#tipsfornewmedregs, please

On Thursday, I said goodbye to the staff in my current medical receiving unit. I’ve worked with a lot of them for four years, on and off. I’m certain I’ll be back again, someday. I pop onto the ward at the beginning of next week for a couple of days, and then on Wednesday it’s all change.

New commute. New colleagues. New corridors to get lost in. New job.

The first Wednesday in August — as it was in the beginning, is now and shall be forever, world without end.

My final weekend before changeover will be spent doing an online induction module, building furniture, and taking deep breaths.

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This is what the inside of my brain looks like right now.

I’m pretty sure the new FY1s think they are the only ones who are nervous.

I am thirty-two years old and have a hip that aches if I sit cross-legged for too long, and yet every summer I still get ready for my first day at new school and worry if the other kids will like me.

So.

If anyone has any #tipsfornewmedregs, this would be the time.

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People Make Bad Choices If They’re Mad Or Scared Or Stressed

All over the UK, newly graduated medical students are starting to look ahead to the first Wednesday in August and their first day as Actual Proper Doctors.

If they are anything like I was, they’ll be having increasingly terrifying nightmares about holding the cardiac arrest bleep on their first night. And getting lost. And they’re the only one on the arrest team. And they can’t remember how to do CPR. And there’s a dragon in the corridor. No? Just me? OK.

A couple of years ago, I wrote a long piece that contained practical advice for new doctors. If you are a new doctor and you are looking for bullet points on where to get help, how to ePortfolio, the unsettling but central role that half-coloured in ticky boxes will come to play in your life, and other things, that piece is here and still contains the best advice I have to give. Over on Twitter, search the #tipsfornewdocs hashtag, and remember that we all remember this and that almost none of us bite.

Today, I want to talk about something a little bit different. I want to take a bit of time to think about resilience and self care.

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The idea of ‘resilience’ is a psychological one that has to do with the capacity of the collective and of the individual for what I’ll call ‘coping’. It was defined by Andrea Ovans in the Harvard Business Review as “the ability to recover from setbacks, adapt well to change, and keep going in the face of adversity”. In the last few years, it’s developed into a buzzword in the language used to talk about and to public sector workers. The first time I became aware of it as a thing that was being said to doctors was during the junior doctor contract negotiations in 2015.

Now, the first thing to say is that I’ve never met a junior doctor who didn’t possess resilience. It is a requirement of the job. It is a requirement of getting the job. So, the second thing to say is that when the government talks about junior doctors not having resilience, they are lying.

But if what they mean is that junior doctors have proven increasingly unwilling to be actual martyrs — well, yes, that might be true, and that might also not be a bad thing.

As a teenager, I wanted to be John Carter from ER. I wanted to live all the hours in the day for my job. There is a picture of a recruitment poster for Emergency Medicine going around at the moment that invites applicants to “choose surviving on coffee and adrenaline”. It is a terrible message to send, but half my life ago it was absolutely what I wanted for myself. And even as a slightly more elderly medical SHO, there are days when that kind of thinking still has its seductive qualities. On the seventh day in a row of thirteen hour days, I can enter a mental state that is some sort of meld of beautifully Zen and utterly psychotic. I know all my patients inside out and back to front, and half the patients of the other teams, too, and I am completely on it and, look, I just live here now and I’m pretty sure that’s actually fine. (I have a bad-coffee-and-sleep-deprivation-fuelled memory of this precise thought process going through my brain, about eighteen months ago, and also I think I was skipping down a corridor at the time.)

It is perfectly possible to live like this for short periods of time. I clearly do and so do lots of other people, not all of whom are doctors. It is not sustainable. A period of work like that has to be punctuated by a period of rest and rejuvenation, or else the whole thing falls apart. I love my job, but my capacity to do it for thirteen hours a day without a day off is not infinite. I believe that that is true of any human in any job, no matter how much they might love it.

It is partly because no one has an infinite mental or physical capacity. In this job, that part of it is a patient safety issue as much as it’s anything.

It is also partly because you do eventually go home from your job, and it is at that point that you remember there is no food in the fridge and that you have no clean pants.

And that’s the part we don’t hear about enough when we hear about resilience. We don’t hear about self care: about how to keep ourselves alive and fed and sane and happy. In fact, we too often hear the opposite of that: that to do the things we need to do to take care of ourselves is selfish or lazy or uncommitted or in some way not being a team player. That is a perception that I want to challenge.

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First, put on your own oxygen mask.

Maslow's Hierarchy of Needs

Maslow’s Hierarchy of Needs. (Wikimedia Commons)

There are lots of ways to look after yourself well, and I can only talk about what works for me and what hasn’t worked for me. This is the part that is non-negotiable. You need to eat. You need to drink. You need to sleep. You need to put on your own oxygen mask first. You need to remember to go to the toilet.

I am pretty sure that if anyone had said any of that to me in the week before I started FY1, I would have rolled my eyes too. I was worried I might accidentally kill someone, not that I might forget to pee. Trust me, you will forget to pee.

The need to eat and drink and sleep is about more than keeping yourself alive. It is about that, too, of course, but it’s also because everything seems so much worse when you haven’t.

This is a crap job, sometimes — for all sorts of reasons. A tip of the hat to @DrTonyGilbert on Twitter who aptly described this as “those nights where you’ve been punched and your shoes are full of ascites and you think, ‘I could’ve worked in a bank'”. The world will be much more manageable on the other side of a good meal and eight solid hours of sleep. I’m not saying those things will fix everything, but they will make most things look a lot less dire.

So:

  • FY1s cannot live on coffee and Mars bars alone.
  • Eat breakfast. You don’t know when you’ll next get a chance to eat.
  • But do eat lunch. There are really very few things that can’t wait until you’ve eaten a sandwich and had a drink.
  • If you can get off the ward for a break to eat lunch, do that. The days when you eat with a sandwich in one hand while writing a discharge letter with the other hand will come, but they should be the exception rather than the rule.
  • Drink. If your patients’ kidneys need fluid, so do yours. The correct response to, “Doctor, Mrs Jones has only passed 30 mls of urine in the last 3 hours,” should not be, “Well, that’s more than I have.” Get a reusable water bottle and use it.
  • Meal plan. If you can make food with leftovers, you can come home from an on call shift and have a home-cooked meal in the time it takes to transfer a plate from the fridge to the microwave. This is a wonderful thing. It also means that you’re less likely to collapse on your bed and fall asleep without eating.
  • The existence of supermarkets that will provide you with ready-prepared food and people who will bring delivery food to your house is evidence of the kingdom of heaven on Earth. It isn’t sensible to live off them, perhaps, but they have their uses.
  • Comfy shoes. Get some.
  • Take care of your physical health. Register with a GP. If you are a doctor with a chronic illness or a physical disability, take the time you need to take care of that. A friend of mine, Dr Beth (no, we are not the same person), wrote a blog post recently about this which was aimed particularly at doctors who have diabetes but which I think is worth reading for everyone.

Learn how to say no.

Take your days off. Take your annual leave. If your work emails are connected to your phone, learn how to unsync them.

There will always be situations where someone needs a shift to be covered on short notice. People get sick. People have family emergencies. Rota coordinators fail to take into account the fact that the staff grade’s contract was only for six months and ended last week. You will end up being the person who covers these shifts some of the time. You do not have to be the person who covers these shifts all of the time.

At some point, you will be asked to participate in rota monitoring, where you fill in a form for a couple of weeks with your rota hours compared with your actual hours. Your Trust is supposed to use this to ensure that your rota is legal, that your department is staffed appropriately, and that you are being paid correctly. If you are asked to work differently to your usual practice or you are asked to lie about your hours, say no to this too. (However, do not expect the person from the rota monitoring department to understand your job. I gave up fighting that battle on the day one of them tried to insist that I should be leaving the cardiac arrest bleep behind when I went to eat lunch.)

Likewise, there will always be work that needs to be done outside of normal work time. This will sometimes be valuable, and sometimes not. Like the online induction module that even as I type I am side-eyeing in my learnPro account, which will take time that I could instead have spent learning something about cardiology before I commence my six month cardiology rotation. The point is, there are exams, and ePortfolio, and quality improvement projects, and things to read and learn. This isn’t entirely a bad thing. It is part of what being a professional is. But develop some sort of system to deal with it so that it doesn’t end up taking over your whole life, because it absolutely will if you allow it to.

Don’t forget to look after your mental health, too.

There are lots and lots of doctors who have mental illness. It is not a shameful thing. It is not an unusual thing. Don’t ever let anyone tell you otherwise. You will not be the only doctor who takes medication to maintain your mental health, or sees a counsellor or a psychiatrist or goes to therapy. Do what you need to do to keep well, just the way you do for your physical health.

If the above does not apply to you, don’t presume it never could and don’t ever be ashamed to ask for help.

My sanity has been saved — so many times and in so many ways — by having brilliant friends.

If you are struggling, please talk to someone.

If you think you aren’t struggling, please talk to someone anyway.

Your most readily available resource is your colleagues. You may not have met your fellow new FY1s, yet, but you will become each others’ most reliable support. (The thing about getting off the ward for lunch if you can? It’s even better if you can get lunch together.) There is no one who understands this weird job like the people who are going through it with you. Use your seniors. Your educational supervisor is there to support you, not just to tick boxes on your ePortfolio. If they aren’t supportive or you think they’d be difficult to talk to, there are other consultants. If that seems too intimidating, your regs and SHOs did this not too long ago and I promise most of us are nice. The administrative staff, too. In my FY1 year, it was known that our postgraduate administrator’s office door was always open for a cup of tea and a biscuit and a bit of a cry and I think we all took her up on that at least once.

You won’t be the first person to have cried in a sluice; that’s what sluices are there for. If you cry in the sluice every day, that’s not okay and please talk to someone.

It is okay to not be okay, but people won’t know you need help unless you tell them.

Do the things that make you happy.

I suppose there is a professional bit to this, about finding your niche and finding your people and not worrying when you don’t like every single rotation you do as an FY1 or even FY2. I’m pretty sure that I grew up thinking it was all “being a doctor” and I know that I have friends and family who pretty much still think it’s all “being a doctor”, but one of the brilliant things about medicine is that it’s all so very different. I think that’s all true, and you’ll do that.

But what I really wanted to say was, remember that you’re still a person as well as a doctor.

I can’t tell you what it is that makes you happy.

The things that make me happy include but are not limited to:

  • Real books
  • Sunday dinner with people I love
  • Running around the parks of Glasgow or along the Clyde with music or a podcast and the sound of my feet on the tarmac
  • The work I do in “my” cathedral
  • Taking the extra five minutes in the morning to make real coffee
  • Cats who like to give me Eskimo kisses
  • A knotty bit of Beethoven and the adrenaline rush from singing it on stage
  • Netflix and Yarn

Your list will not look like that. You will have your own list. But remember to find the time and space to do the things that make you happy.

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Listen, I am not good at all of this and some weeks I am not good at any of it.

You are about to do a thing that is real and hard and that you can never be properly prepared for, not really. For the first few months, you will be more tired than you have ever been in your life. You are going to do a job that is brilliant and terrible, and that will give you unsurpassable highs and will also completely break your heart. You owe it to yourself to look after yourself while you are doing it.

And for when absolutely everything else fails, I always keep emergency ice cream in the freezer. It’s a start.

Dear Baby Doctors

Dear Nearly New FY1s,

I remember my shadowing as a blur of paperwork and an urgent sense that I needed to assimilate all the knowledge in the week I had before someone handed me a pager and left me with actual responsibility for actual patients. I kept thinking that eventually I’d be escorted from the building when someone realised that I’d graduated medical school by mistake. I felt a little bit as if Sputnik had landed on my head.

You can’t have missed what’s been going on in the the last fortnight: take that seriously, by all means, we’re being disrespected and disenfranchised and lied about, and, yes, be furious and be engaged and get involved, but don’t let that ruin this for you and don’t think for a minute that it means we love our jobs any less. The political bullshit: yes. The job, the being doctors, the looking after people: no. The thing about the #ImInWorkJeremy pictures wasn’t just that we were in work, it was that we mostly looked pretty happy to be there.

I love this job. Yes, it is hard and exhausting, and you’ll have days when you want to scream and days when you come home and sit in the dark and cry at the cats. I love it anyway. It has terrible days, but it also has days when I catch myself thinking, I can’t believe I get to do this for a job. I think it’s the best job in the world. I hope you will too.

There is a lot of advice that I could give, and I’ve tried to do that below. I’ve stolen a few of my #tipsfornewdocs from my Twitter colleagues and I’ve tried to credit them appropriately.

But there are only three things really: care for and about your patients, remember ABCDE, and don’t be scared to ask for help.

Love,

Beth

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On Days

– Be early.

– Comfy shoes. Get some.

– At the beginning of the day, ask the nursing staff the following questions: is there anyone sick, is there anyone new, is there anyone going home?

– I thought until recently that this was self-evident, but you need to go on the ward round.

– Whatever you need, it is in the secret drawer at the nurses’ station: pens, markers, death certificates, chocolates. Ask. (@STIrwin)

– Cultivate relationships with the nurses, the pharmacists, the person carrying the on call microbiology bleep, and the radiologists.

– You will develop compulsive tendencies regarding lists and systems of half coloured in boxes. This is normal.

– Eat something.

– Drink something. Don’t succumb to on-call AKI.

– There are no routine investigations. If you don’t have a reason for doing it, don’t do it.

– For blood transfusions and contrast scans, you shouldn’t be using anything smaller than a pink venflon.

– Ask where the phlebotomist leaves the blood forms for the samples that they couldn’t do. There’s really nothing quite like getting to three o’clock, chasing all the bloods, and realising that half of them haven’t even been taken yet…

– If a patient has died or if a patient has a complicated discharge, phone their GP.

– Never ask a GP to chase an outstanding result. If a test has been done in secondary care, it is the responsibility of secondary care to follow it up.

– The bloods need chased and acted upon. It is important that you record a low potassium, but it is also important that you do something to replace it. It is important that you draw a circle around a rising CRP, but it is more important that you try to find out why and do something about it. If you get a weird result and don’t know what to do about it, ask.

– Do a fluid / insulin / warfarin / gentamicin / vancomycin round before you go home.

– Don’t take the on call bleep home. (@DrLatifaPatel)

– There are some things that it is bad manners to hand over to the on call team. PRs, for example.

On Nights

– A routine for the day before going onto a run of night shifts is essential, and you have to figure out what works for you which will not be the same thing as what works for someone else. This advice from the Royal College of Physicians is a good place to start.

– Try thinking of your nights as something to be embraced rather than something to be endured. As an FY1, this is where you’ll get to practice some actual medicine.

– Eat something.

– On ward cover nights, try doing the following in this order: 1) if you are concerned about anyone you’ve been handed over, let your SHO know that you’re going to review someone sick and might be calling for help or advice sooner rather than later, 2) go and review them, 3) take a tour of the wards that you’re responsible for, to ask the nurses if they’ve got any routine jobs that need doing and to ask them to keep a list of routine jobs for when you come back round later in the night, and 4) actually go back round later in the night.

– At 5am on a busy night shift what you need is a piece of white toast with a lot of proper butter and a strong cup of tea. (@traumagasdoc)

– Give me the grace to accept with serenity the things which cannot be fixed overnight, the courage and skills to fix the things which should, and the wisdom to distinguish one from another. (@drewseybaby)

– If you are asking switchboard to put you through to the haematology lab or the biochemistry lab at 3am, take the extra ten seconds to make sure they know you really do mean the lab and not the consultant. I mean, they’ll still get it wrong sometimes but at least you tried.

– If you are covering an area that doesn’t have a formal handover in the morning, do make sure to either ring round or visit wards where there were overnight issues.

– Your bed is the best place in the universe. Seriously. You will never look at it in the same way again.

On Your Fellow FY1s

– Be kind to each other.

– If you’re ever tempted to burn bridges, remember that medicine is a really small world and you’re probably going to be referring patients to each other for the next thirty years.

On Receiving

– Do some.

– Don’t listen too much to the horror stories. It is one of my favourite things in the world and if you approach it with a little bit of enthusiasm you’ll learn more here than anywhere else in FY1.

– In surgical receiving, don’t forget to do a coag and a group and save.

– Try to corner someone who has done receiving before and interrogate them about how the post-take works. If you’re starting on receiving and haven’t spent your shadowing week there, this might mean cornering the outgoing FY1 or SHO who has just come off night shift. They will almost certainly not mind. It is a system unique to each individual department, and consultants who have worked in their department for twenty years often have a tendency to think that that system is something we pass on to each other through divine inspiration. I worked in a surgical department once where they were very particular about how and in what colour things were written on a paper handover and two different whiteboards.

On Bad Days

– People make bad choices when they’re mad or scared or stressed. Breathe.

– There is no shame in tears.

– If you make a mistake, admit to it.

– Your first failed arrest call will be awful. Your second one will be awful, too. Eventually, you won’t always (but you will sometimes) need to cry in the sluice afterwards but it will never not be awful. That’s okay. There are some things we aren’t meant to get used to.

– The first time you have to confirm death, take someone in with you.

– Some days you have to come home, eat a banana, and go to bed at 7.30. Tomorrow is another day. (@medicalaxioms)

On Learning

– Eat when you can, sleep when you can, read when you can, learn something new every day. (@TraumaAnnie)

– Reflection is valuable. Reflection all in a rush at the end of May because you haven’t done any yet for ePortfolio is not.

– There is no getting away from exams, but nor is there any obligation to take them at the very first available opportunity. The fact that everyone else is sitting an exam not an actual reason to sit an exam.

On Getting Help

– No one expects an FY1 in August to be functioning at the same level as an FY1 in July.

– If you aren’t sure, ask. (@PenfoldDr)

– If your patient is sick and you’re out of your depth and your immediate senior can’t or won’t come, your next step is to go to their senior.

– If your patient is sick sick sick and you’re assessing them, I absolutely do not expect you to wait for all their investigation results to come back before you come to get me.

– SHOs don’t bite.

– The med reg is your best friend.

On Patients

– #hellomynameis

– Your patients are people. Don’t ever refer to them as diagnoses or bed numbers.

– Always remember that a patient, usually unwell, is at the centre of all that you do. (@DrMarkMcInerny)

– For your patients, a hospital is almost never going to be something as benign as the place where they go to work. It isn’t a big deal for you to go into hospital in the morning. It is a huge deal and usually a really scary thing for them, and that shouldn’t be minimised.

– A patient with a chronic condition will usually know more about their disease than you will.

– The importance of ideas, concerns, and expectations isn’t just a medical school thing. It’s a real thing.

– Don’t make assumptions.

– Listen.

– Care.