1. Clinical Judgement and Decision Making

Descriptor: ‘Working beyond the level of Foundation Doctor. Fully appreciated the wider needs of the situation & seeks team input. Would manage independently’

• The bar for a 5/5 score is set at a candidate working beyond the level of an FY2 doctor and who would be able to lead the clinical scenario independently.  
• This should prompt candidates to demonstrate situational awareness when answering clinical questions. Simply saying that you would give an asthmatic patient ‘oxygen and nebulisers’ does not acknowledge the ‘wider needs’ of the situation 
• An outstanding answer will also include an awareness of who else in the clinical team is able to help you execute the treatment plans and formulate differentials. It will also describe communication with the patient or any relevant carers.  
• Be clear to explain which specific task you would ask which member of staff to carry out. Clearly it would be inappropriate to ask the porter to insert a cannula, but where roles and responsibilities can vary (eg. some nurses can carry out IV cannulation and others cannot), simply saying that you would ask each member what they are capable of doing will go a long way to demonstrate good team working on top of your decision making skills. 
• Be mindful of where your scenario is set – if you are in an isolated location, mentioning that you need extra help or will have to call for help sooner will demonstrate good situational awareness.  
• ‘Managing independently’ is not the same as attempting a rogue one-man-show! 

Descriptor: ‘Always alert to symptoms and signs which may destabilise patient’ 

• The age-old medical school mantra holds true here – if there is an obvious threatening abnormality, you should highlight it as soon as possible. For example, if your scenario includes a patient who has a GCS of 5/15, it is important that you mention a prompt airway assessment and an escalation for an airway-trained doctor to come to the scene.  
• ‘Always alert’ implies that you should mention appropriate reassessments of the patient’s clinical circumstances to pick up on any deteriorations 

Descriptor: ‘Always reviewed the situation. Demonstrates forward planning. Always probed for information’

• Simply saying that you will reassess a patient is only a typical answer. For an outstanding answer, you should mention what you are looking for in your reassessment and why. For example, in a case of acute asthma, you may consider saying that you would reassess their observations and ABG after commencing nebulizer therapy to find out if your treatment is working or if the patient is continuing to deteriorate in spite of it as escalation of care or planning for invasive ventilation may be necessary.  
• ‘Forward planning’ does not only encompass escalation of clinical care to a senior or to another specialty. It also includes:  
  – where a patient should be treated (should you move them from majors to resus?), 
  – updating patients or carers (warning them that if they deteriorate they may require invasive ventilation so that when care is escalated it does not come as a big shock), 
  – and alerting theatres/ radiology/ cardiac catheterisation suite if a patient needs surgery/ scans/ stenting (these ‘special’ locations in the hospital require whole teams to be mobilised and forward planning means that you understand that these teams need to be set up and ready for your patient) 
• ‘Probing for information’ demands a demonstration of lateral thinking and averting tunnel vision. Be sure to seek further information at each reassessment of the patient to ensure there are no new complications arising. 

Descriptor: ‘Excellent structure to answer. Correctly prioritised information and tasks. Provides clear plan of action.’

• In as much as is possible, structure your answers. Your interviewers will follow your answers more easily and thus award points for things you mention, and you will score more points for presenting yourself well under pressure as well as in the ‘global rating’. 
• Part of structure is prioritising. Adopting an ABCDE approach in most cases will demonstrate good prioritisation. Be aware of other factors outside of the ABCDE structure that may be relevant in certain specific scenarios such as safeguarding, staff safety (aggressive patient), confidentiality – which may rank quite highly as a priority depending on the situation you are given. 
• ‘Clear plan of action’ should parallel a structured assessment. There is little good in conducting a perfect ABCDE assessment without treating any of the abnormalities identified! 

Descriptor: ‘Decisive and appropriate, clearly able to function independently’ 

• In step with ‘prioritising information and tasks’, you are also expected to act on them accordingly (ie. treat the Airway before the Disability issue). 
• Decisiveness is demonstrated in your prioritisation of your management steps. It is also communicated in your style of answer. Avoid saying ‘maybe’ or ‘might’ unnecessarily. Delegate tasks with assertiveness and clarity (for example, ‘I will ask the porter to deliver these blood samples to the laboratory for rapid group and screen and crossmatch while I continue assessing this patient’s bleeding’). 
• Reiterating the point made above, ‘functioning independently’ is NOT the same as acting as a rogue one-man-show. Rather, you should demonstrate a clear understanding of what you are treating, how it is best treated and an ability to lead a team to achieve it.