What to do at the end of Panel Interviews

A note on end-of-interview questions

At panel interviews, you will have the opportunity to ask questions. This is optional - you don’t have to ask any questions, you will not be evaluated on whether you asked questions or not, but I find that it leaves a good impression - it shows that you care, you did your homework and you’re curious about the curriculum and the environment. A little research about each school (15 minutes) goes a long way. Here are some semi-intelligent questions you could ask:

“As a resident/medical student, how do you feel about the diversity of patients and cases in a small city such as London?”

“I have read on your website that electives during clerkship are dispersed throughout third and fourth years, as a resident/medical student, how do you feel that this has affected your choice of residencies? Did you have enough exposure to each field to take the necessary electives?”

A note on end of interview

At the end of panel interviews, you’ll be asked if you have anything to add to your application. At this point, it’s appropriate and recommended to thank the interviewers for their time and a summary of why you think you qualify. I said something to the effect of: “One of the things I’ve really learned from my graduate supervisor is that anytime you give a talk or an interview, you should always thank the people involved, so thank you so much for the opportunity to meet with me. I’m not the smartest applicant but I do come with a rich and diverse set of experiences that I think will greatly enhance the class of 2017 and the community at large.” 

Personal - Conflict

One of the essay questions from the 2012-2013 University of Toronto application cycle. 

Tell us about a conflict you had with another person and how you maintained a respectful 
relationship with them.

Journalist Dorothy Thompson famously observed that: “peace is not the absence of conflict but the presence of creative alternatives for responding to conflict.” I believe conflict is inevitable in any professional setting, but it always presents a creative opportunity to develop and reinforce interpersonal relationships. In the summer of my third year, I worked with another summer student on a joint research project in [PI name]'s laboratory. Unfortunately within the first few weeks it became apparent that she was not completing the majority of her work. My initial gut feeling was frustration; the success of our project depended on a collaborative team effort. However, I was reminded by the wisdom of a good friend to “be kind, for everyone you know is fighting a hard battle”, and I aimed to resolve this conflict in a professional, mature, and understanding manner. I invited her out to coffee and listened to her concerns about the project. Through our conversations, I learned that she had been struggling with some difficult family situations in recent months. I therefore challenged myself to see the world from her perspective and respond in a kind and understanding manner. We mutually agreed to re-divide our responsibilities, and having had more research training, I offered to tackle the more demanding experiments. She agreed and we had a healthy relationship and highly productive work experience that summer. I am proud to say that we remain good friends to this day. 

Framework for Quotation Questions

Framework for answering QUOTES questions.

A subset of MMI prompts will present with a quote and the simple instructions to “discuss with interviewer.” I had a lot of trouble with these as I felt that the question was open-ended but the interviewers expected you to address specific points. I learned this the hard way after an embarrassing 8 minutes with an aggressive interviewer who told me that I had told him nothing. What they’re really looking for is for you to define what the quote means to you, and correlate that to a personal experience that exemplifies the quality. Essentially this is the “give an example where you …” question in disguise. To that end, here’s a framework I developed for answering quotation questions.

1. Define what the quote means in its original context to its original author.

2. Explain what this quote would mean to you.

3. Give a personal example that exemplifies the quote.

4. (optional) Give a personal example of how this might relate to you and medicine.

An example question:

“Try not to become a man of success but a man of virtue.” - Albert Einstein

Discuss the quote with the interviewer.

Follow-up questions:

What does success mean to you?

What does a man of virtue look like to you?

Can you think of an example in your life where you chose virtue over success?

Case Study - Minors & Truthtelling

A 12-year old boy is diagnosed with a terminal illness (e.g., malignancy). He asked the doctor about his prognosis. His parents requested the doctor not to tell him the bad news. What should the doctor do in this situation?

Example answer:

I think this scenario raises numerous questions that are fundamental to the practice of medicine, such as patient autonomy and the physician’s duty to tell the truth. An additional facet of this scenario that the prudent physician must consider is the autonomy of minors and the obligation to minimize emotional harm to both the patient and family members. The ethical questions raised in this scenario addresses whether or not physicians should disclose the truth to minors where parents have requested that physicians not do so.

For this specific scenario, I can definitely see both sides of the issue. On one hand, not disclosing such information would prevent undue emotional harm to the patient and family members. It would respect the parent’s wishes and intentions to prevent harm to their children and “make the most of the time left” without the burden of terminal illness and allow the parents the freedom to tell their child when they feel appropriate. Furthermore, disclosure may involve the breaking of a ‘trust’ between the parents and the physicians and may lead to a mistrust of the medical profession itself. On the other hand, the primary obligations of the physician are to the patients and not family members, and the patient autonomy and wishes must be respected, even in the case of minors, given that they can understand and appreciate the situation they are in. Ageist attitudes that indicate that children are incapable of understanding major life decisions have not been borne out in the research. Furthermore, physicians are not free to employ deception in their practice, but should disclosure a reasonable amount of helpful information that the patient wishes to know.

Given the various interests of different parties in this specific scenario, the physician would be wise to explore with the child what he understands about his condition and what he expects out of this situation. The physician must assess his level of capacity and maturity possessed to determine if he is making an autonomous choice about knowing his condition. If the patient is capable of understanding and appreciating the situation, the physician should explore if the patient wishes to know the truth or if he would like the physician to act in a limited paternalistic manner and do what is in his best interest. I believe that physicians should disclose the truth that a reasonable patient would want to hear in their situation, except in certain circumstances, such as when the patient has waived the right to know. If the child would like to know, care must be taken to disclose the information in a hopeful and manner respectful to the child. Lastly, the physician should attempt to explain his actions and his reasoning to the parents to minimize friction between the family as well as the health care team, and provide additional support to deal with the burden of a terminal illness. The physician should also make careful notes of his reasoning and his actions in the patient’s chart. 

Case Study - Jehovah's Witness

An eighteen year-old female arrives in the emergency room with a profound nose bleed. You are the physician, and you have stopped the bleeding. She is now in a coma from blood loss and will die without a transfusion. A nurse finds a recent signed card from Jehovah's Witnesses Church in the patient's purse refusing blood transfusions under any circumstance. What would you do?

This is the classical ethics question. We’ll go through it using the Doing Right algorithm and provide an example answer.

1. What is the case?

Patient comes into the ER requiring a blood transfusion. However, her prior wishes are to refuse all blood transfusions on religious grounds.

2. What are the ethical dilemmas?

The ethical issues involved primarily revolve around patient autonomy vs. beneficence.

This issue is further

3. What are the alternatives?

There is a single choice to be made:

Give her the blood transfusion or Don’t give her the blood transfusion.

Special consideration must be applied as this case involves an incapable patient with known prior wishes.

Which is part of the larger question of:

Should physicians be allowed to override patient wishes?

4. How do the principles apply?

Beneficence
Beneficence involves the physician’s duty to act on the best interest of the patient. Physicians are trained to prolong life and heal illness, and it runs counterintuitive to forgo a life-saving treatment. It is only natural to want to override someone’s decision to save their life.

Autonomy

Patients have a limited right to choose their therapy but an almost unlimited right to refuse treatment. If the patient is capable, then their autonomy always triumphs over beneficence. However, if the patient is incapable, then her prior wishes must be respected. If her prior wishes are not known, then a next of kin or family member may make a decision for her consistent with her prior beliefs. If a next of kin is not available, then a surrogate decision maker may be appointed to act on the best interest of the patient. In this case, the patient’s prior wishes are known and therefore must be respected even if it means the death of the patient. In certain circumstances, you could override her prior wishes if an argument could be made that she was incapable when she made her prior wishes, but there is no indication of this. Another circumstance is if the signed card was dated 20 years ago and recent indications suggest that she no longer holds this belief, however, this is not the case here.

5. What is the context? Who else is involved?

Canada is celebrated for its acceptance of a diversity of cultures, religious beliefs and social values. Religious beliefs, however idiosyncratic, if it is a deeply held conviction, will always trump autonomy.

6. Propose a resolution

In this situation, because the patient has recently stated her wishes, they must be respected. Do not order a blood transfusion.

7. Critical considerations

Because this is an emergency situation, there is not enough time to properly explore factors surrounding the patient’s refusal of blood transfusions. For example, are the patient’s wishes consistent with her past beliefs and behaviors? Are there any social or cultural pressures that might have influenced her to make a non-autonomous choice at a certain point in the past? Are there any close friends or family that can provide insight into the patient’s refusal of treatment? All these are questions that should be addressed if time allows to properly do right by the patient.

8. Action

Example answer:

“I think this scenario raises numerous questions that are fundamental to the practice of medicine, such as patient autonomy versus the physician’s duty towards patient beneficence. The ethical questions raised in this scenario addresses whether patients should be allowed to refuse a life-saving therapy that will likely result in their death. Should physicians be permitted to override these decisions in emergency situations where the patient is incapable?

In this specific scenario, I can definitely understand both sides of the issue. On one hand, physicians are trained to be healers and provide the best possible medical intervention to prolong life where possible, and the decision to refuse a life-saving therapy may appear to be counterintuitive to the duty to care and treat patients. On the other hand, the decline, and rightly so, of medical paternalism in recent decades has led to a revolution in patient autonomy. Patients are free to choose and refuse therapy if they are capable of understanding and appreciating the situation, and this right must be respected by physicians. This scenario is further complicated by the fact that the patient is currently incapable. For incapable patients, their prior capable wishes regarding treatment should always be followed, even if they may appear irrational to the practitioner. Where prior wishes are unknown, a substitute decision maker should be found if the situation is not an emergency, and failing that, the patient should be treated according to their best interest.

In this case, I would not order a blood transfusion as the patient has prior wishes that such interventions not be performed on her. Patients should be treated as capable unless evidence indicates otherwise. However, one should be especially diligent in cases where serious outcomes may result, and there are certain factors that need to be explored in regards to capacity and the patient. For example, are the patient’s wishes consistent with her past beliefs and behaviors? Are there any social or cultural pressures that might have influenced her to make a non-autonomous choice at a certain point in the past? Are there any close friends or family that can provide insight into the patient’s refusal of treatment? I understand that this is an emergency situation and not all of these factors can be explored in a timely manner. I believe that while physicians will always want to provide the best possible care for their patients, patients have the right to make therapeutic choices, and in the courts have consistently upheld the capable patient’s rights to refuse treatment based on deeply held religious or cultural beliefs. As a physician, I would respect the patient’s wishes and not transfuse.”