London AFP Applications and Interviews

London AFP Applications and InterviewsDr. Areeb MianAcademic Surgery (AFY1)Cambridge

Content

• London Application + Selection process

• Interviews – Clinical, Academic, and Personal Overview

• Academic foundation programme (AFP) or Specialised foundation programme (SFP)?

• ‘Academic’ changed to ‘Specialised’

Why apply for the AFP?

• Dedicated time to do research

• Develop your research/teaching skills

• Great for building up your CV and portfolio

• Opportunity to set yourself up for future research jobs

• Avoid the SJT factor

• Welcome break to focus on other things

Application process

• Apply at the same time as the normal Foundation Programme through oriel

• You can apply for two separate Academic Units of Application (AUoA)

• (Longlisting), Shortlisting, Interviews, Offers, Cascade

• 48 hours to accept AFP offer in January

• If you accept – you are withdrawn from the national foundation application pool

• Still have to ‘pass’ the SJT

Academic Unit of Applications (AUoAs) vs FP Deaneries

• 15 AUoAS across the UK vs 20 Foundation Programme Deaneries

• e.g. London and Kent, Surrey & Sussex = 1 AUoA• e.g. Cambridge = 1 AUoA

• Can apply for 2 AUoAs

Stats

https://foundationprogramme.nhs.uk/resources/reports/

London AFP Application Timeline

Applications open (8th of September)

Applications close (22nd of September)

Applicants informed of shortlist score (13th October)

Applicants invited to interview (26th October)

Initial offers made via Oriel (12th January 2022)

London AFP programmes

Ranking preferences

• Think carefully about what jobs you rank as you may end up with job you don’t want

• Be aware of the cascade system

London Longlisting – Decile cut offs?

Year Decile cut off score2019 402018 392017 382016 42

NO longlisting using EPM (decile) scores this year!

https://london.hee.nhs.uk/recruitment/medical-foundation

London changes this year

https://london.hee.nhs.uk/recruitment/medical-foundation

London Shortlisting/Scoring

London Shortlisting/Scoring

London Shortlisting/Scoring

Final score

White space questions

No WSQs for London

Harry will discuss these in his talk

FAQ about AFP/SFA

https://foundationprogramme.nhs.uk/faqs/academic-foundation-programme-faqs/

https://london.hee.nhs.uk/recruitment/medical-foundation

Summary of Application Process

If accepted: Withdrawn from foundation programme applicationIf declined: Return to normal foundation programme application

Offers (48 hours to accept/decline) in January

Interviews

Shortlisting

Rank preferences within AUoAs

Apply to up to 2 AUoAs alongside FP application

Tips to boost your application (younger years)

• Presentations

• Publications

• Prizes (medical school, conferences, competitions)

• Teaching/Leadership experience

• Intercalated BSc

AFP INTERVIEWS OVERVIEWClinical and Academic

Interviews Overview

• Every AUoA interview structure will be unique

• Common mixture of features including• Clinical• Academic• Personal• Ethics & Professionalism

• November to January • Often two separate interview stations (can be combined or more)• May have option to choose or are automatically allocated a slot• Start preparing after applications submitted

Beneficial for future applications – CST, IMT, GP etc.

Cambridge interview

• 25 minutes

• Clinical case discussion and academic interview with same panel

• 3 person panel• Neurosurgeon, radiologist, layperson

• Medical emergency + Ethics discussion

• Academic –• Discussed my research, methods, results,

translatability to clinical practice• Personal questions

Cambridge Interview

“What do you hope to achieve through the AFP?”

“Imagine you are being interviewed by a BBC journalist, please explain the results of a research project you were involved in”

“How would you design a study to investigate the effects of anticoagulants in vascular trauma patients?”

“Have you contacted a supervisor? What will your project involve?”

“Please describe an interesting clinical trial you would design if given the chance.”

“Stem cells seem to be talked about a lot in the media, where do you see the future application of such research?”

“What statistic would you use to measure the effect of X on Y?”

London Interview

• Registration and identity checks 10 minutes • Review of abstract and clinical scenario 14 minutes• Panel 1 interview (academic) 10 minutes • Panel 2 interview (clinical) 10 minutes

• Typical format =

CLINICAL: 3x emergencies or 1x long case discussion+

ACADEMIC: Motivation questions + 1x abstract critical appraisal

Clinical Interview

• Be confident

• Prepare answers to common questions

• Deal with problems as they arise

• Have a structure to guide your reasoning and management

• GOAL is to demonstrate you are a safe F1 who can prioritise patients through sound clinical reasoning

• Large overlap with acute care station in finals

• Practice Practice Practice

Example scenario

You are the on-call surgical FY1 and have been bleeped about the following patients:

Patient 1 – 85 year old lady is two days post-operative for left lower zone lobectomy. She is dyspnoeic, pyrexial and has a saturation of 88%. Her son approaches the ward staff to express his dissatisfaction with his mother’s care. He wants her to be discharged immediately.

Patient 2 – Nurse tells you a police officer is asking to speak to you about a trauma patient’s injuries. Your consultant is in theatre, and your registrar is taking a referral in A&E.

Patient 3 – A known epileptic patient on the ward is having a seizure

Typical structure

CLINICAL SCENARIO1. Patient who is critically unwell

2. Patient on their way to becoming critically unwell

3. Patient thinking about becoming unwell AND/OR Ethics scenario

Approaching the clinical interview

1. Find out more 2. Prioritise3. Assessing an acutely

unwell patient or Ethical scenario

4 . Safety net

Most often clinical scenario(s) with acutely unwell patient(s)

Approaching the clinical interview

• B-ABCDE-HSGD• Before you get to the patient• ABCDE• History (AMPLE)• Senior advice• Review local guidelines• Document

Before you go to the patient

Assessment Intervention1. Find out: patient’s name, hospital ID,

location +/- brief hx (SBAR handover)2. Observations: SO2, HR, BP, RR, T

+/- ECG)3. Gather: notes, drug charts and fluid

charts4. If multiple patients, inform the nurse

you are seeing another sick patient but to carry out 15 min obs inform you or your senior to any sudden deterioration

1. If acutely deteriorating à 2222 peri-arrest/arrest call.

There are X number of multiple unwell patients, I would prioritise patient A over patient B because…Safety is my absolute priority. I would inform a senior as soon as possible that there are potentially X unwell patients and would ask if another member of the team can see the other patient.

Airway

Assessment Intervention1. Vocalising? à assume airway is

patent2. Added sounds? – sounds

suggestive of obstruction(stridor, snoring, gurgling)

3. Examine the oral cavity – for loose objects/denture

4. Protect Cervical spine if an injury is possible (e.g. trauma patients)

1. If concerned about airway, establish a patent airway using• Airway Manoeuvres - Head Tilt

Chin Lift, Jaw thrust• Airway adjuncts

nasopharyngeal• oropharyngeal airway

• Call anaesthetist if airway is compromised, 2222 -> Intubation & Ventilation

2. Suction of secretions/blood – wide-bore suction under direct vision

3. Removal of foreign body

A – “ I would like to assess the patency of the patient’s airway”

Breathing

B –“I would like to examine the respiratory system using a look, listen and feel approach”

Assessment Intervention1) Look – chest expansion, tracheal

deviation, chest wall deformities, respiratory effort

2) Listen – air entry (equal?) and additional sounds

3) Feel – expansion and percusion(equal?), position of the trachea (central/deviated)

4) Obs: O2 sats, RR

1. Sit the patient up2. If concerns about breathing/low sats

• 15L high flow 02 through non rebreathe mask*

• *88-92% sats for chronic retainers

• If poor or absent respiratory effort à use a bag valve mask

3. If no respiratory effort --> call arrest team (2222)

Consider: • ABG• CXR

Circulation

C –“I would like to assess the patient’s circulatory status”

Assessment Intervention

1) Look: pallor, cyanosis, and distended neck veins (JVP)

2) Feel: • Peripheral & Central Pulse

Rate, Rhythm and character • CRT <2seconds

3) Listen - Heart Sounds4) Obs: HR, BP, UO

1) Investigations• Gain IV access (2 wide bore

cannulae in ACF) – send bloods if time allows (which ones and why)

• 12 lead ECG (dynamicchanges)

• Catheterise2) Actions

• Consider fluid challenge – 500 vs 250ml (HF) over 15 mins

3) If NO CARDIAC OUTPUT à Call arrest team/2222

Disability

“I would like to assess the patient’s neurological function

Assessment Intervention1) Level of consciousness - GCS /

AVPU2) Pupils equal & reactive to light3) Gross neurological deficit? - Tone4) Blood Glucose5) Obs: Temperature

1) Correct blood sugar2) If overdose - antidotes3) If unresponsive or GCS </= 8 à

Call anaesthetist (airway risk)

• Consider:• CT Head

Exposure

Assessment Intervention1) Skin 2) Wounds3) Calves – tenderness/swelling4) Abdo exam5) PR6) Surgical site7) Cover patient with blanket

1) Treat as appropriate

History, Senior, Guidelines, Document

• H – History (AMPLE)• Allergies• Medications• PMH/ PSH• Last meal• Events leading up to illness

• S – Senior input – Who can you escalate to?• Your SHO/SpR/Cons• Med/Surgical SpR• Major Haemorrhage protocol• CCOT• MET CALL/Peri-arrest• Crash call

• G – Review local guidelines• D – Document

Approaching the clinical interview

• B-ABCDE-HSGD• Before you get to the patient• ABCDE• History (AMPLE)• Senior advice• Review local Guidelines• Document

• Goal is to demonstrate you are a safe f1

Possible Scenarios (not an exhaustive list)

• Shock• Hypovolaemic shock• Haemorrhagic shock• Anaphylactic shock• Septic Shock• Cardiogenic (unlikely) • Neurogenic (unlikely)

• Cardiology• ACS – STEMI• ACS – NSTEMI• Narrow complex tachycardia• Broad complex tachycardia• Atrial fibrillation• Severe pulmonary oedema• Cardiac Arrest• AA/AAA/Dissection• Infective endocarditis

• Respiratory• Acute severe asthma• Acute exacerbation of COPD• Pneumothorax

• Pneumonia• Pleural effusion• Pulmonary embolism• Deep vein thrombosis

• Neurology• Head injury• Meningitis• Subarachnoid haemorrhage• Stroke• Status epilepticus• Delirium• Syncope/ collapse

• Gastroenterology/Surgery• Acute GI bleeding• Acute appendicitis• Acute cholecystitis• Acute pancreatitis• Intestinal ischemia• Post op fever – anastomotic

leak etc • Bowel obstruction

• Endocrinology• DKA• Hypoglycaemia coma• Adrenal failure• Thyrotoxic crisis• Myxoedema

• Renal• Acute kidney injury• Renal Colic• UTI

• Other• Sepsis• Hyperkalaemia• Hypokalaemia• Blood transfusion and blood

products reactions• Poisoning• Alcohol • Confusion

Academic interview

• Format will vary for each AUoA

• Some, if not all of the following may be covered• Motivation for AFP• Previous research experience and research interests• Understanding of research• Critical Appraisal

• STRUCTURE, STRUCTURE STRUCTURE

• PRACTICE, PRACICE, PRACTICE

Academic interview

• Why do you want to do an AFP? Why did you apply to this AUoA? What do you hope to achieve through AFP? Why are you a suitable candidate?

• Must demonstrate • Understanding of self – motivation, interests, and career

goals• Understanding of AFP – how will AFP enable you to reach

your goals

• CAMP – useful structure to answer this question• Clinical – particular specialities or clinical experiences

offered by certain AFPs• Academic – opportunities to enhance your research or

teaching skills • Management – developing leadership skills and positions of

responsibility • Personal – location/other

Academic interview

• Other questions• Tell us about a paper you read recently that

interested you• If you had X amount of money, describe a

research project you would design

• Other personal questions include • Tell us about your research/teaching/leadership

experience • Tell us about your research interests• Tell us about a time you dealt with conflict

• STAR framework• Situation, task, action, results

• Overlap with WSQs – know your answers

Academic interview – Critical Appraisal

• London – you will be given an abstract to prep with a clinical case in about 14 minutes

• Structure is critical!!!!!• Assessing your ability to

• Summarise• Critique and analyze • Identify sources of bias

• Most often an RCT• Can be interviewer or interviewee led

NEJM, Nature, Lancet, Annals, BMJ

Critical appraisal in a nutshell

• INTERNAL VALIDITY (BIAS ASSESSMENT) = How well do the observed results represent the truth and are not due to methodological errors (aka biases)

• EXTERNAL VALIDITY = GENERALISABILITY

QR PICOK RAMBOS RP FEC

• QR = question and relevance • PICOK = summary of the study

(population, intervention, controls, outcomes, key findings)

• RAMBOS = internal validity (recruitment, allocation, maintenance, baseline, blinding, outcomes, statistical analyses)

• RP = external validity (resources, populations)

• FEC= Funding, ethics, conclusion

Critical Appraisal Structured Approach

From Dr Maddy Ardissino’s Lecture

Question and Relevance + Summary – QR PICOK

• What was the research Question?

• Why was it Relevant? • Large number of patients with the disease• High mortality• Poor QALY

• Population • Intervention • Control • Outcomes

• Primary• Secondary

• Key findings

Study design • What was the research design? • Was the design appropriate to answer the question? Hierarchy of

evidence• Pros and Cons of different study types

Internal Validity - RAMBOS

• Recruitment • Consecutive• Multicentre

• Allocation • Randomised or non

randomised• How was it done?

• Simple, block, cluster

• Allocation blinded vs open label

• Maintenance • Drop out rate?• Treatment outside equal?• Intention to treat analysis or

Per protocol analysis?

• Blinding• What level?• Outcome adjudication blinding?

• Outcome• Clinical or surrogate? Composite? • Designed a priori? • Follow up period/completeness • Clinical vs statistical significance

• Statistics• Power/Type 2 error• Statistical models used• Effect size• Statistic used - Relative risk/Odds

ratio/Hazard ratio and why?• Sensitivity/Specificity • ARR/RRR • Number needed to treat (1/ARR) • Number needed to harm (NNH)• p-values (alpha, type 1 error)

External Validity (RP) • Resource availability

• Specialised equipment? Available throughout the world? • Cost effectiveness (on patent?) QALYs – Quality adjusted life years that treatment will

bring (used by NICE to determine funding of therapies)

• Population representativeness • Population (Inclusion/Exclusion criteria) - Are the patients in the study similar to the

target population?• Age, gender, BMI, height, ethnicity, lifestyle

• E.g. bias against older people and those with comorbidities• Other medications• More/less ill than patients you see• More/different level of attention during study than you could ever give in real life • Smoking, alcohol, other drugs

• Intervention• Acceptable for pts? Frequent follow-ups?

• Control• Placebo or gold standard

• Outcomes• Clinical outcomes significant?

• Recruitment• Mode of recruitment? - recruitment bias - more likely to get patients who are

enthusiastic to apply, not representative of real life • Primary or secondary care

Funding, ethics, conclusion (FEC)

• Funding• Funded or non funded? – conflicts of interest? • Pharmacological/University/Research institute? • Conflicts of interest? • Pharma company funding does NOT mean that it is a bad

study

Funding, ethics, conclusion (FEC)

• Ethics (Declaration of Helsinki)• Population – informed consent? • Intervention – Clinical equipoise? • Control – gold standard or placebo• Outcomes

• Safety outcomes? Risks/side effects? • Data safety monitoring board – power to stop the study early if harmful

• Type of study - Are some participants being given an inferior treatment?• Pillars of medical ethics:

• Beneficence = clinical equipoise • Non-maleficence - interim analysis, safety outcomes, plcaebo, data

safety monitoring board, protocol in place to stop study if it goes bad-declaration of helnski

• Justice - expensive drug, research is for the good of society and will benefit all

• Autonomy - Consent, capacity, voluntary, informed, free to withdraw

• Good Clinical Practice (GCP) is the international ethical, scientific and practical standard to which all clinical research is conducted.

Funding, ethics, conclusion (FEC)

• Conclusion• In conclusion, this is a … that showed … resulted in …..• Its main strengths are…... However, it is also limited by ..…

and …… • Considering the effect size observed and the importance of

the research question, I would consider incorporating elements of this study in my clinical practice. However, ideally the treatment of patients should never be based off one study. Meta-analsysis or systematic review should be carried out to make a definitive conclusion

QR PICOK RAMBOS RP FEC

• QR = question and relevance • PICOK = summary of the study

(population, intervention, controls, outcomes, key findings)

• RAMBOS = internal validity (recruitment, allocation, maintenance, baseline, blinding, outcomes, statistical analyses)

• RP = external validity (resources, populations)

• FEC= Funding, ethics, conclusion

Critical Appraisal Structured Approach

General interview tips

• Be able to summarise your projects, presentations, teaching/leadership experiences in a few sentences

• Use examples + Create a bank of examples • Practice applying to different questions

• Do not rehearse answers, prepare points for common themes• Why AFP?• Why this university/hospital?• Leadership/management/teaching experience

• Structure• STAR, CAMP

• Reflect• Revise the common medical emergencies for the clinical

component of the interview• Revise critical appraisal for the academic component of the

interview

Preparing for interviews

• Step 1• Oxford handbook of clinical medicine – emergencies section• How to read a paper (first half)

• Step 2 • Practice questions, clinical scenarios, and critically appraising abstracts

• Step 3• Practice with friends, contact previous AFP applicants• Feedback and improve

APPLY FOR THE AFP

Tips

• Read relevant prospectus

• Plan, write and iterate white space questions early

• Learn emergencies (finals)

• Look at useful resources

• Speak to current/previous AFP’s

• Not a waste of time, useful for finals

Resources

• Clinical• Oxford handbook of

clinical medicine -emergencies section

• Academic• How to read a paper by

Trisha Greenhlagh• The Doctor’s Guide to

Critical Appraisal by GosallNarinder Kaur and GurpalSingh Gosall

• Medical interviews by Oliver Picard et al

• Previous/Current AFP doctors

Thanks for listening

Dr. Areeb MianAcademic Surgery (AFY1)

Cambridgeareeb.mian15@imperial.ac.uk