How to nail the MSRA

Almost as dreaded as MRSA, the Multi Specialty Recruitment Assessment (MSRA) has recently become a key part of any application to specialty training in the UK for a variety of choices of specialty. Both James and Will managed to sneak their way into anaesthetic training before it was introduced, however our resident blogmaster Dr Rory Heath has recently sat – (and crucially nailed) – the MSRA, so he has a few helpful tips and tricks to help you on your way.

What is the MSRA?

The MSRA is a standardised, written examination used to assess applicants hoping to enter specialty training in General Practice, Psychiatry (Core and CAMHS), Radiology, Ophthalmology, Obstetrics and Gynaecology, Community and Sexual Reproductive Health, and Neurosurgery – but if you’re here on Anaestheasier, it’s more than likely that you are taking the MSRA to apply for anaesthetics.

Why does an application to anaesthetics require the MSRA?

ANRO, the Anaesthestics National Recruitment Office, have written their own statement to say that the MSRA

‘has been designed to assess some of the essential competences outlined in the Person Specification and is based around clinical scenarios’,

while HEE expands on this by explaining that the MSRA assesses

‘the foundation level of competence’

i.e. those competencies required to complete the Foundation programme.

💡 See the person specification for Anaesthetics Core Training and for Acute Care Common Stem (ACCS).

But why?!

Who knows, but it likely comes down to a combination of the following two factors:

1) Selection

2) Feasability of selection process

Some might argue that the broad medical knowledge base required for a career in General Practice bears little resemblance to the narrow, highly specialised technical abilities required for a career of drugs, tubes and gas. Others may suggest that a broad situational judgement-based assessment serves as a good baseline assessment of suitability to a variety of specialties, so this shouldn’t matter all that much. While many people readily show frustration at yet another set of exams – both are understandable perspectives.

Some people may also hope to expect that the MSRA falls out of use, as we continue to hope that coronavirus precautions may be further reduced, bringing back the hard-earned portfolio and face-to-face interviews. However, until then, the team at Anaestheasier want to make your life easier by creating a guide to help you nail the MSRA, if you end up having to sit it. (Probably).

  • The MSRA forms part of the selection process to interview, where you face-to-facers will shine and your portfolios will be very helpful.
  • The MSRA forms 15% of your application score – a sizeable chunk of your aggregate score that you should aim to optimise for application success!

How is the MSRA structured?

💡 To excel in any challenge, it’s important to know the format of the test and what is expected of you.

The MSRA is structured in two parts; the Professional Dilemmas (PD) section, and the Clinical Problem Solving (CPS) section.

Professional Dilemmas:

Do you remember the Situational Judgement Test at medical school? Well you’re about to experience a whole world of Deja vu! The PD section ‘provides scenarios in the workplace for applicants to demonstrate their judgement about the most appropriate behaviours in that context’ (HEE).

The PD section is 95 minutes long, asking 50 questions, but note that this was the arrangement for me, and may be subject to change over time, so please check that this is the same with your cohort!

Clinical Problem Solving:

This tests an individual’s application of knowledge to make clinical decisions. HEE say that this knowledge is based upon the Foundation Programme competencies. In other words, Do as a sensible F2 would do.

In our experience, the MSRA is less knowledge heavy than other entry exams (e.g. MRCP part 1), but still requires active learning and revision above and beyond the clinical exposure of working and attending teaching within the foundation programme. Some find luck when winging it – the rest of us might consider taking a proactive approach of systematic learning and revision.

Tips for the MSRA

Tips for PD:

Many people find it difficult to revise for SJT-type exams – after all, the temptation is to think that it tests your intrinsic moral substance (character flaws be damned!)

Your score isn’t all inevitable though, and there are definitely things to do to know the test, and although you don’t know the markscheme, you can know what the markscheme is based upon.

  • Know your time. 70 questions over 95 minutes = 114 seconds per question. Practice mock exams with a clock running.
  • HEE describe three core competencies which their questions aim to test; Professional Integrity, Coping with Pressure, and Empathy and sensitivity. These are outlined on this document here, page 4/9. It’s worth a read to understand what they expect from you, but you are already likely practicing these qualities in your daily life and work.
  • Familiarise yourself with the GMC’s Good Medical Practice.
  • Use a SJT question bank.

Tips for CPS:

  • Know your time. The CPS paper asks 97 questions in 75 minutes = 46 seconds per question.
  • The questions are ‘single best answer’ or ‘extended matching questions’. Read the question to know how best to answer it!
  • The questions test various ‘domains’ of clinical practice:
    • Investigations; Diagnosis; Emergencies; Prescribing; Management.
      • This is a useful frame work for any revision notes you might make about a particular condition e.g. asthma.
  • Question banks are very helpful, especially those with a ‘textbook’ feature – making the above point easy to achieve.

General Tips:

Answer all the questions as there is no negative marking. You miss all the shots you don’t take!

Start revising little and often, early – it will help to consolidate information before the exam and will avoid last minute panic. Furthermore, learning whilst working makes both activities more fun – You will feel rewarded the next time you remember and implement recently learned information into your practice!

That’s it from us – Good luck, and if you have any useful tips of your own, please share them in the comments!

Dr Rory Heath

Anaesthetics Core Trainee

Emergency Drugs

Part of the morning ritual of a novice anaesthetist is drawing up a pristine set of emergency drugs for the day’s list. There’s something satisfying about quietly cracking ampoules of deadly drugs open and labelling the syringes ‘just right’. And as with everything in anaesthetics, we’ve already hit a point of controversy.

Some consultants will advise you to draw up a full tray of emergency drugs for each list, while others will insist it is a waste of drugs and plastic and that you shouldn’t need them that quickly if you’re doing your job properly.

My advice? Draw them up. Especially as a novice. Why? For two main reasons:

There’s enough on your plate

The learning curve is steep enough as it is without the added stress of having to find, crack open, draw up and administer drugs that you really need to be giving within a minute or two. Having them sat reassuringly on your anaesthetic machine labelled at the ready was a real confidence booster for me.

You’ll use them if they’re there

If you’ve got a syringe of ephedrine drawn up and ready to go, you’re far more likely to actually use it than if it is sat in the cupboard. Then when you find the patient’s blood pressure just a little lower than you’re comfortable with, with a heart rate in the fifties, then giving 3 – 6mg of ephedrine is not going to do any harm, and it allows you to practice with the tools of your new trade. It’s useful to get experience with seeing how these drugs work, and how much effect you get from a given dose. That way when you actually need them, you’ll be far more comfortable using them. A lot of consultants seem to take pride in not needing emergency drugs, suggesting that if your anaesthetic is good enough, then you’ll avoid having to give them. Personally I disagree, particularly with vasopressors. If you’re giving someone a syringe full of propofol, causing their entire vascular system to relax, to me it makes total sense to counteract that with a little metaraminol or ephedrine just to replace some of that vascular tone – but hey – each to their own.

Standard recipe for an emergency drugs tray

Metaraminol 0.5mg/ml
  • For hypotension with a heart rate above 60bpm
  • Give 1ml and assess response in 30 seconds
  • If you’ve given more than 10ml in divided doses, then you should think about an infusion, and maybe even a central line and noradrenaline
Ephedrine 3mg/ml
  • Usually comes as 30mg in a 1ml vial
  • Draw up 9ml of saline into a 10ml syringe, then add your 1ml ephedrine to make 3mg/ml
  • Give 1 – 3ml boluses and assess response in 30 seconds
  • There’s no point giving more than 10ml in total, because it exhausts the body’s noradrenaline stores – move onto metaraminol or noradrenaline next
  • Usually comes as 200microgram/ml in either 1 or 3 ml vials
  • Used to treat airway secretions (45 mins before induction ideally)
  • Also used for bradycardia – generally considered more ‘gentle’ than atropine
  • Usually 600microgram/ml
  • Used for profound bradycardia, particularly in paediatrics (20microgram/kg)
  • Used for rescue sedation, in case patient wakes up agitated, bites the tube or develops laryngospasm
  • 2 – 5ml bolus to re-establish control of the situation
  • Often forgotten until you need it!

Top Tips for a productive Taster week in Anaesthesia

It can be difficult for prospective trainees to fully understand what a career in anaesthetics is like. Unless a trainee has an intensive care medicine job lined up before they apply to Core Training, the chances are that they may have only met the elusive anaesthetists at emergency or trauma calls, before a patient is whisked away to theatre, or after pleading to the vascular access gods. Luckily, taster sessions are at hand.

Taster days are ‘not essential but will be desirable… to demonstrate interest in specialty and [to] also help you decide if it is the correct specialty for you.’

HEE Yorkshire and Humber

How can you organise a taster session, and what might you learn?

How to organise taster sessions.

Firstly, this is off your own back.

Doctors in training, such as in the foundation years, will likely have a quota of salaried days that they may take to gain experience in specialties that interest them. Usually, it is only about 5 days – which co-incidentally appears to be the minimum number of days that will stand up as a sign of ‘commitment to specialty’ in job applications – so spend your taster days wisely and choose anaesthesia.

It will definitely help to bring the topic up with your educational or clinical supervisors who may know the right contacts, so bring it up early at start of placement meetings.

You need to find out who a few people in your Trust are:

  • The RCoA College Tutor at your ‘local education provider’/Trust, who should be able to give some good advice about a career in anaesthesia and to point you in the direction of people to help you organise your taster sessions.
  • The anaesthetic rota coordinator, who will be able to find sessions that have availability for you to join. You shouldn’t turn up at the theatres without being rota-ed in because theatre time is essential learning time for anaesthesia trainees and for other learners, such as student ODPs, paramedics, nurses and medical students.
  • Your rota coordinator for your current specialty, who will need to find a time in your current rota that allows you to be released while the rota remains safe.
  • An additional avenue to pursue would be to become acquainted with your friendly neighbourhood anaesthetists, in theatres whilst on a surgical placement, during debriefs after emergency calls, or during lighter times at mess events. They might be able to point you in the direction of the anaesthetic consultants who really interested in teaching, or the lists that are particularly high-yield for practical skills e.g. the emergency CEPOD list, certain urology lists etc.

What your taster week might look like

  • With the help of the rota-coordinator, you should be able to form a structured schedule that should provide a wide exposure to anaesthesia.
    • Look to attend lists with multiple different consultants
      • Consultants working in anaesthesia often have other commitments, such as in research, ICU, pain medicine etc – so by meeting many consultants, you can gain insight into these additional anaesthesia-related specialties, too.
    • Look to attend lists of different surgeries
      • Different lists offer different opportunities. A relatively ‘simple’ list might have many short cases requiring only a supraglottic airway – useful if you’ve never put in an I-gel before, and useful to see a fast turnover of anaesthetic inductions. A good list for this might be a general surgery emergency list (with abscess drainages etc) or a gynaecological surgery list.
      • Longer operations often require a more complex anaesthetic, while operations in more frail patients likely need more sophisticated invasive monitoring. If you wanted to gain experience in laryngoscopy and intubation, or to see or partake in central venous access or arterial line placement, an elective or emergency colorectal list with big operations might provide a suitable learning environment.
    • Look to meet trainees!
      • It’s very important to learn from trainees – after all, they’re doing the job that you think you want. What’s it like, really?

💡 What should you ask consultants and trainees to really understand what life in anaesthesia is like? Find out more in an upcoming blog post…

What you might expect to do and learn during your taster week

  • Practice tricky things
    • Knowledge and skills of vascular access, airway manoeuvres and the use of emergency drugs are useful regardless of your future specialty.
    • Anaesthetic room time is a great opportunity to practice these tricky things in a controlled environment and readily accessible expertise
    • Learn how to cannulate properly.
    • Learn how to draw up drugs properly.
    • Jaw thrust and bag a patient properly.
    • Learn how to use an guedel/oropharygneal airway, an I-Gel/LMA, and direct/video laryngoscope, bougie and ETT properly.
  • See how the anaesthetist does tricky things
    • Textbooks will teach the alveolar gas equation and pharmacokinetics of anaesthetic agents, but watching or experiencing the changing of gears between I.V. and volatile agents, paralysis and reversal and the manipulation of cardiovascular or respiratory physiology is a demonstration of the art of anaesthesia.
  • Meet a variety of people and gain an appreciation of the team-based environment of theatres.
    • The presence of an ODP helps to aid the smoothness, safety and efficiency of an anaesthetic, while they provide an extra pair of eyes, hands and experience when things go awry. In the day to day, ODPs often do much of the essential hard work such as checking the anaesthetic machine and moving patients around the theatre environment, while also being great people to chat to and learn from as a prospective anaesthetic trainee.
    • You will meet some real characters!
  • See how good communication is done!
    • Some people are naturally good communicators, whilst some stumble over words or don’t quite say what they mean. I’m often in the latter category, but working towards being in the former, which means I listen particularly hard to the friendly and gentle babble of an anaesthetic room that effective teams create to comfort and quieten the anxieties and fears of patients.
    • If you want a masterclass in communication techniques, attend a paediatric anaesthesia list.
    • More broadly still, it’s just lovely to be in an environment where the team works together regularly, if not daily. Unlike many other theatres within medicine, my experience is that the anaesthetic room is not the place for big egos or enemies but is one of friendly banter and generally a good way to pass time; this must be all due to the wafts of Sevoflurane released during my poor preoxygenation attempts.
  • Anaesthetics is based on the practical application of knowledge.
    • Anaesthetics is fundamentally rooted in physiology, which although means that much of anaesthetics practice requires a sound understanding of physics, various eponymous constants, and other equations; by applying a stimulus, we can expect and predict a response. Whether it is understanding the pharmacology of a neuromuscular blocker on a neuromuscular junction with an expectation of the subsequent effect, or of the effects of metaraminol on the cardiovascular system, the effects of interventions in anaesthesia is much more tangible than, for example, the effect of a monoclonal antibody in a subtype of rheumatoid arthritis. For many, the rapid responses elicited by practical application of theoretical knowledge makes anaesthesia a very engaging and satisfying career.

To conclude, here’s a checklist for your taster week:

  1. Go in with an open mind and a desire to see, do, and learn everything.
  2. Ask your own questions, find out what you want to know to see if anaesthesia can provide a career with interest and sustainability over the long-run.
  3. Come out with practical skills and the perspectives of juniors, seniors and allied healthcare staff.
  4. Enjoy the time away from the ward rounds, charts and discharge notes; you’ve only got 5 days of paid taster days.
  5. Get feedback from your tutors, or obtain a certificate, and remember to reflect on your experience daily!

Dr Rory Heath

Clinical Fellow in Emergency Medicine

All systems go

Systems. Habits. Ways of doing things, lining things up, preparing vials of drugs or positioning the ultrasound just-so.

Everyone has one.

Everyone is a bit different; all built from advice from different mentors or in response to different previous disaster-pants moments – a product of the necessary learning curve in anaesthestic training.

As a junior trainee, or a prospective doctor on a taster week, or maybe even an experienced doctor making a move to a new department, watching how other established anaesthetists set themselves, their kit, their drugs and their team up before launching into mission mode is an informative experience.

Today I learned about one anaesthetist’s technique of putting opioids into 5ml syringes, muscle relaxants into a 10ml syringe, and propofol into a 20ml syringe – a system learned in the time-critical arena of pre-hospital care, where differing syringe sizes to identify which drug is which provide tactile information in addition to the visual reminder of a coloured drug label sticker – an extra layer of redundancy to ensure safety during an RSI in a dark corner at 3 in the morning, and a great tip for a junior.

Sometimes, however, watching this preparation and comparing it to our own system (or lack of system) can be intimidating; Is my system not good enough? Which system is best? Which to choose? Will this make or break my anaesthesia delivery?

Maybe there is one single anaesthetic preparation set up that will rule them all.

On the other hand, we might be liberated by the existence of a wide breadth and individuality of the systems employed by individuals; That there are so many systems, yet many safe and effective anaesthetics given, means that there are no major differences between the outcomes of different systems.

So, maybe there is no ‘optimal’ set up!?

The excellent principles of rigour, organisation and checklists to enable safe practice are seen throughout anaesthetic practice, and there are many circumstances where the consequences of poor systems are so disastrous that it should take much to contemplate whether an off-piste route should be taken e.g. CICO scenarios.

But, with regard to the large and multi-faceted task of delivering an anaesthetic, the smaller, personal details might not matter so much (as in they probably won’t help another practitioner). Whether you protocolise your pre-gas checks by lining everything up, drawing some drugs up and but leaving others in their vials, or use specific syringe sizes to mark out opioid, hypnotic and muscle relaxants is by-the-by; its success for you probably won’t translate into success for another practitioner with different experiences, habits or foibles. Our systems just play around the edges of a greater whole i.e. the principles of anaesthesia.

In summary, take comfort that no system is best, but the best one is the one that you choose and works for you (safely and consistently).

Dr Rory Heath

Clinical Fellow in Emergency Medicine