My first day as Dr Aslam

IMG_1586

As most of my colleagues geared up for the infamous black Wednesday, according to my rota that was my day off.

Cue anticlimax and a few pangs of jealousy seeing the various social media messages about the first day at work.

It would be black Thursday for me then. Not quite the same ring, but equally as terrifying.

My day began freakishly quietly. I should have suspected something earlier.

The ward where I went for all of my shadowing was void of all doctors. They can’t all be late I thought. They weren’t — they were all in a different place. Cue mad dash, six flights of stairs later, and I finally made it to the right place.

Looking less composed that I had hoped to appear (outwardly at least) on my first day, no one seemed to notice me (thank goodness).

Back to the base ward to start any jobs, and get ready for the ward round. I had barely put my bag down when I was asked to prescribe an antiemetic for a patient.

Hardly the most dangerous drug, but you wouldn’t have guessed it by my compulsive checking of the British National Formulary.

The morning wasn’t so bad, until I offered to help someone out and spent around an hour trying to sort through a massive drugs list including those for Parkinson’s disease, which needed to be given at the correct time.

At one point, I felt like crying. A million drugs to write up, unknown doses, a confused patient and hypoglycaemia (that was just me, way past lunch time).

So, I started laughing and my new best friend, ‘Mr Ward Pharmacist’ joined me. Crying is time consuming and I couldn’t be bothered. Laughing made my first challenge easier.

Finally, I managed to get some lunch and chat with one of my friends, another F1, who was also flagging and had forgotten to drink water and so needed paracetamol for a headache.

Some STAT reading post work
Some STAT reading post work

Our patients were our priority and our own fluid balance and analgesia needs were definitely falling by the way side. If we were patients, our doctors would certainly be guilty of neglecting us.

Recharged somewhat, I went back to the ward. I was feeling quite happy at this point. Not too many jobs to do, just chasing a few bloods. But the problem is the abnormal bloods, which, as a doctor, are my responsibility to act on.

A low magnesium and several queries about setting up a magnesium infusion kept me more than entertained for the remained of the afternoon. As did the gazillion discharge summaries.

I finished at 6pm – two hours later than rostered — and would have been there longer if I didn’t say ‘I’m sorry you need to bleep someone else about that’. Ward work never ends. But my efficiency levels had by this point.

I can already see this F1 gig is going to be tiring and the monotony of ward jobs isn’t what most of us entered medicine for.

end of the week wind down
end of the week wind down

But there are definitely ways to make it enjoyable. I fully intend to celebrate every win — every successful cannula or blood take — because I know that there will be setbacks which tend to stick in the mind.

And remember to talk to patients (and say #hellomynameis) who will keep me going. There is always time to appreciate a patient’s fabulous dressing gown or slippers.

Tips and Tales from the foundation programme #3 Winnie’s Words of Wisdom

11798399_10156062088455107_407857722_n
Can we all just take a moment to appreciate this jumpsuit. Thank you.

I have just completed the daunting rite of passage of foundation year one. Starting out, I found there to be lots of resources for the practical challenges you may encounter during FY1, but guidance on how to simply be a good FY1 and what to realistically expect, best came from the wisdom of doctors that came before me. I hope I can do the same for you in some way.

Medical school cannot really entirely or directly prepare you for the challenges, trials and triumphs that come with the reality of foundation year one. However, you can make it through to the end. You have been beaten, broken, crushed, and battered by the gruelling experience of medical school, and as a result you are resilient, driven, competitive, fast-learning and adaptable.

To put it simply, there exists no other person more qualified or more suitably refined for this job than you are. 

Be prepared 

Getting off to a good start is really important, and I didn’t really appreciate this until much later on in the year. What I mean by this specifically, is making sure you’ve got all your mandatory and statutory training done and training for any software programmes completed as early as possible. This will set you up nicely for the year and will just mean that you won’t have that dreaded dark cloud of admin hanging over your head the entire time. I actively avoided all kinds of training, but it all eventually caught up with me and ultimately I ended up having to park myself in the library for hours to get it done before the deadline. Please try not to do this. Sadly, mandatory training is actually mandatory.  Getting all the training malarkey done early or doing as you go along will make for a more stress-free and more enjoyable FY1 life.

The e-portfolio 

The saga continues! Make achievable targets in each rotation so that you do not have to catch up the whole time (which was the story of my life). Also try to do a reflective piece of writing at least once a week – there’s nothing worse than trying to reflect on something that happened six months ago. If you’re an aspiring GP you will have to become very fond of this, so start now! Try and maintain a good relationship with your educational supervisor. They will undertake regular reviews with you to ensure your e-portfolio progresses throughout the year. Any concerns with or if there are issues with your supervisor (whether educational or clinical supervisor), please do try and address them. However if these issues cannot be resolved, it may be possible to change supervisors, so don’t be afraid to take action if you have concerns.

The e-portfolio has quite a few components, which you will soon become very familiar with so I will spare you the details for now. However, I will just say that I regret not being more forward and assertive with asking for senior doctors to sign me off for certain things. I ended up doing so many practical procedures that were unaccounted for because I felt like a nuisance always asking doctors to sign me off. Please don’t have this same attitude. People are busy and sometimes senior doctors may seem unapproachable, however they have an obligation to teach and to ensure that you are progressing adequately through your first foundation year. So be politely but unapologetically assertive. 

First on-calls 

I was pretty terrifyied. But all the nursing staff and senior doctors know that this is all new to you, so everyone’s threshold for helping you out tends to be pretty low. Hospital guidelines are a magical fountain of knowledge, and I rely on them heavily until this day.  Secondly, make sure you know where the BNF is kept, or have a pocket prescriber handy. Don’t rely on asking people the doses of things as people, despite their year of experience, can make mistakes. Ultimately if your signature is next to the medication prescribed, then this mistake is unfortunately yours. I was once asked by a consultant on a fast-paced ward round to prescribe penicillin. He literally handed me the open drug chart, and of course I prescribed it. In my hast, I failed to realise this patient’s penicillin allergy. Luckily there was no harm done and this mistake was picked up before the medication was given. However, I was entirely to blame for this incident. My point is, try always to be vigilant, check things, ask questions and challenge things if you have any doubts. Rely only on objective sources for medication doses. My nose is forever and shamelessly inside the BNF, and if you feel you need it, yours should be too. Furthermore, for your on-calls, make sure you have all you essential medical devices and utensils i.e. stethoscope, pen torch, multiple pens, clinical notepaper, list of patients.  It’s common to be bleeped a fair bit during medical on-calls, but just remember that everything does not need to be seen immediately, and sometimes things do not need your ward presence at all.

Prioritise – this will come with time, as will your judgement on the severity and importance of bleeps.  Remember also that sometimes it is not possible to complete everything on your to-do list by the end if your shift. Try your best but it is important that you do not compromise the quality of your patient care because you’re rushing.  If you don’t finish, don’t worry and don’t be disheartened. This is what the gift of handover is for.

Help-seeking 

It is really important, especially on on-call shifts, to know when you are out of your depth and to know when and how to seek senior- or the relevant support. The source of help that you decide to seek is really quite case dependent. However, generally for medical problems on-call, your first port of call should be your senior house officer. If they then feel it’s appropriate to escalate, they will suggest calling the registrar. Whomever you do speak to when seeking help, make sure you know the following: name, date of birth and relevant medical background of the patient; their presentation to hospital and their current issue; your examination findings and recent observations; any results of relevant and recent investigations (Chest x-ray, bloods, ultrasounds, ECG); any treatments or methods of management implemented so far and the patient’s response to them. This seems like a lot to remember, but actually it’s essentially just the brief presentation of a clerking. It’s always a good idea to have the patient’s notes, observations chart and drug chart on the table in front of you, and also the investigations and imaging programme open on a computer. Make sure you also state clearly why it is that you need advice it or feel it is appropriate for the patient to be reviewed by a senior, and be ready to give a differential diagnosis (“I think this patient may be in pulmonary oedema”  or “I think this may be unstable angina”). After all of this, it may be that the person on the receiving end of your message thinks that you have inappropriately called them, and as a result you may end up feeling a little silly for your so called trivial predicaments. Just remember that no one will ever penalise you for calling for help, whereas if you refrained from calling for help is a potentially disastrous situation, you could land yourself in a bit of trouble.

Help with academic support and career advice, can be sought after in your clinical and educational supervisors, and help with emotional/ personal support can be sought after in colleagues and also in whomever is appointed as the pastoral figure.

Locum shifts 

Locum shifts are pretty much available in all trusts and are great for those who don’t mind giving up a bit of free time to earn a little extra cash on the side. If this interests you then you should email your administrator soon after starting to enquire about how locum shifts are advertised and distributed. Usually the rule is first come, first served, however I have heard of occasions when one specific junior doctor gets personally notified before others about locum shifts – which is obviously outrageous, so ensure that this does not happen! For some doctors, locums may be an absolutely “no-no”, and free time may be valued more highly than monetary rewards. But for others, it can be really worth it, especially if you suffer from shopaholicism or have picked up the travel bug (both afflict me).  The rate of locums are probably variable across different deaneries and perhaps even trusts, but generally for FY1s the rate is £25 per hour. This means that you could earn about a third of what you earn in a month, in just one weekend (12 hour shifts). That’s a pretty sweet deal if you ask me.

Academic stuff 

I’m not so much an academic myself, however there are things that you will need to complete as an FY1 regardless of you career direction. As a requirement of the e-portfolio, you need to complete an audit of some sort. It can be on anything, however if you have an inclination towards a specialty at this stage, then I would definitely base the audit on something relevant to that specialty. There are lot of opportunities that will arise throughout the year for courses, seminars, events, workshops, poster competitions, publications and all the rest of it. If you are keen, then look out for such emails! If you are looking to go into specialty training you will also need to start thinking about putting together a portfolio of all of you academic achievements. You should have a careers event during the year, which should further inform you about this.

Taking respite 

Being a junior doctor, the expectations for seniors can sometimes seem ridiculous; the sense of responsibility can be overwhelming; and on several occasions you will suffer the misfortune of missing an important family function, of your best friend’s birthday.  This is why you deserve a good old break. It’s really important to try and maintain a healthy life-work balance. I would really encourage trying to continue any extra-curricular activity that you did prior to starting FY1, or even trying something new. I would encourage you to be sociable. Its always really nice to vent to your fellow F1s – no one understands the perils and pain better than a fellow FY1. Lastly take annual leave, and enjoy it! Taking annual leave is different at every trust – sometimes it’s assigned to you in the rota, other times it’s first come first served. Don’t worry too much if it is assigned, it is possible to swap if you ask early.

Always just remember to work hard but play harder – it’s the key to survival!!! 

A few good resources

  1. http://doc2doc.bmj.com/assets/secure/youwillsurvive.pdf
  2. The Hands-on Guide for Junior Doctors (Hands-on Guides) Paperback – 18 Apr 2011 by Anna Donald (Author), Mike Stein (Author), Ciaran Scott Hill (Author)
  3. Pocket Prescriber 2014 (Pocket Prescriber Series) Paperback – 2 May 2014 by Timothy RJ Nicholson (Author), Donald RJ Singer (Author)

Massive thank you to Winnie for taking the time out of her holiday (what a massive babe) to write this. 

Tips and tales from the foundation years #1

Before me and a lot of my friends begin our first jobs around the country as junior doctors (where on earth has the time gone because this is terrifying) I thought some blog posts from people who have been there before would be in order.

Hope you find them useful and feel free to share these posts! Also if you’re on Twitter (and if not get involved, I’m such a fan) follow #tipsfornewdoctors for more gems.

Today post was written by my friend Hattie

Firstly, congratulations to all the new doctors, you’ve earnt your new title! F1 is a bit like learning to swim at the deep end but with arm bands. It’s a big step. You know the theory but actually doing it is different. However you are not the first batch of new doctors to learn to swim. Your SHOs, SpRs, and even consultants will remember, however vaguely, what it was like. They are your arm bands. They will support you, guide you and save you and your patients on countless occasions this year as you splash your way through your first diagnoses, prescriptions and decisions. If you don’t know something, just ask, help is only a bleep away. Just make sure you’re got the information at hand to help your colleague make decisions. (Notes, drug chart, obs, examination findings, any imaging, bloods and in an acutely ill patient the ABG result). Everyone feels like an imposter at some stage.

You will get scared/tired/feel useless at some point and you are not alone, we have all felt like this. When this happens, speak to your fellow F1s or SHOs, they will support you, reassure you and tell you they feel or have felt the same. There’s nothing quite as demoralising as not being able to bleed a patient or get a canula in. But it’s happened to us all, don’t be too disheartened. The nurses and especially senior nurses are some of your greatest allies. They’ve been there, done it and have the t-shirt. If they say a patient isn’t well, listen to them.

Never be rude to a colleague whatever their job role or grade – it’s unprofessional, not conducive to good team work or good patient care. Mistakes happen, be supportive and sympathetic of your colleagues. One day it will be you making the mistake.

F1 is a rite of passage. You are the most junior doctor in a team. You do the jobs that have to be done. Sometimes you may feel like all you do is paperwork and canulas, but you will still learn a lot of clinical skills. The year will fly by.

e-Portfolio is something we all have to do. Start early and chip away at it and link the curriculum as you go. It’s far less painful than doing it all last minute, when invariably you’ll be on nights, oncall or have a cold.

Look after yourself and don’t let work consume you. Keep up that hobby/sport/activity that you love. It’s easy to come home feeling too tired to do anything but make an effort and it will help you realise work isn’t the be all and end all. Socialise; vent about your frustrations, discuss things you’ve found hard and talk about things other than work! Eat well and sleep.

The first time I was asked to see a patient in pulmonary oedema, their breathing sounded bubbly from the end of the bed. I had never seen or auscultated proper pulmonary odema before. I thought it was pulmonary oedema but still asked the sister if the patient sounded wet to her. She replied calmly and without being patronising, that they did. Then I stood, looking at her, so calmly she asked me if I would like her to give some fruesemide…50mg? Needless to say she was guiding me, not asking me. On her return she said gave me an x-ray form and told me that she’d rung the radiographer to come to do a portable. I hadn’t asked for a form or thought of an x-ray at this point, but she knew what needed to happen, prompted me through my first acute pulmonary oedema and kept that patient safe. She also handed me an ABG syringe with the x-ray form!

There will be many firsts, just do your best, enjoy yourself and ask for help whenever you need it. You will be fine!

case_study29_image1

 

 

Big thank you to my friend Hattie for kindly taking the time to write this.