My experience of working as a ST4 trainee in acute internal medicine at Hull Royal Infirmary
This is my experience of working as a ST4 trainee registrar in acute internal medicine at Hull Royal Infirmary.
MY TIMELINE
1. I received my rota on the 17th of July
2. Most of my correspondence with HR was done via email and I had to go for a face to face ID check on the 4th of August which lasted 5 minutes
3. I started in AMU on the 5th of August.
I was added to the AMU WhatsApp group by a group of helpful trainees a few days prior to starting and they showed me the rota, gave me a briefing of how things worked here and this was incredible helpful.
MY DUTIES
As an acute medical registrar rotating in AMU, these will be my duties:
1. Run ambulatory care from 0900 to 1700 with a consultant ( who is present there from 0900 till 1700, has no other clinical duties and another consultant takes over from 1700 to run it till 2200)
2. Cover a zone of AMU from 0800 to 1600. The AMU here is huge and it is impossible for a registrar to cover the whole unit. So they have dedicated one zone to an acute medical registrar, which has around 12 patients. We are expected to see the patients seen the previous day, manage any unwell patients in that area and help the consultant ( who is there in that zone from 0900 to 1700 so we are not alone).
3. Run another zone of AMU independently from 0800 to 1600- do the ward round, make management plans and if there is any issue, we can approach the consultant on call.
4. Cover the COVID ward from 0900 to 1700- do ward rounds, assess unwell patients and discuss everything with a consultant who is present in the ward from 0900 to 1700.
5. At least one day off per week ( so we work 4 out of 5 weekdays) for personal development in which acute medical registrars can work on their specialist skills and QIPs, etc.
The rota is made one of the AMU consultants who is the clinical lead for medicine and is extremely proactive.
MY EXPERIENCE
DAY 1
I was not expected to work this day and my rota mentioned 'induction' ( to ensure that I was well settled and knew the system)
This was very different to my other first days in my previous trusts ( Slough, Harrogate, York and Scarborough where I had a 2 day induction). This time, because of COVID they did not do any face to face training/ induction. This had its own issues as no one knew what to do. However the trust had loads of non trainees from SHOs to registrars who had been working here for a longer period of time and they new the system hence I got to sit on a computer and learn how to work the new system, do my e learning, email loads of people. None of the consultants bothered me during that time and this way, I was able to sort out everything.
In the afternoon, I went to ambulatory care to learn the pathways and the patient cohort we get there as I was rota'd in to do .
DAY 2 AND 3
I was able to run ambulatory care with a consultant and by the end of the day 2, I got the hang of it and become more confident. We had 2 SHOs, 1 ACP, registrar and a consultant.
DAY 4 ( Monday)
I was on one zone of AMU with a consultant who asked me to see half of the ward. I had a very helpful SHO and FY2 with an ACP there to help. The consultant had a SHO and a FY1 as well. So we were a total of 6 doctors ( one consultant, one registrar, 2 SHOs , one FY1 and one ACP) for a total of 13 patients.
This is a typical week for me :
Day 1- AMU 0800 to 1600
Day 2 - Ambulatory care unit 0900 to 1700
Day 3 - COVID ward 0900 to 1700
Day 4- personal development day
Day 5 - AMU 0800 to 1600
LEARNING OPPORTUNITIES ON AMU
1. Acute medical registrars are allowed to act up as consultants even as ST4 trainees. They are not left alone at any point though and there is a consultant there to help. I was allowed to post take patients under supervision. This is an excellent opportunity to gain confidence to get the hang of what your expectation would be as a consultant.
2. Procedures - from USS guided cannulations to lumbar punctures. You get plenty of opportunities.
RMO 2- ward cover long days/nights :1700 to 2100 then 2100 to 0900
Upon starting here:
1. Access to the IT system
2. Access to radiology images
3. Access to the intranet
4. Car parking permit
5. Scrubs ( we are provided 2 pairs of scrubs by linen services)
6. Access card for wards
7. Payroll details
8. Access to the website through which I can claim for expenses
9. Mandatory training - I get 8 hours off in lieu for doing the mandatory e modules at home.
I have to do the aforementioned things every time I change trusts and this is my 5th trust in the NHS. It is still the same process yet all the systems are so different. It does get better with time and I have learnt to adapt quickly but in a safe way to ensure I get settled well and early. It took me a few months to settle into my first job as a non trainee in the NHS , a few weeks to settle in my second job , a few days to settle in my third job and this time it took me a day to settle.
MY TIMELINE
1. I received my rota on the 17th of July
2. Most of my correspondence with HR was done via email and I had to go for a face to face ID check on the 4th of August which lasted 5 minutes
3. I started in AMU on the 5th of August.
I was added to the AMU WhatsApp group by a group of helpful trainees a few days prior to starting and they showed me the rota, gave me a briefing of how things worked here and this was incredible helpful.
MY DUTIES
As an acute medical registrar rotating in AMU, these will be my duties:
1. Run ambulatory care from 0900 to 1700 with a consultant ( who is present there from 0900 till 1700, has no other clinical duties and another consultant takes over from 1700 to run it till 2200)
2. Cover a zone of AMU from 0800 to 1600. The AMU here is huge and it is impossible for a registrar to cover the whole unit. So they have dedicated one zone to an acute medical registrar, which has around 12 patients. We are expected to see the patients seen the previous day, manage any unwell patients in that area and help the consultant ( who is there in that zone from 0900 to 1700 so we are not alone).
3. Run another zone of AMU independently from 0800 to 1600- do the ward round, make management plans and if there is any issue, we can approach the consultant on call.
4. Cover the COVID ward from 0900 to 1700- do ward rounds, assess unwell patients and discuss everything with a consultant who is present in the ward from 0900 to 1700.
5. At least one day off per week ( so we work 4 out of 5 weekdays) for personal development in which acute medical registrars can work on their specialist skills and QIPs, etc.
The rota is made one of the AMU consultants who is the clinical lead for medicine and is extremely proactive.
MY EXPERIENCE
DAY 1
I was not expected to work this day and my rota mentioned 'induction' ( to ensure that I was well settled and knew the system)
This was very different to my other first days in my previous trusts ( Slough, Harrogate, York and Scarborough where I had a 2 day induction). This time, because of COVID they did not do any face to face training/ induction. This had its own issues as no one knew what to do. However the trust had loads of non trainees from SHOs to registrars who had been working here for a longer period of time and they new the system hence I got to sit on a computer and learn how to work the new system, do my e learning, email loads of people. None of the consultants bothered me during that time and this way, I was able to sort out everything.
In the afternoon, I went to ambulatory care to learn the pathways and the patient cohort we get there as I was rota'd in to do .
DAY 2 AND 3
I was able to run ambulatory care with a consultant and by the end of the day 2, I got the hang of it and become more confident. We had 2 SHOs, 1 ACP, registrar and a consultant.
DAY 4 ( Monday)
I was on one zone of AMU with a consultant who asked me to see half of the ward. I had a very helpful SHO and FY2 with an ACP there to help. The consultant had a SHO and a FY1 as well. So we were a total of 6 doctors ( one consultant, one registrar, 2 SHOs , one FY1 and one ACP) for a total of 13 patients.
We were done with the post take, ward round and jobs by 12 PM. After that, I clerked a patient just to get the hang of it and did a few odd jobs.
DAY 5 ( Tuesday)
I was on the COVID ward. This was our team - one consultant, me, 2 SHOs, 3 FY1s for a total of 13 patients. So a total of 7 doctors for 13 patients. We were done with the ward round by 11 AM, the team carried out jobs, discharges and we were done by 2 to 3 PM. I was then able to send half of the team home early and sent the rest by 4 PM and just stayed on the ward till 1700.
MY ROTA
The non highlighted days are my normal 0800 to 1600/0900 to 1700 days
The orange highlighted days are my days off- zero days, weekends
The circled days are my annual leaves/time off in lieu ( TOIL)
The yellow highlighted days are my on calls on the weekend - 0900 to 1700
The pink highlighted days are my long on calls on the weekend - 0830 to 2030.
DAY 5 ( Tuesday)
I was on the COVID ward. This was our team - one consultant, me, 2 SHOs, 3 FY1s for a total of 13 patients. So a total of 7 doctors for 13 patients. We were done with the ward round by 11 AM, the team carried out jobs, discharges and we were done by 2 to 3 PM. I was then able to send half of the team home early and sent the rest by 4 PM and just stayed on the ward till 1700.
MY ROTA
The non highlighted days are my normal 0800 to 1600/0900 to 1700 days
The orange highlighted days are my days off- zero days, weekends
The circled days are my annual leaves/time off in lieu ( TOIL)
The yellow highlighted days are my on calls on the weekend - 0900 to 1700
The pink highlighted days are my long on calls on the weekend - 0830 to 2030.
The green highlighted days are my night shifts- 2000 to 0800
the days underlined red are my 1700 to 0500 shifts
The blue marked days are my locum shifts I have booked in my favorite hospital - Scarborough which is an hours drive from where I live and do them on a regular basis to save up and keep in touch with management as I plan to work as a consultant once I complete my training. Despite doing a significant number of locums, I still have 2 days off every week to enjoy with my family PLUS a day off as personal development.
This is a typical week for me :
Day 1- AMU 0800 to 1600
Day 2 - Ambulatory care unit 0900 to 1700
Day 3 - COVID ward 0900 to 1700
Day 4- personal development day
Day 5 - AMU 0800 to 1600
I will be in acute medicine from August 2020 to April 2021 and then work in ITU till August 2021.
LEAVES
I booked all my annual leaves in advance hence have had no issues so far. I have also been able to get days off for study leave and time off in lieu for out of hours teaching and when I worked on bank holidays.
LEARNING OPPORTUNITIES ON AMU
1. Acute medical registrars are allowed to act up as consultants even as ST4 trainees. They are not left alone at any point though and there is a consultant there to help. I was allowed to post take patients under supervision. This is an excellent opportunity to gain confidence to get the hang of what your expectation would be as a consultant.
2. Procedures - from USS guided cannulations to lumbar punctures. You get plenty of opportunities.
3. You get to make a decision about discharge / transfer of a patient on AMU to a specialist ward and learn when either of these are indicated as you have a consultant there to help.
LEARNING OPPORTUNITIES IN AMBULATORY CARE
1. We get to see patients on our own, then get to discuss doubtful cases with the consultant.
1. We get to see patients on our own, then get to discuss doubtful cases with the consultant.
2. Plenty of opportunities to learn what cases can be ambulatory.
LEARNING ON THE WARD
1. Leading the ward round
1. Leading the ward round
2. Teaching colleagues
3. Leading the MDT
4. Making decisions about discharges.
3. Leading the MDT
4. Making decisions about discharges.
All of these learning opportunities are supervised and every consultant I have worked with so far is very supportive and helpful.
MY GIM ON CALLS
CONSULTANT COVER
AMU:
2 consultants from 0800 TO 2200
2 consultants from 0800 TO 2200
AMBULATORY CARE:
1 consultant from 0800 to 2000
1 consultant from 0800 to 2000
ELDERLY AMU ( EAU):
2 consultants from 0800 to 2200
ELDERLY WARDS ON WEEKENDS
0900 TO 1800
COVID WARDS
0900 TO 1700 - Acute medicine/GIM consultant on weekdays
0900 TO 1800 - Acute medicine/GIM consultant on weekends
SPECIALTY SUPPORT
0900 to 1700 weekdays and then non resident on calls out of hours.
Cardiology registrar available in Hull from 0900 to 1700 for cardiology referrals and then based in Castle Hill out of hours for advice/taking over.
There are 5 different RMO ( registrar shifts) in Hull Royal Infirmary:
RMO 1 - 0800- 2000/2000-0800
RMO 1 - 0800- 2000/2000-0800
DAY
RMO 1 is based in ED resus during the day. As this is a teaching hospital, we get a lot of complex patients. We have 10 resus beds , mostly with unwell medical patients ( GI bleeds, low GCS, ? COVID patients requiring O2) plus trauma patients plus unwell surgical patients.
We are also involved with seeing patients in the main ED department who need a registrar review ( maximum 1 or 2 a day).
RMO 1 alse carries the RMO 2 bleep from 0900 to 1700 on weekdays and takes referrals/ reviews unwell patients on other wards ( ie surgical, gynae wards) who have acute medical problems. There are not a lot of unwell patients and hence the bleep hardly goes off during this time.
I personally stay in ED resus ad see unwell medical patients as soon as they come in to support the ED team and make an escalation decision early. I also go to the main ED department to help the ED team make decisions about patients who could go to ambulatory care if the team is really busy. I also clerk medical patients there to ease the load on the AMU team. The ED team here is amazing with loads of ED registrars and at least 2 consultants but when it gets busy, they do need support from the medical team and I try my best to help with that.
The best thing about working in such a big center is that we have specialist support 24/7- be it gastro/respiratory/cardiology/neurology/renal.
NIGHTS
RMO 1 is based in AMU as the consultants leave by 2200. RMO 1 helps with senior reviews of patients clerked by the FY1s, SHOs and ACPs and also liaises with the AMU nurses in charge to transfer patients to outlier/specialist wards.
RMO 1 also goes to ED RESUS if called and takes the COVID phone from RMO 5 at midnight.
RMO 2- ward cover long days/nights :1700 to 2100 then 2100 to 0900
These are the ward registrars and help with any pleural procedures out of hours ( ie chest drains/NIV, etc). They also take referrals/ reviews unwell patients on other wards ( ie surgical, gynae wards) who have acute medical problems.
RMO 3 - Ambulatory care from 1700 to 0500
These registrars help on ambulatory care unit from 1700 to 2100 and when there are no more patients, they help RMO 1 or RMO 5 from 2100 to 0500 AM.
RMO4 - Weekend care of elderly support - 0900 to 2100
These registrars help on the elderly wards - there are 3, with 30 patients each. Each elderly ward has an allocated SHO/FY1 with a geris consultant for all 3 wards.
The registrars review any unwell patients, patients who could be fit for discharge after a medical review and help the geris consultant till 1300.
After lunch, RMO 4 goes to ED and works with the 'FIT' team ( which has an OT, PT and doctor) to assess patients, deem them fit for discharge and make advance care plans by communicating with care homes/next of kins.
Then RMO 4 goes to the elderly assessment unit which already has a consultant doing the ward round. The RMO 4 helps with any unwell patients/clerking after the consultant leaves.
RMO 5 - COVID registrar from 1700 to midnight weekdays and from 0900 to 2100 on weekends
RMO 5 helps in assessing COVID patients on the wards and liaise with the respiratory team and ITU.
If RMO 1 is busy, they help with reviewing ? COVID patients in ED resus.
These RMO's come from different specialties as well. So on one night, we will have a respiratory registrar as RMO 2, a gastro reg as RMO 5 and a renal reg as RMO 1 - this way we can get specialist opinions there and then if we are stuck with a complex patient.
Overall, I as a registrar feel very supported and have plenty of colleagues to ask for advice.
COMMUTING
I live in Beverley and drive to work. Without any traffic, it takes 20 minutes. And with traffic/rush hour it takes 30 to 40 minutes.
Parking is a nightmare in Hull but as I tend to arrive latest by 0830 AM when I am due to start at 0900 AM and at 0745 when I am due to start at 0800 AM, I get a parking space easily - I had to park in private parking only one in the past 3 months.
DIFFERENCES BETWEEN DISTRICT HOSPITALS AND TERTIARY TEACHING HOSPITALS
This has been an amazing experience so far. The AMU of a tertiary teaching hospital is very different to district hospitals.
These are the main differences:
1. Consultant support from 0900 to 2200 on ambulatory unit with a registrar there from 0900 to 1700.
2. Very well staffed Acute unit and ambulatory care.
3. One dedicated leader ( in this case it is our clinical lead and director) who takes full responsibility of the rota, ensures all acute units are well staffed and we are all learning rather than getting overwhelmed with small tasks.
4. Plenty of fancy equipment - we have a new USS machines which is for AMU and a very fancy infrared handheld vein finder.
These are the main differences:
1. Consultant support from 0900 to 2200 on ambulatory unit with a registrar there from 0900 to 1700.
2. Very well staffed Acute unit and ambulatory care.
3. One dedicated leader ( in this case it is our clinical lead and director) who takes full responsibility of the rota, ensures all acute units are well staffed and we are all learning rather than getting overwhelmed with small tasks.
4. Plenty of fancy equipment - we have a new USS machines which is for AMU and a very fancy infrared handheld vein finder.
5. The acute medical registrars get to train loads- I was running ambulatory care with a consultant and learning a lot by discussing the relevant cases with him and getting feedback.
6. We get personal development days - at least one day off to develop our personal skills.
7. It is not overwhelming- we are done with ward rounds with lunch, everyone eats on time and leaves on time.
8. An excellent in-reach team of specialists who will take over patients immediately. The cardiology registrars saw a few patients in ambulatory care and AMU who were immediately taken over by them and transferred to the appropriate wards. They did not end up in a random 'general medical' ward and were appropriately managed by the right teams at the right time.
9. Investigations are done within hours instead of days as there is more equipment and more technicians to run them.
10. Well staffed on call team - we have 4 medical registrars with set duties and each of them is from a different specialty so we can get specialist input from our colleagues at any point. Plus there is a consultant on call for each specialty as well.
11.Everyone is very keen to do QIPs. We have a lot of specialist consultants and registrars who are willing to work on any specialist specific project we have.
INDUCTION
This is what I had to sort out prior to starting work here:
1. Fill out the million forms HR and occupational health had sent.
2. Email my personal documents to HR
3. Request for reimbursement of relocation expenses
4. ID check
5. Got an idea of my rota ( which was emailed to me 3 weeks prior to starting ) and contacted my colleagues in acute medicine at Hull Royal to get an idea of my work expectations
INDUCTION
This is what I had to sort out prior to starting work here:
1. Fill out the million forms HR and occupational health had sent.
2. Email my personal documents to HR
3. Request for reimbursement of relocation expenses
4. ID check
5. Got an idea of my rota ( which was emailed to me 3 weeks prior to starting ) and contacted my colleagues in acute medicine at Hull Royal to get an idea of my work expectations
Upon starting here:
1. Access to the IT system
2. Access to radiology images
3. Access to the intranet
4. Car parking permit
5. Scrubs ( we are provided 2 pairs of scrubs by linen services)
6. Access card for wards
7. Payroll details
8. Access to the website through which I can claim for expenses
9. Mandatory training - I get 8 hours off in lieu for doing the mandatory e modules at home.
I have to do the aforementioned things every time I change trusts and this is my 5th trust in the NHS. It is still the same process yet all the systems are so different. It does get better with time and I have learnt to adapt quickly but in a safe way to ensure I get settled well and early. It took me a few months to settle into my first job as a non trainee in the NHS , a few weeks to settle in my second job , a few days to settle in my third job and this time it took me a day to settle.
Overall, it is a great place to work. There are plenty of opportunities to learn and teach. All doctors here fell well supported and have had an excellent experience.
WHAT I LOVE ABOUT WORKING IN HULL ROYAL INFIRMARY:
1. I as a registrar feel very supported, be it on AMU, ambulatory care or when on call out of hours.
2. I am learning a lot - seeing patients independently and having someone to ask for advice/assess me.
3. Very good ED department who support medical registrars and appreciate it when we help them.
4. 24/7 specialty support - A patient with a GI bleed will be assessed and have a scope within 2 hours even if it is 0300 AM if the patient meets the criteria.
5. 24/7 cardiology support. There is a cardiology reg 24/7 for advice/ taking over cardiac patients.
6. Very good acute unit - proactive consultants who want to maintain patient flow.
There are a few things which are not very good which I have escalated and cannot discuss them on an open forum like this however I have always felt that my suggestions have been taken on board.
OVERALL EXPERIENCE
Love the acute medicine and ED team here and how supportive they are. These placements are very good for acute internal medical training.
FAQs
Is there any difference between a district hospital and a huge teaching hospital at SHO level?
Is there any difference between a district hospital and a huge teaching hospital at SHO level?
No there is not. I have worked in district hospitals as a core medical trainee year 1 and 2 and then as a ST3 registrar. I did not find that I am lacking in any skill/knowledge upon starting in a tertiary teaching hospital as a ST4 trainee registrar.
Does it make a difference as a registrar?
The best thing about a speciality training post is that you get to rotate in district as well as tertiary hospitals so when you become a consultant, you have worked in all sorts of setups.
I would have worked in Scarborough ( ST3), Hull , Harrogate and York as a trainee registrar before I become a consultant and these different work environments will help me learn what is good and what is not so that I can implement the positive things when I start as a consultant.
I would have worked in Scarborough ( ST3), Hull , Harrogate and York as a trainee registrar before I become a consultant and these different work environments will help me learn what is good and what is not so that I can implement the positive things when I start as a consultant.
You move trusts every year. It must be hard!
Yes, relocation is not easy. I easily get attached to a hospital, the amazing healthcare professionals working there and it always breaks my heart. I always drive home with tears in my eyes on my last day but in the long run, working in different trusts helps a lot in my training.
Yes, relocation is not easy. I easily get attached to a hospital, the amazing healthcare professionals working there and it always breaks my heart. I always drive home with tears in my eyes on my last day but in the long run, working in different trusts helps a lot in my training.
Induction and working in a new system must be a pain!
It always is! New systems, new ways of doing things but it becomes easier and as I mentioned above, with time it does not take long to settle in. I have found my FY1 and ACP colleagues extremely helpful in teaching me how everything works as the FY1s have been shadowing/working in the same trust for a few weeks and ACPs have been there for a significant time. Consultants and nurses also understand that we are new and they all help.
If I had it my way, I would do 2 things:
1. Ensure the IT systems of all NHS trusts is the same
2. Ensure the aisles in all supermarkets in every city have the same items in the same order.Trust me, looking for lentils at Morrison's after a long day at work is not what you want.
It always is! New systems, new ways of doing things but it becomes easier and as I mentioned above, with time it does not take long to settle in. I have found my FY1 and ACP colleagues extremely helpful in teaching me how everything works as the FY1s have been shadowing/working in the same trust for a few weeks and ACPs have been there for a significant time. Consultants and nurses also understand that we are new and they all help.
If I had it my way, I would do 2 things:
1. Ensure the IT systems of all NHS trusts is the same
2. Ensure the aisles in all supermarkets in every city have the same items in the same order.Trust me, looking for lentils at Morrison's after a long day at work is not what you want.
I will keep updating this blog as I continue working here.
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