MMI Template: S.P.E.D.
Have a systematic approach to MMI’s will make a huge difference on your interview day. Here is an example of one template you might use; note that you should feel free to adjust the template to your own preferences. There is no single template that is the most effective – the key is just having a structured approach.
For an introduction to the Medical School Multiple Mini interview, Click Here.
S.P.E.D.
Summary: This is where you can quickly provide a recap of your understanding of the prompt. The interviewer is familiar with the prompt, so you don’t have to do this in detail, but it sets the stage for the rest of your interview.
Problem: When applicable, directly explain what the primary issue highlighted in the prompt is. You are almost always asked to make a decision in these types of ethical stations, so try to make it clear what the conflict in that particular situation is. This is where it helps to have a cursory understanding of the four pillars of medical ethics (autonomy, beneficence, non-maleficence, and justice). Is there a conflict between autonomy and beneficence, such as in a case where a patient wants something that is contrary to medical indications? Or is it simply a question of justice, such as when you are in the position of deciding who would receive a liver transplant in the context of scarce resources?
Explanation: Here is where there is some variability in approach. Some people like to talk through what their decision is, and then take a devil’s advocate approach and explain why the other position makes sense as well. Another option is initially talking through both options without making a decision: why does giving a liver to the young person with alcohol use disorder make sense ? What factors support giving the liver to the older gentleman? You can talk through your thought process out loud, explaining what factors you are considering that would support each respective decision (talking through one possible decision first and then the other). When discussing your thought process, it can be extremely helpful to tie the factors supporting each decision back to ethical principles when appropriate.
Decision: Make it clear what you ultimately decided after carefully walking through your thought process. In the explanation section, you already demonstrated that this is not a black and white issue and that you are carefully thinking through all sides of the issue. If the prompt asks you to make a decision, however, make sure that you make a decision. There are no right or wrong answers, so if you were able to articulate yourself well and explain your rationale then your decision will simply be based on the information you presented. You’ll be tasked with making many difficult decisions as a physician, and you want to convey you understand the nuanced nature of the ethical dilemma while still being able to put your nickel down. If there is time left and it is appropriate given the prompt, you can make connections to other current issues or touch on how the scenario interfaced with a physician’s responsibility.
THREE TIPS FOR THE EXPLANATION SECTION OF THE TEMPLATE
– When applicable, include personal anecdotes that support your point. This makes your response much more personable, memorable, and can go a long way towards strengthening your response.
– Be non-judgmental and empathetic in your response. While you are tasked to make a decision, you should treat everyone you discuss as valuable human beings and demonstrate empathy to all parties involved when explaining your thought process.
– Feel comfortable explaining what other contextual factors you would’ve liked to explore when explaining your thought process (does the elderly woman refusing care have collateral/family members that can speak to her normal cognitive function or what her wishes would have been like without an altered mental status?). Often, you will not receive a response from the interviewer, but this shows that you are considering other factors as well.
EXAMPLE: UTILIZING THE TEMPLATE
Let’s say you are given a situation where an elderly patient is refusing treatment for an otherwise lethal condition and you are tasked with deciding if you would treat her or not. You’ve read the prompt for two minutes and will now be entering the room.
Introduction: Okay, so this isn’t really part of the template. But remember that this is still an interview and not simply an exam! Introduce yourself professionally, be amicable, and shake your interviewer’s hand.
Summary: My understanding of the situation is that I am a physician for an elderly patient who is refusing medical treatment for a life-threatening condition, and I have to make a decision about whether or not we should proceed with treatment.
Problem: In this situation, there’s a conflict between patient autonomy and beneficence. The two options we are considering here are to either respect the patient’s wishes and not treat her, or to proceed with a medically indicated therapy.
Explanation: If we do not treat the patient, we would be respecting her autonomy. Patients should have a right to make their own medical decisions, even if those decisions are against medical advice. Proceeding with treatment without the consent of the patient would infringe on her right to dictate her care. At the same time, there is a clear medical indication and the patient is at risk of losing her life without treatment.
The main issue with adhering to the patient’s request, then, is that the patient would die from a treatable condition. As such, foregoing treatment would not be concordant with the ethical principle of beneficence, which states that physicians should do what is best for our patients. In this case, it can be argued that the decision to initiate therapy would be what is best for our patient. Even if the patient does not want treatment, a physician who wants to treat her in this situation is simply trying to do the right thing and prolong her life, avoiding an unnecessary death. The main issue with this decision is that It is clear that the patient does not want treatment based on what she has informed us, so we would be ignoring the ethical principle of autonomy.
I’ve actual witnessed a similar situation in my own life, where my aunt refused medical care for her colon cancer. She was informed that denying medical care was extremely dangerous, and that because of the early stage of her cancer there was a high likelihood that treatment would be effective. She still decided, however, that she did not want to be treated. While this decision did not make sense to her providers, she was unwilling to go through the side effects of chemotherapy and wanted to rely on her faith instead. At first, I was very conflicted and even upset, because I understood that rejecting therapy was essentially a death sentence – I did not understand why her providers were not more insistent. I asked myself, isn’t it their primary responsibility to improve the health of their patients? I was finally able to realize, however, that my priorities did not necessarily align with that of my aunt’s. The providers had ensured that her wishes were met by respecting her ability to make her own decisions, thereby sticking to the ethical principle of autonomy. My aunt understood the consequences of her decision, but she stood by that choice. It is what she wanted, and that made it the right choice for her.
Decision: While it’s easy to assume that a patient would want a lifesaving treatment, I came to understand that is not always the case. I had fallen into the trap of paternalism, where we expect physicians to make decisions for patients without empowering them to make their own decisions. Similar to my aunt who understood the risks and benefits of treatment as well as the consequences of refusing treatment, I would want to make sure that the patient has decision making capacity. If the patient was deemed to have decision making capacity, then in this case I would respect her wishes to not receive medical care. If the patient does not have decision making capacity, then this becomes a more difficult situation where I would have to rely on a surrogate decision maker, because the patient’s stated wishes might not truly reflect what she would have wanted.
This was a really interesting ethical dilemma, because it touches on the fact that in our quest to care for our patients, we might at times superimpose our own ideas of what a positive outcome looks like. The potential medical benefits of a treatment might not be the most important thing to a patient, however, and we as physicians must remember to work with our patients and commit to a shared decision-making approach that empowers them to make informed health decisions.
Debrief of Example
When you first start practicing these prompts out loud with the given time restraints, it’s okay to feel stressed—it’s okay to draw blanks, it’s okay to mess up, and most importantly, it’s okay to be honest. You may think that the sample MMI responses you see online (like the response above) would be impossible to recreate in the moment. But please keep in mind that the example I have provided here came with practice. I also have the opportunity of sitting down and typing out my thoughts. For your MMI station, having any kind of template and practicing will be key to a successful interview. Try not to get caught up in the details and do your best to focus on the structured approach!
REMEMBER THAT EVERY PROMPT IS DIFFERENT AND THIS IS ONLY A TEMPLATE
You’ll still need to be ready to improvise and sound natural in your responses; some MMI stations are more interactive and will ask follow up questions during your response, while some will simply let you finish and then have you sit in silence until the buzzer sounds. Be comfortable with the silence and do not feel that you need to add to your response if you were able to already communicate all of your thoughts.
FINAL MISCELLANEOUS MMI ADVICE
Conflict Between Ethical Principles
There will not always be a clear conflict between ethical principles, and sometimes you might just have to use the circumstantial information to support each point. For instance, when deciding between a liver transplant for a young patient with alcohol use disorder or an older gentleman in the context of scarce resources (the ethical issue is justice, but there is not a conflict necessarily with another ethical principle): the young patient with alcohol use disorder has the pros of greater potential benefit and contribution to society but the older gentleman does not have a history of alcohol use disorder. For the explanation section of the template, you can talk through these thoughts until you’re ready to make a decision.
Ethical Principles
Understand the principles of autonomy, beneficence, non-maleficence, and justice. The first three principles are relatively straight forward, but you’ll likely have to do a bit of a deeper dive for the principle of justice. In fact, a more nuanced understanding of justice would make a response to the liver transplant situation described above much stronger. Utilitarianism and the fair innings approach to justice might favor a young alcoholic patient receiving a liver, while desert-based justice would suggest that the older gentleman should receive the liver. You don’t need to know all of these different ethics buzzwords – just try to define what justice means to you and how you would apply it to different situations. You are not expected to be an expert in biomedical ethics. Instead, the focus is still on explaining your thought process and being able to justify a decision in an articulate way.
Thinking Outside the Box
Be careful about making non-decision decisions. While thinking outside of the box and stating that you choose Option C instead of A & B might be appropriate in certain situations, most of the time it will simply be interpreted as eluding the responsibility of making a real decision. You have to acknowledge that it is a complex situation, but also be willing to explain what you would actually do in that situation.