User:Consultantinterview/NHS consultant interview

The appointment as consultant is considered as a pinnacle of medical career. Consultants in NHS are appointed by an Appointments Advisory Committee (AAC) at interview.

The make-up of an Appointments Advisory Committee (AAC) is laid down in a Statutory Instrument (The National Health Service – Regulations 1996 No 701). The core membership of the committee is as follows: •	A lay member (non-executive director) •	College assessor •	Chief executive •	Medical Director •	At least one consultant from the employing trust •	If the job includes a substantial research or teaching commitment a further representative of the local university is required. The questioning usually follows a set pattern and in the following order:

•	College Representative •	University Representative •	Hospital Consultants (usually 2) •	Medical Director •	Chief Executive •	Lay Chair

College Representative: Usually same speciality but from outside the region. He is there to see if you are appointable. They could ask about your specific training for the post for which you are applying. Will ask you about General Medicine experience, specialty experience etc University Representative: Only present if there is a major teaching commitment so you will be asked about teaching and your experience and ways in which you know you are a good teacher e.g. feedback from students. He will also ask about research interests, publications, why/why not academic post. Hospital Consultants: You should know them already from pre-interview. They will ask what you will bring to post, how you will improve their department, how you will fit in their team, etc. They are the most interested parties there. Be positive it is surprising how few people can sell themselves. Medical Director: is concerned with Clinical Governance and Safety. May ask you about audit, complaints, safety concerns etc. Chief Executive: How will you benefit the trust? Your management experience and your understanding of NHS policies. Where do you see yourself in 10 years time? Lay Chairperson: Usually a non-executive member of trust board. They will run the interview. The lay chair will want to know a bit about you outside medicine.

The interview lasts around 45 minutes or more. The interviewers will have clarified their objectives in general and decided on a format and a set of questions for each interviewee. Commonly, AACs take a formal structured approach where the interviewers take it in turns to ask questions reflecting their particular interests. In the final stage you will be given the opportunity to ask questions and the Chair will inform you of how the result will be conveyed.

Questions- Most questions asked map to a theme like about yourself/CV, teaching, research, management related questions etc.

Few examples of interview questions at medical consultant interview:

Isn't clinical governance only for doctors, nurses and allied health professionals?

Definitely not! Clinical governance is for everyone. It relates to all people who are involved in the treatment and care of patients. Clinical governance is the appropriate governance (or control) of clinical (patient health) care, and therefore encompasses everything that has any impact on the quality and patient experience of that care. This means that it ranges from issues of cleanliness, comfortable environments, good food and excellent communication through to the skills required to produce first-class results in complex operations. Similarly the domestic worker on a hospital ward has a key role to play in ensuring a clean and pleasant environment for patients, as well as helping to control infection. Other NHS staff, such as office based managers and secretaries also contribute to high standards of care. They may never see a patient during their working day, but they have a responsibility for making certain that all aspects of their work take account of the quality and safety of care to patients. So all NHS staff, whatever their role, are responsible for making sure that their own contribution to the massive jigsaw that makes up health care provision is delivered to the highest possible standard for patients – and that’s what clinical governance is all about.

How do you think a blame-free culture can be brought about in the NHS?

•In aviation, airline staff is rewarded for reporting mistakes and failures. More importantly, they can be disciplined, if not sacked, for not reporting. That says something about the culture and the pride which airline workers have in their safety record. •What will it take to instill that sense of pride about safety in NHS staff? We recognise that there may be many barriers to creating a ‘blame free’ culture. But we feel that many of those barriers are psychological, the fear of what someone else could do to you. Part of that process is helping NHS staff realise they don’t need to feel threatened or feel guilty about reporting after they’ve done so. We’ve got to look after the staff and recognise the traumas that many staff experience from being involved in adverse events.

How would you manage the budget?

A budget is essentially a financial plan for the short term, usually one year, allocated to each department. The budget is divided between pay or fixed (staff related expenditure) and Non-pay or variable expenditure (goods and services) to cover all the running costs of the department for the duration of the budget. The process of managing the budget can be broken down into 4 stages •Establish actual position- In general, the budget can be divided into monthly blocks. It is important to focus on the future position to control the budget. The calculation of out-turn (Amount of spend to date/number of months to date X12 equals projected out-turn) formula will provide the year end position for pay and non pay expenditure. •Compare actual expenditure with budget totals- this will indicate whether the budget is over or under spent and help you identify the spending pattern. For e.g. use of bank and agency staff will create potential overspending, thus careful monitoring is essential. •Establish reasons for variance- Variance is the difference between the budgeted amount for the month and the actual amount spent. The reasons for variance must be sought. It could be due to an anticipated increase or decrease in workload and therefore be of no particular concern. However, variance may be completely unexpected and in such cases the reasons must be found •Take action- Variance could be due to mistakes. Items may have been wrongly attributed to a budget or miscoded and end up in the wrong division of the budget. These problems can be corrected with the help of the finance manager. The budget must be checked for every transaction and corrected where necessary.

What do you think about management issues? Do you think it’s something we should he getting involved in as clinicians?

•Clinicians serve the public and the patients by using their skills to provide the best possible advice, treatment and care. But we can only do this if the money available to the NHS is used well. Failure to do so results in less care and of a lower quality. Money will only be used well if clinicians are fully engaged in managing it. Ultimately, it is clinicians who are responsible for the way in which services are delivered to individual patients and it is they who commit the necessary resources. •Improving the quality of care and providing more responsive services for patients can only be achieved by strong involvement of local clinicians in the management of the service. •This includes having the understanding, the tools and the ability to manage resources effectively and use them well to the benefit of patients. This will empower them to lead change and improve services. Without clinical involvement, the progress will be much slower and the outcomes poorer. •This is not about focusing on cost and cost alone. It is about how money can best be used to improve the quality of care, combining operational and clinical effectiveness. Efficient use of resources and good quality services go hand-in-hand.

What is your approach to resolving conflict?

Conflict is an inevitable part of all relationships and is not in itself an indicator of a poor team. It causes a team to function badly only when it is not addressed. The conflict needs to be addressed at once. Often when the problem is pointed out early, and discussed, resolution follows. If this is not possible, then dispassionate fact-finding may be necessary. In resolving conflict, be tough on problems, not on people. Here are some possible conflicts and suggested solutions for each. If these issues occurred in your team what do you think the response could be? •Is one member being blamed for all the team’s problems? This is often the sign of a dysfunctional team, so look at what else is going wrong before you act. •Is one individual behaving badly? Talk to them personally. •Is team leadership at fault? Think about what you could do differently and let the team know how things might change. •Has the team become divided? Re-establish the overriding team goal and bring everyone in on how to achieve it best. •Can the conflict be used constructively? Take the problem seriously and explore all possibilities.

How do you deal with a difficult colleague?

Dealing with a drunk colleague (as an example)

My first concern would be the safety of the patient. However I have a duty of care to my colleague and the hospital too. Patient safety- I will talk to my colleague/consultant and send him home. (if difficult enlist help of another consultant or clinical director). I will review all the patients seen by him and complete the ward round. I will also recall all the patients discharged by him. I will ensure that appropriate cover is arranged for him, if needed. Duty of care to colleague- I will arrange a taxi for him to go home and check on later to ensure he has reached home safely. I will discuss with him (if consultant- will pass on the incident to clinical director) and try and help. You could suggest occupational health referral. Insist that his behavior was not appropriate. Duty of care to the hospital- Keep accurate records and inform your consultant or clinical director. Background You must protect patients from risk of harm posed by another colleague's conduct, performance or health. The safety of patients must come first at all times. If you have concerns that a colleague may not be fit to practice, you must take appropriate steps without delay, so that the concerns are investigated and patients protected where necessary. You have a few options: a.You can report your concerns to your clinical or medical director b.You can discuss your concerns with National Clinical Assessment Service (NCAS). NCAS can provide advice on local procedures and may assess the practitioner to clarify any issues and then offer recommendations for resolving the concern. c.Report your concerns to the GMC If you think the action taken has been insufficient, contact the GMC. Acting on concerns about a colleague is never easy but all NHS staff have a professional duty to do so in order to protect patient safety and help the practitioner involved.

Where concerns about performance have arisen it may be helpful, at any stage of the process, to consider why this has happened. THINK ABOUT:

The individual’s health and other factors

•	Does the individual have a physical or mental illness? •	Is the individual depressed or suffering other mental illness? •	Might alcohol or substance misuse be involved? •	Has there been a recent major life event?

Knowledge, skills and behavior

•	Is there a difficulty with clinical knowledge and skills? •	Might a deficiency in education, supervision or continuing professional education be contributing to the problem? •	Was the practitioner’s induction appropriate or sufficient? •	Does the individual have difficulty understanding the limits of their competence? •	Is the problem predominantly one of the practitioner’s behaviour or attitude? •	Is this new behaviour or is it an exacerbation of long-standing problems?

The job

•	Have work factors changed? •	Is there a problem with technological advances or techniques? •	The work environment •	Are there team difficulties? •	Have there been major organisational changes? •	Could issues relating to equality and diversity be a problem? •	Could bullying or harassment be a problem? •	Are there any systems issues that contributed to the performance difficulty?

How would you react if one of your female junior colleagues refused to treat a patient who is a known rapist?

GMC guidance-If carrying out a particular procedure or giving advice about it conflicts with your religious or moral beliefs, and this conflict might affect the treatment or advice you provide, you must explain this to the patient and tell them they have the right to see another doctor. You must be satisfied that the patient has sufficient information to enable them to exercise that right. If it is not practical for a patient to arrange to see another doctor, you must ensure that arrangements are made for another suitably qualified colleague to take over your role. All patients are entitled to care and treatment to meet their clinical needs. You must not refuse to treat a patient because their medical condition may put you at risk. If a patient poses a risk to your health or safety, you should take all available steps to minimize the risk before providing treatment or making suitable alternative arrangements for treatment.

How would you react if a patient refused to be treated by one of your junior doctors because he is foreign?

First ensure that the patient is compos mentis. Most trusts will have a policy governing the racist behavior. Racist behavior would be considered an assault on a member of staff under many trust policies. Most trusts have a zero tolerance policy towards abusive patients and care may be withdrawn for persistent offenders.

Most trust policies would recommend

a.	Explain to the patient that their behaviour is unacceptable and explain the expected standards of behaviour, which must be observed in the future. b.	If the behaviour continues, the responsible clinician will give an informal warning about the possible consequences of any further repetition. c.	Continued behavior after a formal warning will lead to immediate exclusion from the Trust premises by the security staff/police. Such an exclusion from Trust premises would not mean that he would not receive care, as his clinician would make alternative arrangements for him to receive treatment.

Tell us about an ethical dilemma you have been involved in?

Remember, Medical ethics rests upon four key principles: •	The principle of autonomy – individuals have a right to be self-governing •	The principle of non-maleficence – the patient should not be harmed •	The principle of beneficence – the benefit of the patient should be promoted •	The principle of justice – equals should be considered equally Two representative examples of ethical dilemma: Mary is clinically depressed and take a lethal overdose. She leaves written instructions asking not to be resuscitated. If you arrived at Mary’s side in time to do so, would you resuscitate her? Living wills (advance directives) are valid in English Law. However, an advance directive must be written by a person who has mental capacity. We do not know if Mary had psychotic depression. Nor do we know if she understood the consequences of her refusal of future treatment. The clinician should treat Mary until she is sufficiently competent to make her own decision about further treatment. The legal defence of 'necessity' would cover any treatment (including resuscitation) which was necessary to protect Mary's life, and which could not reasonably be delayed. The idea of this question is to discuss an ethical dilemma. The most important bit of the answer is how you dealt with it. So in the above question, you could have discussed with the psychiatrist to get further guidance. (so define the dilemma and then discuss how you resolved it) Another example

Mike is in a persistent vegetative state. Mike is legally alive (spontaneous resp and heart beat) but a decision to withdraw nutrients and antibiotics with the intention of ending his life would not necessarily be unlawful. There is no legal duty to provide treatment that is no longer considered in the patient’s best interests. Although the withdrawal of life support is factually the cause of death, the legal characterisation of this ‘terminal regime’ as acting in the best interests of the patient, means that the causative action has no legal consequences. 11.	You see a patient verbally abuse a nurse. What is your response? Firstly ensure that the patient’s behavior is not due to his/her underlying medical condition. If it is willful, warn the patient that the behavior is unacceptable. If the patient persists he should be given a formal warning. If the behavior is repetitive, he may be removed from the trust premises by the hospital security. However, his care should not be hampered and the responsible clinician should make adequate arrangements for transfer of his care. Most trusts have policy regarding dealing with violent/abusive patients.

One of your peers arrives constantly late for work in the morning. What do you do? For minor concerns (coming late) about performance an informal approach may be all that is needed. Here, a discussion with the individual concerned, aimed at improving their performance or conduct, may be sufficient to resolve the issue. Dealing with the matter informally provides the opportunity for both parties to agree the way forward without the use of formal disciplinary or other procedures. Even if an informal approach is taken, the outcome of the discussion and agreement reached should be communicated to the practitioner in writing and notes kept of all meetings held.

One of your junior colleagues is placing patients at risk. How do you react? The patients safety is paramount. So notify immediately his supervising consultant. In general, Interventions to improve the practitioner’s performance may include the following: • An educational programme: clinical, personal or organisational skills • Referral to occupational health with onward referral and follow up of any health problems • Mentoring by a trusted practitioner • Supervised practice • Behavioural coaching • Modification of duties.

Describe how you would manage the diverse demands on the service given the resource available to you?

This is essentially about setting a budget and managing it.

Setting a budget- this depends on forecasting the numbers of patients, patient days, nursing resources needed, other costs of supplies and personnel etc. Decisions on setting the budget should be based on reality and real trends rather than historic data.

The process of managing the budget can be broken down into 4 stages

•	Establish actual position- In general, the budget can be divided into monthly blocks. It is important to focus on the future position to control the budget. The calculation of out-turn (Amount of spend to date/number of months to date X12 equals projected out-turn) formula will provide the year end position for pay and non pay expenditure. •	Compare actual expenditure with budget totals- this will indicate whether the budget is over or under spent and help you identify the spending pattern. For e.g. use of bank and agency staff will create potential overspending, thus careful monitoring is essential. •	Establish reasons for variance- Variance is the difference between the budgeted amount for the month and the actual amount spent. The reasons for variance must be sought. It could be due to an anticipated increase or decrease in workload and therefore be of no particular concern. However, variance may be completely unexpected and in such cases the reasons must be found •	Take action- Variance could be due to mistakes. Items may have been wrongly attributed to a budget or miscoded and end up in the wrong division of the budget. These problems can be corrected with the help of the finance manager. The budget must be checked for every transaction and corrected where necessary.

Tell me how you would bring this new technique into the trust?

You may be required to set up services not presently in existence how would you go about this? How will you make sure those patients playing a part in the set up of the service?

The steps to setting up a new service/technique are

Defining the need- •	Why new services are needed? Will the service alleviate a significant risk to the trust? Will the service help the trust and/or PCT meet government targets? Does the service fit in with the trusts strategic direction? Demand and capacity theory is at the forefront of a lot of modernisation work. You will need to demonstrate that the demand on your service exceeds its capacity, whether that is staff, buildings or equipment. Activity data is a powerful tool and most trusts will have an Information Team who would be able to provide you with a range of activity information linked to you or your service

•	Costs and benefits of the services Costs- assess the resources required including staff. You will need to discuss the funding with potential sponsors. Sponsors could be your own trust or the PCT. What type of funding might I access? There are two types of funding: revenue (this funding is added to your budget year on year; for example, staff salaries have a revenue implication) and capital (this funding is a one-off resource allocation and is usually linked to equipment or buildings). Where would the funding come from? Trust Capital, PCT or SHA. Various incentive schemes - can provide useful funding opportunities. This type of scheme will usually have a proforma which will tell you the information that will be considered in the bidding process - it will also be explicit in what it requires to be delivered in return for the investment, particularly around waiting times and access. •	Write up a business case- stating basically- the need for the services (detail your research) and the cost and benefits of the services. Be clear about both costs and benefits for your department, the organization, the wider community and include immediate, short and long term implications. It is often the financial implications of proposals that carry the most weight and so make the financial case for the changes you are proposing as powerfully as possible.

Your service or general manager will help you write up the business case. They are there to support you in delivering your clinical service. The service manager and/or a member of the financial team can help convert your ideas into the required business case.

•	Implementation- implement the changes gradually with strict monitoring. Audit the service to ensure that the objectives set in the business plan are achieved.

Public and patient involvement is vital in the development and improvement of any services. Services need to be responsive to the needs of the patients and public as they are end users of all services. I would ensure patients involvement in services by involving the public and patient forum as well as regular patient surveys.

Case Study 1 - The Clinical Nurse Specialist

Problem: busy clinics, long waiting list and perhaps an NSF requirement Solution: introduction of a clinical nurse specialist to work alongside consultant teams in clinic and undertake a telephone follow-up clinic. In your business case you will need to: •	establish the case for need •	provide an analysis of current and predicted demand •	assess how the proposal will resolve future service demands (activity flow changes, •	operational policy changes) •	estimate costs of the proposal - capital or revenue - e.g. salary, equipment,accommodation etc. •	provide the associated support costs e.g. perhaps an increase in diagnostics.

Case Study 2 - Medical Equipment

Problem: equipment at the end of its asset life and/or opportunities for advances in equipment to support service provision Solution: replacement of equipment with a revised specification. In your business case you will need to: •	establish the case for need •	provide options for purchase including changes in practice and operational requirements •	cost assessment - total purchase or lease, consumable costs, staff changes and maintenance requirements •	clinical risk assessment and quality advantages •	the implications of ‘do nothing’.

What is your main weakness?

Admit a minor weakness. But present your weakness with a positive spin. Practice responding to this question. It'll take a few dry runs before you sound succinct and articulate. Options: •	My family would probably accuse me of being a workaholic because I can’t relax while there’s something that needs doing. •	Tendency to take your work home (which you can resolve with the help of your family and personal will) •	Impatience- I know I could improve my patience when working with people who don't work at the same pace as I do. What I have found is that by helping such members, I can move the project forward instead of being frustrated and doing nothing. •	My biggest weakness? I would say chocolate, especially milk chocolate. •	No Research background- but you can still say I can critique a research paper and teach my juniors to do the same.

Is a higher degree important in modern medicine and gastroenterology in particular? Do you think all SpRs should do Research?

The government has made a strong commitment to research. Research is (thus) one of the key components of clinical governance. However, it does not mean that all doctors should be involved in research. Research is expensive. Research for the sake of CV will only lead to waste of resources, which can be more appropriately utilized involving people interested in research. You can always involve yourself in research without undertaking a higher degree. You can always support research by helping recruit patients to clinical trials from your practice. However, it is important for all physicians to understand the principles of research as it underpins evidence based medicine. So for example it is important to be able to critically appraise a paper/research paper and form a judgement as to whether the conclusions presented can be implemented in your own practice. These skills are best acquired through exposure to a degree of research but can be gained through journal clubs too or attending appropriate courses.

When will you say a research a good research?

Clearly all research is not well conducted. The quality of the research depends on •	Hierarchy of study design- in the following order RCT, non randomized controlled trial, observational studies, case reports, expert opinion •	Study quality- assessing the study for randomization process, blinding of the subject/investigator, use of appropriate statistics, whether the study was adequately powered, whether the study and control groups were well matched, whether all the study subjects were accounted for in the results etc •	Generalisability- whether you can implement the conclusions of your study to your practice (this will depend whether the study group is in any way similar to your practice patients)

If you are asked to read one section in an article, which section will you read? Why?

Methods section is the most important to me because unless appropriate methods are used to answer the relevant research question- the results and conclusions may be flawed. Of particular importance in methods are- •	Process of randomization •	Whether the investigator and subjects were blinded •	Process of recruitment •	Whether ethics and R and D approval were sought •	Power of the study •	Statistics used and its appropriateness •	Baseline characteristics of the study and control group and whether they are adequately matched

How do you go about setting up a Research project?

Steps •	Asking the right research question. Decide what specific area you wish to research. Once you have decided on a topic, do a literature review of the topic, focusing on research in the last 2-3 years. •	Finding a person/expert interested in the research question. Alternatively you may wish to talk to a unit/person with an established research track record and check whether they have any interesting projects for you •	Arranging funding •	Further steps like Ethics and R and D approval You can read more at http://www.tig.org.uk/research_intro.htm

When doing Research, what is the one most important factor to get right?

Planning, What you want to research and where. Planning a good project (i.e. a project that is practical, feasible and answers an important question) needs thorough planning. A pilot run is also important to ensure that everything is working according to plan.

What specific skills have you learnt which make you a good teacher?

I have learned a lot through experience, observing good teachers and the course. A few of the specific skills which I have learned and regularly employ are

•	Plan my teachings in terms of learning outcomes. This is rather obvious as the purpose of teaching is to foster learning. The purpose of my teaching is to make students think and learn rather than being a source of information and factual knowledge. •	Introduce my teaching by exploring or referring to the background knowledge needed for the session. Subsequent teaching would be organised and structured so that key concepts are presented in a hierarchic order. I would summarize at the end to reinforce key concepts. Handout the lecture notes prior to the teaching so that the learners could focus better. This is based on the cognitive theory principles that learning is a constructive process of schema activation, schema construction and schema refinement. This suggests that existing knowledge acts as a scaffold on which new knowledge structures are built. The learning is likely to be much more effective if prior knowledge is activated before presenting the new concepts. Also the new knowledge would be assimilated better if it is presented in a structured and organized way. The new schema could be further refined and reinforced by summarizing the key concepts at the end. •	Actively encourage students to take charge of their learning and foster deep learning principles. I would provide key concepts and encourage students to search for other relevant material on the issue to develop an understanding. Another powerful underlying principle was one of behaviourist theory that independent learners learn best. Students learn best when they take responsibility of their own learning. •	Create an environment of trust, relationship and mutual respect by being non-threatening, committed and responsive to the needs and aspirations of the learners. •	Provide regular feedbacks and encourage them if they are doing well and guide them in the deficient areas. Positive feedback is important not only from the reinforcement principle of stimulus- response theory but also the learning is likely to more effective and efficient if the learners are informed as to how well they are doing(cognitive feedback principle). •	Provide teaching in a real world context i.e. create a context in which the problem is relevant. Encourage students to construct multiple perspectives on an issue either by suitable examples or by collaborative learning. Very often learners fail to transfer class room teaching to the real world. The teaching should thus be in a real world context and further multiple perspectives should be debated so that the learner can adopt the perspective that is most suitable to them in the particular context. Also for the teaching to be effective the learning of content should be embedded in the use of that content. This would avoid the difficulties of putting the theory in practice (constructivist cognition).

How do you identify your training needs?

By reflecting on my practice

The medical professional is now expected to reflect upon their practice, identify their learning needs, plan and undertake the learning and then evaluate the process.

So I

Review- look at my own life experiences Reflect- sort out what I have learned from these experiences Record- document the insights gained from taking an honest look at myself.

These steps would lead to identification of learning needs. You will next need to think about how or what needs to be undertaken to successfully achieve the identified learning needs. This will help you identify the learning resources needed and a reasonable time scale

How would you ensure that your team is up to scratch?

Use the seven pillars of Clinical Governance to answer the question

•	Education and training- supporting the CPD needs of the team •	Clinical audit- regularly auditing the practice, making the changes and improving the care •	Clinical effectiveness- use of EBM •	Risk management- by promoting a blame free culture, I ensure mistakes are pointed/admitted and lessons learnt. •	Research and development- actively participate in research •	Openness •	Patient and public involvement- to ensure the team is aware of their feedback and responsive to their needs.

I also encourage reflective practice, provide regular feedback and ensure participation of all team members in decision making.

Ref-

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