There will be many of you who are anxiously waiting to commence your internship across Australia in the next few weeks. onthewards is here to help with the transition.
Over the next few days, we will highlight previously published blogs and podcasts (with links) on topics that I think are very important to start your internship.
Organisation. This is what often separates the excellent junior doctor from an average one in the eyes of your supervisors and peers. This may be somewhat surprising, as during medical school it was your knowledge or clinical skills that determined your performance.
The importance of organisation for junior doctors was noted in a recent Australian study which asked interns how they or their peers knew they were doing a “good job” . Interns almost universally described their performance and those of their peers in terms of completion of daily tasks. A good performance was characterised by efficiency and consistency; a poor performance resulted in increased workload for other interns.
In my experience, there seems to be a “halo effect” with organised and efficient junior doctors assessed by their supervisors to perform better in domains such as knowledge and clinical decision-making on end of term assessments. Being organised makes you seem smarter!
But you may ask how do I become more organised and efficient? Many of you would have heard the expression “Proper Planning and Preparation Prevents Piss Poor Performance” or the 7Ps. This expression is believed to have originated in the military during World War 2 and is a phrase that captures some of the keys to being a better organised junior doctor.
You need to plan your day. This usually involves preparing a list and writing down a list of tasks. No matter how good your memory is, you will need to write or type the information down somewhere. This may involve an excel spreadsheet or a blank piece of paper with patient stickers on it. One of the more common methods is to print the list of your patients and draw a grid below it with tasks for each patient (e.g. scans, consults, discharges). A word of caution, I have fielded a number of complaints related this confidential information being left in cafes or hospital car parks. So please dispose your paperwork in the appropriate waste management bin at work.
Planning is not only about improving your own performance but also assisting your colleagues who are looking after your patients when you are not there. Writing a list of issues and plans, especially leading into a weekend, makes the reviewing of patients much easier for those doctors covering to ward.
Preparation is key to organisation. This may require you to turn up early before the ward round (the pre-round) to check the notes and speak to nursing staff about any issues that may have arisen overnight. A quick review of the patient results to make sure there is nothing critical that requires action is also useful.
Preparation also includes having equipment and paperwork readily available. You don’t want to have to leave the ward round to find a new medication or fluid chart so have extras with you on your ward round.
Looking ahead, especially in relation to discharge planning is crucial. If a patient needs a Webster pack for discharge medications or an allied health review to ensure that appropriate services are in place for when they go home, that needs to be considered days before discharge.
The discharge letter, especially for long admissions, requires preparation prior to the date of discharge. This can often be commenced and saved, at the time admission with the widespread implementation of electronic medical records. Avoid the production of discharge summaries that are merely a daily list of events and investigation results and try to summarise the pertinent features of the admission. Those reading your discharge summaries will be grateful.
Prevention (A stitch in time saves nine)
You will be rewarded if you ask questions of your registrars and consultants earlier rather than later in the day. This will prevent potential errors secondary to miscommunication, delays in completion of consults and investigations and help prioritise your workload. During your ward round, consider what questions to ask that will help plan your day. Ask your consultants and registrars, in a polite manner, whether the CT scan needs to be performed today or how will it change the patient’s management? When is the patient planned for discharge? What clinical question are you asking when ordering a consult? These are the questions that you will be asked as an intern when you ring up for a consult or try and convince a busy radiology registrar to perform your CT scan urgently. Knowing the answer to these questions will prevent any potential delays for your patients in those tasks being undertaken.
Try and write in the notes at the time of the ward round. This can be difficult for surgical ward rounds because you do not always get a chance to go back and fill in the gaps. At least, get your plan for the day in the notes. Follow this up with a conversation with the Nurse Unit Manager so that you both understand what the plans and priorities are for all of your patients for the day. This will prevent lots of phone calls from nursing staff wanting an update or clarification on the progress of your patients.
Prioritisation is my addition to the 7Ps. In most terms, there is more than enough work for you to do in the day and typically only increases when covering wards after hours. A key question you will face daily is what do you need to do now and what can wait. This is sometimes a clinical decision (chest pain versus a rash) but may also relate to administrative tasks. Some of these decisions will be influenced by the unwritten rules of your hospital. For instance, in many hospitals discharges need to be completed by 10am, so discharge medications need to be submitted the day prior to discharge; consults need to be requested before midday if they are to be completed on that day. These deadlines should be at the back (or probably front) of your mind when you are organising your day.
Prioritisation sometime requires saying no to a request that is non urgent or explaining that it will need to be completed later in the day. Communication of the reasons why this task is being deferred is important.
Communication within your team is also essential. Can you leave the ward round, to ring for the urgent scan or consult? Ask your colleague or registrar to continue to write in the notes whilst you slip away and organise the urgent test or consult.
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