One of the possible scenarios given commonly in medical school interviews is that of allocating limited resources. For example, it may be presented similarly to the following scenario: :
"Imagine you are the head of the surgical department in a hospital. There are two patients, A and B, both requiring an urgent liver transplant, but there is only one viable liver. Patient A is a 32-year old social activist with a drug abuse history. Patient B is a 78-year old woman who takes care of 3 children whose parents died in a car accident. How would you decide who to allocate the liver to, and why?"
While it may seem like a complex issue and a tough nut to crack (especially under stressful interview conditions), there is only a limited number of factors that you should consider when giving an answer, but that would help you score the maximum number of points:
☠️ Consequences: Inquire what the consequences of not getting the transplant are for both patients (if not explicitly given). Based on the limited amount of information provided, we shouldn't assume both patients will suffer equally dire consequences if they don't receive the transplant. What if one of them can wait a few days or even weeks until another organ becomes available?
🧬 Clinical aspects of care. Is one of the patients more likely to benefit from a certain treatment than the other? Are they equally well suited for the intervention? In the case of organ transplants - which patient is a better match for the organ to be transplanted?While the organ may benefit one of the patients more than it would the other, determining whether the transplant will be successful may be an even more important indication.
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🧓 Quality-Adjusted Life Years (QALYs). The metric refers to the number of years in perfect health that the intervention is predicted to give. Hence, when dealing with limited resources, it may be useful to determine how to allocate the resources to maximise the number of QALYs for the patients. Important factors to consider when trying to optimise the number of QALYs are the person's age (the younger the person, the more likely it is they will live longer) or the current health state and health predispositions of that person (for instance, whether they have any comorbidities that would limit their quality of life). Side note: QALYs are actually used by the National Institute for Health and Care Excellence (NICE) in decisions regarding the introduction and allocation of new treatments and technologies in the NHS.
🔢 Age. Besides the higher likelihood that younger patients will live longer after a transplant, younger patients are usually less likely to suffer from complications due to treatment, which in turn increases the chances of it being successful.
🏡 Circumstantial factors: For example, if a patient already received two liver transplants but continued to pursue unhealthy lifestyle choices (say, binge drinking), chances are they may not use the donated organ as effectively as a healthy individual may do, bringing them lower on the priority list.
👩👩👦👦 Dependants. In line with the utilitarian approach, we may choose to maximise the positive effect of our resources by helping the largest number of people. Hence, a lone mother of two may have a priority over a female the same age, as through helping the former patient, not one but three individuals benefit.
Note that these aspects aren’t related to the clinical needs of the patient. Therefore, they won’t constitute realistic arguments in practice, as all decisions in the NHS should be based on clinical need (as per the NHS’s founding principles). Even so, these aspects may serve for meaningful hypothetical discussion at an interview, so you can keep them in mind.
1. Consult senior colleagues before making the decision. While the scenarios you are given during medical school interviews are hypothetical, acknowledge how tough it would be for a doctor to solve such a problem in real life.
2. Think about the information that is lacking. It may happen that you are given a piece of information from a specific category about only one of the patients (for instance, patient A’s age is specified, but not patient B). This may make it impossible to compare that aspect between patients. However, you shouldn’t skip it - acknowledging that it may be an important factor to consider will show you are a lateral thinker and is likely to score you extra points.
3. Whenever you’re faced with a scenario, try to rephrase it to the interviewer at the beginning. This way, you will make sure you remember all crucial elements. In case you miss something, the interviewer should correct you, but this shouldn't affect their assessment of your answer. Frequently you may also be given a piece of paper with the scenario written out, so feel free to refer back to it if you forget any of the details.
1. Assuming one of the patients has a self-inflicted disease (when talking about organ donations). Many candidates fall into that trap without realising that even the diseases, which may be strongly linked to unhealthy lifestyle choices, such as lung cancer, may be caused in a different way (as much as 10% of lung cancers develop in non-smokers!). To highlight your understanding of this, make sure to explain to the panellists that you are not passing judgement as to what caused the disease, but rather on the current clinical need for treatment.
Imagine you are a member of the executive board of NICE, and you have to introduce one of the two new limited-use drugs for the same condition, A or B. Drug A is efficient 90% of the time, while drug B is only 50% efficient. However, drug A costs twice as much as drug B. Which drug would you approve and why?
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