Understanding your workplace

Supervisors tell me that some doctors “just don’t get it”. Usually, this is not related to inadequate clinical knowledge or skills but rather describing doctors that struggle to work and adapt to their role in the clinical team. What separates the experienced RMO on the ward from a first-term intern is not wider medical knowledge. In fact, most residents say that they have forgotten much of the minutia they learnt in medical school but they now know the important “stuff”. An underlying principle of the podcasts and videos produced at onthewards is to identify and highlight some of the key areas of knowledge that are considered by your colleagues to be important.

Unwritten rules to learn as a new intern

There are many unwritten rules in hospitals and terms that describe what behaviours are expected of you by your medical, nursing and allied health colleagues. For example, there are expectations that you will complete all your discharge summaries prior to changing terms, order appropriate blood tests for the weekend, write up fluids to continue during the night and prescribe warfarin doses before going home. Many of these expectations are not explicitly stated in hospital protocols or term descriptions.

An accurate understanding of how the system works within your hospital will help you better organise your day and improve your efficiency. These rules, norms and values are typically learnt by observing the behaviours and actions of more senior doctors. For those of you who are in medical school on clinical rotations, this should be one of your goals for the term. Through experience, you will learn to better navigate the complicated medical system and hospital structure in which you work.

However, understanding the organisation and system in which you work is not always self-evident to many doctors. These doctors can often struggle or take more time to settle into each term. In contrast, some interns are able to adapt or socialise into new terms easily and a possible underlying reason is that they are able to quickly learn the unwritten rules. This may be innate in some doctors but is also a skill that can be learnt, with experienced doctors being more adept at managing the frequent transitions into new clinical rotations.

Tips for transitioning into a new term

The following are some of my general tips and suggestions to assist your transition into a new term.

• Before starting a new rotation seek out junior doctors who have previously worked on the term and ask them questions about how the term works. This peer to peer handover is often done over the phone but face to face is preferable. Try to include the registrar that you are about to work with in this meeting, if possible.
• Many hospitals also have a “living” written document that is updated each term by the junior doctor and describes the term and role expectations from their perspective. If there isn’t one for your term, consider writing one to help your next colleague.
• If possible, go to the ward a week prior to starting and introduce yourself to key members of the team such as the Nurse Unit Manager (NUM) and the ward clerk (even better if you remember their names on your first day!).

These are all simple strategies to ensure that you quickly adapt to your new role.

Orientation and talking to previous interns

The organisation also has a responsibility to provide you with an appropriate orientation to the hospital and each term. Hospital orientations are frequently burdened by information overload and a heavy weighting towards human resources topics such as fire training and manual handling.

I have found the most valuable content is delivered by the previous cohort of interns who are in the best position to understand your upcoming role. But please feel for the organiser of your orientation – it is the only time there is guaranteed 100% attendance and much of the content is mandatory.

Seek senior input

I have noted the importance of understanding the rules, norms and values of your hospital and how they are typically learnt through observation of behaviours. This has been framed from a perspective of improving your performance. But not all learnt behaviour in the workplace is positive. For example, a recurrent theme in the analysis of medical errors, especially those that have occurred after hours, is the failure of junior doctors to seek assistance with a clinical problem. This failure to recognise the need for senior input may be directly related to knowledge, skills and experience, with the junior doctor being “unconsciously incompetent” though believing that they have the skills to manage a situation.

More concerning is that learnt behaviours may also contribute to the failure to escalate concerns for a deteriorating patient.  Junior doctors may avoid asking for assistance from a senior clinician because of concerns that they may be perceived as incompetent or there is an understanding within some teams that senior clinicians are not contacted after hours. Patients get sick at all times of the day, not just at convenient times for your registrars or consultants. As the junior doctor on the ward seeing your patient at 3am, you must advocate for them and ensure they get the best possible treatment, irrespective of the time of day.

Junior doctors also have valuable input

It is also important that we recognise junior doctors, whom often have a variety of prior life and work experiences, are able to view how a hospital functions with a fresh set of eyes. They can see and identify when processes can be improved, barriers removed and innovations made. However, it doesn’t take long before these junior doctors become “normalised” to the culture of a hospital and become sick of fighting against the prevailing “that’s the way we do things around here” mentality.

I think if we better utilised the untapped potential of the junior doctor workforce and worked harder to engage them, our hospitals and patients would be better off.

What tips and suggestions would you include to assist the new intern to better understand their workplace and transition into a new term?