Working on AMU can be a daunting experience for many. However with proper support and guidance, it is an excellent place to work, learn and make friends.
I loved working on AMU so much as a SHO that I decided to apply for specialty training and I am the nutter who enjoys working here as a ST4 trainee registrar.
This post is about what Acute medicine is all about and what is expected of you as a junior doctor on AMU.
THE ADMISSION PROCESS IN THE NHS
Patients are admitted via the following routes:EMERGENCY DEPARTMENT
These patients can walk in/ come via ambulance and are assessed and managed by the emergency department team. This is a group of clinicians ( ranging from FY1 to consultants, ACPs, physician associates and nurses) who run the department
Once they have been assessed by the ED team, they will either be discharged or be referred to specialties like medicine, surgery, paeds, ICU, psychiatry, etc
AMU
If they are for a medical admission, these patients are then admitted to the acute medical unit ( AMU).
The medical team ( FY1s to registrars) assesses these patients ( known as clerking) and makes plans for them. Then these patients are seen by a consultant ( post taked) and either:
1. Kept for 24 to 48 hours in AMU/medical short stay ward
2. Transferred to a medical specialist ward like respiratory, gastro, renal, cardiology, etc
3. Discharged
OTHER ROUTES
Some patients are admitted to AMU via:
1. Direct GP referrals - usually, the GPs talk to a nurse in charge/ consultant ( also known as APIC - acute physician in charge)
2. Admissions via outpatient clinics
3. Admissions via ambulatory care
A TYPICAL DAY ON AMU
0800 to 0830 AM
HANDOVER
Attended by APIC, any other post take consultants, AMU consultants, registrar on AMU, medical registrar on call, SHOs, FY1s, ACPs, PAs on AMU that day, nurse in charge
0800 AM
https://omarsguidelines.blogspot.com/2019/12/handing-over-patients-in-different.html
The night team based on AMU hands over any
- ICU transfers
- unexpected deaths
- unwell patients
Then the night team goes through the patients they have clerked. Usually, one health care professional sits at the computer and the team goes through the list of patients on AMU.
The consultants add on any jobs which need urgent attention like an ABG of a patient who is oxygen, etc
A typical handover:
This 65 year old male was admitted with shortness of breath, cough productive of green phlegm. His CXR shows left sided consolidation and his CURB-65 score is 4. He is 2 liters oxygen and his ABG showed type 1 respiratory failure with a PO2 of 9.2
He is on IV antibiotics and he has been stable overnight
AFTER THE HANDOVER
The consultant distributes juniors. Usually the rota already allocates juniors to different jobs. An example would be
One ACP and a junior with each post take consultant. One scribes, the other does jobs.
One SHO for ward jobs - starting with the urgent jobs first
One FY1 for discharge summaries
2 SHOs for clerking
AMU registrar to see the patients already post taked. Usually has a ACP/PA/junior doctor with him/her.
WARD ROUND 0830 to 1130 AM
POST TAKE WARD ROUND
The consultant sees the clerked patients in detail, starting with the most unwell patient
There are 2 different consultants:
1. Those who prefer to document everything themselves
2. Some who prefer a junior to document
They go through the clerking of the junior doctors, then investigations, OBS, review the drug chart, escalation plans and then see the patient.
They then make a plan and what the estimated date of discharge is or whether they need admission to a medical specialty/ need to be seen by a specialty.
HANDOVER 1130 TO 1200 PM
After the post take ward rounds, the team get together in the office and go through all the patients. This is usually attended by the consultants, registrar on AMU, junior doctors/ACPs/PAs on AMU , discharge coordinators, AMU nurse in charge and therapists ( physio and occupational therapists).
The main purpose of this huddle is to improve patient flow. So a summary of all patients, why cannot they go, anything the discharge coordinators can help him and any patients who need a therapists review prior to discharge.
A typical handover
This 65 year old male, CURB65 score of 4, now off O2, SO2 remains stable, we have switched him to oral antibiotics, bloods show improvement of CRP, WCC, can go home. Discharge summary has been done and is with pharmacy.
1200 to 1230 PM
Lunch time
This is the time lunch is served to patients. Usually everyone from the AMU team also has their lunch at this time as well.
1230 to 1600
The post take consultants continue to post take patients clerked after their ward rounds and make plans for them.
1600
The AMU junior doctors who started at 0800 to 1600 and are on normal days go home. They handover to their colleagues
The AMU consultant and registrar go home as well. The medical on call consultant stays on AMU till 0800 or 2200/ a new consultant comes.
1600 to 2000
Patients continue to be clerked, post taked, discharged, transferred to other medical specialties.
2000
HANDOVER
This is attended by medical registrar on call at night, junior doctors/ACPs/PAs covering AMU at night and the day on call team
It is the same process as the morning handover but a bit faster.
Unwell patients are discussed first
Any pending jobs from the day are handed over
The day team then goes home.
A JUNIOR DOCTORS ROLE ON AMU AND WHAT YOU CAN LEARN
1. Attend the morning handover- You will learn how to handover patients in medicine. What is relevant and what you could do differently
2. Attend the post take ward round
-You learn a lot during this. Consultants often do teaching during this time and you also see how patients are clerked and anything you could do differently.
3. Do ward jobs
You can learn procedures
https://omarsguidelines.blogspot.com/2020/02/procedures-sho-is-expected-to-do-in-nhs.html
https://omarsguidelines.blogspot.com/2020/12/cannulation-venepuncture-and-doctors-in.html
Even typing up a discharge summary helps - when you go through the notes to see why the patient came to hospital and the events since admission. You can also look through images and quiz yourself on what the findings are then look at the reports like CT scans and MRI scans to check if you are right on not.
4. Attending the afternoon handover and leading it
If you have been on the consultant post take ward round, you can actually present the cases post taked. You will learn how to lead handovers this way and gain excellent leadership skills.
5. Seeing and assessing unwell patients
If the registrar/consultant are busy, you might be asked to see an unwell patient. This will help you gain confidence. Remember to stick to the basics - A to E assessment and management.
6. Attending teaching sessions
Every acute unit has lunch time teaching sessions at least once a week. In the pre-COVID era, we got nice lunches sponsored by drug representatives followed by teaching by a consultant/registrar/SHO colleague.
7. Clerking patients
https://omarsguidelines.blogspot.com/2019/08/how-to-clerk-medial-patients-safely-and.html
WHAT YOU CAN GAIN FROM YOUR ROTATION ON AMU
PORTFOLIO REQUIREMENTSAs a trainee medical SHO ( core medical trainee from 2017 to 2019- now replaced by IMT), I got most of my portfolio items signed off in AMU.
This is the list of work based assessments:
https://www.jrcptb.org.uk/assessment/workplace-based-assessment
Here is how:
ACATS
I presented the cases I clerked overnight to the day AMU consultants in the morning handover and asked them to fill an ACAT - I did not have to physically be present during the ward round ( that is very tiring).
One ACAT needs to have 5 cases. I used to clerk 15 to 20 patients in a night shift as a SHO.
CBDs- case based discussions
During my day shift, I would discuss cases with the consultant and get a CBD signed off.
Mini CEX
Mini Consultation Evaluation Exercise
During my day shift, my consultants would observe me examine a patient/lead a consultation and sign me off for a mini-CEX
DOPS
I got all my DOPS signed off whilst working in AMU
-Chest drains
-Ascetic drains
-LPs
-Cardioversions ( whilst managing the defib machine during a CRASH call)
MSFs
I worked very closely with HCAs, ward clerks, therapists, discharge coordinators, nurses and supported my ACP/PA/FY1/SHO colleagues and hence was able to get good assessments from all of them.
http://omarsguidelines.blogspot.com/2018/01/nurses-in-nhs.html
MCRs
I requested the consultants to sign multiple consultant reports - which is basically an assessment form by consultants.
Leading CRASH calls
I was able to lead the CRASH call and hence was able to get this signed off as well.
Discussing DNACPR
In my trust, SHOs were allowed to fill out DNACPR forms. And I regularly discussed escalation plans where appropriate
https://omarsguidelines.blogspot.com/2020/02/teaching-session-ceiling-of-care-in-nhs.html
Reflections
I reflected on cases I had clerked, huddles and CRASH calls I led and any teaching I did/attended and was able to link it to my curriculum.
Teaching observations
I got plenty of opportunities to present in our weekly teaching sessions and this way, got that part of my portfolio ticked off.
QIPs and audits
There are plenty of opportunities to do these on AMU. It is very easy to get signed off. The ward clerks are very proactive so can get you the notes of patients you want to audit within a few days. The consultants are more than willing to supervise you in these projects.
This way, I was able to meet all my portfolio requirements whilst on AMU.
LEADERSHIP
1. Seeing unwell patients, leading CRASH calls
2. Leading the handover
3. Working with consultants and managers on improving patient flow
4. Working with the rota team and improve the rota
5. QIPs and audits
6. Leading teaching sessions
7. Organizing regular socials
ATTAINING SKILLS WHICH WILL HELP YOU BECOME A GOOD REGISTRAR
You get to:
1. See ambulatory care patients - helping you decide if a patient actually needs admission
https://omarsguidelines.blogspot.com/2020/05/working-in-ambulatory-care.html
2. You get to see and manage unwell patients 3
3. You see a variety of cases
4. You get to do procedures
5. You get to teach colleagues
WHY DO DOCTORS NOT LIKE AMU
If the trusts management is good, then it helps a lot.
I have had the pleasure of working in some amazing trusts -
Wexham Park Hospital, Slough
Harrogate
York
Scarborough
Now Hull
In all of these trusts, the management helped the consultants to improve patient flow. They assisted wherever they could. Unfortunately this is not the case in every trust. They can sometimes be very rude, rigid and unhelpful and this creates a bad atmosphere.
CONSULTANTS
THE GOOD
A friendly, helpful and kind consultant makes a huge difference. I have seen consultants:
1. Bring in treats for the whole team
A consultant brought in ice cream for the whole team on a hot summers day.
Another consultant used to take the whole AMU team for coffee when the ward was not busy.
2. Encouraging regular night outs with the whole team (pre-COVID), funded by them
3. Sitting with struggling juniors and helping them - it does not take long to recognize that something is not right with our colleagues.
4. Helping SHOs in their PACES exam- by giving tips, supervising them, teaching them.
5. Helping them sign things off their portfolios.
6. Encouraging SHOs to apply for acute medicine and helping them prepare well for their interviews.
THE BAD
At the same time, I have seen some horrible consultants:
1. Arguing with the night team during the morning handover why they did not do a particular investigation
2. Feeding back in a very negative way to junior colleagues who have worked very hard.
3. Not taking a nurses concerns about an unwell patient seriously
4. Requesting a million unnecessary tests on a patient
6. Do not care about patient flow and do not work with management in helping improve things.
Unfortunately, we have a lot of locum consultants. They are paid anything from 100 to 150 GBP an hour. Some prefer to keep themselves 'safe' and make decisions which never make sense. Since they are not substantive, they do not need to worry about improving patient flow, ensuring the morale of juniors is good.
Having said this, I have seen some amazing locum consultants who have mentored me, helped me and still encourage me. I have also seen substantive consultants who are extremely rude, horrible and unsafe.
Remember, always escalate such people to the management:
https://omarsguidelines.blogspot.com/2020/01/bullying-and-stress-in-nhs.html
ROTA
This is very dependent on the management.
THE GOOD:
I have worked in trusts where the rota team
1. Has made the rota for the whole year and displayed it online. The junior doctors can swap into vacant shifts ( in case they are on call on a day/night they have a commitment) or take up locum shifts.
2. They run a very efficient WhatsApp group where they put out urgent locums
3. Good locum rates. They can offer upto 60 GBP per hour to SHOs and even FY1s.
4. If the wards are extremely well staffed and AMU is struggling, they might ask a few SHOs on the wards to help on AMU
THE BAD
1. Uninterested rota team
2. Poor, low locum rates
3. Do not care if there is understaffing
This can be changed by escalating issues and suggesting solutions.
PATIENT FLOW
Patients do not stay on AMU for long. They are either transferred to other wards or discharged. You just see them once and may not see them again.
I personally like this part as I like to see a variety of cases. But this may not be everyone's cup of tea
NO SKILL SET
Gastroenterology has OGDs, liver transplant clinics, etc . Respiratory has bronchoscopies, lung cancer clinics , etc
Acute medicine is just general internal medicine. Some people think that this is not a specialty and you are not specializing in anything.
However, acute medicine has specialist skills:
https://www.acutemedicine.org.uk/specialist-skills/
UNWELL PATIENTS
AMU does have unwell patients - sometimes a lot and sometimes all patients are stable. Some doctors may not like dealing with unwell patients all the time ( and this might be based on their personal experience of working on AMU for 2 months and all they have seen are unwell patients) . This can be stressful for some.
MYTH THAT CONSULTANTS ARE ALWAYS ON CALL
A typical rota is:
Monday
Ambulatory care from 0900 to 1700
Tuesday
AMU from 0800 to 1600
Wednesday
Off/admin day
Thursday
On call from 0800 to 2000
Friday
Off/specialist skill
1 in 4 or 1 in 6 weekends ( ie on call over the weekend every 4 to 6 weeks)
AMU consultants share medical on call rotas with other medical consultants who do GIM ( respiratory, gastroenterology, renal, etc) and are on call overnight once every 2 to 3 weeks depending on how many consultants there are.
So overall it is not a bad rota. There are plenty of locum opportunities even as a substantive consultant over weekends - the rates can vary from 100 to 150 an hour.
PERSONAL EXPERIENCE
I have personally loved working on AMU. The whole team from HCAs to consultants is charged and hyperactive. They are all very friendly and we have an excellent time together. The management has been open to ideas and even as a SHO, they used to listen to me and with the support of my consultants, I was able to bring changes to the acute unit.
The team I worked with helped me settle in the UK and some even nominated me for awards. I learnt that with hard work, positivity and kindness we can all go a long way and can change the dynamics of the work place.
Similarly, some of my colleagues did not have such a good experience. They were bullied, mocked and they felt burnt out because of understaffing. They also discouraged me from applying to acute medicine as a specialty registrar and they did not mean bad. It was just that they did not have such a good experience.
So we are given advice based on personal experience - which can be either good or bad. And your personal experience will also depend on various factors mentioned above.
MY OPINION ABOUT AMU
1. I have had a very good experience of working in AMU in 5 different trusts
2. This is my specialty. This is what I will be doing till I retire. I absolutely love it and I will resign the day I stop enjoying it.
These posts might help:
https://omarsguidelines.blogspot.com/2020/05/why-i-went-for-acute-internal-medicine.html
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