The following guide is meant to give you an insight into how a viva might take its course. If you were to go on a course they would give you a list of headings within a powerpoint presentation and maybe put you under pressure. If you can get one of your colleagues who have sat the exam recently to put you in the driving seat, you will find out how much you really don’t know.
When reading the questions ask yourself….” Could I honestly answer this?”, and try and talk out aloud. The answers you give in your head are very
different.
Here is an example of how a viva may flow. Click on the relevant buttons to advance from question to question. Note a double click will hide the question.
You line up outside. On entry to the examination hall 2 examiners are waiting. They will start off with a straightforward question.
- “What sort of anaemia is the general surgeon likely to see in the clinic?”
- “A 76 year old lady is referred with anaemia. How would you go about managing this? “
- Firstly listen to the question. ‘managing’ not investigating, treating.
- Start off “ I will take a history with specific reference to
- Appetite
- Upper GI symptoms - Hearburn, dyspepsia, dysphagia, etc.
- Relevant NSAID, steroids etc
- Lower GI symptoms – change bowel habit, bleeding, melaena
- PMH – is the patient fit? If they have dementia and live in a nursing home, or had an MI 2 weeks ago this will change your management
- Investigation
- Bloods, haematinics,
- OGD, Barium Enema
- Why do a barium enema? Why not a Flexi, colonoscopy?
Have a clear answer for this type of question. If you do a test or an operation you need to justify why you would do it as opposed to an alternative.
I would have said. A Barium enema carries a risk or perforation of 1:10,0000. It has a mortality of 1:60,000. A colonoscopy carries a risk of perforation 1:700 and a mortality of 10% if this happens i.e 1:7000. A flexi will not visualise the caecum so is not useful to investigate the colon for anaemia.
- Your OGD and Barium enema are normal what would you do next?
- Look at haematinics – “Iron deficiency picture”
- Barium follow through
“any other way you could look at the small bowel?”
- Capsule endoscopy.....
“ This is normal what next”
- Meckels scan.....
“ this is normal what next?”
……I ran out of answers
THINK: The answer to this question is often easy. They wanted I suspect an answer more like this..folow the link
http://www.wmsurgeons.com/kb/entry/202/
Topic 2
- “Tell me how you about the risks of DVT and prophylaxis”
- "A 78 year old lady resents with RUQ pain, fever raised WBC and jaundice. How would you manage her?"
In this scenario you could go through the options
- Acute Cholecystitis with Jaudice in a fit patient
- Biliary Colic in a fit patient
- Acute pancreatitis and gallstones + jaundice
- Jaundice and Cholangitis and gallstones
- Complex disease (Mirizzi’s and Gallstone ileus)
etc, etc
At the end of the day what they want is what YOU would do,
not a list of options that you could do.
So say something like :
“I would, in a fit patient with no co morbidities and who has no signs of severe sepsis, manage them with:
- Initial rescussitation
- Bloods,
- iv fluids,
- catheter
- Antibiotics
- An USS to assess the biliary tree.
If they had an obstructed duct I would arrange and ERCP followed by a Lap cholecystectomy within 6 weeks on an elective list.
IF you can do a emergency Lap chole and OTC, have the training and experience and can back up your argument with the evidence then say this is what YOU would do.
Discussion
The main thrust of this sort of discussion centres around recent debate as to the best treatment of CBD stones:
- ERCP followed by lap chole
- Lap chole & OTC with laparoscopic clearance of CBD stones
- Lap chole followed by ERCP to clear the duct
To some extent this depends on your experience and centre. I would go for option 1, and argue that even with upper GI surgeons in a small DGH, CBD exploration laparoscopically is necessary very infrequently.
e.g For a surgical department doing 100 Lap chole’s a year, 10 will have CBD stones, and 50% of these will pass spontaneously. Therefore 4 or 5 will require duct clearance. Is this enough to remain competent even if you or a dedicated Upper GI surgeon were available for all cases?
See these links:
http://www.wmsurgeons.com/kb/entry/206/
http://www.wmsurgeons.com/kb/entry/205/
Subspecialty
This viva went badly for me. But from a bad experience you can learn alot. Therefore if you are sitting the exam I would strongly suggest you speak to those who sat the exam more than once. There are common themes. (LINK)
The format of the viva is similar to the above. You are likely in this to get asked about topical subjects. So here is an example of the examiner being a little cunning.
Topic 1
- “ What are the components of an ‘Enhanced Recovery’ program?"
This is quite topical and in all the journals.
Therefore this topic stood a good chance of coming up somewhere. In this case there are no text books. Reading the Companion Series to Surgical Practice will not have helped.
A link to a summary can be found here.
http://www.wmsurgeons.com/kb/entry/213/
The viva then went on to a discussion on how you can place your incisions to minimise pain. In a right hemi for example transverse incisions……
The smile, the satisfaction of the hole I was blindly digging grows and then there comes the subtle change in the viva that is leading you ever onward……..
Topic 2
- “What are the perceived benefits of Laparoscopic colorectal resections?”
The benefits are….
- Less bleeding
-
Reduction in post operative pain
- Therefore reduction complications – chest, wound, cardiac
- Less pain translates to early ambulation
- Short post operative stay
- Earlier return to normal activity
- Without compromise in leak rates or oncological clearance and presumed therefore post operative survival.
- …“what’s the evidence?”
Do I need to know papers?
YES!!
When you hear people say "you do not need to quote the literature" this is an example of a scenario where this is completely wrong.
CAUTION: people have failed when they start quoting journal articles wihtin an answer. Looking good by quoting the latest journal articles is impressive, but not to your examiner. They are wondering ....do they just know the theory or could they cut it in the real world?
Having said that they do ask.
Therefore you need to know the seminal papers in your specialty within the last few years. There is a subtle difference in quoting journal articles to support 5 different ways of doing a right hemi-colectomy, but saying ‘this is what I would do….’
then if they ask “why”………..you can then quote the literature
In this section of the viva the examiner wanted the laparoscopic trials….how they were conducted, how many in each arm of the trial and what they showed. ( CLASSIC, COLOR, COST)
Every paper is open to interpretation, but if you follow the natural gist of the viva what he was after was an admission that for a right hemicolectomy through a transverse incision in a thin patient is as good as a laparoscopic resection in terms of short term outcomes. DO NOT ARGUE WITH THE EXAMINER.
Topic 3
- “What would you do with a 78 year old woman with a rectal cancer on flexible sigmoidoscopy that comes via the 2 week wait system?”
If she was fit for resection I would stage her with CT and Pelvic MRI
- “Staged as T3 on MRI with enlarged mesorectal nodes, what would you do next?”
- Her results of imaging and histology need to be discussed in the context of and MDT, but evidence suggests she needs long course chemo radiotherapy.
- “She returns after her long course chemo radiotherapy….What would you do next?”
I would re-stage her with CT chest / abdomen and pelvis
Buzzer
If it goes badly………
Do not panic. Talk about it if it helps. The subspecialty as above is how I would have like it to have gone. It wasn’t that smooth, in fact it was awful.
You can compensate in situations like this. So I went for a long walk and focused on the next viva
