Selection into specialist training can differ markedly depending on your specialty choice. In addition, it is liable to change rapidly over the coming years. There are currently two main groups of specialties – those that have a period of core training (general surgery/core medicine/psychiatry/acute care common stem) followed by further competitive selection into subspecialties and those that are ‘run-through’ and do not have a stage of further selection. The latter includes specialties such as general practice, histopathology, neurosurgery, ophthalmology, microbiology, paediatrics, radiology, obstetrics and gynaecology and public health. For more information on the selection process, see http://www.medicalcareers.nhs.uk/.

In terms of postgraduate exams, it is currently possible to enter for the first part of the MRCS (surgical membership) exam as soon as you are granted a medical certificate; the final part can then be completed whenever the candidate is ready. For MRCP (medical membership) you need at least 12 months experience (i.e. complete FY1) to enter the first part. Once this is completed you can again sit for the final two parts whenever you are ready. In the past, it was not encouraged for trainees to take postgraduate exams during foundation training. However, it is now compulsory for core medical trainees to complete all parts of the MRCP in order to fulfil requirements for their ARCP sign-off and be able to take up ST3 posts. It is therefore advisable to complete the MRCP as soon as you are able to. For the other specialties (anaesthetics, pathology, psychiatry, radiology emergency medicine, etc.), it is not usually possible to sit any exams until on a training programme. There are lots of diplomas that can be completed if you are itching to work on your postgraduate CV; the British Medical Journal (BMJ) careers section has good articles on most of them.

Around a third of Foundation Programme graduates do not immediately progress to specialty training in the United Kingdom. Some choose to work and travel abroad in order to gain new work and life experiences. Australia is particularly popular as no entry exams are currently required, working hours are flexible and trainees report gaining more hands-on experience and enhancing their skills. Some trainees seek more clinical experience doing ‘trust grade’ posts in the United Kingdom – these posts can sometimes provide an advantage if the trainee chooses to apply to that specialty in the future or failed to secure a training post at the first attempt. Other valuable learning experiences include the National Medical Director’s Clinical Fellow Scheme where junior doctors can be seconded to organizations such as the Department of Health, the NICE or the Royal College of Physicians and develop skills in leadership, management and health policy. It is also possible for Foundation Programme graduates to pursue higher degrees (e.g. MD or PhD) or research experience before committing to specialty training.

The Internet

Using the Internet in the NHS is fraught with precautions and limitations. All hospitals will have local policy about the level of Internet access and what is allowed. Be aware of these. A few pointers:

• Be careful with confidential or potentially sensitive information in emails, particularly if you try to forward emails from work to home email addresses (the opposite way round is generally much easier).
  
• Keep discussions of clinical cases anonymous even in closed teaching sessions like grand rounds.
  
• The hospital intranet will often have archives of local policy, the local formulary and contact details of various people.
  
• Keep hospital email and personal email distinct. Most hospitals are giving doctors’ their own email account. You can get a universal NHS one at www.nhs.net; this is highly recommended as it is likely that you will be working within the NHS for a long time and can be used to get patient information from different trusts in the form of secure email. In addition, many people like www.doctors.net.uk although it is not recommended by the NHS for transference of patient data.

Online medical databases

NHS Evidence is a good starting point for clinical information. This includes useful resources like clinical pathways represented in the Map of Medicine (NHS-approved clinical flow charts) and Clinical Knowledge Summaries (formally Prodigy), a summary of evidence-based information provided for the National Institute for Health and Care Excellence. Take a little time to familiarize yourself with this NHS service – it is improving all the time!

Other websites rich in online content are:

• The British National Formulary at www.bnf.org can save you time if you cannot find the ward’s BNF. Your hospital should have a subscription to it.
  
• PubMed at www.ncbi.nlm.nih.gov/PubMed.
  
• The General Medical Council (GMC) at www.gmc-uk.org.
  
• British Medical Journal at www.bmj.com
  
• The New England Journal of Medicine at www.nejm.org.
  
• The British Thoracic Society at www.brit-thoracic.org.uk has very detailed guidelines on the diagnosis, investigation and management of respiratory disease.
  
• eMedicine at www.emedicine.com is a useful quick reference on common and rare diseases. It is directed towards US doctors, though. A comparable UK service is offered by www.gpnotebook.co.uk

Clinical governance and paraclinical work

In addition to all the work directly involving patients, you should strongly consider getting involved in the other aspects of medicine. Not only is it a worthwhile learning experience, but also it is good on your CV and occasionally enjoyable! The amount of paperwork and the organizational obstacles can be very daunting but your seniors should be supportive.

Clinical governance is increasingly important for all doctors. As a minimum, you should know what it means and how to go about the process of audit.

Clinical governance is defined by the system through which NHS organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which clinical excellence will flourish. It is traditionally classified in terms of the seven ‘pillars’:

1. Clinical effectiveness and research
   
2. Audit
   
3. Risk management
   
4. Education and training
   
5. Patient and public involvement
   
6. Using information and information technology
   
7. Staffing and staff management

Clinical audit

Clinical audit is simply the measurement of clinical practice against a specific standard and its effectiveness with the aim of improving it. It is useful to get involved in clinical audit as you will learn about management, common pitfalls and the difficulties in implementing change in a large organization. You can easily get involved in an existing audit by speaking to the relevant consultant or your hospital audit department. Alternatively, you can start a new one. Retrospective audits are generally easier to conduct than prospective ones unless your daily work overlaps with audit. You can start by looking at local or national guidelines that the service you work in should ideally meet. Then you need to decide how to measure whether the guidelines are being followed or the standards achieved. Here are some ‘tips’:

• Design a form with all the data parameters you want to collect.
  
• Use the clinical coding department to your advantage. Here you can get a list of clinical codes that fit the scope of your audit. From there, you can get hold of a list of patients.
  
• Don’t try to track down all the notes yourself. Your clinical audit department is far more efficient at getting them. The ward clerk or the secretary for your department/consultant should also be able to request patient notes.
  
• Spreadsheet programmes are very good at sorting out the data once you have collected it.
  
• Find an occasion to present it. Invite everyone involved. Monthly local audit meetings are a good way to present your data to a wide range of healthcare professionals including consultants.
  
• Do not forget to think up solutions to any deficits you discover and make these recommendations as part of your presentation.
  
• If you are working in the same hospital for more than a few months, consider repeating your audit once your recommended changes have been implemented. An audit cycle is not truly complete until it has been repeated at least once. In this way, you can see if your changes have effected a change for the better.

The audit cycle involves the following steps:

Step 1: Identify an issue or problem.

Step 2: Set criteria and establish a ‘gold standard’.

Step 3: Observe practice and collect data.

Step 4: Compare performance with criteria and standards (data interpretation).

Step 5: Make recommendations to implement change.

Step 6: Re-audit to establish effectiveness of change and ‘close’ the loop. If the process is repeated again, it becomes an audit ‘spiral’.

Quality improvement projects

The GMC expects all doctors to take part in systems of quality assurance and quality improvement, and this forms part of the appraisal and revalidation process. Quality improvement projects aim to improve patient experience and outcomes using systematic change methods and through changing provider behaviour. Quality improvement projects use a plan-do-study-act cycle and aim to make a difference in a relatively short space of time rather than the traditional audit model.

Successful quality improvement projects need to have specific, measurable, achievable, relevant and time-bound (SMART) goals. An example could be to improve weekend handover by introducing a patient pro forma with specific and relevant clinical information. There are a number of journals and conferences that encourage innovation and creative thinking to improve healthcare. You could consider submitting your completed project for publication in one of these journals (e.g. BMJ Quality and Safety) or present work at relevant conferences.

Case reports

There is an element of luck in writing a case report, since you need an interesting case to write about. However, a good case need not be a rare one; common cases can be just as good, especially if there were pitfalls in the diagnosis or management of the patient:

• You will likely need pictures or videos of any diagnostic imaging, so make sure you get consent from the patient and involve the photographic unit.
  
• The BMJ or the Journal of the Royal Society of Medicine has good formats to follow.
  
• Good case reports are short and succinct. Journals are rarely interested in any superfluous details.
  
• Your case report does not need to follow strictly the chronology of events in the patient. By holding back on the result of a key investigation until the end of the case report, you can create necessary drama!

A popular choice amongst trainees is to submit a case report article or clinical image (as a picture quiz) for BMJ Endgames. This is a weekly section published in the BMJ intended to help junior doctors prepare for their postgraduate examinations and professional development.

Communication

For an enjoyable job, good communication is essential. As a junior doctor, you may make about 10–15 phone calls for every patient you admit. You may interview up to 5000 people during the year. You will write volumes of notes that others will rely on and that might one day be used as evidence in court. You will physically touch thousands of people.

Although most medical schools do teach communication or relationship skills, you are still supposed to largely pick them up from your seniors. As you have probably already observed, many seniors are lacking in personal and communication skills. It pays to develop your own skills; they will save you bleeps, headaches, time and lawsuits. Over 90% of UK medical defence cases result from poor communication rather than from negligence. Many so-called personality clashes between healthcare professionals, patients and relatives can be solved by effective and imaginative communication:

1. It is really important and difficult to write legibly at 3 a.m. Write for others as you would have like to have things written for you. A fountain pen can force you to write legibly (or it can make things even worse!). Block capitals can be a good way to keep your writing legible if you have very messy writing.
   
2. Write your name and bleep number on ward boards. This is very helpful for the nursing staff if you are on call (e.g. 14 May cover: Jo Bloggs’ bleep 1413). Never deliberately omit your bleep from the notes – the doctors who do this are unprofessional and potentially compromise their patients’ care. It doesn’t take many episodes of trying to get hold of a member of a different specialty who did not leave their contact details to understand the importance of this.
   
3. Let people know if you are distressed about something. Try not to transform grief or fatigue into defensive behaviour, such as silence or arrogance. People are usually pretty good at helping you out if they know what’s up; you don’t have to tell everyone but having a confidant such as your educational supervisor or a sympathetic senior can be invaluable and can help arrange cover if you need to attend a funeral or counselling.
   
4. We have all been shouted at unreasonably by colleagues at some time. Try not to take it to heart or to say something you will later regret. If they do have a legitimate point underlying their intemperance, learn the lesson and move on. If you experience sustained and unprofessional bullying from another member of staff (which does happen in hospitals), you should seek to stop it, either by assertively explaining to them that their behaviour is unacceptable (this may be easier said than done) or by taking the problem to a trusted senior or manager. The BMA helpline can assist too, for example, by helping to identify whom to take the case to next. Do not ignore it – you are a professional and do not deserve to be treated as such.
   
5. Most junior doctors lose their heads from time to time. Don’t be afraid to say you’re sorry. People usually respect apologies.
   
6. If conflicts arise, some useful tips include:
   
   
   
   • Ask yourself, ‘Are you sure you’re right?’
     
   • Does it matter?
     
   • Try turning difficult questions back to the person asking them. For example, you can ask them: ‘What makes you ask that question?’
     
   • Try to appear calm, despite what you may feel inside.
   
   
7. There are many resources to help people understand choices about treatments more thoroughly, such as videos, pamphlets and online information. Contact a clinical nurse specialist, librarian or district health authority to find out if any are readily available.
   
8. Use an interpreter if necessary. Interpreters can usually be contacted through the switchboard for a telephone interpreter or can be booked by the ward clerk for a face-to-face session.

Consultants and senior registrars

• Each consultant will have certain things they want to know about each patient (sometimes for no apparent reason). Your predecessor is usually a good source of this kind of information.
  
• NEVER say you’ve done something when you haven’t. It makes your team lose their trust in you and you may never get it back.
  
• Impress your seniors by being straightforward and by knowing your patients well. This matters much more in your job than having read the latest NEJM issue. As the junior doctor, you are expected to have the most contact time with your patients; it can be very frustrating for your consultant to turn up to the ward round and ask a patient’s blood results or social situation only to find that you haven’t prepared this information in advance.
  
• Try to know your patients as well as you can, but do not be too disheartened when it seems that your registrar or consultant effortlessly knows more about each patient than you do. Much of this is experience. However, it is also the case that whilst you are furiously looking for notes, your seniors have time to absorb information and think about the patients. They will also spend time that you are not aware of discussing patients with colleagues or relatives and in meetings/theatre/clinic. All these encounters are ‘hidden’ from you but give your colleagues information you do not have. Likewise, you will hold some information that your seniors do not; sharing this will invariably make you look good and will be appreciated by the team.
  
• It takes time to learn ‘what you need to know’ for ward rounds and about each patient. Be tolerant with yourself – you are still learning.

GPs

You will talk and write to many GPs; some you will get to know quite well. The following are some recommendations from a number of GPs, including Joe Rosenthal, a GP who also teaches at the Royal Free Hospital in London:

1. Phone requests for admission:
   
   
   
   • First check from your team if you can accept referrals. If not, politely redirect them to the correct person.
     
   • Have paper and pen ready.
     
   • Be polite.
     
   • Listen first.
     
   • Take down the following: name, age, problem, hospital number, GP name and number and expected time of admission.
     
   • Ask for a list of the patient’s medications, particularly if the patient may be confused.
     
   • Inform casualty.
   
   
2. Phone the GP on discharge if the patient:
   
   
   
   • Self-discharges
     
   • Is in an unstable condition
     
   • Has poor home circumstances
     
   • Dies
     
   • Needs an early review

Don’t rely on the post! This can sometimes take weeks to reach a GP’s desk.

3. Discharge letter. Complete before the patient leaves. Many are now electronic but ensure that it includes:
   
   
   
   • Patient details
     
   • Name of consultant
     
   • Name of ward
     
   • Diagnosis and important negative findings
     
   • Treatment given
     
     
     
     • Changes to regular medications
     
     
   • Treatment on discharge
     
   • Follow-up arrangements
     
   • What the patient has been told
     
   • Your name and bleep number
   
   
4. Think about the resources the GP has in his or her surgery. Try to avoid things like ‘repeat CXR in 1 month’ on the discharge form. The GP is not an outpatient service and it may be much more difficult for them to arrange certain tests than it is for you. If there are loose ends requiring tests in future, set up a clinic appointment.

Nurses

It is crucial to get on with nurses, who are fantastic allies. They know most of what you need to know as a junior doctor and are usually keen and willing to teach you. Nurses are trained in a range of things that doctors aren’t and vice versa, so the teams are complementary – remember this and use it to your advantage! Here are some hints for starters:

• Always introduce yourself to nurses and other staff when you’re new on a ward.
  
• Always tidy up after yourself, especially your own sharps. Most needlestick injuries arise from sharps someone else did not clear up.
  
• Don’t expect nurses to do things they are not qualified to do. Nurses may have extended roles (such as IV drug administration) but they may not do it. It may be frustrating for you that a certain nurse cannot take blood or put in a catheter, but it is not their fault. Think how bad you would feel if your consultant lost their temper with you for something you could not do. Be careful about putting responsibility onto nurses; they do not have your training and you should not expect them to make the same judgements that you do. Also, remember that when making requests, nurses can be struck off much more easily than doctors.
  
• Do unto nurses as they do to you. Make them cups of tea or coffee or offer to do an IV round if you’re on the ward without much to do. This helps to create an easy, generous atmosphere on the ward, which makes coming to work much more fun.
  
• To avoid heaps of bleeps, you can consider asking nurses to write down tasks and have one nurse bleep you with the list every couple of hours or so. Tell them you will return to do a round at a specific time (or at a particular hour – say, between 4 and 5 p.m.).
  
• If you foresee problems with a patient overnight, discuss these with the nurses. Arrange ‘bleep thresholds’ for foreseeable problems. Instructions such as ‘call me if his systolic falls below 100’ may seem superfluous, but they suggest that you are on top of the problem and indicate your willingness to respond promptly. This reduces the frequency of those ‘just thought you might like to know…’ bleeps.
  
• If multiple bleeps are a real problem, consider arranging a meeting with the medical or surgical manager and nursing staff to work out a better system. This is the sort of thing hospital managers are employed for. Talk to your senior if he or she is supportive. Try not to jump into this though if you are new to a job; often with a little time you will find that a system that seems strange or untenable actually works quite well. Frequent bleeps are often a symptom of nurses feeling under pressure or unsupported. It may also be that they are nervous about your accessibility. If you build relationships with them and they trust you to be there when there is a real problem then you will see the frequency of bleeps reduce dramatically.
  
• If you have a plan in your head for a patient or can foresee a problem a patient might have (e.g. a delayed discharge date), let the nursing, social work and occupational therapy staff know so they can help you with it rather than having to nag you for information.
  
• Write instructions to nurses in the medical notes, but also tell them. Ideally, it is best to have a senior nurse present when you do a ward round who can then hand over nursing tasks to their colleagues. If it is very important, then you can check later and reiterate it. Nurses have long lists of jobs to do, just like you do, and similarly, they can sometimes prioritize poorly or forget something that you have said.
  
• Save time: get to know how team nursing works on your ward. Basically, team nursing means that nurses work in independent, often colour-coded teams, each of which looks after a certain number of patients. Do not try to elicit information about a ‘red’ patient from a ‘green’ nurse (see Team nursing). Also, don’t be surprised if nurses assume that doctors work in a similar fashion – more junior staff may assume that only a certain number of the patients are ‘yours’.
  
• Nurses often work in three 8-hour shifts or sets of 12.5-hour shifts. Their rota is usually kept in the nurses’ office. It may be helpful to know when a particular nurse will be available.
  
• Try not to interrupt nurses when they are meeting for the shift ‘report’, on handover or on their breaks. Remember that breaks are sacred to nurses; if there is something urgent, then another nurse will always be covering their patients.