Reflecting on the last 12 months, I would never have guessed that my first year as a junior doctor would be so gratifying, terrifying, surprising, boring, funny, sad, exciting, puzzling, stressful, enriching… This year has HAD. IT. ALL. The 2.5 days of shadowing during induction left me feeling somewhat unprepared on my first day. Thankfully, I had a wonderfully supportive team and friendly colleagues to guide me as I bumbled through my first few weeks on the ward.
F1 has inundated me with new experiences and the learning curve has been steep. I reviewed a patient with “abdo pain” only to diagnose them with a pulmonary embolism after convincing the on-call radiologist that a CTPA was absolutely necessary. After all, “I don’t take referrals from F1s for CTPAs”. I advocated for patients. I held their hands. I relieved an elderly gentleman of his painful paraphimosis preventing a urological emergency in a hospital which has no out of hours urology service. I told frightened family members their loved one might not make it through the night. I spent a whole morning liaising with radiology, gastroenterology, dietitians and a worried wife to organise a PEG (percutaneous endoscopic gastrotomy) extension for my patient, only for it not to go ahead. I was shouted at by frustrated patients and anxious relatives. I’ve clapped and cheered as Covid patients were safely discharged home. I watched as others didn’t make it. I cannulated. I catheterised. I laughed. I cried.
Some of you may already have some stories to tell as coronavirus forced you out of medical school and onto the wards as doctors earlier than expected. Others may have volunteered for the NHS or worked as HCAs. Or maybe you focused on enjoying your “final months of freedom”. Whatever your circumstances and prior experience, starting F1 can be daunting. It would be impossible for me to try to teach you everything you need to know about being a doctor and *surviving* F1 so I will simply highlight a few points to remember.
You are not alone
Sometimes you may hear horror stories about F1s left on their own to manage a ward of 30 patients on their first day or dealing with a deteriorating patient with no senior support. Remember these are just horror stories! The overwhelming majority of foundation trainees do not share these experiences. In reality, you are never alone as an F1. There should always be an SHO, registrar or consultant responsible on your ward who you can call on (even if they are busy in clinic, surgery or seeing a referral elsewhere). You are not expected to know everything - especially in the first few weeks - so please ask even if it’s just for reassurance!
Recognise what is your job and what isn’t. Sometimes you may have jobs and paperwork pushed your way that isn’t really your responsibility. There are ward clerks who book appointments and arrange transport, discharge co-ordinators who liaise with social workers about social care, nursing staff who change dressings and administer medications. Whilst it is not unreasonable to help your colleagues when you have the capacity, it is generally quicker, safer and better for your patients when the correct person completes the job they have been trained to do!
What can I do for you?
Learn how to delegate when necessary. If you are on call covering the wards and you are asked to review a sick patient, always ask the nurses to obtain any useful investigations (e.g. ECG, blood sugar, neuro obs) and check if they can take bloods, cannulate or run blood gases. They won’t necessarily volunteer to do these things if you don’t ask. They can help you get a head start in managing the patient before you have even stepped onto the ward.
HELP! It’s an emergency!
MET (medical emergency team) calls and cardiac arrests
Many new doctors’ ask, “When is it appropriate for me to put out a MET call?”
If you’re worried about airway compromise, put out a MET call.
If you need more hands, put out a MET call.
If you’re thinking about putting out a MET call, then it’s time to put out a MET call.
If a patient arrests then it’s a no brainer, put out a MET/cardiac arrest call (it’s normally the same team).
You will never be asked, “Why did you put out a call?” but you may be asked, “Why didn’t you put out a call earlier?”. If you ever do need to put out a MET call, remember to pull the emergency buzzer by the bed if you haven’t already and ask someone to put the call out for you. Never leave an unwell patient alone!
Your hospital may also have a critical care outreach team (CCOT) comprised of skilled nurses with ITU and resuscitation experience. If your patient is unwell but the team on the ward is able to manage them without involving the medical emergency team, they are a very useful point of contact. They can assist you with your initial assessment and management and are very handy with cannulas and blood gases!
Love to learn
It may seem obvious that the aim of foundation training is to equip you with the necessary tools and “foundation” to become a good doctor. However, the NHS is a public service and system that relies on its staff to “get the job done”. It is easy to succumb to service provision (doing cannulas, writing discharge summaries etc.) and forget that you are also there to learn. You may no longer be a medical student but you are still training. Keep asking questions even if you don’t need to know the answer to do your job. Don’t be afraid to ask for teaching from your seniors or to learn new skills or procedures. You don’t need to be able to drain ascites or perform a lumbar puncture as an F1 but learning these skills makes the experience much more interesting! It can be difficult to learn or practise certain skills when SHOs and registrars are hunting for procedures they need to get signed off, but that shouldn’t completely obstruct your own learning.
Your network is your net worth
Take the time to know your nurses, HCAs, ward clerks, consultants, pharmacists, physios etc. Not only is it invaluable to have people you can rely on, but having a good working relationship with your colleagues means that if you need to make a questionable referral, ask for a sign off or request for TTAs to be authorised and dispensed after 5pm then you know who to call on. You will also have a more enjoyable work life if you have friends to laugh and commiserate with!
There are always numerous opportunities to get involved during foundation training including teaching, leadership, management and quality improvement. You could plan weekly bedside teaching with medical students, organise events for the mess, advocate for your fellow junior doctors in the JDF (junior doctor forum) or design an audit/QIP. Don’t underestimate the value of getting involved in the medical community: locally within your hospital or more widely in national meetings, events and conferences. Remember this is probably the first time in a few years where you won’t have to come home to books, study and revision so you can maximise what you achieve during the working day. Getting involved does not only increase your non-clinical skills and your sense of belonging in the workplace, it can also help you in your career as in my next point.
When I grow up, I want to be…
If you’re like me and you have no idea what career you want to pursue in medicine then you’re probably not thinking about applying for your next post or training programme after foundation training. Unfortunately, if you’re not keen to take time out of training then you have less time than you think to develop your portfolio and apply for that next step. I’ve been enjoying F1 so much, I’ve only just woken up to the fact that applications open in November! Fortunately, F1 is a fantastic year to build up your portfolio simply by “getting involved” as I described in my last tip. Keep a record of any teaching you deliver and ask for written feedback from students. Write up your quality improvement project (QIP) and submit an abstract to a conference or journal. Request a letter of recommendation from the mess or JDF detailing your contribution to the welfare of junior doctors in your Trust. All of these things and more contribute to any application you make for training programmes after F2. There is considerable overlap between what different specialities and programmes are looking for in your portfolio. It doesn’t matter if you don’t know what you want to do yet.
I’m sure many of you will have tried to choose jobs which cater to your interests or future career plans. However, if you don’t have that O&G job you really wanted or the ortho job of your dreams, then don’t worry. Tasters are a great opportunity to try out a specialty of interest or something completely new with which you are unfamiliar. You may be eligible to up to 5 taster days during F1. Completing taster days can show commitment to specialty. Even if you do not end up choosing that specialty as a career, it will serve as a talking point in interviews for why you decided on something else. I was fortunate to undertake several taster days in Paediatrics during F1 which were insightful. However, despite years of flirting with the idea of becoming a paediatrician, after my taster I realised that perhaps Paediatrics isn’t for me.
Healthy mind, healthy doctor
This job can be immensely rewarding but at times stressful and emotionally draining. Look out for each other at work and check in with your medic friends at other hospitals. Sometimes, you may be involved in particularly distressing MET calls or cardiac arrests or have difficult encounters with patients. It’s important to try and debrief with your colleagues or team afterwards to talk through what happened, how you felt and what could be done better in future. This doesn’t happen all the time and it isn’t always the culture especially amongst more senior doctors or consultants. Don’t be afraid to initiate this as it can be very cathartic and beneficial for your wellbeing and professional development. Sharing some of these challenging experiences with your housemates, friends and family (medical and non-medical) is important and you will need a network of people to turn to throughout your career.
Leave on time! You don’t always need to be a hero. There is a system in place that should enable you to hand over outstanding jobs to the next shift. Obviously, don’t abuse this by handing over work that could easily have been completed during the day. Always ask yourself, “If I don’t do this now, will it jeopardise my patient’s safety or unnecessarily delay their discharge?”. If the answer is no, it can wait until tomorrow. Remember, leaving just 15 minutes late every day for a month adds up to 5 hours of lost time!
If you do have to leave late or if you find you’re having to come into work early in order to carry out your normal duties then please exception report. Exception reporting is the system whereby you inform your employer that your actual work differs from your agreed work schedule i.e. you have worked beyond your rostered/contracted hours. The report is sent to your educational supervisor, clinical supervisor and guardian of safe working or director of medical education. You should try to exception report within 2 weeks of the incident or 1 week if you want to claim payment. For any additional hours you work (this can be as little as 15-30 minutes!) you are eligible to either time off in lieu or additional pay. The exception reporting system exists not only to ensure that you are properly remunerated for any excess hours you work, but to highlight any issues with your work schedule. For example, if enough doctors submit exception reports enough times regarding the same rota then it suggests that the work schedule is inappropriate and needs adjustment. This can translate to the work schedule being changed in the future to accommodate the 30 minutes at the beginning of every shift that you need to update the ward list or the extra hour needed every other week to complete your Horus portfolio.
There are lots of useful apps available to support you during F1. Below are some apps I regularly use:
Search for your trust and download their guide to access the most up to date trust guidelines on antibiotic prescribing. Find the correct antibiotic, dose, route, frequency and duration based on the indication and alternatives in case of allergy. Please note that some trusts have additional guidelines available to view on Microguide for example;
• Barking, Havering and Redbridge University Hospitals Trust - “Pharmacy Clinical Guidance” with useful prescribing information on replacing electrolytes amongst other guidelines
• University of Southampton NHS Foundation Trust - “DiAppBetes” for diabetic emergencies and more
• Oxford University Hospitals NHS Foundation Trust – “Pain Guidelines” for pain management in different patient groups
Always remember to refer to your Trust or national guidelines first before looking at others!
Again, search for your hospital and save it to your favourites. You can find the extension and bleep numbers for every ward and department in the hospital. The data is crowdsourced from staff members so occasionally the information is out of date. However, it’s very easy to add new numbers, edit existing ones or flag when the data is incorrect.
Despite being vital for the PSA exam, the BNF is not necessarily the “know-it-all” resource for prescribing. Some drug monographs are very detailed and allow you to discern the correct dose of apixaban, for example, stratifying by indication, stroke risk factors and dose adjustments if there are bleeding risk factors. However, other monographs are quite vague. For example, if you want to know the exact dose of thiamine and vitamin B compound to give to a patient at risk of refeeding syndrome then expect to find a range of doses to choose from. You will find what you prescribe may come down to personal preference, trust guidelines or the classic method of “choosing the lowest dose” or “the one in the middle”. If you’re ever stuck, ask a senior or your helpful ward pharmacist!
Now that you’ve finished medical school you don’t necessarily need to calculate the Glasgow score for severe pancreatitis from memory. This app will do it for you! Just sign up for free access.
Other commonly used apps and websites
Dr Toolbox – available on the app store. Requires a Trust login.
PocketDr – available on the app store for £2.99. Requires a Trust login.
TOXBASE – requires a Trust login.
Medusa – requires a Trust login.
Whatever happens please don’t forget to…
FY1 is an incredible year. It is the first time in your career when you can call yourself a doctor and the only time you will have so little responsibility as one. You may just be starting now but before you know it your first year as a junior doctor will be over. Enjoy it whilst it lasts!
Join the Melanin Medics F1 Doctors Mess Online Group:
Virtual support network for African and Caribbean F1 doctors in the UK
Dr Stephanie Ezekwe MBBS BSc (Hons)
Academic Foundation Year 2 Doctor in North Central and East London