Clinical Oncology Interview – Answers

Dear Friend,

Happy bank holiday weekend to you all. I managed to make it through my run of 7 consecutive shifts, and am finally feeling a bit recovered. Though, with IMT, the moment you start feeling a bit better, you know the set of hard shifts is just around the corner. And lo and behold, after this week I will again be back onto night shifts. But let’s not stress about that for now. 

Last week, I went through what I was asked in my clinical oncology interview, and gave you a chance to draft your answers. This week, I will go through what I said which helped me score 100% in my interview and land me my dream job. 

Clinical station (10 minutes)

Scenario 1: You are the oncology registrar who is asked to review an elderly man in the ward who is confused. The gentleman has a background of metastatic non-small cell lung cancer for which he is on palliative radiotherapy.  

• What would you do next?

With all these clinical scenarois, I stated that the first thing I would do is an A-E assessment to stabalise my patient. I talked very briefly about this, as they expect you to know how to do an A-E assessment. I then stated I would take a full history – if this patient is confused I said I would take a collateral history. If they did not cut me off at this point, I would then go into invesigations and differnetials, but they paused me to ask these questions individually. 

• What are your main differentials?

I stated that this patient likely has delirium and said this could be a variety of reasons. I used the acronym PINCH-ME to go through pain, infection, nutrition, constipation etc. However, I also said, given his oncology background I would want to think of 3 important differentials, including a space occupying lesion in the brain (metastasis) as well as electrolyte abnormalities like hypercalcaemia and hyponatraemia. 

• What investigations would you request?

I broke this down in bedside, bloods and imagine. At the bedside, I would do an ECG (especially if there are electrolyte abnormalities) and a VBG (this looks at glucose, Na and calcium). In terms of bloods, I said I would do a confusion screen with B12, folate, bone profile, inflammatory markers, and imaging with a CT head. 

• What would be your management?

By this point they told me that the calcium levels were 3.5. So I said I would start fluids as first line. I said I would escalate to my consultant and also refer to endocrine as next steps might involve steroids, cinacalcet. I then said I would inform the patient and NOK and also talk about ceilings of care. 

Scenario 2: A 40 year old female patient who is 3 days post chemotherapy for locally advanced colorectal cancer calls in saying she is not feeling well. She reports some left sided chest pain and feeling a bit sweaty. 

• What would you do next?

I said I would ask some very basic questions – I said I would try to refrain taking a whole history over the phone and instead ask the patient to come in for formal assessment. I would assess if they can come in, whether by taxi, drive or even if they need an ambulance. 

• What are your main differentials?

I said as they are only a few days post chemo, my most important differential would be neutropenic sepsis. However, I then said in light of their symptoms, other things to keep in mind is pulmonary embolism, pneumonia, cardiac causes. 

This lady explains that she does not want to come to hospital as she has 2 small children at home and there is no one to look after them.

• How do you proceed?

I explained this is a complex situation, but one I have experienced before. I said I would be honest to the patient regarding the risks involved. I would ask if anyone else to take care of the children such as partner or other family member. I also said that she might not need admission – if we review her and everything is fine she may be able to go home. Also explained that if admission was necessary we could involve paediatrics to admit the children whilst she is unwell. 

• If she refuses to come in, what else could you offer?

I said this is about working with the patient to offer alternatives to mitigate the risk. For example to be followed up in the ambulatory care area of the chemo day unit for assessment. 

Ethics station (10 minutes)

This station had 2 panellists. The station was divided into 2 ethical scenarios, each of 5 minutes. There was no reading time before either of the scenarios. 

Scenario 1: You are in clinic and are recruiting a patient for a phase 2 clinical trial. 

• Please explain how you would go about doing this to the patient. 

I said that this raised a few key ethical principles. The first is about autonomy and informed consent. Making sure your patient has all the important information in order to be able to make a proper well informed decision. It also brings in beneficence, acting in their best interests and non-maleficience. 

I said that I would explain what a clinical trial involves and why we are doing it. I talked about randomsiation, which means that we do not know whether they will have the drug or placebo and why this blinding is important. I also explained about safety, regarding that we might know a few side effects but others may be unknown so have to be honest about this. I explained how they might be followed up, give them a leaflet and time to make their decision. 

• Is there any training that you would need to undertake for this trial?

I said I would do the NIHR online course about Good Medical Practice. I also would have my e-learning up to date. I would make sure I read up about the trial and spend time with the leading consultant learning how to recruit patients. If there are nay procedures involves, e.g. tissue sampling, I would undertake training in these areas and with the data analysis. 

• Who else would you involve?

I said I would involve the leading consultant. I would also put the patient in touch with the CNS who is involved in the trial and helping coordinate the research trial. 

Scenario 2: You are the oncology registrar and one of your patients on the ward is very unwell with neutropenic sepsis. Her BP is low and you feel she needs ITU support for inotropes. The lady’s partner says that she had an advanced directive that she would not want intensive care treatment and by taking her to ITU you are going against the patient’s wishes. 

• How do you proceed?

I explained that this scenario raises questions about capacity. I also explained we have to balance beneficence and non-maleficence. 

I explained that the question regarding advanced directive is only valid if the patient does not have capacity. So I said I would first do a capacity assessment on the patient herself – if she has capacity then we would go with her decision. 

If she is lacking capacity, this is when the advanced directive becomes valid. I said we would need to see the physical copy. In addition, advance directives are very specific to certain situations – and require even more scrutiny when it comes to life-saving treatment, which this is. So this would need to be checked. If the AD is not relevant, then I explained would check for LPA and if not it would be about acting in her best interests. At this point we would take into her views and also the views of the NOK. I also explained this would need ot be done in a calm and empathetic manner and give support to the reletive who must be going through an emotional time. 

Motivation and portfolio station (10 minutes)

This station had 2 panellists. The station was divided into 2 parts, each of 5 minutes. There was no reading time before this station.

First half: 

• Tell me why you want to clinical oncology

For these questions, I had prepared answers in advance. My structure involved talking both about the clinical side (first) and then the academic side of oncology. CLincialy, I spoke about my gynae-onc placement, time in clinics, my taster week in clinical oncology. Academic speaking, I spoke about my AFP in gynae-oncology, research papers. And then I summed it up by saying this field gives me the perfect balance of both. 

• Tell me from your experiences where you have demonstrated initiative.

I used a non-clinical example for this. I explained that during the pandemic, I set up an online medical education portal called In2Med. I talked about the success of this platform and how off the back of this I secured my book deal too. They were impressed by this. 

Second half:

• Where do you feel the field of clinical oncology is advancing?

I said this is a hard questions as there are so many new developments. Regarding clinical oncology, I spoke about the new radiation delivery methods like proton beam therapy. I then said alongside this, there is a move to personalised medicine, and even using AI to determine which patients are likely to respond. Here I brought in a research paper I had read. 

• Tell me about a typical week of a clinical oncologist

I said a typical week is varied and that is what I like about the career. I basically went through my taster week – saying it involves a couple of MDTs, a couple of clinics depending on tumour site, radiotherapy planning time and then other time either for academia, education etc. 

• Tell me about any challenges you might face during training. 

I spoke about how oncology is an emotional draining career and how this might affect trainees. But I mentioned strategies I had learnt to overcome this such as having hobbies out of medicine. I also spoke about staffing shortages and how this impacts patients meaning they might be diagnosed later and be more frustrated. 

Summary

That sums up my clinical oncology interview. Performing well in the interview is only possible if you have done plenty of work in advance to build your portfolio, and then work to know this inside out and learn how to frame your answers. 

I hope you find this useful and best of luck in your future applications. 

Drug of the week

Mirena (levonorgestrel)

The Mirena coil is a small, plastic, T-shaped device inserted into the uterus that releases the hormone levonorgestrel. 

It’s a highly effective, long-term, and reversible method of contraception, lasting up to 8 years. It can also be used to treat heavy menstrual bleeding. 

It releases levonorgestrel, which is a prostestogen which prevents endometrial proliferation and thickens cervical mucus

The IUS is effective 7 days after insertion and women should also check for threads like the IUD

Advantages

Very effective (>99%), Long-term (10 years), normal fertility returns as soon removed

Can be used when the COCP is contraindicated and during breastfeeding

Periods become lighters (or stop) and may reduce pain with dysmenorrhoea

No systemic hormonal side effects

Disadvantages

Does not protect against STIs, risk of pelvic inflammatory disease and ectopic pregnancy

Increased risk of functional ovarian cysts

Irregular bleeding for 3-6 months post-insertion

Risk of uterine perforation –  severe pelvic pain, sudden changes in periods, dyspareunia 

A Brain Teaser

A 50-year-old man presents to the GP clinic with a 2-day history of nausea and dizziness. He says that this is intense but not debilitating. The dizziness is constant but exacerbated by head movement. He states that the dizziness is affecting his balance. Upon further questioning, he revealed he had a cough over a week ago, which was resolved without issue.

On examination, you note horizontal nystagmus. Hearing is normal bilaterally.

What oral medication should the GP prescribe to alleviate this individual’s symptoms?

A: Chlorpromazine 

B: Fluphenazine

C: Ganciclovir

D: Prednisolone

E: Prochlorperazine