Dr Benjamin Janaway @drjanaway Psychiatrist, Writer and Science Communicator. Working on a novel. Widely published. Media enquiries via DM. RTs usually endorsements. Future Silver Fox. Aug. 07, 2019 5 min read


I will try to be comprehensive, so feel free to add more and #retweet to build this thread. Best of luck to all of you, and remember, you earned your place.

1) Listen - to your patients and seniors, they know more than you do. Especially the patients, they are experts in themselves.
2) Reflect - this allows you to spot mistakes, ways of improving, and learn about yourself.
3) Document - if it isn't written down, it didn't happen.

4) Compare new results with old ones - ECG, bloods, unless you know what's normal for the patient, you don't know what's abnormal. Patterns guide our treatments.
5) Use a chaperone if examining a patient - make sure to document who was with you. This is for your career.

5) Pay attention to detail - only experience will allow you to make gut decisions, the rest is about gathering information and recording it. It helps provide excellent care.
7) Hospital Policy and Guidance - use it, usually evidence based and means your decision is supported

8) Ask for help - it is tempting to show your skills, but it is respected to know your limits. Ask for help early and develop a healthy way of addressing uncertainty.
9) Embrace uncertainty - medicine is a science, but biology is complex. Psychiatry - even more so.

10) Talk to the nurses - they know more than you about the patient, they will spot changes earlier, they know the ward, hospital and system. They are your greatest ally.
11) Respect all staff - you are not captain of the ship, you are one of the rowers.

12) Order bloods early (*unless specified,) you will get results back quicker, and make decisions in a more supported environment
13) Use Baysian thinking - be deductive in your reasoning, look toward establishing or ruling out diagnoses. You will get things wrong...

14) When you make a mistake - admit it, seek help, do not delay. We all make mistakes. Correcting it helps the patient, ourselves and our relationships with others. Be humble.
15) Never forget social care - patients will need help, so ask about family support, home, transport.

16) Structure - plan your day and clerkings, look to seniors for advice. A structured history is a comprehensive one.
17) Read previous notes - you don't know your patient until you do. In psych we read up to 10 years worth before even saying 'hello'

18) If its an emergency - don't delay. Call the crash team, start ILS. Call for the defib if needed, always use 10/10 communication. i.e 'Get the defib, come back and show me.'
19) Prioritise - see urgent cases first, uses NEWS scores as a good way of prioritising

20) Always follow up on interventions - leave notes saying to report back to you at x time, or if y changes. We must review our plans.
21) If it isn't working - reconsider diagnosis or treatment, seek senior help

22) Know your limits - at the moment you know a language but not how to speak it. Experience comes with exposure, so take all you can get. Make sure to reflect after a few days.
23) Learn your formulary - get ahead by developing a knowledge of what you use regularly.

24) Be realistic - you can't do everything in a day, don't take on non urgent cases 5 minutes before you are supposed to leave, just handover sensible plans.
25) Use 'SBAR' - it is developed to provide actionable clinical information quickly.

26) Educate and help others - share your knowledge, but be aware that you are still learning.
27) Keep time in mind - that 'easy thing' may end up taking an hour. Always keep a buffer.
28) Consultants - are your friends, teachers and safety net. Treat them with respect.

29) Challenge your assumptions - always keep an open mind, when we feel we know everything, we begin to miss things. This job is a curriculum you will never complete.
30) Potassium - learn the ECG changes, be proactive, if in doubt, retest.

31) Respiratory rate - can be first sign of decline, look at the pattern. Do not ignore a subtle rise over time.
32) Sepsis: diagnose early, treat early, increase survival. See hospital policy and call microbiology for advice.
33) Urine output - catheter if possible

34) Keep cool - chaos happens quickly and people will look to you. Use ABCDE, review interventions. Take a deep breath and seek help early.
35) Make a plan - have an idea of what is happening before you call the Med Reg.

36) The Med Reg is your best friend during out of hours, but they are extremely busy. So have a plan ready, listen, and structure your report to them. If you want them to come see the patient, say it.
37) Same for surgery! Do not be afraid to call.

38) Gossip - stay away from it. Hospitals are notorious for it, and can be like high school. Keep personal boundaries! Respect goes both ways
39) Practice - keep doing examinations, you will never be surprised of an undiagnosed diastolic murmur if you have heard 3000

40) Caveat - expect the unexpected, but don't pretend to be Dr House. It probably isn't lupus, so think of uncommon presentations of common illness first.
41) Teamwork - care is a team dynamic. You do 5% of the work, the nurses, patient and other teams do the rest.

42) Self care - you are not superman/captain marvel. You are not able to work without sleep. You cannot work under too much stress. You need to eat. Self care comes first.
43) If you are struggling - seek support early. Mental health or physical. Your hospital is duty bound.

44) Leave it at the door - once you walk out, try to leave it behind. Enjoy your free time, keep hobbies, explore your new town or city, make friends. Doctors are crap at this. We are not martyrs to the cause.

45) Expect loss - patients will die. Hours will overrun. Do your best to prepare for these realities, but also know that you cannot be asked to destroy yourself due to systemic failures.
46) Imaging - call radiology and think clinically, what does this shadow mean?

47) Test with purpose - monitoring, ruling out or in, or simply policy, don't do a test unless you would act on the results. Blood samples hurt, CT emits radiation. Be conservative but safe.
48) Join a union and get insurance.

49) Be open with colleagues - they are in the same boat, some better, some worse, support each other. They are your family for atleast this rotation.
50) Be realistic in your expectations of self - not everything has to be 50/50.

This isn't everything, but dammit I have boundaries. X

You can follow @drjanaway.


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