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Your firstday
Preparation forprofessional practiceThis paid induction is usu-
ally online and face to face but there is a dierence between what you
want to know before starting and what trusts are obliged to tell you. The
best people to talk to are your predecessors, and extra shadowing and
background reading about your rst rotation specialty helps immensely.
To reduce the cost of face- to- face induction there is a trend towards
eLearning, but the BMA is clear:induction is work and if done outside of
work should be reciprocated nancially or with time o inlieu.
Pay rollIt can take over a month to adjust pay arrangements so it is vital
to give the nance department your bank details on or before the rst day
if you want to be paid that month. Hand in a copy of your P45/ P60too.
Parking Check with other sta about the best places to park and
‘parking deals’; you will probably need to get several people to sign aform.
CyclingTrusts usually provide safe storage for bikes and sometimes you
can save money on repairs/ new purchases with ‘cycle to work’ schemes.
ID badge Used to access restricted areas of the hospitals. If you need
more access than most (eg crash team members) then request ‘access all
areas’, or equivalent. If the card doesn’t give access then return or x it.
ITComputer access allows you to access results, the Internet, your trust
email, and, in some hospitals, the clinical notes and ePrescribing platform.
Also ask for an NHS.net account so you can access it securely from home
and keep the same email when moving between trusts. Memorize all the
passwords, usernames, etc and keep any documents handed out. Ask for
the IT helpdesk phone number in case of diculty.
Rota coordinator You should get to know your medical stang de-
partment well as they can make your life a lot easier. If you haven’t received your rota in advance then get in touch withthem.
Mobiles and social mediaInduction may be the last time for a while
you are all in one place. Exchanging numbers makes social activities, rota
swaps, and learning opportunities easier to organize, but there will usually
be rolling, trust- wide WhatsApp groups you can join. If not, create one/
ask your FP representative to coordinate eorts (E Box.7).
Important places inthe hospitalTry to get a map; many hospitals
have evolved rather than been designed. There are often shortcuts.
Wards Write down any access codes and nd out where you can put
your bag. Ask to be shown where things are kept including the crash
trolley and venepuncture equipment.
Canteen Establish where the best food options are at various times of
day. Note the opening hours— this will be invaluable for breaks on- call.
Cash and food dispensersHospitals are required to provide hot food 24h a
day. This may be from a machine.
Doctors’ messEssential. Write down the access code and establish if there
is a fridge or freezer. Microwave meals are innitely preferable to the food
from machines. For problems, contact the mess president.
13YOUR FIRST DAY
14 CHAPTER Being adoctor
Occupationalhealth
Most hospitals have an occupational health department that is responsible for ensuring that the hospital is a safe environment for you and your
patients. This includes making sure that doctors work in a safe manner.
You can nd your local unit at Mwww.nhshealthatwork.co.uk
CommonvisitsDuring the FP, your contact with occupational health is
likely to be one of the following:
Initial checkDepending on the procedures you will be undertaking, you
may require a blood test to show you do not have hepatitis C or HIV;
they will need to see photographic proof of identity, eg a passport.
Hepatitis B boosterThis depends on local policies and your antibody levels.
Needle- stick/ sharps injury/ splashes Ep. 03.
IllnessIllness that aects your ability to work may require a consultation.
Infection controlPatients are commonly infected by pathogens from
the hospital and ward sta. The infections are more likely to be resistant
to antibiotics and can be fatal. It is important to reduce the risk you pose
to your patients:
• If you are ill, stay home, especially if you have gastroenteritis or an
upper respiratory tract infection (URTI)
• Keep your clothes clean and roll up long sleeves to be bare below the
elbows in clinicalareas
• Avoid jewellery (plain metal rings are acceptable) and wrist watches
• Clean your stethoscope with a chlorhexidine swab after eachuse
• Wash your hands or use alcohol gel after every patient contact,
even when wearing gloves; rinsing all the soap o reduces irritation.
Clostridium dicile spores are resistant to alcohol, so always wash your
hands after dealing with aected patients
• Be rigorous in your use of aseptic technique
• Use antibiotics appropriately and follow local prescribing policies. For
more information, contact your local infection controlteam.
Sharps and bodilyuidsAs a doctor you will come into contact with
bodily uids daily. It is important to develop good habits so that you are
safe on thewards:
• Wear gloves for all procedures that involve bodily uids or sharps.
Gloves reduce disease transmission if penetrated with a needle—
consider wearing two pairs for treating high- risk patients
• Dispose of all sharps immediately; take the sharps bin to where you are
using the sharps and always dispose of your ownsharps
• Vacutainers are safer than a needle and syringe. Most hospitals now
stock safety cannulae and needles for phlebotomy, use of which
decreases the risk of needle- stick injuries yet further
• Some laboratories may have specic labelling and transport
requirements for blood samples from patients with HIV and hepatitis
B+C; check your local policies
• Consider wearing goggles if bodily uids mightspray
• Cover cuts in yourskin
• Avoid wearing open- toed shoes or sandals
• Make sure your hepatitis B boosters are up todate.
What tocarry
Essentials
Black pens These are the most essential piece of equipment. Carry a
few as people often lose theirs. Blood bottles are usually labelled with
printed stickers but specimen bottles may still need a ballpointpen.
Stethoscope A Littmann
however better models do oer clearersound.
Money and cardsOut of hours, loose change is useful for food dispensers
but most places will takecredit/debit cards.
ID badgeShould be supplied on day and may come with a printerfob.
BleepOften at switchboard, in handover, with colleagues, or on theward.
Mobile phone A plethora of medical apps can make your life much easier;
however, signal can be variable so don’t forget your bleep. Always check
who has written your apps and whether it is a reliable source. Most Oxford
Handbooks, including this one, are now available as an app. Although previous rules restricting their use have largely been eased, it does not look
good to be always on your phone, and it remains the case that they can
interfere with monitoring equipment in ICUs, CCUs, and surgical theatres.
Optionalextras
Clipboard folder Ep. 8.
Pen- torch Useful for looking in mouths, eyes, and ears; very small LED
torches are available in camping shops or over the Internet and can t
onto a keyring or be attached to stethoscopes to prevent colleagues
borrowing and not returningthem.
Tendon hammer These are often hard to nd. Collapsible versions can
be bought for £2– 5, or keep a full-sized one in your bag on the ward.
Alcohol gelClip- on alcohol gels are cheap, will mean you never have to go
searching, and can be more ‘predictable’ than those on theward.
WarddressPatients and sta have more respect for well- dressed doc-
tors, however it is important to be yourself; be guided by comments from
patients or sta. While it may seem restrictive, everyone working in the
NHS is bound by local dress codes. Typically, long hair should be tied back
and jewellery should be kept to a minimum. A pair of smart, comfy shoes is
essential— you will be on your feet for hours and may need to movequickly.
ScrubsTraditionally worn in procedural specialities, scrubs are more ac-
ceptable on call but can appear informal. Check local policy.
®
Classic II or equivalent is perfectly adequate,
15WHAT TO CARRY
K Box .7 Socialmedia
The GMC, BMA, and individual trusts publish guidance for doctors
regarding their use of social media. While Facebook, Instagram, X,
and WhatsApp have many benets for us as professionals and individuals, all blur the line between public, private, and professional life, and
none guarantee condentiality. In using them, we must remember our
duty of condentiality, to treat colleagues fairly, and to maintain trust
in the profession. Any posts should consider the impact on patients,
yourselves, and the profession, avoiding derogatory or oensive comments. Misuse can lead to action by trusts or theGMC.
16 CHAPTER Being adoctor
How tobeanF
Being an F involves teamwork, organization, and communication— qualities
that are not easily assessed during nals. As well as settling into a new work
environment, you have to integrate with your colleagues and the rest of the
hospital team. You are not expected to know everything at the start of your
post; you should always ask someone more senior if you are indoubt.
As an F, your role varies greatly (ask your predecessor) but includes:
• Clerking patients (ED, pre- op clinic, on- call, or on theward)
• Updating patient lists and knowing where patients are (Ep. 8)
• Participating in ward rounds to review patient management
• Requesting investigations and chasing their results
• Liaising with other specialties/ healthcare professionals
• Practical procedures, eg taking blood (E pp. 542–3), cannulation
(Epp. 546–7)
• Administrative tasks, eg theatre lists (E p. 0), TTOs (E pp. 82–3),
re wri ting drug charts (E pp. 167–8), death certicates (Epp. 248–9)
• Speaking to the patient and relatives about progress/ results.
Discharge lettersDischarge letters are your responsibility and without
them patients cannot leave the hospital. Not only are well patients very
keen to be at home, unwell patients needing admission also need to leave
the ED and be moved onto the ward. This process is called patient ow
and is vital in the day- to- day running of the hospital, and making sure
patients are being cared for in the right environment. While there are many
factors that slow down patient ow, patients, clinicians, and management
sta will thank you if high- quality discharge letters are prepared well in
advance. Keep tabs on estimated discharge dates and if you’re not sure,
enquire with your colleagues about who may be going home tomorrow or
the day after.
BreaksMissing breaks does not make you appear hard- working— it re-
duces your eciency and alertness. Listen to your body. Make time to
rest and eat—chocolates from the ward don’t count. You are entitled to
30min for every 4h worked. Use the time to meet other doctors in the
mess; referring is much easier if you know the team you are referringto.
Know your limits If you are unsure of something, don’t be embar-
rassed to ask a senior, particularly if a patient is unwell. If you are stuck
on simple tasks (eg cannulation), take a break and either try later or ask a
colleague totry.
Responsibility You may have to make dicult decisions, some of
which may have potentially serious consequences. Always consider the
worst- case scenario and how to avoid it. Be able to justify your actions and
document everything carefully.
Expectations For all patients under your care, seniors will reasonably
expect you to know the current problem list, medication, and the details
of any recent procedures or investigations, including key recent blood results. Initially this may seem impossible, but with time and careful practice,
your memory for such details will improve. Being ‘present’ helps a lot.
YourbleepWhat at rst seems like a badge of having ‘made it’ quickly
becomes the bane of your existence. When the bleep goes o repeatedly,
write down the numbers and then answer them in turn. Try to deal with
queries over the phone; if not, make a list of jobs and prioritize them, tell
the nurses how long you will be, and be realistic. Ask nurses to get useful
material ready for when you arrive (eg an ECG, urine dipstick, the obs
chart, notes, equipment you may need). Encourage ward sta to make a
list of routine jobs instead of bleeping you repeatedly. The bleep should
only be for sick patients and urgent tasks. Learn the number of switchboard, since this is likely to be an outside caller waiting on the line. Crash
calls are usually announced to all bleep holders via switchboard. If your
bleep is unusually quiet, check the batteries. Consider handing over your
bleep to a colleague when breaking bad news, speaking to relatives, or
performing a practical procedure.
Dropping thebleep inthe toiletThis is not uncommon; recover the bleep
using non- sterile gloves. Wash thoroughly in running water (the damage
has already been done) and inform switchboard that you dropped it into
yourdrink.
Other forms ofbleep destructionYou should not have to pay for a damaged
bleep, no matter how dire the threats from switchboard; consider asking
for a clip- on safetystrap.
LearningYou need to be proactive to learn interpretation and manage-
ment skills as an F. This is especially true when most of the decisions
you make will be reviewed by a senior almost immediately. Despite this,
‘Bloods, CXR, senior r/ v’ is not an adequate plan and represents a failure
to engage with a learning opportunity. Formulate an impression, dierential diagnosis, and management plan for each patient you see and compare
this with your senior’s version; ask about the reasons for signicant dierences. See Box.8.
T Box .8 Service provision vs training?
Acute trusts need doctors to see patients so that they can be treated,
discharged, and the trust reimbursed. Behind this simple fact lies an important point of tension between the aims of the trust and those of
the individual doctor, who will want to develop and acquire new skills.
As a foundation doctor, you are in an educationally approved post, for
which the LETB releases funds to the trust. It is therefore important that
you should be given the opportunities to train and develop, and that you
should be released from routine ward work to attend all dedicated training
sessions. At the same time, the discharge summaries need to be typed, the
drug charts rewritten, and a seemingly endless number of venons resited.
The challenge for all involved is to achieve educationally useful outcomes
within these constraints. This situation is not unique to the FP— all doctors within the NHS have to balance these demands and some of those
tasks you aspire to be able to perform will be the same tasks that have
become routine and even frustrating for your seniors. There are no simple
answers, but a preparedness to work hard, a keenness to seize educational opportunities whenever they present, and a supportive educational
supervisor will all go a long way to achieving professional development.
17HOW TO BE ANF
18 CHAPTER Being adoctor
Getting organized
Your organizational abilities may be valued above your clinical acumen.
While this is not why you became a doctor, being organized will make
you more ecient, ensure you go home on time, and free up time to
make the most of learning opportunities as and when theyarise.
Your ward All departments have dierent ways of working and these
will usually have evolved this way over time for good reason. Equally,
some things may have become out of date and may need updating. If you
have an idea, discuss it with your predecessors and seniors and consider
taking the lead on an audit or quality improvement project.
Folders and clipboards These are an excellent way to hold pa-
tient lists, job lists, handbooks, and spare paperwork along with a portable writing surface. Imaginative improvements can be constructed with
bulldog clips, plastic wallets, and dividers.
Contents Spare paper, drug charts, DNAR forms, phone numbers, job
lists, patient/theatre lists, spare pens, ward accesscodes, and this book.
Patient lists Fs are often entrusted with keeping a record of the
team’s patients (including those on dierent wards, called ‘outliers’) along
with their background details, investigation results, and management plans.
With practice, most people become good at recalling this information,
but writing it down reduces errors. They are usually electronic and may
be manually or automatically generated, allowing every team member to
carry a copy. Lists are invaluable for discussing/ referring a patient while o
the ward but must be kept condential and disposed of securely (Ep. 85).
Job lists During the ward round make a note of all the jobs that need
doing either on your list or on a separate piece of paper. At the end of the
round, these jobs can be distributed among your other team members.
Serial results Instead of simply writing blood results in the notes, try
writing them on serial results sheets (with a column for each day’s results).
This makes patterns easier to spot and savestime.
Timetables Along with ward rounds and clinical jobs there will be
many extra meetings, teaching sessions, and clinics to attend. There are
three blank timetables at the end of this book to use for this purpose
(E pp. 636–640).
Important numbersIt can take ages to get through to switchboard
so carrying a list of common numbers will save you hours (eventually you
will remember them). At the end of this book there are also three blank
phone number lists for you to ll in (E pp. 635–639). Blank stickers on
the back of ID badges can hold several numbers.
Ward cover equipment Finding equipment on unfamiliar wards
wastes time and is frustrating. You can speed up your visits by keeping a
supply of equipment in a box. Try to ll them with equipment from storerooms instead of clinical areas. Alternatively, if you are bleeped by a nurse
to put in a cannula, you could try asking them nicely to prepare the equipment ready for you for when you arrive (it works occasionally).
Being ecient
Despite the years spent at medical school preparing for nals and becoming a doctor, being ecient is one of the most important skills you
can learn in the FP and one that you will value throughout your career.
Working hoursWhile you are contracted to work a xed number of
hours you will often work more, especially towards the beginning of your
career. To make your day run smoothly, get organized rst thing (eg review unwell patients, overnight events, nursing concerns, patient lists, and
latest test results).
Time management You will nearly always seem pressed for time,
so it is important to organize your day eciently. You will get better at
shifting your attention. Prioritize tasks in such a way that things like blood
tests can be in progress while you chase other jobs. Requesting radiology
investigations early in the day is important as lists get lled quickly, whereas
requesting bloods for the next day and prescribing warfarin can wait until
later on. Prepare discharge summaries and TTOs well in advance to avoid
being the rate- limiting step in getting patientshome.
On- callIt will seem like your bleep never stops going o, especially when
you are at your busiest. Write down every job, otherwise you run the
risk of forgetting what you were asked to do. Consider whether there is
anyone else you could delegate simple tasks to, such as nurse practitioners
or ward sta while you attend to more urgenttasks. At rst saying no will
be dicult but not all tasks should be completed by the on-call doctor:
prescribing a regular statin does not need to be done overnight.
How tobe ecient
• Make a list of common bleeps/ extensions (Ep. 636)
• Establish a timetable of your team’s activities (Ep. 637)
• Make a folder/ clipboard (Ep. 8)
• Prioritize your workload rather than working through jobs in order. Try
to group jobs into areas of the hospital. If you’re unsure of the urgency
of a job or why you are requesting an investigation, ask your seniors.
You will get better at this with time, but part of your job is prioritizing
according to clinical need; some of the jobs can wait until tomorrow
• If you are working with another Foundation trainee, split the jobs at the
end of the ward round so that you share the workload
• Run through the patient list throughout the day to review progress
• Submit phlebotomy requests at the start/ end of each day (nd out
what time the phlebotomists arrive); if a patient will need bloods for
the next 3 days then request them all together with cleardates
• Be aware of your limitations, eg consent should only be taken by the
doctor performing the procedure or one trained in taking consent for
that particular procedure
• Bookmark online or get a copy of your hospital guidelines/ protocols,
eg pre- op investigations, anticoagulation, DKA, pneumonia, etc
• Get a map of the hospital if you haven’t got your bearings
• Remember the names and faces of your colleagues and patients
• Talk to your predecessors to get hints and tips specic to yourward.
19BEING EFFICIENT
20 CHAPTER Being adoctor
Healthcare in the UK
The NHS is the world’s 5th largest employer and while impossible to appreciate fully, a general understanding helps contextualize your role. Since its
inception in 948, the NHS has aimed to provide quality care that is free at
the point of use and based on clinical need alone. It is an important part of
our UK identity and by global standards, per capita, is good value formoney.
Government Since 999, devolved governments in Wales, Scotland, and
N Ireland have had control over their NHS and healthcare budgets. Funding
comes almost entirely from general taxation, totalling £49bn/ yr in England.
Department ofHealthGovernment department led by the Health Secretary re-
sponsible for healthcare policy and overseeing the NHS in England;
Social Care Act
948, legislated for more healthcare regulation and patient involvement, and decentralization of healthcare/ budget responsibility. Allowed businesses to compete with NHS providers for service provision;
of the total NHS budget, GPs, nurses, hospital doctors, and lay members now
lead 42 ‘integrated care systems’ (ICSs) in buying (commissioning) local services
(including secondary care, mental health, and community services). GPs themselves as well as highly specialized services are still commissioned nationally.
ProvidersCommissioners purchase services from providers, which can be GPs,
the private sector, voluntary sector, or hospitals. Many trusts are ‘Foundation’
trusts, that is, have more nancial and managerial freedom (the intention being
to provide more exibility to better suit local patient needs).
Arm’s- length bodiesNon- departmental public bodies that are associated
with but have some independence from the Department of Health;
Education England
and drive improvements;
(CQC; for care quality) and NHS Improvement (for nances) are responsible for monitoring, inspecting, and reporting on providers to ensure they
provide quality care within the resources available. Both have powers to advise and intervene if necessary. Pending parliamentary approval, the Health
Secretary plans to merge NHS England, Health Education England, and
NHS Improvement;
balancing the potential gains in quality and quantity of life against nancial costs,
NICE provides guidance to patients and providers on the ecacy and costeectiveness of new treatments and technologies over previousones.
Outside agencies(E p. 3, p. 2.) Trade unions Represent doctors
and if supported by members can call for industrial action over employment disputes. Campaign for better conditions and comment on
health issues.
for GPs and hospital doctors alike.
Association
Council
cial register of UK medical practitioners, controlling entry onto the
register, and removing members where necessary. The GMC sets the
standards that doctors and medical schools should follow;
Colleges
training in the various medical specialties.
A 202 parliament act and the largest NHS reorganization since
CommissionersWith two- thirds
Ensures the workforce has the skills to support healthcare
Healthcare regulatorsThe Care Quality Commission
National Institute forHealth and Care Excellence (NICE) By
British Medical AssociationThe largest doctors’ trade union,
Hospital Consultants and Specialists
Focuses on the needs of hospital doctors; General Medical
An independent regulator responsible for maintaining the of-
Medical Royal
Independent professional bodies that develop and provide
Health and
Health
NHS hospitals
Most FP rotations are hospital based. By simultaneously providing and
improving care over time, hospitals become a mesh of old and new, ecient and inecient, purpose-built and repurposed. Because improvement
occurs in cycles of renewal, expansion, upheaval, and rebuilding, all hospitals
are dierent, and very complicated. But there are also many similarities. An
awareness of these improves orientation, and our ability to facilitate lasting
change.
Hospital types Hospitals can be gouped by the size of the area they
cover, though most t into > category. Most FP rotations are in regional
or local hospitals;
viding quaternary and tertiary-level care to dierent regions;
pitals Specialized hospitals usually linked to a university (for research) and
medical school (for teaching), providing tertiary and secondary care to a
single region;
care to a town or city;
private hospitals. Note, most NHS hospitals in England are organized as
trusts, or as part of a trust, consisting of a group of hospitals working
together. These can be hospital or Foundation trusts
has its own board of governors, on which Foundation trainees can sit, if
willing and elected.
Hospital boards
strategy, operations, and nances of the hospital or trust. Led by the chief
executive who is in charge of, and responsible for, the hospital. Composed
of various executive directors, each with their own responsibilities (see
below);
Non-executive board A second board responsible for holding the ex-
ecutive board to account. Led by the chair and composed of non-executive
directors, who are a heterogenous group of appointed, experienced professionals from dierent backgrounds and sectors. They provide a unique
and independent perspective on hospital strategy and performance;
governors
sta. Found only in Foundation trusts and also led by the chair, the board
of governors holds the non-executive board to account. Note, hospitals in
multi-site trusts may have trust-wide and site-specic boards.
Hospital directors
executive directors varies between hospitals, but as well as the chief executive usually includes a director of communications, education, estates,
nance, governance, information, medicine, nursing, operations, quality,
research, wellbeing, and workforce;
usually divided into divisions, each with their own medical, nursing, and operational director;
clinical departments, typically anaesthetics, ED, GP, ITU, medicine, psychiatry, paediatrics, radiology, and surgery. Your ward or specialty will sit under
one of these. Each has a departmental or clinical director, who reports to
the divisional director, and oversees the long-term strategy and day-to-day
running of the department. For example, writing clinical guidelines, dening
professional standards, writing board reports, hiring new sta, and responding to complaints or signicant events.
Supra-regional hospitals Highly specialized hospitals pro-
Regional hos-
Local or district hospitals General hospitals providing secondary
Other hospitals Include community, psychiatric, and
(E p. 20). The latter
Executive board Employed managers responsible for the
Board of
A third board composed of voluntary members of the public and
Executive directors The number and conguration of
Divisional directors Clinical services are
Departmental or clinical directors Divisions oversee various
21NHS HOSPITALS
22 CHAPTER Being adoctor
Communication and conduct
Good communication with patients and colleagues is a vital part of thejob.
All communicationWhenever you are communicating with another
health professional (Box .9), include your name and role, the patient’s
name, location, and primary problem, what you would like them to do and
how urgently, and how they can contact you if there are any problems.
T Box .9 Handover
Reductions in working hours, a move towards shift- based rotas, and
the increased cross- cover between specialties mean the number of
doctors caring for a patient during their stay has increased, making the
eective transfer of information more important. Handover occurs at
the start and end of every shift, and it is vital that it is given enough time
and thought. Some are formal handover meetings chaired by a senior
while others are more informal. Either way, the incoming doctor must
get a clear idea of the situation including the names, locations, and
clinical details for unwell patients and those needing review, as well as
other outstanding tasks that need doing. Giving and receiving a good
handover is a key skill and one you should pride yourself on perfecting.
Written communication
Clinical notes Ep. 76.
Referral letters Ep. 86.
Sick notes Ep. 84.
TTOs Epp. 82–3.
Self- dischargeIf your patient wants to discharge themselves, speak to them,
ask why, manage their concerns, and explain why they need hospital management and what may happen if they leave. If they have capacity, then ask
them to sign a ‘self- discharge form’ and do a TTO as normal.
Professional conductAs a doctor you are a respected member of
society and a representative of the medical profession, and people will expect you to act in a certain way. While this does not mean you cannot be
yourself, there is a big change from medical school and you must be aware
of expectations:
• Always introduce yourself, especially over the telephone or when
answering a bleep; ‘Hello’ is notenough
• Wear and display your ID badge at all times in hospital
• Never be rude to colleagues/ ward sta; you will get a bad reputation
• Never be rude to patients, no matter how they treatyou
• Never:shout, swear, scream, hit things, or wear socks with sandals
• Do not gossip about your work colleagues; address any problems you
have with a colleague directly and in private
• When you do something wrong, apologize and learn from your
mistake; it’s a natural part of the learningcurve
• If you are going to be late, let the person know in advance especially for
handover or wardrounds
• If you think it is not appropriate for you to do a job then run it by the
ward sta or your seniors. Ask for help if you feel overrun withtasks.