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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5230_Библиотеки_им_академика_М_И_Перельмана.pdf
Audit
Audit is simply comparing practice in your hospital with best practice or
clinical guidelines. There are six main stages to the ‘audit cycle’:
1. Dene standards (eg replace cannulae every72h)
2. Collect data (duration of placement for 50 consecutive cannulae)
3. Compare data to standards (87% of cannulae replaced in72h)
4. Change practice (present data to colleagues and propose new
approaches, eg date of placement written on cannula dressings)
5. Review standards (replace cannulae every 72h unless nal dosein2h)
6. Reaudit (repeat data collection after 3mth— has anything changed?).
Without reaudit, the cycle is not complete and those assessing your audit
will look for evidence ofthis.
Why does audit matter?The aim of audit is to improve the quality
of patient care; it allows a unit to applaud areas of strength and improve
areas of weakness. Audits will also benet you as a FP doctor since they
are important in job applications and interviews and without at least one it
will be hard to get a ST job. Try to do at least two during yourFP.
Choosing an audit Almost any aspect of hospital/ ward life can be
audited. Choose something simple that interests you; alternatively, look at
relevant guidelines and choose one that is simple to measure.
Dening standardsTry searching the National Library for Guidelines
(accessible via Mwww.library.nhs.uk); alternatively, dene best practice
yourself by asking seniors and supervisors about what is expected.
Collecting dataThe simpler your audit, the quicker and easier this will
be. There are many ways of doing this including checking clinical notes,
questionnaires, and monitoring activities yourself. Try to make your
methods objective so that you do the same for every set of notes/ subject.
Compare data tostandardsThe method for doing this depends on the
type of data you have collected; it is easy to do some simple statistical tests on
data— seek advice from your educational supervisor or other seniors.
Change practiceTry to present your audit to relevant clinicians, eg an
FP teaching session or a ward meeting; use your ndings to propose feasible changes to practice and discuss these with the audience.
Review standardsYou may feel that the original standards you dened
are still suitable; alternatively, the process of auditing may have shown you
that these standards need updating.
Close the loop Repeat the data collection to see if the changes to
practice have made a dierence; it is a good way to stay in touch with old
wards and looks fantastic onaCV.
Example auditsA fewideas:
• Are ECGs performed within 20min in ED patients with chestpain?
• Are drugs prescribed in accordance with local guidelines?
• Do all patients have appropriate thromboprophylaxis prescribed?
• Do patients admitted with chest pain have their cholesterol measured?
63AUDIT
64 CHAPTER Being adoctor
Presentations and teaching
The thought of having to give an oral presentation provokes anxiety in
most of us. Being able to relay information to an audience is a valuable
skill and one which gets easier with time and experience, though it is
helped by a logical approach.
Types of presentation There are four main types of presenta-
tion:audit/ research, journal club (critical appraisal of research), case presentation, and a teaching session.
When is thepresentation?If you have months to prepare then you
can really go to town, while if you have only a few hours you need to concentrate on the essentials.
How long should it last? A 5min presentation will still need to be
thorough, but less detailed than that lasting an hour. The length of the
presentation will also aid you in choosing thetopic.
What is the topic? Clarify as early as possible the topic you are to
present and any specic aspect of the topic you should be discussing. If
you can choose the topic, select something you either know about or are
interested in researching.
Audience Are you presenting to your peers, seniors, or juniors? Are
they ignorant of the topic or world experts? This information will determine the level of depth you need to gointo.
Venue and means ofdelivery How far away is the audience, how
big is the screen (so all your text and diagrams are clear)? Will you use your
laptop or their computer? Back- up on memory stick in current as well as an
older version of PowerPoint in case your computer isn’t up todate.
Sources ofinformationDo you already have books on the subject?
Read about the topic on the Internet by undertaking a search with a website such as Mwww.bmj.com. Search PubMed using keywords; recent review articles are a good place tostart.
If there is no information If you cannot nd enough information
then it is likely you are not searching correctly; ask library sta for help.
If there really is a lack of information then consider changing the topic, or
choose an easier approachtoit.
How many slides? This depends on how much detail is present on
each slide. On average 20– 25 slides will last about30min.
Slide formatDon’t get too clever. Slides should be simple; avoid bor-
ders and complex animation. PowerPoint has numerous pre- set designs,
though remember it is the content of your talk the audience needs to be
focused upon. Consider using a remote slide advance device (<£5).
Presentation formatThe presentation is in essence an essay which
the speaker delivers orally. It should comprise a title page with the topic,
speaker’s name, and an introduction which states the objectives. The bulk
of the presentation should then follow and be closed with either a summary or conclusion. Consider ending with a slide acknowledging thanks
and a nal slide with simply ‘Questions?’ written on it to invite discussion.
TitlesGive each slide a title to make the story easy to follow.
FontShould be at least size 24. Ensure the text colour contrasts with the
background colour (eg yellow text on blue background). Avoid using lots
of eects; stick to one or two colours,
bold, italics, or underline features.
GraphicsUse graphics to support the presentation; do not simply have
graphics adorning the slide to make it look pretty.
How much information Avoid overcrowding slides; it is better to
use three short slides than one hectic one. Each slide should deliver one
message and this should be in six bullet points orfewer.
Bullet pointsUse to highlight key words, not full sentences.
PowerPoint eectsKeep slides simple. Avoid text ying in from all dir-
ections and don’t use sound eects as these distract the audience.
RehearsingGo through the presentation a few times on your own so
you know the sequence and what you are going to say. Then practise it in
front of a friend to check timing andow.
Specic types ofpresentation
Audit/ researchEnsure you give a good reason why the audit or research
was chosen and what existing research has already been undertaken.
State your objectives, your method, and its limitations. Use graphs to
show numerical data and clearly summarize your ndings. Discuss limitations and how your audit/ research may have been improved. Draw your
conclusions and indicate where further research may be directed. Thank
the appropriate parties and invite questions/ discussion. See audit/
research section E p. 63,p. 68.
Journal clubBegin with a brief explanation of why you have chosen to discuss
the particular clinical topic and list the articles which you have appraised. Aim
to include why the study was undertaken, the appropriateness of the study,
the methods and statistics used, the validity of the study, and make comparisons between dierent studies. Include latest guidelines and invite discussion
regarding how the research may aect current clinical practice. Finish with
a summary of the studies undertaken, their results, and where they were
published for future reference (Box.20).
Case presentation The presentation should tell a story about a patient
and let the audience try and work out the diagnosis as though they are
clerking the patient for the rst time. Name the talk something cryptic,
eg ‘Headache in the traveller’. Refer to your patient by initials only and
make sure patient details are blanked on all images and test results.
Present the history and physical examination. Invite audience suggestions
for the diagnosis and management. Give the results of investigations and
again invite the audience to comment. Give the diagnosis and discuss
subsequent management. Summarize with an outline of the topic and
management; end with a question/ discussion session.
Teaching sessionIt is helpful to base a topic around a patient if this is appro-
priate. Keep the session interactive; have question slides where the audience
can discuss answers. Summarize with learning points; it is helpful to provide
a handout of your slides for people to take away (Ep. 67).
65PRESENTATIONS AND TEACHING
66 CHAPTER Being adoctor
Giving thepresentation
Equipment Make sure there is a projector/ computer available and that
it works. Leave enough time in case you need to nd new equipment.
TimingArrive early and check your slides project correctly. Leave the title
page projected so the correct audience attends.
SpeakingSpeak loudly so you are heard at the back. Agood speech de-
livered inaudibly disappoints more than a bad one delivered audibly.
Body language Stand at the front and avoid obstructing the projector.
Talk directly to your audience to appear more condent and see their
response.
BeginningIntroduce yourself and your position, outline the topic, and ex-
plain why you chose it. Ask whether everyone can hearyou.
To use notes or notYou shouldn’t need notes but have them available.
StyleKeep it professional, but show you are human; it is acceptable to be
light- hearted and make the audiencelaugh.
PacingYou will talk faster than you think. Take your time and use silence.
QuestionsDecide before if you want questions during or after. Anticipate
what they might be and prepare for them. Say if you don’tknow.
Feedback Whenever possible ask for feedback and learn from the
comments. Consider sending a ‘Developing the clinical teacher’ assessment (Ep. 9).
Box .20 Critical appraisal
Critical appraisal is the assessment of data in scientic articles. Though
many evidence- based resources are available, a basic understanding of
academic skills such as critical appraisal forms part of the postgraduate
curriculum and is a fundamental part of being a good doctor. During
the FP, your skills may be tested via a journal club, research project, or
by a complex patient. Becoming procient is a lengthy process because
scientic writing can seem strange and intimidating and research is by
its nature highly specialist. The following is a useful structure to focus
the mind when reading, contextualizing, and critiquing scientic papers:
IntroductionWhat question is being asked? Is it important, original, interesting,
logical, and testable? What does it add to what we alreadyknow?
MethodsDo the methods answer the question? ‘TROPES’ is useful:
• Type of study— interventional or observational, retrospective or
prospective?
• Risk factor— if observational, is the risk factor or disease clearly dened?
• Outcomes— primary (usually clinical), secondary or tertiary/ exploratory
• Population— who was included/ excluded; do they represent your
patients?
• Ethical issues— was there funding, a conict of interest, and/ or
ethical approval?
• Size— sample size and length of follow- up.
ResultsWas follow- up long enough? Were the statistics appropriate?
DiscussionWas the study valid internally (the study itself) and externally
(generalizability to clinical practice)? Were biases identied/ reduced?
Remember that correlation does not equal causation.
Teaching medical students
Teaching will benet you as much as the recipient; it will challenge you to ll
any gaps in your knowledge and organize your thinking on the subject. You
may not feel that you know enough to teach medical students but you are
probably the best teacher on the ward for them, for two reasons:
• You have recently passed the nals exam that they are trying to pass,
often at the same medicalschool
• Finals are meant to test core medical knowledge; this is what you do
every day when you clerk and manage a patient.
PortfolioKeep a record of teaching sessions, ideally with feedback (con-
sider using a simple online survey tool). At least once a year you will need
to complete a ‘Developing the clinical teacher’ form assessment (Ep. 9).
Teaching principlesWhatever information you are trying to convey,
it is important to follow a few simple guidelines:
• Be clear about your objectives. Pick a couple of main points to deliver
• Plan what you are going to teach to give it structure
• Be interactive; this means that the students do some of the work and
also are more likely to rememberit
• Try not to use too much medicaljargon
• Give relevant examples
• Check the students’ understanding throughout and invite questions.
Suitable patientsOne of the worst parts of being a medical student
is nding suitable patients to take a history from or examine. You can use
your patient lists (E p. 8) and rst- hand experience of the patients to
guide medical students to conscious, orientated, and friendly folk or those
with clinical signs. Better still, oer to introduce the student.
Clinical examinationOer to watch the student examine a patient
and give feedback on their technique. You are likely to examine more patients in your rst month as a doctor than in all your years as a medical
student so your clinical skills will have advanced very quickly.
FP applicationsWith all the recent changes to medical training, many
students feel bewildered about what lies ahead. Once again you are in the
ideal position to advise since you have already successfully applied for the
FP. Simple advice about which are the best jobs, how to ll in the application form, or even showing a copy of your own form can be a greathelp.
Clinical approachYou can also teach ‘how to be a doctor’- type skills
that are rarely passed on. The trick is to choose a simple subject you know
lots about,eg:
• Managing chest pain/ breathlessness
• Fluid management and volume assessment
• Writing innotes.
67TEACHING MEDICAL STUDENTS
68 CHAPTER Being adoctor
Research and academia
ResearchWhatever direction you see your future career heading in, the
opportunity to undertake a period of research will help you gain insight
into this vital area that underpins all of medical practice as well as to develop the skills necessary to understand research output. You don’t need
to cure cancer— often the most successful projects are those that set out
to answer a simple, well- formulated question.
Academia This is not turning your back on clinical medicine, but rather
adding a new dimension to your clinical experience:most academic doctors do
research alongside clinical work. There are many advantages (interest, worldwide conferences, really understanding your subject, making a dierence) but
pay is not one of them. There are various training routes for academics detailed as follows— there is no one single way in; if at any stage you want to do
research or a PhD there are always opportunities if you look andask.
Foundation yearsThere are small numbers of 2yr FPs with academic
components (E p. 6). These are often a normal Fyear with a 4mth academic attachment in F2 (eg academic rheumatology); a few have academic
components scattered throughout F2±F.
ST yearsThere are also academic ST positions called ACFs. Most of these
are available for entry either at ST or ST3 level and are 2– 3yr long, including
clinical rotations alongside 25% of working time set aside for academic work.
The rst year will be almost entirely clinical; the purpose of the second and
third years is to give you the opportunity to design a PhD/ MD research project, generate preliminary data, and apply for funding. Once you successfully
get funding, you enter the training fellowship.
Training fellowship This is a 3yr research project designed by you
with the aim of getting a PhD (or alternatively a – 2yr MD) with small
amounts of protected clinical time to maintain your skills.
Clinical lectureshipWith a PhD/ MD under your belt, you can apply
for a 3– 4yr lectureship post. This will give you clinical experience while
training to consultant level, and allow you to pursue postdoctoral research
interests. You will again need to apply for funding, eg a clinician scientist
fellowship. Once you have completed this post you will be eligible for consultant or senior lecturer positions.
Finding a project Although some academic posts will come with
funding already tied to a specic laboratory or project, the most rewarding
projects are often those that you design yourself, together with a senior
academic mentor. It is important to speak to a range of people and read
and discuss broadly. Keep three things in mind: () do I get on with the
supervisor and have other clinicians had good experiences in the group?
(2)Does the project interest me? (3)Where will the project lead (eg will
you be able to apply for the career or subspecialty that you want)?
FundingOne of the challenges of academic medicine is that you often
need to raise funding to pay for yourself and your research. The process
can take time (eg >6mth) and involves lling in multiple forms. Always talk
to your potential supervisor for advice on the best options.
Chapter2
Life onthewards
The medical team 70
The multidisciplinary team 72
Daily ward duties 73
Ward rounds 74
Writing in the notes 76
Common symbols in the notes 78
Anatomical terms and planes 79
Forms
Investigation requests
Radiology 8
Discharge summaries (TTOs/ TTAs) 82
Fitness to work notes 84
Referrals 85
Referral letters 86
Common ward dilemmas
Being on-call
Night shifts 90
Pain 92
Nutrition 96
Nutritional requirements 97
Healthcare-associated infections 98
Aggression and violence 02
Needle- stick injuries 03
Surgery
Pre- op assessment
Bowel preparation 06
Surgical terminology 07
Preparing in- patients for surgery 08
Adjusting medications for surgery 09
Booking theatre lists 0
Surgical instruments
The operating theatre 2
Post- op care 4
Post- op problems 5
Wound management 6
Common elective operations 7
Stomas 9
80
88
04
69
70 CHAPTER2 Life onthewards
The medicalteam
The changes to medical training have caused confusion about the names
and roles of dierent trainees. The medical team usually consists of four
levels of responsibility:() consultant level, (2) registrar level, (3)SHO
level, and (4)F (house ocer level). Many rms may have more than one
doctor at each grade of responsibility. Indeed, doctors of the same grade
may have subtly dierent professional circumstances, as detailed below.
F level These are doctors in their rst year after medical school with
provisional registration from the GMC. The limited registration means that
F doctors can only work within an approved NHS foundation programme
post and have some restrictions on their work (hospital trust policies vary).
F role Fs manage the day- to- day running of the ward including
ward rounds, ward jobs, procedures, and reviewing unwell patients;
E p. 73 for more detail.
SHO level Doctors with full GMC registration. This term refers to
several posts with a range of experience.
F2These are doctors in the second year of the FP; this will often be their
rst experience in the specialty and at SHO level. Expectations vary:in
some trusts/ specialties, F2s will usually share a rota with F doctors.
F3/teaching fellow Doctors who have taken an extra year (or more) before
progressing into a specialty training pathway. These jobs are designed and
advertised by individual NHS trusts and therefore vary in terms of clinical
commitments. Most will have dedicated time for teaching or research.
Internal medicine trainees (IMT–3) Most hospital medicine specialties re-
quire 2 or 3 years of general medical training. The IMT3 year is designed
to facilitate the transition to medical registrar and IMT3 doctors may
‘act-up’ as the medical registrar on call.
Junior specialt y training registrar (StR, ST– 2/ 3)Doctors in specialties with
run- through training (E p. 45) who will progress to registrar- level specialist training unless they fail to attain competencies or exams. Despite
the title, it is misleading to call them ‘a registrar’.
Academic clinical fellow (ACF) The academic equivalent of ST– 2/ 3 and
IMT– 2/ 3 who perform a similar role, except that they have 25% of
their time set aside for research. The situation can become confusing in
certain posts, where ACFs are appointed at ST3level.
Fixed- term specialty training appointment (FTSTA) A post for doctors who
were unwilling or unable to secure an ST/ CT post. The posts last year
and will be at ST, ST2, or ST3 level. At the end of the year they can
apply for an ST or FTSTA post at the next level if they have attained the
relevant competencies.
GP specialty trainees (GPST–3) Doctors undertaking hospital rotations as
part of their GP training programme.
SHO role These doctors are your rst port of call for help. They can
advise on patient management, ward jobs, and supervise practical procedures; they often work alongside Fs on the ward, though they may
have clinic and theatre commitments too. They are an excellent source
of advice on careers, applications, exams, training courses,etc.
Registrar levelIf you describe yourself as ‘a registrar’ most people will
assume that you are at this grade.
Senior specialty training registrar (StR, ≥ST3/ 4)In most specialties this grade starts at
ST4 level, though some start at ST3 (‘Group 2’ specialties, usually those with no
acute medicine commitment). These doctors work towards CCT (Certicate
of Completion of Training) and can then apply to the GMC specialist register to
work at consultant level.
Specialist and associate sta (SAS) doctors These are doctors with at
least 4 years of postgraduate experience who work in a specialty but
are not within a specialty training programme. Rather than working towards a CCT, they can apply to join the GMC specialist register by CESR
(Certicate of Eligibility for Specialist Registration).
Clinical fellow A specialty doctor who also has eg research, teaching, or
management duties. They may need to secure an ST3/ 4 post afterwards.
Clinical lectureship The academic equivalent of ≥ST3/ 4. They will split
their time between clinical and research work.
Registrar role These doctors supervise the day- to- day running of the
ward; they perform similar jobs to consultants (ward rounds, clinics, theatre lists) but with fewer management responsibilities. Registrars usually
receive referrals from other teams and will spend time reviewing these
patients too. Their presence on the ward varies between specialties.
Consultant level These are the most senior doctors on the team;
there are several posts at thislevel:
ConsultantThe most common post at this level. Reached by obtaining the
CCT (E p. 45) or via proof of equivalent training known as theCESR.
Academic Doctors who split their time between research and clinical
medicine. They may be called ‘honorary consultants’ alongside an academic grade (eg senior lecturer, reader, associate professor, professor).
Associate specialist A doctor with consultant- level ability and experience
who does not have a CCST/ CCT/ CESR. They do not have the accountability or management commitments of consultants.
Consultant role Consultants are responsible for everything that happens
on the ward including the actions of junior doctors. They may lead ward
rounds, work in clinics, supervise a research laboratory, or spend time
in theatre; their level of involvement in the day- to- day running of the
ward varies between specialties and management styles. They will perform your FP appraisals (E p. 27) and are a good source of advice for
careers, audits, presentations, etc. If ever you need help and only the
consultant is available, then do not hesitate to contactthem.
Other team members
Mid- level practitioners Advanced nurse practitioners (senior nurses with
additional training) and physician associates (graduates of a dedicated 2yr
master’s programme). Specic responsibilities vary and are evolving but
many can specialize, clerk, perform medical procedures, and prescribe.
Medical students Medical students are present in most hospitals and
should be encouraged to become part of the medical team.
71THE MEDICALTEAM
72 CHAPTER2 Life onthewards
The multidisciplinaryteam
NursesThese have a ‘hands- on’ role, ranging from administering medi-
cations to attending doctors’ rounds. Don’t be afraid to ask their advice—
their experience means they can often help you out. Most can take blood
and perform ECGs, some can cannulate and insert male urinary catheters
(all female nurses should be able to insert female catheters).
Nurse practitioners These are specially trained senior nurses who
can assess acutely unwell patients, perform practical procedures (eg cannulation), and assist in theatre. Most cannot prescribe, although there are
some who are qualied to use the nurses’ formulary (Ep. 166).
Specialist nursesThese include stoma, respiratory, pain, cardiac, dia-
betes, tissue viability, and Macmillan nurses. They are excellent for giving
advice and are an important rst port of call for the junior doctor.
Healthcare assistants (HCAs) These perform more basic nursing
tasks, eg personal care, recording observations, nger- prick glucose. They
cannot dispense medication or give injections, but many can takeblood.
Bed managers These perform the dicult task of managing hospital
bed status, and arranging transfers and admissions. They need to know
when your patients are likely to be discharge ready, so they can plan ahead
for routine admissions. Therefore this information is important to know.
Discharge coordinators These work with social workers,
physiotherapists, and occupational therapists to expedite patients’
discharges, and often help in nding social and intermediate care placements (Box 2.).
Occupational therapists These work with patients to restore,
develop, or maintain practical skills such as personal care. They assess patients’ homes for changes required to help with activities. Many elderly patients require OT assessment before discharge— nurses usually make the
referral. OTs work in primary and secondary care (Box 2.).
Pharmacists These dispense drugs and advise on medication. They
check the accuracy of every prescription. Some hospitals have a medicines
information line that you can call for prescribing advice.
Phlebotomists These are professional vampires who appear on the
wards with the sole aim of taking blood. They often appear at unpredictable times, and may not come at all at weekends, so leave blood forms out
in advance. Some can take blood from central lines and perform blood
cultures. If asked nicely they may accept requests mid-phlebotomy round.
Physiotherapists These use physical exercises and manipulation to
treat injuries and relieve pain. Chest physios are commonly found on
respiratory and surgical wards to help improve respiratory function and
sputum expectoration by teaching specic breathing exercises. Involve
them early in patient management— nurses usually make the referral, but
do not hesitate to discuss your patient’s needs or progress directly with
them (Box 2.).
Social workersThese support patients’ needs in the community. They
assess patients and help organize care packages (invaluable for elderly
patients). Where residential care is required, they help guide the family and
patient through the decision- making process and nancial issues. They are
also involved in child protection and vulnerable adult safeguardingwork.