Author: Lucy Cain
Dr Lucy Cain is currently an SRMO at Children’s Hospital, Westmead and had kindly shared some of her tips for getting through internship in this blog post.
A) Day-to-day ward tips
- Consider carrying a folder (opinions are divided – it will mark you as an intern) – use it to store several spare sheets of progress notes, medication charts and discharge scripts ( /- other useful paper forms depending on the term e.g. consult sheets, consent forms, RFAs). If you’re doing a geris term, you might want to add lube and microlax enemas!
- Set a reminder on your phone in the afternoon to order bloods for the next day.
- Check with registrar/consultant at beginning of term about which daily bloods to order. Think carefully about ordering daily bloods – not every inpatient needs bloods every day (especially INRs – refer to your local warfarin guidelines for how often to check and for how to adjust doses in the event of unstable INRs).
- Before you go home, remember to rewrite medication charts, finish all your warfarin orders and write up IV fluids for the next 12-24 hours if you can (don’t leave it up to the after-hours residents or you’ll get a reputation).
- On morning ward rounds, mark down which medication charts are due to be rewritten (i.e. those that will run out before you next see the patient) so you can return to do them later in the day (same for charting warfarin if you’re waiting for INR).
- Don’t forget to chart warfarin, variable dose medications e.g. gentamicin, prednisone (it should probably be discussed on the ward round but if not, check with your registrar) – it’s hard for after-hours doctors to guess what to chart.
- During ward rounds, write every single job down on your patient list – you might think you’ll remember it all but you won’t.
- Do a paper round with your registrar after the ward round (especially if it’s a quick consultant ward round) to make sure you’re on the same page – try to do this over coffee for team bonding!
- Start discharge summaries early in the admission and add to it as you go – less daunting than starting afresh the day before the discharge.
- Keep discharge summaries brief – don’t copy and paste the ED notes. Include only the relevant information for the GP – i.e. diagnosis, (brief) outline of the treatment provided in hospital and most importantly, the discharge plan – follow up instructions, outstanding investigations, etc. If there is something you want the GP to do (e.g. arrange an investigation or refer to a specialist, etc. call them to let them know).
- Learn how to use a fax machine!
- For consults/handovers – use the ISBAR framework and always have the bloods displayed on the computer in front of you, the obs and medication charts on the desk in front of you and the progress notes. It helps to have written the consult sheet before calling so you’ve already thought about what the other person might ask. If you are consulting cardiology and the patient is already known to a cardiologist, it helps to have already chased the cardiology letters before calling.
- You’ll often be handing things over to the after-hours resident – if so, ask them to do a specific task (e.g. review fluid status 1 hour after a fluid bolus) rather than something general (evening residents hate getting the handover “just have a look at patient X”). If handing over to chase an investigation, HAVE A PLAN for what to do with the result e.g. “I’ve just sent off electrolytes. Please chase the results. If the potassium is still high (>6 – BE SPECIFIC), please give some more insulin/dextrose and repeat the electrolytes again in 6 hours.) Especially true for handing over serial troponins.
- When accepting handovers from day teams, seek out this information – make sure the team tells you what action they want taken – if they don’t know, then they should find out and tell you before they go home. Also find out who else knows about the patient (e.g. have they also handed it over to the med reg in charge?).
- When getting phone advice or discussing admissions with consultants, try to repeat the plan back to them before they hang up so you get it right. Before making the phone call, have a list of questions you want answered e.g. do you want DVT prophylaxis? Should the patient be fasted?
- When organising imaging, if you have time, do it in person – it’s harder to be rude or say no to someone if they’re standing in front of you. Also, have the relevant extra information at hand (e.g. for a contrast CT, the radiologists always ask for the creatinine, for interventional radiology they like to know the platelets and recent coats).
- Prioritise – MET calls and Clinical reviews take first priority, followed by calls from concerned nurses (though beware – these also need to be triaged) and then the list of jobs in the book.
- Prioritise the jobs in the doctors book – IVC for antibiotics due now beats IVC for maintenance fluids in most cases.
- It’s not really your responsibility to explain results from the day to patients or talk to family members about non-urgent things – if you have time, you can look through the notes and do your best but often it is OK to leave this up to the day team.
- When reviewing a patient, always look through their notes (before you’ve seen the patient if you have time) – often the team will leave helpful instructions e.g. if fever >38, needs blood culture but only one every 24 hours.
- There are some teams/specialists who will want to be called for changes in patient status (differs at each hospital) e.g. haematology usually want to be called if a neutropenic patient develops their first fever. Get to know which teams like to be called.
- You are not alone – your registrar is paid to supervise you; they are expecting your calls. If you’re not sure, call them – that’s what they’re there for!
- Refer to your hospital’s policies/guidelines – should be available on the intranet – not a solution to every situation but a good start.
- Help each other out – if you’re having a quiet shift, do some jobs for someone else or take dinner orders and organise food to be delivered (especially on a long weekend shift). If you’re busy and someone offers you help, accept the offer!
- Take breaks to eat, go to the toilet and make sure you get off the ward every now and then. If you stay visible on a ward, the nurses will find more jobs for you to do!