Your alarm clock fires off and awakes you from your blissfully ignorant slumber. You press that snooze button between ten and twenty times until reality finally hits you hard: You are a Day One Junior Doctor.
(Part 2 can be found here)
You are the doctor.
It’s a peculiarly sudden transition. You dreamt that the hazy grey period between completing your medical finals and starting your first day on the ward would last forever. We hope that this summary will provide a few pearls of wisdom that many of us wish we knew before we started our first day as a doctor.
Listen to part one of the episode below:
The very first thing you should do is say hello. Don’t underestimate how important having a good working relationship with all the staff in your working area is. These are the people who will support you on your toughest day and your first impression will last for at least the first month.
There is no such thing as a ‘predictable’ day on the wards, but that doesn’t mean that it can’t have structure. Usually the first port-of-call when you arrive on your ward is to establish which patients need to be seen on the ward round. You may be attached to a certain consultant, or you may know that you need to see all the patients of a certain specialty. Either way, you need to have a list of patients that need to be seen by your team that morning.
The list of patients may be something you can just print off from an automated on-screen summary of patients. It may be a list that you and members of your team have generated, like a spreadsheet of sorts that is continuously updated (more on that later). Either way, know which patients to visit on your ward round, and where the patients can be found. If at all unsure, ask a member of staff on the ward. A ward clerk will often know the answer to this question.
Your consultant then arrives, and it’s off you go. As your team reviews each patient in turn, you will be constantly be adding all the jobs that need to be completed that day to your list: ‘Request CT, refer to cardiology, chase MRI report, discuss with microbiology, check U&Es…’. Your list will get progressively longer as the ward round continues. Once all the patients have been seen and your consultant thanks the team before leaving the ward, you’ll have your battle plan ready for the day. Now you’ll just need to work out which jobs to do first.
Prioritising jobs can be something of an art in itself, but it’s something that you’ll pick up very quickly. Hopefully it goes without saying that if you see a sick patient on the ward round who needs to be managed quickly, that will take priority. Sometimes you may even have to deviate from your ward round to ensure that this happens quickly (e.g. prescribing and organising blood transfusions, contacting critical care). Of course, that’s just one end of the extreme.
Jobs that tend to take top priority include organising radiological investigations of some description (CT scans, MRIs, chest x-rays etc.) especially if you want any chance of these being done the same day. Referring patients to other specialities will also find a place on top of your priorities list. For example, if you are working on the gastroenterology ward and review a patient on the ward round with a complex cardiology issue, you may be asked to write a referral for the cardiology team to review that patient. Specialists who pick up those referrals may not have time to see those patients if they are referred later in the day and they often will be regarding treatment decisions.
Look after yourself
Once you’ve ticked off all the jobs on our list, it’s then a good time to have lunch and take a break from the wards for bit. Even if you haven’t completed everything, take a break when you need it. Skipping lunch will make you less effective as the day wears on. A hungry doctor is not a happy doctor.
If nothing else, spending time away from your ward give you space to relax a little. You can chat to your colleagues or just have some time to yourself.
After you return, you may then want to check the results of investigations ordered that morning. These will include scans and blood tests taken earlier in the day. Not all will be back but especially with bloods, you will become accustomed to the timing of results. Go through your list of patients, check their blood results and perform any action that may be required as a result. For example, do the blood results reflect an AKI? Is there a hypokalaemia? Has a patient’s haemoglobin dropped suddenly? These are scenarios that you don’t want to leave until right at the end of the day. Document in the notes the results and any actions taken. If you are unsure about the next step then ask someone, whether your SHO, Registrar or Consultant.
As mentioned earlier, you will become very used to carrying around a list of patients that fall under the care of your team. Some jobs require you to generate a spreadsheet of all your patients (manually adding patients who become admitted and removing patients who are discharged) with plenty of added information next to their names. This might include:
- Recent radiological investigations
- Blood results
- Current treatment
- Actions required
- Relevant discharge information
Every team has its own list etiquette but ultimately a good list comes down to a balance between making it informative and keeping it concise. The list in this context is supposed to be a master-view of all your patients’ issues and priorities, communicated to your entire team as part of a safe handover and as a useful aide-memoire. Keep it relevant. Keep it up-to-date. Don’t leave it lying around for a member of the public to find.
If you need help
Of course, there is no such thing as a predictable day, especially when you’re on-call. One of the most important things to realise and remember is that there is always someone to turn to. If you are worried about a patient after having reviewed them and started initial management, someone will need to know about it. That may mean contacting your SHO (senior house officer) and asking for help and support, or contacting the registrar who will certainly want to know about any sick patients that may need further review or senior action.
Sometimes you may even be required to contact the consultant directly if you feel that there is a medical issue that he or she will need to know about. Whoever you decide to contact will often reflect the urgency of the situation and you will very quickly get a feel of which senior to contact in each situation. Regardless of whether you contact your SHO, registrar or even consultant, have confidence in escalating. Don’t ever sit on the fence; just contact a senior. They’ll thank you for it every time.
Who you gonna call?!
In keeping with escalation, it is vastly useful to know who your team is around you. Make sure you have the contact numbers/bleeps of each member of your on-call team and your normal ward team. It is also worth possessing a few more useful contact numbers to hand including blood sciences (biochemistry and haematology), the transfusion laboratory, the radiologist on-call/of-the-session, your consultants’ secretaries and the clinical nurse specialists. As Katherine mentions, the Induction App is a useful tool to find numbers you may need.
Clinical nurse specialists have a wealth of specialist knowledge and are often underused in hospitals. Examples include nurse specialists in diabetes, heart failure, urology, oncology, upper/lower GI, inflammatory bowel disease, hepatology. These incredibly valuable members of clinical staff are often very quick to respond to queries or issues related to their specialist area and are always only too happy to help. They often will assist with the ongoing management of conditions and review patients daily alongside organising follow up from discharge. Talk to them, understand their job roles but also be interested in what they are suggesting as you will learn a lot in the process.
As well as relying on a range of healthcare and medical professionals to answer questions or help solve issues, your hospital will have a set of local guidelines for you to use. Take advantage of these. When you start working on the wards, you will quickly be faced with an AKI or electrolyte abnormality or you may be required to manage cardiac chest pain or even an upper GI bleed. Your hospital will more often than not have plenty of dedicated guidelines for you to print off and follow. Even if you feel confident in managing a condition, it’s always worth consulting your guidelines, even if it’s just to maintain confidence that you have considered all the appropriate aspects of care. Pay attention to your antibiotic and sepsis guidelines as these are ones you will likely use the most.
Finally, after a patient has been transferred to your ward, reviewed by your team and optimally treated, they will be discharged from hospital. Very often patients will require follow-up in the form of outpatient clinics or repeat blood tests or other investigations that may need to be reviewed by a patient’s GP. Whether they require follow-up or not, one thing is certain: their GP will want to know about their hospital admission.
Writing a discharge letter a skill in its own right. You need to carefully and accurately explain to the patient’s GP all the relevant details of why they were hospital, how they were treated and what to expect after discharge. The GP will want to know as much detail as possible that would be relevant to the ongoing care of that patient. These details include:
- Summaries of investigation reports
- Important blood tests
- Specific antibiotics or medications used
- Whether there were any complications or issues during their care
- What follow-up has been organised
- Whether the GP needs to review the patient or perform any follow-up blood tests (when do they need to do this? What exactly do they need to review? What action would you expect?)
Essentially, a discharge letter acts as the main source of communication from the hospital to the GP. So make it accurate and make it informative.
Hopefully this will serve as a bit of a rough introduction as to what to expect from your first day working as a newly qualified doctor. You’ll discover new things every day about how you work and how you approach problems. One of the many joys of the job is developing as a medical professional.
Always remember to be safe, talk to those around you, and of course, understand that you are not alone.
Dr Jack Hannah
Posted in: Working Life