► Your nurse is rude and blunt with you and your patients all morning, which is very out of character for her – what are some of the things you must take into consideration and what possible steps might you think about taking?
First and foremost, Seek Information: is there something going on in the nurse’s personal life, has something happened at work this morning, or is the nurse simply just having a “bad day”?
Show Empathy and understanding in the fact that work and personal life can be stressful, and sometimes we might need to just take some rest and time to recuperate. Suggest possible actions to the nurse, such as taking the rest of the day off (provided that you have a suitable replacement available in the practice) or just taking an hour off to compose herself. Her Response will be important because you need to remind her that whilst she is at work, the patient’s care and safety needs to come first, and possible consequences could include harm to the patient.
Consider exploring the following topics with the nurse:
Has something happened at home?
Has something happened at work?
Was it something you said or did?
How can you help the situation? Is there someone you can talk to in order to mediate the situation?
What do you need to do immediately – should the nurse take some time off? Or seek some help?
What do you need to do long term to stop this occurring again?
Does the nurse need more professional help such as with a counsellor?
► You notice that one of the other doctors at your practice is acting in an unethical manner and carrying out treatments that the patient does not need. What would you do?
Take care when answering this question – you have an overall duty of care to the patient and they must be your first priority. You should consider the different avenues of raising your concerns – should you speak to the doctor, or the practice manager, or the GMC?
You must not take one polarised opinion, rather take a balanced view and weigh all the information up. For example, you do not know what the doctor had planned for the treatment and there may be a logical and acceptable reason behind his treatment. You should not keep quiet if you have concerns, but raise it with someone who has greater authority than you. They should then investigate accordingly. You should not escalate the situation too quickly (for example, to the GMC) before understanding the situation and informing those above you.
Therefore, you must first Seek Information and clarity on the situation; as mentioned, there may be a perfectly valid reason for treatment, which you have not been aware of. Next, show empathy and understanding when speaking to the doctor; tell them you understand the stress of reaching annual UDA targets and that it is very difficult for everyone, but we should not be completing unethical and unnecessary treatment just for our own benefit. You should see what Action the doctor wants to take, and you may be required to follow up with a Response such as alerting your practice manager or principal doctor to investigate, providing the original doctor understands the possible Consequences. Finally, your main priority is to ensure no harm comes to any patients, and you may need to escalate the issue further (for example, to the GMC) if you believe patients are coming to harm.
► You are a 3rd-year medical student and you see the exchange of two other medical students on Facebook, discussing patients on a private page. They refer to the patients as Mr X and Mrs Z, but they still use some identifiable features such as the diagnosis and treatment of both. What should you do?
You should contact them immediately. Explain to them that they must not discuss professional experiences online. Even though it is a private page, access can still be gained by the public, or the posts could be shared by another member of the page onto a public domain. It is still possible that they could be identified indirectly, and that would breach confidentiality. Explain to the students that their exchange breaches confidentiality and risks damaging public trust in the profession. Recommend that they delete the conversations immediately and do not post further. If they refuse to do this, advise that you would have no option but to escalate this further to the responsible bodies within the medical school.
► This station includes a scenario where a patient has difficulty attending a GP surgery. The patient is normally in pain and requires emergency treatment. Your task in this station is to determine the issue, discuss the possible consequences of the situation, the best management and how it could be remedied. You should also discuss the wider implications on the community that this situation may impose.
In the scenario, you will be given one of many different reasons as to why the patient cannot attend the clinic. For example;
The patient may be frail and elderly, and thus unable to attend alone.
The patient may have learning difficulties or may be deaf or blind and require a carer to bring them.
The nearest doctor may be extremely far away with poor transport links for the patient to use.
The patient may be wheelchair-bound and there may be steps into the practice with no wheelchair ramp
Whilst this is by no means an exhaustive list, it serves to give you a rough idea as to the different issues that arise.
The main topic of discussion in this station should be equality, fairness, and the right for everyone to receive healthcare and medical treatment. If you are unfamiliar with these topics or would like a reminder of how these link to the NHS Values and General Medical Council (GMC) Principles, follow the link to those sections. Your discussion should demonstrate your thorough and deep understanding of the principles of medicine and healthcare, and the purpose which clinicians serve.
Your answer should be thoughtful and well constructed. We recommend that you answer the station with the following structure proposed below. Of course, there will need to be much room for adapting this structure, as you may be interrupted by the examiner if they wish to probe a specific point you have made further. This merely serves as a rough guide:
Acknowledge the topics that are to be discussed first. You may wish to do this through a brief summation of the key points of the station. For example, you may wish to highlight that the patient who requires a wheelchair ramp to access the practice is being denied to the right to treatment through a lack of equality and diversity. Link this back to your understanding of the NHS or GMC rules and guidelines; both the NHS and the GMC declare that all patients should be treated equally, given equal right to access and receive treatment, and should not be denied this right due to a disability, physical or otherwise. It could even be argued that this lack of access to basic healthcare could even be a breach of the patient’s human rights.
You should then discuss the possible consequences. There are many avenues of discussion here, but you should think about the implications that this situation would have on:
The patient – if they are in pain, the pain could get worse. If there is an infection, it could become life-threatening. The patient may associate this negative experience with all future doctors and therefore may develop a fear or anxiety towards the doctor. They may also decide not to return to a doctor at any point in the future, so their oral and overall health may deteriorate.
The practice – the practice could develop a poor reputation as an unwelcoming or unaccommodating practice in the future, deterring future patients away from them. The practice would also be in breach of its commitment to the NHS and GMC standards, as they are unable to treat patients who require wheelchair access. This would have legal and ethical repercussions to consider.
The community and the medical profession – consider the wider impact this situation may have on the community. There may be more patients who are wheelchair-bound or require assistance with access to medical practice in the community. They will also be unable to attend and receive treatment. This means that ultimately the community’s overall health would suffer, and there would be implications that could subsequently follow. For example, patients who are unable to access the medical practice may then deem it appropriate to attend A&E. This would, unfortunately, be a use of limited NHS resources in the hospital setting as they would likely not have any equipment or material required to help, whereas the medical practice is specifically designed to help relieve medical pain and problems. In addition, eventually, the reputation of this practice will be tarnished as one which lacks equality and fairness, and this reflects badly on the medical profession as a whole. One of the GMC Standards is to uphold the reputation of the medical profession and to never create any reason for the patient to mistrust the profession; clearly, by breaking this trust, the practice has jeopardised medicine’s status into one of disrepute.
Finally, you should discuss the potential ways in which the situation could be corrected, as well as how the medical profession can ensure that such a situation does not occur anywhere else. Consider the immediate actions that the practice can take (for example, do they have alternative access at the rear of the building that the patient could safely use?), then consider the more long-term management (for example, building a dedicated ramp with an assist button that would alert a member of reception to come and help). You should also consider the actions that the wider community and the NHS could take. Is there scope for domiciliary visits from the doctor? Domiciliary visits are where the doctor is contracted to travel to the patient and treat those who may be housebound or have difficulty with transportation. Should there be more regular assessments from the NHS and their Care Quality Commission (CQC) in determining how accessible a practice is for patients?
Once you’ve discussed these, it is always recommended to summarise your most important points. This allows the examiner to determine how much of an understanding you have on the situation, and then allow them the opportunity to ask any further questions they may wish to. If at any point you are unsure of the answer to an issue, do not attempt to waffle your answer. Clearly explain that you are uncertain, but then using logical and judgement, deduct a sensible and well-reasoned argument and justify your decisions.
► You are the executive of a charity which funds many local causes. Your budgets have been cut significantly and you need to choose 1 out of the list of following causes to keep running (for example, a) sports club for 10-year-olds, b) a food bank that helps the homeless, c) transport services for disabled patients to and from hospital appointments). Justify your choice and explain what impact this will have on the local community.
Clearly, this is a difficult ethical decision to make. You should make this clear in your answer – that there are serious repercussions to choosing one of the options and leaving the others. You should think outside of the box and come up with an original idea. In your answer, you should make clear that, where possible, you would try to consult others who may have more knowledge, intelligence or experience in the particular area. This shows your thoughtfulness and your ability to acknowledge that you may not have all the answers yourself. In this way, you can demonstrate that you are willing to learn from others, too.
Your answer should weigh up the pros and cons of each option, and be sure to discuss your train of thought with the examiner. Discuss whether there could be other contingency plans in the local area to help these causes: for example, if there were other charities that worked solely on daycare for disabled patients, it may be easier to negotiate to help one of the other causes that require more assistance and help.
Finally, your decision should be made based on which option would make the biggest difference, to the biggest group of people. For example, in this given scenario, a food bank serves a much greater benefit to the local population than a holiday club for a small group of school-children. Do not forget to answer the question FULLY, as the second part asks you to elaborate on the possible impact this may have on your community.
► You are given a list of gifts you have received from patients (iPad, signed picture of the patient’s favourite music band worth £2500, Christmas card, chocolate, wine bottle). Rank them in order of appropriateness. Why have you put them in this order?
Whilst the act of receiving a gift from a patient is not forbidden, certain items are frowned-upon and doctors are recommended to politely decline. As a general rule, small items with a monetary value of less than £30-40 are generally agreeable to accept. This includes items such as Christmas cards, boxes of chocolates, bottles of wine or small personal items; it is generally seen that accepting small gifts which show the patient’s appreciation of your time and effort strengthens the bond between doctor and patient.
Items of high value, such as electronic equipment, extremely expensive personal items or gift cards, are best avoided as they may be seen to burden the doctor with the expectation of delivering free treatment for the patient next time or “returning the favour”. With these items, you can politely decline the patient’s gift and inform the patient that there are certain rules or regulations around gifts in medicine and that some cannot be accepted. Reiterate that you appreciate the gesture and importance of the gift very much.
In this given question, ranking the Christmas card, chocolate and a bottle of wine above the iPad and the expensive signed photograph will award you the marks needed to succeed in this station. The exact order is of little importance provided that you can justify it – for example, you may select the expensive signed photograph as more appropriate than the iPad because you may have discussed the music band with your patient and developed a bond over their music, whereas the iPad has little emotional significance.
► You are in a nightclub with some friends who are doing the same course as you. One friend brings a bag of white powder which you suspect is cocaine. What do you do?
All ethical scenarios are extremely difficult to tackle. In order to answer an ethical scenario such as the one above, candidates need to understand the underlying principles of ethics in medicine. Ethics and ethical decision-making can be broken down into an individual choosing one moral imperative (also known as an ethical pillar) over another. Moral imperatives can be seen as “unbreakable golden rules” that an individual abides by. Examples of moral imperatives include: being honest, being loyal, do no harm to others, keep your promises, respect others, always be kind, compassionate and caring.
These imperatives usually guide an individual into doing “what is right”. The difficulty of the medical school ethical scenarios lies in the fact that usually two or more of these imperatives conflict with each other, and candidates must decide which imperative they keep, and which (if any) they break.
Within medicine, there are 4 moral imperatives or ethical pillars that must be followed:
Autonomy: this means that patients have the right to make their own decisions regarding their own health, even if you believe they are making the wrong decision. An example of this could be a situation where an individual refuses to have a filling in a tooth that has decay; if viewed from the medical profession and their perspective, this is the wrong decision as the decay could progress, lead to infection and ultimately pain. However, patient autonomy dictates that the individual is free to make their own decision, and thus you cannot force them to have the filling done. Autonomy becomes very complicated if a patient is mentally ill and has been deemed unable to make decisions for themselves. For the purpose of the medical interview, you do not need to worry about this disparity.
Non-maleficence: this pillar means that medical professionals do no harm to their patients
Justice: This pillar focuses on the impact a medical professional’s actions could have on the wider community. For example, a doctor should not be using a medicine or treatment that is extremely scarce or expensive on a patient who does not need it, because it would be a waste of resources that could have been beneficial for the wider community and someone else who truly needed it.
Beneficence: all the actions a doctor carries out must benefit the patient. In other words, doctors must do good.
When tackling an ethical scenario, you must first decide whether any of the four ethical pillars of medicine are involved. If they are, these are your first priority and must be addressed immediately. If none are apparent, then you must refer to your own personal moral imperatives. Please be aware that many of your own personal moral imperatives may fall within one of the 4 medical ethical pillars; for example, your personal belief of “always being honest” would fall under the pillar of “beneficence” because you are providing patients with the truth of the situation, which ultimately helps benefit them because they are able to use their “autonomy” to decide what decision they want to take.
In addition, you must then consider the NHS Constitution and the GMC Guidelines, both of which outline how a medical professional must act. In this scenario, your friends (who are also medical students) are taking illegal drugs. This complicates the situation further because there is now a legal aspect of the scenario that is beyond ethics. It is widely acknowledged that drugs are commonly used among university students, but this does not make it acceptable.
When answering this scenario, you should make it clear to the examiner that this is not an easy decision and that many factors are involved. You must account for the 4 ethical pillars of medicine, as well as your own moral imperatives. Then, you must also account for the NHS and GMC guidelines that doctors (and medical students) are expected to follow and respect. In answering ethical scenarios, often the best answer does not commit to one path of action but considers many “ifs and buts” that could alter the course of actions. In other words, having an answer that is developed around an “it depends…” logic is often a very good one.
The first factor to consider is whether everything you have seen or heard is an absolute fact. Are you sure the bag of white powder you have seen is definitely cocaine? Could it just be a fake powder that your friends pretend to consume to “look cool”? You must acknowledge to the examiner that you cannot act rashly because you do not have all the facts and you are acting based on assumptions. As a result, you should not act immediately or without careful thought.
Next, you should acknowledge that there are multiple different things that you could do. Remember, in these ethical scenarios, there is usually no right or wrong answer, and the examiner wants to see how you think logically and deal with an ethical dilemma. You should explain that there are imperatives here that are being broken, both by your friends and also by yourself. If the students are indeed taking cocaine, then they are acting very irresponsibly. Your primary concern should be the safety and well-being of the patients that may come into contact with the individual who may be taking drugs.
The GMC clearly advocates that your primary duty as a doctor or medical student is to your patients. If you feel that patient safety is at risk due to a colleague’s conduct, performance or health, then you have an obligation to take steps to protect them. The day after the event, you should speak to your friend privately; tell them that you will support them but that the matter needs to be brought up with a senior at the university. If your friend refuses to do so, then you must inform them there is no option but for you to do that personally. Universities will all have a thorough protocol on dealing with situations such as this, so it is not necessary for you to take on the burden by yourself.
► You suspect some of your medical student friends are taking drugs on a night out. What are the ethical considerations that are relevant to this situation?
There are many ethical and legal issues that you must take into consideration. Your answer should be carefully organised and logically discussed.
a) Consider the aspects related to the law: taking certain drugs is against the law, and punishable by legal sentencing. You must not be guilty of participating in any illicit activities, but ideally, neither should your friends. Is this an issue that you would raise with the police? Or would you privately discuss your concerns with the friends taking the drugs?
b) Consider aspects related to the individual’s health: drugs are harmful and damaging to the human body, and many are addictive in their nature. Your best interests should also be in the health and well-being of your friends. If they have taken illegal drugs that night, your first priority should be their health and safety.
c) Consider the reputation of the medical school, and the possible consequences within medicine: on a night out, you are likely to interact with members of the public, some of whom may be patients at the hospital. What image does this present of medical students? Does this image reassure patients of their own safety? Would the student be safe in carrying out medical treatment the following day or the following week on a patient?
d) Consider the GMC and NHS guidelines and constitutions. Should you be alerting faculty within the medical school of what you have seen?
This is clearly a very difficult scenario which would not only test your loyalties to your friends but also tests your responsibility as a future medical clinician and healthcare professional. Although the obvious answer may be to alert the police that there is an illegal activity being undertaken, this would jeopardise the future prospects of your friends, irreparably damage the friendships you have built, and also tarnish the reputation of the medical school. It may be wise in this scenario to avoid giving a definitive answer as to what you would do. Instead, explain to the examiner that it is a very tough decision to make, but that you would need to take in all the factors discussed above, along with the unique considerations of the exact event at the time.
If you feel that any individuals’ safety or health are at immediate risk on the night out, you should explain that you would alert someone and raise concerns with those who can help. If there is no immediate risk of harm, then it may be wise to spend some time carefully thinking about the options, and raising your concerns with those of greater responsibility, such as staff members of the Medical School or Liaison Officers for the university, thus allowing them to decide the proper course of action. Universities will all have a thorough protocol on dealing with situations such as this, so it is not necessary for you to take on the burden by yourself.
► You are a doctor working in general practice. Your team are approached one morning by the police, requesting information regarding one of your patients. Can you provide this information?
The issue of confidentiality and the patient-clinician trust is raised here. Ordinarily, the strict confidentiality laws prevent you from disclosing information regarding a patient unless there are specific extenuating circumstances to override this. One such situation is in relation to the police. The police are not automatically entitled to access personal patient data and information unless they produce a court order.
In the absence of a court order, information can still be given to the police, provided that it has been confirmed that it is to prevent or detect serious crime, including apprehending or prosecuting offenders. However, this is an extremely “grey area”, as it is still technically a breach in the patient’s confidentiality and you may be liable to repercussions as a result. When considering such a breach, the doctor must be satisfied that there is a definite public interest or justification. It would be extremely unwise to make any serious decision such as this alone, and it is always recommended to discuss the situation with other senior members of the team, such as the principal doctor and the practice manager, as well as the doctor’s indemnity (the legal advisors who are assigned to advise and protect the doctor). Without any further consultation, it would be extremely unwise to breach the patient’s confidentiality, even at the request of the police.
If a court order can be provided, then the information can be passed as required. However, the medical team must ensure that it is only information that is absolutely necessary, and nothing further. It would still be wise to communicate any transfer of information to the police with the principle doctor or practice manager before doing so. This should all be documented accordingly and accurately.
► The mother of a 17-year-old boy phones the practice requesting information on the treatment her son is having at the practice. He always attends alone and lives with his father. What should you do?
This scenario raises the topic of confidentiality once more. The information regarding any attendance to the doctor, any treatment planned or completed and any personal information that the son communicates with the practice is strictly confidential. The information can be disclosed to the mother provided that there is express permission from the son (which should be documented accordingly).
In the UK, the legal age of consent is 16, thus meaning that the patient can receive medical or medical treatment without parents’ consent or knowledge. In addition, you should review the material on Gillick Competence covered in our Ethics Section for further explanation and analysis.
► How would you deal with a patient who is HIV positive or has AIDS?