Practice Test

This chapter presents two practice tests with a mix of question types (e.g. multiple choice or ranking), content (e.g. domain- tested), and styles (e.g. patient, colleague, or personal). Each includes 30 questions and broadly reflects the type of questions likely to be asked in the SJT. To make the most of this test, you should complete it in one sitting within an hour before checking your answers. When checking your answers to ranking questions, remember that credit is still given for ‘near misses’ and so there is no need to hit the ‘correct’ sequence every time. The practice test answers are not accompanied by detailed explanations. For this reason, it would be preferable to complete all the questions in Section 2 before attempting the test. To replicate the SJT as closely as possible, you should ideally complete these questions within an hour under formal examination conditions. Once you have attempted all the questions, turn to to check your answers. It is difficult to interpret your final score, as your rank will depend entirely on how well your colleagues (and every other medical student in the country) fare. If you are organized, you could arrange a study group to work through this book and/ or complete the practice test. Marking your answers as a group will give some indication as to your performance relative to others. It will also provide an opportunity to discuss the various options (including disagreement with our answers) and so gain a deeper understanding of the issues tested by the SJT.

Coping with Pressure

The Foundation Programme is tough. New doctors have to cope with taking responsibility for patients for the first time and managing the logistical difficulties that inevitably face those working in a complex environment. They often have to balance multiple competing priorities. Perhaps computed tomography (CT) scans need to be requested by 9.30 a.m. if they are to be scheduled for the same day, Mrs A has chest pain, Mr B is an outlier on a distant ward and has become acutely short of breath, and Mr C’s relatives are angry because they have been waiting to speak to a doctor for an hour. You are part- way through taking blood and have three bleeps to answer (all potentially important but conferring new tasks), and your consultant needs to complete the ward round before her clinic starts . . . This would not be a remarkable day by any means. It can be difficult to balance these responsibilities and do so without cutting corners. Criticism is inevitable as it is rarely possible to keep everyone happy all of the time. Questions within this section will explore your resilience and ability to work under pressure. Through your responses, you will need to demonstrate a willingness to remain flexible, manage ambiguity, and adapt to changing circumstances. The ability to remain calm while handling stressful situations arising with patients, relatives, and colleagues is of the utmost importance. Problems must be resolved directly but may require a diplomatic approach to avoid conflict. It is therefore important to speak to others respectfully, seek help early on, and remain aware of your own limitations. There is growing recognition that such pressures can have long- term health implications for junior doctors. You must be aware of threats to your own health, and the British Medical Association (BMA) has reiterated that you have a duty to ensure that your ‘health problems do not affect patient care’. Informal (so- called ‘corridor’) consultations are discouraged, and Good Medical Practice (2013) is clear that ‘you must, wherever possible avoid providing medical care to yourself ’.

How Can You Prepare?

The Improving Selection to the Foundation Programme (ISFP) project does not believe that it is possible to be ‘coached’ through the SJT. This is generally true. Knowing the ‘right thing to do’ in any given situation is a matter of internalized values and intuition. However, no one seriously accepts that candidates are born with a fixed level of situational judgement. This is clearly something that develops over time and therefore can change. In addition, the SJT does not set out to test your values but whether you understand the values and attitudes expected of an FY1 doctor. This is why you are instructed to answer questions as you ‘should’, not as you ‘would’. The principles on which foundation doctors should base their behaviour are learnt and internalized throughout medical school. However, knowledge of these principles can clearly be learnt in the same way as any other part of the medical school curriculum. Most final- year medical students are satisfied with the FY1 posts to which they are allocated. For 2017 entry, 74% were appointed to their firstchoice foundation school, and 94% to one of their top five preferences. Those who were not initially pleased often look back in retrospect and are satisfied with their allocations. Your score on the SJT is unlikely to make or break your career. However, the same can be said of medical school finals. You will almost certainly pass finals— upwards of 95% of final- year students do so— and your ultimate career destination is unlikely to hinge on your cumulative examination score. But this is not a reason to go into finals unprepared. The truth is that every point on the SJT, as in finals, could mean the difference between your chosen outcome and something different. A point lost on the SJT could result in your leaving your first- choice foundation school and moving across the country for work, or not having a high enough score to capture your chosen specialty as a Foundation Programme rotation. Increasing competition for FY1 posts means that not everyone can be appointed.

Working Effectively as Part of a Team

Teamworking is an inevitable part of working within a complex multidisciplinary environment. Thankfully, most interactions with other members of the healthcare team will be positive and constructive. Unfortunately, such happy circumstances do not make for particularly interesting SJT scenarios. The following section is therefore full of colleagues that are angry, rude, dishonest, unprofessional, and even intoxicated. In Raising and Acting on Concerns About Patient Safety (2012), the General Medical Council (GMC) states that ‘all doctors have a duty to raise concerns where they believe that patient safety or care is being compromised by the practice of colleagues or the systems, policies and procedures in the organizations in which they work’. The GMC proposes taking the following steps in sequence when you develop serious concerns about a colleague: ● Raise the concern with ‘your manager or an appropriate officer of the organisation . . . such as the consultant in charge of the team, the clinical or medical director’. Alternatively, a foundation doctor may raise their concern with an appropriate person responsible for training such as their Foundation Programme Director. ● Raise the concern with a regulator (such as the GMC), professional body (such as the British Medical Association), or charity (such as Public Concern at Work). This step should be taken if you have exhausted options for raising the concern internally and there is an ‘immediate serious risk to patients, and a regulator or other external body has responsibility to act or intervene’. ● Raise the concern publicly. This step should be taken when you have exhausted options for raising the concern internally and have ‘good reason to believe that patients are still at risk of harm’. Your usual duty is to avoid breaching patient confidentiality. This is a highly unusual and significant step to take and is unlikely to be appropriate without first having taken advice from an appropriate organization such as the GMC, BMA, or Public Concern at Work. The questions within this section highlight your ability and willingness to work with team members. You will need to work collaboratively and respectfully within a multi- disciplinary team, as well as provide advice and support to colleagues.

Patient Focus

As a junior doctor, you are constantly pulled in different directions by multiple competing interests. These include those of your immediate bosses (possibly multiple consultants, a registrar, and an SHO), Educational Supervisors (Clinical Supervisor, Foundation Programme Director), fellow FY1 doctors, other healthcare professionals (nurses, physiotherapists), ancillary services (laboratory, radiology), patients’ relatives, representatives of the Trust (infection control, human resources, information technology), and many others. In amongst all of these is a patient, if not many, for whom all of these individuals are also working. It will not come as a surprise that Good Medical Practice (2013) states early on that you must ‘make the care of your patient your first concern’ and ‘treat patients as individuals and respect their dignity’. In addition, Good Medical Practice requires that you: ● listen to, and respond to, their concerns and preferences ● give patients the information they want or need in a way they can understand ● respect patients’ right to reach decisions with you about their treatment and care ● support patients in caring for themselves to improve and maintain their health. One challenge is when patients reach decisions that are contrary to the best available medical advice. The archetypal case in point is that of a Jehovah’s Witness at risk of life- threatening haemorrhage but refusing a blood transfusion. In such cases, remember that: ● you should never assume what someone’s beliefs are just because they come bearing a particular religious label. It is always right to ask the patient what they believe and what they will accept under different circumstances. For example, some Jehovah’s Witnesses will accept cell salvage and some blood substitutes ● seek advice early, particularly if the stakes are high (e.g. active bleeding). Your own seniors (SpR, consultant, etc.) and the on- call haematology team are good places to start. They may direct you to other resources that you might contact (with the patient’s consent) such as the Jehovah’s Witnesses’ Hospital Liaison Committee ● document all conversations (with the patient and colleagues) carefully ● ultimately, an adult patient with capacity has the right to refuse treatments— however much you disagree and even if this ultimately results in their death.

Tips for the SJT

1. Put yourself in the position of a new FY1 doctor when answering each question. But remember that they are asking what you should do, not what you would do. 2. You should be a paragon of virtue when answering all questions. Remember always that you are unfailingly honest, respectful, open, and fair to colleagues, patients, and relatives alike. It is difficult to imagine scenarios with answers that would require you to be otherwise. 3. If a question involves patient safety (e.g. critically unwell patient, drug error, etc.), your priority must always be making the patient safe. 4. The well- being of your patient is your first priority. Other considerations (e.g. relatives, targets, fear of being told off, going home on time) are always secondary. 5. ‘Seeking senior advice’ and ‘gathering information’ are difficult to criticize and tend to be safe options. Similarly, it is rarely incorrect to document events or complete a formal incident form. 6. Remember your limitations. As an FY1 doctor, you should not usually break bad news, consent patients for operations, administer cytotoxic or anaesthetic drugs, or manage critically ill patients without support. ‘Call a senior’ is the correct answer in these cases. 7. Understand basic concepts of medical law, e.g. when confidentiality can be breached, determining incapacity, consent in children, the doctrine of double effect, and detention under the Mental Health Act. You do not need to know specifics (e.g. sections of Acts), but a practical understanding will guide some answers. 8. As an FY1 doctor, your Clinical Supervisor is usually a consultant for whom you work during a particular rotation. They are an appropriate source of support for clinical development and problems within the team. Your Educational Supervisor is akin to a Personal Tutor, i.e. responsible for your overall welfare and development throughout the year. They can advise on pastoral issues, professional development, and difficulties with your Clinical Supervisor. 9. Try to complete all questions within the given time frame as random guesses may be identified by the scoring software and awarded zero.

How are SJT Questions Created?

The SJT questions were created following the professional attributes identified from the FY1 job analysis. Questions were written by volunteers at a series of dedicated workshops. The volunteers were not all doctors but should have been familiar with the FY1 role and have worked with junior doctors within the previous two years. The ISFP Project Group employed 89 people to write SJT questions, of whom 69 (77.5%) were senior doctors, two (2.2%) were lay representatives, and the remainder were undeclared. In terms of background, 59 (66.3%) were from a range of acute specialties and 12 (13.5%) from community specialties. This team created a bank of 453 possible questions. These were scrutinized by a team of psychologists who accepted 360 questions as passing this initial stage. A select few writers were asked to moderate all questions to ensure that scenarios were realistic and the terminology was in use across the UK. This group eliminated additional questions, leaving a total of 306. A series of focus groups was then held with foundation doctors who scrutinized the test instructions and up to 20 questions each. They proposed a number of amendments and whittled down the total question bank to 275 items. Once a question bank was established, it was trialled using a panel of subject ‘experts’, i.e. people with similar qualifications to the question writers. Questions survived this process if they achieved a satisfactory level of concordance, i.e. enough experts independently arrived at the same answer under test conditions. A total of 200 questions went forward to be used in the SJT pilots. The SJT model underwent two pilots. The second and larger of these took place in 13 UK medical schools, involving 639 final- year students. Students reported that the content seemed relevant to the Foundation Programme (85% agreed) and that the questions were fair (73.3%). The reasons for understanding how questions are created are to appreciate the following: ● A lot of thought has gone into every question. There should be no ambiguities (unless intended) or ‘tricks’. ● They are written (largely) by senior doctors who are presumably interested in medical training and development.

Does itt Work?

Improving Selection to the Foundation Programme (ISFP) undertook a wide- ranging review of options for allocating new doctors to FY1 posts. It selected the SJT. Whether the SJT works or not depends on whether it can accurately predict ‘good’ doctors. There is no real consensus about how to measure the effectiveness of foundation doctors, and so the SJT question is unlikely to ever be resolved to everyone’s satisfaction. However, variations on the SJT have been used in selection to some specialties (e.g. general practice (GP) and public health training). They are also used by many firms in the commercial sector. The SJT pilots suggested a high degree of internal reliability (α = 0.79– 0.85). It was also shown that SJT performance is positively correlated with extraversion, openness, and achievement. A subsequent study (MacKenzie et al. 2017) has shown that SJT score was predicted by emotional non- defensiveness, aloofness, and empathy, as suggested by the non- cognitive component of the UK Clinical Aptitude Test (UKCAT). The SJT score is also correlated with UKFPO performance (MacKenzie et al. 2016). Interestingly, SJT score is not correlated with performance at medical school as measured by the EPM (Simon et al. 2015). Advantages of the SJT over the previously used ‘white space’ questions include the following: ● invigilated conditions so that no one can seek external help with answers ● less reliance on creative writing skills ● questions directly address prioritization, teamworking, and professionalism— all of which are important qualities for new doctors ● evidence from other sectors suggests that situational judgement questions can effectively predict job performance. Although students are unlikely to relish sitting another high- stakes examination in their final year, earlier selection methods were perceived as both burdensome and unfair. A number of studies have suggested that the SJT is unpopular amongst both medical students and faculty members (Sharma, 2015; Sharma et al. 2016). It is impossible to please everyone and you are most likely to approve of this method in retrospect if your score is high enough. Criticisms of the SJT include: ● As noted on, the SJT and EPM are not equally weighted.

What Does the SJT Test?

The SJT was developed to test nine professional attributes identified from a detailed analysis of the FY1 role. These attributes are as follows: However, the SJT recognizes that there is considerable overlap between these attributes and that some cannot be effectively assessed with a written test. As a result, SJT questions focus on the five attributes highlighted in bold. It is worth considering what the SJT requires of candidates according to each key attribute. Candidates must be honest, trustworthy, reliable, and aware of ethical issues (e.g. confidentiality). They should challenge behaviour that is unacceptable or risks patient safety. Candidates should take appropriate responsibility for their own actions and omissions. Candidates must be resilient and remain calm under pressure. Judgement should not be affected by pressure and candidates should develop appropriate coping strategies. Candidates should communicate (verbally and in writing) concisely and clearly. They should be able to vary their communication style appropriately and to negotiate, and be willing to engage others in open dialogue. Candidates should always show respect to patients. They should adopt a collaborative approach to decision- making with patients as well as maintaining courtesy, empathy, and compassion. Candidates should be able to work in partnership while respecting different views. They should share tasks fairly and ask advice from others when necessary. Despite appearances, the SJT is a knowledge- based examination. It is important to remember throughout that questions ask what you should do, rather than what you would do in any given situation. Therefore, it is a test of whether you know the ‘correct’ action and not whether you would act correctly if working as a doctor. For example, a question might introduce you as an FY1 doctor on a busy ward. You are told to examine an elderly patient of the opposite sex and all the nurses are occupied elsewhere. You might have seen doctors examine patients under these circumstances without a chaperone. You might even think that this would be your approach in real life. However, you know on some level that a better solution is to insist on (or at least to offer) the presence of a chaperone.

Commitment to Professionalism

The Royal College of Physicians (RCP) has defined professionalism as a ‘set of values, behaviours, and relationships that underpins the trust the public has in doctors’. Dame Janet Smith has described professionalism as ‘a basket of qualities that enables us to trust our advisors’. The RCP has imagined some of the qualities that might be included within Dame Janet’s basket as ‘integrity, compassion, altruism, continuous improvement, excellence, and working in partnership’. The General Medical Council (GMC) has taken this further in the ‘Professionalism in action’ section of Good Medical Practice (2013). According to the GMC, good doctors ‘make the care of their patients their first concern: they are competent, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues, are honest and trustworthy, and act with integrity and within the law. They also work in partnership with patients and respect their rights to privacy and dignity. They treat each patient as an individual. They do their best to make sure all patients receive good care and treatment that will support them to live as well as possible, whatever their illness or disability’. The Medical Protection Society (MPS) has, however, been clear that ‘professionalism’ is not the same as ‘perfectionism’. Although professionalism encompasses the ambition to provide high- quality care, mistakes are an inevitable part of working as a doctor. For the MPS, ‘true professionalism comes into play when mistakes are made . . . knowing what to do when things go wrong and how to react appropriately can make all the difference in ensuring high standards of patient care are maintained and a speedy resolution is reached’. Situational judgement questions within this section will test your probity by exploring responses to scenarios that might require you to challenge unacceptable behaviour, maintain confidentiality, and, as always, prioritize patient safety. You need to demonstrate a commitment to achieving your various clinical responsibilities, as well as a desire for continued learning and a commitment to helping the development of others. These scenarios test your honesty towards patients and colleagues, and a willingness to admit mistakes.