Example 8 · Asked to work beyond your competence

The question

You are an F2 doctor on a night shift. The registrar, who is busy in the emergency department3, phones and asks you to perform a procedure on a patient on your ward. You have never been trained in or supervised doing it.2 The patient is stable and the procedure is not time-critical.4 The registrar sounds stressed and says everyone has to pull their weight tonight5.

Choose the three actions that, taken together, are the most appropriate response1.

A: Tell the registrar honestly that you have not been trained in this procedure and cannot do it safely without supervision9.
B: Ask the registrar whether they could supervise you once they are free, or who else competent could do it tonight10.
C: If the procedure is not done overnight, document this clearly and hand it over to the day team11.
D: Watch a training video, then attempt the procedure and call the registrar if you run into difficulty6.
E: Ask an experienced nurse on the ward to talk you through the procedure while you do it12.
F: Agree to do it so that you don’t add to the registrar’s stress7, then leave it until the end of your shift in case someone else becomes free.
G: Tell the patient that the procedure is delayed because the registrar has asked an untrained doctor to do it8.
H: Ask the nurse in charge to phone the on-call consultant at home13 and ask them to come in to do the procedure.

Try it first. Choose your three, and for each one write down what it adds that the other two don’t.

Step 1 · Read the instruction

WHAT TO DO
Check the format first.

Instructiontaken together, are the most appropriate response
Choose three. The set must fully resolve the situation: by the end, the procedure should either be done safely or be safely planned.

Step 2 · Work out your role and who is affected

WHAT TO DO
Ask what you can safely do. A competence limit stated in the stem is a fact, not a feeling.

ScenarioYou have never been trained in or supervised doing it.
This is a clear limit, not just a lack of confidence. The GMC says you must work within the limits of your competence, so attempting the procedure unsupervised is ruled out from the start.
Scenariowho is busy in the emergency department
The registrar is your senior and is under pressure, but not available right now. Their being busy doesn’t change what you’re competent to do.

The people affected are the patient, who needs the procedure done safely, the registrar, who is stretched, and you.

Step 3 · Separate facts from assumptions, and find the risk

WHAT TO DO
Check for urgency. Emergencies are the one situation that can change what’s acceptable, so look for whether the stem describes one.

ScenarioThe patient is stable and the procedure is not time-critical.
There’s no emergency. The exception in which you might do what you safely can because no one else is available doesn’t apply. There is time to arrange supervision or someone competent.
Scenarioeveryone has to pull their weight tonight
This is pressure, not a clinical reason. As your health, limits and commitments says, pressure from a senior doesn’t create an emergency.

Don’t assume that the registrar would be angry if you said no, or that the procedure must be done tonight. Neither is stated.

Step 4 · Name the tension and write your task

WHAT TO DO
List the separate needs.

You want to be helpful to a stressed colleague and a team player, but you must work within your competence and keep the patient safe. There are three needs:

be honest about your limit;
find a safe way to get the procedure done, through supervision or a competent colleague;
make sure it isn’t forgotten if it can’t be done tonight.

Your task: I need to be honest that I can’t do this safely alone, help find a safe way to get it done, and make sure it is handed over if it isn’t done tonight.

Step 5 · Strike out options with a clear flaw

WHAT TO DO
Remove options involving work beyond your competence, dishonesty or unprofessional behaviour first.

Option Dcall the registrar if you run into difficulty
D means attempting a procedure you’ve never been trained in. “If you run into difficulty” means help arrives only after something has gone wrong, and a video isn’t supervision.
Option FAgree to do it so that you don’t add to the registrar’s stress
F agrees to something you don’t intend to do yet, and can’t do safely. It hides the problem, and the procedure might be left undone without anyone knowing.
Option Gbecause the registrar has asked an untrained doctor to do it
G blames a colleague to the patient. It’s unprofessional, would worry the patient and does nothing to get the procedure done.

That leaves A, B, C, E and H. Two of these, E and H, look like they get help, so read them carefully.

Step 6 · Work out what each remaining option contributes

WHAT TO DO
For each option still in play, ask which need it meets, and whether its help is the right kind.

Option Acannot do it safely without supervision
A meets need 1. It says honestly what your limit is and why.
Option Bwho else competent could do it tonight
B meets need 2. It offers two safe routes: supervision when the registrar is free, or someone competent. A refusal combined with a plan is stronger than a refusal alone.
Option Chand it over to the day team
C meets need 3. It is a safety net, so the procedure isn’t forgotten if it can’t be done overnight.
Option Etalk you through the procedure while you do it
E looks like getting help, but nothing says the nurse is trained in this procedure or able to supervise you doing it. You would still be attempting it without appropriate supervision.
Option Hphone the on-call consultant at home
H would get a competent operator, but it is disproportionate. The procedure isn’t time-critical, and H goes around the registrar, who is coordinating the night. Escalation should match the need.

Step 7 · Build a set of three and test it

WHAT TO DO
Test for coverage, compatibility and necessity. Overlap isn’t automatically wrong if each option adds something different.

Provisional set: A + B + C.

Coverage: you’re honest about your limit, you seek a safe way to get it done, and there’s a safety net if it doesn’t happen tonight.
Compatibility: A and B are naturally part of the same phone call, and C follows if neither route works overnight.
Necessity: A and B overlap, since both involve the registrar, but they do different jobs. A says what you can’t do; B offers a way forward. Without A, your limit isn’t stated clearly. Without B, you refuse with no plan.

Test the swaps. Replace B with E, and you have refused safe help and accepted unsafe help instead. Replace B with H, and you overreact to a non-urgent request and bypass the registrar. Replace C with either, and nothing protects the patient if tonight’s plan falls through.

What could change the answer

WHAT TO DO
Ask which fact would make your preferred set wrong.

In a genuine emergency, with no one more competent able to attend in time, you would do what you could safely do while calling for help. The stem says the patient is stable and the procedure isn’t time-critical, so that doesn’t apply.
If you had been trained in the procedure and needed only occasional supervision, a different plan might be appropriate. The stem says you have never done it.

The exam-speed version

Choose three, together.
I’ve never been trained to do this. The patient is stable and it isn’t time-critical. The pressure is not a clinical reason.
Needs: be honest, find a safe route, hand it over.
Strike out D (beyond competence), F (dishonest) and G (blame). E and H look like help but aren’t the right kind. A, B and C.

Take this into your next question

Lesson: say no with a plan. A clear refusal combined with a safe way forward (“Can you supervise me later, or who else could do it?”) beats either one alone.

When it applies: procedures, prescribing and any request beyond your competence. See working beyond your competence.

Asked to work beyond your competence