By: Ryan Kelly
You’re about to walk into your first MMI station, and you can feel the interview jitters coming on. Before you enter the room, you’re given a prompt and have two minutes to take notes and gather your thoughts. Piece of cake, right?
How do you spend these two minutes, other than sweating, pacing, and holding down your lunch?
These minutes are crucial, so don’t waste too many of them on your nerves. You’ll have eight minutes (or five or six in some cases) to give your response, and although you don’t need to fill all of your time, you’ll still want plenty of things to say. So start writing down notes immediately.
Let’s use some examples to illustrate the thought process and note-taking:
One of your patients, a 17-year-old male, has disclosed to you that he has been having unprotected sex with other men and wants to start taking PrEP so that he can reduce his chances of contracting HIV. You try to recommend alternative courses of action, but he is adamant about his choice and says that he will deny it vehemently if you inform his parents and will simply find a way to buy it from a friend or on the black market. How do you handle this situation?
In general, I recommend using a set of five steps to answer ethical dilemma stations. I feel like you can apply these tips across the board in an MMI, except for the acting/communication stations (we’ll get to those later).
You don’t need notes to restate the prompt, but your first step should be isolating the competing ethical stakes. In other words, you should write down what you see as being the central conflict of the dilemma - what is the prompt testing?
In this case, it seems like the competing ethical stakes are the patients’ well-being and personal preference verses your limitations in treating a minor and your professional opinion of what’s truly best for his health.
Writing this down can help guide the rest of your answer and steer you away from making mistakes or going on tangents.
Part of what makes ethical dilemma prompts difficult is that they don’t give you all the necessary info, so it’s up to you to fill in these blanks. Write down any question that pops into your head:
What do I know about PrEP? Pre-viral, prescribed, pill
Can I treat him as an adult? Or do I have to tell his parents? What are the laws where I’m practicing?
How frequent is he having unprotected sex? How many partners? Has he been tested?
Why does he refuse other forms of protection? Motivations? What’s the best rhetoric for a 17-year-old?
How does he talk about the black market? Aggressive threat or passing comment? How much does he know about the risks?
Use shorthand notes to help speed up the process; your notes only need to make sense to you.
Your stance will probably hinge on the questions you wrote above, so you might as well add notes along the way about your solution for each possible scenario:
If I can treat him like an adult, then I’d...
If I cannot treat him as an adult, then I’d...
If his tests come back positive, then I’d...
If his tests come back negative, then I’d...
If I can educate him and steer him towards other options, then I’d...
If he still only wants PrEP despite my recommendations, then I’d…
You can see how the questions you ask create “forks in the road” that could steer the situation one way or the other. It’s good to consider as many outcomes as possible, since this shows you as anticipatory and adaptable.
There is a lot to consider here. For example, if you’re practicing in a state/setting that allows you to treat him as an adult, then you can simply educate him, get him tested (if he’s willing), and hopefully steer him towards safer choices. If you can’t treat him as an adult, you’ll have to inform him about the laws and your obligation to inform his parents about any testing/prescriptions/etc. Even if this turns him away from the clinic, you’ll have to follow the rules.
You may not have time to write out your course of action for every scenario, but having the if/then considerations written as an outline (like the above notes) should be enough to keep your response structured and comprehensive.
In your last seconds of prep time, quickly jot down all the laws, rules, limitations, restrictions, etc. that you’d need to respect as a healthcare professional. That way, you’ll be able to bring them up towards the end of your response. This will show the interviewer that your awareness and conscientiousness.
Legal considerations: his minor status, patient confidentiality, his disclosure to potentially commit a crime on the black market, his potential HIV status and potential intentions of spreading it through unprotected sex
In these stations, you’ll be given a scenario to roleplay with at least one other actor. You’ll be given a role (doctor, teacher, friend, etc.) and some details about the problem or conflict at hand.
In my experience, the acting stations of an MMI can be broken down into two approaches. You’ll either want to always be closing or always be searching. Let’s explore the thought process and note-taking for each kind of scenario.
ACTING STATION: The parking garage at your work has assigned parking spots. On leaving your spot, you are observed by the garage attendant as you back into a neighboring car, a BMW, knocking out its left front headlight and denting the fender. The garage attendant gives you the name and office number of the car’s owner, telling you that he is calling ahead to the car’s owner, Tim. The garage attendant tells you that Tim is expecting your visit. Enter Tim’s office.
If you read the prompt and it seems like you’ve made an error/mistake and are clearly in the wrong, then you’ll want to always be closing. Essentially, you’ll want to go above and beyond (within reason) to rectify the problem.
In this scenario, Tim is likely to be pretty upset. The actor might even yell at you or make you feel foolish for your mistake in the parking lot. Your best move is to write down all the ways you could placate him and reach a peaceful resolution. Try to write them down in the order you’ll use while acting:
Take full ownership for the careless mistake (avoid excuses)
Exchange insurance information with Tim
Offer to have his car towed to his favorite mechanic
Offer to get him a cab home from work at the end of the day
Offer to get some lunch delivered to the office if he planned to eat out that day
Potentially help him get a rental car if his work depends on use of a vehicle
If this sounds overboard, and more than you’d do in real life, GOOD. You want plenty of ammunition if Tim is disgruntled and hesitant to cooperate. Basically, you want to continue to offer him options for how to fix the situation, to the point where it’d be tough for him to find any more gripes or reasons to berate you. This will let you close effectively, giving even the savviest actors little recourse for pushback or intimidation tactics against you.
ACTING STATION: You are working on a group project with five other students. One of the students, Emma, doesn’t show up for meetings or if she does show up, she is late and leaves early. She has put very little effort into the group project but shows up on the day of the presentation and tries to take credit. Talk to Emma.
If the actor is confused, scared, or seems to be withholding information, you’ll want to always be searching. You should ask questions (from a place of concern - not judgment) to learn more about the person and situation.
In this scenario, you want to give Emma the benefit of the doubt and write down some possible questions you could ask her:
Is there something going on in Emma’s life that’s preventing her from working?
Maybe she has completed her part and the group just doesn’t know about it?
Was the group’s meeting schedule preventing her from attending?
These will be the first questions you’ll want to ask the actor, in a non-accusatory way. This gives Emma the chance to divulge something, like a stressful part-time job or illness in her family. If the actor drops a bomb like that, it will often give you an avenue for an easier resolution. In general, non-judgmental questioning will make the actor more amicable to your conversation.
It’s also smart to write down some options you can offer Emma, especially if she’s not able to explain or justify her lack of effort or commitment:
If she had a legit excuse, we could go talk to the professor together and ask for a small extension.
If not, I could present her with a choice - she can explain things to the professor now, or we can do the presentation. But if it goes poorly, then she’d be putting the group in a tricky spot - either live with a bad grade or report her to the professor.
Notice how one choice sounds a lot better than the other? If you can come up with this kind of “friendly ultimatum,” it will hopefully steer the actor towards an agreed-upon solution.
Again, try to use shorthand notes to help give yourself an outline, since you likely won’t have time to spell EVERYTHING out.
Due to the variance in prompts, there’s no exact formula for success in the MMI. But hopefully I’ve given you a better sense of how to focus your efforts and devise your approach during those precious two minutes.
Alright - it’s time to enter the room and face the station - take a deep breath.
Are you ready?