YOU WILL

SURVIVE
BMJ’s guide for newly qualified doctors
Compiled by Tom Nolan, Imran Qureshi, Sarah Jones and Daniel Henderson
Edited by Sabreena Malik and Matthew Billingsley

Sponsored by
 CONTENTS

Starting life as a junior

doctor is one of the biggest 1 INTRODUCTION
challenges you’ll face. Five or 2 THE FIRST DAY
six years of medical school
can make even the keenest
3 ON-CALLS
student feel institutionalised. 4 NIGHTS
Now, starting work, suddenly
6 WARD ROUNDS &
everything has changed. New
people, new places, and new
NOTES
responsibilities. Self doubt 8 COMMUNICATION
can creep in: How will I cope
10 DE-STRESSING
on call? How will I keep up on
ward rounds? What if I prescribe everything wrong? Don’t 12 SKILLS STATION
worry. Be reassured by the fact that every doctor in the 14 FIRST YEAR TALES
world has been through this and survived. Many of them
FROM BMJ CAREERS
contributed to this booklet.
“You will survive” started out as a discussion thread 18 USEFUL EXTRAS
that received over a thousand tips and cautionary tales on
20 REFERENCE
BMJ’s online clinical community, doc2doc. It now includes
valuable words of wisdom written by junior doctors for
INTERVALS
BMJ Careers and Student BMJ. 21 PHONE NUMBERS
Good luck with the new job. I’m sure you, like most, will
look back on your first year with fondness. Make sure you log
on to doc2doc.bmj.com to tell everyone how you’re getting on.
Fiona Godlee, editor, BMJ
July, 2013

There are many things to remember legal representation if they are involved
when starting out as a hospital doctor, in any of these situations, ensuring
but securing medical legal assistance complete peace of mind.
might not be high on your list. You We are delighted to sponsor this book
will have NHS indemnity for the work as it is full of valuable advice from your
you do within your NHS contract but medical peers which we believe will help
for disciplinary issues, GMC referrals, you survive some of the challenges of
coroners’ inquests or fatal accident being a junior doctor.
inquiries, the NHS won’t help you.
MDDUS members have 24-hour access Jim Rodger, head of professional services,
to assistance, support and, if necessary, MDDUS

YOU WILL SURVIVE | 1

 THE FIRST DAY

Surviving the first day

The first day will always be frightening says junior doctor Karin Purshouse. Here are some
of her “glad I dids” and “wish I’d knowns” from Student BMJ’s junior doctor survival guide
• When shadowing, keep notes of crucial information—for example, how to request imaging
or other investigations, such as 24 hour electrocardiogram tapes, echocardiograms, and
oesophagogastroduodenoscopies; how to order bloods; where the ward stocks cannulas,
catheters, and other essential equipment.
• Check where to go for handovers and on-calls, and keep a list of useful bleep numbers.
• Always ask when you need help or clarification; no one will be cross—usually quite the
opposite—and you’ll look far more stupid if you make it up and risk someone’s safety.
• Most people don’t know the doses for drugs off the cuff, so either ask or look it up. Make
friends with the pharmacist on the ward. They will rescue you in times of prescribing and
discharge summary need.
• Learn the names of everyone on your ward—write them down if necessary. They are the ones
who will get you through those first weeks.
• If you’re faced with an emergency on day 1, remember your training (you can’t go far wrong
with an ABCDE assessment), but don’t be a hero—call for help early on.
• Most importantly, the friendships made with fellow new doctors are crucial to your sanity. A
debrief over a drink is the perfect antidote to a stressful first day. You will get through it.

First days to forget

I started in the Eastern General in Edinburgh on 1 August 1976, and experienced my first death from
medical error the next day. I don’t remember the woman clearly, but she certainly wasn’t sick. I
admitted her for investigation of pernicious anaemia. The other doctor, Phil, whom I had bonded
with over dissection at medical school, had also just started. He was responsible for doing the sternal
puncture but because he had done several as a student he got a medical student to do it. She didn’t
draw any marrow so Phil took over and rapidly filled the syringe. Seconds later the woman was deeply
unconscious. It turns out the needle had penetrated a major artery. She exsanguinated.
Phil who seemed remarkably unfazed by the whole experience at the time, subsequently became
an anaesthetist, an alcoholic, and a drug addict. He was eventually struck off, and died more than
10 years ago. All this may have been nothing to do with the death of the woman but more with his
drinking as a student. He spent most of his first term trying to drink 100 pints of beer in a week.
Richard Smith, England

I pulled the sheets back and there was melaena everywhere. I felt a cold rush of panic ... A massive upper
gastrointestinal bleed was the final straw on a terrifying first day as a medical foundation year 1 doctor
in a new hospital. How do you request an echocardiogram again? Where do the blood request forms for
the phlebotomist go? How have I forgotten my radiology/computer/patient record passwords so quickly?
I don’t even know the dose for oral co-amoxiclav. With a medical emergency in the middle of all of this,
my to do list was getting ever longer. By the time my senior house officer arrived I was mopping my tears.
Karin Purshouse, England

2 | BMJ GUIDE FOR NEWLY QUALIFIED DOCTORS

 ON-CALLS

How to survive on-calls

Prepare for your first on call with these tips from those who have gone before you

Receiving jobs via the bleep Tips from BMJ’s community

Advice from Maham Khan in Student “Before that dreaded first on call you
BMJ’s junior doctor survival guide may well feel terrified and completely
• Confirm and write down the patient’s out of your depth. This is natural.” Adam
name, hospital number, and location. Simmons, England
• Never accept a job without knowing the
clinical context of the patient—e.g., if “Different wards have different layouts, so
the job is to chase a urea and electrolytes you won’t know where all the equipment
blood test, does the patient have known is. Save time by carrying some equipment
renal impairment? (ABG syringes, cannulas etc) in an on
call bag, along with a small reference
• If asked to chase results always confirm
book (Oxford Handbook) and a chocolate
what the plan is if the result is abnormal. bar.”Michael Haji-Coll, England
• Be familiar with the early warning scor-
ing system used by the nursing staff ito “It is normal to feel sick the first time you
help prioritise which patients to see first. are on call.” Claire Kaye, England
• If the bleep goes off rapidly in succession
note the numbers and call one at a time. “Busy or not, always have a break and
eat when you’re on call. You will make
And Roberta Brum says: yourself far, far more efficient.” Helen
• Be polite, inhumanly polite, even when you Macdonald, England
want to scream your head off after being
bleeped for the 100th time. Personal and professional
survival
On-call can be a fun experience and an
excellent opportunity to learn how to man-
age acutely unwell patients. It can give you
the chance to perform procedures you might
not otherwise get to do, and is an ideal time
to complete eportfolio assessments such as
clinical evaluation exercises, core proce-
dures and direct observation of procedural
skills. It is important, however, to remember
your level of competence—for example,
never discharge or accept care of a patient
without discussion with a senior.
Maham Khan, England

YOU WILL SURVIVE | 3

 NIGHTS

Surviving night shifts

Sarah Welsh has just finished her house officer year at Sunderland Royal Hospital,
England. She advises on working at night in Student BMJ’s junior doctor survival guide
Routine is key. The concept of sleeping when the sun is shining and your friends are playing is difficult,
and weekends are especially challenging. To ensure a good day’s sleep: have blackout blinds, use an eye
mask, turn your phone on silent, make sure your room is cool, and earplugs are a must. You might also
need to warn your housemates or neighbours so they don’t come banging on your door. Physical activity
or reading a book before crawling into bed is healthy and can help you nod off.
The first couple of nights are the worst. Everyone uses a different method when switching from days to
nights. Some stay up late then lie in on the day of their first night shift. Others find that their usual night’s
sleep, plus an extra nap, works best. Despite what people say, the best method is not going out partying.
If you are lucky enough to have chance to nap on the shift, be careful not to get used to it. Such a
routine can be more detrimental in the long run. Do not worry about feeling tired at work because you can
rely on adrenaline to kick in when needed.
Having a good meal before starting a shift is important and isn’t too difficult because it often coincides
with your usual evening mealtime. During the shift make time for something to eat and drink, whatever
the workload. Although you may not feel like eating at 3 am, it is important to fuel yourself. Caffeine is
tempting, but try not to rely on it; you’ll regret it afterwards.
Night shifts can be daunting, but the experience is unique. Hospitals have a different character
overnight, and the minimal team of professionals creates an intimate feel.

A night to remember with Mr M

At 0430 I got a call that scared the life out of me! Mr M (a 70-something year old admitted
for investigation of a “mass” on his liver) had just passed about a litre of blood from his
back passage. I went to see him straight away. To my horror, he was clammy, sweaty, and
peripherally shut down. His BP was 80 systolic. Thankfully, he
had two points of IV access. I asked one of the nurses for some “To my horror he
Gelofusine urgently. The nurse also offered to take the patient’s was peripherally
full blood count, clotting screen, and a group and save. I noticed shut down”
that he had been made “not for resuscitation” at the hospital he
had been admitted from. Realising this patient was potentially peri-arrest, I contacted the
on-call medical SpR. I begged him to come as quickly as possible. To my relief, he was on the
ward within 10 minutes. Fortunately, we managed to stabilise Mr M such that he could go for an
urgent CT angiography, which revealed that he had suffered a tear in his cystic artery.
So, what did I learn from this experience? It taught me the importance of the doctor on call
and the nurses on the ward working together as a team. It makes such a difference when bloods
can be taken quickly and IV fluids put up promptly. I also learnt the importance of involving
senior doctors when you need them. Never be afraid to ask your seniors for help or advice, no
matter how trivial the issue. The most dangerous junior doctor is the one who doesn’t ask for
senior help when it is clearly warranted!
Nights can be scary – but they do make us better doctors. Declan Hyland, England

4 | NEWLY QUALIFIED DOCTORS

 NIGHTS

Making a splash on nights Tips from BMJ’s community

On my first night on call as a surgical house
officer I was called to see an agitated, “Remember, it is possible to enjoy this job even
tachycardic, and mildly hypotensive patient in the middle of a night on call.” Andy Shepherd,
who was second day post-op after bowel England
surgery. He had “The SHO walked
only passed 10 in to find me “When asked to a see a patient during the
ml of urine in 4 covered in urine” night, ask the nurse to do a fresh set of
hours. I arrived observations and any other relevant tests (ECG,
to find a clearly sick and possibly septic BM, bladder scan etc) while you make your way
patient. ABC assessment was good (except down to the ward.” Shamil Haroon, New Zealand
for his tachycardia). He had abdominal pain
but was too agitated to tell me more. On “Some hospitals can be cold at night. If you
examination he was guarding around his have a quiet spell there is nothing worse than
lower abdomen: it was very tense, but he still sitting in the mess feeling cold, so bring a
had bowel sounds. His fluid balance chart jumper. If it looks pretty sensible then it’s
probably fine to wear down to the wards
showed 1 litre in (over the past 24 hours), and
during the night.” Jo Godfrey, Wales
approx. 500 ml out from his catheter (all day).
“He’s hypovolaemic,” I thought. So we gave “On my surgical nights I told each ward that I
him a 500 ml Gelofusine bolus followed by a would do a mini jobs round at three points during
6 hr bag of Hartmann’s. Over the next hour the night. This meant that annoying jobs (writing
his agitation worsened. up fluids, rewriting drug charts, etc) could get
I called the SHO who, after shouting at done in a single sitting. On some very nice wards,
me for waking him, asked if we had done a the staff would get me a hot drink and snack ready
bladder scan. We hadn’t thought of that. The for when I was expected!” Carmen Soto, England
scan showed over 900 ml urine. The catheter
“It’s surprising how hungry you can feel at 0400
was completely blocked. Ready to pass a new when all the shops and canteens are closed. So go
one, we disconnected the bag, and deflated prepared.” Mahomed Saleh, England
the balloon. I was promptly soaked by the
900 ml of urine before I’d even withdrawn the
catheter. The patient sighed in relief, and the
SHO walked in to find me covered in urine!
Advice for surgical nights:
• Do catheter flushes and bladder scans
before panicking about fluid balance
• Don’t feel guilty about waking seniors
• Bring spare clothes/find out the theatre
changing room code
Sarah Jones, England

YOU WILL SURVIVE | 9

WARD ROUNDS & NOTES

By the time you’ve found the notes and started writing, the ward round
may already have moved on. This advice should help you get by

Using SOAP & BODEX Tips from BMJ’s community

“Do the following before the ward round:

The mnemonic BODEX is a good for ward
1. Put all notes are where they should be
rounds: Bloods, Obs, Drugs chart, ECG,
and X-Rays/imaging. 2. Check blood/scan results are in the notes
3. Prepare discharge and phlebotomy forms
And when writing in the notes, remember 4. Familiarise yourself with new patients.” Imran
SOAP: Qureshi, England
Subjective - How is the patient feeling?
Retake any relevant parts of the history Whenever I make an entry, I print my name,
(e.g. do they have chest pain?) with my job description (shrink, Chief PooBah
Objective - How do they look? Write etc), date, and exact time. It is legible. I then
down the obs and your examination
sign. Many years later this may save my rear
findings.
Assessment - Your impression of what’s end. Roger Allen, Australia
going on (e.g. pulmonary oedema
improving, no new issues). A three or four line problem list at the top of each
Lastly, document your Plan. notes entry helps structure my plan–especially
Will Buxton, Sussex when alone on a ward round. Tim Baruah, England

A low note
One of my lowest moments as a house officer was being on a cardiology ward round as the lone
junior. Just as I began writing in the notes, my registrar grabbed them and started writing himself. I
felt so embarrassed. Writing notes is one of the few things a house officer is expected to do without
supervision, and I was clearly rubbish at it. And this registrar was obviously frustrated at my
incompetent note taking.
I have since learnt that writing notes is a more important job than it first “The registrar
seems. A good last entry from a diligent house officer can make all the was obviously
difference when on call. So what makes a good note entry? frustrated at my
• Documentation of how the patient is today. Note down vital signs, any
note taking”
history or examination that is performed on the ward round, and any
discussions that have taken place between you and the patient (see SOAP opposite). Recording what
the patient has been told is useful for on-call staff.
• A clear management plan. Mark each task as “done” in the notes once completed.
• Different consultants and registrars like different styles of note keeping, so find out what they expect.
If you are in any doubt over what has been said on the ward round, don’t be afraid to ask for
clarification–it’s far better than writing something that makes no sense to anyone else.
Gayathri Rabindra, England

6 | BMJ GUIDE FOR NEWLY QUALIFIED DOCTORS

 WARD ROUNDS & NOTES

How to write in the notes - seven tips to remember

In Student BMJ’s junior doctor survival guide, James Conlon describes note writing
techniques he picked up as a junior doctor at the Royal Infirmary of Edinburgh, Scotland
1. Clinical notes must be clear, accurate, example, when looking after an acutely
and legible. The UK’s General Medical unwell patient—it is good practice to
Council (GMC) states that the following note down a timeline of events in a
information should be documented retrospective entry in the notes.
in patient records: relevant clinical 6. When recording a clinical assessment
findings; decisions and management of an unwell patient it is usually
plans (and who has been involved in appropriate to document findings in an
making these decisions); information “ABCDE” manner. Relevant microbiology
given to patients; prescribed drugs and and fluids status should be recorded.
details of treatments and investigations The entry should include a clinical
being instigated. It is good practice to impression and management plan.
ensure that the indication and estimated
7. Details of discussions with relatives
duration of antibiotic therapy is
should be documented. The names of
recorded in the notes.
family members should be noted and it
2. All entries in the notes should have a is helpful to document their relationship
time and date documented as well as a to the patient.
title—for example, registrar ward round,
foundation year 1 review. The person
making the record should document
their name, grade, signature, and
contact number.
3. Every page of the clinical notes should
have patient details at the top—patient
identity stickers are useful for this.
4. Sometimes the person making the
clinical record is not the person
interacting with the patient—for
example, a consultant ward round. The
name and grade of the clinician leading
the interaction should be documented.
It is good practice to record the names of
all members of the clinical team who are
present on the ward round. This might
be too time consuming, and so initials
(with a key) could be used.
5. The GMC says that doctors should aim
to make records at the same time as
the events being recorded or as soon as
possible afterwards.[1] If there is a delay • Find your next job at careers.bmj.com
in documenting clinical findings—for

YOU WILL SURVIVE | 7

COMMUNICATION

Top tips for talking on the telephone

James Conlon’s advice from Student BMJ’s junior doctor survival guide
• The SBAR (situation, background, assessment, and recommendation) format is a useful tool to
use when discussing patients over the telephone. It is important to state who you are, what your
grade is, and why you are calling. If the patient is unwell, state this early on in the conversation.
• When discussing a patient, have the clinical notes, results of recent investigations, as well as
drug and observation charts to hand. It is important to take time to read through the notes before
making the call if the discussion is about a patient whom you do not know well.
• Document the name and grade of the person you have spoken to as well as the time of the phone
conversation. Record a contact number for the person you have spoken to so that it is easy to
contact them again.
Get answers from a community you
can trust • doc2doc.bmj.com

Breaking bad news

My advice on breaking bad news is:
• Don’t beat around the bush
• Don’t use euphemisms
• Don’t talk to fill the silence.
People hang on to hope until the last, so be kind
and compassionate, but don’t delay the message,
and say clearly that the person “has died.” Allow
time for this to sink in, and then offer to answer
questions or be of other assistance. It is useful to
have a nurse with you to remain with the bereaved
if you are busy.
Rochelle Phipps, New Zealand

SBAR - how to ask for help from a senior

Situation: “My name is Dr X, FY1, and I’m calling from Ward X; I need to tell/ask you about X problem”
Background: Patient age, reason for admission, relevant comorbidities, current issue, current obs,
relevant investigations (ensure you have the notes, charts, and drug card handy when you call)
Assessment: “Based on my findings I think the current problem is. . .”
Recommendation/request: “I recommend we do X, Y, and Z; does that sound ok?”
or “I request your advice” or “I request that you come to help”
Before you put the phone down make sure you either have a plan that you understand or a guarantee
(even better: an approximate time) that the senior will come to help.
Ensure you document that you’ve contacted a senior; include his or her name, bleep number and the
outcome of the discussion.
Sarah Jones, England

8 | BMJ GUIDE FOR NEWLY QUALIFIED DOCTORS

 COMMUNICATION

Communication tips from BMJ’s community

BE POLITE
“Be polite: people have long memories. Be concise: seniors will be grateful for a brief summary of
the patient you want them to see Be precise: know exactly what you want.” Mahomed Saleh, England

“Nurses have long memories. Always treat them with respect, and they will help you out of all
imaginable (and unimaginable) tight spots.” Rochelle Phipps, New Zealand

“Remember the power of a careful apology (‘I’m sorry that happened’).” Sarah Jones, England

“However inane the request, remember each phone call is usually from a person with genuine worries
about a patient.” Adam Asghar, England

Smile over the phone. Smile at your patients. Smile at your seniors.” Andy Shepherd, England

“Be nice to everyone, even porters. It makes it so much easier to get things done. People will do you
favours because they remember you as the doctor who always says hi.” Maryam Ahmed, England

“Greet clerks, healthcare assistants, and nurses using their first names.” Preetham Boddana, England

BE CALM
“Be calm. It helps you deal with problems in an organised, rational, logical, and safe manner. It also
instils confidence in the people around you, from the nurses to the patients.” Carla Hakim, England

“Organise your thoughts. Communicating with colleagues will then improve. Peter Martin, Englnd

TAKE TIME WITH PATIENTS

“Never, never, visit a patient at the bedside without some tactile exchange.” William Hall, USA

“When communicating with patients, give them time to absorb all you say.” Adam Asghar, England

“Listen to the patient for they are telling you the diagnosis. Diagnosis is 80% history. Be empathic,
learn to read body language, and learn to control your own body language.” Peter Martin, England

WORK AS A TEAM
“After the ward round, discuss and allocate urgent jobs. Arrange a meeting later in the day to do
outstanding jobs and to avoid handing over routine jobs to the on-call team.” Heather Henry, England

“Most consultants would prefer you to call them rather than for a patient to suffer.” Matiram Pun, Nepal

“Be clear when requesting tests; you are communicating with other professionals.” Peter Martin, England

YOU WILL SURVIVE | 9

 DE-STRESSING

How to look after yourself (and why you need to)

Being a doctor can be stressful; here’s how to maintain a good work-life balance by
junior doctor Henry Murphy, writing for Student BMJ’s junior doctor survival guide
Staying sane as a newly hatched junior layers build up with experience, until you
doctor is near impossible. You can arm start to resemble the doctor you hoped you
yourself with a fancy clipboard, an array of could be.
prescription pens, and a 1.5 L bottle of water, Here are my tips for your first year:
but the overwhelming pressure you are under • Look after yourself first. Always, always
often outweighs the desire for lunch, and eat and drink. Every day. That’s basic
you won’t believe how difficult it is to stay survival. A quick bite to eat can make you
hydrated—or even to go to the toilet—at work. feel ready to tackle (almost) anything.
Remember wanting to be “involved” as a • Talk, exercise, join the doctors’ mess.
student? You will soon find yourself toiling • Don’t give up trying to be good at your
in a specialty you dislike, for a consultant job. Practising bad medicine in the
who hates you; caring for patients with name of efficiency helps nobody.
sudden onset symptoms—always suddenly • Learn from your mistakes daily.
onsetting before lunch or at 5 pm—and their • Keep up with appearances; if it’s not on
demanding, dissatisfied relatives, while the your eportfolio, it did not happen.
nurses bleep you incessantly for discharge • Make time for your extracurricular life:
summaries you care little about writing. housework, relationships, a social life,
It can be hard to remember the privilege and your education and progression.
of caring for someone when you turn up Neglecting these aspects of life for work
in the middle of the night to do the rectal is not sustainable.
examination your colleague couldn’t be • Always be honest and professional with
bothered to do. You will get things wrong. everyone.
You are gullible and corruptible. You are • Ask for help when you are struggling.
inexperienced and slow. Nobody will notice • Work within your level of competence.
your daily struggle to keep the wards “ticking • Be proud of your achievements.
over” until something goes wrong. • Enjoy it; it is
Are you wondering how you can cope? the best and
You can’t. One day, you will crack under the the worst
pressure. You will feel awful for a while, but year of your
you will heal with a layer of resilience. These career.

Advice on rotas
“The earlier your supervisors know about a problem, the sooner rectifying attempts can be made. If you
are given a ridiculous rota, come up with an alternative and present it to those responsible for it. You
may not achieve instant success, but you can strive to improve patient safety and working conditions,
rather than grinning and bearing it.” Adam Asghar, England

10 | NEWLY QUALIFIED DOCTORS

 DE-STRESSING

De-stressing tips from BMJ’s community

EXERCISE
Join a gym or take some other form of regular exercise. When you get crash calls you don’t
want to be too tired to be of any use when you arrive! Imran Qureshi, London

Take a few minutes a couple of times a day to walk as briskly as possible from one end of the
hospital to the other, preferably outside. Susan Kersley, England

“Work hard, play hard. Exercise is probably the best destressor. Alcohol is probably the worst. Do
NOT self medicate with hypnotics or antidepressants. Seek help if necessary.” Peter Martin, England

FOOD
“Have food with you at all times to avoid protracted periods of hypoglycaemia. That liquid yoghurt or
those all-bran biscuits in the pocket of your white coat are priceless.” Tiago Villanueva, Portugal
“Don’t drink too many caffeinated drinks; don’t be tempted by sugary foods when stressed; take a
break for meals, don’t skip them.” Susan Kersley, England
“Always have breakfast as you just never know when lunch will be.” Maryam Ahmed, England

SLEEP
“Sleep is more important than partying, even when it seems like you have no life. You don’t, but
eventually you will, so don’t ruin your mental health before you do.” Rochelle Phipps, New Zealand
“Make sure you get a good night’s sleep before any on calls.” Kiki Lam, England

ANNUAL LEAVE
“Organise your annual leave early so you can plan when and where you’re going to go on holiday
for that all important stress relieving break.” Adam Simmons, England

OTHER
“Remember, stress makes you make mistakes. The best way to relieve stress is to take your
work easy but responsibly. Take feedback or comments positively. Don’t let any irate comments or
remarks bother you too much; they come and go. You should be more worried about your patients
and the care you give.” Matiram Pun, Nepal

“Get to know your fellow house officers. Sitting in the mess or accommodation lounge moaning
and laughing about the day, and commiserating about shared experiences, was one of the best
ways I had of coping with stress.” Gayathri Rabindra, England

“Read fiction. Anything.” William Hall, USA

YOU WILL SURVIVE | 11

 SKILLS STATION

How to cannulate difficult patients

We’ve all struggled with venepuncture. Here is some advice on getting it right
Grossly oedematous patients are difficult to cannulate because it is difficult to even see a vein to
puncture. You can get around this by placing the tourniquet tightly, high up on the patient’s arm,
then pressing very firmly but gently on the dorsal surface of the patient’s hand for, at the very
least, 1 minute–the longer, the better, though. This pushes all the fluid away and should leave you
with a clear view of a juicy, fat vein! You must have your needle ready, though, because the fluid
can return very quickly and obscure the vein again.
Warm water can make veins visible and palpable. Get a small bowl or beaker (the ward should
have plastic ones) and fill it with water that’s hot, but bearable. Explain to the patient what you
would like to do and why you are doing it. Then place the tourniquet high up on his or her arm,
and ask them to submerge his or her hand in the warm water. Keep it there for 5 minutes. The heat
should bring the veins up for you to puncture.
Gloves can have a great tourniquet effect–not by using them around the arm, but by getting the patient
to wear one. Estimate the patient’s glove size, then give him or her a glove one size smaller to put on,
explaining that it will be quite tight and what you hope to achieve. Remove the glove after 5 minutes and
cannulate away! You can also combine this with the warm water effect. Robin Som, England

...and how not to do it

• Tell patients it’s just a tiny scratch before you go
digging into their flesh in every possible direction.
• Prepare your patients by telling them they’ve got
difficult, narrow, and wiggly veins.
• Tell the patient you got into the vein but the tiny little
valves on the veins are blocking your plastic cannula
from moving in.
• Tell your patients they have fragile veins when you
give them a great big haematoma.

If all else fails, call the friendly on-call anaesthetist (don’t call the same anaesthetist twice in the same day;
never call them within the same hour; get your fellow house officer to be the bad guy). You know you’re in
trouble when the on-call anaesthetist tells you that they are not a cannulation service . . . then you think
subcutaneous morphine or fluids, supplemented with regular diclofenac intramuscular injections, might
just be the easier, or, realistically speaking, the only option you have left. Yee Teoh, England

• Follow BMJ’s community on Twitter at www.twitter.com/doc2doc

12 | NEWLY QUALIFIED DOCTORS

 SKILLS STATION

How to confirm death Get stuck in

If asked to confirm death, you need to write: Scottish respiratory consultant Tom
• Asked to verify death Fardon tells new doctors on BMJ’s
• No response to painful stimulus community site to put themselves
• Pupils fixed and dilated forward and not to hide
• No heart sounds (for 60 seconds)
Starting work on a busy ward is daunding, no
• No breath sounds (for 60 seconds)
• No carotid pulse (for 60 seconds) doubt, and it can be seen as an easy way out to
• Time of death (HH:MM on DD/MM/YYYY) hide away somewhere, and stay out of the way
Note whether there was a pacemaker palpable of the big scary grown up doctors. If you hide
(for whoever does the cremation form), then away, you’ll not be noticed, but it’s the juniors that
sign, name, and date the notes, and provide a put themselves front and centre, speak up, are
clear contact number. keen, and show initiative, that will get the most
Sarah Jones, England out of the job, and are more likely to get a rapid
response when they phone the reg for help when
ABGs: get rid of the bubble the quagmire hits the fan. The best house officers
Arterial blood gas analysis of a patient with I’ve had have been the ones who stood up to be
severe pneumonia showed a normal pO2 but counted from day one, the ones who asked the
on reviewing the patient I found him clinically questions, offered solutions, took the initiative
worse than the blood gas “The patient (and the on call bleep), and made things happen
suggested. I repeated the ABG was severely - they made mistakes, sure, but they learnt from
myself to find the patient was hypoxic” those mistakes, and became great doctors.
severely hypoxic. The person
who ran the first blood gas analysis had not
removed the gas bubble from the syringe.
Professional development tip
Lessons learned: always remove the bubble “Organise an audit early as it may take time
from blood gas syringe and treat the patient, to gather information from notes. Re-auditing
not the test result. is important to complete the audit cycle (and
Farhat Mirza, England impress at interviews).” Kiki Lam, England

Why you should look underneath those dressings

“We saw green I was clerking a patient with sepsis who had subtle signs of a chest
discharge from infection but not enough to explain the degree of his illness. The patient
the ulcer–quite also had a dressing over his foot. In his letter the GP had written that he
embarrassing had examined a small ulcer on the patient’s foot, which he thought to be
for me” healthy so had applied a fresh dressing. For this reason I did not examine
the foot. Later, when the consultant asked to remove dressing, we saw
green discharge from the ulcer and cellulitis around it–quite embarrassing for me. The
lesson: always to look underneath dressings, even at the cost of annoying the nurses.
Farhat Mirza, England

YOU WILL SURVIVE | 13

 FIRST YEAR TALES FROM BMJ CAREERS

“Doing the job of your dreams and learning

something new every day”
The busy on calls, moments of intense systematic while managing acute medical and
pressure, and facing difficult situations surgical problems.
with little experience to fall back on have all The most important aspect of this year has
contributed to a steep learning curve, which been reflecting on my attitudes and beliefs,
every FY1 trainee encounters. and how these have played an important
During my haematology rotation, seeing the role in realising my career goals. On several
effects of cytotoxic drugs on patients and being occasions I have had to communicate very
able to provide medical and emotional support difficult information to patients and their
was enlightening. Owing to a prolonged families. This has been challenging but
hospital stay with many patients experiencing extremely rewarding.
severe illness, it was vital to develop an open, I can fully appreciate the importance
trusting, and supportive rapport. of being an effective team player, developing
Colorectal surgery was my last rotation; good communication skills, and always having
with a high turnover of patients, good a patient centred approach.
organisation and prioritisation were essential. The skills I have acquired as a junior doctor
Being mostly ward based, I appreciated having have been invaluable.
done my medical and intensive care rotations Nida Gul Ahmed, England
beforehand, allowing me to be thoroughly
 FIRST YEAR TALES FROM BMJ CAREERS

“Will I ever get good at this?”

As a 12 month old baby doctor, I’ve had developmental milestone delays, but I’m
starting to walk after a long “bum shuffling” phase learning organisational skills.
At the start I was very apprehensive about my crash bleep going off. Well,
I’m a bit sorry to say that I now love crash calls. I may still be nervous, but
the adrenaline rush is invigorating. My first ever chest compression began
with the sound of a cracked rib and the two minute cycle exhausted my
arms, but the sweet sound of an output and a pulse brings a smile to my
face. I was called to another patient who arrested in the ward toilet. He didn’t make it, but I still
thought that I could do this sort of stuff forever. Does that make me weird?
There is a lot wrong with the house officer year: portfolio stress, getting blamed for everything,
fatigue, worry, annual leave planning, and that old chestnut, death. But all is forgotten when I’m
dealing with an emergency and I remember that I wouldn’t want to do anything else.
Clinton Vaughn, England

Advice about seniors from BMJ’s community

I had great relationships with my seniors, especially the postgraduate trainees and the housestaffs. It’s
because of them that the daily grind of the work (~70-80 hours/week) didn’t bother me that much–I was
among friends. They show you the way when you freeze attending a patient with cardiogenic shock for
the first time. I remember my senior in general surgery staying back till 0100 to supervise me doing a
venesection. And when everything goes snafu they are the ones to bail you out. Debajyoti Datta, India

“Pre-empt questions: neurosurgeons will want to know a patient’s GCS, serum sodium and INR;
renal physicians will want to know the pH and serum potassium etc.” Adam Asghar, England

“The only stupid question is the one you don’t ask.” Maryam Ahmed, England

“My mind went blank—all those lectures on fluid

balance and I still couldn’t think of what to give”
There is nothing like learning on the job.
Looking back I recall my first week as terrifying—I even feared fluid prescribing, which like many
other things is now second nature. As the weeks passed I gained confidence and picked up the
tricks of the trade, quickly realising that as long as the jobs got done everything remained sweet.
From putting out blood forms to ordering chest x rays, managing acutely unwell patients, and
making nerve racking telephone calls to the on-call registrar, I fulfilled my role. Not a day passed
without an exciting moment or a learning opportunity.
Omar Barbouti, Kent

YOU WILL SURVIVE | 15

 FIRST YEAR TALES FROM BMJ CAREERS

“My confidence was destroyed when I was told

that the previous junior doctors were the best
the consultants had seen, and had worked to
the level of senior house officers”

Difficult, stressful, and sometimes negative

experiences from the past year tend to stay
with me, more so than the numerous exciting,
fulfilling events. Memories include being unable
to cannulate patients, making inadequate
referrals, or watching patients improve
medically, then suddenly deteriorate and die.
Positive moments include talking to patients
and relatives, and being thanked for clarity
and empathy; patients recovering after being
seriously unwell; and being complimented by
consultants and registrars for doing a good job.
I have enjoyed and benefited greatly from
the camaraderie between FY1s, and I have
been fortunate to work within good teams, as
well as with some great nursing staff. My most
interesting conversations have been in the
evenings or at night—making it almost worth
being at work during antisocial hours.
With each new rotation I initially felt out of
my depth, and yet by the end of four months I
became more confident and was able to make
more independent decisions.
Tabassum A Khandker, England

BMJ’s community advises on ordering tests

“Do not book urgent investigations on the system and just wait; find out the protocol for urgent
investigations in your hospital and follow it.” Heather Henry, England

“There is (or should be!) no such thing as a ‘routine’ investigation. An investigation should answer a
uestion, preferably one to which you already know the answer.” Peter Martin, England

16 | BMJ GUIDE FOR NEWLY QUALIFIED DOCTORS

 FIRST YEAR TALES FROM BMJ CAREERS

“Having half expected “There’s something about

to be a glorified medical the pressure of being
student, I realised expected to know that can
something had changed” make you crumble”
This has certainly been a year of learning to It can also ensure you learn something and
swim at the deep end. learn it well.
My first night shift was spent covering a The foundation year really lived up to its
medical ward just after Christmas when there name, providing the foundations to build my
had only been skeleton staff for four days. It career on. The gear shift from medical student
was emotionally and physically draining and to working doctor ensures there is plenty
made me want to walk away from my medical of responsibility, and with it pressure. Each
career, but I realise now I am better off for it. specialty I have rotated through this year has
Call me crazy, but I have gone from fearing given me different perspectives of hospital
night shifts to welcoming them as a pleasant medicine.
change. Yes, I still feel that bleeps could be It hasn’t all been fun and games, but every
used as instruments of torture, but there is day has been packed with new learning
a surreal tranquility about walking down and practising a huge range
dimly lit corridors and talking in whispers. of skills. The workload is
The satisfaction of accurately assessing immensely diverse and
and managing an unwell patient, inserting has included being the
a difficult cannula, or being offered a well first on scene at crash
buttered piece of toast are bonuses. calls; navigating
Having said that, it never ceases to frustrate the murky waters
me how the day you finish nights is called of medical ethics;
“time off.” Surely giving me 23 hours to auditing and
readjust my sleeping patterns does not equate administrative
to a mini holiday? work; and holding a
Foundation year has taught me how to dying patient’s hand
be a doctor in more ways than one; clinical in his last moments.
knowledge, although important in its own Week by week I have
right, has almost been less relevant than felt myself becoming
mastering a calm and confident approach to a more competent and
stressful situations. confident doctor.
Yasmin Akram, England Ali S Hassan,England

• Want to know more about pay, working conditions, or what it’s like to work in certain
specialties? Find out all this and more in BMJ Careers focus at careers.bmj.com

YOU WILL SURVIVE | 17

 USEFUL EXTRAS

Some of the hundreds of other tips we got from BMJ’s community

“Don’t be afraid to ‘blow the whistle’ “You are junior doctor, not superman, and people know
if you witness a dangerous incident.” this; mistakes are expected. This is how you learn. Ask
for help, and you will usually get it. If after the first few
“Don’t instruct over the phone weeks you still do not like your job, talk to someone
without later writing in the notes.” about it. If you bottle things up you are in danger of
becoming ill yourself.” Catriona Bisset, Scotland
“Know when to hand over something
that takes you beyond your limits.
Otherwise you will walk through
the corridors with the hospital’s “Most importantly, try to have a life outside
problems on your shoulders, and medicine, as medicine is a profession that easily
that’s the med reg’s job!” takes over your life.” Tiago Villanueva, Portugal
Adam Asghar, England

“Everyone gets frightened and tired, and feels like an imposter at some
stage. Work to your capabilities, never be afraid to admit you don’t know,
and you will be fine!” “Don’t be afraid:
help is only a
“Never write down an examination finding that you didn’t actually examine” bleep away!”
Michael Haji-
“Wear comfortable shoes and laugh a lot.” Coll, England
Rochelle Phipps, New Zealand

“Drug companies lie occasionally and mislead often. Do not obtain your
information from representatives. There is no such thing as a free lunch.
Read the evidence for yourself (critically).” Peter Martin, England

“Gradually, you will become more familiar with ‘what happens next’ in any situation, and
you will grow more confident. Then you will get overconfident and cocky and make an error
that shakes you (hopefully not a serious one). You’ll go back to being uncertain about when
to be scared, but not quite as uncertain as before. Over time this will build up into a corpus of
familiarity, humility, and confidence that you can depend on.” David Berger, England

18 | BMJ GUIDE FOR NEWLY QUALIFIED DOCTORS

 USEFUL EXTRAS

Nearing the end. A blog by House Officer on BMJ’s community site

Post night-shift ruminations: I feel very lucky to be in a vocation that uses the power of science to help
people. I should be sleeping now but my mind is still buzzing from all this job-satisfaction. Watching
the sunrise at dawn I was suddenly struck by the beauty and nobility of my profession—the profession
of those whose hearts embrace their fellow human beings and whose minds critically analyse the
laws of nature. Seeing the ward of slumbering patients basked in the early morning sunshine I felt the
reassuring tug of the unbroken chain that stretches back in time to Hippocrates.
My fellow junior doctors would understand the farcical and ironic nature of the above paragraph.
Some of you more straight-laced senior docs might not. It’s almost a year ago that we all started out as
newly qualified doctors. At the time a consultant friend of mine told me: ‘As a junior you see the best
and worst of human nature—mostly the worst.’ At the time I dismissed it, but now that I think about
it, I find it difficult to totally disagree with him. Since last August I have done precious little ‘doctoring’
but a tremendous amount of typing and phlebotomy. They told us that our learning curve would be
exponential—this is probably true—it’s at least supralinear; but an interesting side effect is that my skin
thickness also grew rapidly. There’s something about the interesting combination of being on the lowest
rung of the ladder and regularly seeing death and disease that facilitates the growth of an emotional
callus. The newly qualified version of me last August was a delicate soul—sensitive to criticism and
yearning for appreciation. I am now somewhat changed by the relentless summation of incidents that
happen to the typical junior doctor. Here are some examples:
• Patient’s relative: ‘No offense, but you don’t seem to know what’s going on.’ Me (in my head):
‘You’re very astute.’
• Young gastro patient: ‘I spend most of my time in hospital. I have no social life and no girlfriend.
You don’t know what it’s like.’ Me: ‘I kind of know.’
• Radiologist: ‘I agree that she needs a CTPA but I’d like to be asked by at least your registrar.’
• Patient: ‘My eye doctor is also Chinese but he’s nice.’
• Registrar (at the end of a 13 hour nightshift): ‘Please perform a PR before you go home.’
• Surgical registrar: ‘If you accept a house officer-to-house officer referral again I will cut off your
testicles.’ Me (in my head): ‘Your surgical instruments cannot cut through steel.’
To the new graduates this year, I give you some advice to be remembered at 0300 when your bleep
rings so frequently that the plastic begins to melt:
1. As a house officer you are the lowest of the low. Remember that fact.
2. Don’t get on the wrong side of nurses. Not because of any multidisciplinary teamworking
nonsense but because they have power over you, and people with power will always use it to
harm others.
3. As a house officer you are the lowest of the low. Remember that fact.
4. Your seniors (these include the healthcare professionals and the catering staff) will not care
about what you’ve done well, but only what you’ve done badly.
5. As a house officer you are the lowest of the low. Remember that fact.
6. All this will pass. Death is coming to all of us. Even the universe itself is dying a heat death.

YOU WILL SURVIVE | 19

 S CO R I N G S Y S T E M S R E F E R E N C E I N T E R VA L S

Patients in AF: aspirin v warfarin (CHADS2) Community acquired pneumonia (CURB65)

Congestive heart failure 1 Confusion New onset 1

Hypertension (treated or not) 1 Urea > 7 mmol/l 1

Age > 75 yrs 1 Respiratory rate > 30 1

Diabetes 1 Blood pressure Sys < 90 or dia < 60 1

Stroke/TIA 2 65 Age > 65 yrs 1

Score 0 = Low risk Score 0-2 = Mild to moderate CAP

Score 1 = Moderate risk – daily aspirin Score 3+ = Severe CAP
Score 2+ = Moderate to high risk – warfarin
(if not contraindicated) Abreviated mental test (10 point AMT)
Seek senior advice before starting treatment Age 1
Date of birth 1
Year 1
Time of day (without using clock) 1
Wells scores:
Place (city or town is acceptable) 1
for PE Monarch (or prime minister) 1
Clinical signs of DVT 3 Year of World War I or II 1
Alternative diagnosis less probable than PE 3 Counting 20-1 (can prompt to 18, e.g. 20, 19, 18) 1
Heart rate > 100 bpm 1.5 Recognition of 2 people (e.g. doctor, nurse) 1
Immobilisation or surgery < 4 weeks ago 1.5 Recall of 3 points (e.g. address or 3 objects) 1
Previous DVT/PE 1.5 NB: Variations exist; this is a guide.
Haemoptysis 1
Cancer 1 Pancreatitis scoring (Glasgow system)
PaO2 < 8.0 1
Score <2 = Low probability of PE
Age > 55 1
Score 2–6 = Moderate probability of PE
Score 6 + = High probability of PE Neutrophils (WCC > 15 x 10 9 /l) 1
Ca2+ <2.0 mmol 1
Renal Urea > 16 mmol/l 1
for DVT
Enzymes LDH > 600 IU/l or AST > 100 IU/l 1
Active cancer 1
Albumin <32 g/l 1
Paralysis, paresis, or recent plaster Sugar BM > 10 1
immobilisation of the leg 1
Recently bedridden for > 3 days Score 0-2 = Mild to moderate pancreatitis
OR major surgery within 4 weeks 1 Score 3+ = Severe pancreatitis (may require HDU/ITU)
Localised tenderness in area of deep venous
system 1 Chronic kidney disease (CKD) staging
Entire leg swollen 1 Stage 1 GFR > 90 ml/min with structural/
biochemical abnormality
Calf swelling by more than 3 cm
compared with the asymptomatic leg 1 Stage 2 60-89 with an abnormality (as above)
Pitting oedema – greater in the symptomatic leg 1 Stage 3 30-59 ml/min
Collateral superficial veins – non-varicose 1 Stage 4 15-29 ml/min
Alternative diagnosis as likely or more Stage 5 < 15 ml/min
possible than that of DVT -2 Labelling someone as having CKD requires two samples
Score < 2 = Low probability of DVT at least 90 days apart
Score 2+ = Moderate to high probablility of DVT Online GFR calculator: www.renal.org/eGFRcalc/GFR.pl

20 | NEWLY QUALIFIED DOCTORS

 ESSENTIAL TELEPHONE NUMBERS

Anaesthetics Medical manager

A&E x ray Medical records
Anticoagulation clinic Medical registrar
Anticoagulation nurse Microbiology
Bed managers Mobility physio
Biochemistry on-call MRI
Biochemistry OT
Bone scans Outpatients
Breast nurse Pain team
Cardiology Palliative care
Cardiology clinic Pathology
Care managers Payroll
Chest clinic PGMC
Chiropody Pharmacy
Coroner Phlebotomy
CT Physiotherapy
Dermatology clinic Porters
Diabetes nurse Pre-op
Dietitians Registry
Doppler SALT
EEG Surgical manager
EMG Ultrasound
Endoscopy Vascular USS
Eye clinic X ray
Facilities
GUM clinic SURGICAL WARDS
Haematology
Hearing & balance
Histology
Histopathology
Human resources MEDICAL WARDS
IT
ITU
Liaison psych
MDM coordinator

YOU WILL SURVIVE | 21