The first day on the wards, learning about systems and processes, can be a daunting time for junior doctors, says Dr Lynelle Govender, contributing author to Medical Protection and Lecturer, University of Cape Town

Medical school teaches you about pathology and patients but doesn’t always teach you about the administrative duties required to manage those conditions and treat patients. Every order that your consultant gives on a ward round will inevitably require a form to be filled and sent in the right direction. The doctors’ rooms in the wards are usually piled high with stacks of forms in unlabelled pigeonholes, each a different colour and for a different purpose.

Even if you do find the right form, you may make the classic mistake of not filling it out in proper duplicate or triplicate. At the risk of seeming silly, grab your senior medical officer on the first day and ask them the basics about the forms, especially for common things (x-rays, discharge summaries, lab forms). It will save you a wealth of time later, which you will gladly use up on doing actual procedures.

Staff and sticking together

For a brief period, your consultant will have a ward round, your senior may or may not stick around to help with ward duties and for the rest of the day it’s just you on the ward, seemingly alone. The truth is though, you are not alone. You are surrounded by a team of nursing staff. Forming good relationships with nursing staff cannot be stressed enough. Be polite, learn names, and under no circumstances flaunt arrogance or superiority.

The nurses have been working in the wards far longer than you have. If you are polite, they tend to help you with learning the system and doing tasks. If you are rude, they won’t. If you are fortunate enough to have another intern working on the same ward as you, help each other, even if you are in different ‘teams’ or ‘firms’. Finish your work and check on your buddy. This is the only other doctor who will be in the ward all day with you. They will need your help, and one day you will certainly need theirs.

Organisation

In a ward, you may be looking after 50 patients or more. Each person with a different name, number and different set of instructions for the day. It adds up, it gets confusing, and then it gets crazy. All sorts of people become doctors: people who are good at being organised, and people who have a more chaotic approach to tasks.

On the wards, though, it doesn’t matter what kind of person you are. It is vital that you have an organised approach to your workload for the day. Whether it is a clipboard or notebook, write your ward work down as you go along in the round with the consultant. After the round, separate things into what needs to be done first, and what things can be done together. The busier your ward becomes the more essential it is that you have a strategy. Time management is, ironically, a skill that is learnt over time. You will become faster and faster at doing procedures and making notes, and you will become cleverer and cleverer at the little tricks to getting things done efficiently.

I had a very strict consultant who once said there was no such thing as too much ward work. It was only the fault of the intern for not being efficient enough. This is a rather harsh approach, and obviously not always true; however, it does reflect the level of expectation that your seniors will have on you. The pressure placed on you as an intern on your first day can be insurmountable.

The workload is immense. Some seniors are wonderful; they can help you with your paperwork, procedures and even provide the emotional support structure you need. And some seniors leave much to be desired. Working unsupervised is horrible under any circumstances, but on your first day it can be downright dangerous. If you are unsure how to do a procedure, stop and ask. It is no longer about your pride, or your senior’s attitude, it is quite simply about providing safe treatment for the patient.

Finally, in coping with the first day on the wards, the most important person you need to remember to look after is yourself. It’s not complicated. Eat when you are hungry. Drink water often. And ask for help as often as you need to. The learning curve is initially very steep, but with surprising speed you will master the wards and learn to cope in situations that were once beyond your strength or expertise.

Case study

Dr S is a newly-qualified doctor. On 29 December, he has orientation at the hospital where he will start internship on 1 January. His first rotation will be obstetrics and gynaecology. General orientation is little more than a series of presentations by various members of the hospital management. The head of department of O&G then fetches her group of interns and takes them to her department. But here, orientation continues as another presentation in yet another overcrowded room. The newly-qualified doctors breeze through the wards, but they are not provided with any practical information.

As 1 January is a Saturday on this particular year, only two interns will be required to come in. These two interns will do the first call for the rotation. The first call of a rotation is the absolute worst. Not only are you completely inexperienced in clinical aspects of the department, but you are also unsure of the practicalities of the system. The head of department expects two interns to volunteer for this madness. Silence. Dr S quickly realises that no-one will volunteer. He raises his hand: he will do it.

1 January rolls around and before he knows it, Dr S is outside the hospital walking in for his first day. In medical school, you imagine this will be a grand affair. It’s your first day working as an actual qualified doctor, after all. It is none of those things. Work starts almost immediately as you push through the labour ward doors. Dr S is expected to start the ward round in the labour ward. The registrar who is supposed to be accompanying him has been called to theatre for an emergency caesarean and has taken his fellow intern with him. Quite suddenly, Dr S is alone.

He tries his best to see the patients, and come up with appropriate management plans, but even the simplest of ward tasks become a challenge because he does not know the system. He doesn’t know which forms to use to order blood tests, or how to order units of blood after hours, or what number to call when he has to book an emergency case in theatre. Thirty hours pass by in a blur of work and stress. Before he knows it, the call is over... and it’s already 2 January.