The FCEM Management Viva - The Basics

The Management Viva

Total of 35min

There is a structured marking grid with ideal Answers

The pass mark is 60-65%

The aim is to assess:

• Ability to prioritise and time manage


• Decision making


• Delegation


• Communication Skills


• Medico-legal awareness


• Governance


• Ethics & Probity


• Managing your staff


• Recognising educational opportunities


• Knowledge of complaints and disciplinary procedure

Common Themes

• Complaints


• Doctors with difficulties


• Freedom of information


• Staffing issues


• SUIs /Adverse events


• Policy Declarations from other departments

The In Tray

• 5 minutes Reading time


• 15 minutes viva


• Usually maximum of 9 items


• Consists of your Diary Card, Letters, memos, emails


• The first 5 minutes is the most important make sure you read everything, and sort them in order of priority


• Write post it notes of key bits. You can also write or underline on the exam papers.


• You get marks for talking about everything in the in tray even the fillers


• Diary Card is the most important as it gives details of your department and offers ways to link things in for extra marks


• Keep it in front of you

Starting the Viva

• Check the department first – if it is melt down then everything else waits.


• Do I have a clinic or a ward round?


• Can a middle-grade start it?


• What meetings do I have? When are they? Who will be there?


• Do they tie into anything in my box?

Structure of answers

• Have structure to your answers. The following headings might help.


• Always talk about information gathering and how you going to do that. (Patient’s notes, statement from staff, CCTV, IT records, etc)


• Patient issues – Is the patient safe now? Was the treatment/management appropriate?


• Staffing issues – Are there any staff member affected and how? Don’t forget about the pastoral care.


• Short term solutions – Junior doctor teaching session, removing sharps and putting appropriate sharp bins, etc.


• Long term solutions – Making formal policy or pathway.

Prioritising your In Tray

Three levels of priority:

1. Important and time dependant – You need to sort out now


2. Important but not time dependant – You can sort out later


3. Neither important nor time dependant

Tell the examiners how you have done this.

Marking and Scoring Well

• Remember that it is a fixed scheme with ideal answers, every piece in your in- tray carries marks, but value varies (2-12)


• Spend more time on complicated ones


• Score higher by finding the tie ups to diary and other items in the In-Tray


• Be decisive – don’t sit on the fence


• Mention the links and tie ins


• “I’d like to check on the patient”


• Delegate appropriately


• Secure copies of notes and documents


• Take minutes of important meetings


• Empathise with the situation


• Address the issues


• Use guidelines


• Know the organisations who can help – CQC, NPSA, NCAS etc


• Know the processes at your trust – download and read your policies

The common pitfalls are:

Sounding like you have just learnt off the answer

Not touching on all parts of the in-tray

Not moving on in a timely manner

Arguing with the examiners

The Long Case

• More difficult to predict


• Complex multifaceted case


• Once you look up from reading it they will start quizzing you

On the day of the Vivas

• Dress if going for an interview.


• Lots of hanging about on this day.


• Be calm.


• Time is short, so make good use of it


• Read all the papers and have something to say about each of them


• If the examiners try to move you on then let them


• Don’t look up from the long case until you have read it all


• Don’t get aggressive.


• Be polite

With input from London FCEM Course

The FCEM Management Viva - The Basics

Ovarian hyperstimulation syndrome (OHSS)

Ovarian hyper stimulation syndrome (OHSS) is the most serious consequence of induction of ovulation. It may occur after stimulation of the ovaries into superovulation with drugs such as human chorionic gonadotrophin (hCG) and human menopausal gonadotrophin. It is rare with clomifene except in polycystic ovarian syndrome (PCOS).

Grades and associated clinical features:

Mild OHSS

• Abdominal bloating.


• Mild abdominal pain.


• Ovarian size usually <8 cm.

Moderate OHSS

• Moderate abdominal pain.


• Nausea ± vomiting.


• Ultrasound evidence of ascites.


• Ovarian size usually 8-12 cm.

Severe OHSS

• Clinical ascites (occasionally hydrothorax).


• Oliguria.


• Haemoconcentration haematocrit >45%.


• Hypoproteinaemia.


• Ovarian size usually >12 cm.

Critical OHSS

• Tense ascites or large hydrothorax.


• Haematocrit >55%.


• White cell count >25 x 109/L.


• Oligo-anuria.


• Thromboembolism.


• Acute respiratory distress syndrome.

Risk factors:

• Polycystic ovarian syndrome (PCOS) greatly increases the risk.


• Younger women are at greater risk.


• High oestrogen levels and a large number of follicles.


• The use of hCG for luteal phase support.


• Administration of gonadotrophin-releasing hormone (GnRH) agonist.

Presentation:

• Symptoms usually appear 4 or 5 days after harvesting of eggs.


• There is abdominal pain and distension due to accumulation of fluid.


• In 1 or 2% of cases with very enlarged ovaries, the patient is ill with severe pain, nausea and vomiting.


• There may also be pleural effusions with fluid passing from the abdomen into the pleural cavity.

Investigations:

• Ultrasound of the ovaries and abdomen for fluid. A possible risk in this condition is torsion of the ovary and ultrasound scan may suggest this.


• FBC,as there may be haemoconcentration. (Serious findings are haematocrit above 45% and white cell count above 15 x 10⁹/L.)


• U&E and creatinine, as renal function may be impaired. (Serious findings are sodium below 135 mmol/L or potassium above 5.0 mmol/L.)


• Coagulation screen.


• LFTs.


• CXR and lateral (to assess any pleural effusion).

Management:

In mild cases:

Analgesia and increased oral fluids will suffice. The condition will settle rapidly unless pregnancy occurs, when it will take longer to subside.
In moderate cases:

Admission to hospital for thromboprophylaxis and monitoring may be judicious.
Severe cases:

These require very careful monitoring of fluid balance:

• An initial bolus of a litre of fluid intravenously (IV) should be followed by enough to maintain urine output of 30 to 40 ml an hour.


• A diuretic should be given if urine output is inadequate.


• Aspiration of ascites or pleural effusion can relieve symptoms.


• Albumin may be given to replace circulating volume and it may need to be given periodically:


• Clear guidance on the management of the acute, severe condition is not available but each aspect is tackled as required and intensive care may be required.

Ovarian hyperstimulation syndrome (OHSS)