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Still swelling. Are you? Are we live for you or? I think so. Uh cause swelling for me. OK. Maybe we are. I'll give it a minute. OK, cool. Hello everyone. Um My name is Shruti. I am an FY three. I, one of the um co-lead for um mind the F by one division. And today we've got doctor Emma Whiting who's going to talk about organization and ation of ward work and on calls. Um This is quite important because a lot of you, when you start working, you will have a lot of admin roles and trying to be on top of your work is really, really important. So I'm actually looking forward to the webinar myself and I hope you learn a lot from it as well. So, over to you. Um Hi, everyone. Yeah, I'm Emma. Um I'm an F three level at the moment, like clinical teaching fellow based in the West Midlands. And yeah, as Shruti said, I've been asked to give this talk on organization and prioritization, which I'm kind of gonna split into like ward stuff and then on calls because they're slightly different and then we'll talk a little bit about like your health and like support for when you're an F one and partly when your kind of job and who you can escalate things to, which would have drilled into you through med school and also who you can talk to if you're having any other kind of concerns, um, which I don't know about you, but no one told me about during med school, um, will probably take about half an hour I would say and then there'll be plenty of time for questions at the end. If you have any questions at all throughout, then feel free to post them in the chat. Um And I will, if I can see the chat, then sort of answer them there and there or otherwise we can answer them at the end, but they will get answered. Ok. So let's get going then. So I hope you can all see my slide, please post if you can't. Um But firstly, congratulations. Um I think most of you here are probably kind of final year medical students going into F one. And so you're probably looking like the top picture graduating medical school, feeling very happy. And we wanna get you to a position where you have these doctors at the bottom who look happy and competent and look like professional do cleaning. However, there will be times you're at work and you will feel or look like this and this is probably gonna be on the busiest days of the ward on call shifts where you have a million and one things to do. And we're gonna talk today about how to your time and how to prize all of things that are kind of being. So this is the kind of structure of what we'll talk about. Firstly, we'll talk about prioritization. As I said, we'll split that first into ward work and then on calls, then we'll talk about asking for help. And so the clinical aspects of like unwell patients and then moving on to like more pastoral support ro to support et cetera. And then as I said, plenty of time for questions. So picture this. You're on a ward round, you're an F one, I've got a few patients that I'm gonna kind of tell you about. These are their ward round plans. And as we go through, I want you to think about how you're gonna prioritize each of these patients. And then I'll ask you to put in the chat kind of your order of what jobs you would do for the patients. So patient one, they're admitted with ac or community acquired pneumonia and they're improving on antibiotics. The plan from the ward round is that they're discharged today and you need to do their tt or in other words, they're to take out or to take away or medications that they need to go home on and their discharge letter, patient two was admitted with cellulitis. They're not improving on antibiotics. Um But they're clinically reason. So you asked to discuss with microbiology and change to alternative antibiotics if required by micro patient. Three is a patient who's medically fit for discharge. They're awaiting social care. They're bowel was last open. They don't have any abdominal pain. The plan was to start laxatives. Four is a patient admitted with a fractured neck of femur, they're in pain and the, the plan is that they need to have their analgesia increased. Patient five was admitted with an A K I. Their potassium on the VBG is now 6.9. Um if you don't have the reference ranges in your brain, then that is worryingly high. So the plan for this is to manage their hyperkalemia. Uh firstly, with an ECG, send some lab bloods and then get hyperkalemia management under way. And then finally, patient six was admitted with a UTI which has been treated. Um they need discharge to a nursing home today and the nursing home says that they need to arrive before 12 p.m. So the plan is to do their TT and their discharge letter A a. So have a think um write it down on a piece of paper or write it down in the chat, the kind of order of which patient jobs you would do. I will say with this that there isn't necessarily a right order. And when I made this, I think my specific order that I did it in when I made, it might not necessarily be the order looking at it now that I do it in. And so if you write something different to what someone else has already written, then don't worry about it. Um We can discuss it though. So I'll give you a couple of seconds until people start posting. So, are you guys able to post in the chart? Just because no one has sort of said anything yet. Treaty. Could you kind of confirm if they can or not? Oh, yes, cool. So we've got patient 542361. Please keep posting 54, similar, similar. Ok. Everyone's getting kind of five and four in the beginning. Mixing everything else up a little but not an awful lot of change. Oh, it's actually quite great that you can see it because in recent I see it. Yeah. Yeah. Now I can see it. Ok. Cool. Fine. So I think your answers are generally similar to what I would say. Um Certainly, you know, as I said, they're not necessarily all exactly the order that I had put it in when I first made it. Um but that's not really a problem. Um Let's go through then the order that I have done it in. So I went for patient five first. Um So this is patient who needs hyperkalemia management and if we don't treat them quite quickly. Um And I think every one that I've seen in the chart has put this patient as their first priority. So this is the sickest patient. And so the one that we would go for first, I've then gone for patient two. Next. Um This is a trickier decision and the lines get a little bit more blurred because we obviously don't have. Um OK, so some people are saying the audio is cutting out. Um I'm not sure how to kind of troubleshoot that if I turn my microphone off. OK, I'll turn my microphone off and on again. So maybe that will work. Is that better for anyone? I can hear you better. There's just only one part where you sort of cut out. OK, fine. So I'll keep going. Please let me know again though if it, it's cutting out again. Um So in case you didn't hear what I said, then I said patient is gonna be the sickest patient. Um They need hyperkalemia management, we need to treat them as soon as possible. Um Everyone got that that I saw, I think one for patient too and it's a little bit, I haven't given you more clinical details. We don't really know how sick the patient is. I think I said they're clinically well, but that's quite a broad spectrum. Um The point is that they're not improving on antibiotics. We need to have that discussion reasonably quickly with micro um they might need to prioritize their referrals that they're getting in. They might need to prioritize their, their kind of workload and their, and it's a reasonably kind of time pressured thing to be changing their antibiotics if they're not working and they're sick enough to be in hospital cellulitis, then I went for patient form, the patient's, um, analgesia. Um, and again, this is quite difficult because we don't know how much pain the patient is in. If they're crying out in agony, I might have done that sooner. If they're not in an order of pain, then we might leave it until later. And so bear that in mind. But in my kind of um list and I on for, it's not nice to leave the patient in pain, but it's not necessarily life threatening. And then I started thinking about the kind of less urgent jobs. Um and I always put TTS and discharge letters into less urgent things. I know that I've said with patient six that we need to get the patient discharged as soon as nursing home won't accept them after 12, et cetera. And that's quite a common thing that happens at the end of the day that that patient is clinically. Well, we want to get them home to the nursing home or to wherever they're going as soon as possible. But the patients who were sick in front of you are kind of your priority, right? Um So then you start thinking about getting those kind of jobs done. Actually, the more urgent one before the less urgent one and then I've put starting the laxatives as the least kind of pressing concern in this case. Um, and that's mostly just because it doesn't necessarily matter if you start them at lunch time or if you start them at nine o'clock in the morning. Um, I would say however, remember with TTS that pharmacies might have a cut off time and I'll talk to about this a little bit in a minute. And so I've said that they're less urgent, but if you're needing medications from pharmacy, just try and get it in before any kind of cut off time to get that done today. For example, um, where I work, the cut off time was about two o'clock and if you requested att O after that, then the patient probably wouldn't get their medication that day. Um, if anyone else kind of has strong feelings and really disagrees with the order that I put them in, then by all means discuss that in the chat, I'm more than happy to kind of have a discussion. Ok. So then I'm gonna come on to kind of a few tips and tricks for how to prioritize stuff on the ward round and it starts on the ward round itself. Ok. So quite often, hopefully you won't be the only person on the ward round. You'll probably have a registrar, a consultant and a couple of other juniors. So between the juniors, you might, you might think about splitting the patients up. Ok? And the way you could do that would be to split like one bay of the ward. So you each kind of have 46 patients to see and you do everything for them. It might be that you kind of piggyback on each other. So you alternate patients. If there's three of you, you might alternate patients and have one person just doing jobs for the ward round and picking up the jobs. So it kind of depends on what everyone else wants to do, what works for you and the team, what the consultants like. I personally quite like the piggybacking and switching patients and going you, you do one and then I'll prep the notes for the next one and then see that patient et cetera because it means you can get a few jobs done in kind of in the middle of patients as well. I'd say keep a jobs list throughout the ward round. Um We'll talk about jobs lists um in a little bit more detail, but essentially this is what your jobs look like. The reason for keeping it throughout the ward round is that you then don't have to go back after the ward round and review all of the different notes and um double check what the plans are and stuff. You've kind of got that in front of you and it, it doesn't kind of waste your time. So when you make your jobs list, you obviously write down the jobs that you want to do. So for example, here, jobs list E DS is your electronic discharge summary or your discharge letter. For example, physio and occupational health referral for Jerry's S pr um and it goes on and then I've got some boxes after what I've written where I've got a half, a half um colored inbox, then that means that the job is half done. So for example, we take bloods, half colored in. That probably means that I've taken the bloods, I've sent them, but I don't have the results back yet. Um If it's a fully colored inbox, then that means that the job is complete and we can move on. OK? Um Some people don't color in half the box, some people lying through the box, but whatever, if it's kind of not fully colored in, it's half done. Um If it's fully colored in it's done and that's kind of a general medical thing that a lot of people understand. I'm just waiting for my slide to load. OK. Um You can do some quick drops during the ward round. So this is why I quite like that piggybacking as I was saying, because it gives you a little bit of time in between patients. So for example, say you've just seen a patient and the plan for that patient is they're in pain, let's increase the analgesia dose. Then it's easy enough providing, you know, the analgesia dose to just increase it there. And then so if it's something simple enough, something that won't take very long, just do it there. And then during the ward round and it stops you having to write it down and come back to her and come back to the patient and everything. And then afterwards make sure that all of your jobs and all of your patients are kind of evenly allocated amongst all the team members. And so some people advocate for having their own list of jobs and other people advocate um for having kind of like a communal jobs list. And sh and I were actually just talking about and had like up in before. Um I gave this to, I find that you have a communal jobs list amongst schools mostly because then you can check that it's kind of evenly allocated and you can check that people have a similar number of patients and a similar number of jobs to do. And if, for example, you finish your jobs early, you can start work on someone else's jobs and vice versa. Um Having said that though sometimes you might want to keep your own little jobs list and I'm the kind of person who likes to write everything down. And so I might write more down than my colleagues might necessarily want written down on the sort of master jobs list, whatever works for you though. Really? OK. And then moving on to natural prioritization of jobs. Then, um I've already said do quick jobs during the ward round. And then after that, I, so I've sort of said if you're ranking your jobs, then obviously prioritize your sick patients first. And I think you all knew that from everyone, ranking that hyperkalemia patient as the first patient to go and see, then it gets a little bit more difficult to work out what to do next. And as I said, I can't necessarily tell you the exact order of every jobs, but I can give you a few pointers so you can work it out. So then I talk, think about like the time sensitive sort of tasks that you want to be doing next. These quite often include investigations or requesting investigations like bloods, especially if you think about the way a ward runs. If you take bloods at four in the evening and you finish your shift at, there's no way the blood results are gonna come back and you're gonna be handing that over to the on call doctor. And that's not fair. Take bloods earlier in the day, the blood results will get back when you're still on your shift. And you don't necessarily need to hand it over. Similarly for requesting other investigations like CTS or xrays and stuff. If you request them earlier in the day, they're more likely to happen, um, like that day or at least the next day and then referrals as well. And this is what I was kind of getting at with that micro patient, the one with cellulitis, if you discuss that with microbiology sooner, they can prioritize their workload. And it's more likely that they'll be able to give you their opinion or come and see the patient or something earlier in the day. And then you can actually plan a little bit sooner and then we move on to our less urgent tasks. And so in the, in the most part discharge letters and TTS are going to fall into the less urgent stuff. Um I have mentioned the cut off time for TT S. So do be aware of this. It is really, really annoying if you miss that cut off time and the patient doesn't get their medications and their discharge is delayed because of that. But having said that you need to prioritize sick patients in front of you first, the patients were enough to be going home. They're probably not really really sick. Ok. So try and get it in for in for the cut off time, try and do it in the morning, et cetera soon after the ward round. But prior to sicker patients, um a little bit higher up then think about is there any discharge timings? Then the patient in the nursing home who needs to go home before 12 is quite a kind of common um a a common scenario and then also prepare in advance. Um There is nothing worse really than the sinking feeling of coming back after, say a weekend or a holiday. And you realize that a patient who's been on the ward for four months is going home that day and no one's prepared their discharge letter if there's a long, if there's a patient who's been, been on the ward for even more than sort of a, a few days, I would say, start preparing the discharge letter, just add in kind of things that happen as they happen and it makes it so much easier um for when the patient is discharged. And if you know that they're getting discharged the next day, for example, you can basically do the whole letter and then just add in like the last couple of points of the plan on the day they're getting discharged. Um And then other less urgent tasks include adjusting non urgent medications, non urgent referrals, et cetera, et cetera. Ok. Um I'll come to the questions, I can see um a coming up in the chat, let me finish this slide and then I'll kind of find a time to answer them. So most importantly, on the ward round, I would say communication is absolutely key. So first and foremost, you need to communicate with the other nurses and allied health professionals who might be on the ward. Firstly, you wanna update them about the ward round about the ward round plan, um update them how the patient is doing the longer term plan, et cetera. Update them with any jobs that you want them to do. If, for example, a patient needs a hearing dip. If you just write that in the plan and expect the nurse to come round and pick that up, I can promise you, it's not gonna happen if you have a good relationship with like the nurses and health care assistants and everything on the ward and you ask them politely if they could do a urine dip or a swab or something like that, then it's much more likely to get done. Um And then finally tell them about like your jobs list and your priorities. It's quite a common scenario. Um If we think back to kind of my made up scenario of the patient who needs to get discharged before 12 o'clock, that nurse who knows about the discharge is gonna be getting a lot of pressure from her boss, from the care home manager, from everyone else that the patient needs to go home. She or he probably doesn't understand your other jobs and priorities. And at the end of the day, your hyperkalemia patient is so much more important than the discharge. So be open, tell them if you have a sick patient, tell them that you have other things to do that you're gonna get around to it as soon as you possibly can and similarly be realistic with patients and relatives. It's such a heart sinking feeling when you're on the ward round and a consultant promises a patient that they're gonna be going home in the next hour and you're standing there and you know that you haven't requested their TTS and you haven't done their discharge letter yet and there's absolutely zero chance they'll be going home in the next hour. So chat to the patients and relatives be realistic that it might be later in the afternoon, for example. Ok. So I shall pause here one second and just have a look at questions. So, is there a typical tt cut off time? Um, I can't necessarily answer for every hospital at my hospital. I think it was two o'clock. Um, for kind of your normal TTS. Um, it's going to be longer if you have really, really comp complex TTS if maybe you have controlled drugs on them, if they need a blister pack, blister pack or something like that. But for your normal TTS, it's probably gonna be early afternoon kind of time. Um, if you know that a patient's going home and you don't think their medications are gonna change, you can always request their TTA S a day, two days in advance. Um, so that on the board, they're ready to go for when that patient goes home. Um, next question, when on call, should I start clocking from when the GP gives the history over the phone, including ordering likely blood tests? Um, so if you're an F one on call. Um, you might be taking referrals over the phone. Um But more likely, I think it would probably be an S or arrange taking GP referrals if it is you, however, then obviously take the full history and if your senior agrees, then you bring the patient in and I would start clocking that patient when they come in. And so then you take, you start taking your history, you examine the patient and you go through and you take the bloods and you send the tests. Um I I would have the patient in your mind if you know they're coming in, think about what you might need to be doing, but there's nothing you can really do before they get to hospital. Um I hope that answers your question. If there's no other questions, then I shall move on. OK, so let's move on to kind of some similar scenario. So this time you're on call, you're on a night shift this time. So remember we're in the middle of the night and we have some more patients. So patient number one, you were handed over to review their bloods, full blood count and CRP for a patient on antibiotics. Um And you've been asked to convert it to oral antibiotics from IV if the inflammatory markers are down trending. Patient number two, you're bleeped to review a patient in ed query sepsis. The sepsis six has been started and the nurse or doctor who bleeps, she says they really don't look well. Patient three, you'll oblique to rec cannulate a patient who's currently on IV antibiotics. Patient four, you're asked to review a chest x-ray to confirm G tube placement. The feed needs to resume in the morning. Remember we're in the middle of the night. Uh Patient five, you'll believe to review a patient on the ward with new onset chest pain and the nurse says that they look pale and sweaty. And then finally, patient six, you'll bleak to review a patient whose catheter is not draining, they're in pain. So take your time, have a think and then similar to the last one, just write out the numbers that you would go and see these patients on which. Sure. Cool. Mhm. Yes. OK. Right. OK. Good. I think we're all kind of on the right lines. Vast majority of people going 5 to 6 1st. A little bit of disagreement with the last couple. But yeah, I think we're on the right lines and I think you guys seem to have found this one slightly easier and cool. So I think I essentially agree with what you're saying. Um So as I said earlier, the sickest patients first. Um So there's two sick patients here. We've got a patient with new onset chest pain on the ward and then we've got a patient in Ed with query sepsis. The reason you go for number five first is because they're on the ward. They haven't been seen by a doctor yet. You're the doctor who needs to go and see that patient. Patient number two might be really sick, might be sicker than pa um, patient number five. But they're ned treatment has been started. Yes, they don't look well, but you need to prioritize the patient who's had no treatment started yet. Um, then we move down to kind of the slightly less urgent things. Um, but still patients that you kind of want to see and that's why I've put the patient whose catheter isn't draining and they're in pain. Um, acute urinary retention is a urological emergency. We need to go and sort that out. Um The patient isn't as kind of acute as if they're having an M I or if they're septic, but we want to go and see that patient number three, I put after that ble to rec cannulate a patient on IV antibiotics. Um We need more information essentially to properly prioritize this. Um First question that you'd ask, um, the nurse or whoever's leading you to rec cannulate the patient would be, when is the antibiotics due? If the antibiotics aren't due for another six hours, you're not going to rush to go and cannulate that patient. Um If the antibiotics were due an hour ago and they're really sick, they're septic and they're looking horrendous, then you might push that further up the priorities and do that a little bit sooner. Um So essentially you need more information and however you've interpreted that would kind of inform where you put. Patient number three. The other thing with that is also that there's other people who can cannulate, um nurses can cannulate the psych team, can cannulate and I'll talk about them a little bit later on. Um But you, you're not the only person in the hospital who can cannulate patients then one and for they're less sort of urgent jobs. Um So patient, number one, you need to review their inflammatory markers and convert to oral antibiotics. Um Yes, you need to do that. You need to check the bloods at some point. You're not gonna cause an awful lot of like life threatening harm or anything like that if they got another dose of IV antibiotics or something like that. Um And so yes, you need to do it but not emergency. And then the reason I put number four as the last one that you need to do is because feeding doesn't need to resume until the morning and at the moment it's the middle of the night. And so that's certainly something that can wait a little bit longer. Um Certainly in all the hospitals I've worked in, the nurses would not start an NG feed until it's like the um g placements been confirmed on the chest x-ray. So if it hasn't been confirmed yet, really, the nurses won't start it. Um So that's less high on my priority. List. So a few kind of hints for out of hours prioritization then. So firstly, when you start your on call shift, you'll be given a handover. Um when you're accepting handovers, don't just blindly say yes to everything. You can ask questions and you can say no, OK. So a really, really common thing is handing over blood results or scan results or something for you to chase, make sure you don't just accept. Oh yes, I'll chase the full blood count. You need an idea of who the patient is. Why they've done the full blood count. Why you need to chase it, what you're expecting and what you need to do with that information. So with the last patient we talked about it was chase inflammatory markers, convert to oral antibiotics. You don't want to be in a situation in the middle of the night when you see that, oh, the inflammatory markers are coming down. But what's the plan? What do I do with this? So ask as many questions as you need to. Secondly, ask yourself, do you need to do this job out of hours or will doing this job out of hours change the management of this patient. Um If it, if it won't, for example, if it's talking to a, a relative of a patient who isn't especially unwell. If it's um doing a discharge letter or something like that, they're not out of hours jobs. So you can politely decline to do them and defer that for the day to you as always prioritize the sick patients, which you guys knew how to do. Um, remember that you can ask nurses to or um other kind of staff on the ward to start investigations and management as you're going to the patient. For example, with the cannula patient, you could ask if anyone else can do a cannula with the patient with chest pain. You could ask if they could do an ECG and send a drop before you get to the ward. And then finally, if you're in a hospital, especially one that you still uses paper notes, think about like locations of jobs. Um So you might wanna do if, if they're non urgent, do a few jobs in one ward before moving on to the other ward and you might wanna do similar jobs at the same time. For example, if you're sitting down at a computer to check blood results, you might do that for all of the blood results you need to check to save time. Ok? So we've kind of done the main bulk of the of the talk. Now we've talked about privatization and we'll now move on to asking for help, which shouldn't take um very much longer. Does anyone have any questions if you paste them now in the chat before we move on? Otherwise I shall plow through? Ok. So let's keep going then and then um any other questions I will come to at the end. So we'll talk a little bit about asking for help. And so firstly, we'll talk about escalating sick patients. So like your clinical asking for help and then we'll talk a little bit about kind of other sources of help. So let's say you're on the ward and you've got some sick patients, there's this kind of escalation hierarchy. So if you're the F one above you, then you've got your F two S and your ss, your registrars and then your consultants in general, you're probably gonna be escalating like sick patients to your registrar. That's why I kind of put them in bold on that hierarchy. There's some circumstances where you might go to your F two or your sh first, for example, if you're not quite sure about the patient, if the registrar isn't there, um If they're not kind of acutely, really, really unwell, then it's absolutely fine to go to a sh especially if they're kind of a bit more senior like, you know, AC T two IMT three, something like that. Um You could also potentially escalate to your consultant if you wanted to, your consultant is there to help you. Um If your registrar is standing next to you on the ward, I wouldn't go straight to the consultant. But if you have any kind of issues getting to your registrar or getting any other help, then go to your consultant, phone them in the middle of the night like they're there for the patients. Essentially, they're your priority if it's a sick patient and you just need an extra pair of hands, for example, with a cannula or someone to um you know, help you send some bloods or something like that. Then by all means, ask other F one sss and stuff like that, but be a bit careful, you can't be escalating like sick patients to the F ones. And remember that you've also got your alli professionals again for an extra pair of hands. If someone's sick, you're gonna need a set of observations. You're gonna need blood sending, can you doing it? Nurses and your other allied health professionals can do that. And then similarly, if you don't have a particularly sick patient, but you're just feeling really overwhelmed and you need help doing all of your jobs, you can talk to your other F one S and SS, they'll be able to help like delegate amongst the juniors as well as, as I said, the nurses and health professionals, they can do stuff like you can live, you can escalate to your reg and stuff. But remember that they probably have other priorities as well. They might have an afternoon in clinic or something like that. And so in general, your sick patients work up the hierarchy. Reg is probably going to be your first point of call for a sick patient managing jobs tends to be amongst the juniors. So out of hours tends to be quite similar. Um escalations. Again, if you have an sho who's um good and helpful and accessible, then, yeah, definitely escalate to them. Otherwise it's gonna be your registrar who is probably your first point of contact. Um And if you can't contact them, then probably your consultant. Um I phoned a consultant in the middle of the night when I couldn't get through and they were absolutely fine about it. Um The patient is the first priority. Um Again, if it's just an extra pair of hands, then another F one ss et cetera nurses, allied Health Professionals. And so I mentioned earlier, the psych team and there's also kind of a team of people called critical care outreach. You might not have these in every single hospital, but you'll probably have some kind of um similar team to this. So these are so the psych team is like you um very experienced nurses who basically save the day or save the night when you're on call, they run the hospital. If you have a problem. Like if you're struggling with a cannula, if you need an extra pair of hands, they'll come and help you. If you can't get hold of your registrar, they might tell you who else is on call that you could get hold of that. A fantastic kind of overview for help when you're panicking. Um I remember I bleak the cy team once for doing a catheter and I just couldn't do the catheter and I didn't have much experience. It was the beginning of f one. I really didn't want to contact the urology reg. She was at home. Um And this fantastic psych team nurse turned up and just magically did it. Um So they're friends and then for the sicker patients, sometimes it's the same team, sometimes it's different. You might have critical care outreach teams um to come and see like the real sick patients and see if they might need to go to I and then managing jobs is similar. Again, your psych team can help with that if it's um can you no catheters, et cetera, et cetera. Uh Remember nurses can help and remember that you have your other F ones and ss um working alongside you. OK. So moving away from your kind of management of your acutely unwell patients, um There's some other sources of support here to help you as an F one. I don't know about you guys, but no one really told me about these when I was in medical school and it took me a little while to work out different people's roles. So, first and foremost, you've got your clinical supervisor and this is a consultant assigned to you for that rotation and they're normally someone who you'll work with most days. OK. So they're a consultant on that job. So they're your supervisor for four months. They'll do your horus sign offs at the beginning of your placement at the and at the end of your placement and sometimes in the middle, they're also responsible for doing your placement, supervision group or your PSG and your TABS. And both of these are kind of like multis source feedback. And so this is when you have like multiple different members of the team, different consultants, registrars, nurses, doctors, physios, et cetera, et cetera. And they all fill in kind of online forms and talk about how you are as a doctor and a person, your clinical supervisor kind of conducts that and normally needs to talk about that. They're also there for any work related concerns. So if you're struggling on the job, if you're struggling with prioritizing things or not understanding how the wall is running something like that, then your clinical supervisor is a great person to contact, then you've got your educational supervisor. So this is a consultant who's assigned to you for the whole year. Now at my F one FT hospital, then it for my first job, my clinical supervisor and my educational supervisor were the same person and then obviously the clinical one changed. And so they, I've worked with on my first job, but you don't necessarily need to work with them. They do your ho sign offs at the beginning and ends, beginning and ends of each placement and then they do your like end of year sign off as well. They also kind of look at more educational aspects. Um and so they'll do your PDP review, which is like your personal development plan. So they're kind of looking at your career planning and your career development and your educational um needs and checking that they're met and everything as well as checking that you're kind of ok. So if you have any concerns throughout the year, I would say these are the two main people you contact clinical supervisor is mostly for clinical concerns. But if you get on them with them pretty well, then by all means contact them for any concerns. You have educational supervisor again, if you get on with them rather than contact, contact them with any kind of concerns, wellbeing concerns, et cetera, et cetera. And then you've got kind of your training program director or your foundation program director. This is kind of the overall supervisor. Um and they have a lot of kind of overview of your CS, your clinical supervisor and your educational supervisor. Um I've never approached mine, I would say in general, if concerns aren't resolved by the other two people, your clinical or educational supervisor, then you might contact them. They're there. They exist, but they wouldn't be your first point of call. Um I, I won't answer all the questions in the tab now, but I see one saying what's Tab and PS GPS G? Is that placement Supervision group that I said, and Tab is the other kind of multis source feedback thing where you get all the doctors and nurses and people on the ward to write about how you are as a doctor. I'll come back to the other questions afterwards, but I hope that makes sense. Ok. And then there's a few other people um in your hospital who might be able to with things. Firstly, you have the guardian. Now, this is normally a consultant who has assigned this role. Um You might not necessarily have ever worked with them or really know who they are, but you'll get the details via the trust internet. Normally this is someone who can offer you like your advice and support, especially if you have to contact your clinical supervisor or your education supervisor and they can give you advice on how to escalate things. Um They can escalate things anonymously for you with your permission, they can escalate things and say your name. Um So depending on the issue, they can kind of help you to resolve that, especially if you don't want to talk to anyone else about it, then you have the guardian of safe working as well. And in some hospitals, this is the same person as the freedom to speak up guardian in my hospital. They're different people. Essentially, this person oversees the safety of like junior doctors working conditions. Um for example, checking that you have rest spaces and appropriate rest periods and you're not put on ridiculous rotors with no rest in between on calls, et cetera. Um So if you find that you're not getting your brakes, you're completely burnt out by the rotator. You don't think it's compliant, et cetera, et cetera, then you can contact your guardian that's safe working. The next kind of body is the junior doctor's forum. So this is slightly different in that this is not one person, this is a forum or a meeting and that happens. I can't remember exactly how often I think it happens every couple of months and this is where all kind of junior doctors of your grade will get together along with key members of the trust. And so that's for example, the guardian of safe working might be there, the freedom to speak up. Guardian might be there a few consultants, nurses or sort of senior nurses and stuff might be there. Um any issues that you bring up, get highlighted to them and then get brought forward to whoever needs to hear them. So for example, um if you need to talk about, you don't have a rest space on the T and O ward, then that might get taken forward. Or if you're saying that you're always leaving late on um respiratory, then that might get taken forward. Similarly, if you say that the mess doesn't have enough snacks or anything, then maybe the me S President will be there to take it forward. So any issues you have, you can bring up at the junior doctors for. And then finally, I just want to talk about occupational health as well. Um And so occupational health in most hospitals, I've heard of are really, really friendly and are certainly there to support you. And so if you have any mental or physical health concerns that arise, that might require support or adjustments to your working, then they're there to kind of put these in place, um tell the rota coordinators and everything that you have these adjustments and to kind of look after you and through occupational health, you can access other support as well. For example, you can access counseling services and things like that if you're struggling. And then I think this is my last slide maybe. Um Finally just talking about a couple of kind of other ways that concerns get raised. And the first of these is exception reporting, um I won't talk through how you physically do this because it will vary completely between different hospitals, but you will get told about it. In your induction, it will be on your trust internet like how to physically do the form. Um Essentially, if you're regularly finishing late or missing breaks or missing teaching or anything, then that's a problem with the ward or the roter that needs highlighting, it means it's short staff, the workload doesn't kind of match the number of doctors there and you fill in an exception report every single time that happens. OK? That then gets flagged to the department leads or to the guardian of safe working or G OS W as I put there and it results in firstly, that being highlighted to the department and so that on ongoing changes can happen, they won't employ other, other doctors or change your ros without exception reports. And then for you, it also means that you get paid for that time or you get time off in. So for example, if you stay half an hour late, every single day for the whole quite a lot of days that you probably added up, um I would say be a little bit flexible when you exception report, for example, say you're in your first week and you don't know what you're doing and you're finishing 15 minutes late because you're just not managing the workload very well, maybe hold off exception reporting for that kind of thing. But then if, when you do know what you're doing and you've realized that the workload is actually too high and you're staying an hour late every day or something, then by all means, do exception, report that. And as I said, remember you can exception, report missing teaching and missing breaks if you miss teaching and you don't get enough teaching hours for F one or F two that comes on you and that's gonna be pretty stressful at the end of the year for you. Um So make sure you are highlighting that early if you're not getting your time off. And then finally, just a quick word about clinical incident reporting. Um in I think most hospitals, this is called data. This is just the system that they use. Um but there might be other systems. And so that's why I kind of call it clinical incident reporting. Um This is a way to highlight any patient safety concerns near misses or like actual harm that happens to patients. Um The spectrum of things that get reported on this is very, very variable and it's highlighted as an opportunity to learn from events that happen. I wanted to highlight this in particular because firstly, if you have a, if you witness something that you think is wrong or something that you think is unsafe, then by all means you can put in a clinical incident report, anyone can do it, it's everyone's responsibility. And I also wanted to say though that at some point in F one or F two, someone will probably put in a clinical incident report which you'll be named on. There's a culture of people saying that they're going to de you or they're gonna put in one against you. You can't do that, you don't put one in against a person, you put one in against an event that's happened. OK? I want to stress that if that does happen to you don't worry about it. Obviously, it's a spectrum of what gets reported. Um I had one when I was in f one about something that was really, really minor. I discussed it with my clinical supervisor and it was never spoken of again. I reflected on it in my portfolio. Um So the majority of the time nothing ever comes and flu you around or anything like that. So honestly, don't stress, it probably will happen. It's a learning opportunity. Um I'm happy to kind of answer any questions about them as well. OK. So in summary, um we've covered quite a lot actually. So firstly, remember to keep your jobs list when you're on the ward round and remember to delegate jobs between the juniors whilst you're on the ward round in terms of prioritization and organization of your time, um prioritize the sick patients and then think about your more time sensitive jobs like blood xrays requesting stuff, referrals, et cetera. And then remember that obviously some jobs can wait. I would argue that there's no such thing as a really urgent kind of discharge letter. Um Within reason, then think about when you're on call, we've talked about escalation of unwell patients. Um And finally, we talked about various sources of support for unwell patients and then for you as well. OK. So I'm very happy to take questions. Um I'll have a look through the chat in a second. So whilst I'm doing that, I've put on a feedback link, which is this first QR code here. If you fill in the feedback forms then you get attendance certificate and then I will you R code to the F one mentor whatsapp group. Um So some of you might be aware that we've set up kind of f one mentoring program, which is under way. Um This whatsapp group is slightly different to that. And so it's a space where any one can join it um for general kind of advice, queries, stuff like that to your whole year group. And then we'll get current foundation doctors on it as well to answer any questions that you've got. So please join it. If you think it will be useful. Why you do that? I shall go through the chat. Thank you, Emma. That was very, very informative as well. Um So I'll, I'll read out some of the questions that have come through. Um So someone said, Andrew, I had said, could you say a little more about how you can effectively as critical care outreach? Fine. Yeah. So as I said, they kind of will vary between the hospitals and the exact role of them will vary. And so I don't wanna be too kind of specific about it. Um If you've got a patient who you're worried about and you're thinking you might need to be going to ICU or something, then they're a great kind of group of people who would come down and review that patient for you, help your patient. It's normally made of nurses like specialist critical care nurses, but sometimes you might get doctors involved in it as well, I would say, however, though, that if you've got a sick patient, you would already have escalated that patient to probably your registrar. Ok. And so as an f one that would be after discussions with your registrar, um, I've used them also in times where I'm really, really worried about a patient and for whatever reason, my registrar can't come down and help me. Um if they're sort of say stuck in the theater or something like that, and I can't get a cannula into this really sick patient. And I need a second pair of eyes in that circumstance as well. Then by all means escalate to whoever you need to escalate to like patient is your priority. That makes sense. Yeah. Yeah. And that answers nicely. The next question which was if patient is sick, how do we know whether to escalate to registrar or critical care outreach? And as you said, you first escalate within your team. So it will be the registrar if they're really unwell. Um And if the, if the registrar is not there, um then you can get some um advice from the sho or speak to your critical care outreach. But normally what happens is the registrar assessed the patient and they might themselves say, ok, this patient may need critical care outreach and they may ask you to have that discussion, but it's likely that the registrar themselves would have that discussion. Um Now the next oh And the next question, do you have to do your tab in one rotation? So you have to do one tab per year. Um And just to rehab, that's the kind of the multi source feedback thing where loads of different people have to fill it in. Um It, to be honest, can be a real fast. No one has any time to do anything and people definitely don't have spare time to be filling in forms. Um I would normally say try and do it in your first rotation because then it's easy to get it out of the way. It's so much more relaxed. If you've done it, it's over and done with and then you can just move on. Um Some people do it in their second rotation. For example, if you're on a placement that doesn't have that many people working there or not many kind of different allied health professionals, um You can do it in your second rotation. Um But first thing really is when people do it, I would also say though that it needs to be done before A RCP, which is at your end of year, kind of sign off meeting thing which um UN hopefully doesn't actually happen at the end of the year. It happens in about May in May and it can come as a little bit of a surprise. So please don't leave your tab or anything like that for your third rotation, you won't have formed those kind of relationships with people to get them to sign forms and talk about you and stuff before AC P. So, yeah, Pras normally sometimes I can, we've also got more um, sessions planned for July and one of them, one of the sessions will be on your A RCP and your E portfolio. So we'll speak about this in more depth there as well. So don't, don't get too freaked out about all this terminology. Um Oh Someone has asked, are you able to put the fy one chat link in the chat? Do you happen to have a whatsapp link that you can share? Um I can find it um I can have. So the next question is, do you have tips for dealing with bullying or difficult colleagues? We are having another um separate um webinar on that as well um On communication which is happening next week on the sixth of July. Um But I, I can sort of stall a bit if you're looking for the link. Um Emma. Yeah. So it is, it is not a very pleasant experience, of course, being bullied or having difficult colleagues. But if you feel like um let's let's break down the difficult colleague uh into a subcategory. So if it's a difficult colleague due to they're not sharing the workload um with you well or fairly, then it's best to see if it's a sort of repeated pattern number one. And perhaps, um, as you will be creating your, um, job list, um, where, you know, Emma said that creating a communal job list is really important where you write down all your job lists needed for that particular ward and then you sort of designate, maybe trying to tackle it, using that job list might be helpful. Um, you want to be, you shouldn't, um, what's the word? Confront them, um, on a 1 to 1 basis directly. And first of all, you need to try and see whether there are other ways that you can overcome the issue in a more slightly tactical way, such as, you know, getting like these job lists done and explicitly, um, dividing up the jobs. Um, but if you feel like it's getting to a point where, um, you're, you're not able to, that they, they're fobbing off or you're having difficulties and of course you can raise it with your clinical supervisor, um, as well. Um, if it's a repeated thing, um, what do you, what would you say em? Yeah, I completely agree with all that. I think if it's kind of reasonably minor things and you feel comfortable trying to solve them locally, then by all means, I think that's always a good solution but completely agree that don't hesitate to chat to your CS, your clinical supervisor or your educational supervisor. And then also remember that freedom to speak up, Guardian I talked about so they are literally there for like bullying concerns really. Um It's, they're fantastic, especially if the problem is with your clinical supervisor or your educational supervisor and hopefully it isn't. Um, but they can give you kind of anonymous or confidential advice and escalate things anonymously as well. And if it is a consultant that's sort of bullying you and you can always go to educational supervisor as well in that, in that sort of um situation to gain some advice. And maybe you want to go to education supervisor first as you would have established a rapport with them and sort of using anonymous sort of mentioning anonymously initially. And then if you feel like that hasn't helped, then you can of course go up to your guardian of um speaking up, guardian, freedom to speak up um person as well. Um If you're able to talk to your peers, um if it, if it's like another fy one and you are able to talk to them in a nice way, sort of directly, then of course you can, that, that's probably better um if you can do that, but if not, you can always get some help. And I go, what resources would you recommend for preparing for F one? Um Yes, you have passed medical school. Ok. And so your medical school have told you that you've got the amount of knowledge that you need, otherwise they wouldn't have passed you. Ok. So don't stress for the next month, you guys have the ability to be competent doctors. You will either have, have already graduated or will be graduating. They are telling you you can do it. So don't stress you're fine. Um, if however you do want to prepare for stuff, then obviously I'm going to plug my be. Um, there are genuinely some really, really useful pages. Um, for example, there's a whole article about useful apps to download to your phone. I'm not going to go into a whole list of apps, but there are really good ones. They're just listed in the article. Um So I'd have them on your phone. There's stuff about, I think I've even updated one about how to do a ward round, how to document it, how to organize a jobs list, like basically what I just said. So mine believe is really good. Otherwise you guys will be fine. You pass medical school. I've just um put a link to the playlist of um webinars that we've created this year. So the apps and stuff are covered in our first webinar. Um So if you go onto the link, um you'll, you will have access to your, to our first webinar and you can have a look and to be quite honest, like you can learn a lot, well, you can learn X amount by listening to other people listening to other people experience, but you're going to learn the most when you start doing your job and I know it's quite daunting and these tips and tricks that we've picked up is purely based on what we have learned from us doing the job. Um, and you really do learn a lot on the job. Um So as long as literally, I genuinely feel like as long as, you know, how to do a good, a te um sort of, um, an assessment on an unwell patient and you're friendly and you, you know, you're able to work with other people and have a good rapport that's already setting you up in a good light. Um, to be quite honest and important, you need to be willing to learn. It's not like medical school where you've got the right diagnosis. The diagnosis from an F one to be quite frank is not the most important thing is about how you're handling the patients in a safe manner. And that's why prioritization and which Emma talks about today about sick patients is really important because that's what's gonna make you sort of look and come across well, amongst the medical team or the surgical team, whichever team you're working for. So that's the main thing. We cool. Um, any other questions? So how many people do you need to sign you off on your tab? I think. 12 out of 20. Yeah, it's, um, you get a different, they specify who needs to do it. So it has to be a certain number of consultants, I think it's, I want to say two consultants, two other doctors. I think one is allowed to be another f 12 nurses, physios, et cetera. So, yeah, I think 12 rings a bell. Um Essentially you have to send it to like everyone you can think of. Um because people don't sign it. Um I think I've sent my F 21 to maybe 30 people and I just scraped the, the threshold and so it's not just a number you need, it's the the breadth of people. So just send it and nag people and you'll get it done like including ports um healthcare um healthcare workers. Anyone you can think of pharmacist, ward clerks, et cetera like literally everyone but not patients. Um They are, they are quite kind of careful with the number of F ones and stuff but you can't just get your Yeah and nurses have to be of a certain band. So band five and above um for some, some of them as well. Cool. Uh Next one, how can you prepare in advance for discharge letters? Particularly for long term patients? Yeah. So if you have a long term patient, um I would start writing a discharge letter. So for example, you could start by saying um patient X came in with these symptoms, she was diagnosed with this. We did this um And then when a new kind of event happens, say something else goes wrong, you treat for something else, you do other investigations, just add it in, just add a different paragraph, you could even bullet point it and then put it into like more paragraphs, um, kind of as they get closer to discharge. Um, but it's so much easier if you've got all of the main events in front of you before you have to go back through every single page of their notes. Um, for kind of shorter term patients, you can just write the discharge letter but try and again, prepare it like the day before. Um if you need to go home the next day and then as I said earlier, we can send off the TT S the day two days in advance if you don't think the drugs will change um in that time, especially if it's like complicated things, plaques, controlled drugs and stuff. Um So yeah, just have in the back of your mind the patients who might be going home and patients who have been there for a long time and just start bullet pointing at least. Yup. Um Someone's commented grateful, thanks for your helpfulness. Great. And Emma has put the link to the whatsapp Chat for the one mentorship um chat. So have a look into that. Um Its data used for safeguarding concerns regarding a patient too. Ie if a patient reports domestic violence, that's a good question. Um It's not, no, certainly not in my hospital. So it's any kind of like clinical event. Um a patient safety concern related to like their hospital stay. So something that we can learn from as a clinical team, um if you have other kind of patient safety concerns out of hospital, et cetera, then it would be other safeguarding teams and things like that. Um If you say if some kind of thing that we can change has happened. So for example, if you have a patient who's been the victim of domestic violence, and then for some reason, we let the perpetrator that onto the ward and into their beds space, then that potentially is a data. But your concern about the domestic violence itself goes down different safeguarding pathways which will vary between like trusts. OK. That makes sense. Yeah, exactly. That. Um and that's it. I don't have any more questions written up here. Um Any final questions. But yeah, I just wanted to echo what you said in terms of so you can support your supervisors are and if you have a really good relationship with them, then they are a great source of um help really. Um especially educational supervisor, whatever issues that you're having, whether it's work related, non work related and you're finding things difficult, you can always approach them and it's ok if you're feeling a bit low in, in the beginning um about work and you feel a bit lost. Um You will unfortunately feel that feeling maybe another time during work and stuff and be quite um burdening at points. If that's the case, please speak to people, please speak to people within your um working team, um, your supervisors and get help because that's not a sign of weakness. Um And it's better to look after yourself um, before you can look after someone else who's unwell. So, you know, rest and um make sure you've got all the energy um within you as well. So yeah, just wanted to echo that because that's really important because we do seem to neglect ourselves unfortunately. Um due to work, I completely agree with that. Um And right, final lots of, thank you. Thank you very much. Um I'm, I'm really help. I'm really glad that you guys um tuned in and the next webinar um would be on the sixth of July. I'm going to send out um er posters for the next, er, sessions in July. We've got about um 86 to 8 sessions planned. Um So the next one is on the sixth of July and it'll be on difficult discussions. Um So, and that'll be at 7 p.m. as well on medal. So hopefully we'll see you then and do sign up to that um event as well. All the events for July have been published on medal so you can already begin to register for the events. Thank you. Yep, that's great. And if you can also um complete the feedback form for this particular session, that'll be really, really helpful because I look up um previous feedback um from last year to improve this one et cetera. So it'll be very useful for us. Thank you very much. Thank you and thank you Emma as well. You're welcome. Ok, thank you. Yeah, bye.