Gareth speaks with Dr Scott Williams, a clinical fellow on ITU at Chester and previous Core Medical Trainee about some handy tips to help Foundation Doctors excel when working on a ward.
Working on a ward is synonymous with being a junior doctor. In the UK Foundation Programme, we can rotate through up to 6 different wards over 2 years, potentially at different hospitals. You will find that each ward will have different processes and ways of working, the teams you work with will have different dynamics. Alongside desperately getting to grips with the peculiarities of each environment, you are also expected to brush up on the clinical aspects of the specialty.
The first task you have which can often be the hardest is to get yourself organised. The ward you work on may have their own list they use already in place or you may not. Some places may use a simple electronic print out of the patients on the ward or under the consultant or specialty. The essential thing is to have a system that works for you but consider what is essential and what isn’t. Commonly, a lot of information gets stored on the handover list and it takes a brave person to delete parts that have become outdated or irrelevant. Below is an example of a list you could use.
However you do it, keeping your list up to date is the next step. Ensuring jobs are written legibly and any information needed, especially clinical details if it’s a discussion, investigation ordering or referral may be important. In line with keeping the list updated is having a visual system to know at a glance what is finished and what is outstanding still. We talked about a “box system” for knowing the progress on jobs. How we use the system is as below.
The main organisational aspect that come with practise is knowing how much time you have and will need for certain jobs. Venepuncture or cannulation may take 5 minutes for one person and 20 for another. A referral may take 2 minutes to write but 30 minutes if it’s a verbal discussion and you’re in a queue. So the important thing is having in your mind how long tasks will take but also the order they need to be done in. An unwell patient with time-critical things will always come first but what come after that? We feel that anything that will take a long time to come back or is essential for the next step in patient care, whether discharge, treatment or diagnosis should come next because these thing keep the flow going on the ward and keep patients moving forward. A good majority of ordering for investigations or referrals can be done on the round by computer. If you do not have electronic based ordering then ensure you have a stock pile of order forms to hand as simultaneous consultant requests and orders saves much in time later.
The thing that is ubiquitous with the happiness of a ward is the flow of patients. With rare exception, people will always be glad to be going home and the staff to see them leave. The way this is enhanced is just like ordering, at least the take home drugs can often be done electronically on the round whilst the senior is there. This enables you to ask queries but also allows pharmacy to start working on them as soon as possible and avoids forcing the nursing staff to nag you about them later. Whenever possible, the discharge summary should be completed at the same time and if not at the next practical stage.
One aspect that will definitely make life better for everyone on the ward is paying attention to how you interact with others. I have always preferred using my first name rather than formal title however that is my preference and I know people who the idea of that is almost abhorrent. In my opinion, placing a title in a greeting establishes a barrier through professional hierarchies that needn’t exist in today’s world. You will likely address your allied health professional colleagues by first name so why should it be different in reverse? First names terms make you more approachable and personable. When I start in a new environment, I introduce myself to everyone I have to interact with, sometimes more than once if I forget I have already done so the day before. The politeness you show should be universal regardless of situation and you should avoid rising to any rudeness you encounter. There will come a time when the effort you put in and attention you’ve paid to building rapport with the staff will pay off.
The above photo does nothing but make me hungry, especially writing this having finished an on call shift. Food and your breaks are important in order to keep yourself healthy let alone working effectively. Taking 30 minutes in order to rest and escape the ward environment is vital. Going without food or rest you will find your thought processes are slower, motor skills are less fluid and if you’re anything like me you will become grumpy. Admittedly, I have before now escaped a ward round to sneak a biscuit from the staff kitchen on a ward. When the consultants realised what I was doing, we started taking 5 minute short breaks around 10.30am if it looked as though the round was going to last beyond 11am. It worked. We would feel slightly revitalised and often be more efficient. Ensure you have lunch away from the ward and where possible try get some natural light and fresh air. Working in South Wales as a F2, I would often have a break on a bench overlooking the countryside.
Finally we come to how to review a patient on the round. Scott uses the helpful mnemonic SOAP.
S – Subjective. How does the patient feel they are doing today? Do they think their symptoms have improved? How are they doing with mobilising and self-care?
O – Objective. What are their numbers and investigations telling you? Are their observations getting better or worse? Are their blood results changing? What scans have results that impact on the patient?
A – Assessment. Does your review of the above factors change the diagnosis for the patient or add a new one? Do you need to start a different treatment or therapy based on this?
P – Plan. What is your plan to continue addressing the diagnosis and problems highlighted by your review? Try to think about a plan in terms of answering a series of questions. Do you need more investigations to further the diagnosis and treatment? Do you need to ask a colleague or senior to help formulate your plan? Does the patient need an intervention or treatment to address the issues you’ve found? Importantly, are there are ongoing therapies that are no longer required and can be stopped to de-escalate treatment? Can the patient be helped to mobilise and do you need to plan for discharge?
We hope you find this guidance useful but if there are other things that you feel have been missed and need adding then please get in touch. If we get enough together we may look to produce a guide for working as a Foundation Doctor free to download.
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