toddler doctor

Take AIM

Just before Christmas, I spent a weekend down in Bristol at Take AIM, a conference aimed at junior trainees who have an interest in acute medicine.

The second year of core medical training is notable for a sharp uptick in the number of times per week a person is asked if they’ve had any thoughts as to the specialty training they might consider. I tell them that I’m applying to ST3 in Acute Medicine, and they’re startled — either by my questionable life choices or my level of decisiveness, I’m never quite sure.

“Oh, and — really?” asked my most recent clinical supervisor. “Do you think I could get you to change your mind?”

I should be clear, my choice of medical speciality is hardly the first time I’ve had a questioning eyebrow raised at my life choices. My life choices have, after all, led to me sitting on the M74 on my day off looking for exit signs to Lesmahagow with my only provisions being a boot full of wedding paraphernalia, and being in the back of a Jeep reversing backwards around the corner of the shelf of the Ngorogoro Crater while the part of my brain not occupied with screaming asked if this was really how it was all going to end, and nearly getting arrested in the middle of Tianenmen Square. And those things all turned out brilliantly. So.

The raised eyebrows can be flattering, in their way, if their purpose is to persuade me out of my specialty and into theirs, which is sometimes.

But — unspeakably frustrating in another way.

At this point in CT2, some people haven’t made up their minds, which is fine: that’s why staff grade posts and taking time off from training are good things to do. I have, though. I had my time off from training, remember, and I needed an Archimedean epiphany fuelled by sleep deprivation and adrenaline, but I’m done. I’m sure. I’m not a foundation trainee who ought to be prudently murmuring about keeping her options open. I’m in, and with my eyes wide open. If my mind wasn’t changed by perpetual backshifts in a hospital that was literally closing down around me and where we occasionally had to see patients in the cupboard for lack of bed space, it is unlikely to be changed by the prospect of thirty years as an oncologist.

I know when I was ten that I thought that a doctor was a doctor and it was all basically the same thing, but it’s not like that’s actually true.

Yes, isn’t it nice that we don’t have to all be the same thing?, I want sometimes to say.

I’ll be honest, mind: I understand in my brain why my particular thing isn’t for everyone. In my heart, I don’t really understand why anyone would ever do anything else.

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Heart and Brain: TheAwkwardYeti.com

The frustration of being a core medical trainee is that it feels — and is — a terribly peripatetic existence. I don’t yet have my tribe, or whatever the collective noun for my specialty colleagues would be. An insanity of acute physicians, perhaps. I still don’t have that, five years in. My experience is that nor do most CMTs. You sort of have to go looking for it, and therefore my weekend in Bristol was precisely what I needed.

Take AIM was the initiative of registrars training in acute medicine and has the stated intent of promoting what is a still relatively new and rapidly expanding speciality to juniors. It gets funding from Health Education England and support from the Society of Acute Medicine, and it has consultant input, but it’s still principally led and run by senior trainees — which, as someone who isn’t yet but hopes soon to be in specialty training, is a helpful thing for me, to hear from people who are in a position to tell me what the next five years of my life are likely to look like and who are willing to do it in a warts and all kind of a way. My first real contact with them was in October 2015, when I joined in an hour-long discussion on a Sunday evening on Twitter and came away from it feeling that thing you feel when you have found your people and they get you.

Bristol was like that, too, but better.

It had a bit of careers advice in it, and a bit of debunking of the more commonly held myths of acute medicine. Personally, I’m considering getting the sentence No, I’m Not Just Going To Be The Med Reg Forever tattooed across my forehead. It was also very well populated with very lovely trainees who were keen to chat about training and careers between the main sessions.

A lot of the day was education on acute medical topics. The philosophy went something like: “We are going to expect you to engage in acute neurology teaching first thing on a Saturday morning, but we are going to make sure that you are very well caffeinated for it.” That’s basically what I mean when I call them my people.

I would not dare to speak for everyone on this, as training experiences vary across the UK and everyone’s experience of their own training is different anyway, but the topics covered are ones that in my experience are covered badly, not enough, or not at all. To take an example from one of the earlier national conferences, in 2015, a session on “The Pregnant Patient on AMU”. It is not a thing that I’ve ever been taught and yet is a patient demographic that I happen upon all the time. It is incredibly exciting to me to spend a day being taught useful things by people who understand what happens at the front door of the hospital and want to help make it happen better, and that was what that day felt like. The presentations from the Bristol conference are all available online for those of an acute medical inclination, and a Storify, which includes video of a hundred people doing the dermatome dance, still first thing on a Saturday morning, has been put together of the day as told via social media.

It didn’t convince me that I want to be an acute physician; I knew that already. I think it reinforced for me that I’ve made the right decision.

I apply for a job in a month. For those of you who have been on this particualr merry-go-round with me for the last five years: Yes. Again. It’s a bit scary, this time. I remember when I was an FY1 that I definitely thought the registrars were the Proper Grown Ups. If you need me, I’ll be taking deep breaths with my head between my knees.

Have We All Survived Changeover?

*clears throat*

Doctors.

How are you all doing?

It’s just about a month now since changeover. I hope that’s time enough for you to have figured out where the toilets are, and how to get hold of psych on call in the middle of the night, and which of your seventeen computer passwords is the correct one to make a CT scan happen. It’s not quite enough time yet to have unlearned the learned response for the way to do things in your old hospital, though; your hospital, where you knew everyone’s name and you knew the protocol for prescribing vancomycin without asking a pharmacist, two nurses, and an FY1. It’s not quite enough time for your new hospital to feel quite like your hospital yet, or for you to not still feel just a little bit at sea.

FY1s, have you stopped needing to suppress giggles yet when you tell people that you’re a doctor? Are your seniors being reasonable and helpful? Are you getting to teaching? Are you remembering to eat and drink? Are you okay? If you are not okay, have you found someone to talk to about that?

I am sort of aware, FY1s, that it would be comforting if I let you believe that the confusion and weirdness of August changeover is inversely proportional to seniority and that it gets less weird and confusing after you’ve done it a couple of times, but, for many many reasons, that would be a lie.

In August, there are new medical registrars who have never had to be the med reg before. FY2s have just completed their first month of being the SHO, and that’s a big step up. All over the NHS, junior doctors have started new training programmes and been given new responsibilities and some are doing it in new Trusts or Deaneries that are entirely foreign to them and where their support networks are not. August is scary as hell. This is why we all walk around the whole month looking like Sputnik just landed on our heads. And for the record, I’ve been working in my Trust for four years and I’ve been working mostly at an SHO-equivalent level for those same four years, and August is still scary as hell. I’m a quarter of the way through this rotation, and I still have not learned everyone’s names or the intricacies of my very specialty-specific and very new-to-me computer system or how a kidney, you know, works.

FY1s, let your comfort if you need it be that every year from now until the end of time we are all in this particular period of weirdness together.

So, therefore, how are the rest of you doing? Are your seniors being reasonable and supportive? Have you found your educational supervisor yet? Have you worked out who exactly it is that you’re on call for? Are you even as we speak lost in the rabbit warren of interventional radiology in a hospital whose layout you still do not quite understand and need one of us to come let you out? (Is that one just me?) Do you need a hug?

Welcome. Pull up a patch of floor. We’ve got cookies and coffee and mutual terror and spare copies of Cheese and Onion.

A Requiem for PACES, and Alleluia

In my third year of medical school, I volunteered to help with the running of the PACES exam at one of the big Glasgow teaching hospitals. It was an opportunity to spend all day dinging a bell, to eat an heroic quantity of Quality Street, and to, between circuits, be shown some clinical findings more complex than those we were usually given in our medical school OSCEs.

In June, I sat PACES.

You may recall that the last time I wrote, I had put myself into some kind of fugue state refreshing the results website.

I passed.

And, you know, saying that, it still doesn’t feel quite real, even two weeks later.

I passed.

And — well, let me explain this, a little bit.

In the UK, one of the criterion for progressing in a medical career is to complete the necessary postgraduate qualifications to become a member of the relevant specialist “College”. There is a Royal College of Surgeons, and a Royal College of Emergency Medicine, and a Royal College of General Practitioners, and so on. The membership qualifications for the Royal College of Physicians come in three parts, of which PACES is the final part. In all, they have taken three years, untold hours, and a significant amount of actual money spent on exam fees, revision materials, and all the caffeine in Glasgow. I also have less hair than when I started.

The first two parts are multiple choice. The first part is six hours long (with a break in the middle), and I have previously described it as being not unlike spending six hours having one’s brains kicked in by a rugby team. I took it four times. The last time was in the Newcastle United football stadium, one of the stranger places I’ve ever been in the name of my medical education. The second part is nine hours long, and I sat that only once but in a room that contained no air during the hottest two days there have ever been in the west of Scotland. After 27 hours worth of multiple choice exam, I had lost the will to live but had grown very comfortable with colouring in boxes in 2B pencil.

The third part is not like that.

I think the thing that will perhaps best describe PACES is for me to say that even while in the middle of actually taking it, I was aware that I was muttering frantic karmic apologies to every single doctor at whom I had dinged that bell back when I was a third year medical student.

“You will be fine,” my consultants had been saying to me in the week leading up to it. “You’re a good doctor.” This was kind of them, but I kept reminding them that being competent at my job and appearing competent in this exam were two very different kinds of competent.

You wake up too early in the morning. You try to eat breakfast. You travel to a hospital that is not your own, and may not be exactly in the back of beyond but certainly feels like it. I went off to the conference suite of a hotel that is attached to the national specialist cardiology centre — a place that I have spent a lot of time on the phone to, but, despite nine years of living in Scotland, had never seen for myself. “This is Dalmuir, where this train will terminate,” said the Scotrail tannoy, which felt ominous. You sit in a room where time stops, making nervous small talk with the other four people who are taking the exam with you, filling in your name and candidate number on sixteen separate pieces of paper and flicking frantically through Cases for PACES as you try to remember the indications for liver transplant.

The next two hours pass at warp speed.

The basic structure is the same for everyone: assessments of communication skills and ethics, examinations in the four major body systems, and a final station two-case grab-bag of can-be-absolutely-anything. The patients are sometimes actors, but are mostly real patients who have been recruited in for the day. In my version of the exam, I was asked to take a history from a woman who I promptly blanked on half of her presenting complaint, I was asked to counsel a young man who was angry with my boss, I struggled to find anything at all wrong with the patient whose abdomen I was examining, and trying to listen for heart sounds I briefly wondered if my stethoscope had turned itself off. In the middle of telling me about his syncope, one patient, who had also mentioned that he was on a blood-thinning medication, said that he had hit his head on the ground when he had fainted. “I haven’t really,” he said when I started trying to look for a head injury. “I’m allowed to tell you that I haven’t really.” The whole time, there were two examiners, watching, scribbling things on those pieces of paper that I had painstakingly filled in back in the room-where-time-stopped.

As each of my examinations was completed, I turned to them, tried for a winning smile, and began, “Mr Jones is a fifty seven year old gentleman. He is comfortable at rest…”

In this exam, stage fright is a real thing.

A week earlier, in Edinburgh, I had sat down after making a speech to the great and the good of the Scottish Episcopal Church and said that if failing my exam was the price I had to pay for being there, it would have been worth it. (I could, after all, have sat it again in the autumn, which would have been a pain but hardly the end of the world.) Now, on the other side of it, it’s not that I’d necessarily recommend spending three days at General Synod as a revision strategy for PACES, but the experience does throw a person’s whole idea of what counts as an intimidating room into rather harsh perspective.

They go on to ask questions. I said things like, “I would want to get an abdominal ultrasound,” and, “I would expect the left hemidiaphragm to be raised on chest x-ray,” and, “Oh, hell, I’m sorry, I totally forgot to ask him about that,” and, at one point, “Well, on a SPECT scan you’d normally see, uh — ” and, screwing my nose up as I tried and failed to articulate it, drew a picture of what you’d normally see on a SPECT scan with my fingers in the air.

And then that bloody bell dings and you get the hell out of there while shouting through the door, “I’d do an ESR and a CRP, too!”

Forget having your brains kicked in by a rugby team.

“I think I’ve been smacked in the face with a baseball bat,” I said, collapsing in the car.

It wouldn’t have been the end of the world, of course, to take it again, but am I ever glad that I haven’t got to.

(Im)patiently Waiting

My job is all wait and hurry up.

It’s about waiting for the patients to roll in the door from ED and waiting for the urgent labs to come back and waiting the two minutes for the next rhythm check.

Once, waiting for the gas machine to finish an uninterruptible calibration cycle so that I could process the blood gas that I’d run across from a different building at 2am. The clock said it took about fifteen minutes. I still think it took about three hours.

And then it’s about the hurry up and the spaces between the waiting: the three patients needing sorted out all at once, the electrolytes with numbers that trigger a very particular on switch in the brain, the flurry of activity that happens at metronomic two minute intervals during a cardiac arrest.

The last two weeks, I’ve been suffering through a different kind of waiting.

It is two weeks ago today that I sat PACES, the clinical and final part of the exams for Membership of the Royal College of Physicians.

First, there was the waiting around before the exam. The waking up far too early and pacing the kitchen. The nervous twitching on the train out to the hospital in Dalmuir. They ask you to arrive an hour early, so obviously you arrive two hours early and have nothing to do but sit, looking at the walls, trying and largely failing to recall the causes of cerebellar syndrome and making desultory small talk with four strangers whose faces are all different shades of green.

And, then, finally, the hurry up: the two hours that ended before I’d properly registered that they’d started.

I beg of you, do not ask me how it went.

My colleagues mostly think that it will have been fine.

I mostly agree, but the reason I mostly agree is because I think I’ll be fine either way. I’ve taken this exam comparatively early, and I have plenty of time to take it again.

This incredibly sensible way of looking at things has not stopped my hairline slowly receding every day that passes with no result, or, for the last thirteen days — and, remembering how patient I was with the gas machine and its calibration cycle, you will be unsurprised to learn that this is a time period that I have come to perceive as my entire life — my main extracurricular activity being the act of hitting refresh on the MRCP website.

A person can go a bit mad. “I’m sure I sat it,” I said to a colleague today. “I don’t think it was a delusion.”

I am not good at this part.

Is That Even A Word?

You know, there are the days when I ask for specialist advice, and I nod and I ask at least vaguely intelligent follow ups and I write down all the investigations that they want me to arrange and I say thank you and I hang up the phone.

There are days when that comes with a side of nerding that’s based in never having seen That Really Cool Thing before in real life.

And then there are days when I ask for specialist advice and they know things that are so weird that I nod and I ask follow ups about spelling and I write down all the investigations that they want me to arrange and I say thank you and then the conversation is over.

And then I say, “Soooooo, just for my own education. WTF?”

Entirely Bonkers (But All The Best People Are)

It was quarter to eleven on a Sunday evening, a year or so ago. I had spent the weekend in one of the busiest of the old hospitals in Glasgow, and a half hour earlier had finally handed over the medical receiving bleep to my nightshift colleague. I talked to one of the nursing staff, checking on the management plan for a patient who hadn’t yet come over from the emergency department with their notes.

I’d come back to my department to document a few things that existed in my head but not yet on paper. I looked over a few blood results. My post-work plans were to attend with all due urgency to the food that was waiting a mile down the road for me and my FY1 before seeking horizontalness.

And standing at the nurses’ station at the end of the thirteenth hour of my Sunday, I blinked.

“I could do this forever,” I thought. And then: I can do this for a job!

And then: “I’ve gone mad.”

I was mentally and physically exhausted, bursting with joie de vivre and exultation at the sense of a job done to the best of one’s ability. I was flying high and obviously preparing to crash. It was clearly not the moment to make life-altering decisions about my career path, and so I fetched my coat and went off to my pizza and my bed.

But over the next few weeks that thought kept coming back to me and I kept poking at it, like a bruise that won’t go away.

The remit of acute medicine is (and here I’ll paraphrase from the JRCPTB website) that it concerns the first 72 hours of assessment, diagnosis, and management of adults who are admitted to hospital with a medical illness — the definition of “medical illness” being a very broad church but essentially meaning anything that couldn’t, in theory, be fixed with a scalpel. The idea of being a person who is trained in acute medicine with a view to that being the thing they have expertise in and then does it as their whole job is a very new one. Indeed, it wouldn’t have been possible when I started medical school in 2007. In the autumn of that year, I was given a tour of the recently opened acute medical unit in one of the local DGHs and the fact that that existed was considered hugely innovative. It didn’t become a specialty in its own right until the mid-2009.

I did an acute medical job in FY1, and loved it. I did an acute medical job in FY2, and loved it. In the year I took out of training last year, I spent 80% of my working hours in a really lovely job that I honestly enjoyed and for the rest of the time did locum shifts in my old receiving unit where I bounced around like the Energiser Bunny on steroids before ending up in my car at midnight marvelling that people were actually paying me to do something that I loved so much. All the career options that I’d mulled over and not been able to settle on during FY1 and FY2 had one thing in common: the part where I’d kept saying, out loud, even, that my priority was to be able to keep doing acute medicine. My favourite thing in the world (other than chocolate, maybe) is the part of my job where I start with a completely white piece of paper. And then from various sources there’s a whole muddle of information that doesn’t make sense, may not all be relevant, and more often than I’d like contradicts itself, and I get to try to organise it into a coherent narrative and work out what to do next and, on the very best days, actually fix it. And to a certain extent all of medicine is about that, but acute medicine is about that.

And a part of the reason that that was my priority was that I couldn’t choose an organ. My internal narrative went along the lines of: “I like the idea of endocrinology but haematology is still super interesting and the lungs and heart are kind of important and do things that I’d like to know more about but the liver is cool too and the kidneys work by magic which is amazing.” My personality is best described as Definitely An Adult Physician, But Eternally Indecisive About What Kind Because The Medical Specialties Are All Brilliant.

I like getting to start at the beginning. I like unpredictability. I like that even the things that are about pattern recognition aren’t the same, because people aren’t the same. I like listening to peoples’ stories. I like talking to patients and their families, and trying to demystify things for them. I like doing simple things that make big differences. I like doing practical things. I like being busy and useful. I like lists of problems and complicated things that I can start to unravel. I like teaching. I am fond of the occasional shot of adrenaline in my coffee.

Just before Christmas, I was involved in a Twitter conversation organised by the Society of Acute Medicine. A consultant who evidently has more poetry in his soul than the JRCPTB described the specialty as, “It feels like you’re standing in the hospital’s engine room every day.”

That’s it. That’s what I want.

As someone who is not yet in specialist training, the most frustrating thing about it is the number of people who look at you as if you’re having a psychotic break when you tell them that it’s what you want to do. I get why it isn’t for everyone, I do, but it’s for me, I think. In retrospect, the most surprising thing about my epiphany at the nurses’ station on that Sunday evening was only that it had taken me so long to have it. And if I am a little bit mad, I think that’s okay. As the Cat said to Alice, we’re all mad here.

All About The Glamour

If you ever find yourself thinking about going into medicine for the cars (with lights and sirens) and the booze (rx: diazepam and Pabrinex) and the women (competent women in scrubs are attractive in real life, too), remind yourself of this:

It will happen from time to time that you are eating lunch and doing paperwork, when one of the nursing staff will appear, and, via eyebrow semaphore and a series of deeply apologetic hand gestures and the fact that with the other hand they are carrying a distinctive shape covered in an array of paper towels, communicate something that, eventually, leads to you saying,

“Oh, God, do you want me to look at it?”

For All Doctors: New and Old, Starting and Starting Over and Starting Again

Go placidly amid the noise and haste, and remember what peace there may be in silence.
As far as possible without surrender be on good terms with all persons.
Speak your truth quietly and clearly; and listen to others, even the dull and ignorant; they too have their story.
Avoid loud and aggressive persons, they are vexations to the spirit.
If you compare yourself with others, you may become vain and bitter;
for always there will be greater and lesser persons than yourself.

Enjoy your achievements as well as your plans.
Keep interested in your career, however humble; it is a real possession in the changing fortunes of time.
Exercise caution in your business affairs; for the world is full of trickery.
But let this not blind you to what virtue there is; many persons strive for high ideals;
and everywhere life is full of heroism.

Be yourself.
Especially, do not feign affection.
Neither be critical about love; for in the face of all aridity and disenchantment it is as perennial as the grass.

Take kindly the counsel of the years, gracefully surrendering the things of youth.
Nurture strength of spirit to shield you in sudden misfortune. But do not distress yourself with imaginings.
Many fears are born of fatigue and loneliness. Beyond a wholesome discipline, be gentle with yourself.

You are a child of the universe, no less than the trees and the stars;
you have a right to be here.
And whether or not it is clear to you, no doubt the universe is unfolding as it should.

Therefore be at peace with God, whatever you conceive Him to be,
and whatever your labors and aspirations, in the noisy confusion of life keep peace with your soul.
With all its sham, drudgery and broken dreams, it is still a beautiful world. Be careful. Strive to be happy.

Max Ehrmann, Desiderata

Change

It’s changeover day on Wednesday. I went to the supermarket after work today, and almost without thinking about it I did the sort of grocery shop you do when you’re about to go onto a run of nights. I haven’t done nights since the Commonwealth Games, but in my new job I’m starting on Team Nightshift.

In this job, as a trainee, a year is a long time to stay in one place. I’ve been here through the FY1s and SHOs switching jobs in December and again in April, and through the registrars changing over in February. And now that everyone is moving again, it’s time for me to go too.

People keep asking if I’m looking forward to leaving, which isn’t a question with a straightforward answer. I’m looking forward to starting my new job, but I’m not exactly looking forward to leaving this one. I’ve grown comfortable in it where I am. It’s been a long time since I’ve been the new girl; even on my weekend locums, it’s mostly been going back to jobs that I’ve done before and places where I’ve been remembered. I’m going to be brand new on Wednesday, in a hospital and a department that I’ve never worked in before, and, due to rota complexities, am going to be brand new all over again next Monday. My most oft uttered words for the next fortnight are going to be a variation on, “where are the venflons?” or maybe, “where are the toilets?”.

This time of year is weird for more than just the FY1s.

The job I’m going to is the beginning of the training post that I wanted all along. It will be good for me, and it is the next step in the journey of what I really want to do with the rest of my life.

My gap year came on me unexpectedly, taken for geographical reasons rather than career reasons. I’ve learned a lot about haematology and developed a lot of transferrable skills; I’ve passed two parts of my MRCP, I’ve audited some things, some of them important things; I’ve worked with some brilliant people; I’ve run a marathon; and I think, maybe, in a roundabout sort of way, I’ve figured out what I do want to do with the rest of my life. Not a bad year for a year that I hadn’t really been looking to take in the first place.

The first Tuesday in August is always a bit bittersweet, I think. I’ve liked this job and I’ve had a long long time to get settled in it, and that makes it just that bit more unsettling than usual. But it’s time to move on.

“Scarecrow,” said Dorothy. “I think I’ll miss you most of all.”

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

*

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.