The clinical scenario in an advanced training interview is not testing whether you know the guideline. The panel assumes you do; you have passed the RACP clinical examination. It is testing whether you can run the service at the level of a senior registrar: decide under uncertainty, act when the consultant is distant, lead the team, and hold the conversation with the family. Answering it as a basic trainee, by assessing thoroughly and then calling for instructions, is the commonest way to lose marks.
How the scenario runs
A presentation from the specialty's acute core, usually with two minutes of reading time, then questions in stages: the first decision, a complication or a result, a communication task, and what you would do afterwards. The head of unit probes between stages, because the point is to see how you reason when the obvious step is not available.
The scenarios by specialty
Each specialty has a short list of emergencies and hard decisions that units use because they discriminate:
- Cardiology: ST elevation two hours from a cath lab; the unstable broad complex tachycardia; the patient with chest pain and a normal troponin who wants to go home.
- Respiratory: the tiring asthmatic; massive haemoptysis; the patient with COPD and the question of ceiling of care.
- Gastroenterology: the variceal bleed the endoscopist cannot control; acute severe colitis not responding to steroids; the deteriorating patient with liver failure.
- Nephrology: the dialysis patient with a potassium of 7; the acute kidney injury that needs urgent dialysis in a hospital without it.
- Geriatrics: the delirious patient whose family want them home; the fall on anticoagulation; the frail patient and the decision about surgery.
- Oncology and haematology: febrile neutropenia; the conversation about stopping treatment; the patient with a new diagnosis who does not want their family told.
- Endocrinology: the thyroid storm; the adrenal crisis; the patient with diabetes and recurrent severe hypoglycaemia.
- Neurology: status epilepticus; the stroke outside the window; the patient with suspected Guillain Barré and a falling vital capacity.
Whatever your specialty, list the ten that a senior registrar must manage alone overnight and prepare each.
What senior registrar level sounds like
- Decisions, stated in the first person, with the reasoning. "I would start the infusion now and arrange transfer" rather than "transfer should be considered".
- Action when help is distant. The consultant is an hour away or the cath lab is two hours away: say what you would do in that time, including retrieval, telehealth, and the interim treatment.
- Leadership of the team. Who you would delegate to, what you would ask the resident to do, how you would keep the rest of the ward safe.
- Escalation with a plan. The phone call to the consultant has a plan and a question in it, not a request to be told what to do.
- The conversation. When the panel introduces the family or the patient, speak to them. Acknowledge, explain plainly, agree the next contact.
- Afterwards. The documentation, the debrief, the incident report if one is needed, and what you would change.
The end of life decision
Most specialties include a scenario about limits of treatment: the frail patient with a poor prognosis, a family who want everything done, a decision about escalation or resuscitation. Answer as the senior clinician who can hold that conversation: the clinical reality, the patient's wishes if known, the family discussion, the decision, its documentation, and the consultant's involvement. Show that you can lead it and that you know when to bring others in.
Practising
Talk each scenario through aloud against a clock, then have someone interrupt half way with a complication and introduce a family member. The panel will, and the ability to keep structure while adapting is the mark of the top band.