Dr Mahibur Rahman
The Situational Judgement Test (SJT) for final year medical students plays an important part in your ranking for the applications for Foundation training (FPAS). Whether you have a great Educational Performance Measure (EPM) score or not, the SJT will influence which placement you get.
In this article, Dr Mahibur Rahman discusses some key tips to help you improve your score so you can get the placement that you want.
1. Understand the basics
The exam lasts 2 hours and 20 minutes and has 70 questions, although only 60 of the questions are marked – the other 10 are pilot questions. Pilot questions are mixed in with the examined ones, so you need to treat them all as live questions.
There are two types of question – ranking and selection. In a ranking question, candidates will be presented with a scenario and 5 options – the options need to be ranked from best (1) to worst (5). This format makes up two thirds of the exam, with each question being marked out of 20.
Selection questions have 8 options, and candidates should select the 3 options that taken together make the best response to the scenario. This format is a third of the exam, with each question marked out of 12.
Sample questions for each type are given below:
Sample SJT ranking question
While working on the medical wards as an FY1 you are asked by a nurse to complete the discharge paperwork for a patient you are not familiar with. This includes a summary of the admission as well as drugs to be taken home when discharged. You are in a hurry and on the post-take ward round. The rest of the team is about to start discussing the next patient that was admitted overnight.
Rank in order the following actions in response to this situation (1= Most appropriate; 5= Least appropriate)
A – Ask the nurse what drugs the patient needs and the diagnosis, so you can quickly note this on the discharge paperwork and keep up with the ward round
B – Explain that you are busy at the moment but that you will come back and do it as soon as the ward round is complete
C – Sign the paperwork and ask the nurse to complete the summary and medication while you join the rest of the team
D – Check the patient’s notes and complete the paperwork with a summary of the admission and all required medication – you can catch up with the ward round later
E – Ignore the request. The nurse knows you are on the post-take round and can ask you later
Sample SJT selection question
You are an FY1 working in obstetrics and gynaecology. You see a lady on the labour ward who is having a massive postpartum haemorrhage. In the last few minutes she has become very unwell and is now unresponsive and continuing to bleed. From reading her notes you know she is a Jehovah’s Witness and has signed a form in antenatal clinic stating she declines all blood products even if her life is threatened. The midwife looking after her states that she asked the lady a few minutes before she became unresponsive if she would accept blood products if her life was threatened and again she said no. Her husband is holding his new born daughter and states you must do everything you can to save her even if that means giving her blood.
Choose the THREE most appropriate actions to take in this situation
A. Give blood products as this is an emergency and they may be life saving
B. Do not give blood products even if it means she comes to harm
C. Put aside the patient’s wishes as her decision suggests a lack of capacity
D. Explain to the husband that you have to respect the patient’s decision
E. Ask the husband to give formal consent on behalf of his wife to give blood products
F. Do everything else you can to save the patient’s life
G. Do nothing else as she will inevitably die without blood products
H. Contact your consultant and ask them for permission to give blood products in the best interests of the patient
2. Learn the domains being tested
The SJT questions are written to test whether you have the attributes deemed important to be a good Foundation doctor. These are divided into 5 domain areas. A good first step in your preparation would be to understand the key attributes and behaviours being tested. Learning what is being assessed will help you pick between options based on how well they demonstrate these attributes. The domains and some of the key attributes are:
Commitment to professionalism – punctuality, honesty, taking responsibility for own actions, challenging unacceptable behaviour, ethical practice, respecting confidentiality.
Coping with pressure – remaining calm and in control when dealing with difficult situations, good judgement, seeking support when required, dealing with confrontation appropriately.
Effective communication – sensitive use of language, adapting communication according to the needs of patients and relatives, using clear and understandable language, good written communication.
Patient focus – empathetic towards patients, showing respect to patients, putting the patient at the centre of care, providing reassurance appropriately, willing to spend time with patients and relatives, considering patient safety at all times.
Effective team working – understanding the roles of team members, willing to take direction, showing respect to colleagues, delegating and sharing tasks effectively, sharing knowledge and expertise with colleagues.
The full list is available in the official SJT monograph
3. Revise the core knowledge being tested
While the SJT does not test clinical knowledge, there are questions that assess knowledge of what is deemed to be good practice based on core guidance from the General Medical Council (GMC). Most of this comes from Good Medical Practice and some of the explanatory guidance published by the GMC. This includes areas such as confidentiality, maintaining boundaries, care of children and younger people, raising concerns, end of life care and advanced directives, and even the use of social media. The SJT asks you to answer what you “should do” rather than what you “would do” – i.e. what does the guidance say a good doctor should do in the ideal situation. This is much easier to do with a good working knowledge of the key guidance.
4. Spend time on the ward
A useful technique to deal with scenarios in the SJT is to try to picture the situation in your mind. This is much easier if you have spent lots of time on the wards. Try to observe how the doctors communicate with patients and relatives, how the team interact with each other, and the roles of different members of the multidisciplinary team. If there are areas from the GMC guidance that you are unclear about, it can be really helpful to talk through potential issues with a junior doctor – they may have encountered similar situations in real life and can talk you through approaches they used to deal with it.
5. Work through the official practice paper
The official Foundation Programme SJT practice paper is a complete 70 question SJT paper. There is an interactive version that you can do on a computer, and also a paper version. Doing the paper version, and getting used to completing the paper marking sheet will help familiarise you with the format and improve speed on the day. There is a marking key with detailed explanations so you understand the rationale behind why some questions are ranked the way they are.
6. Read the scenario carefully
Sometimes keywords have a big impact on the best response in both ranking and selection questions. Try underlining important words as you read. For example, your approach may differ in a situation where you suspect inappropriate behaviour compared to when you are certain of inappropriate behaviour. This small difference might change where you ranked waiting to gather more information, compared to raising an issue with a senior colleague for example. For ranking questions, there are different types of question – most ask you to rank from most to least appropriate, but some ask you to rank according to the order in which you would do things, how important considerations are to the situation or how much you agree with different statements.
7. Use only the information provided in the question
In some scenarios there will be limited information. In real life, it might be possible to get clarification or gather more information from the patient or a colleague. In the exam, your answers should be based only on what you are told in the scenario and the options. Do not make any assumptions – an incorrect assumption may lead you to a poor response.
8. Look at all the options before assigning any rankings (ranking questions)
For ranking questions, it is important to go through and consider all the options before you start deciding on the order. If you read the first option and decide it is a “bad” option, you may mentally place it last. This may then impact your thinking when reading other options – you may not remain objective and could end up fitting other options around the preconception that option A is the worst. The ranking questions are comparative not absolute – so rather than “good” or “bad”, it is about comparing one option to the other possibilities – “better” or “worse”.
9. Make sure your choices make sense when taken together (selection questions). In the selection questions, all 3 options that you select should be looked at together as a combined response to the scenario. In some cases you can eliminate options if they would contradict each other or would not make sense when taken together. If you are confident that an option that suggests seeing a patient when a chaperone is available is correct, then you could eliminate another option that suggested seeing the patient immediately without a chaperone. A good way to check if your answer is likely to be correct is to read all 3 options back together and see if they make sense together. If they don’t you should consider changing at least one of the options.
10. Double check you have marked the correct options. The SJT paper is machine marked so check that you have marked the answer sheet correctly – transcription errors are a silly way to lose marks. In ranking questions, if you accidentally marked option A and option E as the best options (rank 1), you will be awarded zero marks for BOTH these options. In the selection questions, if more than 3 options are marked, the total score for the entire question will be zero. If you transcribed the answers to question 1 to the box on the answer sheet for question 2, it would be possible to accidentally mark all the later questions in the wrong box and have a serious impact on your overall score.
11. Keep to time
To complete the entire paper, you have just 2 minutes per question. Try to be disciplined – if you are not entirely sure of the best answer, it is better to put down your best guess and move on. You will still get marks for answers that are not perfect but close to the best answer. For ranking questions, you get 8 marks for the worst possible ranking. If you are fairly close, but not quite perfect, you can still get 16 or 18 marks. Spending an extra 2 minutes to get the perfect answer may only increase your score for that question from 18 to 20 (2 extra marks) – whereas using that 2 minutes to answer another question will get you at least 8-20 extra marks. Even worse – the question you spent a long time on could turn out to be one of the pilot questions, and so carry no marks.
The Foundation SJT plays an important part in determining where you will be placed for your first two years after qualifying. Understanding the attributes that are being tested, and learning the core GMC guidance will give you the basic tools to help you prepare. Practising sample questions and getting used to the format and time pressures will help you to get the best possible score on the day.
Dr Mahibur Rahman is a portfolio GP and a consultant in medical education. He is also the medical director of Emedica. Emedica has been offering courses to help medical students prepare for the Foundation SJT since 2012. We have helped students from every UK medical school prepare, with 97% getting one of their top 3 rotations in 2017.