#mrcp

Clerking:For clerking, there’s usually a proforma in most trusts that covers the basics, and allows you to work through a system without forgetting anything obvious. If there isn’t, try to stick to a clerking layout that works for you. For example, I’d usually start with presenting complaint and the history of that, work in a review of systems by this point (and add in anything I think of later when I examine them), work my way through their medical and social history, then explore their concerns and expectations, and finish on drug history and allergies (why? Becuase I find writing up drug charts in the middle ruins my flow, but by the end you’re basically just chatting and wrapping up loose ends, and if there’s anything I am likely to forget and have to go back to ask, it’s allergy history, until I realise I can’t prescribe anything without asking that question!). You may find a different order works for you; the only thing that matters is getting all that information down, and letting your brain process it to formulate a diagnosis and therefore plan of action. The tricky thing is that patients will sometimes go off on a tangent, and you have to weigh up the importance of getting back on track with just not being rude or seeming like you don’t care. I usually let them talk for a short while about something that is irrelevant, then explain that we can explore X thing later, and that I’ll make a note of it, but right now we need to focus on Y. They say that at the beginning of a consultation, if you let someone talk for 1-2 minutes, they will almost always give you most of the information that you need. So the general rule is that you start off with open questions ‘What’s brought you in?’ Or ‘What’s the issue today?’ etc, and then, once they’ve had a chance to  say what’s on their mind, you can hone it down with closed questions to find out exactly what you need to know. It takes practice, and some people are still going to be vague, and others will still go on tangents. with time you realise how to most efficiently get investigations done; rather than wait for A&E to do it, sometimes I’ll take bloods/cannulate myself (because waiting longer for the result would be worse for the pt and myself because I’ll be 3 patients down the line by that point), or I’ll request imaging or ask nurses to prepare a treatment before I’m done wrapping everything up and documenting, if I think it needs to happen urgently. Start treatment as soon as possible, but if you are worried, then get senior help involved early. Even if you can’t quite post-take yet, you can always discuss them with an SHO or reg.

Ward Cover:Ward cover is its own kind of hell, and it’s really hard to be efficient when your bleep keeps going off, and you get all sorts of jobs that are different levels of urgency and severity. I would advise you to take a few sheets of paper with you, and be prepared to write down your bleeps and jobs as they happen.Firstly, I triage the jobs I’ve received at handover in terms of severity; sometimes I write numbers next to the names in order of priority, at other times I just remember which order I’ve decided to do things. There will be jobs you’re asked to do at particular times (that ABG in 2 hours’ time, those bloods in the morning) that you’ll need to remember to do. Then, as you get bleeped, write down the number first (in case you get a barrage of bleeps in rapid succession), then, once you call, write down each patient , leaving space between them so you canfill in some details and put a mini tick list next to each one. Do not put down the phone until you have the following: Name and Surname, DOB and hospital number, and bed number on the ward (plus ward name); anyone escalating concern regarding these patients in anything other than an arrest situation has time to get you these pieces of information. Be kind and patient with the nurse or student nurse on the phone, but explain that you need as much information as possible to be able to do your job. Whilst you’re on the phone, you can use the opportunity to ask the nurse to help you; ask for a new set of obs (if not done; usually they’ll call you just after doing one). If they can take bloods, ask them if they can please so. If they can get kit (like a catheter, or NG tube) ready, ask them if they can please do so. Things like bladder scans, female catheters, NG tubes, sometimes bloods and cannulas and cultures can sometimes be done by nurses. Each hospital is a little different, but after a short while you’ll kow what you can reasonably ask for help with. Don’t take the mickey; nurses will value and respect you if you’re clearly not just trying to make them do all your work. Explain that you’ll be around as soon as you can, but that if they can do XYZ it’ll help you deal with the patient faster. In turn, be helpful to the nurses and if you can see they are busy, then do simple things like repeat a set of obs etc yourself. When you walk onto the ward, find the nurse who called you, and make sure they remain accessible for support or to action whatever plan you agree on; sometimes people will want to walk off and do other things, but remember this rule: if the patient is clinically sick enough for them to call you to see them rapidly, they are sick enough for the nurse looking after them to stick around within reach when you are assessing or treating them. If the nurse looking after them is on their break, someone else will ahve to cover and give antibiotics/fluids/nebs etc. Sometimes this means politely asking people to stick around with you if it looks like they are about to walk off to do something relatively unimportant. Yes, they will have their other jobs, too, but a sick patient should be everyone’s priority first and foremost. You should never hold them back from other work unnecessarily, but if things look or sound dire, make sure you have all hands on deck. Even basic life support requires 2 people; you cannot and need not handle a sick patient alone.

Once you have taken some messages, your triage order of priorities might have to change; ‘review patient’s sore toe’ has to come below ‘ patient is wheezy and struggling to breathe’ or ‘febrile patient, ? sepsis’.  That way, when you work through, you’ll feel like you are dealing with the most urgent things first. Anything non-urgent left at the end of the night can be left for the day team; you can chat with them in the morning if you want to make sure it’s not missed. Meanwhile, if you find yourself overwhelmed with sick patients, talk to your seniors. Call your fellow FY1 covering the other side. Call your SHO. If things are dire, call your reg. You have people who can help you, so let them know if you have too many sick patients to handle, or if you’re not sure how to triage them. If you’re swamped with bloods/cannulas, most ward sisters can help with those in a pinch, as can site managers. Most site managers can also certify the dead; this is a low priority job for me overnight (dead patients aren’t getting any deader if you ‘confirm’ they are dead 1h later, and live patients are more important), but you’re usually not the only person who can do that job. Remember to prioritise based on clinical urgency first and foremost. It’s OK to tell whoever is calling you that ‘I’ll try to come when I can, but I have sick patients to see, first”. If the issue is something non-clinically urgent like “relatives want to discuss grandma’s laxatives at 10pm but you’ve never met grandma and you have 3 septic patients and a crash call first”, it’s perfectly OK to tell the nurse this: you will try to come when you can, and the relatives are free to wait (visiting hours permitting) as long as they wish. But you cannot guarantee that you will come any time soon, or at all, as you have sick patients to see at this point in time. If they wish to speak about a plan put in place by the day team, you recommend they call the ward in the morning to book a meeting with the day team to discuss their concerns. I rarely tell my colleagues or patients ‘no’ outright, because I do want to help whenever I can, but I’ll be honest if a particular job has to be low on my priority list because I have sick patients to see. This is also true for talking to the nurses escalating concerns on the phone, or cheekily grabbing you in passing to rewrite 5 drug charts once you finish seeing a sick patient, when you’re power-walking your way to your next patient. Do those jobs if I have nothing to do, but if you’re busy, apologise and explain that you’ll do them when you can; people are reasonable when you are.

If you miraculously have not too much on your plate, then I like to ask the ward if there are ‘any other issues’ before I leave it to go to the next ward (because walking those long corridors after they bleep you for paracetamol 30 mins later is a time waster). You can still tell them that you’ll come back to do some jobs, or just tell them that some jobs are something the day team can handle, if you think it can/should wait. But it can avoid that annoying ‘running between the same 5 wards constantly every 15 mins for pointless stuff they could have told me earler’ feeling’. Also, just let the nurses know that you’re one person covering X number of wards (and probably hundreds of patients) so it’ll take you a while; many of them just don’t know what ward cover looks like at night from a doctor’s perspective. A lot of nursing students or nurses are shocked when we chat about that kind of stuff. There’s absolutely ways to have that conversation without being snippy or coming off as defensive. Take your break when you can. I like my break around 2-3 am on a night shift, because that’s when things tend to settle. But if things pipe down for you a bit sooner, take that opportunity whilst you can. Try to drink plenty of fluids, even if it means availing yourself of vile NHS tea or coffee or tap water. When you feel like the world is ending, it’s time to drink something and have a biscuit. 

Ward Rounds:For ward rounds; make sure your blood requests are always out for the phlebotomists before they come around. If you have new patients in the morning, try to see if you can get those cheeky requests put in in the morning just before the phlebs come around.  For the ward round, you’ll have to work out a system to prepare the notes for your consultant as fast as possible, depending on how many juniors you have, and your consultant’s personal way they like things done. If there’s 2 or more juniors, I usually tag team it with them; we both see half the patients, but whilst I’m getting the notes for one ready, they can see one with the consultant. Some consultants love this approach, others hate it. In terms of the ward notes, different specialties will like different kinds of basic notes. I’ve laid out mine quite differently depending on consultants’ preferences and how different specialties run things. But most are amenable to something like the following layout as a rough rule:

(date and time in the margin)

Dr X ward round.(I use the  Dr Y/Dr Z, bleep 1234 model when it’s just me and the registrar)

(age) (gender) and brief summary of salient points/presenting complaint.

e.g 64 year old female presenting with SOB and cough, purulent sputum, 4 days.

Then their brief medical background

Then a list of current issues.For example 1) CAP, on day 3 amox and clarithro. 2) UTI, 3) hyponatremia, 4) ongoing physio

You can then briefly write out any bloods and investigations under their own heading.

Following this, I leave a gap for talking to the patient and examining them. There will usually  be a SOAP framework for assesing them on observation. I draw out my little lungs and hexagonal abdomen so I leave enoug space.

Finish up with impressions/issues (leave a gap for a list), and then plan (definitely leave a gap for a list).

The best notes I ever saw utilised a lot of bullet points and numbered lists; it was care of the elderly/geriatrics, so everyone naturally had like 5 comorbidities minimum, 6 issues at any one time, and long, long lists of plans. And I’ve taken that with me into future jobs. Never be afraid to take up space in notes; making things clear, well-spaced and easy to read will always serve you better than cramped-close set notes that are barely legible. Give your notes space to breathe, but don’t write any more words than you need to, when preparing them.