The clinical scenarios in an ST3 surgical interview look like the ones at core level and they are scored differently. At CT1 the assessors want a safe SHO who resuscitates and escalates. At ST3 they want a registrar who makes the decision: to operate, not to operate, to transfer, to wait. Candidates who answer at core level, resuscitating thoroughly and then phoning the consultant for instructions, lose the marks that matter. This guide is about the decision.
The scenarios that turn on a decision
- The deteriorating patient after a colectomy with a leak on the CT: back to theatre tonight, or radiological drainage, or intensive care first?
- The eighty year old with dementia and a perforated viscus: operate, or palliate?
- The patient on warfarin who needs a laparotomy: how long do you wait for reversal?
- The pelvic fracture with hypotension: the binder, the angiography suite, or theatre?
- The painful cold leg: embolectomy now, or imaging first?
- The massive bleed the endoscopist cannot control: interventional radiology, or the operating theatre?
- The trauma patient who is stable for now in a hospital without the right specialty: transfer, or operate here?
The structure that scores
- Resuscitate first, briefly. The assessors assume you can; say it in a sentence and move on.
- Gather what the decision needs. The specific investigations and their findings, the patient's wishes and their baseline, the family's understanding, the resources available tonight.
- Name the options. Two or three, with the case for each in a sentence.
- Decide, and say why. In the first person: "I would take this patient to theatre tonight because..." If you would wait, say for what and for how long, and what would change your mind.
- Involve the consultant with a plan. The phone call has the assessment, the decision and a question in it: "I think this patient needs a laparotomy now, I have booked theatre and spoken to the anaesthetist, can you come in?" Not "what would you like me to do?".
- Speak to the patient and the family. Consent, honestly, including the risks and the alternative, and for the frail patient the conversation about what the operation can and cannot achieve.
- Say what you would do afterwards: the documentation, the handover, the morbidity and mortality presentation if it is your complication.
The frail patient
The perforated viscus in the eighty year old with dementia is the scenario that most separates candidates, because the right answer is a conversation rather than a plan. Assess the patient's baseline and frailty, find out what they would have wanted, speak to the family and the nursing home, involve the consultant and the anaesthetist, and decide together whether an operation is in the patient's interests. Say that you would be comfortable with palliation if that is the decision, and how you would deliver it. The assessors are scoring whether you can hold that conversation.
The complication you own
The anastomotic leak after your own operation tests honesty. Say what you would do clinically, then that you would tell the consultant what you observed, take part in open disclosure with the patient and the family, present the case at the morbidity and mortality meeting, and reflect on the operation. Do not speculate about blame to the family; do not hide it from the consultant.
The consultant two hours away
The assessors ask it in most scenarios. The answer is that you act: you take the patient to theatre with the consultant on the phone and the anaesthetist in the room, or you arrange the transfer, or you start the interim management, and you document the decision and the conversation. A registrar who waits two hours with a bleeding patient fails the scenario.
The probes
- The patient refuses to go back to theatre.
- The anaesthetist is not happy to anaesthetise.
- The family want to know whether something went wrong.
- What would you do differently in the original operation?
- There is no theatre available for three hours.
Prepare each. The anaesthetist's concern is a safety veto to be understood, not overridden; the family question is open disclosure; the theatre delay is a prioritisation conversation with the theatre coordinator and the consultant.
Practising
Take the ten emergencies your specialty's registrar must manage alone and prepare the decision for each: the options, the choice, the reason, the consultant call. Then have someone probe with the consultant two hours away and the patient refusing. The structure is learnable and the decision is what the assessors are waiting to hear.