Preparing for FY1 - Part 1 (19 July 2023)

SPEAKER_00 0:00

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SPEAKER_02 0:42

This is our first episode in our mini-series for new junior doctors, where we'll be discussing practical tips for your first week of work. I'm Libby Sampe, and today with fellow TMC members Dr. Kat Ralston and Dr. Marilena Gianudi, we will be going through some practical tips for the new FY1s. Of course, you'll be starting on different rotations, so we're aiming to keep the discussion very general so it's relevant to everybody. Hi Kat.

SPEAKER_03 1:06

Hi Marilena. Thanks, Libby. I'm Kat Ralston. I am a medical education fellow and a geriatrics registrar in Edinburgh.

SPEAKER_00 1:14

Hi Libby, I'm Marilena. I am a cardiology registrar and currently out of programme doing my PhD based in Leeds.

SPEAKER_02 1:22

Thank you very much. It's great to have you both. So I suppose I just wanted to start off the discussion thinking about how to prepare for your first day on the job. Well, at the end of medical school, you have a bit of an assistantship period, which is when you are following and watching FY1s in the job and trying to sort of practice those normal reviews and sort of the day-to-day stuff. It's usually not in your place of work that you will be starting an FY1, but you also have your shadow week, which starts a few days or a week before you actually start your FY1. And that's when you will get to shadow the FY1s in the job you're going into in your place of work. I was just wondering how did you find Shadow Week and how did you get the most out of your shadow week before you started work back in FY1?

SPEAKER_03 2:05

Yeah, I remember it quite vividly. I think my shadowing week was quite good because I basically did the job of the FY1 while the FY1 supervised me. So when I started, I'd asked if I could do that with the FY1 because I really felt like I needed to be able to start on that Wednesday and know exactly what I was doing. So I basically did the task and they just helped or watched me. And I think that was probably one of the most helpful things is actually just getting really immersed and doing the job that you're going to be doing in a week. And I think probably the key thing for that is to really think about, you know, what your goals are before you start your shadowing week, and then have a little bit of an expectation setting with that if I won that you're shadowing. So meet them at the start, take 10 minutes and just speak to them about what you want to get out of it, just to make sure you're getting the right things that you need out of that shadowing week.

SPEAKER_00 2:48

So I had a slightly different experience. My first job was psychiatry, which for anyone who is in the same position as me, I know that you're probably going to be thinking that it's the worst start ever, but I promise you, you will be absolutely fine. So I kind of did what Kat did. At that time there was no F1 before me, there was just an F2 on the ward. I remember I had a little notebook. I wrote down absolutely everything as to every question I could think of, but mostly trying to think ahead like, if I have this problem, who do I ask? What time should I be here for? Like technically the wardra may start at nine, but do I need to be here much earlier? And I'm not saying that, you know, we should be spending our time going, you know, outside our working hours, but I do think it's important, especially at the start, just knowing how much time you may need to prepare for the day ahead of you. And I basically did what Katsuchi did, like tried to do as much of the job as I could with her there. What I would like to add though is that for those of you who are starting on psychiatry or those of you who are starting on medicine and then will be going to surgery, you will have, even though it's not technically instilled as a shadow week as you change your rotations, people are almost expecting that of you when you do rotate. So even though you have this dedicated time before your very first F1 job, I don't think that with each job that you have going forward that you're expected to just pick it up on that changeover day. There is that grace period of a few days. I remember when I went from a psychiatry job to a medical job. For my first three days, I had the SHO and the red with me doing every single job, even it was December, so technically I should be a grown-up F1 doctor by that point. But I was fully like supported. So I guess I just really want to emphasize the point that you will have support throughout the year. It's just that that shadow week is your dedicated support time.

SPEAKER_02 4:39

Yeah, absolutely. I definitely agree with all those points. Essentially, even just each rotation, you're going to be getting the support. There will be someone there for continuity who will help you learn how to do that job. So even though you have the dedicated shadow week at the start of FY1, it's not to say you don't have that continuous support through each change in rotation. My experience was slightly different because I started FY1 during the pandemic. So I actually had a big four-month block of interim FY1 as my equivalent of shadow week, which was brilliant because I really got to get to know the job and the hospital and things. I agree with all of your points. I think also the little things that are important in your shadow week, if you have a week or a few days on reward, is getting to know that local area. So focusing on how do you call this person, how do the bleeps work, making sure your printer is up because that's a nightmare on the first day, and making sure all your IT is set up. Because ideally, in your assistantship back in medical school, you should have gone through all those how to do a review, how to do a fluid assessment, etc. And then the shadow week is really getting into how does this local area work if you've not worked there before.

SPEAKER_00 5:43

I just want to add, take the time in your shadow week to meet the team that you'll be working with. Go out of your way to, you know, meet the nurses, meet the healthcares, and try and get that team spirit going early because they're the people you'll be working every day and they're the people that will help you if you have periods. I don't want to say where you struggle, but there will be good and bad days at work. And if you have that team support, the bad days will be much better than you're anticipating them to be.

SPEAKER_02 6:10

I'd really recommend if you're not given one to get yourself a name badge because this just makes life so much easier for everyone involved. Everyone will recognize your name and more like to, you know, you feel a bit more part of the team when everyone knows each other's name. So I would really recommend if you're not given one to get a name badge, definitely. Did you have any other ways that you prepared for your first day or your first week, or even just going into new rotations? How do you prep yourself?

SPEAKER_03 6:33

What's your routine? Usually if I'm going into a new rotation, it's almost like the shadow. I'll tend to speak to who the outgoing people are, people who've worked there before, just to get a general sense of like what the situation is on the ward, what the consultants are like, what the day-to-day is like. Because I think going into it, knowing a bit about what you're going to be doing is really helpful. And I think otherwise, it's kind of like just being a bit organized. So knowing how you're going to get there, knowing how long your commute's going to take, I would always try and get there 10, 15 minutes early anyway, just to let myself like get ready and have time and have a cup of tea and print out the word list and things. So I think not being late means that you're much less stressed on that first day. And almost even think about like what you're going to wear and have that set out, make sure you're bringing food and things like that. So that's kind of my general like first day plan.

SPEAKER_00 7:19

And the other thing that I would add, in terms of you know, how you get there is parking. Always trick parking. The number of hospitals that don't have parking and you have to park 10-15 minutes away and walk. Or, you know, if you're gonna have to do that, is it better if you get the bus or the train? Just try and think of that because those are the little stresses that you don't want on that day.

SPEAKER_02 7:36

Yeah, absolutely. That's really helpful. I was thinking we could maybe chat a little about rotors just in general, because they can be quite confusing, as I'm sure we're all aware. I don't know what your experience is like, but I suppose every rotation, you know, ultimately they all have different types of rotors. You've got the sort of block rotors where everyone just rotates around the same shift patterns. Other ones are a bit more random. Obviously, you can have lots of different types of shifts. So you've got the long days, which tend to be nine till nine or eight till eight. You've got the evening shifts, which can be shorter, so like four till ten. And you can also have the short days, so nine till five, and then obviously you've got night shifts and various assortments of different shift patterns. Did you have any other types of rotors that you've been involved with or that you thought would be useful to highlight to new juniors coming in?

SPEAKER_03 8:24

I love how the short day is nine to five.

SPEAKER_02 8:26

Hello, hello.

SPEAKER_03 8:28

I think for rotors, you know, it's it's gonna be different everywhere. And I think just knowing the general times of the start and the end time and knowing where you need to be and things, you'll get used to that quite quickly. I think the only thing about rotors I would say is in terms of like requesting leave and stuff, that I would do that as far in advance as possible. So if I'm going into a new rotation, I'll be emailing the rotation person two months in advance at least to say these are my requests and that's what I want, and getting your study leave, which comes a bit later when you're thinking about junior doctors. So just trying to be organized and putting in leave in advance. Sometimes if you're on a job that's really busy, then you have these little pockets of like happiness in between, which is your annual leave. And I think I would organize to have a really regular, so a week every two months almost of annual leave all set out in advance. Annual leave is important, and that's the other thing I would say. Get your requests in early so that you have that to look forward to.

SPEAKER_00 9:17

The things that I would add to that is to be careful because there are some medical jobs that actually start at eight, and that can be in the same trust as medical jobs starting at nine. There are some hospitals where every job starts at eight. So just be careful of your actual start time, because I think sometimes we assume, or certainly I assume when I started work that digital jobs start at eight and medical jobs start at nine, but that's not always the case. So just be super duper careful of what your actual start time is. And then the only other thing that I would be wary of, kind of following on from Kat's point with rotors and annual leave is that there are some rotors where your annual leave is almost like you don't really have much say over it. It's just that block, which can be a bit restrictive, but unfortunately, it's just the way the rotor works. So just make the most of it and try and make your plans around it. It's so important to have things to look forward to. So yeah, definitely plan your annual leave early and then know that you know I'm gonna work four weeks solid, but then I've got this week to look forward to.

SPEAKER_02 10:14

Yes. And just to add, obviously, in some cases, you do have those set blocks spaniel leave already embedded in the rotor. And if you have a really important, you know, a wedding to go to or something, it is sometimes, of course, possible to switch around. So definitely get in touch with your fellow colleagues and the rotor coordinator about that. And uh, hopefully people will try and help you out as much as they can.

SPEAKER_00 10:33

And I guess now would be a good time to think about when you do get your rotor, think about study leave as well. So if there's, you know, an educational opportunity, and maybe not in your first job, because that might still be a bit overwhelming, but as you go through your F1, you'll have to do your ALS course, you'll have to do certain educational events that you'll need to attend. So as soon as you have that date, try and get that booked in and talk to your rotor coordinator, ask for a shift swap, or just make sure you have that time off but in advance.

SPEAKER_02 11:02

Absolutely. I was also hoping we could talk a bit about the day-to-day stuff, sort of ward rounds, who to escalate to, handovers and things like that. So I thought we could chat a bit about the ward rounds to start with and how to navigate your first ward round or the first few ward rounds. Because often it can just be you and a consultant or you and a reg on the wards going around seeing all of your patients. And it can get quite fast-paced at times, especially when people are interrupting you along the way to ask for things and the computers are being slow, etc. Do you have any tips or tricks for juniors on the ward to sort of navigate that and how to keep their jobs lists straight and things like this?

SPEAKER_03 11:41

Yeah, the wardround, do you think it's straightforward when you're a medical student and when you're actually doing it in real life, you realize it's actually a bit of a complex beast, isn't it? I think the first thing to say is that generally we're not looking for the FI ones to know everything and have all the skills ready. Actually, what we're just looking for is people that are interested, you know, they're organized and they're willing to learn. So actually, people just being interested and keen on the wardround is really the main thing that I think makes a word run work well. I think we've said before in that shadowing week, really important to know the ward schedule. So, like when are the consultants doing the ward rounds? When are you being expected to do reviews? When does the phlebotomist come? How do you find out if they've come or not come? You don't want to get to two o'clock and realize none of your bloods have been done. So know how do you request those bloods for the next day if you've got a phlebotomist. So thinking about actually, you know, what happens on the ward, do you have a huddle in the middle of the day with the multidisciplinary team? These are really important things to know. And quite a few wards will have like almost a schedule on a whiteboard on a wall. And if it doesn't have that, I would advocate making that because that just makes it very clear as to what's happening on every day. And in terms of jobs lists, everyone has their own way of doing it. I would tend to do it on a ward map layout, so patient by patient and write jobs down. I think the most important thing is having a jobs list and making it as you go round. So not waiting until the end and having to go back through every patient's notes again, just doing it at the time. And if you're not sure about a job, then asking about it at the time that that job comes up. So ask, ask, ask. I always want to know if something's unclear. And it's much easier to sort out at the time than having to call that person back in the future. Some other people like to divide it into categories, so things like you know, phone calls, requests for radiology, reviews, discharges, and that can be quite a nice way of doing it as well. So you kind of work out your own style of what you want to do. It doesn't really matter which way you do it, but just have a system and keep it organized and make sure you're doing it as you go. That's my sort of main jobs list and sort of general word tips.

SPEAKER_00 13:30

What I'll add to the jobs list is when you do write your jobs list, don't put, you know, bed 14 and then the job that you have for that. Because even throughout the ward round, patients can change. And I've seen it where you know a jobs list has been made with bed number 14, and then thankfully nothing bad happened, but you realize that the patient that you saw on bed 14 is no longer bed 14, and you're running around trying to remember who it was. So always have a patient identifiable, even if it's their initials next to that bed number when you are writing your jobs list. And as Kat said, I do think it's really important that you do that as you go along. And I would very much advocate that you do it. I have seen juniors try to not have a jobs list and just try to remember, and I mean that stresses me out so much. And however confident you feel, I do think it's a really good idea to have it, even if you can just, you know, show your senior that you know what's going on. In terms of wardrobe, the thing that I will add is that you'll find that your seniors will have a different way of documenting. And it will take you some time to realize what they feel is important to be documented. Don't take it personally because everyone has completely their own style. And you may find, you know, like some of the older consultants may get a little bit frustrated if you're not writing things exactly the way you want them to, but this is them 30 years down the line, and they know specifically, you know, what they want in their ward round entry, and that's okay. You're not expected to know how each individual consultant wants their ward round done. So try not to take things personally, write down what you think is pertinent. If you're not sure, always ask. And again, just as Kat said, no one will mind you asking questions if you're unsure. And if there's one thing that you should be doing throughout your life, and to be honest, throughout your career is asking. No one knows everything. And when we think we know everything, that's when mistakes are made. And it's actually better to ask as you go along, and you know, things can be corrected as you go along and things can be prevented as you go along if you ask.

SPEAKER_02 15:23

Yeah, absolutely. I think that's something to live by in medicine is just to keep asking questions if you need to, absolutely. I was just thinking if there's anything else I was going to add to the ward round. I suppose it really depends on how many people you have on the ward round, what you can achieve in the ward round. Keeping the jobs this, as you say, is really important. If you can manage to do that on the ward round, excellent. If not, make sure you have everything written on the computer so you can at least go back and check a few patients if you've not managed to drop down what you needed to do. But otherwise, if you are able to, if there's an FY2 or someone else on the ward round with you, try and do a few little jobs on the way round. So things like fluid prescriptions, super quick to as you go around, requesting an x-ray again can be done quickly on the computer. So trying to tick off a few of the jobs as you go is always helpful if you can manage. But if not, I mean you just do it afterwards, that's not a problem.

SPEAKER_00 16:13

Just to add to that, that's where it's really important to get to know your team because you'll work in teams where everyone says, Bay one are my patients, bay two are my patients, bay three are my patients, and I've seen juniors not really helping each other because you know they're like, This is my bay, this is your bay, deal with it. I personally feel that the teams that I've worked best in are the teams where you know each junior may have an overall awareness and responsibility for that bay, but everyone checks in with the jobs, and that's where if you have a good jobs list, you can help each other out. But if you can only read it and you only know what it is, no one can help you either. And I think that's quite good when you first start to, you know, talk to your team and say, Well, how do you want us to go forward with ward rounds? Shall we, you know, share all the jobs? Is everyone gonna be responsible for a bay? Personally, I think it's better if you do share the jobs because inevitably there will be days where you know bay one is much busier than bay two and vice versa, and you don't want to be sat around not helping your colleague when they're struggling, because that's only gonna boomerang on you. But that is just good to know how you're gonna go forward working within that team.

SPEAKER_03 17:18

Yeah, I totally agree, Marlena. I think that kind of expectation at the start and working out a plan for how you're gonna do the ward round is useful. And it'll be very different on different jobs. So some surgical jobs, there'll be like four FY1s, and in that case, on a ward round, you might even switch about. So one person types, one person looks at the medications, and for the second patient, you kind of swap so that one person gets the notes ready because it's quite fast-paced. Whereas on a medical ward round, you might have more time and maybe less FY1s, and you work out who's gonna do what and try and do jobs on the way around. But I think working as a team is really important. Often wards will have job books, and I think just having a master jobs list in a jobs book is really important. And the key thing to try and understand that and work out what you're gonna do is to have sort of pauses or huddles through the day with your teams. I would always advocate having a meeting after the ward round, particularly if not everyone's gone on that ward round. Talk through the jobs, make sure you've got everything down, and then to divvy up what you're gonna do. And I think yes, it's good for one person to have oversight over different areas if there's a few of you, but actually really helping each other out and thinking about that prioritization. So there'll be some things that really need to be done quickly where some things can wait. And if you work as a team, that prioritization bit is much easier and you'll get things done much more efficiently. And I think that's a really good point, Marlena.

SPEAKER_02 18:28

Just stemming off the whole idea of teamwork, obviously there are lots of people around you. If you're needing a hand or just needing some advice, obviously on the ward, you'll be yourself, so an FY1, there should be, there will be a senior around whether they're on the ward or not, either an SHO, a registrar, and obviously you have the consultant. So just thinking a bit about escalation, if you have concerns about a patient or you're worried about a plan, you're not quite sure where to go next. I was wondering if we could chat a bit about who you're going to be going to and how to get in contact with them.

SPEAKER_00 18:59

I think it very much depends on what you're trying to escalate. If it's something like, you know, a practical skill. So I haven't been able to get the bloods, I haven't been able to get, you know, this cannula in, I think then you need to think about escalating to your second most senior person. So if you're the F1, you'll escalate to your F2 or to your, you know, SHO. And that generally as a rule can apply even to sick patients, but there is always a limit to what the person right on top of you in the hierarchy can do. And I think certainly during daytime hours, if there is, you know, a registrar on the ward and you are worried that this patient is very, very sick, they have a new score of 10, you know, 11. And depending on the hospital policy, that patient may just need to be escalated directly to your registrar. And I think during induction, you will be told that, you know, all patients within use of six or in use of eight need to be escalated to a registrar. Well, if that's the case, the decision has already been made for you. I think in general, having gone through a kind of the ranks, no one will get mad at you for escalating a poorly patient. And even if a registrar says, you know what, the SHO can deal with this, that's okay. Because they know that this patient was poorly and you were worried about them. And even if they don't tell you, they will keep checking the notes of the patient. They may pop in to see what they look like. So never feel that you can't escalate to the most senior person. It's just about thinking, what can this person do? And that's where I go back to kind of the practical skills, because if you go to the SHO first and they can't do it, well, then that will be escalated to the registrar. So there is always this hierarchy in place, and it's just about who is there, who is most accessible, and who has the time and the skills. So I don't think there's a right or wrong answer. I think the most important thing to take away is that if you do feel out of your depth, you escalate. And everyone will do that no matter what position they are in. Whether they're in SHO, they'll escalate to the rich. If you're a rich, you'll escalate to the consultant. If you're a consultant, you're gonna escalate to a colleague. No one stays in an unfamiliar or an unsettled situation and deals with it themselves. And I think there's this unexpected rule that when you graduate medical school, you're supposed to have the answers, you're supposed to deal with sick patients, you're supposed to be able to accumulate, but that's not the case. Sorry, that was probably a very long-winded answer to your question.

SPEAKER_03 21:16

No, I totally agree, Marlena. I think it's such an important point that when I think when you first start, you think that everyone knows everything all the time. And that's just not the case. Even you know, up to consultants, they will need to ask for help. Everyone needs help. So I completely echo that point that the most important thing is to call someone if you're not sure or you're not comfortable. I would much, much rather be called at any time, even if they think it's a silly question. There's no such thing as a silly question, first of all. And if I get a question like that that I can answer easily, great. That's like ideal when I'm the med on call. The worst thing is if something happens and I don't know about it and I find out about it six hours down the line, and it would be much easier if I just knew about it straight away. So I'd much rather to have that call as soon as someone is getting that feeling that they're actually they're a bit uncomfortable. Unsure and just escalate that problem. So absolutely. And the other thing I would add is just think about, you know, generally your registrar will go off and be doing something else in the afternoon if they've done the ward right. So or your consultant. They might be in clinic, they might be on call. So find out how you're going to contact that person once they leave. So before they leave, just in case, like, how can I get in touch with you? What's your bleep? What's your phone number? Where are you going to be? Just so you know where that person's going to be, how to call them. And in some places, the senior might do a check-in. So might say, right, I'll come back to the ward at three o'clock or four o'clock and sort of questions that might seem less important, but you know they can be mopped up by someone coming in. That's often quite a nice system. So it might be nice to ask, are you going to come and check in? And I'll run through things then. So just finding out what your senior's system is can be really useful as well.

SPEAKER_02 22:44

Yeah, I agree. I think ultimately the best top tip I would give anyone starting out and throughout the whole of their career is just listen to your gut. If you feel like you don't quite know what to do or you don't quite know what's going on, just call someone. Because ultimately you're just going to go home and stress and not sleep. And it's all worse off for the whole team and for the patient if you don't just listen to your gut. So I think ultimately I go by if I know I'll worry about this when I get home, I'm going to ask someone because that's I think ultimately the best way to know that you've taken the best care of your patient, you've got someone involved, you've settled your own mind and made sure that there's a definite plan in place. So that's usually what I go by. That's my motto, Libby. What do I need to do to sleep at night?

SPEAKER_03 23:28

And if that means talking to my registrar or my consultant to sleep, then that's what I will do. I do exactly the same. So if I have that uncomfortable feeling in my gut, if I'm not happy, then that's when I need to call someone. And I think everyone has that. So that's a really good barometer.

SPEAKER_00 23:41

And I think that's what our training has led us to do. Our training hasn't led us to have the answers for everything, but it's just led us to be able to recognize, you know, uncomfortable situations. You're not expected to have the answers you're expected to know when you need help. And that is what medical school has taught you to know the basics, because you're only going to build on those depending on what specialty you go into. And then you just need to be safe. That is the most important thing.

SPEAKER_02 24:04

Yeah, absolutely. And I think just another quick thing to add on to who to ask for help is just being aware of who's actually on the ward with you. So someone who I've worked with a lot, and honestly, they've helped me out so much throughout my FY1 and FY2 are the pharmacists on the wards. So they're a brilliant source of knowledge. So, you know, if you're a bit stuck on, oh, which dose should I give for this? I can't quite find it in the BNF, but I'm not quite sure what to do. The pharmacists always have your back for that kind of question. Also, the nurses, they absolutely know their patients inside out. If they think something's up or they're worried, they have a wealth of experience that you can, you know, tap into when you're worried about something. So it's not just always needing to go up to, you know, your SHO or your registrar, ask who you think might be helpful on the ward, who's going to know a little bit and give you some advice. Yeah, absolutely. That's all really helpful. And I was just wanting to chat now a little bit more about sort of handover and how to do referrals and things like this. I know everyone has their own little system for how to hand over. I know a big thing I've used in FY1, FY2 is S-bar. It's something you're obviously taught in medical school. I think ultimately if you use that, you can't really go wrong. Certainly when you're handing over to the night team or to a colleague, it's really good to have that punchy first line so they know exactly what's going on. You know, oh, I'm really worried about this person, or I'm not worried. Can you come and see them? Etc. Certainly before going over to ham, night shift, hospital at night handover, essentially at the end of the day, one person from that department will go to hospital at night team and hand over any outstanding jobs. And you'll be handing over to a group of people who will be taking on for the night shift. And that can be quite an intimidating process because it feels a bit like an interview, it's just you and then there's sort of five or six people listening to your handover. So I always say it's really good to write down your handovers before you go so you're clear, you're efficient, you make sure you get the right points across. And also just giving them the opportunity to ask you questions. And I suppose also you can ask them questions at that point too. But do you have any other thoughts about either being on the receiving end of handovers or referrals or giving handovers yourself? Any tips that you would give to new doctors coming in?

SPEAKER_03 26:08

I think the key thing is preparation, particularly for hand handovers, so hospital night. So I think often people feel like they need to keep doing tests, doing tests right up to the wire, and then they'll rush down to handover because they want to think, oh, if I do this last cannula, then that'll be one less thing off of the hospital night team's jobs list. But actually, the hospital night team got the whole night to do the jobs, and they will be able to get those things done. I would stop doing anything new half an hour before handover and then just write down what you're gonna handover, make sure you know exactly what you're gonna handover, what your question is, what the task is that you want them to do, and tidy up any last bits, you know, your notes and things like that, chase bloods that you've sent to check if they're not back yet before handover, before you go. So just have like a good half an hour of just organizing yourself for handover, and the hand team will be much happier with that than if you've done that last cannula. Because actually, having an organized handover is really important and really appreciated by the hospital at night team. And the other thing is don't kill yourself and stay late to get all these things done that there's a whole team there to do. You know, you're handing over for a reason. You're going home and you're handing over your work. So don't worry about handing over stuff. It's expected. That's why there's a handover. The main thing we're looking for is just people to be organized and know what they're asking, know what the question is or what the task is. So organization and making sure that you leave on time, I think is really important because you will have had a long day if you're handing over. Usually that's a 12-hour day. So you just need to get organized and get home. Totally agree with having a structure. And I think the most important thing, you know, S-bar's been hammered in to people in most medical schools. I think the headline part of it's the most important. So put a headline, that sentence that you talked about, Libby, to grab attention and just tell me right at the start what you want or what the question is, so that I know what I'm listening for in the rest of the handover. So headline, most important bit, I think, of that. And just to quickly say on referrals, so I'm often more on the receiving end of referrals nowadays. Again, that headline tip is really important. Put that right at the start. And I think one of the most important things is know what you're asking. So know what the question is. Because quite often your senior will say, Can you just call cardiology about that? And you're like, Yeah, yeah, great. And then you get to that phone call and you're like, I actually don't know what they want. And I'm hoping that the cardiologist will know just by me telling them the story that they know. And actually clarifying that at the point that someone has asked you to do it, or when you're thinking about making that phone call is really important. So, what's the question? Is it for advice? Is it for review? Do they want to take that person over? You know, what are you calling for? And the other thing is just thinking about who you're calling. So what a cardiologist wants to know might be different from a surgeon, will be different from intensive care. So just thinking about what parameters that particular specialty will want to know. And the last thing I'm going to say about this is just be honest. When you're taking a referral, I will generally be asking questions just to try and clarify what's going on and help me sort of prioritize it in my mind. I'm not expecting you to know the answer to every question. And if you don't know, that's totally fine. But the worst thing that can happen is if someone doesn't know and they make something up or they be vague about that are I think that's something. And if that changes how I'm prioritizing in my head and how I'm making decisions. So if you don't know, just say you don't know. That's absolutely fine. Just be honest about it. And that's the most important things for me.

SPEAKER_00 29:06

Things that I will add to that. I think for going to Handover, I completely agree that you need to be prepared. Again, because it's been my bug fair. When you're handing over a patient, don't hand over a bed number. Hand over a name and either an NHS or a hospital number. I've been in handovers where bed numbers have been handed over, and I have been the mean writch that has sent someone away to get us patient identifiables. Patients can move. There can be patients with the same names on the same ward, and handover needs to be safe, and it can only be safe if you know what you're doing for specific patients. So I would always go to handover with a name and identifiable number for that patient. The other thing when you're handing over is think about what do you want that person to do with what they are chasing and taking over from you. So if you're saying, can you please chase these bloods, the person that you're handing over to may have never met this patient, but they need to know what they need to actually go. So for example, you know, and you chase these bloods, if their CRP is going off, and white cells are going off and their temperature is going off, can you please switch them to either antibiotics? But they'll probably need a clinical review as well. So with each job that you hand over, you need to explain why you're doing that. Otherwise, something that could be very important could be misconstrued as not very important at all down at the bottom of the priority list, and that's how things get missed. So that's what I would say about handover. In terms of when you are ringing to refer a patient, I completely agree with what Kat said. You know why you're referring that patient. If you're ringing to refer a patient to a senior so that they can come and review, go and see the patient yourself first. There is nothing worse than being told to go and review a patient and you realizing that no one has seen this patient before you, you know, not even ops have been done. And that's not because you know your senior can't be bothered to see their patient, but it's because they may have another 10 sick patients to see. And it's so important that that initial review has happened because then we can say to the more junior person on the team, Well, I've done this, can you now do this, this, and this? And that only really works and gels well when you've already made that initial contact with the patients and you know what's going on with the patient. So those would be the only two points that I would have to add to what Kat has said already. Yeah, absolutely.

SPEAKER_02 31:18

I think the thing that really resonates with me is being honest on the phone when you're doing referrals or when you're handing over. If you don't know the answer, just say, I'm sorry, I don't know. I can look it up for you or I'll find out and call you back because ultimately, if we don't know the answer, that's totally okay. And just being honest about that is the most important thing. Just making sure that if you're making a call or a referral, trying to have as much information in front of you as you can. So try and get the news chart in front of you in case someone asks you what their blood pressure is doing, etc. Get them up on the screen in front of you so you can quickly check different blood tests and things. Just so you have everything accessible. So if you do get a question you don't know the answer to, you can try and quickly have a look and see if you can find out while you're on the phone. Going off from that on a slight tangent to sort of on calls, lots of the new junior doctors will be doing on calls. So this will include out of hours work, usually in the evening or overnight. I thought we could chat through a bit of a typical on-call, typical night shift, and how that works and how you manage getting through things like night shifts, how you prioritize things, or just those little tips about, you know, do you have a nap, do you not have an app, etc., just to help with anyone sort of preparing to go straight on to nights?

SPEAKER_00 32:28

It's quite difficult because each department that you're working will be slightly different and will expect different things of you on a night shift. And I think that's again where it's so important during that handover to understand what is expected of you, what jobs you've got handed over. And what I tend to do is after any night handover, sit down with the jobs that I've been handed over and prioritize them and know that you know what, in this next hour, I have to do this, this, and this. If you've been handed over poorly patients, I think it's good to get a feeling of them really quite early on in the night, whether it's going to review them, reading their notes, because inevitably you will be wrong about them. And I think if you have time, it's always good to go and eyeball them at the start of the night because you may have never met this patient before. And actually, if they are such good to get worse, you've got nothing to compare that to. Or again, if they're to get better, you've got nothing to compare that to. So I think once you've sat down with your jobs list, seeing that you know, I have to chase X amount of blood, I have to do X amount of cleanliness, I have to review these patients, it's good to then think about how you're going to tackle that. Obviously, poorly patients will always take priority. And I think that's the way that I tended to go about back of the house nights. I think when I first started, I was really bad at taking breaks, especially at night. Personally, I can't eat on a night shift. Like I'll have a yoga and a piece of fruit, but that's just me. I know loads of my colleagues will be able to eat. I think it would be bad to assume that you can sleep on a night shift because sometimes you just either don't have the time or you know it can be frowned upon by the nurses or by more senior members of staff, but you must have a break. And there is nothing that I can emphasize more than that. Even if you know it's mental, even if you say, you know what, I am just going to the staff room for 10 minutes. I need a cup of tea, I need to eat, I need to refocus because that is you protecting yourself, and by protecting yourself, you're protecting the patients and their safety. So always make sure that you stay hydrated, you go to the loo and you have the time to take a break. And kind of following on from that, I think it's then slightly different if you work in areas where you're expected to clock a lot. So whether you're on the medical assessment unit or the surgical assessment unit, your job there is to look after the sick patients, but also to clock the patient so they're ready for the day shift. You do as much as you can do, but that is the nature of those areas. They will constantly have a high turnover. But if you don't manage to clock every single patient on that shift, that doesn't necessarily have a reflection on you and your work ethic. It's a reflection on how busy the hospital is, how high the turnover is. And it's better that you clock six patients, but do it thoroughly and safely than rush to clock ten patients and actually you've missed very important things or you haven't repeated important investigations that will be needed for the morning. So I think it's just very important in having an awareness of what is expected of you in that area of work that you will be, and again, keep escalating. You are not by yourself. Even at night, yes, the team is smaller, but you are part of a team. Yeah, absolutely.

SPEAKER_03 35:34

I love that, my alena, about eyeballing people at the start of the shift. I think that really resonates with me. I think that's really important. Get to know who you're going to be seeing, and that gives you an idea of how they're getting on through the night shift. All I would add is it'll be different everywhere. So, you know, it's difficult to go through what hustle night will look like for you where you're working, but certainly know which areas you're covering. So usually you'll be given an area if you're working back of house. So on the wards, know where you're covering and know what your role is within the team. And part of that will usually be a cardiac arrest huddle as well. So you'll usually be on the cardiac arrest or medical emergency team, and they should have a huddle to allocate roles and get to know the team during that and know what your role is supposed to be during that cardiac arrest, which for an FI1 will generally be scribing, taking notes, doing CPR, running things to the lab, things like that. So just know what you're supposed to be doing when that bleak goes off. And I think just in terms of patient reviews and things, I think just fall back on what you know, that like A to E assessment for an unwell patient. That's really useful, means that you don't miss anything. In most cases, you know, try and get a feel for what's going on with the patient, do some relevant tests, you know, bloods a gas, an X-ray, whatever's relevant, and then escalate. But if it's an emergency, if you turn up and the patient's having a seizure or the patient looks really sick, don't bother to do that. Just pick up the phone and get your Reg there, get your senior there. So some people feel compelled to be doing the test and the assessment before they call someone. But actually, if you're really worried when you get there, just pick up that phone and get that person on the way while you're doing that. And in terms of general tips, I think you need to find your own routine. Generally, having like a good blackout blind is very important because you're sleeping in the daytime. And when I've done nights and when I've had to stay on site, I've brought my own blackout blends that stick to the window for like babies, which I think has been very useful. I've got like a wake-up alarm clock that has like a gradated light, so it kind of lights up over half an hour, and that's quite good, I think, for my sleep hygiene and making me get into that rhythm. I would always try, I know Marlena says she doesn't eat well, and I can totally resonate with that, but I try and bring a proper meal and just try and eat as much of that as I can because I think the food options overnight at hospitals are generally not very good. So I think make sure you're bringing enough food to keep you going and absolutely take your break. So I was rubbish at that as well. I remember as an FI1, and you think, I'll just do this next thing, I'll just do this next thing. I'm a good FI1 if I get all my jobs done. But actually, you're much less efficient and you're much more likely to make mistakes if you haven't had a break. And pretty much everything can wait. Only if there's like a literal cardiac arrest or medical emergency going on, that's okay, don't go on your break then. But everything else can wait for you to have half an hour to have your break. So just really try and keep that with you and make sure you're taking that half an hour and ask questions. I'll just reiterate that we want to be asked questions and we want to know if you're worried about things.

SPEAKER_00 38:13

And the only other thing that I'll add more from a safety point of view is find out early on what hospital accommodation is like because you may finish a night shift and feel unsafe to drive home, and that's okay and that's expected. And actually, it is much better for you to admit that to yourself than to get into your car and drive home. So ask, well, ask either, you know, at the beginning of your job or even if you know you've forgotten after handover, ask the consultant, you know, after the morning handover, ask the consultant who can I ask about hospital accommodation because I don't feel safe to drive home. But there is nothing more important than looking after yourself throughout your working life, but especially when you work shifts and difficult hours. And again, if you finish twilight shifts and you feel uncomfortable walking to your car, always ask security. Like you do not have to go through anything that you know you feel uncomfortable, you feel unsafe with by yourself. There are people in the hospital to make those difficult working hours more safe for you.

SPEAKER_02 39:11

Yeah, absolutely. I think that's a really important point to make. Make sure that you're safe. That's the most important thing at the end of the day. Those are really helpful tips. I was just thinking a bit about sort of, well, not sort of safety, but I think one thing that is very difficult when you first start as an FY1 is if you don't quite agree with something that's going on or you don't feel comfortable with a plan, or you feel like something's maybe missed, and you are struggling to sort of raise that with colleagues. This is something that probably resonates with everybody. When you first start out, a lot of people will be nervous. I know I was. I was certainly very nervous about the job and about this new level of responsibility that I had. And you're doubting yourself at times, you're doubting how you're feeling, or you're doubting the plans that you're making, you want to run them past someone. And it can be quite difficult if you disagree, perhaps, with a consultant's plan. And I was just wondering if you had any thoughts or if you've ever dealt with difficult situations in that respect as a junior where you've had to stand up for something you're worried about or ask more questions in that respect.

SPEAKER_03 40:14

Yeah, I think speaking up is really important. It's actually really vital to making sure that patients stay safe. And it can be a whole range of things. So even something as simple as if you're on the ward round and the wardround's running too fast and you can't write the notes, so you can't write the jobs plan, then actually just speaking up and saying, look, can we slow down a bit just so I can make sure that I get these jobs done? I can't imagine anyone being annoyed to you doing that. And I think it's important to note that having a speaking up culture is a lot about what your leaders and your seniors are doing and about the culture of the organization. So it's not just all on the individual. And we need to be role modeling these behaviors as seniors as well as asking people to speak up, because it's very well just telling people to speak up, but actually they need to feel like they're able to. So it's everyone's business, it's not just you as a new FI1 having to speak up. But thinking about some sort of individual tips that I think might be quite useful. So if there's time, if it's not kind of an emergency situation, but you're just not quite sure about that plan, then often starting off being curious can be useful as opposed to conflict. So thinking about it as a learning opportunity, you know, well, I don't quite understand that. I thought maybe you would do this. Do you mind just explaining how you came to that decision just for my own learning? So I would often get asked that as a senior, and I take that as a really nice educational opportunity. And if I can't explain my own decision making as a senior, then something's gone wrong with my decision making, hasn't it? And I'd be delighted if someone has pointed something out to me that I've forgotten because there's lots going on in all of our minds all the time. And we make two to three mistakes a day, like that's being proven. So we're relying on our teams to pick those up. So often you'll see in a cardiac arrest, the senior will do a bit of a pause, a summary and say anything else. That's really good, allowing your team to speak up, but also they're relying on you. So, you know, I'm relying on my team and my consultant is relying on me to pick something up if actually they might have missed something. I think that's a really important thing to know that actually generally we're looking for people to point things out. I'm very happy to explain why that decision was that decision, or say, oh, thank you so much for picking that up. I didn't know that. Let's do that instead. And I think often as well, you might feel like as an FY1, you might be asked to do things that you might not feel comfortable with, you know, thinking about breaking bad news if you've not done it before, or maybe some procedures. Often thinking about things like graded assertiveness can be useful. So that can start off quite soft, but can give you a way to escalate if you're not getting the response you need. So there's different models for that. One is called cuss. So the C is concerned, so I'm feeling concerned about that patient, or I'm concerned about doing that task. The U is uncomfortable, so I'm uncomfortable with doing that arterial bug class, or I feel really uncomfortable about how well that patient is. The first S is safe, so I think this is a patient's safety concern, or I'm worried this might not be safe. And the second S is stop. So that's more in an emergency situation. For example, the wrong drug about to be given to the patient, and you just need to say, stop what you're doing, let's step back and have a think about it. So that can be a way just to get the words around being assertive and thinking about as an individual how you can kind of start low but escalate your concern if something is happening. But I'd also much rather want to know as a senior if the person I maybe had asked to do a job, felt uncomfortable with it, and I can find someone else who can do it or that or I can help them. So it can also be used as an educational thing, like actually, I haven't done a tour buggest before. Can you come with me or can I observe you or can you come with me and can you show me? So it can be a learning opportunity as well. Yeah. So that's my kind of general speaking up tips.

SPEAKER_00 43:33

I think that's really, really good. And I would have nothing to add to that. I think the only thing that I would say is you are a member of that team. And just because you're the most junior member doesn't mean that you aren't part of the team. So I think it's really easy when you first start work to, as we've said multiple times, to assume that everybody knows everything because they're more senior than you. But actually, you're fresh out of medical school, your knowledge is probably at the peak that it's ever going to be, and you are a member of that team. So do feel free to talk about, you know, things that you may be concerned about or things that you don't understand. Personally, I completely agree with what Kat said. And I think when I was in those situations, I would always adapt the curious approach and say, oh, you know, why are we doing this? Because actually it may be a different way of thinking that you hadn't thought about. And I think that's the way of it seeming less confrontational. But I do completely agree with what Kat said and the custom model, because then that's all graded depending on the situation that you're in. But just never forget that you're part of that team for a reason. And we do want your opinion. And actually, most of the time, you may be the doctor that's seen this patient the most out of anybody. And you may know that, you know, this patient is not the same today as they have been for the last week. And you're seeing like, no, no, they're fine. But again, going back to listen to your gut and just feel empowered to do what you've trained five or six years to do, and that is to look after patients.

SPEAKER_02 44:53

Yeah, absolutely. I think those are really important things for everyone, to be honest, in any workplace, really, to make sure that you're comfortable and you know how to, you know, you have the confidence and you you know that you have the rights to say if you're a bit worried about something, and things like the custom. I'd never heard of that, but that's a really useful thing to know about. Actually, thanks for introducing that. So that's great. I thought we could talk a bit about general well-being for starting out in the new job, just to round off the podcast. It's quite an important part of starting a new job. It can be very overwhelming. Ultimately, you need to make sure you're okay in yourself. And I thought this would probably be a good thing to just sort of round off the podcast with. I don't know if anyone wants to lead with any of their thoughts about how to keep yourself well while working.

SPEAKER_00 45:36

I think having a work-life balance is really important and it's something that we keep getting told about that actually we possibly don't do very well at. Or I think we'll just go through phases of, you know, work being the priority, then, you know, our personal life being the priority. And I think that most likely that's what will happen for most of us. I think in order to have a good work-life balance when you start, and it all feels quite overwhelming, is knowing what is expected of you at work and what you want to achieve. So personally, I think it's quite good to touch base with your educational supervisor really quite early. They will be looking after you for the whole year. Your educational, your clinical supervisor will be the same person for your first job. I think if you meet with them early, set out, you know, what you want to gain from that job early, then you have something to be aiming towards whilst you're at work and you almost have a plan in place. So that almost takes the pressure off the working aspect of, you know, well-being. And by doing that, you know who you can escalate to by creating that relationship quite early. If you do struggle, you've got that protocol when you are at work to, you know, say that actually I'm struggling either in my work or in my personal life, because your educational supervisor is there to guide you throughout that year. And then I think it's really important to, you know, try and keep up with your hobbies, try and make sure that you have plans with friends. And yes, rotors can get in the way of that. So you might not be able to go to, I don't know, football practice or netball practice once a week like you previously did. But it's really important that when your rotor allows, that you do take that time to do it so that you can feel a bit more like yourself again. Because you've spent these last five or six years being a student, yes, going to placement, but under different circumstances. And now you have this different responsibility. And it can be so easy to lose yourself in that. But I think that's where it's really important to, you know, make sure you have your annual leave booked in, make sure you plan regularly to see your friends and family, make sure you keep up with your hobbies or you know, take on new ones. I think mess events can be quite helpful in the first year, especially if you've moved to a new place and you don't know anybody. That can be a quite good way of meeting people and talking to people about what you're going through because there are lots of people that actually don't have a big medic circle and that's okay. But I do think it's important that you do have a group of medics who you can discuss, you know, oh, I had a really bad day and this happened that will understand that. And I think the most important thing is to just keep talking. It doesn't matter who you talk to, it might be your friends, it might be your family, it might be your supervisor, it could be anybody, but just keep talking. Don't keep anything, you know, bottled in and try and cope with the pressure that you may be putting yourself under by yourself.

SPEAKER_03 48:19

I think that's so important, mylena. I'm just gonna echo that kind of keep talking to people. I think that also links on with sort of imposter phenomenon. So people feeling like they might be a fraud or might not know what they're doing. But actually, if you start talking to people, everyone feels like that, at least some of the time, all the way through. And actually, what helps with that is just debriefing with your peers and chatting and really understanding each other's experiences. So I think that's so important. The other thing I'm just gonna add is sort of leaving on time. So the vast majority of things can wait till the next day. And if you're not entirely sure, then ask your FY2 or the Reg on the ward when you're in the first few days, what do I actually need to do today and what can I go home to get a feel for it? But there's almost nothing short of a medical emergency, which actually there should be a team after five who's looking after that that you need to be there for. So leaving on time is so important, you know, it can wait. I would also just echo actively scheduling in nice things. So booking out, getting going out for dinner, booking that holiday, going away for the weekend, you know, put them in the diary so you've got those to look forward to. That's what I would say. Absolutely.

SPEAKER_02 49:16

I think those are really good points to end on, actually. I think ultimately the most important thing is to remember that everybody has been in your shoes, everybody has gone through the system and everyone knows what it's like and how it feels. We're here to support you. Everyone in the hospital is here to support you. Your friends and family are also there for your support. And I think it's just remembering that when you're going through because there'll be some tough days, but you know, we're all here to help. That's the main thing. So just ask questions if you need. Thank you so much, Marlena and Kat, for joining us on the podcast. I think it's been a really useful discussion. I've certainly really enjoyed it anyway.

SPEAKER_00 49:49

Thanks so much. And good luck to everyone starting.

SPEAKER_03 49:52

It'll be good fun. It'll be absolutely fine. Best of luck.

SPEAKER_01 49:56

If you would like to hear more information and discussion about starting FY1, then please come along to our annual evening medical update, Top Tips for New Doctors in July, where speakers will be discussing more about starting work, including a question and answer session. Please find more details on our website. We hope to see you there.