BECOMING A BETTER DOCTOR

Chapter 5
BECOMING A BETTER DOCTOR


With contributions from Dr Rahul Mukherjee


Postgraduate medical training in the United Kingdom has undergone significant reforms in the last decade. Newly qualified doctors embark on a 2-year Foundation Programme to develop core generic skills and take responsibility for patient care. Trainees may then complete specialty training before gaining entrance onto the specialist register or the general practitioner (GP) register. The duration of this additional specialty training varies from 3 to 8 years depending on specialty. During this period, trainees can do a number of things to develop their clinical skills, increase their knowledge and become a better doctor.


Foundation Programmes (United Kingdom)


Foundation Programmes are compulsory for all UK graduating doctors. The programme is intended to streamline training so as to ensure that all junior doctors develop a set of core transferable skills and to reduce the bottleneck when entering the registrar grade. Foundation Programmes are divided into 2 years (FY1 and FY2) that are now usually paired within the same training deanery.


FY1 trainees are comparable to the pre-registration house officers in the older system and are frequently still called that. Placements are of variable length between 3 and 6 months, but most programmes have six placements of 4 months each across a 2-year programme. Typically trainees spend a minimum of 4 months in surgery and medicine. During FY2, many programmes contain a general practice placement recognizing the importance of primary care in healthcare delivery in the United Kingdom. During the first year, if not already allocated during your job selection, you will have an opportunity to put forwards your preferences for placements in FY2. Ultimately you should choose your placements based on your interests as well as any gaps you may have in your experience. It will be useful when applying for specialist training posts if you can demonstrate a clear path from your initial foundation jobs to the specialty you wish to pursue. For example, a GP trainee may want initial experience in general medicine and surgery before undertaking specialized rotations in paediatrics and obstetrics/gynaecology. Although it is emphasized that the foundation jobs you undertake will not influence selection to specialist training, most trainees who are successful in securing specialist training posts have demonstrated significant commitment to their specialty through audit experience, logbook of procedures and attendance at relevant courses. Having gained some experience in the specialty you want to go into during foundation training certainly helps but is not mandatory.


It may be worth noting that a core commitment of the NHS is to try to accommodate flexible training. This includes the foundation years. Trainees may elect to complete their training less than full time at the outset and the arrangements for this vary between trusts. Some trusts offer a slot-sharing arrangement, for example, where two trainees share one full time post and the pro rata out of hours. It is possible to take time out of the Foundation Programme (e.g. due to maternity leave), but this may lead to a delay in the completion date of your programme. In these circumstances, it is advisable to speak to your Foundation Programme training director and educational supervisor at the earliest opportunity to ensure that appropriate procedures are in place and arrangements made for your return to training.


Academic Foundation Programmes


In addition to the clinical Foundation Programmes, there are a number of academic programmes (around 400 in the United Kingdom) where trainees have protected time to develop their research, teaching or leadership skills. These are prestigious posts and form part of the Integrated Academic Training Pathway to help develop the next generation of academic clinicians and research leaders. All academic trainees must complete the same clinical competencies as standard clinical trainees but get less ‘clinical’ time to do so. This means that you have to be highly motivated and organized to fulfil your academic and clinical aspirations.


During your academic Foundation Programme, you will have a period of ‘protected research time’. The protected research time can be delivered in a number of ways. Most jobs provide a dedicated 4-month block with no clinical duties, but others offer a day release every week or even weekly blocks of research separated by longer periods of clinical work. Some trainees choose to spend this time in a laboratory developing their knowledge of basic science whilst others complete a clinical project. This protected time gives an invaluable opportunity to produce work that can be presented at national and international conferences as well as published in peer-reviewed journals. Completing an academic Foundation Programme also demonstrates your commitment to a particular specialty and gives a distinct advantage when applying for the next stage in the Integrated Academic Training Pathway – the Academic Clinical Fellowship phase.


Assessments


Your meetings with your educational supervisor should be focused on the progress of your training. This will largely be based on your assessments. Although a rapidly changing area, the assessment tools currently in use include the following:



  1. Multi-source feedback (peer assessment tool) and team assessment behaviour (TAB)

    You should pick a range of assessors from amongst your peers, consultants and other healthcare professionals (including physiotherapists, pharmacists, nursing staff and healthcare assistants) and ask them to complete specific questionnaires about your clinical skills and conduct on the wards. You also complete a self-assessment and the results are collected and presented to you in your meetings with the educational supervisor. This exercise is aimed at finding out your strengths and weaknesses. It can be very demoralizing to discover your weaknesses (or what other people think are your weaknesses) but you should not shy away from selecting more critical assessors. Although compulsory for progression, these assessments are not currently used in any competitive sense so you should choose assessors who are likely to give you an honest appraisal. The most critical assessments are often the ones that help you learn the most about yourself and how you are perceived by different members of the multi-disciplinary team. It can also be very useful to gain feedback from patients, and some specialty programmes are beginning to incorporate ‘patient surveys’ into the assessment process.


  2. Mini-clinical evaluation exercise (CEX)

    You will have to find several clinical scenarios to be assessed on. These are extremely varied and can be found in the curriculum of your Foundation Programme on your ePortfolio. The assessor is usually a senior registrar, consultant or GP. It can be difficult to arrange an occasion where a real clinical scenario, assessor and you coincide. You may be able to go to a clinic and be observed whilst taking a history or doing a clinical examination. The post-take ward round can also be a good place to conduct a brief clinical exam in front of your consultant. It is usually best to complete the assessment on ePortfolio as soon as you have done it, but often sending your consultant a reminder via an ePortfolio link at a later time, with a brief summary of the clinical scenario, is needed.


  3. Direct observation of procedural skills (DOPS)

    You will have to find a variety of clinical opportunities to demonstrate your prowess. The procedural skills do not need to be complex; they can be fairly routine and straightforward (e.g. venepuncture, taking an ECG) and will happen at least once a day on every ward. As such, there will be no shortage of occasions to be assessed. That said, if you have a mind to go into a particular specialty (e.g. anaesthetics) an interview panel will probably be more impressed if you pull out examples of several central line insertions you have done than if you can only prove your ability to take blood. The trick again is to find the assessor first and then offer to perform the task that the assessor was going to do. It can often be difficult to find the opportunities to perform certain procedures (e.g. chest drain insertion, central line insertion, abdominal paracentesis). Some hospitals have pleural intervention units where a respiratory physician with a special interest may perform lists where they insert chest drains under ultrasound guidance. It may be worth getting in touch with these consultants and expressing your interest to observe one of their lists and perhaps get an opportunity to do one yourself under supervision. If your hospital has an interventional radiology unit, they may have lists when they perform procedures under ultrasound guidance. Cardiology units will routinely perform diagnostic angiography via femoral/radial arterial line insertion.


  4. Case-based discussion (CBD)

    This is the more traditional format where you pick cases you have seen to discuss with your consultant or other senior medical team member. History-taking, examination, differential diagnosis, investigation, management, record-keeping and ethical aspects are areas you will have to cover. If you see surgical pre-admissions or patients on an acute take, then these are easy opportunities to complete the task. If you rotate through accident and emergency, this also offers many opportunities for near complete clinical encounters.


There are minimum numbers of assessments you will need to do, but do not be limited by them. The more assessments you have, the more you will learn and the more you will have in your logbook as evidence of adequate training. Surgical logbooks are not essential at foundation level of training, but if you are an aspiring surgeon it is useful to keep a log that you can show at interview to the panel.


In addition to these ‘minimum’ prescribed assessments, you are expected to be a lifelong learner and a ‘reflective practitioner’. The latter means taking time to think about events that you have been involved in (both positive and negative) and searching for the underlying lessons they can teach you.


Reflective pieces in practice should be done at least once a month and uploaded to your ePortfolio. In some foundation schools, they are a mandatory requirement to pass the year and are easier to do monthly rather than have a huge number at the end of the year prior to your Annual Review of Competence Progression (ARCP).


Situational judgement tests


In order to improve recruitment practices in the United Kingdom, many programmes including the Foundation Programme are using situational judgement tests (SJTs) to assess job relevant behaviours and select the best candidates for any given post. SJTs consist of a series of hypothetical scenarios that you may encounter as a junior doctor. Questions are either ‘ranking questions’ where candidates rank five responses to a clinical scenario or ‘multiple-choice questions’ where candidates may choose the three most appropriate actions. These aim to test the candidates’ professionalism, communication, teamworking and coping with pressure.


There are still many unanswered questions about the discriminatory power of SJTs and whether they represent a robust and reliable method for selecting trainees to UK training programmes. Many specialty training programmes however, including core medical training, are piloting the use of SJTs to assess recruitment into programmes. There are now a number of books and online resources dedicated to preparing candidates taking SJTs for postgraduate medical training.


Moving on from the Foundation Programme


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 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.


Information technology


It is becoming impossible to practice medicine without a basic level of technical knowledge. Most people will be familiar with using computers for word processing, email and web surfing, but there is a lot more out there:



  • Junior doctors move around a lot, and with the plummeting cost of computers, laptops are much more practical. Decent laptops or an iPad has become cheaper in price and having an iPad handy might allow you to work on a case report or read the latest issue of the BMJ during a quiet on-call period. Be sure to get permission if connecting your computer to hospital equipment (e.g. printers, network points). There are numerous smaller alternative devices now available, and many of the more business-oriented mobile phones have word-processing capability.
  • Electronic tablets and smartphones such as the iPhone/iPad and alternative Android devices are becoming ever more popular with medical professionals. Each can be loaded with a lot of medical software including formularies, patient list software, medical calculators and textbooks. Many of these are free and some trusts are now also using trust-specific apps for easy access to guidelines, such as antibiotic prescribing. Most medical software (especially formularies) are designed for North American doctors, so they may not always be relevant.
  • All UK hospitals now have networked computer systems for accessing patient details, blood results and ordering tests.
  • The use of mobile phones in hospitals is a controversial area. The best advice is to follow local hospital policy (and not the behaviour of your consultant!). At the very least, it will make it less likely for patients and relatives to follow suit and start answering calls during ward rounds!
  • Digital photos or videos are best taken formally. The written consent of the patient should be explicit about what the images can be used for, and a copy of it should be filed with the patient’s notes. Remember that you are responsible for the images. The medical photography department can help for more difficult photos (e.g. fundi) or get better pictures of clinical signs for case reports. Taking images without patient consent, even if anonymized and strictly for educational purposes, is rarely supported.

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:



Keeping up with the literature


The information and technology explosion is real. There are several ways to keep up to date with stacks of international journals with minimal fuss; we wish we had known about these when we were students!



  • Adopt a ‘problem-based’ approach to reading. This means reading whatever you need to answer real questions rather than blindly scanning journals with minimal retention and maximum boredom (see Evidence-based medicine). You will remember much more of what you read if your patient depends upon it, and you’ll probably also find it more interesting. The age-old advice of reading up on clinical conditions you see still holds true. Good review articles are often excellent, up-to-date sources of information on a particular clinical topic.
  • Good-quality systematic reviews, especially those using meta-analysis, are the most efficient studies to read [1] because they combine the results of many individual studies, adding statistical power and giving you an efficient overview of the topic. Much of the write-up in these studies flows around methodology and may be difficult to read unless you are specifically appraising the literature. However, if you can convince yourself relatively quickly that this is adequate, then the conclusions are often very useful and clinically relevant.
  • Learn to critically appraise what you read so that you can evaluate studies yourself rather than relying on the authors’ conclusions. It is true that most published studies, even in leading medical journals, do not have reliable results because the study methodology was not rigorous enough. Critical appraisal is a simple process that enables you to be much more discriminating in what you read (see Evidence-based medicine).
  • If you are a member of the BMA, you will automatically receive a copy of the BMJ every week. There is a ‘research news’ section of the BMJ which contains summaries of the latest clinical studies in other general medical journals. This can be a useful way of keeping up to date on research developments.

Evidence-based medicine


Evidence-based medicine is a central tenet of being a good doctor. Basically, evidence-based medicine involves using research findings to give clinicians much more statistical power in interpreting everyday clinical data rather than relying on anecdotal evidence. Not only do people who practice evidence-based medicine find that they become more aware – and critical – of research findings, but they quickly become adept at solving difficult problems and find that they can engage better in medical debates. Evidence-based medicine can be practiced by teams or by individuals.


Evidence-based medicine involves carrying out three key steps:



  1. Ask a clear question about the problem you are trying to solve (e.g. should I anticoagulate an elderly woman with asymptomatic atrial fibrillation?).
  2. Search the literature for good-quality evidence using a structured, hierarchical search that gives you the most statistically powerful research first. Search first for systematic reviews, second for randomized controlled trials and lastly for other types of studies.
  3. Critically appraise the evidence you have found to see whether or not its findings are reliable and relevant to your situation. To do this you need a list of questions, which help you to assess the methodology of the research. There are various books and courses to boost these skills. The evidence then should be combined with your clinical knowledge and practically applied to the patient in question, taking into account their wishes.

If in doubt, look it up and discuss with your seniors or ideally at a formal journal club.


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.


Courses


Education is more than just working on the wards, attending grand rounds and reading books. There is a wide array of courses one can take on; these are regularly advertised in the BMJ careers classified sections and fall into several broad groups:



  • Examination courses are aimed at doctors sitting postgraduate exams and try to condense everything you need to know in a short period of time (5 days or a weekend). They are often overbooked, so apply early. Despite what you may hear, it is not necessary to attend these courses to pass an exam. They are largely based around boosting confidence.
  • Skills training courses are extremely varied from the more clinical ones like the Resuscitation Council’s advanced life support (ALS) courses to less clinical ones like courses teaching interview technique. Resuscitation Council courses are invaluable and should be top on the list of courses you do. It is now a requirement that ALS is completed by the end of FY2 in most foundation schools. ATLS is a popular choice amongst the more trauma/surgery minded. Check which courses are compulsory or organized by the deanery before using up your own time and money. You may be able to use your study budget for these courses, which is useful as the cost can add up to significant amounts of money.
  • Lecture courses are generally more suited for more senior doctors but may be interesting, particularly if in a field that you are interested in becoming a part of.

Attending specialty courses can be used to demonstrate your commitment to a particular field when it comes to job applications, so it is useful to find out what may be available at an early stage. There are many good courses run throughout the year at the Royal Society of Medicine and the Royal Colleges (surgeons, physicians, anaesthetists, etc.), by BMJ Masterclasses and via local deaneries.


Professionalism


It may be the case that no one ever specifically teaches you how to be a professional. Don’t worry if the transition from student to doctor is full of bumps and jolts – it certainly was for us. There isn’t much mystery to being ‘professional’; it’s mostly about communicating well, building relationships and being responsible for what you say and do. However, this is no small thing to accomplish.


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.



  1. 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

  2. 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.

Helpful things to know about nurses



  • Nursing grades (varies between hospitals)
Sep 27, 2017 | Posted by in PATHOLOGY & LABORATORY MEDICINE | Comments Off on BECOMING A BETTER DOCTOR
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