I am currently based in respiratory medicine ( as part of my 6 months placement for acute internal medicine ST3 training).
The ward I am based on also has diabetes and endocrinology patients. It is a 32 bedded ward with a hyperacute bay ( where we do NIV and nasal high flow O2) and 3 side rooms (where we can also provide NIV, nasal high flow to patients who need to be barrier nursed).
We have 2 respiratory consultants ( who come twice a week) and 3 diabetes and endocrinology consultants ( one comes everyday and 2 come once or twice a week).
We have a junior doctor allocated to each consultant. The minimum number of junior doctors on the ward is 4.
THE MEDICAL TEAM:
One respiratory trainee registrar
One non trainee registrar
One acute internal medicine registrar
3 FY1 doctors
1 FY2 WAST trainee
3 IMT year 1 trainee SHOs
And there are non trainee SHOs in the trust who can cross cover if we do not have the minimum numbers
The members of this team are on nights/on days/annual leave/study leave and hence we are not always around at all times but usually there are 5 doctors including registrars. Hence each consultant has a doctor to see his/her patients.
MY TIMELINE
I wake up at 0700 AM, have breakfast, take a long warm shower ( which involves me day dreaming about buying an old classic Ferrari or a boat, and sometimes something more useful like a QIP) and leave at around 0810. I drive to work which is a 10 min drive.
I pick anyone who wants to be picked up ( I have offered my pick and drop services to all doctors working in my trust as long as they are on the way ) and get to work at around 0830 AM.
After putting my things in the staffroom, I meet the nurse in charge and ask these questions:
1. Is there anyone sick whom (s)he wants me to see before 0900 AM.
This is very rare. Although we have an unwell patient on NIV, the critical care outreach team is very good at managing this out of hours and we have an amazing team of respiratory specialist nurses who can do ABGs and adjust the NIV settings accordingly so it is very rare that I need to do anything.
2. If not, are there any urgent discharges I can do? ( We are very hot on discharges and we are trying to improve patient flow by identifying potential discharges and doing their medications and summaries as early as possible).
3. Usually, I manage to do 2 or 3 discharge summaries before 0900 AM.
4. The team of junior doctors start coming in and by 0855 AM, we have the whole team there.
5. The junior doctors then inform the ward clerk which consultant they will be working for and the ward clerk puts their names and contact details on our whiteboard so that the nurses know which doctor to contact for a particular patient.
Usually, there are 10 to 15 patients under each consultant
6. I usually take up the consultant who is not there that day or if there is no junior doctor allocated to that consultant ( for me, it does not matter if it is endocrinology or respiratory- I have already worked as a CT1 trainee in an amazing respiratory department plus I did loads of locums as a non trainee SHO in the hyper-acute bay in a respiratory unit as my first job in the NHS hence I do not feel that I need to work in respiratory 24/7 to meet my learning needs). If the consultants have junior doctors already and I am an 'extra', I act as the discharging doctor/doing urgent jobs doctor ( I sit at a computer and ask all juniors to immediately inform me if the consultant has deemed a patient fit for discharge or if there is an urgent job to do). This way the junior doctors can continue on their ward rounds without being disturbed by the nurses/distracted from other jobs
7. We print out the lists of patients under the respective consultants.
8. The nurse in charge then leads the morning handover ( attended by the doctors including registrars and consultants, OT,PT, discharge coordinator) in which the following patients are identified:
- Sick patients
- Patients on NIV/ nasal high flow
- Confused patients
- Patients who had falls/ issues overnight
- Potential discharges who need a doctors review ( We have an amazing group of nurses who go through the patients notes and bloods to identify potential discharges)
- Potential discharge who need to be seen by PT/OT
- Patients who have not had VTE or oxygen prescribed
- Patients who are not more than 24 hours of IV antibiotics.
- Patients who are barrier nursed and if there is any reason why they are in siderooms
- Any staffing issues
- If I am the discharge doctor, the nurse in charge lets everyone know.
9. Then we start our ward rounds at 0910 AM.
10. If I am doing a ward round, I prefer to do it on my own as I want to see all the patients before 12 PM and then help my other colleagues.
11. I always do my ward round in a SBAR technique
http://omarsguidelines.blogspot.com/2017/05/guideline-for-junior-doctors-working-in.html
And try to mention what the active issues are and why they need to stay in hospital. I also document what the estimated date of discharge is.
12. I do discharge summaries as I go along as I have just seen the patient and have the whole narrative since admission fresh in my mind. I keep updating the discharge coordinator at the same time.
13. The other team members approach me if they have any concerns. Once I have ensured that they doing fine, I go an see the outlier wards ( each consultant has around 3 to 5 patients in outlier wards).
14. I see them in a similar way ( see points 11 and 12) and see as many patients as I can before 12 PM.
15. We have another ward huddle at 12 PM which is doctor led. This is attended by the nurse in charge, discharge coordinators, OT/PT, respiratory specialist nurses.
These are the things the doctors mention:
- Why is the patient still in hospital?
- Does the patient need to be seen by OT/PT
- What we can do to expedite the discharge ( the discharge coordinators feed this back to the bed managers who then try to expedite whatever is keeping the patient in hospital - ie, rehab beds, specialist opinions, any scans, etc )
We do this team wise - ie one consultants junior doctor goes first, followed by the next. If the consultant feels the the junior doctor may struggle ( ie a new FY1), (s)he leads this huddle and this way, the junior doctor learns how to lead it.
16. Once I am done with the huddle ( usually by 12 15 PM - at this time, lunch is being served to the patients hence we cannot review anyone UNLESS they are sick) , I ask my colleagues if they are all right and help with urgent jobs.
17. At 1230, we have all seen the ward patients and some/all of the outlier patients.
18. I then go and see the remaining outliers. By 1300, I have seen all the patients and done the relevant patients discharge summaries who are going the same day.
19. I have lunch at the hospital cafeteria at 1300.
20. I come back to the ward at 1330 and help my colleagues ( My aim is that all juniors should have seen their patients, done the urgent jobs and discharge summaries by 1400).
21. We are all done by 1430. Some of us then go to clinics ( I try to ensure that IMT trainees attend as many clinics as possible). I also try to ensure that the IMT trainees who are preparing for their MRCP exams can sit in a peaceful place and study.
22. I then do the non urgent discharge summaries and liaise with the discharge coordinator if there are any potential discharges identified for the next 2 days and do their discharge summaries ( I try not to bother any of the other junior doctors for this).
23. By 1500, I am completely free. We usually manage to discharge 6 to 8 patients ( once, we discharged 15 patients) and then we start getting patients from other wards/the acute medical unit.
24. I quickly eyeball the new patients ( regardless of which consultant they are admitted under) to ensure the relevant investigations are requested and they are not acutely unwell which needs a senior review.
25. I then chase any outstanding investigations for the patients I have seen and help my colleagues if they have any queries.
26. I then work on my e portfolio from 1610 to 1650. 30 to 40 minutes dedicated to your portfolio everyday is more than enough. I also respond to any assessments FY1s, GPST, IMT doctors send to me.
I have a logbook on my work drive.
This is my logbook:
Date of my on call
NHS numbers of patients I saw on my on call ( patients I clerked and any unwell patients I saw)
Name of consultant on call that day
I then go through the discharge summaries of those patients and then copy paste them to my e portfolio AFTER removing the patients details ( name, age, dates of admission, any names of specialists) and add them to my reflections and then also comment on what I learnt from them.
I then link these to the relevant curriculum items on my portfolio.
As I clerk around 10 to 15 patients on a single shift and see around 5 to 10 unwell patients, I have a reasonable cohort. As I took up a few on call locum shifts as well, I am running behind on this ( ie I have logged reflections 2 months ago ).
This helps in the following ways:
- I learn what I could do differently
- I get to meet my portfolio needs
- I can copy paste the exact reflections and send them as ACATs to the relevant consultants.
27. By 1650, I am all done and then ensure if anyone has any concerns.
28. I ask the nurses if they need anything doing urgently.
29. I leave at 1700 sharp and drop any colleagues who need a lift back home.
30. I get to spend at least 4 hours with my daughter ( she sleeps at 2100) and then have 2 hours with my wife ( we go to bed at 2300). 6 hours is a very reasonable amount of time to spend with my family after a 9 to 5 shift.
MY TIPS:
1. I learnt all the above by other registrars I worked with. None of this is my own idea.
2. As a registrar, I feel that it is my duty to ensure that all unwell patients are seen urgently ( hence I try to prioritize them when I come at 0830), my colleagues are relaxed ( and I volunteer to do urgent discharges, help them see unwell patients, etc) and we all get our breaks and leave on time.
3. Work closely with managers - the ward manager, nurse in charge and discharge coordinators and I are on excellent terms as I help them prioritize patient flow and safe management of patients).
4. Make a WhatsApp group for your ward doctors. Ask them NOT to mention any patient identifiable data but ask them to ask for help if they are struggling. This way, everyone helps and none of us gets overworked.
5. Be the registrar you wanted to have when you were working on the ward.
6. Enjoy your job! If you enjoy as a medical registrar, you will remain positive and you can spread positivity. You never know how much other people are influenced by you - and it is an amazing feeling when you hear that someone is following in your footsteps and repeating what you have done.
7. You can ONLY enjoy your job when you are experienced enough. I worked as a non trainee SHO for 18 months and then a core trainee for 2 years to become a registrar - I learnt everything in the past 4 years.
8. You will become frustrated. You will feel lost. Use this energy to make a QIP, contact the management and make improvements. You have no idea how much you can do provided you go through the right channels. I am currently working on 3 different QIPs ( with my IMT colleagues) - all of which I identified as issues we can potentially fix.
9. Live nearby - I plan to stay in the same city I will be working at hence I save a lot of time in commuting. I get to spend that time with family and I am less tired.
Most importantly,
Be human! Treat your patients and colleagues like family - even if they are student nurses. Greet everyone and ask if they need any help. No job is too small for you as a registrar. I know a registrar who helped a student nurse make a patients bed - she is now working as a consultant and is well known to help everyone around her. She is one of my mentors.
Dedicated to all the amazing registrars I worked with and I am working with - thank you for the small things you did which made me love my job and spread positivity, love and kindness just like you did.
The ward I am based on also has diabetes and endocrinology patients. It is a 32 bedded ward with a hyperacute bay ( where we do NIV and nasal high flow O2) and 3 side rooms (where we can also provide NIV, nasal high flow to patients who need to be barrier nursed).
We have 2 respiratory consultants ( who come twice a week) and 3 diabetes and endocrinology consultants ( one comes everyday and 2 come once or twice a week).
We have a junior doctor allocated to each consultant. The minimum number of junior doctors on the ward is 4.
THE MEDICAL TEAM:
One respiratory trainee registrar
One non trainee registrar
One acute internal medicine registrar
3 FY1 doctors
1 FY2 WAST trainee
3 IMT year 1 trainee SHOs
And there are non trainee SHOs in the trust who can cross cover if we do not have the minimum numbers
The members of this team are on nights/on days/annual leave/study leave and hence we are not always around at all times but usually there are 5 doctors including registrars. Hence each consultant has a doctor to see his/her patients.
MY TIMELINE
I wake up at 0700 AM, have breakfast, take a long warm shower ( which involves me day dreaming about buying an old classic Ferrari or a boat, and sometimes something more useful like a QIP) and leave at around 0810. I drive to work which is a 10 min drive.
I pick anyone who wants to be picked up ( I have offered my pick and drop services to all doctors working in my trust as long as they are on the way ) and get to work at around 0830 AM.
After putting my things in the staffroom, I meet the nurse in charge and ask these questions:
1. Is there anyone sick whom (s)he wants me to see before 0900 AM.
This is very rare. Although we have an unwell patient on NIV, the critical care outreach team is very good at managing this out of hours and we have an amazing team of respiratory specialist nurses who can do ABGs and adjust the NIV settings accordingly so it is very rare that I need to do anything.
2. If not, are there any urgent discharges I can do? ( We are very hot on discharges and we are trying to improve patient flow by identifying potential discharges and doing their medications and summaries as early as possible).
3. Usually, I manage to do 2 or 3 discharge summaries before 0900 AM.
4. The team of junior doctors start coming in and by 0855 AM, we have the whole team there.
5. The junior doctors then inform the ward clerk which consultant they will be working for and the ward clerk puts their names and contact details on our whiteboard so that the nurses know which doctor to contact for a particular patient.
Usually, there are 10 to 15 patients under each consultant
6. I usually take up the consultant who is not there that day or if there is no junior doctor allocated to that consultant ( for me, it does not matter if it is endocrinology or respiratory- I have already worked as a CT1 trainee in an amazing respiratory department plus I did loads of locums as a non trainee SHO in the hyper-acute bay in a respiratory unit as my first job in the NHS hence I do not feel that I need to work in respiratory 24/7 to meet my learning needs). If the consultants have junior doctors already and I am an 'extra', I act as the discharging doctor/doing urgent jobs doctor ( I sit at a computer and ask all juniors to immediately inform me if the consultant has deemed a patient fit for discharge or if there is an urgent job to do). This way the junior doctors can continue on their ward rounds without being disturbed by the nurses/distracted from other jobs
7. We print out the lists of patients under the respective consultants.
8. The nurse in charge then leads the morning handover ( attended by the doctors including registrars and consultants, OT,PT, discharge coordinator) in which the following patients are identified:
- Sick patients
- Patients on NIV/ nasal high flow
- Confused patients
- Patients who had falls/ issues overnight
- Potential discharges who need a doctors review ( We have an amazing group of nurses who go through the patients notes and bloods to identify potential discharges)
- Potential discharge who need to be seen by PT/OT
- Patients who have not had VTE or oxygen prescribed
- Patients who are not more than 24 hours of IV antibiotics.
- Patients who are barrier nursed and if there is any reason why they are in siderooms
- Any staffing issues
- If I am the discharge doctor, the nurse in charge lets everyone know.
9. Then we start our ward rounds at 0910 AM.
10. If I am doing a ward round, I prefer to do it on my own as I want to see all the patients before 12 PM and then help my other colleagues.
11. I always do my ward round in a SBAR technique
http://omarsguidelines.blogspot.com/2017/05/guideline-for-junior-doctors-working-in.html
And try to mention what the active issues are and why they need to stay in hospital. I also document what the estimated date of discharge is.
12. I do discharge summaries as I go along as I have just seen the patient and have the whole narrative since admission fresh in my mind. I keep updating the discharge coordinator at the same time.
13. The other team members approach me if they have any concerns. Once I have ensured that they doing fine, I go an see the outlier wards ( each consultant has around 3 to 5 patients in outlier wards).
14. I see them in a similar way ( see points 11 and 12) and see as many patients as I can before 12 PM.
15. We have another ward huddle at 12 PM which is doctor led. This is attended by the nurse in charge, discharge coordinators, OT/PT, respiratory specialist nurses.
These are the things the doctors mention:
- Why is the patient still in hospital?
- Does the patient need to be seen by OT/PT
- What we can do to expedite the discharge ( the discharge coordinators feed this back to the bed managers who then try to expedite whatever is keeping the patient in hospital - ie, rehab beds, specialist opinions, any scans, etc )
We do this team wise - ie one consultants junior doctor goes first, followed by the next. If the consultant feels the the junior doctor may struggle ( ie a new FY1), (s)he leads this huddle and this way, the junior doctor learns how to lead it.
16. Once I am done with the huddle ( usually by 12 15 PM - at this time, lunch is being served to the patients hence we cannot review anyone UNLESS they are sick) , I ask my colleagues if they are all right and help with urgent jobs.
17. At 1230, we have all seen the ward patients and some/all of the outlier patients.
18. I then go and see the remaining outliers. By 1300, I have seen all the patients and done the relevant patients discharge summaries who are going the same day.
19. I have lunch at the hospital cafeteria at 1300.
20. I come back to the ward at 1330 and help my colleagues ( My aim is that all juniors should have seen their patients, done the urgent jobs and discharge summaries by 1400).
21. We are all done by 1430. Some of us then go to clinics ( I try to ensure that IMT trainees attend as many clinics as possible). I also try to ensure that the IMT trainees who are preparing for their MRCP exams can sit in a peaceful place and study.
22. I then do the non urgent discharge summaries and liaise with the discharge coordinator if there are any potential discharges identified for the next 2 days and do their discharge summaries ( I try not to bother any of the other junior doctors for this).
23. By 1500, I am completely free. We usually manage to discharge 6 to 8 patients ( once, we discharged 15 patients) and then we start getting patients from other wards/the acute medical unit.
24. I quickly eyeball the new patients ( regardless of which consultant they are admitted under) to ensure the relevant investigations are requested and they are not acutely unwell which needs a senior review.
25. I then chase any outstanding investigations for the patients I have seen and help my colleagues if they have any queries.
26. I then work on my e portfolio from 1610 to 1650. 30 to 40 minutes dedicated to your portfolio everyday is more than enough. I also respond to any assessments FY1s, GPST, IMT doctors send to me.
I have a logbook on my work drive.
This is my logbook:
Date of my on call
NHS numbers of patients I saw on my on call ( patients I clerked and any unwell patients I saw)
Name of consultant on call that day
I then go through the discharge summaries of those patients and then copy paste them to my e portfolio AFTER removing the patients details ( name, age, dates of admission, any names of specialists) and add them to my reflections and then also comment on what I learnt from them.
I then link these to the relevant curriculum items on my portfolio.
As I clerk around 10 to 15 patients on a single shift and see around 5 to 10 unwell patients, I have a reasonable cohort. As I took up a few on call locum shifts as well, I am running behind on this ( ie I have logged reflections 2 months ago ).
This helps in the following ways:
- I learn what I could do differently
- I get to meet my portfolio needs
- I can copy paste the exact reflections and send them as ACATs to the relevant consultants.
27. By 1650, I am all done and then ensure if anyone has any concerns.
28. I ask the nurses if they need anything doing urgently.
29. I leave at 1700 sharp and drop any colleagues who need a lift back home.
30. I get to spend at least 4 hours with my daughter ( she sleeps at 2100) and then have 2 hours with my wife ( we go to bed at 2300). 6 hours is a very reasonable amount of time to spend with my family after a 9 to 5 shift.
MY TIPS:
1. I learnt all the above by other registrars I worked with. None of this is my own idea.
2. As a registrar, I feel that it is my duty to ensure that all unwell patients are seen urgently ( hence I try to prioritize them when I come at 0830), my colleagues are relaxed ( and I volunteer to do urgent discharges, help them see unwell patients, etc) and we all get our breaks and leave on time.
3. Work closely with managers - the ward manager, nurse in charge and discharge coordinators and I are on excellent terms as I help them prioritize patient flow and safe management of patients).
4. Make a WhatsApp group for your ward doctors. Ask them NOT to mention any patient identifiable data but ask them to ask for help if they are struggling. This way, everyone helps and none of us gets overworked.
5. Be the registrar you wanted to have when you were working on the ward.
6. Enjoy your job! If you enjoy as a medical registrar, you will remain positive and you can spread positivity. You never know how much other people are influenced by you - and it is an amazing feeling when you hear that someone is following in your footsteps and repeating what you have done.
7. You can ONLY enjoy your job when you are experienced enough. I worked as a non trainee SHO for 18 months and then a core trainee for 2 years to become a registrar - I learnt everything in the past 4 years.
8. You will become frustrated. You will feel lost. Use this energy to make a QIP, contact the management and make improvements. You have no idea how much you can do provided you go through the right channels. I am currently working on 3 different QIPs ( with my IMT colleagues) - all of which I identified as issues we can potentially fix.
9. Live nearby - I plan to stay in the same city I will be working at hence I save a lot of time in commuting. I get to spend that time with family and I am less tired.
Most importantly,
Be human! Treat your patients and colleagues like family - even if they are student nurses. Greet everyone and ask if they need any help. No job is too small for you as a registrar. I know a registrar who helped a student nurse make a patients bed - she is now working as a consultant and is well known to help everyone around her. She is one of my mentors.
Dedicated to all the amazing registrars I worked with and I am working with - thank you for the small things you did which made me love my job and spread positivity, love and kindness just like you did.
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