Entry to higher anaesthetic training is competitive, with a well documented bottleneck at ST4, and the interview is where candidates with similar portfolios separate. It uses structured stations with two assessors, pitched at a senior anaesthetic trainee who will shortly be the registrar on call alone. This guide covers the questions and scenarios that recur and what the assessors are listening for.
The format
Structured stations, each with two assessors, covering clinical and professional scenarios, commitment and portfolio. Timings vary by round, but the shape is consistent: a clinical scenario with staged probes, a professional or ethical scenario, and questions on your training, commitment and current issues in the specialty. Scoring is against judgement, professionalism, communication and commitment.
The clinical scenarios
At ST4 the assessors expect decisions, not escalation. The scenarios that recur:
- A trainee calls from a remote site with a failed intubation and falling saturations, and you are the senior on call. Then the surgical airway has been attempted and failed.
- Your list is running late and a colleague needs help with a bleeding patient in another theatre.
- A surgeon wants to proceed with an elective case you believe should be postponed.
- An obstetric emergency and a trauma call arrive together out of hours.
- A patient wakes in recovery in severe pain after a failed block.
- A patient tells you in the anaesthetic room that they have changed their mind.
- An ODP tells you the machine check was not done properly before the first case.
- A frail elderly patient with multiple comorbidities needs an emergency laparotomy.
Structure the answer as the senior trainee: the immediate actions, the decision, who you involve and in what order, the communication with the surgeon, the patient and the family, and what you would do afterwards. When the assessors worsen the scenario, make the next decision rather than retreating to the consultant. Say when you would call the consultant and what you would ask for, but show that you can run the first ten minutes yourself.
The professional scenarios
- A registrar asks to do a complex case unsupervised.
- You suspect a colleague has been diverting controlled drugs.
- A consultant's plan is one you believe is unsafe.
- A junior made an error in theatre that reached the patient.
Patient safety first, then information, then escalation through the right route, then support. Know the obligations: the GMC's guidance on colleagues, the duty of candour, the controlled drugs accountable officer. Say what you would do and the next step if it fails.
Commitment and the portfolio
- Why anaesthetics as a career, and what have you done to demonstrate commitment at this level?
- Talk us through your training and what has prepared you for ST4.
- Tell us about an audit or QI project relevant to theatres, pain or perioperative care.
- What teaching have you done, and how would you teach as a registrar?
- What research or publications have you been involved in?
- Which subspecialty interests you, and why?
- What are the biggest issues facing anaesthetics in the NHS, and how do they affect training?
The assessors have your portfolio and will probe: the logbook numbers, your role in the audit, what the research found. Answer with a specific and a reflection each time.
Current issues in the specialty
Expect at least one question on the state of the specialty: the workforce census showing a shortfall equivalent to over a million operations a year, the ST4 bottleneck itself, theatre productivity and the waiting list, anaesthesia associates and the Leng review, perioperative medicine, NAP7 and perioperative cardiac arrest, and sustainability. Pick three, say what you have seen, and say what a registrar can do about one of them.
What the assessors score
Decisions made and explained, awareness of when to involve others, honest handling of complications and errors, communication with surgeons and patients, evidence of commitment at this level, and an understanding of the specialty's place in the NHS. The common failure is the candidate who answers every scenario by calling the consultant.
Preparing
The eight clinical scenarios talked through aloud as the senior trainee, with the worsening prepared. The professional scenarios with their next steps. One minute answers to the commitment and portfolio questions with a specific in each. Three current issues with your own view. Then timed practice with someone who probes, because at ST4 they will probe hard.