The Care and Feeding of Your On-Call Junior Doctor

1. Thou shalt have a basic grasp of mathematics.

You are looking after between seven and twenty patients. Your FY1 is looking after a minimum of 96 patients. She is entirely within her rights to growl when you try to tell her that you are “very busy”.

2. Thou shalt learn how to read a EWS chart.

The score for BP is for systolic BP, not diastolic BP — a diastolic BP of 8o does not trigger an urgent clinical review, no matter how many times you try to tell me that it does. The nausea score is not part of the EWS — you cannot decide that a patient whose obs are all normal is scoring EWS 3 because they were sick three times. And if a patient has had their parameters adjusted, you need to observe the new parameters —  your FY1 is unlikely to be impressed with your long-standing COPD patient’s SpO2 of 91%.

3. Thou shalt put non-urgent jobs on the non-urgent jobs list.

You do not need to page your FY1 to rewrite a Kardex.

4. Thou shalt not put urgent clinical reviews on the non-urgent jobs list.

A review of a patient with a new tachycardia does not belong on the non-urgent jobs list. A review of a patient who has dropped her systolic BP by 40 in the last hour does not belong on the non-urgent jobs list. A review of an unconscious patient with a blown pupil does not belong on the non-urgent jobs list.

5. Thou shalt not harrass.

It is a waste of your time and your FY1’s time when you page her “just to check whether you’re coming back to the ward” or “just because we haven’t seen you yet today”. She has not forgotten that she is covering your ward and she has not gone for coffee. If you have not seen your FY1 for a while, it is because the brown stuff is hitting the fan somewhere else. The only way your FY1 knows that you are paging her with a stupid question rather than a properly sick person is if she stops what she is doing and calls you back, and if you are the third person to pull your FY1 away from a properly sick person just to tell her that it’s been a few hours since she looked at her non-urgent jobs list, she will be rude to you and she will not apologise later.

6. Thou shalt learn how to use a telephone.

Do not page your FY1 and then walk away from the phone. Do not page your FY1 and then pick up the phone to make another phone call. Do not page your FY1 to the paging system.

7. Thou shalt not expect on a Saturday that which can (and should) wait until Monday.

You may be right in thinking that your patient’s high blood sugars, which have been high for a fortnight and which they are asymptomatic of, are steroid induced, but your on-call FY1 is not going to make a unilateral decision at the weekend to stop steroids that they were started on by a neurosurgeon for their brain tumour.

8. Thou shalt use SBAR.

The on-call FY1 has never met your patients before. If you ask your FY1 to review a patient, she will expect you to know why you want them to be reviewed, what their current obs were, what their obs were before that, and whether a plan has been made by their day team. If you ask your FY1 to review a patient urgently, she will expect you not to have gone on your break in the three minutes it takes her to walk up the stairs.

9. Thou shalt read.

If you ask your FY1 to prescribe analgesia/anti-emetics/fluids for your patient who is, quote, not written up for any, your FY1 will assume that you have actually checked and will be unamused when she comes to the other end of the hospital and opens up the Kardex to discover that you had not checked and that those things had been there all along.

9. Thou shalt realise that it is in your best interests that your FY1 does not keel over in the middle of the ward.

If your FY1 says at 6pm that she is leaving the ward to buy lunch and will be back in five minutes, do not block her path and ask her to “just…” unless your patient is actively trying to die. It is at this point more important for her to treat her own hypoglycaemia and acute renal failure than it is for her to treat your patient’s nicotine withdrawal.

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12 comments

  1. Ha! Great list! It’s the same everywhere. I would add:

    – Thou shalt not page to say “the family is here and wants to see you”

    – Thou shalt not ask what the long-terms goals are for the patient (and more importantly, that the whole extended family is here to discuss long-term goals)

  2. Ah, how pleased I am that I never again have to do a ward cover on call (well, apart from ITU ward cover but that’s a bit different).

    What used to really wind me up was when they’d start a call with “you know the patient in H5?” etc. They seem to forget that you haven’t actually had time to memorise the location and details of every single patient on the 10 wards that you are covering.

  3. Another – Thou shalt never, ever use the phrase “he’s just not himself doctor”. Either he’s sick, in which case tell me he’s sick, or he’s not, in which case don’t tell me about him. If the patient in question has ruptured his AAA (not even kidding, that was the phone call I got), tell me about his SBP of 60, not that he ‘doesn’t look quite right’.

    1. Oh, and while I’m on this rant – Thou shalt not assume that your FY1 is incompetent because he or she is not doing what you want him to do. She knows how to do it. She just doesn’t think it’s a good idea. You are well within your rights to ask for another opinion, but please do not patronise her and/or print instructions for the intranet. (“Please start this non palliative patient with hiccups whom I have not given any of his PRN meds o0n a haloperidol syringe driver.” “No.”)

  4. Pretty much sums up my frustrations of the life of an F1 so far. I wish i could print this off and put it on all the wards

  5. Pedantic point but …a diastolic BP is actually very important. How do you think upper GI bleeds die of MIs? You could argue it’s more important than systolic.

    1. I agree, but the numbers on an Early Warning Score relate only to the systolic BP. In the one used in my current Trust, anything less than 110 scores a 1. I would hope that most folk would have a diastolic of less than 110!

  6. Having been on both sides of this, I can see your frustrations and I hope this post is just purely to vent them. However, when I worked as a support worker before med school I genuinely had no idea what the significance of some obs etc. meant and a harsh retort from an FY1 when I was genuinely worried rather than a short, kind explanation (that may have stopped me doing it again) would make me feel awful for the rest of my night shift. That impacts on patient care.

    A lot of nurses don’t have the same medical knowledge obviously and use pattern recognition (they’ve seen a patient like this get sick before). It may seem silly to you, but it’s a safety net when you are too busy to notice and I bet it’s probably alerted you to sick people in the past! Yeah, some of the things that you’ve written about are annoying, but how would you feel if your reg wrote a list like this about you and all the stupid things you’ve doubtless asked them? I know you do get particularly tetchy nurses but it’s no wonder if they have FY1s who are nasty and don’t apologise for it! What do you think made them start acting like that in the first place?

    If you have a genuine problem with certain nurses, you have a duty to try and get the point across in a non-confrontional way or get a senior to try and help you resolve the issue. You are working as a team and this article sounds terribly hierarchical.

    1. This was written on the last night of a receiving weekend during which every single one of these things had happened, in addition to a larger than usual number of patients who were actually sick. I generally get on very well with most nurses and I had spent my whole weekend trying to resolve these issues in a non-confrontational manner – I think I snapped at one person in three days, and I said later that I was sorry. The fact that I had a rant – justified, I think, even a year after I wrote it – once I left doesn’t mean that I wasn’t a professional or a team player while it was happening.

      I would be very surprised if a reg hadn’t written a list like this about FY1s. Hell, I’d be surprised if a nurse hadn’t written a list like this about FY1s!

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