How is your Situational Judgment?

There is currently a furious row ongoing in the undergraduate medical world about the Situational Judgment Test (SJT).  This is a test which medical students need to pass if they wish to undertake the first two years of postgraduate training (the foundation years) in the UK.  (That would be the case for most UK-trained medical students.)  They take the test towards the end of their undergraduate career.  The row has erupted because there seem to be insufficient places available in venues where you can sit the test.  For example, a medical student in Glasgow has had to book a slot in Harrogate (rail fare £300).  The issue of the wisdom or otherwise of travelling such a distance during the pandemic does not seem to have been addressed.  Students are exercised about all of this, the more so because if you fail the test, you can’t proceed with your career, you can’t resit for a year, and you can’t appeal. 

The SJT did not exist when I was a medical undergraduate.  Nor, for that matter, did the UKCAT test, a kind of cross between an IQ test and a daily newspaper’s puzzles page, which prospective medical students need to pass before they can even enter the undergraduate course.  I didn’t have to attend Edinburgh University for an interview, I didn’t have to forward a “personal statement”, I didn’t have to take a gap year caring for Venezuelan street kids, nor spend my summer in a drug rehab centre in Glasgow’s east end.  I just had to pass a few exams with semi-decent grades, and apply. 

So I was curious about the SJT.  I went online and researched it.  I found an online tutorial for prospective examinees.  It lasted about 90 minutes and, from the point of view of a student wishing to find out how to negotiate the test, I would say it was very good. 

The Situational Judgment Test does not assess clinical knowledge or skill, but ethical awareness, and more intangible aspects of being a doctor – the medical schools used to call them “attitudes” – such as empathy and kindness.  The test takes 2 hours and 20 minutes and is time-pressured.  There are broadly three kinds of questions, which I will exemplify. 

A small point: timing is everything.  I wonder if it as appropriate (appropriate – remember that word) to subject a young person to five or six years of rigorous training, and then, only then, almost as an afterthought, to enquire as to whether they are fit, morally fit, to undertake the duties for which they have been trained.  But that’s just a small point. 

All of the questions are based on a scenario.  I guess I could recount the scenarios put forward in the tutorial but I thought it would be more interesting to forward my own – not, note, scenarios I have made up, but scenarios that I actually experienced during my career.

In the emergency department you are asked to see a 12 year old girl who appears to be hyperventilating.  A staff nurse is coaxing her to breathe into a paper bag.  The girl’s highly exasperated mother says “Don’t encourage her by doing any tests.  Just tell her to pull herself together.”

You say to the patient, “Pull yourself together!”

A appropriate

B somewhat appropriate

C somewhat inappropriate

D inappropriate

Next option:

You say to the mother, “Do you mind if I have a chat with your daughter first?”

A appropriate

B somewhat appropriate

C somewhat inappropriate

D inappropriate

You say to the mother, “Don’t tell me how to do my job!”

A appropriate

B somewhat appropriate

C somewhat inappropriate

D inappropriate

You say to both patient and mother, “Do you mind if I carry out a brief examination?”

A appropriate

B somewhat appropriate

C somewhat inappropriate

D inappropriate

You say to both patient and mother, “I think there might be a medical problem here.  Do you mind if I take a blood sample?”

A appropriate

B somewhat appropriate

C somewhat inappropriate

D inappropriate

Next up, you are given a scenario, and then a list of five possible responses which you are asked to put in order of merit, from best to worst:

You are a newly qualified doctor working on a general medical ward.  A local GP sends in a 17 year old girl suspected of having glomerulonephritis.  She has hypertension, and protein in her urine.  While examining her, you find the patient to be pregnant, and, you estimate, at term.  She instructs you not to divulge this information to her family. 

A  You say to the girl, “Don’t be silly.  A thing like this cannot be hidden.  I must tell your parents.”

B   You say to the girl, “Do you get on well with your parents?  If so, would you consider telling them yourself?”

C  You arrange urgent transfer to a nearby obstetric hospital.

D  The patient’s father rings you to enquire after the health of his daughter.  You say, “It’s confidential.  I can’t tell you anything.”

E  You say to the father, “I can’t give you an up-to-date report, but I can tell you we have transferred your daughter to St Elsewhere Maternity Pavilion.  Here is the contact number.”

And finally, you are given a scenario, and then a list of eight possible responses from which you must choose the three most appropriate:

You are working in the emergency department and a staff nurse informs you that an attending junior doctor is ordering narcotic analgesia for his patients, and insisting he himself administer the injections.  The staff nurse has reason to suspect the doctor is injecting himself.

A  You tell the staff nurse just to get on with her own work.

B  You ask the nurse to explain the grounds for her suspicion.

C  You inform the senior Charge Nurse on the floor, and discuss the situation.

D  You ask the doctor’s patient if he has been given an injection.

E  You confront the doctor, and demand that he confirm or deny the accusation.

F  You set up a sting operation in which an actor posing as a patient asks the doctor for pain relief and you install a hidden camera to record the result of the sting.

G  You contact the police.

H  You inform the doctor’s clinical supervisor (consultant) of the nurse’s suspicions.

How did you get on? 

My responses for the first scenario, the hyperventilating girl with the paper bag, were D A D A A.  I have a notion that the UK Foundation Programme Office (UKFPO) would have gone for D A C A A.  After all, there is some merit in pointing out to the mother that you really need to practise medicine conscientiously, as you have been taught.  But “Don’t tell me how to do my job” sounds very abrupt, and is likely to antagonise.  There is nothing to be gained by it, and an awful lot to lose.  Generally, I would tend not to use the “somewhat” options.  Medical decisions of all types had best be clear-cut.  A clinical sign is present, or it is not.  A clinical diagnosis is accurate, or it is not.  You cannot be somewhat septic. 

But by and large I don’t think many medical students would struggle with this question, even if they might struggle with the scenario in real life.  A far more interesting question (this is one for medical students) would be this:

If you could only do one test, you would measure:

A  Full blood count

B  Urea and electrolytes

C  C reactive protein

D  Blood glucose

E  Arterial blood gases

I went with E.  Second best option is D.  That would have told me that the patient had diabetes.  The gases told me she was profoundly sick, probably due to diabetic ketoacidosis.  Now you may say this would not be a fair question to appear in a Situational Judgment Test.  But you can see that the division between clinical acumen and a good bedside manner is entirely artificial.  You are always thinking to yourself, “How can I achieve the best diagnostic and therapeutic outcome while carrying the patient and her loved ones along with me?”

Second scenario:  the occult teenage pregnancy.  Put the 5 responses in order from best to worst.  My answer was C B E D A.

Note that these responses are in order of merit, not order of chronology.  This patient has preeclampsia, therefore the overriding clinical consideration is to deliver her to the right location, and deliver her at the right location.  C comes first.  D is an interesting response.  I don’t think a doctor would land in trouble for telling the father nothing.  After all, that is what the patient has requested.  But I put E ahead of it.  Sometimes, in the interests of humanity, you need a little wriggle room.

Third scenario: the doctor addicted to opiates; best 3 responses out of 8.  Mine were B C and H.  I would still opt for these, but I’m not sure the end result was satisfactory.  The consultant blew his stack, came down on to the floor, confronted his junior, gave him a tremendous bollocking, and suspended him.  But then the junior went to his lawyers and then the whole thing went sub judice and dragged on for years. 

Well, it’s all good fun and certainly instructive to ponder ethical issues and approaches to sensitive areas of human communication.  But I have to say I think the Situational Judgment Test is an absurdity.  You can’t separate out human kindness from clinical professionalism.  Cum Scientia, Caritas, as the Royal College of General Practice has it.  And the idea of reducing Caritas to a series of tick boxes is grotesque.  As you might predict, the marking system for the SJT is absurdly complex.  The SJT is an ivory tower, a ziggurat of burgeoning buttresses and ramparts designed by a remote conclave of academics to ensure its own perpetuity.  They should demolish it, roll up their sleeves, and see a few patients.

Of course most medical students will just shrug and sit the test.  They’ve spent their whole lives leaping hurdles.  You could ask a medical student to index the telephone book by ascending order of the phone number rather than alphabetical order of the names, and they would just get on with it.  Perhaps it is only later in life that you develop a nose for these occasions when you are being asked to paint coal.  Jobs for the boys.  I have a horrible feeling that if now I were sent from Glasgow to Harrogate to sit the test, I would screw the exam paper up into a ball, throw it at the invigilator, and say, “You can stuff your SJT.”           

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