Fails to review analgesia and take back slab off
• Fails to recognise clinical signs of compartment syndrome – pain
on passive stretch
• Does not escalate patient care

Clinical Scenario 32: Septic Arthritis (Knee)

You review a 52-year-old diabetic male with a two-day history of right knee pain
in A&E. His knee is swollen, and he struggles to bear weight. He denies any
trauma or recent illness but is febrile. How would you approach this patient?

I am concerned that this patient has septic arthritis in his knee. He has
a swollen knee, is unable to bear weight, is febrile, and has a risk factor
for diabetes. Septic arthritis is an emergency and requires urgent joint
washout in theatre, followed by culture-directed IV antibiotics. Another
differential is gout. I would attend to this patient urgently.
I would approach this patient using the CCrISP protocol, especially
as he could be septic. I would perform an A–E assessment, and excluding
any life-threatening injuries, I would focus on the knee. If he is systemati-
cally septic, I would start the sepsis 6 – give IV antibiotics, IV fluids, and
oxygen; take lactate level and blood cultures; obtain urine output.
I would obtain a complete history that includes recent travel abroad
and recent illnesses. I would review his observations, including blood
Chapter nine: Clinical Scenarios 111

pressure, heart rate, respiratory rate, oxygen saturation, and tempera-

ture. Blood glucose monitoring is vital. After providing adequate analgesia,
I would then proceed to examine the knee joint. Attention to the presence of
effusion, skin changes (erythema, wounds, warmth to touch, or superficial
infections, like cellulitis), range of motion (active and passive), and finally
ability to bear weight. I would also briefly assess the joint above and below.
Septic arthritis could result in global sepsis and septic shock. I would
gain IV access, obtain initial blood tests (FBC, U&E, CRP, ESR, and uric
acid), give IV fluids and oxygen if required, and request a knee x-ray.
I would then escalate this patient’s care to my registrar. If there are no
skin infections, then I think the patient would benefit from aspirating the
knee joint using an aseptic technique. Ideally, this aspiration should be
performed prior to the administration of antibiotics. I would be keen to do
this under the supervision of my registrar. The colour and consistency of
the aspirate should be recorded. The aspirate would be sent for cell count,
crystals, culture, and gram stain.
If the patient does have septic arthritis, then I would need to prepare
him for theatre. I would explain the potential diagnosis and management
plan to the patient, keeping him at the centre of care. He would need to
be nil my mouth. If able, I would obtain consent and mark the patient.
I would need to inform the anaesthetic team and theatre team.

• Probes
• What are your priorities?
• What further information do you require?
• What investigations would you request?
• Positive markers
• Recognises that septic arthritis is a critical differential diagnosis
• Requests appropriate blood tests
• Recognises the importance of blood glucose monitoring in the
septic diabetic patient
• Escalates patient to the orthopaedic registrar appropriately
• Negative markers
• Fails to recognise the significance of possible septic arthritis
• Uses inappropriate investigations
• Does not consider joint aspiration followed by antibiotics accord-
ing to local guidelines
• Fails to escalate urgently

Clinical Scenario 33: Limping Child – Septic Hip

You are asked to review a seven-year-old boy with pain in his right thigh and
knee in A&E. He has had a viral illness over the last few days and has been
febrile today (38.1°C). The parents have noticed a sudden right-sided limp
112 Smashing the Core Surgical Training Interview

yesterday. He has previously been fit and well and gives no history of trauma.
Outline your approach to this patient.

I am concerned that this patient has septic arthritis of his knee or hip. He
has atraumatic right leg pain, is unable to bear weight, is febrile and had a
recent illness. I would review this child urgently.
I would approach this patient using the CCrISP protocol. I would
perform an A–E assessment, and excluding any life-threatening injuries,
I would focus on the hip.
I would obtain a complete history that elaborates on his recent illness
and any vaccinations. I would review his observations, including blood pres-
sure, heart rate, respiratory rate, oxygen saturation, and temperature. I would
examine the oral cavity, tonsils, and chest. After providing adequate analge-
sia, I would examine the entire right limb, including the hip, thigh, knee, shin,
ankle, and foot. I would pay attention to the resting position of the hip at
flexion, abduction, and external rotation to find which position is most com-
fortable to the patient. I would note the presence of an effusion or swelling,
skin changes (erythema, wounds, warmth to touch or superficial infections
like cellulitis), range of motion (active and passive), and finally ability to bear
weight. I would also briefly assess the pelvis and lumbar spine.
I would gain IV access, obtain initial blood tests (FBC, U&E, CRP, and
ESR), give IV fluids, give oxygen if required, and request hip, femur, and
knee x-rays.
I would then escalate this patient to my registrar for urgent review.
Further investigations could include US scan, MRI scan, or joint aspi-
rate. Septic arthritis is an emergency and requires urgent joint washout
in theatre, followed by culture-directed IV antibiotics. Transient synovi-
tis (irritable hip) is a less severe differential diagnosis in a limping child.
Depending on our findings, the patient might need to go to theatre, and
I would inform the anaesthetic and theatre teams.
I would explain the potential diagnosis and management plan to the
family. Dealing with a sick child could be very stressful, I would ensure
that I speak to both the child and the parents in a way that they understand.

• Probes
• What are your priorities?
• How would examine this patient?
• How would you further investigate this patient?
• How would you escalate this patient’s care?
• Positive markers
• Considers the hip joint as the source of the pathology
• Recognises that septic arthritis is a potentially serious differen-
tial diagnosis
Chapter nine: Clinical Scenarios 113

• Investigates with appropriate blood tests like FBC, CRP, and ESR
• Escalates to the registrar appropriately
• Negative markers
• Does not consider the hip joint as the source of pathology
• Does not consider septic arthritis as a serious differential
diagnosis
• Uses inappropriate examination and investigation
• Does not escalate appropriately

Cardiothoracic
Clinical Scenario 34: Tension Pneumothorax
You are asked to assess a day 1 post-op 52-year-old man in the thoracic ward.
The patient had a right lung volume reduction surgery without intraopera‑
tive complications noted. He is complaining of sudden sharp chest pain and
shortness of breath. His systolic blood pressure is 80 mm Hg, and his heart
rate is 120 bpm. How would you approach this patient?

I am concerned that this patient has tension pneumothorax and he is

developing an obstructive type of shock secondary to mediastinal shift-
ing. I would attend to this patient immediately without delay and would
activate the peri-arrest call. I would inform and escalate to my registrar
as soon as possible.
I would approach the patient using the CCrISP protocol. I would assess
his airway by first speaking to him. I would ensure he is on high-flow oxy-
gen with a target oxygen saturation of close to 100% (unless the patient is
at risk of hypercapnic [type II] respiratory failure). If he responds, I would
move on to assess his breathing. I would look for bilateral chest rise, bilat-
eral chest sounds, and a central trachea. At this stage, if I hear unilateral
breath sounds and feel a shifted trachea, I would be concerned about a
tension pneumothorax. I would immediately decompress the patient
using a large-bore cannula in the fifth intercostal space, mid-axillary line,
according to the latest ATLS guidelines. I would expect to hear a hiss and
an improvement in the patient’s condition. I would arrange to set up a
chest drain procedure, keeping in mind to inform the rest of the nursing
staff to make the preparation more efficient. I would then reassess the
patient, starting at A again.
In terms of circulation, I would assess the patient’s heart rate,
blood pressure, and capillary refill time. I would ensure that bilateral
large-bore access is gained. At the same time, I would take blood speci-
mens for blood gas, full blood count, U&E, LFTs, clotting profile, and
114 Smashing the Core Surgical Training Interview

cross-match. For disability, I would calculate his GCS and obtain his
temperature and blood glucose. I would also quickly expose the rest of
the extremities to assess.
At this point, I would also review the patient’s notes, his operative
record, and any chest drain output that he might have. I would then
escalate promptly to my registrar or consultant. The patient would need
a definitive chest tube placed at the bedside. This would be inserted in
the fifth intercostal space, mid-axillary line, using a sterile technique.
I would infiltrate the area with a local anaesthetic, cut down ‘above the
rib below’, and puncture the pleural with a blunt instrument. I would
then guide the chest drain superiorly and secure it with a 0-silk and air-
tight dressing. I would also need to discuss whether the patient needs to
return to theatre to close an air leak. If this were the case, I would need to
inform the anaesthetic team, nursing, and theatres. Since the peri-arrest
team is also likely to be present, I would direct them to perform certain
aspects of the resuscitation, such as taking blood gas or requesting a
portable chest x-ray.
Throughout all this, I am conscious that this is a highly stressful situ-
ation for the patient and his family, and I would attempt to keep them at
the centre of care by clearly explaining to them the situation and neces-
sary life-saving treatment for such a condition.

• Probes
• What are your priorities?
• What other information would you gather?
• Which investigations should be done, and immediate manage-
ment should be anticipated?
• How would you escalate this patient’s care?
• Where and how would you insert a chest drain?
• Positive markers
• Recognises that this is a surgical emergency which needs imme-
diate surgical management
• Recognises that this requires a team-based approach
• Assesses the patient with a structured A–E approach
• Anticipates the immediate life-saving management
• Escalates to the registrar or consultant appropriately
• Negative markers
• Does not attend immediately and recognise the situation as a
surgical emergency
• Fails to include other members of the surgical team (anaesthe-
tists, theatre nurses, etc.)
• Uses an unstructured approach to patient assessment
• Fails to anticipate immediate management
• Does not escalate patient care appropriately
Chapter nine: Clinical Scenarios 115

Clinical Scenario 35: Haemothorax

You are the core surgical trainee on cardiothoracics. During the ward round, you
notice that the chest drain of a 52-year-old female patient, day 1 post–left upper
lobectomy, is draining frankly bloody output of 500 ml for the past two hours. She
is hypotensive and tachycardic. How would you approach this patient?

I am concerned that this patient has hypovolemic shock secondary to a

haemothorax. She would likely need to return to theatre. I would attend
to this patient immediately. I would inform and escalate to my registrar
and consultant as soon as possible. I would activate the major haemor-
rhage protocol.
I would approach the patient using the CCrISP protocol. I would
assess her airway by first speaking to her. I would ensure she is on high-
flow oxygen. If she responds, I would move on to assess her breath-
ing. I would look for bilateral chest rising, bilateral chest sounds and
a central trachea. I would expect to hear decreased breath sounds and
dullness to percussion on the side of the chest drain. For circulation,
I would assess the patient’s heart rate, blood pressure, and capillary
refill time. I would ensure that bilateral large-bore access is gained. At
the same time, I would take blood specimens for blood gas, full blood
count, U&E, LFTs, clotting profile, and cross-match for four units.
I would start 1 litre of warmed crystalloids stat and have a low thresh-
old to start O-negative blood if the patient continues to be hypotensive
and tachycardic. For disability, I would calculate her GCS and obtain
her temperature and blood glucose. I would then expose her to look at
the rest of her extremities to assess.
I would then review the most recent notes, in particular the operative
note. I do not think any further investigations, such as a chest x-ray or CT
chest, would be of value in this scenario.
After discussing with my registrar and consultant, I would immedi-
ately inform the rest of the theatre team, anaesthetist, nursing team, and
porters in preparation for an emergency thoracotomy in theatre. During
the interim, I would continuously reassess the patient and make sure that
haemodynamic stability is achieved by blood transfusion and correction
of coagulopathy if present.
Throughout all this, I am conscious that this is a highly stressful situ-
ation for the patient and her family, and I would attempt to keep them at
the centre of care by involving them in our decision-making.

• Probes
• What are your priorities?
• What other information would you gather?
• Which investigations should be done, and what immediate man-
agement should be anticipated?
116 Smashing the Core Surgical Training Interview

• How would you escalate this patient’s care?

• Positive markers
• Recognises that the patient is actively bleeding and this is a sur-
gical emergency which needs immediate surgical intervention
(thoracotomy)
• Recognises that this requires a team-based approach
• Assesses the patient with a structured A–E approach
• Requests appropriate investigations (e.g. group and screen, FBC,
coagulation panel) and anticipates the need for immediate blood
transfusion and correcting pre-existing coagulopathy
• Escalates to the registrar or consultant appropriately
• Negative markers
• Does not attend immediately and recognise the situation as a
surgical emergency
• Fails to include other members of the surgical team (anaesthe-
tists, theatre nurses, etc.)
• Uses an unstructured approach to patient assessment
• Fails to arrange appropriate investigations, secure group and screen,
coagulation panel, etc. and anticipate immediate management
• Does not anticipate the need for immediate blood transfusion
and correcting pre-existing coagulopathy
• Does not escalate patient care appropriately

Clinical Scenario 36: Aortic Dissection

You are on night shift at the ward and was asked by the nurse-in-charge
to assess a day 3 post-op CABG patient. The patient is a 62-year-old male,
complaining of dizziness, shortness of breath, and sudden severe, sharp pain
in the chest and upper back described as ‘ripping’. He is hypotensive with a
rapid weak pulse. How would you approach this patient?

I am concerned that this patient has hypovolemic shock from aortic dis-
section. I would attend to this patient immediately. I would inform and
escalate to the registrar as soon as possible.
I would approach the patient using the CCrISP protocol. I would
assess his airway by first speaking to him. I would ensure he is on
high-flow oxygen. If he responds, I would move on to assess his breath-
ing. I would look for bilateral chest rising, bilateral chest sounds, and
a central trachea. If the airway is intact, I would move on to circula-
tion. I would assess the patient’s heart rate, blood pressure, and capillary
refill time.
I would ensure that bilateral large-bore access is gained. At the
same time, I would take blood specimens for blood gas, FBC, U&E, LFTs,
Chapter nine: Clinical Scenarios 117

clotting profile, and cross-match for possible blood transfusion. I would

start 1 litre of warmed crystalloids stat and have a low threshold to start
O-negative blood if the patient continues to be hypotensive and tachy-
cardic. For disability, I would calculate his GCS and obtain his tempera-
ture and blood glucose. I would do a cardiovascular exam and examine
the patient’s central and peripheral pulses.
As I am concerned that this patient has aortic dissection. I would
be quick to escalate this to my registrar and consultant. As the patient
is hemodynamically unstable, I would arrange to perform transtho-
racic echocardiography (TTE), which would provide a good overview
of the nature of dissection. If the dissection is a type A dissection, then
it would necessitate an emergency surgical intervention. I would also
consider trans-oesophageal echocardiography (TOE) for definitive diag-
nosis of acute aortic dissection in addition to the TTE. Depending on
the local expertise and availability, this could be performed in ITU or
operating theatre to confirm the diagnosis and better evaluate the aortic
valve. I would not consider a CT scan as the patient is haemodynami-
cally unstable.
Throughout all these, I would ensure clear communication with the
nursing staff, anaesthetists, and theatre teams. I would ensure clear com-
munication with the patient and his family and would keep them at the
centre of care by involving them in our decision-making.

• Probes
• What are your priorities?
• Which investigations can be done immediately?
• How would you escalate this patient’s care?
• Positive markers
• Recognises that this is a surgical emergency
• Assesses the patient with a structured A–E approach
• Requests appropriate investigations
• Negative markers
• Does not recognise this is a surgical emergency
• Requests a CT in an unstable patient
• Uses an unstructured approach to patient assessment
• Does not escalate patient care appropriately

 linical Scenario 37: Atrial Fibrillation

C
with Rapid Ventricular Response
You are asked to see a day 3 post-op tissue aortic valve and mitral valve
replacement patient. The patient is a 72-year-old female with light-headed‑
ness. Her systolic blood pressure is 100 mm Hg. Telemetry shows no visible P
118 Smashing the Core Surgical Training Interview

waves and an irregularly irregular rhythm with a heart rate of 140 bpm. How
would you approach this patient?

In this scenario, I am concerned that the patient has atrial fibrillation.

This patient could develop haemodynamic instability due to ventric-
ular underfilling from rapid ventricular response atrial fibrillation.
I would inform and escalate to my registrar and attend to the patient
immediately.
I would approach the patient using the CCrISP protocol. I would
assess her airway by first speaking to her. I would ensure she is on high-
flow oxygen. If she responds, I would move on to assess her breathing.
I would look for bilateral chest rising, bilateral chest sounds, and a central
trachea. If the airway is intact, I would move on to circulation. I would
assess the patient’s heart rate, blood pressure, and capillary refill time.
I would ensure that bilateral large-bore access is gained.
I would arrange for an urgent ECG. At the same time, I would take
blood specimens for blood gas, FBC, U&E, LFTs, clotting profile, thyroid
function tests, and cross-match. For disability, I would calculate her GCS
and obtain her temperature and blood glucose.
I would start the patient on rate control medications. In a stable patient,
I would consider oral therapy, but the intravenous route could also be con-
sidered to achieve more rapid rate control. The response to the medication
would be assessed via continuous cardiac monitoring.
I would look for common causes of atrial fibrillation, such as elec-
trolyte derangements (e.g. hypokalaemia, hypomagnesemia) and dehy-
dration. I would also check the patient’s oral anticoagulation status.
Most post-operative cardiac surgery patients are on prophylactic doses
of anticoagulation for venous thromboembolism. If this is the case, then
necessary dose adjustments (keeping in mind the renal profile and other
contraindications) should be made to achieve a therapeutic anticoagula-
tion cover.
As the patient is haemodynamically stable, I would also discuss the
case with the anaesthetist, theatre team, and nursing staff in anticipation
for a possible DC cardioversion in case the patient becomes haemody-
namically unstable.
As atrial fibrillation is the most common arrhythmia after cardiac sur-
gery and is considered benign in a third of patients, I would speak to the
patient to explain and reassure her.

• Probes
• What are your priorities?
• How would you manage this patient?
• How would you escalate this patient’s care?
Chapter nine: Clinical Scenarios 119

• Positive markers
• Assesses the patient with a structured A–E approach
• Requests appropriate investigations
• Escalates to the registrar or consultant appropriately
• Negative markers
• Uses an unstructured approach to patient assessment
• Fails to arrange appropriate investigations
• Does not plan for what happens if the patient becomes unstable
chapter ten

Management Scenarios
William Rea, Saarah Ebrahim, Hari Nageswaran,
Humayun Razzaq, Anokha Oomman Joseph,
and Janso Padickakudi Joseph

Management Scenario 1: Poor Training

You are the core surgical trainee on the cardiothoracic team. There is
an extended healthcare team, including advanced nurse practitioners.
Your consultant expects you to do all the ward jobs, and you find it dif‑
ficult to get to theatre. The nurse practitioner gets to theatre regularly
and is being trained in vein harvesting. How would you approach this
situation?

The main issues in this scenario are the distribution of workload, patient
safety, and my training requirements.
First, I want to seek more information. What is my role on the team,
and what competencies could I acquire during this rotation? Are there
other core surgical trainees in the team and what has their experience
been? Are there specific workflows in place which require the nurse prac-
titioner to assist, such as for complex cases? Is vein harvest a skill that is
also suitable for core trainees? What other operative exposure is avail-
able? Cardiothoracic surgery is a complex multidisciplinary speciality,
and I would consider the broader picture and my role within it. However,
as a core surgical trainee, it is imperative for me to progress surgically
during the rotation.
Patient safety is important in this scenario if the burden of workload
is not shared. This could result in patient care being compromised, and
therefore, the patient would need to be dealt with as a priority. In a long-
term sense, patients might also be harmed if junior doctors do not acquire
the basic surgical skills they should have during CST.
I would show initiative by reflecting on why I am finding it difficult
to get to theatre. Are there other members of the team on the ward that
could help with jobs? Is there anything in particular I am struggling to
do? Could I maximise my time in theatre by, for example, doing urgent
jobs first and then completing the jobs after my theatre time? I would also

DOI: 10.1201/9781003350422-11 121

122 Smashing the Core Surgical Training Interview

speak to the nurse practitioner in a non-confrontational manner to better

understand how they have been able to manage their other commitments
with theatre time. In addition, I might find that they are at the end of their
learning curve and be ready to teach vein harvest.
I would approach my consultant in a non-confrontational manner
and convey my interest in wanting to learn and assist in theatre. I want to
show an interest both on and off the ward and share my training needs
with the consultant. The consultant might have some reasoning as to why
they would like me to do the ward jobs. They might see training opportu-
nities for me outside of vein harvesting.
If I do not feel comfortable discussing with the nurse practitioner
or consultant directly, I might discuss this with my registrar, who could
encourage my attendance in theatre. I could approach the rota coordina-
tor to ask whether my ward days could be built into my rota and have
assigned theatre days.
If my concerns are unresolved, I would escalate them to my trainee
representative. If my training is being impacted significantly, I would
involve my training program director early. The Royal College tutor,
clinical director, and director of medical education might also need to be
involved.
I would aim to manage this situation in a calm and professional man-
ner. Finally, I would reflect on how I have approached this situation and
perhaps make a reflective entry on my portfolio.

• Probes
• What are your priorities?
• What other information could you gather?
• How could patient safety be compromised?
• Who else can you involve?
• Positive markers
• Seeks information proactively
• Speaks directly to the nurse practitioner
• Speaks directly to the consultant and shows an interest and will-
ingness to learn
• Escalates appropriately
• Has insight into the broader context of the team
• Negative markers
• Is confrontational
• Is solely focused on their training needs
• Escalates rapidly, with incomplete information
• Does not offer solutions
Chapter ten: Management Scenarios 123

Management Scenario 2: False Documentation

You are the core surgical trainee on general surgery.
The night SHO hands over a day 1 post-left-hemicolectomy patient, whom
she had treated with sedation for agitation overnight. The patient is found
to be in haemorrhagic shock on the ward round and is taken back to theatre
for an emergency laparotomy.
You notice the night SHO has altered her documentation to state that she
had suspected intra-abdominal bleeding and handed this over to you. How
would you approach this situation?

My main concerns here are patient safety, probity, and professionalism.

Duty of candour also comes into play.
I would want to first seek more information regarding the unwell
patient. I could do this by reviewing the notes and the night doctor’s doc-
umentation, any observational charts, and scans. I would review the oper-
ative note to understand what was found during the return to theatre.
Patient safety is paramount here, and I would ensure that was a priority
in this situation.
I would also consider whether the night doctor is a regular member of
staff or a locum doctor. I would want to know if this level of clinical error
is a recurrent issue and whether anyone else has raised concerns. I would
assess if other unwell patients are at risk of deterioration.
Once patient safety is established, I would speak to the night junior
doctor in a non-confrontational manner to understand her version of
events. I would state my concern that documentation had been altered.
I would enquire whether the night shift was particularly busy, and there
might have been other reasons that this unwell patient was mismanaged.
The junior doctor might have some personal issues that are clouding her
judgement, and in this case, I would try to support and encourage her
to seek further help. They might understand that what they have done
is unprofessional and might apologise and move to rectify the situation.
However, it might be very difficult for me to speak to the night junior
doctor directly, and this would require escalation.
Altering documentation is a serious breach of GMC guidelines for act-
ing with honesty and integrity. Given that I am implicated in this situation,
I would escalate to my clinical and educational supervisors. I would keep
contemporaneous records of all conversations to ensure these are docu-
mented properly. This situation needs to be handled formally. The consul-
tant overseeing this patient and the night doctor’s supervisor would need
to be involved. If necessary, I might want to seek support from bodies such
124 Smashing the Core Surgical Training Interview

as the BMA or my defence union. This situation would need to be esca-

lated to the clinical director of the surgical department. Support would be
required for the night junior doctor, and she might require support from
occupational health or further training and education. If a local investi-
gation shows a deliberate alteration of documentation, this would likely
result in disciplinary action. The decision for further escalation including
to GMC would be made by the consultant and educational supervisor and
would be based on the severity of the situation.
Finally, the patient would need to be informed of the delay in diagno-
sis, applying principles of duty of candour. The patient should receive an
apology. It is likely that the consultant in charge would want to lead this
discussion, but I would have been keen to contribute. Given the gravity
of the situation, I would reflect on my actions and consider a reflective
portfolio entry.

• Probes
• What are your priorities?
• What other information could you gather?
• Who else can you involve?
• Positive markers
• Considers patient safety as a priority
• Understands the gravity of altering documentation
• Escalates appropriately
• Documents conversations
• Considers duty of candour
• Negative markers
• Does not address professionalism
• Does not address patient safety
• Does not address the duty of candour
• Discusses the situation with other colleagues, resulting in a hostile
environment
• Is defensive and/or confrontational

Management Scenario 3: Never Event

You are the core surgical trainee on the colorectal team. You take a patient to
theatre for persistent discharge from a perianal abscess wound that has been
going on for months. You find a retained tonsil swab deep within the abscess
cavity. How would you approach this situation?

A retained swab is a never event. The other issues here are patient safety,
duty of candour, and organisational learning.
Patient safety is paramount in this scenario. I would address the clini-
cal situation, remove the tonsil swab, and debride the cavity as required.
Chapter ten: Management Scenarios 125

Intra-operatively, I would escalate this to my registrar or consultant so

that they could also attend and assess the situation. I would meticulously
document my findings in an operative report and ensure that it is coun-
tersigned by a senior.
In the first instance, the patient would need to be informed once
they are out of surgery. Given the seriousness of the situation as a core
trainee, I would speak to the patient along with the consultant in charge
of the patient’s care. The patient would need to be informed of the intra-­
operative findings and the management going forward. Per duty of can-
dour guidelines from the GMC, I would apologise on behalf of the team
and explain what steps we would be taking to investigate this further and
give them information if they wish to speak to PALS. I would document
the conversation with them in the notes.
I would enter a Datix for this never event. This event would require
a full investigation under NHS England’s Serious Incident Framework.
The organisation should engage in learning from this event, and the find-
ings of the investigation should be presented at the clinical governance
meeting, with all relevant stakeholders. It should also be determined who
the surgeon was at the index operation. The surgeon would need to be
informed by a more senior member of the team. A review of the previous
surgery would need to be performed to understand the events that led to
this never event.
The WHO checklist is in place to prevent situations like this from aris-
ing, and therefore, the error in this process would need to be determined
in the investigation of the incident to prevent it from happening again.
The surgeon who performed the operation should be advised to speak
to their supervisor, as well as the BMA and their defence union. I would
reflect on what other measures could be put in place to prevent this from
happening again, such as more education of staff about following correct
protocols.

• Probes
• What are your priorities?
• What other information could you gather?
• Who else can you involve?
• How should this be discussed with the patient?
• How will this information be relayed appropriately to the rest of
the team?
• Positive markers
• Deals with patient safety as their first priority
• Is meticulous in their documentation
• Considers duty of candour
• Appreciates the gravity of the situation
• Identifies this as a never event
126 Smashing the Core Surgical Training Interview

• Negative markers
• Does not deal with patient safety first
• Does not escalate intra-operatively
• Does not document meticulously
• Does not raise a Datix
• Does not recognise the never event
• Does not consider organisational learning
• Appoints individual blame

Management Scenario 4: Managing Juniors

You are the core surgical trainee on the urology team. Your FY1 comes to work
late almost all days of the week. How would you approach this situation?

My main concerns from the outset are patient safety, professionalism, and
support for my colleague.
Patient safety could be compromised if the FY1’s lateness is causing
others to pick up the workload. The FY1 might miss out on handover at
the start of the day, and this might compromise clinical care. Patient safety
should be a priority throughout, and I would first and foremost ensure
that there is adequate coverage to take care of patients.
I would want to establish if there is a reason for the FY1 coming late
to work. I would speak to my FY1 in a non-confrontational manner and
understand their perspective.
I would ensure they are aware of when their shift starts. In a sup-
portive manner, I would try to find out if there are any underlying issues
preventing good timekeeping. I would find out if the FY1 is undergoing
personal problems that might be causing them to be late to work.
If there are extenuating circumstances such as caring responsibili-
ties or health-related issues, I would work with the FY1 to determine how
I could support them. The team would need to consider what measures
could be put in place to ensure patient safety and the FY1’s professional
success. This might require the input of occupational health, the rota coor-
dinator, the consultants in the department, the FY1’s educational/clinical
supervisors, and the foundation programme training director.
If there are not any extenuating circumstances, I would explain to
them the importance of turning up to work on time. I would then review
the situation over a period to see if there has been any change, trying to
address this informally.
If there are no extenuating circumstances and the FY1 does not change
their behaviour, I would escalate this to their educational supervisor. This
is an issue of professionalism and might have to be dealt with formally. It
might need to be escalated to the foundation programme training director.
Chapter ten: Management Scenarios 127

If there is a significant breach of professionalism that could not be dealt with

at a local level, it might require escalation, even to the GMC. I understand
that this type of escalation could be very stressful for the FY1, and I would
ensure that they are supported and not vilified throughout this process.
Given the sensitive nature of the situation, I would reflect on my
actions and consider a reflective portfolio entry.

• Probes
• What are your priorities?
• What other information could you gather?
• How could patient safety be compromised?
• Who else can you involve?
• Positive markers
• Approaches the FY1 directly
• Considers patient safety
• Is aware of the support networks in place for the junior doctor
• Is non-judgmental
• Negative markers
• Escalates quickly, without full information
• Avoids speaking to the FY1
• Does not consider alternative reasons for lateness

Management Scenario 5: Conflict with Senior

You are the core surgical trainee in urology. The registrar in your firm is
abrupt and makes you feel unwelcome in theatres. What would you do?

This is an unfortunate and far from ideal situation. The main issues here
are professionalism, potential bullying, and the impact this could have on
teamwork.
Once I have realised that this is consistent behaviour from the reg-
istrar, I would find a suitable time and place to talk to them. I would try
to be careful and concise with my words when telling them how their
behaviour makes me feel, and at the same time, I would ask what is mak-
ing them behave like this. I would explain to them that this situation is
making it very difficult for me to achieve the most out of this placement
in terms of clinical skills and theatre opportunities, which is detrimental
to my training. I would explain that this kind of behaviour makes me
feel unwelcome in my own workplace. Whilst having this conversation,
I would keep an open mind to what they have to say and whether or not
there are any concerns from their side. For example, they might be con-
cerned with my level of anatomical knowledge or preparation for cases.
Based on their response and engagement with the discussion, I would
128 Smashing the Core Surgical Training Interview

decide on future steps to ensure that this issue gets resolved in a timely
and efficient manner. I would make contemporaneous records of our
discussion.
I would consider the impact that my relationship with the registrar
has on patient safety. If we are working very closely on a team, then we
need to be able to discuss things openly. In particular, I would need to
be able to ask questions relating to patient care without the fear of being
reprimanded. To ensure that patient safety is a priority, I might need to
involve my consultant early and escalate concerns directly to them.
I would be mindful of the fact that I could and should discuss such
issue with my assigned educational supervisor and clinical supervisor
and see what advice they have to offer. They might also be able to take
steps to mitigate this situation, such as having a formal or informal meet-
ing with the registrar in question to discuss the issue at hand. I would
ensure that I discuss with my AES and CS about protected theatre time,
as there would be other theatre opportunities which I could utilise whilst
this issue is being resolved. I am aware that any training issues could be
raised with the local surgical tutor, who could take the necessary steps to
ensure equal opportunities are being provided. If I have concerns about
mental health or require further support, I might contact the professional
support units or occupational health. If this is significantly impacting my
training, I might also speak to my training programme director or the
director of medical education.
Finally, the registrar in question might also require support. Their
expressions of abruptness might indicate an issue with their personal or
professional life. They might have caring responsibilities, health issues,
or professional issues that are causing them to react this way. With the
correct people involved, hopefully these issues could also be uncovered
and addressed, ideally informally at a local level.

• Probes
• What are your priorities?
• What other information could you gather?
• How could patient safety be compromised?
• Who else can you involve?
• Positive markers
• Recognises the issues of professionalism and potential bullying
• Understands that this behaviour is putting their ability to look
after patients
• Realises that this behaviour is negatively affecting their training
experience
• Is aware of escalation pathways and people to escalate to (i.e.
TPD/AES/CS)
• Recognises the need for support for self and registrar
Chapter ten: Management Scenarios 129

• Negative markers
• Downplays the situation and behaviour
• Does not realise the repercussions of such behaviour on training
• Does not consider escalation
• Does not seek support

Management Scenario 6: Bullying

You are the core surgical trainee on general surgery. You note that one con‑
sultant is rude to another colleague on a routine basis, both in clinics and in
theatres. You have witnessed your colleague being screamed at and called
names. What would you do?

This is a very undesirable situation with a clear-cut display of bullying

on the consultant’s part. I would be most concerned about my colleague’s
mental health and well-being, as well as their ability to concentrate on
work and perform day-to-day clinical duties. This is an issue of profes-
sionalism, with a likely impact on patient safety.
Initially, I would sit down with the colleague informally. I would
inquire what their thoughts are on the matter, whether or not they rec-
ognise the bullying, and whether are they aware of their rights and sup-
port available. The situation is particularly serious if the colleague is a
trainee, as the power differential between consultant and trainee could
be intimidating. I would encourage them to discuss the issue with their
educational or clinical supervisor as well as their line manager. I would
also signpost them to the guardian of freedom to speak up. If the col-
league is a trainee, they might wish to involve their trainee representative,
Royal College tutor, or training programme director. These behaviours
typically follow a pattern and sometimes go unescalated as individuals
are not aware of their rights or means to escalate; however, once escalated,
this could lead to repercussions for the individual involved. I would be
mindful of the mental health impact such situations could have on an
individual and would encourage them to seek health from occupational
health or their GP, making their own well-being the first priority.
In order to protect patient safety, I would offer to cover them for any
clinical work, rota permitting, whilst they work on this issue. I would also
volunteer to provide a witness statement, in case this is required for any
formal proceeding. I would meanwhile advise them to discuss with the
rota manager and clinical lead to not share any clinical commitments with
the consultant in question for the time being.
As a core trainee, confronting a consultant about bullying and
harassing behaviour might feel very daunting. If I felt able, I would
approach this as an informal discussion with the consultant, as they
might not be aware of the impact of their words and actions on others.
130 Smashing the Core Surgical Training Interview

They might perceive the situation differently. Perhaps they think they
are being humorous. However, if I could not speak to the consultant
directly, with the permission of my colleague, it might be sensible to
involve other consultants in the department or the clinical director. If
the concerns are not addressed, this might need to be escalated to the
chief medical officer or even the GMC. The consultant themselves might
need support as their behaviour might be an expression of difficulties in
their personal or professional life.

• Probes
• What are your priorities?
• What other information could you gather?
• How could patient safety be compromised?
• Who else can you involve?
• Positive markers
• Recognises bullying
• Knows the colleague need support
• Discuss with the colleague
• Discusses with the consultant
• Encourages the colleague to report bullying and seek support
• Negative markers
• Is unable to recognise bullying
• Does not signpost about the support available to the colleague
• Downplays the situation
• Is confrontational
• Does not take personal responsibility

Management Scenario 7: Clinical Governance

You are the core surgical trainee on the vascular team. A patient has devel‑
oped a wound infection after a fem-fem bypass. The ward sister states that
this patient is under Mr Brown, and all his wounds get infected. How would
you approach this situation?

The main issues here are patient safety and teamwork.

My priority is to make sure the patient is being optimally managed
and is on appropriate antibiotics based on trust guidelines and recent
wound swabs. If they are systemically unwell, they might require special-
ist management with microbiology. Rarely, they would require surgical
re-exploration.
Once the clinical issues are dealt with, I would seek to gather more
information. I would speak to the ward sister in private and ask about her
concerns regarding the wound infection rate. I would enquire if this has
been looked into before, or if it is a new concern. In a non-confrontational
Chapter ten: Management Scenarios 131

manner, I would also speak to my registrar and Mr Brown to see if this

aspect of our care is something that would merit an audit to investigate it
further.
I want to use my initiative and do two things: raise a Datix and con-
sider an audit or quality improvement project. I would want to raise a
Datix as this is an adverse, event and there is potential for organisational
learning. Once the team agrees, I would contact the audit department of
my hospital to register an audit, looking at the wound infection rate in our
wards in comparison to a local or national standard. This would provide
the infection rates for Mr Brown and the other surgeons within the unit to
indeed see if there is a difference between the different surgeons.
Another way to approach this would be to conduct a quality improve-
ment project. There are multiple stakeholders involved in a patient’s
pathway. I would want to know if there is a standardised pre-operative
pathway that includes antibiotic administration and if this is being com-
plied with. If there is none, then I would speak to my seniors about being
involved in designing a clinical process pathway for pre-operative man-
agement of patients, including antibiotics at induction. Both an audit and
a QUIP could be presented at the morbidity and mortality conference.
There is clearly also a teamwork issue that needs to be addressed,
if the sister in charge was concerned about the wound infection rates,
she should feel empowered to voice her concerns so that things could be
investigated further.
Finally, Mr Brown and his team might require support in order to
decrease the wound infection rates for their patients. This might require
involvement from multiple stakeholders, including the theatre team, post-
operative ward team, and infection control.

• Probes
• What are your priorities?
• What other information could you gather?
• How could patient safety be compromised?
• Who else can you involve?
• Positive markers
• Approaches the scenario in a structured manner
• Escalates appropriately
• Considers patient safety
• Appreciates multiple stakeholders
• Negative markers
• Places blame on a single individual
• Fails to escalate
• Does not consider audit or QUIP
132 Smashing the Core Surgical Training Interview

Management Scenario 8: Conflict Resolution

You are the core surgical trainee on the orthopaedic team. You are in theatre
with your registrar who is new to the NHS. Your consultant is in a meeting.
Theatre staff say that the list is overrunning, and the last patient needs to
be cancelled. You and your registrar feel you will be able to finish the case in
time. How would you approach this situation?

The main issues in the scenario here are patient safety, teamwork, and
professionalism.
The first thing I would do is gather more information. I would take
into account the theatre staff’s concerns and why they think the last case
needs to be cancelled. I would also determine the current time and what
time the list is due to finish to establish with the registrar if this is suf-
ficient time to finish. I would like to know if the concern about finishing
late is a perceived issue or a real issue. I would discuss with the anaesthe-
tist what time realistically the patient would be ready to start the opera-
tion. I would ask the registrar how long they think the case would take.
I would also take into account the patient-specific details – how urgent
the case is, how long they have been waiting, the impact of not delaying
the operation, and how soon they might be able to be rebooked. I would
consider the surgical team. Whilst the registrar might be new to the NHS,
they might be a very experienced and technically competent surgeon. The
consultant being unavailable is another issue to take into consideration. Is
their meeting urgent? Would they be returning? Could I and the registrar
start the procedure and the consultant join us at a critical stage?
Taking all these factors into consideration, I think it is worth having
a multidisciplinary discussion with the orthopaedic registrar, the theatre
staff, the anaesthetist, and recovery staff. Ideally, the orthopaedic consultant
would also be present for this discussion, but if not, they could potentially
join by phone if they were able to step out from their meeting. Between the
group all those factors could be weighed up and a decision to proceed or
delay the case could be made. We should also consider all other options
apart from cancellation, including potentially using another free theatre
(potentially with another team) or using the emergency list if appropriate.
If the decision is made to cancel the patient, I would apologise to the
patient personally. I would attempt to speak to the booking coordinator to
find a new date before the patient leaves the hospital. I might direct them
to the PALS service.
I need to support my team. If theatre staff want to cancel the case
because of overwork and burnout, then this would need to be dealt with
at a departmental level. If, however, the decision to cancel the case was
routed in underlying bias against a registrar new to the NHS, then this is
a cultural problem that needs addressing.
Chapter ten: Management Scenarios 133

I would also consider my consultant’s professionalism in leaving a

new registrar to operate independently. The consultant should not be
attending a meeting at the same time as an elective list that is scheduled,
unless they are confident of the registrar’s abilities and continue to be
available throughout the case. If I have concerns over my consultant’s pro-
fessionalism, I might first choose to discuss this with my clinical supervi-
sor. If this is a recurrent issue, then it might need to be escalated further to
the clinical director or chief medical officer.

• Probes
• What are the issues here?
• What factors would affect the decision whether or not to proceed?
• What are the implications for the list overrunning?
• Who bears ultimate responsibility for making the decision?
• Positive markers
• Approaches scenario in a structured manner
• Takes into account technical and non-technical aspects of theatre
list management
• Gathers relevant information
• Negative markers
• Shows an aggressive response to cancelled cases
• Fails to take a multidisciplinary approach
• Is unwilling to receive new information

Management Scenario 9: Confidentiality

You are the core surgical trainee on the breast team. One of the departmen‑
tal secretaries is looking up her daughter’s CT scan results. She asks you to
interpret the report, which states that there is metastatic breast cancer. How
would you approach this situation?

This is a complex issue, involving probity, confidentiality, and profes-

sional relationships.
The first thing I would do is sit down with the secretary and ask her
if she would like to share what has been happening with her daughter.
Clearly, she is concerned and anxious and would certainly be in need of
support due to the circumstances. It might be that there has been lim-
ited communication between the breast team and the secretary and her
daughter so they have questions that I might be able to answer. Hopefully,
by gaining an oversight of the situation, I could prevent this from pro-
gressing any further.
However, if pressed to provide an interpretation of the CT report,
I would politely decline. I would explain that although I could interpret
134 Smashing the Core Surgical Training Interview

the report, the implications of the report on the management and treat-
ment are not down to me and would be better discussed in the MDT and
communicated formally by the responsible team. I could offer to contact
the breast MDT coordinator to ensure that the patient is discussed at the
next possible opportunity. I might also alert the consultant responsible for
the patient’s care to the fact that a red flag report has been created.
Unfortunately, the secretary’s actions are a breach of information
governance policies within the NHS. Therefore, this would need to be
escalated to the secretary’s line manager. I would speak to my clinical
supervisor in the first instance to see how to proceed with escalating this.
The patient would also need to be informed, as the information might
have been retrieved without her consent. Depending on the secretary’s
manager’s view of the situation, this might lead to retraining or disciplin-
ary action.

• Probes
• What are the issues here?
• How might you de-escalate the situation?
• Who should be informed?
• Positive markers
• Approaches scenario in a sympathetic manner
• Considers avenues of escalation
• Considers the emotions of the secretary and her daughter
• Suggests ways they can help expedite further management
• Negative markers
• Uses an insensitive approach to speaking to the secretary
• Shows no effort to support the secretary
• Reads report and advises the secretary without consideration of
confidentiality or probity

Management Scenario 10: Showing Initiative

You are the core surgical trainee on the orthopaedic team. You work with a
sarcoma specialist consultant, who does very complex surgery. You feel like
you are not being allowed to do anything in theatre and your logbook is suf‑
fering. How would you approach this situation?

This is not an uncommon situation, with issues affecting training and

progression and long-term patient safety.
I would start by gathering some further information by reviewing my
logbook and also reviewing my actions in each recorded operation. It might
then be worth comparing my logbook to other core surgical trainees in the
department to see if they are facing similar issues or if they are getting more
Chapter ten: Management Scenarios 135

practical operative experience. I would assess if I had operative experience

elsewhere, in other lists, or if this is my only time in theatre.
Patient safety is relevant here for the future as a direct conse-
quence of training. If junior surgeons are not trained well at an early
stage, their higher training would be more complicated and might ulti-
mately result in a less well-trained operative surgeon at the end of their
training.
Once I have collected the data, I would discuss the findings with my
consultant, especially if my operative logbook is significantly less exten-
sive than other trainees within the department. But I would be proactive
about making suggestions to remedy the situation. Whilst it would not be
appropriate for a junior trainee to be taking on whole complex operations,
there would be parts of the operation it would be reasonable to expect
the trainee to accomplish under senior supervision. Whilst the dissection
and resection might not be suitable for a core trainee, prepping, drap-
ing, initial incision, and approach, and then closure might be reasonable
to complete unless there are patient-specific issues. I would come to the
cases prepared, having read up about the patient, the relevant anatomy,
and the procedure. Another suggestion might be to request swapping the
occasional operating list with other trainees, allowing them the opportu-
nity to see complex sarcoma surgery whilst I assist and learn from other
surgeons with other subspeciality interests. I would work with the rota
coordinator to facilitate this.
If my suggestions are turned down or not acted upon, then I would
escalate this to my educational supervisor. If still there is no improvement
in my operative exposure, I might involve the director of medication edu-
cation, my trainee representative, and training programme director. The
Royal College tutor at my hospital should also be aware.

• Probes
• What are the issues here?
• How could you broach this topic with your consultant?
• What constructive suggestions could you make to aid your
training?
• Positive markers
• Approaches scenario in a sympathetic manner
• Is non-confrontational
• Has constructive suggestions for ways to improve training
• Considers routes of escalation in the event of no change
• Negative markers
• Escalates inappropriately
• Accepts the status quo
• Is confrontational
136 Smashing the Core Surgical Training Interview

Management Scenario 11: Negotiating Skills

You are the core surgical trainee on the ENT team. You are assisting your
consultant on a head and neck list. He leaves you to close the large neck
wound. When the consultant leaves theatre, the staff start complaining
among themselves. You hear them say that you are operating too slowly and
they want to leave on time. How would you approach this situation?

This is a tricky situation involving multi-professional communication,

training requirements, and a balance with service need.
I would start by apologising that they felt I am operating slowly, but
I would say that I am doing what I feel is safest for the patient and that
rushing would likely lead to a mistake, ultimately taking an even lon-
ger time. I would also stress that this is the best way for me to learn and
that by allowing me to proceed, I would be faster and more precise in
the future. I would avoid mentioning that comments about my speed of
operating are only likely to slow me down further and that surgical speed
is only one marker of technical excellence. I would also consider whether
closing a large neck wound is truly within my competence and whether
I do, in fact, need help to close it appropriately and in time.
I would acknowledge theatre staff’s need to leave on time, as their
time is of value. Theatre staff should not feel overworked and burdened.
I would make the suggestion that I might proceed undisturbed for the
next 15 minutes. If I am not making progress, then I would suggest that
we call either a registrar or the consultant back in to help. If this sugges-
tion is accepted, then I would proceed to finish the case.
Following this, I would reflect on the case and my technical prog-
ress throughout my training. If I feel that I am still operating slowly, then
I might look into getting further practice, either in theatre or on simu-
lated tissues. I could find some expired sutures to take home to practice
my hand ties and other technical skills to improve my confidence and
surgical fluency. I would also discuss with any colleagues if they expe-
rienced similar comments and, if so, how they approached the situation.
Comparing actions and outcomes could help if I were to encounter a simi-
lar situation in the future. I would also debrief the case with my consul-
tant and enquire why they felt they could entrust me with this closure and
take on any feedback.
Finally, I would consider whether the episode in theatre was a micro-
aggression against me. I would consider whether this is a recurring
theme. If the culture in theatres is not conducive to training, then I would
discuss this with my educational supervisor. We might need to involve
other stakeholders, such as the theatre coordinator or theatre team lead, to
see how this could be remedied in the future.
Chapter ten: Management Scenarios 137

• Probes
• What are the issues here?
• What other information could you gather?
• How could patient safety be compromised?
• Who else can you involve?
• Positive markers
• Approaches scenario in a thoughtful manner
• Considers multiple sources of feedback
• Considers methods of self-improvement
• Negative markers
• Does nothing
• Becomes confrontational
• Shows no reflection on personal performance

Management Scenario 12: Dealing with Racism

You are the core surgical trainee. A patient tells you they want to see a doc‑
tor of a different ethnicity than your own. They get abusive when you try to
reason with them. How would you proceed?

The behaviour of this patient is an example of racism and should not be

accepted. Despite trying to reason with the patient, they have become
abusive, and therefore, it is no longer appropriate for me to carry on treat-
ing them. I would stay calm, stop engaging with the patient, and remove
myself from their immediate environment.
How I proceed next would depend on the clinical circumstances. If
the patient requires emergency treatment, I would request the nearest
available suitable doctor to take over their care, ideally someone more
senior than me. Although ill health is not a valid excuse for racist behav-
iour, it could be a contributing factor causing delirium. The patient should
still have emergency treatment.
If, however, they do not need urgent care, usually hospital policy sug-
gests a zero-tolerance approach to abuse against staff. I would escalate
this incident to my registrar, my consultant, and the ward manager. It
should be explained to the patient that their behaviour is unacceptable,
and they could not discriminate healthcare staff for their background.
The patient should be told to change their behaviour.
According to the patient’s level of abuse and whether it is verbal or
physical, it might be necessary to call either hospital security or the police.
My primary concern would be to make the environment safe for myself
and others who might require that the patient be moved to another loca-
tion. If the patient continues to be abusive, senior hospital management
might refuse to provide care.
138 Smashing the Core Surgical Training Interview

I would also clearly document in the patient’s notes exactly what was
said by the patient and the circumstances surrounding it. I would also
record the names and contact details of those who witnessed or were
involved in the incident in case further investigation or evidence is needed
in the future. I would then complete a Datix form to record the incident.
Finally, I would consider the impact this has on my well-being. I would
discuss this with my consultant and my educational supervisor and ask
for further support if required. I am aware that staff support through
occupational health or from the BMA is available and that I should seek
this if I feel my ability to provide patient care and my medical career are
going to be affected by this incident.

• Probes
• Who could you ask for help?
• Would you report this behaviour to anyone?
• What documentation do you need to carry out?
• Positive markers
• Clearly states this is not acceptable behaviour
• Calls for assistance early
• Acknowledges there may be clinical reasons behind the patient’s
behaviour
• Remains calm
• Knows trust policy on racism and abusive behaviour
• Negative markers
• Argues with patient
• Ignores racist behaviour of patient and does not report it
• Fails to obtain help and protect themselves

Management Scenario 13: Rota Cover

You are the core surgical trainee on-call for the day and have finished a
12-hour shift. The night CST has called in sick. How would you approach
this situation?

In this situation, my overarching concern is patient safety. I would also

consider the workload for the surgical staff.
I would first seek to understand the situation completely. I would see
how many patients are left to be seen, how many require urgent interven-
tion, and how many are unwell. I would assess who the night team con-
sists of. Is there an FY1 and a registrar?
I would take the initiative to try and make the situation better. The
team should consider all options. There might be a ward FY1 available on
nights who might be able to cover some aspects of the on-call team’s work.
There might be an individual available on short notice to cover the shift.
Chapter ten: Management Scenarios 139

There might be junior doctors in different specialities who might be able to

cross-cover.
I would escalate this situation to the site manager and the consultant
on-call. They might be able to help with staffing issues. In particular, the site
manager might be able to identify an individual elsewhere in the hospital
who might be able to help with specific duties. The site manager or consul-
tant might be able to source a last-minute locum doctor. I would also esca-
late this to the nurse in charge for admissions, advising that there might be
a delay in seeing patients. The nurse in charge and their staff might be able
to support the team with ancillary duties, such as taking blood specimens,
placing cannulas, or inserting urinary catheters, depending on skill mix.
If no replacement SHO could be found, it would be the responsibility
of the registrar on-call to cover the duties, with support from the con-
sultant as required. If it is particularly busy, the consultant might need
to come in. Although I would not be required to continue working the
night shift, if I am feeling able and capable to do so, I could support my
colleagues by staying on for a short period of time to help complete any
urgent clinical care that is necessary. However, I would be careful not to
provide clinical care when overly tired, and it might be necessary for me
to have a rest period before doing so. I think it is important to be a team
player and help the night team in any way I could in a difficult situation.
However, I would not want to place patients in potential harm by working
outside my limitations.
Finally, the rota coordinator needs to be informed the next morning to
make sure that there is adequate staffing for the next night shift. If uncov-
ered shifts are a regular occurrence in the department, then I would raise
this with my clinical supervisor for further escalation.

• Probes
• What are the issues here?
• What other information could you gather?
• How could patient safety be compromised?
• Who else can you involve?
• Positive markers
• Recognises possible harm to patient care and prioritises this
• Informs the site manager and on-call consultant
• Attempts to help with finding cover
• Negotiates to find a solution and offers some level of help
• Understands the trust policy on requirements for cover in case of
absence
• Negative markers
• Does not help to find a solution
• Does not escalate to the line manager or consultant
• Agrees to stay on and cover the duty despite being tired
140 Smashing the Core Surgical Training Interview

Management Scenario 14: Breach of Confidentiality

You are the core surgical trainee. You walk into the handover room and find
your registrar looking at the medical notes of a patient who is admitted under
a different speciality. How would you approach this situation?

I would be concerned here about a possible breach of patient confidential-

ity. The other issues here are professionalism and the duty of candour.
First, I would approach the registrar and politely enquire about their
reason for accessing the notes. They might have a valid reason for doing
so, such as providing patient care. However, if they do not have a valid
reason, I would remind them of their professional obligation to maintain
patient confidentiality.
If the registrar accessed the notes inappropriately, this is a breach of
the GMC ethical guidance on confidentiality. As this is an issue of profes-
sionalism, unfortunately, I would need to escalate this to their educational
supervisor. Although it is possible that this could be resolved at a local
level, depending on the severity of the breach, this might lead to disci-
plinary action. The clinical director, chief medical officer, and training
programme director might become involved. The educational supervisor
would lead this.
The patient would also need to be told that there has been a breach of
their confidentiality. This needs to be disclosed using the duty of candour.
The patient should be offered an apology and signposted to the PALS
service. It is likely that this disclosure comes best from the consultant in
charge of the patient’s care.
The registrar involved would require support in this scenario, as it
is likely to be stressful. Although I would probably not be best placed to
offer the support, occupational health, the registrar’s defence union, or the
BMA might be good starting points.
I would also reflect in my portfolio about my actions, which are likely
to have a significant impact on a colleague. The episode might also make
team working with the registrar difficult, and I would need to employ
diplomacy and conflict resolution to ensure that the team could provide
good clinical care. In such a situation, it might be necessary to separate the
two of us on the team, and I would coordinate this with the permission of
my educational supervisor and the rota coordinator.

• Probes
• What are your concerns about this scenario?
• What reasons might the doctor have for looking in the medical
notes?
• Whom would you inform about the registrar’s actions?
Chapter ten: Management Scenarios 141

• Positive markers
• Understands there might be a breach of patient confidentiality
• Takes initiative in establishing whether the registrar has a valid
reason
• Escalates appropriately
• Knows trust policy on breach of confidentiality
• Negative markers
• Ignores what they have seen
• Accepts the registrar’s explanation and does not confirm it
through other sources
• Confronts the doctor/becomes angry

Management Scenario 15: Workforce Planning

You are a CST in orthopaedics. You note that there is regular overbooking
of clinics. The service manager regularly pulls you from theatres to cover
these. You are expected to see patients independently in these clinics with
little senior support. How would you approach this situation?

My concerns in this scenario are poor workforce planning, impact on

patient safety, and compromised surgical training.
If I am being asked to see patients without sufficient senior supervi-
sion, this compromises patient care. If this is happening on a regular basis
and I am being reassigned from other activities, including from theatre,
my surgical training is being affected.
I would try and find out why this keeps happening by speaking
with the service manager in case there is a simple problem that needs
resolving. There might be a simple misunderstanding; for example, they
might have mistaken me for a registrar. I could also discuss the issue with
other trainees to see whether its only me that is affected or whether oth-
ers are facing a similar problem. I would approach the service manager
and express my concerns over the overbooking of clinics. I would make
clear the impact that being pulled from the operating room is having on
my schedule and training. I would also express concern over the lack of
supervision. I would offer solutions, such as increasing staffing levels and
rescheduling appointments to reduce the number of overbooked clinics.
If there is a solution where we, as trainees, could be better allocated to
cover these clinics so that we are not losing learning opportunities and all
of us are sharing the workload from clinics evenly, I would be happy to
help organise and manage this. For example, I could work with the service
manager to create a suitable rota for the clinics. It is important to conduct
this conversation in a respectful and professional manner to find a mutu-
ally beneficial solution.
142 Smashing the Core Surgical Training Interview

I would raise the issue with my educational supervisor. I would

review my logbook with them and make sure that I am getting adequate
experience. I would also need to involve my training programme director
in this instance as service priorities are disrupting my training on a regu-
lar basis. There might be other individuals (e.g. trust doctors or registrars)
who might be able to cover some clinics. The Royal College tutor would
also need to be informed.

• Probes
• What issues are you concerned about?
• What information could you gather to support your case?
• Who would you discuss this with?
• Who could you escalate this to?
• Positive markers
• Acknowledges this is a management issue
• Recognises patient care is at risk
• Recognises training provision is inadequate
• Acknowledges their own limitations
• Discusses with others to gather information and data
• Takes initiative in finding a solution
• Knows the structure for escalation within hospital trust and
deanery
• Negative markers
• Does not discuss with other trainees and consultants
• Agrees to manage clinics without supervision
• Refuses to attend the clinic

Management Scenario 16: Drunk Registrar

You are the core surgical trainee on-call. You can smell alcohol on your regis‑
trar’s breath. How would you proceed?

I am concerned here about my registrar’s ability to provide safe clinical

care. Patient safety is potentially at risk. Second, there is an issue of pro-
fessionalism that needs to be dealt with.
I would approach this sensitive situation cautiously. If I feel comfort-
able doing so, I would approach the registrar directly. I would speak to
them in a private space and express my concerns about alcohol on their
breath. I would remind them of their professional responsibilities. I might
ask another medical or nursing colleague to witness the conversation.
If the registrar is not receptive to my concerns or if I do not feel com-
fortable addressing the issue directly, I would escalate this to the con-
sultant. The consultant should advise the registrar to remove themselves
Chapter ten: Management Scenarios 143

from clinical activities and go home for the day to fully recover. I would
make sure they have a safe way of getting home and would offer to
arrange transport if needed.
The rest of the on-call shift would need covering, and so I would also
inform the rota coordinator that a replacement registrar needs to be found
as they had to leave for personal reasons. Any patients already seen by
the registrar would need a second review to ensure the correct decisions
were made.
It is possible this is just an isolated incident. The registrar’s educa-
tional supervisor would need to be informed. However, since this is a
serious breach of professionalism, this is likely to lead to some form of
disciplinary action. The chief medical officer or training programme
director for the registrar might need to be involved.
The registrar involved would require support in this scenario, as it
is likely to be stressful. Although I would probably not be best placed to
offer the support, occupational health, the registrar’s defence union, or the
BMA might be good starting points.
I would also reflect in my portfolio about my actions, which are likely
to have a significant impact on a colleague. The episode might also make
team working with the registrar difficult, and I would need to employ
diplomacy and conflict resolution to ensure that the team could provide
good clinical care. In such a situation, it might be necessary to separate the
two of us on the team, and I would coordinate this with the permission of
my educational supervisor and the rota coordinator.

• Probes
• How would you approach the discussion with your registrar?
• What other information would you gather?
• How would you report this issue?
• Whom would you escalate this to?
• Positive markers
• Prioritises patient safety
• Takes steps to ensure appropriate cover is arranged
• Reports the incident appropriately
• Considers possible underlying reasons for colleague’s behaviour
• Negative markers
• Ignores clinical danger
• Does not report the incident
• Does not consider the colleague’s well-being
chapter eleven

Post-Interview Job Preferencing

Stefanos Gkaliamoutsas and Alex Meredith-Hardy

Preferencing Core Surgical Training (CST) programme posts happens

after interviews. You will be contacted via Oriel to submit your prefer-
ences. Ranking is an arduous task, as you have to preference hundreds
of individual jobs. Some jobs may be run-through training in a certain
speciality (these are currently rare). Other jobs may have a specific sub-
speciality theme. Most jobs are a good mix of various surgical specialities.
Unfortunately, there is no good way currently to find out about the dif-
ferent rotations. Be creative and use your network. You can gain valuable
insights by speaking to former medical school colleagues, junior doctors,
registrars, and consultants about their experiences in different regions.

Questions to Ask Yourself

Some of the questions you may wish to consider when preferencing are
as follows:

• Within which speciality will you be aiming to apply for an ST3 num-
ber in two years’ time?
• How much experience do you need in that speciality to maximise
your ST3 application points?
• Do you risk spending too much time in your preferred speciality
and therefore losing points on your ST3 application?
• How much experience, if any, do you require within allied speciali-
ties for the ST3 programme that you intend on applying to?
• Where do you want to live for the next two years?
• Are there any specialities that you are unwilling to work in?

Reflecting on Your Priorities

Every individual will have different priorities when it comes to preferenc-
ing jobs. Some individuals may have a specific place they want to work
in and will not consider jobs outside this geographic area. Others may be

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146 Smashing the Core Surgical Training Interview

determined to get a themed job within their speciality of interest, as this

will give you more exposure to this speciality and will therefore prioritise
this over location. Approach this period of reflection with a growth mind-
set, understanding that getting a coveted CST post is more important than
the exact configuration of rotations. Unexpected opportunities and expe-
riences may be gained if you are adventurous and geographically mobile.

Ranking Strategy
The key to ranking is to list every single job that you would potentially
accept within the first iteration of preferencing. We cannot emphasise this
point enough. The first iteration is your best chance to gain a CST post.
If you change your mind about which jobs you would accept after the
first iteration, you may miss out on hundreds of jobs that you could have
potentially secured in subsequent rounds. Rank geographically widely
and surgically broadly. We would recommend ranking all run-through
jobs first if you are geographically flexible, followed by speciality-themed
jobs (if you have a preference).
For individuals aiming to get a job in a themed track, we would
advise ranking all these jobs at the top of your list. For example, a trainee
wishing to pursue a career in urology should rank urology-themed pro-
grammes first. These themselves can be differentiated based on location
or preference of the non-urology rotations within that programme. Then
the trainee would rank all remaining jobs they would be willing to accept.
For individuals for whom geography is the most important factor, we
again recommend preferencing as broadly as possible. Candidates often
make the mistake of only ranking a small number of jobs in the first itera-
tion, only realising their mistake when they do not receive an offer. If you
are geographically limited, rank the jobs in your deanery of preference
and at least two or three surrounding deaneries. You can always hold or
reject these job offers later if they really do not fit your life.

Offers Process
All posts that you would be happy to accept should be dragged and
dropped into the preferences column. All posts that you would not con-
sider should be put into the ‘not wanted’ section. Regularly save your pref-
erencing on Oriel as it can time out and you might lose everything that
you have done. The preferences are then submitted.
Do not worry if you do not get offered a job in the first round. There
is a long process of candidates accepting and rejecting jobs, and there are
chances are that you might be offered a post later.
Chapter eleven: Post-Interview Job Preferencing 147

 op Three Tips for Post-Interview

T
Job Preferencing
1. Rank every single job that you would potentially accept within the
first iteration of preferencing.
2. Reflect on your priorities of exposure to speciality versus geographic
location.
3. Have a growth mindset. Be open-minded about jobs to maximise
your chances of getting a national training number.
chapter twelve

Life as a Core Surgical Trainee

Haseem Raja and Janso Padickakudi Joseph

Core surgical training (CST) offers a wealth of opportunities for the

budding surgical trainee. It is a time to grow in your clinical skill and
knowledge while working in the hospital. It also requires significant com-
mitment outside your clinical work to grow personally and professionally.
Whilst the provision of opportunities may differ amongst hospitals and
training programmes, it is incumbent upon you to be proactive with your
learning and seek out opportunities. Asking for advice and support from
seniors will help you navigate the process more smoothly. The biggest
challenge, perhaps, is striking a healthy balance between work and life
outside of CST, so this requires careful attention.
As you progress through CST, you should consider the following four
priorities.

Developing Surgical Skills

First and foremost, CST is about laying the foundation for your surgical
skills. You will have the opportunity to rotate through various speciali-
ties and develop a broad array of skills. You should approach this with a
growth mindset, trying to find opportunities all around you. Be proactive
about getting to theatre as much as possible. However, also recognise the
value of learning outside of theatre, such as attending clinics or being on-
call; it is here that you will learn about decision-making. You should learn
something every day. You should actively seek out feedback on your per-
formance as often as possible and reflect on this. CST is a chance for you to
understand the case mix and lifestyle associated with different speciali-
ties, so enjoy the exploratory part of this process.
A typical week as a CST is varied, consisting of a mixture of sessions,
such as ward cover, on-call, clinics, and theatre. If there is a minor ops
list with office-based procedures (e.g. clinic-based endoscopy, lumps and
bumps under local anaesthesia), these are excellent learning opportunities
for CSTs. Attendance at multidisciplinary team meetings is particularly
beneficial for reviewing scans and observing how cases are managed.

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150 Smashing the Core Surgical Training Interview

Passing the MRCS Exam

Becoming a member of the Royal College of Surgeons by passing the
MRCS examination is a requirement to finish CST. This goal should be
prioritised, especially as preparation for the examination will increase
your knowledge base for your clinical rotations. There is a multitude of
resources available for passing the examination, and further detail can be
found in the portfolio chapter of this book. Although there is not an ideal
timeline for this, passing both parts of the examination earlier rather than
later will then allow you to focus your efforts on developing your clinical
skills.

 ompleting Portfolio Requirements, Both

C
for ARCP and ST3 Applications
At the beginning of CST, you should look at the portfolio requirements
for entry into all higher surgical training programmes that you may be
considering. Here, the process for portfolio preparation starts anew. You
should build on your successes so far and approach developing your port-
folio with rigour and advanced planning. You should consider how you
can progress some of the projects that you have already started – can a
poster you have presented be turned into a paper? Juggling the tasks of
scoring as many portfolio points as possible alongside a busy on-call rota
means that you need to have excellent time management and prioritisa-
tion skills. You should book courses such as CCrISP and ATLS early, as
these are often overbooked. You need to be selective about which research
projects you take on, and only commit to those that have the potential
to be presented or published. This often means being firm and respect-
ful when turning down some interesting research proposals. You should
upload your certificates and evidence contemporaneously so that you do
not need to scramble before ARCP. You should also use every opportu-
nity to send workplace-based assessments (WBAs) to meet your ARCP
requirements.

Achieving a Work-Life Balance

It is essential to achieve a good work-life balance and avoid the risk of
burnout. CST can be physically and mentally draining. You should spend
regular quality time with friends and family, continue your hobbies (or
find new ones), and engage with your communities. Having a support
structure outside of work will set you up for success as a CST when the
going gets tough.
Chapter twelve: Life as a Core Surgical Trainee 151

 op Five Tips – How to Succeed as a

T
Core Surgical Trainee
1. Aim to complete the MRCS exam in your first year of training.
2. Team up with colleagues to complete ARCP/ST3 portfolio requirements.
3. Utilise your study leave allowance and book courses early.
4. Approach rotating through different surgical placements with a
growth mindset.
5. Make time for yourself outside of work.

 ase Study: Haseem Raja, ENT Registrar

C
(West Midlands)
Life as a core surgical trainee during the COVID-19 pandemic was equally
challenging and exciting. Despite being redeployed to the Infectious
Diseases Unit for three months and having significantly reduced training
opportunities in Core Surgical Training (CST), I adapted quickly to these
changes and maximised my learning opportunities. I was in the favour-
able position of having a national training number in ENT surgery, so
I considered myself very fortunate in comparison to my peers.
Based in a large university teaching hospital, my two-year training
programme consisted of four six-month placements in upper GI, ENT
(twice luckily), and plastic surgery. This breadth of exposure was great
for learning and surgical skill acquisition. Providing night cross-cover
for urology and vascular surgery during my first year of training further
enriched my overall experience.
I prioritised the exam at the beginning of CST and, through start-
ing my preparations early, was able to successfully complete both parts
for MRCS (ENT) during my first year. I found the eMRCS question bank
particularly helpful for the Part A MCQ examination. Passing the exam
early provided me with ample opportunity in my second year of training
to focus on improving my skills in theatre and clinic, as well as preparing
for life as an ENT registrar.
Rotating through different surgical specialities provided me with an
excellent opportunity to develop a whole array of skills. Plastic surgery,
my last rotation of core training, in particular, enabled me to hone my
basic surgical skills, including tissue handling and wound closure. Whilst
keeping an open mind to surgical opportunities, it was important for me
to tailor my learning needs to certain areas; my focus was on becoming
competent in performing the common ENT index procedures expected of
a day 1 registrar. These procedures included adenotonsillectomy, inser-
tion of grommets, and microlaryngoscopy. I also made an active attempt
152 Smashing the Core Surgical Training Interview

to get involved in all emergency cases relevant to ENT. To supplement this

learning, I utilised my study leave allowance to attend craft courses, such
as Functional Endoscopic Sinus Surgery and Temporal Bone Dissection.
Whilst I had the security of a national training number in ENT sur-
gery, I was fully aware of the portfolio demands required for ST3 applica-
tions as I had prepared to reapply with the view of moving deaneries due
to personal circumstances. I booked courses, such as ATLS and APLS, in
advance and only committed to research projects with the potential of
being published and presented nationally within 12 months.
To achieve an optimal state of productivity with regard to clinical
work and completing portfolio requirements, I needed to recharge my
batteries periodically with adequate rest and days away from work. I also
made a concerted effort of continuing my hobbies of playing football and
undertaking fitness training outside of work; this was crucial for my over-
all well-being.
chapter thirteen

The Challenges of Life as a

Core Surgical Trainee
Gargi Pandey and Janso Padickakudi Joseph

Once you get your Core Surgical Training (CST) number, you take a sigh
of relief and think, ‘It’s time for a break’. Unfortunately, not. Higher surgi-
cal training (ST3) applications open only a year after starting CST, so the
preparation needs to start immediately.

Tough Workload
Make no mistake, becoming a surgeon is tough. Core surgical training
can be overwhelming, busy and frustrating. The laundry list of require-
ments seems endless. You need to juggle the realities of your day job, pre-
pare for your Annual Review of Competency Progression (ARCP) and
start collecting portfolio evidence for ST3 applications. For example, for
ST3 in ENT to score maximum points, you need nine publications, eight
audits, two national or international oral presentations, two regional oral
presentations, two poster presentations, postgraduate degrees, and more.
It will be impossible to achieve all of this in a single year. You, therefore,
need to plan in advance, set realistic goals, work smart, and also make
time for yourself for rest and relaxation.

Feeling Out of Depth

You may rotate through specialities during your CST in which you have
very little experience. It can be very daunting to start a job with minimal
clinical induction. Often you are thrust into the deep end, especially while
on-call. You may find yourself in a situation where you are expected to
give specialist advice but feel out of your depth. In this situation, it is
important to be proactive, creative, and aware of your own limitations.
Overcoming this feeling will take preparation on your part. Read broadly.
When you encounter a new case, spend ten minutes to read about the
disease pathology; information will stick better this way. Ask questions.
There are no stupid questions. Run every decision past a more senior

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154 Smashing the Core Surgical Training Interview

member of the team initially; the decision-making will get repetitive and
simpler with time. You may need to use Google, YouTube, Up-To-Date,
DynaMed, or other resources to get quick information. The key here is to
be safe and sensible and be aware of your own limitations. Never do any-
thing out of your competence without appropriate supervision.

Not as Glamourous as Advertised

When you imagine life as a CST, you may dream that every day will be
spent in theatres, with the entire healthcare team there to help you prog-
ress. Unfortunately, the reality is that there are multiple competing inter-
ests in the healthcare setting. First and foremost, patient safety and service
provision are key outcomes within the NHS. Often, you will feel that your
training is less important than these system-wide goals. Navigating your
space within the healthcare setting takes grit, creativity, and flexibility. As
a CST, you may be in a situation where you are the most junior member
of a surgical team, meaning that you will be expected to do ward work.
Approach the situation with a growth mindset. Try to find opportuni-
ties around you. Are there ward-based practical skills you can learn? Are
there difficult conversations with patients you can sit in on, even lead?
Can you get to the clinic? Are you able to negotiate with your rota coor-
dinator to have ring-fenced time for operating? In some rotations, your
training will be subpar, and in these instances, you must escalate this to
your educational supervisor and training programme director. Although
the situation may not change in time for you, you can ensure that the edu-
cational value of a rotation can be improved for your successors.

Emotional Well-Being
CST will have a profound effect on your emotions. You will be dealing
with patients who are undergoing life-changing treatment. You will
witness when things go wrong. You will experience death. You will
encounter angry patients and relatives. You will experience conflict in
the workplace. You might feel out of place, undervalued, or bullied. You
may find little value in completing the same administrative tasks you did
when you were a foundation doctor. You may find difficulty in getting
leave to attend life events. You may get to a stage when you are tired or
burnt out.
When you are a CST, you need to take time to focus on yourself and
your mental health. Speak to those around you. Build a community of
trainees who are going through the same thing and debrief with them.
Shared pain is halved pain. If possible, include your significant other,
Chapter thirteen: The Challenges of Life as a Core Surgical Trainee 155

friends, parents, and family so they can support you too. Make time for
yourself and your hobbies. When things get too tough, get help. Speak
to your educational supervisor or occupational health to get this started.

Financial Well-Being
Financially, CST can also be taxing. Exams cost around £1,000. In addition,
you will want to attend other events and courses, some of which are man-
datory. You may need to budget for international travel and accommoda-
tion expenses. Sometimes you will need to pay to get things published.
In addition, this is a time when life events – weddings, children, getting
on the property ladder – occur. Suddenly you are a doctor but still feel
extremely poor.
You need to work on your financial literacy and keep on top of your
budget. Make a list of your income and expenditure every month. Try to
save at least a couple of hundred pounds per month and try to build a buf-
fer so that you are not living paycheck-to-paycheck. Make sure that you
are claiming back on all the study budget you are entitled to. Research
different providers for courses. Some courses (e.g. Train the Trainers) may
be offered for free locally, as opposed to with a £500 price tag by a national
provider.

Leaving Surgical Training

During CST, some individuals will realise that surgery is not for them.
This is all right. Make this decision proudly and use the experiences you
have gained during your life as a surgical trainee to become a better ver-
sion of yourself. You have come this far in your medical career, which
means that you are a hardworking, intelligent, ambitious individual; do
not let anything or anyone take this self-confidence from you. This is not
giving up, it is just choosing a new path. Remember, this is your life and
you have to make it what you want.
chapter fourteen

To F3 or Not to F3
Alex Meredith-Hardy, Gargi Pandey, Anokha
Oomman Joseph, and Janso Padickakudi Joseph

Introduction
A foundation year 3 (FY3 or F3) typically describes 12 months out of train-
ing for doctors who have completed the foundation programme. As a
prospective surgical applicant, you may have already asked yourself the
question of whether you want ‘to F3 or not to F3’. This is an important,
personal decision that only you can make. Candidates who do not receive
CST posts will default to the F3 year and may need to make arrange-
ments quickly. Other candidates will make a conscious decision to take an
F3 year. In this instance, the central question is how/if a potential F3 year
can add value to your life, both personally and professionally. You need
to make an honest assessment of your short-term and long-term goals. In
this chapter, we present both sides of the argument in a bid to empower
you to make the decision that is right for you.
Popularity for an F3 year has boomed, with over 65% of foundation
doctors doing an F3 in 2019, compared to only 17% in 2010 (1). This once
‘alternative’ route of not directly entering speciality training has therefore
become exceedingly popular. It is also becoming more common for doc-
tors to extend their F3 for further years, colloquially known as F4, F5, F6,
and beyond. For this chapter, the term F3 applies to all post-foundation
doctors’ pre-speciality training.

Proceeding Directly to Speciality Training

Since you are reading this book, you are clearly interested in becoming a
surgeon. You may be dipping your toes in the water, or you may already
be firmly committed. In either case, proceeding from the foundation pro-
gramme directly into speciality training may be the right course of action
if you are ready for the exciting prospect of being a surgical trainee.
By formally being a core surgical trainee, you become a part of the
community of surgery in your hospital, regionally and (inter)nationally.
This means your training will be structured, you will be supported by
your deanery, and training institutions will have responsibilities towards

DOI: 10.1201/9781003350422-15 157

158 Smashing the Core Surgical Training Interview

your progress. It also means that you will have clinical, academic, and
professional responsibilities to fulfil. It firmly puts you on the path to
becoming a surgeon in minimal time after graduation; this may become
more important further down the line (e.g. when applying for higher sur-
gical training where the requirements become more demanding depend-
ing on how long ago you graduated).
It is falsely assumed that proceeding directly into speciality training
means you cannot have a work-life balance, cannot travel, or cannot make
time for outside interests. With good planning, all these things are pos-
sible. If you wish, you can choose to train less than full-time. You can
take time to get out-of-programme training, experiences, or research. As a
core surgical trainee, you will have the safety of job security. Being a core
trainee is also a method of trying out this career path and seeing if it suits
you and exploring different surgical specialities. You will be entitled to a
study leave budget, holiday, and sick pay.

Reasons to Take an F3 Year

You may have made a conscious decision to take an F3 year. People take
this year for many reasons, including travelling, working abroad, prepar-
ing for training interviews, gaining further experience in a speciality they
may not have had exposure to, or simply taking a break. The decision is
usually a combination of personal and professional factors.
Foundation doctors may consider ‘push’ or ‘pull’ factors as reasons for
taking an F3 (2). Some of these factors are summarised in the following table.

Negative Factors Positive Factors

• Stressful/negative experience • Natural break on the ‘conveyor
during foundation training belt’ of medical training
• Burnout • Control over time and location
• Lack of speciality exposure • More flexibility
• Feeling unprepared for speciality • Perceived work-life balance
training • Financial incentives
• High competition ratios of the • Increased experience in the chosen
chosen speciality speciality
• Failed application • Time to build portfolio
• Lack of control over time/location • Time to pursue other interests/
hobbies
• Travelling
• Volunteering
• Life milestones
• Exploring alternative careers
Chapter fourteen: To F3 or Not to F3 159

Flexibility and Work-Life Balance

The opportunity to be fully in control of one’s time is attractive. Many
doctors have spent year after year at school, sixth form, university, and
then foundation training and desire a break from the ‘conveyor belt’ of
medical training. The natural break in training after F2 gives a golden
opportunity to take back some control.

Bank or Locum Work

Most F3s continue clinical work in some shape or form. You can either
work directly on a staff bank for your trust/hospital to cover rota gaps or
empty shifts. Alternatively, you can work through a locum agency. One
can choose to take a break from the heavy rota. Some F3s take on a couple
of shifts a week to pay the bills and have the rest of the time to enjoy
life and pursue other interests, projects, and side hustles. On the opposite
end of the spectrum, you can also continue to work (more than) full time,
but with the comfort of knowing that you can take time off on your own
terms. For many F3s, finding a work-life balance is paramount. The flex-
ibility that bank or locum work offers is a huge draw, especially as fixed
rotas can make it difficult to plan life. Everyone seems to have heard a
horror story of a core surgical trainee being on-call on their wedding day,
despite asking for time off in advance!

Financial Incentives
Bank or locum work means can mean you receive significantly higher
pay than a core surgical trainee. At present, a core surgical trainee on an
average 40-hour week gets a basic pay of around £19/hour pre-tax. This
is before additional rostered hours, night duty, and weekend allowance
are factored in. In contrast, the average hourly rate of locums working at
the same level is about £44/hour. This is also before national insurance
deductions, NHS pension contributions, and student loan repayments. It
is obvious that working at the locum rate can be very lucrative. However,
it is important to note that there is no sick pay for locum doctors. If you
were to take time off work due to sickness, you would have no income
during that period.
People have used locum incomes to put together deposits for houses,
start property renovation projects, go on round-the-world trips, pay off
student debt, start investment portfolios, pay for weddings, and many
other things. The possibilities are endless with this ‘leg-up’ to starting
financial independence.
160 Smashing the Core Surgical Training Interview

Career Exploration
It is common for foundation doctors to feel uncertain about which special-
ity training to apply for. It is one of the biggest decisions in your life, and
it is reasonable to give yourself the time and space to consider what you
want to spend the rest of your professional life doing. Foundation training
provides a four-month experience in just six specialities. You may have
had little choice in your allocation of rotations. Some niche specialities
like ophthalmology do not have foundation trainees, so an F3 year may be
a great opportunity to experience this. You may not have rotated through
your surgical speciality of choice. During foundation training, you may
not have spent much (or any!) time in theatre, despite doing surgical jobs.
The F3 year allows you to choose jobs that will give you better exposure
to your chosen speciality.
The F3 year is also an opportunity to gain experience in non-­clinical
roles if this is something that interests you. Examples include medical
writing, research, podcasting, YouTubing, management consultancy,
health tech, global health policy, and business – the list is endless. You
may wish to pursue further education, such as a master’s or PhD, an art
foundation year, or even a carpentry course. Anything is possible! It is just
a matter of deciding how you want to spend your time and planning how
you are going to do it.

Portfolio Building
Surgery is a competitive speciality with high applicant-to-post ratios.
Although the applicant specifications change every year, there are almost
always points for demonstrating teaching commitments, leadership,
research, audits, and commitment to the speciality. Although it is possible
to build an excellent portfolio during foundation years, you can use the
year to really sharpen your portfolio and secure maximum points.
Research and publications are notoriously difficult to get unless you
are in the right place at the right time, know the right people, or are genu-
inely an academic-minded person. The F3 is a brilliant chance to meet
people, network, and importantly have the time to get stuck into proj-
ects which might lead to presentations and publications, enabling you to
finally tick that box.

 ocum Agency, Bank Locum, or Clinical/

L
Teaching Fellowship?
When deciding to take on clinical work in your F3 year, there are several
different routes you can go down. You can sign up to the hospital/trust
Chapter fourteen: To F3 or Not to F3 161

staff bank where you completed your foundation training. The advantage
of this is that you will know the institution, the people, the rota coordina-
tors, and the way things work. You will be agile with the IT systems and
internal processes, causing the least angst on shifts.
An alternative is to sign up to work for a locum agency. Agents will
find work to suit your experience and needs. The benefit of this is that
recruitment agents contact you directly with opportunities of which you
then have a choice. This route can be the most lucrative. Rates can be nego-
tiated through the locum agent on your behalf. The downsides of locum
work are that it can be unpredictable. You must be flexible. You should
be ready to pick up last-minute shifts; sometimes at hospitals, you have
not worked at before. Some people can find this stressful as you may not
always have a predictable source of income. Being in a new hospital with-
out induction or IT training can also be challenging. In general, there is
usually work available if you are flexible and prepared to work in differ-
ent departments and maybe even different hospitals. The other big down-
side is that you will not qualify for any sick pay.
Clinical and teaching fellowships are another popular option for
doctors wanting to continue clinical work during their F3 years. The
advantage of these is that they are a great opportunity to gain a solid
experience in a chosen speciality. This can be outstanding on a CV and
can help with networking. Some of these posts are designed specifically
with the F3 doctor in mind. There may be elements in the job descrip-
tion aimed to appeal to those wanting to improve their portfolio, such
as allocated time for research, audits, or teaching. Some posts even offer
to fund for medical education qualifications. Clinical or teaching fel-
lowships can be competitive to get into but have immense potential for
portfolio development. Clinical fellows usually have the same policy for
booking annual leave as trainees. They do qualify for pension contribu-
tions and sick pay. The downside is that clinical fellows are usually relied
on for service provision and are therefore put on the normal F2/SHO rota.
This may include on-call, weekends, and nights without the enhanced
pay of a locum shift. If you know you want to be a core surgical trainee
but were not successful in your application, this may be the option best
suited to you.

Working Abroad
Another very popular option for many F3 doctors is to move and work
abroad. Many opportunities exist around the world, and medicine is like
a passport! You may wish to do volunteer work, combine working with
travelling, or seek a permanent relocation. Many UK doctors spend their
F3 in Australia, New Zealand, or South Africa. Some never come back!
162 Smashing the Core Surgical Training Interview

If you intend to work abroad you need to start this process early, as there
will be visa and medical regulatory requirement to fulfil.

Reasons to Proceed to CST Reasons to Do an F3 Year

Rights and responsibilities of being a Flexibility
core surgical trainee
Structured training Control over time
Defined expectations Perceived work-life balance
Deanery support Potential financial earnings
Sense of identity as a surgeon Portfolio building
Minimum time after graduation Freedom for long periods of travel
Ability to try a surgical career Working abroad
Actively explore surgical specialities Exploration of interests/careers outside
Job security of medicine
Predictable rotations
Rotas in advance
Study leave, holiday, and sick pay
entitlements

Case Study: Alex Meredith-Hardy

I came across the concept of F3 whilst at medical school when I met an
inspiring teaching fellow who spent several incredible years in Australia
before coming back to the UK.
Progressing through foundation years, I realised I wanted more time
to decide on a speciality, improve my CV, and go travelling. So F3 felt like
the right choice to make. I had an incredible year, but due to the conse-
quences of COVID-19, I went on to take an F4 year.
I was keen to gain more teaching experience during my F3 and was
lucky enough to secure a part-time job as a teaching fellow and anatomy
demonstrator at Barts and the London School of Medicine. This was a
fantastic experience as I was able to develop as a teacher, gain a lot more
confidence in anatomy, and get involved in several projects with the other
fellows which fortunately led to a poster presentation and a publication.
I worked full time with several extended breaks spread throughout the
year ranging between one to two weeks to three months. I rarely worked
weekends and chose not to do any night shifts. I achieved a good work-life
balance and found the freedom to choose when to work extremely liberat-
ing as I had more time for things like exercise, seeing friends and family,
reading, and painting.
I was also able to do some humanitarian work during the F3 year with
Medical Volunteers International (MVI), which runs clinics in the Moria
Chapter fourteen: To F3 or Not to F3 163

Refugee Camp in Lesbos, Greece, the biggest refugee camp in Europe.

I flew out just before Christmas in the middle of lockdown and had an
extremely humbling and fascinating experience working with refugees
there. I am so glad that I was able to go. I am looking forward to the pros-
pect of going back as a volunteer with more surgical experience.
As a graduate entry student who had been studying for a long time,
I had accrued a lot of student debt with little savings despite working
part-time through both degrees. I saw F3 as an opportunity to do locum
work and take control of my finances. With the locum work, I took in the
F3 year I was able to pay off my overdraft and save for my wedding. I was
also able to go on wonderful holidays, replace my 12-year-old laptop, and
enjoy living in London!
In my F4 year, I worked in the breast and endocrine unit as a locum
senior house officer. The flexibility that my breast surgery job offered me
meant that I was able to go on two incredible trips, the first being a trip to
the Caribbean and the USA and the second a three-month backpacking
trip with my husband around Central America. Highlights of my trav-
els include learning Spanish, staying with a local host family in a village
on the shore of Lake Atitlan in Guatemala, volunteering in a biological
research station only accessible by boat in the Tortuguero National Park in
Costa Rica, spending every day outside in nature, hiking mountains and
volcanoes, scuba diving, salsa dancing, seeing amazing wildlife, meeting
inspiring people, reading books, and of course, getting to travel and share
countless special times with my husband. I found out that I had got a CST
training number whilst in a hostel in Guatemala, which was a very memo-
rable day filled with the realisation that my life was all about to change
once back in the UK.
Although travelling is arguably not directly career-enhancing, the
things that I learned and the experiences that I had were certainly life-
enhancing for me. In a way, they made me even more motivated to throw
myself fully into CST. Many of my consultants were incredibly supportive
of me going away, and some even mentioned regretting not having been
able to do these things in their younger lives. So if you enjoy travelling
and you are on the fence about taking an F3, then my advice is to take this
rare opportunity to get away, completely disconnect from normal life, and
have some real adventures before getting stuck into training! The world
is your oyster!

Case Study: Gargi Pandey

I completed my foundation year 2 in 2020 when my exposure to different
specialities was limited due to the COVID-19 pandemic. I enjoyed my sur-
gical rotation during the foundation programme but did not see myself
as a general surgeon. After discussions with friends and colleagues,
164 Smashing the Core Surgical Training Interview

I wanted to give ENT a try. ENT is a surgical speciality that also involves
medical management, treats all ages, and has a variety of subspecialities.
I managed to organise a taster week during my FY2 year before the
pandemic. During this time, I met a female ENT surgeon that inspired
me. Everyone I met was so encouraging, and nobody had the stereotypical
superior surgical personality. It felt like home. I applied to Core Surgical
Training that year on the advice of one of the registrars and was successful
in gaining a number in an ENT-themed programme, but I was still keen
on taking a year out for three reasons. Firstly, I was not sure if ENT was
surgical speciality for me, and I wanted to get more exposure. Secondly,
I wanted to do some travelling. Finally, I wanted to do some locum shifts
and save for a flat deposit. I was fed up with spending money on rent in
London.
Rejecting a training number is a difficult decision. Most of my seniors
advised me to take the job as I may not be able to get the number again the
following year. However, because of COVID-19, I was also unable to get
the surgical experience I needed to decide if ENT was for me. Also, the job
I was offered was not my top choice; therefore, I felt I had nothing to lose.
I rejected my offer and instead began my search for the perfect FY3
job. As I did not accept the offer before rejecting it, future applications
were not affected. However, if you reject it after accepting the offer, you do
have to declare it on your application the following year.
I would advise those wishing to take an F3 year to apply for CST
training during FY2 anyway as this will demonstrate any gaps you have
in your application and show you what you need to focus on in the com-
ing year to make your application stronger.
Applying during FY2 meant I had my portfolio ready and therefore
could concentrate on collecting more points with new projects rather than
chasing evidence. I also knew what to expect at the interview stage and
exactly how to prepare for the following application year.
I began my search for suitable jobs using the NHS jobs website.
I needed to plan a year that was productive but also enjoyable. I narrowed
it down to two jobs: anatomy demonstrator or ENT junior clinical fellow.
Being an anatomy demonstrator had always been on my list as I heard
about all it had to offer. Some anatomy demonstrator jobs offer mentorship
for MRCS examinations and the opportunity to study for a fully funded
PGCert in medical education. Both elements result in high scoring in the
CST self-assessment.
I received an offer for one anatomy demonstrator job and one clini-
cal fellow job. The clinical fellow job would give me exposure to ENT
and help me figure out if this was speciality for me. I felt this was impor-
tant, so I chose the ENT fellow job, and I was extremely satisfied with
my decision.
Chapter fourteen: To F3 or Not to F3 165

I did the ENT fellow job for six months. This job luckily was not very
busy (this is a rarity I must admit). During my time I studied for MRCS
Part A and was luckily given study leave for preparation and the exam
itself. I highly recommend sitting this exam prior to training, as it takes
the pressure off during CST.
My supervisor took me through the self-assessment application and
offered ideas on how to gain maximum points in the minimum amount
of time. I undertook a teaching programme on the ward. I did a quality
improvement project that I presented at a conference in the same year. The
hospital also ran a train-the-trainers course before the evidence deadline.
So my second original job option covered even more elements of the self-
assessment criteria.
I also worked with other SHOs who were also applying. We started
interview preparation together and did mock interviews for each other
and with registrars. All of this helped to maximise my success in CST
applications. I had done so many mock interviews that I was no longer
nervous about the real deal. This all led to a much higher ranking in this
application period and an ENT themed job in London. After the first six
months, I decided to locum for the remainder of the year. I signed up
for a locum agency, but instead of doing ad hoc shifts, I signed up for a
long-term locum. I found this extremely rewarding as I felt part of a team
and had regular income, but still I could request leave whenever I wanted.
This added value to my year as I was able to see my family, go to family
events and friends’ weddings, and also save money for a deposit. This
meant I started my CST job in my own flat!

References
1. Silverton R, Freeth D. The F3 phenomenon: Exploring a new norm and its
implications. 2018 [cited 2022 Oct 31]. Available from: [Link]
2. Church HR, Agius SJ. The F3 phenomenon: Early-career training breaks in
medical training. A scoping review. Med Educ 2021;55(9):1033–46. Available
from: [Link]
chapter fifteen

Medical Students – Planning

a Career in Surgery
Rose Kurian Thomas

Introduction
Surgical training is a notably competitive and challenging medical dis-
cipline to gain entry into.1 Therefore, it is crucial to be meticulous and
well-prepared when you apply. Typically, having graduated from medical
school, you have two to three years of experience working as a foundation
doctor before making competitive applications for surgical training posts.
The key to a successful application is a well-developed surgical portfolio.
Whilst it is feasible to achieve the necessary requirements for an eminent
application during the two/three years as a junior doctor, the medical
school offers the luxury of five or six years of time to prepare for this.
Medical students have substantially more free time and flexibility (with-
out the stressors of working life) to plan and seek out early opportunities
to fulfil the requirements of a strong surgical candidate.
This chapter will outline ways you can maximise your opportunities
as a medical student to widen your horizons. It will show you how to
strengthen your application with adequate surgical experience and sim-
plify the surgical application process – if you decided to go down this
route. Even if you are undetermined about surgery, this chapter will facili-
tate prospects to explore your surgical interests during medical school.

Joining Surgical Societies

Surgical societies are student-led organisations within medical schools
to widen medical students’ awareness and aspirations in surgery.
These societies coordinate a range of opportunities, including surgical
skills workshops, career talks, surgical work experience arrangements,
mentorship schemes, and conferences. Career guiding opportunities
and expedited readiness for a career in surgery are two of the most
noted benefits of surgical society membership for medical students.2
Furthermore, medical students predominantly rely on surgical career

DOI: 10.1201/9781003350422-16 167

168 Smashing the Core Surgical Training Interview

guidance from their mentors.3 Comprehensive involvement in your

medical school’s surgical society does the groundwork for you to net-
work with established surgeons, identify your mentors, and shape your
career decisions.
Most medical schools in the UK should have an established surgical
society. If, however, this is not the case for your medical school, then this
is a key opportunity for you to demonstrate your dedication to the spe-
ciality. Likewise, holding positions of responsibility within the surgical
society, implementing positive changes, setting up society activities, or
creating subspecialised groups can all show commitment to the field of
surgery. Such positions are also fundamental to hone your interpersonal
skills, such as leadership, communication, and teamwork.

Conferences
Surgical organisations annually organise conferences where like-minded
individuals and experts congregate to share knowledge, interests, and up-
to-date advances in surgery. These can be regional, national, or interna-
tional conferences. Attending surgical conferences is not mandatory, but
there are numerous substantial benefits for medical students which can-
not be substituted in lecture theatres or hospital settings.4
Conferences offer the valuable opportunity to submit abstracts to
present surgically relevant projects you have undertaken. This can be
quality improvement projects, research findings, or audits. Successful
abstract submission is an outlet for a poster or an oral presentation about
your project, and some conferences offer prizes for scoring highly in your
abstract, poster, or oral presentations. These achievements hold substan-
tial weight in future applications for surgical training.
A conference offers a common language for medical students to con-
nect with other participants and experts attending the conference. Ask all
the questions you have with no hesitation; the prefix ‘I am a medical stu-
dent’ also offers a free ticket for your curiosity, no matter how advanced
or elementary the question is. Your eagerness is highly acknowledged,
and most surgeons are ardent supporters of conveying their vast knowl-
edge to interested students. Such interactions are great for developing
connections with adept surgeons, and these contacts can be maintained
through a simple email to express your appreciation for meeting them.
This is also a way of signposting further correspondences regarding ques-
tions, advice, and opportunities in surgery.
Your first national or international conference can be nerve-­
wracking, and amidst formal networking with specialists, you may feel
out of depth. One of the best ways to ease into attending conferences
Chapter fifteen: Medical Students – Planning a Career in Surgery 169

is to familiarise yourself with student-led conferences at your medi-

cal school and other medical schools. These conferences are designed
exclusively for medical students on topical matters pertinent to stu-
dents. They can provide a better understanding of conferences and
improve your confidence in both presenting your work and networking
with renowned surgeons.

Courses
Whilst the medical school curriculum is great for theoretical knowledge,
the opportunities for hands-on practice of surgical skills can often be
limited and varies based on medical school.5 Courses on practising sur-
gical skills, using laparoscopic equipment, and surgical simulation ses-
sions are very useful additions to the undergraduate curriculum. They
improve confidence in basic skills learnt at medical school, allow you
to upskill in advanced surgical skills, and explore interests beyond the
curriculum.6, 7 The best part is most conference workshops and surgi-
cal courses offer these remarkable opportunities at heavily discounted
prices for students!
The student affiliate network at the Royal College of Surgeons of
Edinburgh is aimed at augmenting medical students’ practical experi-
ences of surgery. The Royal College of Surgeons of England also offers
affiliate membership. Annual membership for both is around £5–15 for
medical students and entitles access to an abundant source of opportu-
nities, including subsidised surgical courses and educational webinars.
These opportunities refine your skillsets, consolidate your portfolio, and
give you valuable continuing professional development points early on
in your career.
In the following table are some of the courses offered by the affiliate
network and other providers. It also includes their estimated costs and
length of the course.

Surgical Course Provider Cost Length

Foundations of Clinical Royal College of £120–135 2 days
Surgery8 Surgeons of Edinburgh
Future Surgeons: Key Royal College of £110 1 day
Skills8 Surgeons of Edinburgh
Plastering Techniques for Royal College of £124–138 1 day
Fracture Treatment8 Surgeons of Edinburgh
(continued)
170 Smashing the Core Surgical Training Interview

(Continued)
Surgical Course Provider Cost Length
RCSEd Cadaveric Royal College of £45–75 2 days
Intermediate Open Surgeons of Edinburgh
Abdominal Surgery
Course8
Foundations of Royal College of £120–135 2 days
Gastrointestinal Surgery8 Surgeons of Edinburgh
Surgical Anatomy of the Royal College of £85 each Each 1 day
Head and Neck: A Study Surgeons of Edinburgh
Day8
Surgical Anatomy of the
Trunk: A Study Day8
Surgical Anatomy of the
Limbs: A Study Day8
Surgical Skills for Students Royal College of £99 1 day
and Health Professionals9 Surgeons of England

Systematic Training in Royal College of £139 1 day

Acute Illness Recognition Surgeons of England
and Treatment (START)10

Foundation skills in Royal College of £85–120 1 day

Surgery11 Physicians and
Surgeons of Glasgow
Basic Orthopaedic Royal College of £149–189 1 day
Procedural Skills12 Physicians and
Surgeons of Glasgow

Competitions and Grants

There are plenty of competitions and grants available to medical students
for various subspecialities of surgery. Many medical students are not
aware of these opportunities. Making time for these accomplishments as
an overstretched junior doctor is challenging and demanding; however,
as a medical student, you have the knowledge base and timeframe for
partaking in these opportunities. In addition, surgically relevant prizes
and grants from competitions hold significant value in terms of portfolio
points in your future surgical applications. Therefore, save your future
doctor self from added work and pressure by exploring these opportuni-
ties early during medical school!
Chapter fifteen: Medical Students – Planning a Career in Surgery 171

Here is a list of some relevant surgical organisations and the annual

competitions and grants they offer. This is not an exhaustive list:

Organisation Description
Royal Society of Medicine13 Offers a plethora of medical student
prizes in various specialities including
surgical specialities. Prize competitions
include the following:
1. Essay prizes
2. Elective awards
3. Poster and presentation prizes
4. Bursaries and travelling fellowships
British Society for Medical student essay prizes
Dermatological Surgery14
British Orthopaedic Association15
British Association of Urological
Surgeons16
Student and Foundation Doctors • SFO Undergraduate Essay Prize
in Otolaryngology (SFO-UK)17 • SFO UK Innovative Education Prize
• SFO UK Elective Prize
Royal College of Surgeons of RCSEd and Vascutek cardiothoracic
Edinburgh18 surgery placements: Opportunity to
undertake placements in cardiothoracic
surgery at renowned cardiothoracic
centres in the UK
Royal College of Surgeons of Professor Harold Ellis Medical Student
England19 Prize for Surgery – Abstract Submission
Royal College of Surgeons of Lister Surgical Skills National
Edinburgh20 Competition
Royal College of Surgeons of National Surgical Skills Competition
Ireland21
Royal College of Surgeons of RCSEd and Medtronic Surgical Skills
Edinburgh22 Competition
Royal College of Surgeons of Grants for medical students who are
England23 interested doing an intercalated Bachelor
of Science degree related to surgery
Royal College of Surgeons of Barker Dissection Award – for the student
Ireland24 achieving highest grade for dissection
and written report
Royal College of Surgeons of Sayed-Hanson Memorial Award – for the
Ireland24 student achieving highest grade for
head, neck, and neuroanatomy
172 Smashing the Core Surgical Training Interview

Electives
An elective is a self-organised placement that is usually completed as part
of the final year of medical school. This can be done within the UK or
internationally. It is one of the most enthralling and memorable chapters
of medical school and can be done alone or with friends.
Undertaking a surgically relevant elective is a comprehensive way
of expanding your curiosity in surgery. This is also a recognised accom-
plishment in your future surgical training applications as it demonstrates
dedication to surgery. Surgical electives can entail a variety of experi-
ences, including and not limited to clinical experience, research, surgical
medical technology, and surgical medical education.
So far in this chapter, we have discussed the significance of hav-
ing a surgical mentor and expanding your surgical network of contacts.
Applying for electives is a fine example of how these contacts can be
invaluable to organising a fruitful and rewarding experience. Be prepared
to send out lots of emails!
When pondering whether to stay in the UK or go internationally, let
us have a look at the pros and cons of each:
The main advantage of an international elective is the opportunity
to build a global network of professional contacts who can inspire and
improve your practical skills and knowledge in surgical practices not
commonly seen in the UK. The ability to travel and immerse in all that
a foreign country has to offer provides the chance to develop cultural
­competence – an important ability to foster in the NHS, given the huge
cultural diversity of patients we have.
However, international electives are significantly more expensive and
require meticulous planning with more paperwork completion. This is
primarily because there is a more scrupulous approval process due to the
increased health and safety risks associated with an international elective –
although the type of risk is dependent on which country you go to.
The disadvantages of an international elective are the advantages of a
UK elective – they are comparatively easier to coordinate with fewer paper-
work and less associated costs. UK electives are great ways of expanding
your surgical network within the UK as the UK is the centre of internation-
ally renowned surgical institutions and hospitals with highly acknowl-
edged surgeons. It is important to note that previous surgical experiences
at UK medical schools could already provide you with what a clinical sur-
gical elective in the UK has to offer. Therefore, surgical research oppor-
tunities or clinical placements in major UK specialist surgical centres are
good alternatives to broaden your horizons in surgery and to see and do
what you may not have already seen/done at medical school.
Now if you decide on an international elective, a dichotomy between
an elective in a developing country and a developed country exists. An
elective in a developing country can provide better exposure to global
Chapter fifteen: Medical Students – Planning a Career in Surgery 173

health issues and awareness of prevailing health inequalities around the

world. This also facilitates more opportunities to be involved in sustainable
health improvement projects for local communities. In addition, the vast
variety of conditions in developing nations and the differences in surgical
practices compared to the developed world can widen your awareness of
conditions and surgical techniques that are not common in the UK. You
may also have more hands-on experience and opportunities to practice
procedures. However, this goes hand in hand with feeling thrown into
the deep end in quite an unfamiliar healthcare system because you could
be assumed to take on roles beyond your limitations or unsupervised due
to limited resources and/or understaffed circumstances.25
Whilst there is a curtailed variety of conditions to experience in
developed countries than developing countries, you are more likely to
feel comfortable doing a surgical elective in a developed country as it is
likely to have a similar supported and supervised healthcare environ-
ment to the UK. Developed countries also offer the opportunity to work in
highly reputable institutions using state-of-the-art technology which can
improve your awareness of advanced surgical practices and novel tech-
nology. There is also more scope for being involved in research projects
funded by these institutions.
An extensive range of organisations offers student grants for surgi-
cally relevant electives. It is useful to be aware of them so you can apply
before the deadlines pass. Here are some to consider:

Organisation Description
The Beit Trust26 Bursaries for electives in Zimbabwe, Malawi,
and Zambia – £700–1,000
The British Association of Plastic Support for partaking in research, travel, and
Reconstructive and Aesthetic elective related to plastic surgery – £500
Surgeons26
Edward Boyle Elective Bursary26 Support for elective comprising in low-/
middle-income countries within the
Commonwealth – £500
Medical Women’s Federation26 Grants to support female students in their
electives – £100–500
Royal College of Surgeons of • Russel Trust Bursary for surgical elective
Edinburgh27 abroad
• Bursaries for undergraduate elective or
vacation studies
• Cardiothoracic surgery elective travel
awards
• RCSEd/Blinks trust elective travel awards
– £250
• Bursaries for elective placements in Africa

(continued)
174 Smashing the Core Surgical Training Interview

(Continued)
Organisation Description
Royal College of Surgeons of • RCS England Elective Prize in Surgery for
England28 surgical elective in developing country
– £500
• PKK and SK elective fellowships to
undertake an elective in surgery in India
– £1,000
Royal College of Physicians and Medical elective scholarship – maximum of
Surgeons of Glasgow29 £1,000
The Simmonds Bursary26 Financial support for undertaking elective in
UK or internationally with research – £250

Case Study: Rose Kurian Thomas

My initial exposure to surgery began in my first year of medical school.
I joined as a subcommittee member of my medical school’s surgical soci-
ety. There are numerous advantages to this as it requires no prior experi-
ence, you can gain full insight into society, and it paves the way to holding
more senior positions. As a committee member, I had exclusive free access
to all events hosted by the society including surgical webinars, skills
development workshops, career talks, and surgical symposiums.
COVID-19 disrupted my surgical placement, so I did not actually
get into an operating theatre until my fifth year of medical school. But
early involvement in the aforementioned external opportunities gave me
insight into different surgical specialities and built my foundation in per-
tinent surgical practices, such as suturing, abscess drainage, and surgical
drain insertions.
Finally, when I did get into operating theatres, I was truly mind-
blown by the surgeons and surgeries I observed, including on-pump
coronary artery bypass and renal transplant surgeries. I feel very lucky
to have worked with highly established surgeons who were keen to recip-
rocate my interest and develop my practical skills. I was taught different
surgical knot-tying techniques, allowed to close up on patients, trained to
handle the laparoscopic equipment, and given countless opportunities to
scrub and assist in surgeries. I enjoyed this placement so much that this
was probably the only placement at medical school I stayed longer than
12 hours in one day! A poignant memory I have is of a procedure that had
a major artery suddenly bleed – like a jet spray. The surgeons and other
team members were poised, fast-acting in all their decisions, and swift to
retrieve the patient to haemodynamic stability. Observing this in action
was a terrifying but enlightening experience – one of my most inspiring
observations.
Chapter fifteen: Medical Students – Planning a Career in Surgery 175

I have been very fortunate to cultivate good relationships with sur-

geons I have met in my journey of medicine thus far. Two of them have
guided me from the very beginning when I was an inexperienced school
student interested in medicine to now as a final year medical student.
I consider them my medical parents, truly insightful senior surgeons
whom I go to for my career and life queries. One such example was dis-
cussing which degree to intercalate in for my BSc. I ended up doing a BSc
in medical sciences with management because of the following reasons:

1. The modules interested me.

2. It is unrelated to clinical medicine. Imperial was one of the only two
universities at the time offering intercalation in management.
3. This will give me an extra range of unique skills and knowledge that
can set me apart.

Moreover, they have also shown me the realities of life as a surgeon and
kept me grounded, focused, and motivated in my career. I am grateful for
their outpouring of wisdom and the opportunities they have offered me.
Writing this chapter for this book is an example of one of the opportuni-
ties that they have opened up for me as mentors.
During one of my placements, I came across my next mentor. Her
practice of medicine and interpersonal qualities inspired me to what sort
of doctor I wanted to become. I took on a project with her, which we pre-
sented at the Royal College of Obstetricians and Gynaecologists World
Congress. This was a very rewarding opportunity for me because our
abstract was one of the highest-scoring abstracts and was published in the
British Journal of Obstetrics and Gynaecology.
My other mentor is more junior in his surgical training. We have more
of an easygoing and open relationship, which created a safe space to make
many mistakes with no expectations or judgement! I got plenty of learning
done and received valuable individualised feedback! He gave me insight
into the significance of having signed written evidence of all the activities
I partake in, such as courses, projects, teaching experiences, and involve-
ment in societies. I also realised having a logbook and creating a habit of
recording procedures/surgeries is very important for applications because
the number of personally involved cases is vital for your portfolio.
Now that I come to the end of my medical school life, I am really
excited about my elective (and of course to never sit medical school exams
again). I was always certain I wanted an international elective because
I was fortunate to have adequate exposure already in the UK, and since
I am a UK citizen, the NHS bursary covers part of my accommodation
costs for the elective country. The real question was, should I go to a devel-
oping or developed country? I already had the experience of undertak-
ing a medical project in Uganda and therefore have obtained the desired
176 Smashing the Core Surgical Training Interview

exposure of medical practice in the developing world. So to broaden

my horizons, I decided to go to a developed country, such as Canada or
Australia, because I am interested in working in these countries in the
future. After sending many emails, I finally got accepted for an elective
in renal transplant surgery at Royal Adelaide Hospital, Australia, my last
official placement as a medical student.
So that is me ending one big chapter (both figuratively and literally) –
looking forward to seeing where life takes me!

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25. Tahiri, Y. (2020) “Impressions on an Elective Abroad,” McGill Journal of

Medicine, 11(1). Available at: [Link]
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students/elective-bursaries (Accessed: November 29, 2022).
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chapter sixteen

Women in Surgery
Sharlini Sathananthan and Anokha Oomman Joseph

Introduction
Over the years, even though the number of female medical students has
increased, the number of women in surgery is still significantly low. As
the global agenda towards gender equality progresses, there is an increas-
ing need for us to acknowledge the matter of gender inequality in the
surgical workplace. Surgery continues to be male-dominated, with con-
sultant female surgeons representing only 13.2% of the consultant body
in England in 2020 (1).
As surgical registrars who have trained and worked in this field for
many years, although the joy from this work has been unparalleled, the
unspoken reality of gender bias within the speciality – both conscious
and unconscious – has been a sobering experience for us.
Surgery is notorious for traditionally being a male-dominated profes-
sion, and as a result, the speciality leads itself to be deeply entrenched
structural barriers that can inadvertently impede the career advancement
of its female trainees. Although the landscape is rapidly evolving, and we
must not take away from the excellent progress that has been made, there
is still a lot of work to be done.
Barriers and challenges to a career in surgery for women include gen-
der bias, perceptions of a surgeon, work-life balance, motherhood, and
rigid career structures (2). There is a belief held by many that a career
in surgery is not compatible with having a healthy work-life balance, a
happy marriage or raising children (3).
In this chapter, we will shed light on some of the gender barriers that
threaten the progression of so many outstanding women in surgery and
impart some advice on how to tackle these issues.

Gender Bias
Many female surgeons experience gender bias in the workplace that can
have a negative impact on their performance during training (4) and their
overall professional trajectory (5). Up to 66.7% of women in surgery still

DOI: 10.1201/9781003350422-17 179

180 Smashing the Core Surgical Training Interview

experience various forms of discrimination within the workplace and

concerningly high dropout rates are reported among female surgeons (6).
Some of these barriers manifest more overtly; others tend to be more
subtle microaggressions that gradually erode the confidence that female
surgeons have in themselves while at work. Women often cite these bar-
riers as preventing them from evolving into content, happy, independent
surgeons with a feeling of control over their careers and simultaneously
whole and fulfilling personal lives.
One cannot deny the valuable attributes offered by women in the
surgical workplace. Studies report more compassionate and effective
leadership, better physician-patient communication, provision of more
patient-centric care, and even fewer complication rates in surgeries per-
formed by female surgeons when compared to their counterparts (7).
However, for decades now, women have been adapting their lives to
male-centric surgical training programmes that were developed with no
­consideration for the complex needs of women within the speciality.
If you speak to an aspiring female surgeon, she will often tell you that
even as a medical student, she was actively discouraged from pursuing a
surgical career path by well-intentioned senior doctors and mentors, usu-
ally male. Reasons cited would classically include the perceived difficulty
of the ‘gentle’ feminine personality to navigate an uncompromisingly
intense, male-dominated workplace and biased accounts of how a surgi-
cal career is not compatible with healthy family life for women (8). These
presumptions about the unsuitability of a surgical career for women are
often ill-informed and have deterred many young women from seriously
considering the speciality when there is a possibility that surgery might
in fact be a very fulfilling career choice for them.
The perception of female surgeons is an additional problem. Women
are often perceived as being weaker, less competent, and less ­trustworthy
than their counterparts. Men are seen as being more suited to the demand-
ing surgical workload. Women in surgery report being judged far more
harshly than their male colleagues, leaving them feeling the pressure to
reach a much higher standard to prove their worth. Studies show that
women who have more familial duties are often treated as being less
committed to work by seniors. Perception even in the most literal sense
has been highlighted by female surgeons and trainees who felt they
were judged by their appearance rather than their capabilities and quali-
ties, resulting in pressure to be extra conscious about their dressing and
upkeep (9).

The Stereotypical Surgeon

Subtler grievances include the philosophy perpetuated by many within
the speciality that you must have an ‘alpha’ personality to be a surgeon.
Chapter sixteen: Women in Surgery 181

Figure 16.1 Gender barriers faced by women.

Although this is in part due to the high pressures of the strained health-
care services that we work in, the idea that women must be exceptionally
resilient and tough to work in the profession is an exclusive and dam-
aging one. Sadly, it is often perpetuated by female surgeons themselves,
whose own tough workplace personalities have evolved as a by-product of
the culture they were trained in. By implicitly making this a prerequisite
for being considered a good female surgeon, we run the risk of contrib-
uting to a further lack of compassion and empathy within the speciality
which it so desperately needs. All that should be required to be a good
surgical trainee is a conscientious, safe, and dedicated approach to your
work, paired with a progression in competence and the ability to take con-
structive feedback from your seniors. The idea that certain personalities,
genders, and races are more conducive to a career in surgery is inaccurate,
and we must be careful that these ideas are not weaponised as forerun-
ners for people’s personal prejudices (10).

Work-Life Balance
Surgical training is long and often happens at a time when many women
would like to settle down in their personal lives, get married, and have
children. Medical students have been deterred from choosing surgery as a
speciality because they feel they will not have the balance in life that they
want (11). It is good to see the culture around work-life balance evolving
with both male and female doctors wanting more time for social activities
182 Smashing the Core Surgical Training Interview

and flexible working hours (12). However, this balance can be tricky to
strike in a career like surgery where it is not always possible to work the
hours you are contracted.
With the pressure of wanting to become an independent surgeon, you
often have to stay until the work is done. This may be because your oper-
ating list or clinic is over-running, you have a sick patient on the ward, or
you want to stay for the case you have been prepping all day. The unpre-
dictability of the job means it is often difficult to plan things ahead. The
extra publications, projects, and degrees that most surgeons take on dur-
ing training also eat into valuable family time.
Some trainees try and achieve work-life balance by going less than
full-time (LTFT). You can consider LTFT in a temporary or long-term set-
ting if you are in a substantive training post. If this is something you
are considering, then you need to contact your assigned educational
supervisor (AES) and discuss with them your reasons for wanting to go
LTFT. Following this, you need to contact the LTFT administrator at your
deanery and complete the required paperwork. Per the General Medical
Council (GMC), LTFT training should not be less than 50% of full-time
training. In exceptional circumstances, postgraduate deans have the flex-
ibility to reduce this to 20% of full-time training for a maximum of 12
months. It is important that you plan things in advance so that adequate
cover can be sorted locally (13). Ultimately, the decision you make should
be based on what works for you and your situation.

Planning Motherhood and Fertility

Another major barrier that women face when considering a career in sur-
gery is the idea that choosing a career in surgery means that they are
rejecting a family life and their chance to have children.
Certainly, some of these concerns have been raised in the literature.
Female surgeons are more likely to delay having children compared to
male surgeons (14). Some reasons for the delay in having children include
long and busy work schedules, not wanting to prolong training, childcare
issues, and worries about ‘burdening’ colleagues (15). Many female sur-
geons often feel they must pick their career over starting a family.
The average age at first pregnancy is significantly higher in female
surgeons because of worries about finishing training and wanting to
avoid the negative attitudes of peers and superiors (5). Advanced mater-
nal age then in itself becomes a risk factor for pregnancy-related complica-
tions as well as negative fetal and neonatal outcomes.
When female surgeons are finally ready to start a family after they
have completed training, a significant number have issues with fertil-
ity. A study done in America of female surgeons showed that 32% of the
Chapter sixteen: Women in Surgery 183

surgeons surveyed reported fertility-related issues, and 84% had under-

gone tests for infertility. Out of all the babies born to the surgeons in the
study, 13% were conceived using assisted reproductive techniques (16).
The rate of miscarriage is higher in female surgeons compared to
female non-surgeons (17). The rate of miscarriage in female surgeons in
literature is reported to be between 14.9% (17) and 42% (14). It has also
been reported that female surgeons were more likely to experience
pregnancy-related complications compared to other non-surgical col-
­
leagues. This may be due to direct reasons, such as long hours of work-
ing, prolonged standing, and exposure to surgical smoke, radiation, and
anaesthetic gases (5).
Many female surgeons feel that the nature of their work has had a
harmful impact on their pregnancy. A Canadian study reported that 31%
of the female surgeons surveyed felt their work had adversely affected
their pregnancy. This included outcomes such as miscarriage, pre-term
labour, hypertension, and pre-eclampsia.
There is no correct time to start a family. Trainees have children in
all stages of training, and it really depends on your personal situation.
A study in America suggested that female surgeons in training should
have fertility-focused educational interventions. This will provide female
surgeons with the information required to decide if they want to pur-
sue egg preservation and think ahead in terms of family planning, thus
allowing them not to miss out on having children later in life (18).
If you are pregnant and in training, continuing surgical training whilst
being pregnant can be challenging because of the physical demands of the
job whilst experiencing pregnancy-associated symptoms. You can go on
maternity leave from 27 weeks and return to work a year later. But most
trainees like to take maternity leave close to the delivery date so that the
maternity leave clock starts at that point, and they get to spend more time
with the baby. It is important that you involve your GP and local occupa-
tional health department if you are struggling during the pregnancy, as
they can suggest amendments to your work schedule which your depart-
ment has to honour.

Leadership and Mentorship

There is a dearth of female surgeons in positions of leadership and senior
academic rankings, which results in fewer mentors and role models for
women. The Kennedy report has highlighted some of these issues and
made recommendations to address these (19).
The purpose of a mentor is to help you plan and navigate your career.
Their experience in the field means they are well-placed to guide you in
developing your CV, improve your networking abilities, and guide you
184 Smashing the Core Surgical Training Interview

to appropriate courses that will help you build the skills you need for
career advancement (20). You may come across a senior at a workplace
you trust and respect and build a relationship with them in which they
organically become your mentor. The other way to find a mentor that is
separate from your clinical environment is through organisations such
as the Association of Surgeons in Training (ASiT) that have a mentor-
ship programme (21) and Women in Surgery (WiS) (1). Mentorship allows
trainees to develop leadership and interpersonal skills and achieve their
­maximum potential.

Tackling the Culture in Surgery

Female surgeons also report dysregulation from the spectrum of misog-
ynistic attitudes and behaviours attributable to the ‘boys club culture’
within surgery (22). At the far end of this spectrum are the harrowing
accounts of sexual abuse and harassment that so many have bravely come
forward publicly within the last couple of years (23). Although it has been
described as shocking, the reality is many have been aware of this wide-
spread problem for years without the tools to address or improve it. We
must appreciate the gravity of this problem, which presents the greatest
of threats not just to the basic human right of an individual to feel safe at
work but also to the performance and mental well-being of surgeons who
are subject to these kinds of abuse.
A problem that goes hand in hand with this is the difficulty in escalat-
ing concerns about colleagues and seniors. Due to notoriously nepotistic
surgical work environments, there is insufficient support for women who
do decide to take workplace concerns further. There are documented limi-
tations in the disciplinary action that can be taken against senior surgeons
with only very few cases of reported incidents of sexual abuse or harass-
ment within the speciality resulting in a disciplinary trial. Department-
level attempts to conceal and cover up allegations rather than addressing
problems in a transparent way are widely reported. Furthermore, there is
almost inevitable damage to the career of the perceived ‘whistle-blower’
who is seen as disrupting the ‘status quo’ in the process of escalating a
concern against a usually very well-established and well-connected
senior surgeon (23).
Many working within the speciality will tell you there is an implicit
expectation to keep your head down, get on with the work, and have the
self-awareness to know that escalating inappropriate behaviour has a high
chance of damaging your career prospects. Many who have left the career
will tell you the way a complaint was handled was the final straw. If we
are to make the speciality somewhere that women want to work, this must
change.
Chapter sixteen: Women in Surgery 185

What Needs to Change?

The challenges faced by women in surgery, especially the conflict between
familial responsibilities and surgical duties, often lead to women feeling
like they are always sacrificing one for another in a way that is detrimental
to their self-esteem. The guilt from this can deter female surgeons from
continuing in their chosen career path. Studies have shown that this is the
biggest reason for the low uptake of a career in surgery and for drop-out
from a surgical career in women (6, 8, 22). It is time to realise that we are
asking women to pay too great a price to establish successful careers in
this discipline, and more must be done to make surgery a more holistically
supportive and attractive speciality to its female members.
So how do we help address the problem? And how can you be success-
ful, instil confidence in yourself, and drive change at the very start of your
journey as a young aspiring surgeon?

Recommendations
Firstly, although it is important to be aware of the guidance and opinions
of those in positions of seniority, you must develop the ability to criti-
cally appraise and challenge this information. One of the most impor-
tant lessons to be learned as a surgical trainee is the benefit of accepting
feedback and counsel from those around you. This has undoubtedly
played a significant role in our growth. It is often much more difficult
for us to see where we need to improve like our peers and seniors can.
However, you must develop the tools to dissect and evaluate what is
appropriate and constructive and what is irrelevant. Tact and gracious-
ness go a long way in managing conversations with those who are not
imparting knowledge that is useful to you, especially when that advice
is well-intentioned.
Secondly, you should proactively engage with positive, inspirational
role models who do exist within the speciality. Women in Surgery (WiS) is
a national initiative that provides support to women pursuing a surgical
career. It aims to empower female surgeons through mentorship, network-
ing, and education (1). It gives visibility to inspirational female surgeons
who are navigating successful professional and personal lives and sheds
light on their stories. Furthermore, the organisation is constantly challeng-
ing the barriers that threaten the progress of women within surgery and
never fails to celebrate examples of excellent trainers, trainees, and men-
tors within the profession. Interacting with a role model to whom you can
relate is all it takes to give you the drive to succeed.
Seeking out a variety of relatable, motivating, and supportive men-
tors is perhaps one of the most helpful things you can do to help yourself
through difficult periods in your journey as a surgeon. There are also a
186 Smashing the Core Surgical Training Interview

variety of other support groups available. We would like to pay special

homage to two Facebook groups for doctors; the first is called ‘Tea &
Empathy’, which is an informal, peer-to-peer support network that pro-
vides a platform for anonymous advice on a whole range of issues that
affect healthcare professionals. The second is called ‘Physician mum’s
group UK’, which is a network of doctor mums providing peer-to-peer
support, advice, and guidance on a whole breadth of work and life related
issues. Those in training can also seek support and guidance from their
deanery’s professional support unit.
Thirdly, you should take the initiative to build networks that can
drive change. Through collaboration, you can create supportive spaces
to enable and facilitate each other to thrive. If you see a gap in your work
environment for something that may help you or your peers, create a
society, or initiative that aims to address it. This not only allows you to
solve a problem but also creates a network with like-minded individuals,
which in turn will create momentum and increase personal motivation.
Inspired by the Women in Surgery Conference, Miss Sathanathan, one
of the authors of this chapter, went on to create her own surgical society,
Essex Surgical Girls, as a support system for herself and her peers who
were applying to Core Surgical Training. Although it started small, today
this has evolved into a much bigger organisation that supports a whole
community of aspiring female core trainees. You will find that influenc-
ing others positively as you grow will not only compound your sense
of confidence and success but also help boost your portfolio and profes-
sional growth.
In terms of addressing some of the stark inequalities we see between
men and women within surgery, there is a dire need to include men in
the conversation. In a study of over 300 surgeons across Europe, 72% of
women report having suffered or witnessed gender abuse. However, wor-
ryingly, only 17% of male surgeons said they had witnessed gender dis-
crimination at work (24). From these statistics, education about what is
appropriate and inappropriate behaviour is necessary. There is potential
to include this in our curriculums at both a university level and post-
graduate level to effect the drastic change that is needed. Furthermore, we
need to integrate these ideas into the mainstream conversations that are
happening in surgical departments, such as in monthly audit meetings.
It is paramount that sexual discrimination is recognised as an important
ethical issue, which doctors have a moral obligation to recognise and
object to (25). Male or female, it is important to engage, learn, and be a
part of the conversation.
One of the biggest problems we face currently within the speciality is
the need for safe, anonymous escalation pathways for surgeons who are
experiencing bullying, undermining, and harassment within the work-
place. If the goal is justice, the method must be a transparent, accountable,
Chapter sixteen: Women in Surgery 187

and working justice system to address the problems highlighted. There

are organisations working on this, including the recently commissioned
Working Party on Sexual Misconduct in Surgery and the initiative called
Surviving in Scrubs, which aims to tackle misogyny within healthcare.
We must continue to initiate, support, and promote this work and channel
our own experiences to drive change.
If you have witnessed or been subject to something unacceptable that
has made you uncomfortable in the workplace, it is important you process
it. Seek counsel and advice from peers, seniors, mentors, and the groups
and organisations mentioned in this chapter, firstly to gain a wider per-
spective on the situation and secondly to enlist support if you decide to
take it further. Until our escalation pathways become more robust, it is
worth doing a little bit of research into the most strategic and appropriate
escalation pathway in your situation, and you should try to divulge the
information to somebody that is trustworthy or has the power to effect
change. Escalation options include your educational supervisor, college
tutor, guardian for safe working, departmental lead, and educational
deanery (directly or via the GMC survey).

SUMMARY OF HELPFUL STRATEGIES

• Seek counsel from seniors.
• Find at least one mentor and stay in regular communication
with this individual.
• Take leadership and networking opportunities, especially
those that will enable you to drive change.
• Understand and become familiar with escalation pathways in
your department and institution.
• Be aware of the organisations that you can reach out to for
support
• Aim to collaborate rather than compete with peers.
• When dealing with a difficult situation, take some time to
think and process and liaise with those you trust before acting.

Conclusion
It is important that as a community of surgeons and aspiring surgeons,
we seek to understand the multitude of challenges faced by women in
surgery and continue to ameliorate our workplace environment in a way
that facilitates women to thrive, flourish, and put forth their best work.
The motivation to endure, advocate, and drive change does not
always reach us when we are vehemently occupied with our own career
188 Smashing the Core Surgical Training Interview

progression, but we must remember that surgery is no ordinary career. It

is an extraordinary career for extraordinary individuals and the reward-
ing nature of the work we do knows no bounds.
We must choose to be brave, stay within this speciality, fight to navi-
gate healthy career paths for ourselves with our personal goals, and con-
tinue striving to create a better work environment for those that come
after us.

References
1. Royal College of Surgeons. Women in Surgery. [Link]/
careers-in-surgery/women-in-surgery/statistics/.
2. Trinh LN, O’Rorke E, Mulcahey MK. Factors Influencing Female Medical
Students’ Decision to Pursue Surgical Specialties: A Systematic Review. J
Surg Educ. 2021 May;78(3):836–49.
3. Park J, et al. Why Are Women Deterred from General Surgery Training? Am
J Surg. 2005;(190):141–6.
4. Barnes KL, McGuire L, Dunivan G, Sussman AL, McKee R. Gender Bias
Experiences of Female Surgical Trainees. J Surg Educ. 2019 Nov;76(6):e1–14.
5. Anderson M, Goldman RH. Occupational Reproductive Hazards for Female
Surgeons in the Operating Room: A Review. JAMA Surg. 2020;155(3):243–9.
6. Lim WH, Wong C, Jain SR, Ng CH, Tai CH, Kamala Devi M, et al. The
Unspoken Reality of Gender Bias in Surgery: A Qualitative Systematic
Review. PLoS One. 2021;16(2 February).
7. Wallis CJ, Ravi B, Coburn N, Nam RK, Detsky AS, Satkunasivam R.
Comparison of Postoperative Outcomes Among Patients Treated by Male
and Female Surgeons: A Population Based Matched Cohort Study. BMJ
(Online). 2017;359.
8. Giantini Larsen AM, Pories S, Parangi S, Robertson FC. Barriers to Pursuing
a Career in Surgery: An Institutional Survey of Harvard Medical School
Students. Ann Surg. 2021;273(6).
9. Sarsons H. Interpreting Signals in the Labor Market: Evidence from Medical
Referrals. Mimeo. 2019.
10. Whitaker M. The Surgical Personality: Does It Exist? Ann R Coll Surg Engl.
2018;100(1).
11. Ali A, et al. Factors Influencing Career Choice Among Medical Students
Interested in Surgery. Curr Surg. 2003;210–3.
12. Saalwachter AR, Freischlag JA, Sawyer RG, Sanfey HA. Part-Time Training
in General Surgery: Results of a Web-Based Survey. Arch Surg. 2006
Oct;141(10):977–82.
13. Royal College of Surgeons England. Less Than Full Time Training. www.
[Link]/professional-support-development-resources/career-support/
return-to-work/less-than-full-time-training.
14. Möller MG, Elseth A, Sumra H, Riner AN. Time Out! We Must Address
Fertility Preservation for Surgical Trainees. Am J Surg. 2022 Mar;223(3):594–5.
15. Stack SW, Jagsi R, Biermann JS, Lundberg GP, Law KL, Milne CK, et al.
Childbearing Decisions in Residency: A Multicenter Survey of Female
Residents. Acad Med. 2020 Oct 16;95(10):1550–7.
Chapter sixteen: Women in Surgery 189

16. Phillips EA, Nimeh T, Braga J, Lerner LB. Does a Surgical Career Affect a
Woman’s Childbearing and Fertility? A Report on Pregnancy and Fertility
Trends Among Female Surgeons. J Am Coll Surg. 2014 Nov;219(5):944–50.
17. Rangel EL, Castillo-Angeles M, Easter SR, Atkinson RB, Gosain A, Hu YY,
et al. Incidence of Infertility and Pregnancy Complications in US Female
Surgeons. JAMA Surg. 2021;156(10):905–15.
18. Phillips EA, Nimeh T, Braga J, Lerner LB. Does a Surgical Career Affect a
Woman’s Childbearing and Fertility? A Report on Pregnancy and Fertility
Trends Among Female Surgeons. J Am Coll Surg. 2014 Nov;219(5):944–50.
19. The Royal College of Surgeons of England. An Independent Review on
Diversity and Inclusion for the Royal College of Surgeons of England an
Exciting Call for Radical Change. 2021 Mar.
20. Jadi J, Shaughnessy E, Barry L, Reyna C, Tsai S, Downs-Canner SM, &
Myers, S (2023). Outcomes of a Pilot Virtual Mentorship Program for Medical
Students Interested in Surgery. Am J Surg. 2022 Jul;225(2):229–33. https://
doi:10.1016/[Link].2022.07.004.
21. ASiT. The ASiT Mentoring Scheme. [Link]/resources/asit-mentoring-
scheme/the-asit-mentoring-scheme/res1131.
22. Gargiulo DA, Hyman NH, Hebert JC, Kirton O, Gawande A, Tseng J, et al.
Women in Surgery: Do We Really Understand the Deterrents? Arch Surg.
2006;141.
23. Fleming S, Fisher R. Sexual Assault in Surgery: A Painful Truth. Bull R Coll
Surg Engl. 2021;103(6).
24. New Survey Shines Light on Prejudice and Inequality in Colorectal Surgery |
European Society of Coloproctology [Internet]. [cited 2022 Dec 30]. Available
from: [Link]/news/2398-new-survey-shines-light-on-prejudice-
and-inequality-in-colorectal-surgery.
25. Mello MM, Jagsi R. Standing Up Against Gender Bias and Harassment –
A Matter of Professional Ethics. N Engl J Med. 2020;382(15).
chapter seventeen

International Medical Graduates –

Planning to a Move to the UK
Muhammad Talha, Muhammad Salik,
and Anokha Oomman Joseph

British surgical training is world-renowned and produces world-class

surgeons. Pursuing a career in surgery in the United Kingdom (UK) as an
international medical graduate (IMG) is a challenge. In this chapter, we
aim to guide you on how to overcome these challenges and give you the
best chance to get into training.
The first step is committing to the process of moving to the UK to
pursue training. This will take deep reflection and consideration of all
your available options. In general, training in the UK is considered to be
rigorous and meritocratic. However, it is also one of the longest training
programmes in the world for surgery. You may have other considerations,
such as language, family ties, or finances.
Once you have decided, the next step is to get registration with the
General Medical Council (GMC), the regulator for doctors in the UK.
GMC registration is a mandatory requirement to be able to work as a doc-
tor and the route you choose depends on your circumstances and your
level of training. There are four routes for you to pursue if you want to
practice medicine in the UK.

• Professional and Linguistic Assessments Board (PLAB)

• Applying for registration using sponsorship
• Acceptable postgraduate qualifications
• Relevant European qualification

Route 1: PLAB
The Professional and Linguistic Assessments Board (PLAB) exam is the
licensing exam to get GMC registration (1). Prior to sitting the PLAB, you will
need to demonstrate your competency in the English language by sitting the
International English Language Testing System (IELTS) or the Occupational

DOI: 10.1201/9781003350422-18 191

192 Smashing the Core Surgical Training Interview

English Test (OET), both of which are accepted by the GMC (2). These exams
are valid for two years, and you will need to pass your PLAB exams in
this period. IELTS tests your overall ability to communicate in the English
language, whereas OET tests your ability to communicate in English in a
healthcare setting (2).
The PLAB comprises two parts: Part 1 is an MCQ-based theory exam
with 180 single-best-answer questions. Part 2 is a role-playing-based
clinical competency exam. You will need to pass both these exams to be
granted GMC registration. As it is an entry-level exam, it covers the whole
of medicine at the level of completion of your medical degree.
Preparation for Part 1 of the PLAB can take an average of three months
depending on your circumstance. We recommend subscribing to a ques-
tion bank and practising as many questions as possible.
PLAB 2 is an objective, structured clinical examination (OSCE). It
is conducted only in the UK at present. PLAB 2 is an OSCE-based exam
which is conducted only in the UK at present. It has a heavy focus on eth-
ics, communication skills, and professionalism. Dr Aman Arora’s PLAB
2 communications skills resources (including online course, audiobook,
and live course) are a great resource to improve your interpersonal and
consultation skills. The OSCE has 16 stations, which last eight minutes
each, where you will be asked to do a mock consultation.
This exam requires a lot of practice, and we highly recommend that
you attend a PLAB 2 preparation course run (e.g. Swammy, Samson,
Common Stations, or Aspire). It does not matter which provider you
choose as the content of these courses is similar. The key here is to get a
feel for the nature of the examination and the British way of answering
questions. Doing mock exams with the PLAB 2 exam format is impor-
tant for time management. You should do these once you feel adequately
prepared.

 nited Kingdom Medical Licensing

U
Assessment
The United Kingdom Medical Licensing Assessment (UKMLA) is the pro-
posed exam to replace PLAB exams in 2024–2025.
This exam will consist of two parts: the Applied Knowledge Test
(AKT), which will comprise 150 to 200 single-best-answer questions, and
the Clinical and Professional Skills Assessment (CPSA), which will be a
practical OSCE-based exam (3).
Anyone who wishes to practise in the UK will have to take this exam.
Both UK graduates, as well as IMGs, will have to sit the same standardised
exam and pass it to be considered fit to practise medicine in the UK and
get GMC registration. The purpose of the UKMLA will be to ensure that
Chapter seventeen: International Medical Graduates – Planning 193

both patients and employers have confidence in doctors working in the

UK regardless of where they were trained and educated (3).

Route 2: Applying for Registration Using Sponsorship

In order to apply through the sponsorship route, you will need to dem-
onstrate that you possess the experience, knowledge, and skills needed to
work as a fully registered medical doctor in the UK.
There is a list of sponsors that have been pre-approved by the GMC. If
you can satisfy the requirements for the sponsored post and can secure a
job after successfully interviewing, you can apply for a certificate of spon-
sorship, which you will need for the GMC registration.
If your sponsor is not on the GMC pre-approved list, then you cannot
apply using sponsorship and will need to consider one of the other routes (4).

 oute 3: Acceptable Postgraduate

R
Qualifications
It is possible to apply for GMC registration using acceptable postgradu-
ate qualifications such as membership in the Royal College of Surgeons
(MRCS) (5). MRCS is a two-part intercollegiate exam. It is organised by
the Royal College of Surgeons of England, Royal College of Surgeons of
Edinburgh, Royal College of Physicians and Surgeons of Glasgow, and
Royal College of Surgeons in Ireland. You will need to provide a letter from
the college where you passed the exam confirming your membership.
Part A of the MRCS is an MCQ-based theoretical exam, and Part B is
a clinical OSCE-based surgical skills exam. You need to allocate around
six months to prepare for this. The exam can be taken internationally in
a few different countries listed on the Royal College of Surgeons website.
MRCS is a requirement to complete Core Surgical Training. You can-
not progress to higher surgical training without passing the MRCS exams.
Coming via this route has the added benefit of meeting that requirement
while at the same time getting GMC registration. Once you have the
GMC registration, you will be eligible to apply for and work in the UK in
­middle-grade surgical roles as a surgical registrar.
If you are currently in or have finished surgical training in your home
country, then applying for GMC registration with the acceptable post-
graduate qualification route might make more sense. Once you are in the
UK, you can apply for higher surgical training and skip Core Surgical
Training.
The other acceptable postgraduate exam is the Joint Surgical Colleges’
Fellowship Examination (JSCFE) (6). This is a much harder exam com-
pared to the MRCS and one that is similar to the exam normally given at
194 Smashing the Core Surgical Training Interview

the end of higher surgical training in the UK. The JSCFE is aimed at inter-
national surgeons and is held by all four royal surgical colleges (England,
Edinburgh, Glasgow, and Ireland).
Success in both JSCFE Section 1 and Section 2 will allow affiliation
to one of the four surgical royal colleges of Great Britain and Ireland
and, from January 2023, introduce the use of the post-nominal IntFRCS
(College). This post-nominal has been revised as it differentiates the quali-
fication from the Intercollegiate Speciality Examination (6).
At present, you can apply for GMC registration once you have passed
the JSCFE as it is listed as an acceptable post-graduate qualification.

Route 4: Relevant European Qualification

The GMC accepts relevant European qualifications from countries with
both the primary degree and some approved specialist qualifications
listed on the GMC website (7). If you have this, you can apply for GMC
registration.

Special Considerations for IMGs

Applying for Jobs
Jobs are advertised online and can be accessed via websites such as NHS
Jobs and Trac Jobs. Applications are submitted through the same websites.
You do not need to make separate applications for all jobs, as you can
import your data from your previous applications to your next application
and just make suitable changes as you go along. Jobs in Scotland can be
accessed via a separate website, NHS Scotland Jobs (8). Do not miss out on
these jobs as Scotland is a whole another country, and they have the same
shortage of highly skilled professionals as the rest of England, Wales, and
Northern Ireland.
It is very difficult to start with a training post as your first job because
often the requirements needed for these are difficult to get if you are not
already working in the NHS. It is advisable to start with a non-training
job and get to know the system. During this time, you can prepare your
portfolio and get ready for the next round of national interviews. There is
a shortage of highly skilled professionals like doctors. The NHS is always
recruiting.
Jobs are advertised all year long. However, there is a significant
increase in vacancies around August, as a lot of speciality training jobs
start at that time creating a workforce vacuum. This pattern is also
repeated around February for a similar reason.
As you are an IMG, it takes time to understand the application pro-
cess and what it is asking from you. It is important to be truthful in the
Chapter seventeen: International Medical Graduates – Planning 195

application. Lying on your application is a probity issue and may create

problems for future job applications. Make sure you have read the specifi-
cations of the job and ensure your application contains the relevant infor-
mation. You need to keep working towards improving your CV. It can
take several months and hundreds of applications until you finally get
an interview. You will notice with time your understanding of the appli-
cation process improves, and your CV becomes polished. For one of the
authors of this chapter, the first interview invite came after six months
and 300+ applications. The second one came two to three weeks after the
first, and the author secured the job offer after his second interview.

Preparing for Job Interviews

Treat your interview like an exam. Preparation is key. There is a fantastic
interview book titled Medical Interviews, written by Olivier Picard, which
deals with medical interview questions in a very comprehensive way.
Blogs on the internet and IMG groups on social networking sites are very
helpful. We have listed some useful resources at the end of this chapter.
Finally, mock interview practice with someone who is working in the
NHS or who has recently been successful in an NHS interview is a great
way to prepare.

Accepting the Job Offer

Once you have been offered a job, it is important to make sure you clarify
a few things. You have to ask them if they certify maintenance for you
and your dependent (dependents are your family; i.e. partner and kids). If
they do, you do not need to show personal funds in your visa application.
However, if they do not then you need to show sufficient funds to support
yourself and your family for one month in the UK until you start getting
paid. In this scenario, it is better suited that you come to the UK before
your family. You can then apply for your family’s visa after two to three
months, once you have saved some money in your bank to show that you
can support your family.

Visa
Short-Term – Visiting Visa
You must have sufficient funds to support yourself during your stay. If
you are coming to the UK, the anecdotal advice is to have at least two to
three times the savings compared to your expected expenses in the UK.
For example, if you are applying for a ten-day visa, and you expect your
expense to be £1,000, then your savings should be £2,000–3,000.
196 Smashing the Core Surgical Training Interview

It is wise to plan early and start saving up accordingly for the jour-
ney. You can also choose to have someone sponsor your visit instead. The
sponsor has to be a close family member, like one of your parents. They
have to give you a signed letter of support mentioning how much funds
they will be giving you for your trip and you have to attach their bank
statement as evidence of those funds.
You can find the official visa guidance on the UK Visa and Immigration
(UK VI) website. It is important you check this, as the requirements are
updated regularly (9). Typically, the documents that are required for a
visit visa for an exam include your passport, an employment letter and a
no objection certificate (NOC) from your current employer, a police char-
acter certificate, your exam booking confirmation email, a bank statement
or sponsorship letter as evidence of funds available to you for your visit,
and your return ticket with accommodation booking in the UK for the
duration of your stay.
Whilst in the UK for the PLAB 2, you should make the most of your
time and try to get a clinical attachment or courses, such as ALS, under
your belt.

Long-Term – Health and Care Worker Visa

Once you have a job and GMC registration, you will need to apply for
health and care worker visa (previously known as Tier 2 visa) (10).
This visa is aimed at medical professionals, who can come to or stay
in the UK to fill an eligible post in the NHS.
You must have a job offer from an approved UK employer, such as
the NHS, before you apply for a health and care worker visa. Approved
employers are also known as sponsors, they will be sponsoring your
stay in the UK. Your employer will check that you meet the eligibility
requirements and provide you with a certificate of sponsorship. This is
an electronic record and not a physical document. It will have a refer-
ence number, which you will need for your visa application. You must
apply for your visa within three months of getting your certificate of
sponsorship.

Indefinite Leave to Remain

You will need to stay in the UK for five years to qualify for indefinite leave
to remain (ILR). Once you have ILR you will become a permanent resident
in the UK and do not need to apply or renew your visa every few years.
You can apply for a British passport one year after getting ILR (11).
Chapter seventeen: International Medical Graduates – Planning 197

Useful Resources
There are many online blogs and Facebook pages that have useful
resources for IMGs to help plan your move to the UK. We have listed a
few of these here:

1. Salik Surgery Series [Link]

2. Naseer’s Journey [Link]
3. Omar Guidelines [Link]
4. Road to UK [Link]
5. The Savvy IMG [Link]
6. International Medical Graduates (IMGs) in the UK – Facebook page

Active pages have the most members and should be the most helpful.
These pages are free to join and contain useful help and information.
One of the authors of this chapter, Muhammad Salik, maintains a
website called Salik Surgery Series (12), which focuses on applying for
jobs in the UK, interview preparation, surgical portfolio building, and
other aspects of life as an IMG and a surgical trainee.

References
1. [Link]/registration-and-licensing/
join-the-register/plab.
2. GMC Registration and IELTS. [Link]/registration-and-licensing/
join-the-register/before-you-apply/evidence-of-your-knowledge-of-english/
using-your-ielts-certificate.
3. GMC. GMC Medical Licensing Assessment. [Link]/education/
medical-licensing-assessment.
4. GMC Registration Using Sponsorship. [Link]/registration-
and-licensing/join-the-register/before-you-apply/list-of-approved-
sponsoring-bodies.
5. GMC. Acceptable Post Graduate Qualification. [Link]/registration-
and-licensing/join-the-register/before-you-apply/acceptable-postgraduate-
qualifications.
6. Joint Surgical Colleges Fellowship Examination. [Link]/Content/
[Link].
7. GMC Relevant European Qualifications. [Link]/-/media/­
documents/factsheet – international-apps – relevant-european-qualifications-
list –dc11865_pdf-[Link].
8. NHS Scotland Jobs. [Link]
9. GMC. UK Visa and Immigration.
10. [Link]. Skilled Worker Visa. [Link]/skilled-worker-visa.
11. British Citizenship. [Link]/british-citizenship.
12. Muhammad Salik. Salik Surgical Series. [Link]
chapter eighteen

International Medical Graduates –

Planning a Career in Surgery
Muhammad Salik, Muhammad Talha,
and Anokha Oomman Joseph

A career in surgery requires a lot of hard work. You will have to make per-
sonal sacrifices and work on your own time to improve your CV and build
a good portfolio. It takes time to get used to the NHS system, living in a
new country. As an IMG, there are extra layers of challenges to becoming
a surgeon in the UK. Take one step at a time to avoid feeling overwhelmed
by this journey. In this chapter, we will outline ways you can enter train-
ing and navigate a career in surgery as an IMG in the UK.

Making Opportunities
Once you have decided to become a surgeon, make yourself visible and avail-
able. Speak to seniors you are on shift with. Tell them your ­requirements –
is it an audit or a publication you want? Do you need procedures for your
logbook? Are you interested in going to theatre? Once everyone knows you
are interested, they will make opportunities for you. It is then up to you to
work hard and avail of every opportunity you can get.
One thing to keep in mind here is that it is very important to choose
your projects wisely. Do not get involved in a big project which cannot fin-
ish in a defined period. You need to be mindful of time and get involved
in projects that are likely to finish and get you the most marks in your
portfolio.

Foundation Competencies and CREST Form

If you are not in a foundation programme, you will need a Certificate of
Readiness to Enter Speciality Training (CREST) form to be signed in order
to be eligible to apply for a training post (1). You can get it signed by any
consultant you have worked with for three months or more. These are
competencies equivalent to completion of foundation training in the UK.

DOI: 10.1201/9781003350422-19 199

200 Smashing the Core Surgical Training Interview

Some consultants are happy to observe you on the job and sign you off if
they find your performance satisfactory, whereas others will want you to
collect formal evidence before they sign you off.
You should use the Horus e-portfolio program to collect evidence.
Horus is the platform used by the foundation doctors in England to col-
lect evidence for their foundation competencies, and therefore, it has all
the sections needed for the CREST form. If your hospital does not provide
this for free, you will need to get a subscription yourself. We recommend
that you speak to the postgraduate office of the hospital in which you
work and familiarise yourself with the foundation curriculum so that you
can match your e-portfolio with those of foundation trainees.

Route to Surgical Training in the UK

Core Surgical Training (CST)
Following GMC registration, you can get a standalone foundation year 2
post (FY2), non-training jobs, or clinical development fellow posts in NHS
preferably in surgery (2).
Many IMGs have already completed one to two years of postgraduate
experience (including a house job) before coming to the UK, but this inter-
national experience is not officially recognised. In order to get onto the
training pathway, you need to get your foundation competencies signed
off first. Once you have your foundation competencies signed off, you can
apply for Core Surgical Training.
There is an 18-month surgical experience limit for getting into Core
Surgical Training. You will be classed as overqualified and will not be
allowed to apply at CT1/ST1 level if you do a surgical job for more than
18 months post-graduation (not including your foundation training, intern-
ship, or house job). Opportunities to build a surgical portfolio are better in a
surgical job; however, if you already have significant surgical experience, then
it is important to avoid a surgical job so as to stay within the 18-month mark.
After completing Core Surgical Training and passing the MRCS
exams you can apply for ST3 (3).

 kipping CST and Applying to Higher

S
Surgical Training (HST)
Alternatively, you can skip CST in case you have exceeded the 18-month
surgical experience limit, or you choose to go for speciality training
directly. This pathway can be shorter or longer than the conventional
CST pathway, depending on each individual. Some people get their
Chapter eighteen: International Medical Graduates – Planning 201

CST competencies with the Certificate of Readiness to Enter Higher

Surgical Training (CREHST) form signed off in six months, and for
some, it may take two to three years. This form can be downloaded
from the Royal College of Surgeons (RCS) website, and it is a recog-
nised alternative to confirm the competencies of CST. Furthermore,
you will also need to complete your MRCS Part A and Part B exams
before applying for HST.
Remember, it is not a race. Everyone has their own timeline. Work at
your own pace, but remember that determination, perseverance, and hard
work are key. All candidates taking the CREHST pathway previously
would have gotten the Certificate of Eligibility of Specialist Registration –
Combined Programme (CESR-CP). But since 2020, the GMC has confirmed
that eligible doctors on the CESR-CP pathway will be awarded Certificate
of Completion of Training (CCT) upon completion of training (4). Therefore,
everyone completing HST in the UK will graduate with the same certifi-
cate, regardless of where they received their CST competencies from.

 ertificate of Eligibility for Specialist

C
Registration (CESR)
CESR allows doctors who have not completed a UK specialist training
programme but have a combination of qualifications, training, and expe-
rience gained anywhere in the world, to be evaluated as part of an applica-
tion for entry to the GMC Specialist Register. This pathway takes a long
time (5). It is suitable for surgeons who have completed surgical train-
ing in their home country, passed the MRCS, and joined the NHS as a
non-training middle grade after GMC registration. The experience they
gained from their training abroad and non-training posts done in the UK
will need to be demonstrated equivalence to surgeons who have achieved
their competencies with a CCT. Equivalence demonstrated has to be to the
current curriculum current at the time of application; following this, you
will be awarded the CESR (5).

Conclusion
Give yourself time to adjust to a new way of life. You will need to adjust
to your new role and responsibilities, a new country, and a new culture.
Everyone is different and requires a different amount of time until they
become comfortable in their new environment.
Take it easy, take it slow, progress in small steps, and when you feel
ready, pick up the latest CST self-assessment document and start planning
your portfolio development. Set clear goals and focus on achieving them.
202 Smashing the Core Surgical Training Interview

Be mindful of the projects you take on and pick them wisely. Do not
waste time on anything that will not help you in building the perfect port-
folio. Speak to your seniors and other IMGs who have been successful in
this journey for advice.
There are many ways in which you can pursue a career in surgery.
Where you want to start will depend on your own individual experience.

References
1. Speciality Training Health Education England. Certificate of Readiness to
Enter Speciality Training. [Link]
Content/Resource%20Bank/Recruitment%20Documents/CREST%20
2021%20Reference%[Link].
2. Royal College of Surgeons of England. Surgery Entry Requirements.
[Link]/careers-in-surgery/careers-support/what-is-surgery-
like-as-a-career/entry-requirements-and-training/.
3. Royal College of Surgeons England. Career Paths in Surgery. www.
[Link]/careers-in-surgery/trainees/foundation-and-core-trainees/
surgery-career-paths/.
4. Tim Tonkin B. GMC Simplifies Access to CCT. [Link]/news-and-
opinion/gmc-simplifies-access-to-cct. 2020.
5. GMC. CESR Application. [Link]/registration-and-licensing/join-
the-register/registration-applications/specialty-specific-guidance-for-cesr-
and-cegpr/specialty-specific-guidance-for-cesr-in-general-surgery.
chapter nineteen

Dyslexia and Neurodiversity

Carol Leather

The aim of this chapter is to increase the understanding of dyslexia, dis-

cuss its impact on doctors in training, and suggest strategies for success.
You may already have a diagnosis of dyslexia. Alternatively, you may be
struggling with an aspect of work or with repeated failures in examina-
tions, but be unaware of an underlying diagnosis of dyslexia. In either
case, this chapter is for you. While the focus is on dyslexia, there are com-
monalities with other syndromes, such as dyspraxia and attention deficit
disorder (ADD).
The chapter is split into three sections:

• Understanding Adult Dyslexia – a Brief Theoretical Outline

• The Assessment Process – What, When, Why, and How to Tell People
• Support for Examinations and the Workplace – Tips and Strategies

 nderstanding Adult Dyslexia – a Brief

U
Theoretical Outline
Despite the recognition of dyslexia over 100 years ago, it is still an area of
some controversy, particularly in adulthood. It is often misunderstood.
This is not surprising and partially stems from the lack of consensus
regarding the definition. Dyslexia is something of a conundrum because it
is widely recognised as a reading and spelling difficulty. However, many
dyslexic adults – in particular, professionals like doctors – may have devel-
oped their literacy skills to a competent level. Furthermore, the character-
istics of dyslexic individuals vary. Some are articulate, and others struggle
to find words. Some people are visual, and others are not. Some dyslexic
people are successful, and others less so. It is these disparities that lead
to confusion for both dyslexic individuals themselves and those around
them. The heterogeneity of dyslexia in adulthood is predictable as dys-
lexia is developmental. We are all products of our environments, cultures,
family life, educational opportunities, experiences, and personalities (1).
The individuality and the complexity of dyslexia mean that understanding
it and how it affects you as an individual is paramount.

DOI: 10.1201/9781003350422-20 203

204 Smashing the Core Surgical Training Interview

Another reason for the misunderstanding of dyslexia is the dearth of

research in adults. Most research has been limited to children or student
populations and so is not relatable to the workplace. Further, the child
focus in research has influenced definitions, limited the understanding of
the impact in adulthood, and led to some interventions being inappropri-
ate. The literacy skills of many dyslexic adults are competent, especially
when aided by technology. Hence, in some workplace contexts, problems
faced by dyslexic people are broader and include time management and
memory recall (2, 3).

The Positive Impact of Dyslexia

Interestingly much of the research conducted on dyslexic adults in
employment has focused on success attributes (4–6). Successful dyslexic
adults are good problem-solvers. They have good reasoning skills and are
often creative thinkers. The positive impact of being dyslexic is increased
determination, perseverance, and high motivation. Furthermore, some
experts argue that self-awareness and high job self-efficacy are other fac-
tors related to their success (7). Does this sound like you?

What Is Adult Dyslexia?

There are many definitions of dyslexia. Some are narrow in their scope,
referring to difficulty acquiring literacy skills and difficulty with phono-
logical processing (the ability to use the sounds in language to process
the spoken and written words). This has led to the possibility of misdiag-
nosis and misunderstanding, particularly of those adults who have been
described as ‘literate’ dyslexics (8). Medical students and doctors are usu-
ally in this category. They have developed their reading and spelling skills
to a competent level but experience broader difficulties in domains, such as
reading speed and comprehension, written expression, note-­taking, clarity
of communication, time management, memory, and organisation (2).
Researchers and practitioners are now adopting broader definitions
such as that proposed by the British Dyslexia Association.

Dyslexia is a specific learning difficulty that mainly

affects the development of literacy and language-
related skills. It is likely to be present at birth and
to be lifelong in its effects. It is characterised by dif-
ficulties with phonological processing, rapid nam-
ing, working memory, processing speed and the
automatic development of skills that may not match
up to an individual’s other cognitive abilities (9).
Chapter nineteen: Dyslexia and Neurodiversity 205

This definition includes cognitive processes, such as working memory

and speed of processing; the measurement of both is generally required
for a diagnosis. These account for the residual difficulties with reading
speed and comprehension and memory recall.

Neurodiversity
The need for a clearer definition is also important because of the issue of
comorbidity with other specific learning disabilities that come under the
umbrella of neuro-developmental disabilities.
These include the following:

• Dyspraxia: problems with motor coordination, sequencing, plan-

ning difficulties
• Attention deficit/hyperactivity disorder (ADD and ADHD): difficul-
ties with concentration
• Autistic spectrum disorder: social communication problems
• Dyscalculia: a problem with mathematical conceptualisation and
calculation

While there is some similarity in the characteristics of these syndromes, the

causes of each specific disability are different and have different neurologi-
cal correlates. Rates of comorbidity between dyslexia and other disorders
vary but it has been suggested that it is the rule rather than the exception.
To frame all these overlapping syndromes more positively, the
umbrella term ‘neurodiversity’ has been adopted. This concept is seen
as having more positive connotations. It includes a wide range of syn-
dromes, and so there is a larger single voice for advocacy purposes. It also
possibly allows for a more comfortable way to discuss what an individual
might need to work well. It can, however, create even more confusion as
there are no specific criteria for the diagnosis of neurodiversity, but there
are distinguishing profiles for syndromes, such as dyslexia. Some people
argue that each syndrome loses its distinct identity under the umbrella
term, and even dilutes the support and increases misunderstanding. They
prefer to be just dyslexic. In any event, the need for self-understanding
and self-advocacy is important.

The Evidence for Dyslexia

As far back as 1999, Frith developed a framework to gain a better under-
standing of dyslexia across the lifespan, at biological, cognitive, and
behavioural levels; this framework could be adopted across to cover vari-
ous syndromes referred to here.
206 Smashing the Core Surgical Training Interview

Figure 19.1 Frith’s model of dyslexia.

Frith wrote,

Defining dyslexia at a single level of explanation –

­biological, cognitive, or behavioural – will always lead
to paradoxes. For a full understanding of dyslexia, we
need to link together the three levels and consider
the impact of cultural factors which can aggravate
or ameliorate the condition. Consensus is emerging
that dyslexia is a neurodevelopmental disorder with
a biological origin, which impacts on speech process-
ing with a wide range of clinical manifestations (10).

Frith also suggested that each of these levels interacts within the
individual and their environment, which accounts for the heterogeneity
amongst the population of dyslexic adults.
The biological level includes genetics and neurology. Genetics are evi-
denced in the plethora of family and twin studies. The development of
fMRI scans has meant that neurological differences between dyslexic and
non-dyslexic readers can be identified both at the structural and func-
tional levels (11).
The cognitive level involves the processes that are associated with
acquiring information, including learning and reading and also with the
Chapter nineteen: Dyslexia and Neurodiversity 207

Figure 19.2 Cognitive information processing model.

recall and retrieval of the information when required. These processes

include working memory and executive functioning processes. The fol-
lowing diagram is a simple model of information processing.
Everything that we see, hear, say, and do has to be encoded to store
it in long-term memory. Working memory is the system that holds onto
information for long enough to enable it to be utilised or placed in long-
term memory. It is a processing resource of limited capacity. As indicated
in the previous diagram, if working memory is overloaded, then the infor-
mation is rejected. Working memory is involved in the process of multi-
tasking with words and, therefore, affects fluent comprehension, written
expression, and note-taking. The executive functioning processes of
planning organisation and time estimation and management can also be
affected. These inefficiencies in cognitive processing are likely to impact
performance in examinations and on a daily basis.
In the behavioural level, the more visible and commonly recognised
characteristics of dyslexia are weaker literacy skills. These include the
following: poor word decoding, slower reading speeds, weak reading
comprehension, weak writing, problems with appropriate sentence struc-
ture, problems with clarity of expression, and spelling difficulties. These
often persist into adulthood. As mentioned earlier, many dyslexic people
may have dealt with these challenges and have competent literacy skills,
although tasks such as writing up patient notes and responding to emails
are effortful and take noticeably longer.
People can also have some difficulties with spoken language – i.e.
struggling to find the right word and the pronunciation of words con-
taining several syllables, such as the names of drugs. Therefore, answer-
ing questions on-the-spot on ward rounds (even though you know the
answer) can be an issue. Similarly, handovers and note-taking can be
difficult. Likewise, problems with time management and organisation
are frequently reported. Difficulties with memory, including retrieval
of information under pressure, recalling instructions, and remembering
208 Smashing the Core Surgical Training Interview

people’s names are common. All of these make demands on working

memory (see diagram), and cognitive overload can result in poor perfor-
mance in assessment settings, in oral, written, and practical examinations,
and at times in the workplace. Persistent difficulties such as these and/
or unexpected and sometimes continuous failure in examinations trigger
the question – might I be dyslexic?
Other characteristics that are a result of weaker literacy skills and the
hidden and confusing aspects of dyslexia are lack of confidence, frustra-
tion, and low self-esteem. ‘Why can’t I do this as easily as others?’ ‘Why
is my memory so bad?’ and ‘Is there something wrong with me?’ are
questions that people ask themselves. This is not surprising when you
work alongside people who read automatically, complete their write-ups/
handovers/patient notes at speed, and pass their examinations the first
time with little revision but who clinically perform no better and some-
times not as well as you. It is likely that this will undermine your self-
efficacy and your belief that you can do your job well. It is at this point
advice could be sought.

The Dyslexic’s Strengths

Your strengths and abilities are likely to be the main reason that you have
achieved so much already and are clinically very competent, often with-
out recognising you might be dyslexic. It is well documented that dyslexic
people can have a wide range of individual abilities. These include good
verbal reasoning and strategic analytic thinking skills, strong visualisation
abilities, being able to identify the gaps, and seeing the bigger picture.
Often dyslexic individuals are innovative, creative, and divergent think-
ers. Dyslexic people often have good people skills and are determined and
persevere.
It is these skills and abilities that enable you to perform well in
clinical settings. Your good verbal and nonverbal reasoning abilities
result in good differential diagnostic skills. The analytic and strategic
thinking leads to good clinical decision-making and problem-solving.
The good people skills come from empathy and ability to listen beyond
just the words. It is these skills and abilities and a sound knowledge
base after many years of learning that are often recognised at work
by your colleagues, supervisors, and patients. They enable you to be
a good doctor. Good clinical ability and sound knowledge should be
sufficient to pass the examination but when some very competent doc-
tors struggle to pass the examinations, the disparity in performance
between the examination and clinical settings should be questioned and
possibly explored.
Again, perhaps it is time to find out if there is a reason for this
inconsistency.
Chapter nineteen: Dyslexia and Neurodiversity 209

Dyslexia – Why Is It Presenting Itself Now?

Dyslexia can present itself at any time across the lifespan, but it is usually
at times of transition or overload. The transition from GCSE to A-level
where the teaching method changes can lead to unexpectedly poor results.
Likewise, the move to university when independent self-directed learn-
ing makes demands on organisational skills can result in students feeling
overloaded and result in poor performance at medical school. University
to work is another transition into a new learning environment. People are
diagnosed at any one of these times. Nevertheless, being able to put in
more time, perhaps working through the night to get all the assignments
in, means people continue to achieve their goals. However, when in the
workplace, trying to revise for professional examinations is a very chal-
lenging task. There are not enough hours in the day or enough energy
to revise and learn effectively. This is particularly true when there are
increased family demands, young children, or older parents or even after
a difficult day in the clinical setting. The result can be poor performance
in an examination and/or burnout, as well as a huge loss of confidence.
The time to find out a reason you have to work longer and harder than
others should be before this happens. It may be time to seek advice.

 he Assessment Process – What, When,

T
Why, and How to Tell People
There are many reasons for seeking an assessment. Sometimes it is driven
by the individual. They have often wondered why they are different.
Sometimes it is prompted by a family member, a friend, or a colleague being
diagnosed. More frequently now in the medical profession, it is suggested
by educational supervisors or more senior doctors trying to be supportive
when there has been unexpected poor performance in examinations.
An assessment should be an informative, positive experience. If it is
recommended by others, it is important that you are comfortable with
the idea. There is often some pressure to have an assessment. However,
if you have never thought about it, and especially if there are cultural
implications, a positive diagnosis can be a shock and take a while to come
to terms with. It can then be counterproductive. Being well prepared for
an assessment, such as knowing something about dyslexia and the pro-
cess, can help. However, going online to seek information is not always
the best way, as there are a great many negative texts – long lists of all
the difficulties people might experience – and it can be overwhelming.
Ideally, it is best to talk to someone who can explain what it all entails. The
professional support unit or the individual support team at your deanery
or occupational health should be able to help. You should be able to seek
advice and maintain confidentiality if you wish.
210 Smashing the Core Surgical Training Interview

Steps to Assessment
Checklists
Completing a checklist can be helpful as the starting point for consider-
ation for further investigation. One of the most reliable is the adult check-
list (12). However, while it is based on thorough research, it is a subjective
tool. It is a guide rather than a definitive assessment tool. There is the pos-
sibility of both false positives and false negatives. Individuals can respond
to the questions in a way that they think they should answer rather than
an accurate reflection of what they do. Nevertheless, checklists are a good
indicator, and they do help in the preparation process. There are also some
computer-based screening tests available online, but like the checklists,
they can produce false negatives.
It might be that a checklist or screening result may provide enough
of an explanation for an individual, and they do not need to seek fur-
ther assessment. There is little doubt, however, that the formal diagnosis
provides much more information, particularly about where strengths lie.
A formal diagnosis is required if any adjustments are to be made in the
workplace or in examinations.
There are two routes to formal diagnosis: either through referral from
occupational health (OH), human resources (HR), or a professional service
unit (PSU) or by seeking a private assessment. Assessments for dyslexia
should be conducted by trained educational and occupational psycholo-
gists or teachers who have specialist training. A private assessment means
there is total confidentiality. You do not have to mention anything to any-
one until you feel like they need to know. However, a private assessment
can be expensive, and it is important that you do some research into find-
ing an appropriately experienced person who offers the service at a rea-
sonable cost. Being referred through OH, HR, or the PSU means that more
people are involved, but confidentiality should remain within your con-
trol. You are likely to be referred to a recommended assessor. It also means
that there is a support system post-diagnosis.

The Diagnostic Assessment

Any diagnosis, be it medical, psychological, or educational, should inform,
explain, and effect a change. It should not just be a labelling process (11).
The aim of an assessment is to gather information regarding people’s abil-
ities, both strengths and weaknesses. It should outline their educational
achievements and literacy skill attainment, determine any inconsisten-
cies, and provide an explanation for these. The diagnosis, be it dyslexia or
another specific learning difficulty, is the result of a process of differential
evaluation and clinical judgement.
Chapter nineteen: Dyslexia and Neurodiversity 211

Historically, diagnostic assessments have been conducted in person,

where the assessor can more readily observe both verbal and non-verbal
behaviour. However there has been a move towards online assessment.
Some of the measures of assessment have been adapted to deal with this
different administration and are seen as reliable; however, some psycholo-
gists would argue that in a face-to-face interaction, the building of rapport
is easier and the observation of the person’s behaviour when completing
the tests is very important.

The Assessment Process

A diagnostic assessment includes the administration of measures of intel-
lectual ability, cognitive processing, and literacy attainment. If other areas
of difficulty arise or are mentioned by the person, additional testing, such
as for numeracy, or checklists for other specific learning difficulties may
be administered.
The measures of intellectual ability are important in predicting what
people can achieve. Good intellectual abilities are likely to be part of the
explanation for dyslexia not having been noticed previously.
The measures of cognitive processing include tests of phonological
processing, rapid naming, working memory, and symbolic processing
speed. These underlie the development of literacy skills and therefore
impact reading, writing, and spelling attainment. Rapid naming is associ-
ated with fluent comprehension and word finding. Weak verbal short-term
memory is likely to affect remembering lists of instructions, telephone
numbers, and PINs. These cognitive processing skills are related to both
working memory and executive functioning processes and, therefore, can
also affect time management and organisation skills. It is deficits in these
processes that can explain any inconsistencies in performance and result
in a diagnosis.
Measures of literacy attainment include tests of single-word read-
ing, reading speed, reading comprehension, spelling, and writing speed.
Many adults working at a high level, such as doctors, will have devel-
oped their literacy skills to a competent level. However, when measured,
it is apparent that there are residual difficulties with reading fluency and
comprehension, as well as with writing speed. While many people com-
ment that they must re-read to understand or they read slowly, they are
not aware of how effortful the reading process is for them. Unlike other
people, they have not developed their literacy skills to an automatic level.
At the end of the assessment, whatever the outcome, the results should
be explained, and ideally, a diagnosis should be provided. The diagnosis
may be something of a surprise, and people need to be given the time to
ask questions and hopefully feel that it was a positive experience on which
212 Smashing the Core Surgical Training Interview

they can build. They should leave feeling better informed and know what
is available to enable them to move forward. An assessment report is pro-
vided and should include test details, results, and conclusions. It should
also make recommendations for skill development, assistive technology,
and adjustments to the workplace. Preferably the assessment report should
come in two sections: The first part has all the personal information and
test results for individual perusal. The second part is a summary of the
assessment and focuses on the recommendations, which can be shared
with supervisors, colleagues, and employers.

Coming to Terms with a Diagnosis

However prepared people are, the actual diagnosis can generate a range
of emotions. Even for those that were diagnosed in childhood, it can be
a surprise as they may have thought they had overcome their dyslexia
because their reading and writing skills were passable, and they have not
been sufficiently aware of the impact as an adult.
For many people knowing what is causing the problem is a huge relief
as it shows they are not incompetent. They have a reason as to why things
have been so hard. The results can give them more confidence in their
abilities, which may have been subsumed in the effort of learning and
working. It can increase their confidence and their motivation.
There are some people who take a pragmatic stance. The diagnosis
provides them with some extra time during examinations, and that is all
they need to pass. They then move on.
For other people, the diagnosis is not so welcome; it brings with it
confusion, denial, and disbelief: How can I be dyslexic when I can read and
write? How can I have suddenly become dyslexic? This disbelief is sometimes
compounded by others too: You can’t be dyslexic if you have been to university.
People can be frustrated by the identification of problems that they have
always just gotten on with. Likewise, there can be anger that it was not
diagnosed at school. Sometimes there comes a sense of loss, of what might
have been if they had known earlier. Some people feel ashamed and see it
as a disability or are worried that others will see it as such. There can be
fear for the future. They are concerned that it will affect their promotion
or their career progression, and so there can be a loss of motivation.
There is no doubt that even those people who take it positively will
consider some of the more negative responses. The diagnosis can change
how you see yourself for a while. When you are diagnosed at this stage,
you should be commended as you have been studying and working with
an unacknowledged condition that has placed you at a disadvantage in a
very literate world. Despite this, you have achieved a great deal and can
now go even further. You are the same person as before the diagnosis, just
better informed.
Chapter nineteen: Dyslexia and Neurodiversity 213

Disclosure
One of the big questions following the diagnosis is disclosure. Should
you tell people you are dyslexic? Whom should you tell, and when should
you say something? Historically, disclosure rates have been low for fear
of being misunderstood or thought stupid or incompetent (13). Amongst
doctors, fear of discrimination is another concern (14). However, failure to
disclose is associated with a lack of success in both clinical and written
examinations (15). Furthermore, as the recognition of dyslexia increases,
more people are happier about telling people. The positives of disclosure
are ideally greater understanding at work and the provision of reasonable
adjustments at work. The most common adjustment and one that people
often seek an assessment for, and indeed benefit from, is extra time in an
examination. The negative aspect is that people may see you differently,
and there is a fear of stigma. This can be counteracted by considering
what to say and how to present yourself.
It is a very personal decision, and unsurprisingly, peoples’ approaches
are very different. Some people are very keen to tell everyone all about
it. Others are reticent and only bring it up when things go wrong. Some
people mention it when they have been complimented for doing a good
job: I am so glad I passed that exam because I am dyslexic and exams are not the
way I demonstrate my knowledge.
The best time to tell people is when you feel comfortable and as con-
fident as you can about it. When going to a new rotation or placement, it
may be best to leave it to a second meeting so that people see you as an
individual first, not a dyslexic. It is important to know what to say, how
dyslexia affects you, and what you do about it: I am dyslexic, which for me
means I might need a bit of extra time to settle in. Once I am familiar with every‑
thing, I do a good job; or I always make notes to ensure I get it right; or if I have the
speech-to-text software, I will be able to do the admin more quickly. In summary,
try to keep it short, simple, positive, and solution-focused.
Another thing to consider is what to say if supervisors ask what they
can do to support you. Asking for what you need to work well and why it
helps you gives them more confidence in you. For example, you may say,
I need a bit of extra time to learn the new IT system or even clinical procedures,
but once I have learned it, I never forget; or I need to take notes so that I don’t
miss anything; or I like to ask more questions to clarify something.

 upport for Examinations and the

S
Workplace – Tips and Strategies
The diagnostic report should make evidence-based recommendations
regarding the support you need. There are three strands that can be use-
ful to explore both for exams and in the workplace. They are as follows:
214 Smashing the Core Surgical Training Interview

• Skill development: Developing the skills you need will improve your
performance; specialist coaching is usually recommended for this.
• Technological and practical aids: These can make life easier. Assistive
technology – speech-to-text packages, such as Dragon Dictation,
or text-to-speech packages, such as Claro or Texthelp Read&Write
Gold – can help with literacy accuracy. However, increasingly, both
Google and Microsoft 365 have voice recognition and text-to-speech
functions on their platforms. Practical aids can be as simple as more
filing space to be better organised or whiteboards to help plan and
recall information.
• Adjustments to the workplace or training: This includes extra time in
exams or extended training. Some usually admin-related tasks in
the workplace may need to be adjusted.

Reasonable Adjustments
Dyslexia can be considered a disability for the purposes of the Equality
Act 2010. This means that organisations are obliged to make reason-
able adjustments. The response to this has often been a one-size-fits-all
approach, but what is reasonable for one person is not necessarily true of
another. Therefore, adjustments should be evidence-based and tailored to
the individual. The evidence is often provided in the diagnostic report.
Having said that, the most important and common adjustment for any
dyslexic individual is time – extra time to learn and develop new skills
and effective personalised strategies to address the different ways of pro-
cessing; extra time in written examinations to mitigate reading fluency
difficulties; extra time to formulate an answer either in a viva or at work
due to the word-finding difficulties; extra time to produce written work
for processing and to allow for planning and proofreading.

Adjustments in Examinations
Most examination boards will send a list of the adjustments available for
the examination on the receipt of the diagnostic report.
Written examinations adjustments include the following:

• Twenty-five per cent extra time. More time can be granted based on
the recommendations in the report.
• A paper-based examination rather than taking the exam online.
This allows the individual to annotate and interpret the question
more effectively.
• Sitting the examination in a separate room. This allows for reading
the question aloud and avoiding being distracted or distracting oth-
ers. This also benefits ADD candidates.
Chapter nineteen: Dyslexia and Neurodiversity 215

• Paper to jot down ideas. This is particularly useful if the exam is

online.
• An appropriately sized font.
• Coloured paper or backgrounds if required.

 djustments in Vivas, Clinical,

A
or Practical Examinations
Extra time may be given if there is quite a large reading component in
these exams, but there are fewer adjustments. However, the following is
good practice:

• Having paper and pencil to hand

• Being given the time to jot down relevant information
• Allowing candidates to ask for repetition and clarification and giv-
ing them more time to respond
• Allowing time to formulate an answer

Some medical examination boards will also consider allowing candidates

to re-sit an examination more often, discounting previous attempts when
there has been a late diagnosis, acknowledging that they have been at a
disadvantage.

Adjustments in the Workplace

Adjustments to the workplace are made on the recommendations in the
diagnostic report and sometimes on work-based assessments which are
conducted by Occupation Health or, in the UK, Access to Work. The latter
is a government-funded scheme.
The adjustments include the following:

• Extra time to complete documentation – ring-fenced time for admin-

istrative work
• Extra time in training and on equipment and techniques
• Assistive technology – voice recognition, text-to-speech
• Use of two computer screens
• Flexibility around working hours

These adjustments are granted based on individual needs and the

demands of the job. Some might only be needed temporarily while you
settle into your job role and develop task-specific expertise. In these cases,
some adjustments are made on an informal basis and are a result of good
communication between supervisors and their dyslexic trainees.
216 Smashing the Core Surgical Training Interview

Coaching
Specialist coaching is now widely recommended following a ­diagnostic
assessment; increasingly, it is seen as an important intervention that
improves performance and self-efficacy (16). As with psychologists, coach-
ing should be provided by specialist dyslexia coaches who have experi-
ence working with doctors.
The aim of coaching is to increase your understanding of dyslexia,
your abilities and how you learn and work most effectively, and how to
self-advocate.

When I am performing a complicated surgical pro-

cedure, I find it very hard to talk/to describe what
I am doing at that point in time, I am almost in
another zone. I know what I am doing is correct –
I am often complimented on doing a good job but
when my consultant asks me to describe what the
procedure is as I do it, it starts to go wrong. I have
asked if I can tell him after the operation is complete.
(MRCS trainee, personal communication)

As suggested earlier, dyslexia can be simply defined as a language-­

processing difference. It can be hard to multitask with words, so there
is cognitive overload. The working memory does not work so efficiently,
then it might be best to do one thing at a time, as indicated in the previ-
ous quote. It is also important with experience and practice tasks become
more automatic, multitasking can become possible (1). Furthermore, if you
plan and prepare using your executive functioning processes, it mitigates
the working memory inefficiency (2, 3).
The coaching should be led by you to address your challenges and
to enable you to ask for what you need to work well. This is especially
important in the workplace. It should also help to develop specific skills,

Figure 19.3 Information processing model.

Chapter nineteen: Dyslexia and Neurodiversity 217

such as planning and time management, efficient literacy skills if neces-

sary, presenting to others, and of course, strategies for memory, revision,
and examinations.

Strategies for Revision – The Four Ms

Make It Manageable
Plan and break the revision into chunks. Planning is an executive function
process, and it is something we do both automatically and deliberately. It
is one of the keys to success as it usually leads to a better outcome. For
example, we tend to plan a party or a holiday. It also improves cognitive
functioning and, therefore, performance by relieving cognitive overload.
If we think about what we are doing in advance, we are more likely to
complete the task more efficiently. For example, as a doctor, you may read
patient notes in advance, so you know something about them and what
needs to be done before seeing them.
However, planning can take time and does not always work; often,
a day’s to-do list is not completed and revision plans are not achieved.
If this happens, then it is likely that the goals were unrealistic, and it is
more positive to look at what you have achieved and how effective it was
rather than overfocusing on what has not been done. Then just reset the
plan. It was the plan that failed, not you. Furthermore, there is plenty of
research demonstrating people achieve more with a plan than without
one. It focuses attention especially if you work to short goals, working for
30 minutes and then taking a small break to reboot your concentration.
It is good practice to keep a log of what you have covered over the day
or week.
Tips for effective planning include making it realistic, fun, and flex-
ible; having a variety of different activities, such as making brief notes,
drawing and annotating diagrams, and doing questions; and having a
variety of resources (e.g. books, webinars, YouTube, group study). It must
also include ring-fenced time for rest and relaxation. A tired brain does
not work well, and so the revision is less useful (17).

Make Revision Meaningful

Learning and revision are much more effective if you reprocess it into
a format that you find more accessible and if you build on what you
already know. Before looking at a topic, think about and try and recall as
much as you can, then you can identify gaps and fill them. Also, look at
the relevance of the topic – why are you required to learn it? Look at the
high-yield topics – why are these so important? – and ensure you know
these well.
218 Smashing the Core Surgical Training Interview

Make It Multisensory
All learning is better if it is learned or revisited by utilising all your senses.
See it, hear it, say it, do it. This is the reason that most doctors remember
more information about patients they have seen. Therefore, use your clini-
cal experience as much as you can. Making up fictitious cases and hang-
ing information, especially fine detail on this structure, is also good. If
you are trying to learn a particular name of a drug for example, try and
personalise it, give it a character, or add colour.

Use Memory Aids

Make it task-specific. Look at the structure of the information. For exam-
ple, if it is a process, then make a flow chart, or make up a story. If it is a
polysyllabic word or an anatomical label, break it into syllables and use
a colour-coding system. Memory and recall work best if you exaggerate
and elaborate on what is being learned make it funny or personalise it. It
is also important to keep a record of what you have achieved and review
and evaluate it regularly. The review does not need to be in-depth, unless
you really cannot remember the information, but it makes knowledge
more readily accessible.

 trategies for the Exams – Plan,

S
Prepare, and Practice
Success in an exam at this level is more likely if you feel ready for it. If the
revision plan has gone well, then you should be feeling as confident as
you can in your knowledge. Most medical exams have a vast curriculum,
and given the demanding job that you do, it is unrealistic to think you can
know it all. There is an element of luck in these exams, but good prepara-
tion and practice can mitigate this.
Preparation involves practising exam questions, but a note of caution –
just doing questions is often not enough to pass, especially for dyslexic peo-
ple. Dyslexic people need to understand and reprocess the material so they
can recall it more easily. They learn it more thoroughly because rote learn-
ing will not work. They may take longer and do more re-sits, but arguably,
dyslexic doctors who have failed exams on several occasions may have more
knowledge than doctors who pass the first time; they can be better doctors,
and they can have more confidence because of that knowledge.
Nevertheless, practising questions is important for two reasons.
Firstly, you familiarise yourself with the knowledge required and with
the way the questions are phrased. It helps to think strategically and try
to understand why the question is being asked, why it is important, and
what the examiners are trying to assess.
Chapter nineteen: Dyslexia and Neurodiversity 219

Secondly, if you practice doing questions at speed, the same speed as

you need to in the exam, e.g. 20 questions in 30 minutes, you are practising
reading and recalling at pace – which is what the exam requires. Building
this up into three sets of 30 minutes and then four sets of timed questions
means you are building your cognitive stamina. You are preparing your-
self for the mental marathon of the exam and familiarising yourself with
the performance in the day.
Planning and being prepared about what you are going to do on the
day can also help get you in the ‘exam mindset’. It includes what to wear,
what to eat, how to spend the time before and between the exam to com-
bat nerves, and what to do if you get anxious (e.g. breathe deeply); being
pragmatic and moving on are positive options. Exams can be harder for
dyslexic people; it is not the format in which you can demonstrate your
knowledge best. Knowing that you have the skills, abilities, and knowl-
edge to do the job and that your patients and colleagues value what you
do is something that can boost your self-belief, and this leads to success.

Conclusion
This chapter has outlined the complexity of dyslexia and its impact on
adulthood. It is characterised by information processing difficulties that
can become more evident when the demands of life and work increase.
It can take a while to come to terms with and develop new skills. A diag-
nosis should provide an explanation for the difficulties but also outline
the strengths and lead to better self-understanding and finding solutions.
Exams and some aspects of the workplace, especially heavy administrative
demands, are more of a challenge for dyslexic people, but this means you
need to be more creative in your problem-solving: How can I best do this?
Being dyslexic is not a barrier to a successful career in medicine. In
fact, being dyslexic means that you bring more to the role, you are unlikely
to put your patients at risk because you double-check, and you always aim
to do a good job.

References
1. Snowling, M.J. (2014). Dyslexia: A language learning impairment. Journal of
the British Academy, 2, 43–58. doi: 10.5871/jba/002.043
2. McLoughlin, D. and Leather, C.A. (2013). The adult dyslexic: Interventions and
outcomes – An evidence-based approach (2nd ed.). Chichester: John Wiley &
Sons, Ltd.
3. Protopapa, C. and Smith-Spark, J.H. (2022). Self-reported symptoms of devel-
opmental dyslexia predict impairments in everyday cognition in adults.
Research in Developmental Disabilities, 128, 104288.
4. Gerber, P.J., Ginsberg, R., and Reiff, H.B. (1992). Identifying alterable pat-
terns in employment success for highly successful adults with learning
220 Smashing the Core Surgical Training Interview

disabilities. Journal of Learning Disabilities, 25(8), 475–487. Available from:

[Link]
002221949202500802
5. Madaus, J.W., Zhao, J., and Ruban, L. (2008). Employment satisfaction of uni-
versity graduates with learning disabilities. Remedial and Special Education,
29(6), 323–332. Available from: [Link]
[Link]/doi/abs/10.1177/0741932507312012
6. Schnieders, C.A., Gerber, P.J., and Goldberg, R.J. (2016). Integrating findings
of studies of successful adult with learning disabilities: A new compre-
hensive model for researchers and practitioners. Career Planning and Adult
Development Journal, 31(4), 90–110.
7. Leather, C., Hogh, H., Seiss, E., and Everatt, J. (2011). Cognitive functioning and
work success in adults with dyslexia. Dyslexia, 17(4), 327–338. Available from:
[Link]
10.1002/dys.441
8. Miles, T.R. and Miles, E. (1990). Dyslexia: A hundred years on. Milton Keynes:
Open University Press.
9. The Dyslexia Handbook 2021.
10. Frith, U. (1999). Paradoxes in the definition of dyslexia. Dyslexia, 5, 192–214.
11. Shaywitz, S.E. (2003). Overcoming dyslexia: A new and complete science-
based program for reading problems at any level [cited 2023 May 7], 416.
Available from: [Link]
sally-shaywitz-md/1133983833
12. Smythe, I. and British Dyslexia Association. (2001). The dyslexia handbook,
2001: A compendium of articles, checklists, resources and contacts for dyslexic peo‑
ple, their families and teachers.
13. Martin, A.E. and McLoughlin, D. (2012). Disclosing dyslexia: An exercise
in self-advocacy. In N. Brunswick (Ed.), Supporting dyslexic adults in higher
education and the workplace. Chichester: Wiley, 125–135.
14. Kinsella, M., Waduud, M.A., and Biddlestone, J. (2017). Dyslexic doctors, an
observation on current United Kingdom practice. MedEdPublish, 6, 60.
15. Asghar, Z., Williams, N., Denney, M., and Siriwardena, A.N. (2019).
Performance in candidates declaring versus those not declaring dyslexia in a
licensing clinical examination. Medical Education, 53(12), 1243–1252. Available
from: [Link]
16. Doyle, N. and McDowall, A. (2015). Is coaching an effective adjustment
for dyslexic adults? Coaching: An International Journal of Theory, Research &
Practice, 8(2), 154–168.
17. Flinn, F. and Armstrong, C. (2011). Junior doctors’ extended work hours
and the effects on their performance: The Irish case. International Journal for
Quality in Health Care, 23(2), 210–217. Available from: [Link]
[Link]/intqhc/article/23/2/210/1786502
chapter twenty

Out in Surgery – LGBTQ Issues

Mustafa Khanbhai

Not Quite over the Rainbow

Many lesbian, gay, bisexual, transgender, and queer (LGBTQ) doctors
continue to find their workplace to be a challenging environment as they
routinely encounter discrimination from colleagues, staff, and patients,
which leaves them feeling uncomfortable and unwelcome (1). Although
evidence suggests that the climate of acceptance has improved over
the last ­quarter-century, LGBTQ doctors still experience or fear overt
discrimination.
A 2016 survey conducted by the British Medical Association (BMA), in
conjunction with the Association of LGBTQ Doctors and Dentists (GLADD)
(2), found that respondents felt uncomfortable in the environment they
were working in and experienced homophobic abuse, harassment, and
discrimination in employment or education. Across the Atlantic, a similar
survey conducted by Eliason et al. (3) reported that LGBTQ doctors expe-
rienced being denied privileges, promotions, employment, and patient
referrals and face workplace harassment and social exclusion.

Closeted Operating Theatres

Sadly, the experiences of LGBTQ doctors are not uniform across speci-
alities, with surgical specialities historically having more conservative
working environments (4). A recent study (5) uncovered the challenges
associated with LGBTQ equality and inclusion, with surgical trainees
significantly more likely to experience workplace discrimination, harass-
ment, and bullying and twice as likely to consider leaving their program.
These alarming facts are not isolated to surgical trainees. When sur-
veyed (6) about medical speciality choice and perceived inclusivity toward
sexual and gender minority groups, medical students reported surgery to
be least inclusive. The perceived lack of inclusivity in surgery impedes the
recruitment of LGBTQ trainees into surgical training and poses the risk
of missing opportunities to address the unique needs and healthcare dis-
parities present within the LGBTQ community (7). LGBTQ trainees must
expend considerable energy constantly assessing their environments,

DOI: 10.1201/9781003350422-21 221

222 Smashing the Core Surgical Training Interview

struggling to find a balance between self-protection and self-disclosure;

this energy represents a net loss to surgical training programs and the
profession (8).

Embracing a Surgical Gaydar

In the United Kingdom, there has been a positive change to address some
of the challenges facing LGBTQ surgeons. In 2021, the Royal College of
Surgeons of England (RCSEng) commissioned an independent review (9),
led by Baroness Helena Kennedy, QC, into the diversity of the leadership
of the surgical profession and of the College. The report concluded that
the RCS is short on diversity and inclusion and is out of step with our
society and the changing profession of surgery. In addition to the 16-point
action plan from the report, the RCSE chose to develop an LGBTQ strategy
encouraging a culture of upstanders rather than bystanders.
Following on from this report, on 25 March 2022, for the first time
since the inception of the RCSEng in 1800, the RCSEng held a conference
bringing together LGBTQ surgeons and allies in collaboration with Pride
in Surgery Forum (PRiSM), which is now part of the RCSEng network of
LGBTQ surgeons and allies providing visibility, role models, and an asso-
ciation. This move was in the right direction, demonstrating acceptance
and progress in ensuring LGBT surgeons have a voice.
In September 2022, the Intercollegiate Committee for Basic Surgical
Examinations (ICBSE) of the Surgical Royal Colleges of the United
Kingdom and Ireland apologised for an inappropriate question in the
Intercollegiate MRCS Part A exam that was rooted in homophobic preju-
dice. Various doctors on social media voiced their concerns, and the ICBSE
agreed that it was poorly worded and caused offence.
There is still much to be accomplished within the surgical commu-
nity to create a more equitable and inclusive environment for all LGBTQ
surgeons. However, actively addressing issues raised and improving the
diversity within surgery is not simply a bandwagon the RCSEng has joined
but is important for the future of the profession, in terms of ­workforce,
innovation, and surgical talent. Healthcare organisations are also embrac-
ing change and creating a workplace where everyone feels valued – for
example, by introducing the option for employees to have their pronouns
included alongside their names.
Only by challenging the stereotypes that have existed for so long can
surgery grow and continue to attract the most talented individuals from
medical schools. There is a growing movement and changes in policy
that have facilitated our voice to be heard so that LGBTQ surgeons who
have not previously felt comfortable being out at work can see it is now
possible.
Chapter twenty: Out in Surgery – LGBTQ Issues 223

Prideful Resources
The resources available to LGBTQ surgeons are few and far between.
Some of the organisations listed here are working hard to change the sta-
tus quo:

• The Association of LGBTQ+ Doctors and Dentists (GLADD) – https://

[Link]
• Pride in Surgery Forum (PRiSM) – @PRiSM_Surgery
• Association of Out Surgeons and Allies (AOSA) – @OutSurgeons
• Gay and Lesbian Medical Association (GLMA) – [Link]
• Pride Ortho – [Link]

Most healthcare organisations now have a webpage dedicated to LGBTQ

resources, including support on their social media platforms, which dem-
onstrates progress towards inclusivity.

 orn This Way – Case Study: Mustafa

B
Khanbhai
I am currently a speciality registrar in Oncoplastic Breast surgery with
a portfolio career. I have completed a PhD and hold two fellowships as
a clinical entrepreneur and in clinical artificial intelligence. I am openly
gay with my friends and some of the junior doctors but stop short of being
fully open at work. It has taken me a while to trust people before being
open, and every time I started a rotation, there was always a fear in the
back of my mind that people would see and treat me differently if they
found out about my sexuality. I have been very aware of the hierarchy in
surgery, where I felt more comfortable being open with nurses and other
junior doctors but reluctant to disclose my sexual orientation to anyone
senior. I was fearful that being honest about my sexuality would lead to
negative repercussions with respect to career progression and jeopardise
my opportunities by letting my personal life spill over too much. When
moving to a different organisation as part of my surgical training, I was
always a little concerned that I would be allocated to a supervisor who
may have implicit, deeply ingrained beliefs on cisgender heteronormative
societal ideas. Similarly, many LGBTQ doctors feel pressure to conceal
their identities from co-workers and patients due to explicit and implicit
prejudice. Many doctors have to live with the stress of being ‘outed’ when
trying to conceal their LGBTQ identity, thereby damaging personal integ-
rity, workplace community, and productivity (10).
Occasionally hearing homophobic banter in the surgical workplace,
which sometimes had an undertone of malice, made social interactions
224 Smashing the Core Surgical Training Interview

at work very challenging. This affected my interactions at work, where

I would ensure there was minimal conversation about my life outside of
work, and if the conversation headed that way, I would change the subject
immediately. I suspect some of my colleagues would have perceived me as
being frosty as I did not talk about my private life. Perhaps this was because
I still felt that much of my inhibition was coming from myself rather than
from the wider team. Mainly, I do not want people to feel uncomfortable.
Overall, I have generally had a positive response about my sexual-
ity from my immediate surgical team in most rotations. Particularly dur-
ing the latter end of my career, I felt the teams I worked with let me be
my true authentic self at work. I was able to achieve more and be able to
function better at work and emerge successful. This is in keeping with
evidence from the United States where LGBTQ respondents reported the
same levels of satisfaction with their decision to become surgeons (5). This
suggests that promoting an inclusive and equitable environment can be
very effective in retaining LGBTQ surgeons and increasing their level of
personal dignity and job satisfaction.
Personally, I have seen a change in attitudes towards homosexuality
during my career and now feel that surgery and the NHS are good places
for LGBTQ people to progress in. I hope this demonstrates to prospective
trainees and medical students that it is indeed feasible to both be yourself
and have a surgical career. I hope to continue to contribute to our surgical
profession in a positive manner, and I am grateful to be given this oppor-
tunity to do so.

References
1. Burke BP, White JC. The well-being of gay, lesbian, and bisexual physi-
cians. West J Med. 2001;174(1):59–62.
2. [Link]
and-medical-students%20in%[Link].
3. Eliason MJ, Dibble SL, Robertson PA. Lesbian, gay, bisexual, and ­transgender
(LGBT) physicians’ experiences in the workplace. J Homosex. 2011;58(10):
1355–71. doi: 10.1080/00918369.2011.614902. PMID: 22029561.
4. Ramos MM, Téllez CM, Palley TB, Umland BE, Skipper BJ. Attitudes of phy-
sicians practicing in New Mexico toward gay men and lesbians in the pro-
fession. Acad Med. 1998;73(4):436–8.
5. Heiderscheit EA, Schlick CJR, Ellis RJ, et al. Experiences of LGBTQ+ Residents
in US general surgery training programs. JAMA Surg. 2021;157(14):e215246.
6. Sitkin NA, Pachankis JE. Specialty choice among sexual and gender minori-
ties in medicine: The role of specialty prestige, perceived inclusion, and
medical school climate. LGBT Health. 2016;3(6):451–60.
7. Quinn GP, Sanchez JA, Sutton SK, et al. Cancer and lesbian, gay, bisexual,
transgender/transsexual, and queer/questioning (LGBTQ) populations:
Cancer and sexual minorities. CA Cancer J Clin. 2015;65(5):384–400.
Chapter twenty: Out in Surgery – LGBTQ Issues 225

8. Risdon C, Cook D, Willms D. Gay and lesbian physicians in training:

A qualitative study. CMAJ. 2000;162(3):331–4.
9. [Link]/about-the-rcs/about-our-mission/diversity-review-2021/.
10. Lee KP, Kelz RR, Dubé B, Morris JB. Attitude, and perceptions of the other
underrepresented minority in surgery. J Surg Educ. 2014;71(6):e47–e52.
Chapter twenty one

Getting into Core Surgical

Training as an Ethnic Minority
Tolu Ekong, Temitope Ajala-Agbo, and Eniola Salau

Representation matters! You probably read a story of how someone was

inspired to accomplish something great because they saw someone like
them do it first. The challenge with minority groups is that such role mod-
els are hard to find. If you are a future surgical trainee from a minority
group, this is a reality you will in all probability face.
On the other side of the coin, there are patients. Being admitted to a
hospital is a scary prospect. Having surgery is even scarier. Having a sur-
geon who looks like you and understands your cultural norms can go a
long way in putting the patient at ease during a stressful time. So if you are
an ethnic minority and interested in surgery, you are very much needed.
The population of the United Kingdom is around 68 million of which
about 87% are white British. The approximate breakdown of the minority
ethnic groups is shown in Table 21.1.
You may not be aware of the following statistic, but as an ethnic minor-
ity, compared with your Caucasian colleagues, you are more than twice as
likely to fail your professional exams1, 2 and to be unsuccessful in gaining
a core or speciality training position in your desired speciality,3 especially
if your desired speciality is a surgical one. And this is despite having been
trained in a UK medical school and accounting for other contributory fac-
tors. For the black trainee, even when you do get into core or speciality
training, the attrition rate is about 50%; only half of the total number of
black trainees make it to consultant grade, as shown in Table 21.2. The con-
version rate from trainee to consultant as a black female surgical trainee
is even worse.4 There are several theories as to why this may be the case,
although no one truly understands the dynamics and the magnitude of
the effect each factor has.
The observed difference in performance between ethnic minority
groups and their white counterparts has been termed ‘differential attain-
ment’. Differential attainment was first reported in 19955 where several fac-
tors, including biased examiners and learner deficits, were blamed for this
phenomenon at first. However, studies which have taken into account these

DOI: 10.1201/9781003350422-22 227

228 Smashing the Core Surgical Training Interview

Table 21.1 UK Population Data ([Link]

[Link]/uk-population/)

Percentage
White British 87
Asian/Asian British 7
Black/Black British 3
Mixed/multiple ethnic groups 2
Other ethnic groups 1

Table 21.2 Percentage of NHS Medical Staff by Ethnicity and Broad Grade
(NHS workforce statistics, [Link]/
workforce-and-business/workforce-diversity/nhs-workforce/latest – published
Feb. 2020, updated Aug 2020)

factors and others have shown that there is a lot more to the significant dif-
ference observed in the performance of ethnic minority groups in medicine.
There is evidence that interactions with peers and superiors are sig-
nificant in affecting career outcomes.6 The social aspect of learning and,
therefore, the learning experience of ethnic minority groups are believed
to play a major role in the differential attainment observed.7 A review
found that minority medical students ‘experienced less supportive social
and less positive learning environments and were subject to discrimina-
tion and racial harassment.’8 Medical students and trainees learn best
from teachers who support, believe in, and invested in them. This in itself
is a predictor of career success.9, 10
In our opinion, a combination of factors contributes to these statisti-
cal findings, and there is more research to be done on the matter. The
recent spotlight on equality and diversity has forced several organisa-
tions, including the General Medical Council (GMC) and Royal College
Chapter twenty one: Getting into Core Surgical Training 229

of Surgeons (RCS), among many others, to pay attention to differential

attainment. A lot of work is already being done by these organisations
to create awareness and a culture change towards equality and diver-
sity. Nevertheless, much work and time are required to change the given
statistic for you who are planning to successfully apply for Core Surgical
Training.
So what can you do to increase your chances of realising your dreams
of becoming a surgeon? Well, you can lay hold of the experiences, both
good and bad, of those who have gone before you and learn from them.
An increasing number of ethnic minorities are gaining places in surgical
specialities and having successful surgical careers. So what did they do
and continue to do to make this possible? I have identified some personal-
ity traits and actions common in those that have been successful in this
path. Let us review them here.

Have a Solid Plan

Do not become indecisive because you are suffering with imposter syn-
drome and feel like no one looks like you in the surgical world. Of course,
there are not many people that look like you in surgery. Have you read
and digested the given stats yet? This is why you must push through and
become an example to the next cohort.
It is never too early to start planning. The plotting and planning begin
from the first moment you had thought of being a surgeon. You need to
learn to play the game and ‘speak surgery’. There are certain hoops you
have to jump through whether you like it or not. So roll your sleeves up
and get jumping!
Make sure you set yourself up to be known in the surgical community.
Network with other students that have chosen surgery as their career path
(I know they can be annoying at times, but trust me, you need them). That is
how you get the latest tips and find opportunities to be involved in regional
and national projects. Think about taking on leadership positions in your
medical school’s surgical society or similar university-based organisations.
Be part of national organisations that promote and support eth-
nic minorities in medicine and surgery, such as the British Association
of Physicians of Indian Origin (BAPIO), UK Black Surgeons Network
(UKBSN), British Association of Black Surgeons (BABS), and Melanin
Medics. These organisations are also good places for networking and
finding mentors.

Surgical Mentorship and Sponsorship

Find an inspiring role model you admire and ask them to mentor you.
Surgical registrars often make the best mentors for medical students and
230 Smashing the Core Surgical Training Interview

junior doctors. They have been where you are and are not too far removed
to give sound advice. They are often more approachable. If you find some-
one whom you like to guide you along the way, reach out to them, and
they will be flattered and even keen to pass on their insights – trust me!
If you cannot find anyone in your hospital, try social media. Look on
Instagram, Twitter, LinkedIn, etc. This is the one time it is okay to stalk!
The role of mentorship in surgery cannot be underestimated. There
are people who have successfully walked the path you are on or about to
take. They can guide you. Your role model does not have to look like you;
they just have to care enough about your progress and be invested in your
success. Sometimes a mentor is for a season; other times, they are for life.
It may take a while to find a mentor you gel well with, but when you do,
hold on to them tight. Ensure you have a mentor for every stage of your
career.

Believe in Yourself
Get a life or career coach if necessary! You are good enough. You have
what it takes. Now you just have to believe it. I have noticed a pattern of
lack of self-belief with medical students/doctors of ethnic minority back-
grounds. That can adversely impact your performance. So although the
audit, research publications, and presentations are important, it is a good
idea to invest in building your sense of self. Know who you are, your
strengths, and your weaknesses, and understand your likes and dislikes.
Take personality tests to better understand yourself. Get a coach if neces-
sary to work through some of your self-doubts. Confidence is key, and
your Caucasian colleagues already have one up on you here; just being
‘the only’ in the room, which I am sure you often are, puts you on the back
foot. So be proactive with this one.

Be True to Yourself
Bring all of you. Diversity really is needed in the surgical speciality. It
is not just a slogan or a matter of fulfilling the ethnic minority quota.
Our patients are diverse and need a diverse group of surgeons. It is not
just about colour. A lot of ethnic minorities try to fit into the stereotypi-
cal surgical mould. I certainly did so. But after years of trying to fit in,
I realised that my uniqueness made me special and added value to my
patients, my colleagues, and even my superiors. By being yourself, you
bring a different way of thinking into the workplace for the good of all;
marginalised groups are more likely to engage with healthcare services if
they feel that they can identify with their physician.11 Katherine Phillips,
in her research, found that diversity breeds empathy and better cogni-
tive reasoning. Interestingly, she found that just the presence of an ethnic
Chapter twenty one: Getting into Core Surgical Training 231

minority in a team, without them having to speak, causes a diversity of

thinking for the better.12

Be Creative
Do not put yourself in a box. As medics in general, we can lack creativity,
or rather the study and demands of medicine beat the creativity out of us!
Feed your creativity; invest in your hobbies outside of medicine. Hang out
with non-medics. Think outside of the surgical box and the well-trodden
path taken by other medical students/junior doctors. Take out time to
pursue other interests, but be sure to creatively link them to your chosen
surgical speciality, and even if you cannot, exploring other interests for a
season really does make you a well-rounded individual. No one wants a
boring surgeon as a colleague!

Speak Up and Take Opportunities

As ethnic minorities, we can sometimes be found wanting in this area.
Do not shrink back! A senior colleague is talking about a project they are
involved with over team coffee. Be bold and speak up. Ask to join in. That
project could become your first presentation or publication. What is the
worst that could happen? They say no, and you move on. Be keen and be
diligent in everything you do at work; stand out as the responsible and
reliable member of any team you find yourself in. Pay additional attention
to detail. Be kind, and get to know everyone in your sphere of influence,
from the clerk, cleaner, porter, and nurses on your ward to your clinical
supervisors, clinical directors, and even the chief executive of your trust.
It goes a long way!

Community and Family Support

Build a community around you. These people do not have to be surgeons
or medics; they just have to have your back! Surgical training is a mar-
athon, and you definitely need cheerleaders along the way to emotion-
ally support you when the going gets tough. Do not cast aside valuable
relationships in the pursuit of a surgical career. Rather, invest in strategic
relationships; you will be better for it. If you are a person of faith, plunge
deeper into your faith; it can only serve you well.

Keep the End Goal in Mind!

Keep the end in focus. There is life beyond training. Do not get dis-
tracted by side shows! Ruthlessly eliminate time wasters in your life. As
you go further in your training, you will encounter several demotivating
232 Smashing the Core Surgical Training Interview

situations. You may experience personal or family illness, bullying, sex-

ism, poor training, and so on. Build your resilience and prepare for the
possibility of such situations so that they do not knock you off course.
You have come too far and sacrificed too much to let some bully take your
dream away.
For those who choose to start a family during training, it is particu-
larly difficult as your parental instincts will pull you homewards while
your career takes you away from your family. Your training may be
extended if you become a parent, so prepare to see your colleagues move
ahead of you for a season, but it will be okay because you have kept the
end goal in mind!
And finally . . .

Lift as You Climb

Remember to send the ladder down for others. By virtue of your success,
you are a change agent for others. Choose to be an active change agent.
The platform you have is exactly what is needed to change the statistics
given and make it easier for the next generation.

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Index
A emotional well-being, 154 – 155
financial well-being, 155
ARCP (Annual Review of Competency ranking jobs, 6 – 7
Progression) requirements, 150, 153 workload and challenges, 153 – 154
ATLS (Advanced Trauma Life Support) coursework, 169 – 170
model, 46, 78, 101, 150, 152 electives, 172 – 174
attention deficit disorder (ADD), 203, see
also dyslexia and neurodiversity
audio-visual equipment for virtual D
interviews, 58 – 60
dyslexia and neurodiversity
assessment process and disclosure,
B 209 – 214
bank locum work, 159, 160 – 161 coaching, 216 – 217
evidence for and models of, 205 – 208
neurodiversity, 205
C presentation across lifespan, 209
cardiothoracic clinical scenarios, 113 – 119 strategies for revision and exams,
career planning, 167 – 176, 199 – 202 217 – 219
CCrISP (Care of the Critically Ill Surgical supports and adjustments, 214 – 215
Patient, 46, 61, 63, 74, 76, 79, 150 dyspraxia, 203, see also dyslexia and
Certificate of Eligibility for Specialist neurodiversity
Registration (CESR), 201
Certificate of Readiness to Enter Higher E
Surgical Training (CREHST), 201
Certificate of Readiness to Enter Specialty ENT clinical scenarios, 93 – 98
Training (CREST), 199 – 200 escalation pathway, 48, 53, 53 – 54, 54, 124,
clinical scenarios, 61 – 119 186 – 187
clinical/teaching fellowships, 160 – 161 ethnic minorities in surgical training,
competitions and grants, 170 – 171 228 – 232
conferences, 21 – 22, 29 – 30, 168 – 169
Core Surgical Training (CST) F
application process, 3 – 7
developing surgical skills, 149 F3 years (foundation year 3), 157 – 165

 235
236 Index

G preparation for, 11
Professional Dilemmas (PD) section, 10
gender issues
gender bias, 179 – 180
LGBTQ issues, 221 – 224 N
motherhood and fertility, 182 – 183 neurodiversity, 205, see also dyslexia and
see also women in surgery neurodiversity
general surgery clinical scenarios, 61 – 86

O
H
Occupational English Test (OET), 191 – 192
Higher Surgical Training (HST), 200 – 201 Oriel online application portal, 3, 4, 145
orthopaedics clinical scenarios, 104 – 113
I
indefinite leave to remain (ILR), 196 P
International English Language Testing Picard, Olivier, 195
System (IELTS), 191 – 192 plastics clinical scenarios, 99 – 104
international medical graduates portfolio preparation
career planning, 199 – 202 case study, 34
relocation to UK, 191 – 197 evidence-gathering, 14 – 15
interview answers and F3 years, 160
structuring clinical answers, 45 – 49 layout, 15
structuring management answers, 51–56 leadership and management, 32 – 33
MRCS Part A examination, 16 – 17
J operative experience, 18 – 21
overview, 13 – 14
Joint Surgical Colleges’ Fellowship postgraduate degrees and
Examination (JSCFE), 193 – 194 qualifications, 24 – 25
presentations, 29 – 30
L prizes and awards, 25 – 26
publications, 30 – 31
LGBTQ issues, 221 – 224 quality improvement/clinical audit, 26–27
locum agency work, 159, 160 – 161 requirements, 150
LTFT (less than full-time), 182 surgical conference attendance, 21 – 22
Surgical Courses, 16 – 18
M surgical experience, 23 – 24
teaching experience, 27 – 28
management scenarios, 121 – 143 training in teaching, 28 – 29
Medical Interviews (Picard), 195 post-interview job preferencing, 145 – 147
mentorship presentations, 29 – 30, 43 – 44
for ethnic minorities, 229 – 230 Professional and Linguistic Assessments
for women in surgery, 183 – 184 Board (PLAB) exam, 191 – 192
minority groups in surgical training, publications, 30 – 31, 35 – 42
228 – 232
MRCS (Royal College of Surgeons) exam, R
16, 150, 151, 165, 193 – 194
MSRA (Multi-Speciality Recruitment relocation to UK for international
Assessment), 3, 5, 9 – 11 graduates, 191 – 197
Clinical Problem-Solving (CPS) Royal College of Surgeons (MRCS) exam,
section, 11 16, 150, 151, 165, 193 – 194
Index 237

S V
speciality training, 145 – 146, 157 – 158, 160 virtual interviews, 57 – 60
SPIES framework, 51 – 56 visas for international medical graduates,
sponsorship for international medical 195 – 196
graduates, 191, 193
ST3 requirements, 145, 150, 153 W
surgical societies, 167 – 168
women in surgery, 179 – 188
U Women in Surgery (WiS), 185, 186
working abroad, 161 – 162
United Kingdom Medical Licensing work-life balance, 150, 159, 181 – 182
Assessment (UKMLA), 192 – 193 workplace-based assessments
urology clinical scenarios, 86 – 93 (WBAs), 150