Career Focus

On and up

BMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7051.2 (Published 27 July 1996) Cite this as: BMJ 1996;313:S2-7051

How can you get the best out of your hospital posts? Senior registrar Richard Hardern gives some advice

Changing posts - and moving home at the same time - is unavoidable for doctors. You can move from post to post in a form of Brownian motion, but many people know their intended destination, professionally if not geographically. I hope that I can help to reduce unplanned delays and diversions. Change provides opportunities for career development but it also gives rise to inconveniences and anxieties. My aim is twofold: to suggest ways in which the “settling in” process can be eased and to highlight areas that are of particular interest to selection panels.


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Clarify requirements and explain your objectives

Nobody else has the same vested interest in your professional development as you do. Be proactive rather than reactive to keep it on the course you desire. Your consultants may be taken aback, but consider arranging a meeting with them, ideally before taking up your post, to discuss these issues. Establishing exactly what is expected of you in clinical terms will help to prevent your performance from disappointing. If you know their priorities you are less likely to irritate them by following a different agenda, unless you do this deliberately. Do not assume that what you were told before the appointment is still true. Talking to your predecessor usually repays the time taken. Leaving this until the last minute is risky; many people take annual leave at the end of a post.

Before you start

  • Speak to the consultant staff: find out what they expect from you

  • Speak to your predecessor: find out what really happens

  • Consider what the post has to offer you: what opportunities are there for you?

  • Reflect on ways this post could help you reach your intended destination

  • Try to prepare with relevant reading and observing or undertaking practical procedures when possible.

From day one

  • Become organised: telephone bleep numbers, food, and shelter

  • Remember when “please” and “thank you” are appropriate

  • Speak to your patients as people not diseases

  • Speak to your colleagues as people not slaves.

Make time to reflect on your objectives

This may reduce the likelihood of missed opportunities for development. If your consultant knows what you are expecting and hoping for you are less likely to be disappointed. Coming clean about your weaknesses may allow your boss to help plug these gaps - these are training posts after all. You may also wish to establish what problems there are within the unit. Solving these will enhance your reputation.

Expand your clinical experience

One reason for taking up a new post is to learn new skills or to consolidate those with which you have some, but not complete, familiarity. Do not ignore those you have previously acquired. The time taken to check whether the indications, techniques, and equipment are the same as those you are used to will not be wasted. Even if there are no differences bothering to check will not harm your reputation as a thorough and thoughtful clinician. If the unit has written protocols or guidelines ask for an up to date copy. Follow them unless there is good reason not to do so. It is not in patients' interests, and thus, ultimately, not in your own, to say that you are competent to perform a procedure without supervision when this is not the case. Sod's law operates at every opportunity; do not take a chance. Every clinician, not just those on cardiac arrest teams, should ensure that they are familiar with all defibrillators that they may have to use. When moving hospital find out what number to dial to summon the cardiac arrest team. It is dangerous to assume that somebody else will know. Organise yourself Effective self management is not necessarily synonymous with effective clinical patient care, but may help you provide better care with less effort. This can be done with a notebook or with the aid of microchips - the former does not have batteries that run out. As a minimum you will need your own timetable for ward rounds, clinics, theatre sessions (and possibly those of some of your colleagues) and a daily “to do” list. A list of useful telephone numbers is vital. You will learn some off by heart but this will save you time initially. It might include the local “take aways” as well as the chemical pathology laboratory and the extension number of each ward where your patients will be. Other numbers to note down since they may not be available elsewhere are the bleep numbers of colleagues and (where relevant) numbers of long range pagers and mobile and home telephone numbers. Find out the opening times of the hospital canteen (these do not necessarily coincide with the times you will be able to eat) and the arrangements for “on call” rooms.

Consider your impact on others

It has been argued that the difference between good doctors and bad ones lies in how they behave rather than in what they know. Few of us are budding Nobel laureates. We will be judged on how we deal with patients and their relatives, with junior and senior medical colleagues, and with non-medical staff. It is difficult to spend too much time talking to patients. Imagine how they may feel if you are anxious or confused on taking up a new post. The environment is even more alien to them than it is to you.

Many books have been written and courses held about breaking bad news and it cannot be covered in depth here. Those about to start house jobs, however, should note that giving bad news is not enjoyable (though perhaps professionally satisfying if done well). Make an effort to resist the temptation to leave it to someone else to do it. Junior doctors should expect to be shown how it should be done before being expected to do it on their own. Unfortunately, however, it may be erroneous to assume that the way the consultant does it is the “right” way.

There are good reasons not to antagonise the nurses. Senior nurses often act as consultants' eyes and ears. Their views can influence the reference you receive from your consultant. Even if this is not the case they can often make your life more difficult should you deserve it or, if you show them courtesy and consideration, easier. Saying “please” and “thank you” to nursing and other non-medical staff and clearing up your own mess may make you stand out from your colleagues; many fail to do this. Not only does such failure irritate (justifiably) but leaving out sharps is dangerous.

If you are new to a hospital make the effort to introduce yourself in person rather than relying on telephone calls. Speaking face to face with a radiologist the first few times that you need an urgent x rayreport - ask for advice rather than demand a specific examination - may improve your chances of success on subsequent occasions. Clerical, domestic, and portering staff are often “key players.” Patients need them. You may not need coffee and biscuits after a consultant ward round, and probably will not want to hear consultants' favourite anecdotes time after time. But unless there are clinically urgent tasks you should stay - if necessary create an informal rota for who should be the one to feign interest in church architecture or iron age burial sites each week. This may be the only time the consultant will speak to you.

Research

As doctors ascend the evolutionary tree, research tends to become increasingly important. Even if you have no need or inclination to carry out original research cooperating with projects already underway may be educational - if only to confirm your views about the futility of single centre studies with vanishingly small numbers of subjects.

Qualifications

Preparing for examinations is likely to be a preoccupation from school to the end of specialty training. Qualifications are not necessarily synonymous with good medicine nor are they the only element of career development. It is, however, essential so “There are good reasons not to antagonise the nurses” find out early in your new post what opportunities you have to learn - meetings, courses, library facilities, etc. If you are facing clinical examinations do not forget patients on other units. Less junior doctors should also be alert to opportunities to teach as well as to learn.

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