How to Smash a General Surgery Rotation – F1 Survivor’s Guide
My first rotation as an F1 in the East of England was General Surgery. This article is a practical guide to ensuring that you can make the most of it and that you are well prepared.
General surgery is a speciality that deals with intra-abdominal pathologies that are possible to resolve with surgery. Some of the common diseases that you will see include:
- Bowel obstruction
- Biliary cholic/cholecystitis/cholangitis
- Bowel cancer
Some of the common presenting symptoms you will deal with include:
- Abdominal pain
- Bowels not opening/constipation
- Weight loss
- Irreducible lumps
Over the four-month rotation, you will become attuned to looking after post-operative patients who can develop complications, the most common of which is sepsis. You will also improve your abdominal examination skills and general clinical skills.
Your First Week(s)
Regardless of the speciality you start with, you will always begin with an induction week. The induction consists of lectures from various departments and specialities.
You will undoubtedly get bombarded by a tonne of information, half of which you’ll forget immediately. But it’s of no concern as the most critical information gets repeated to you enough times that you won’t forget it.
After the induction, you will shadow outgoing F1s or F2s, who will impart advice on dealing with hospital-specific quirks.
You will have to know a few things within the first few weeks.
- Log in information for computers and software
- How and where to prescribe medications and IV fluids
- How to order and view scans and blood results
- Where the equipment is (e.g. venipuncture, cannula, NG tubes and catheterisation kits)
- How to write in the notes
- How and where to edit and print off the patient lists
- How to order special tests like Flexible sigmoidoscopies, Colonoscopies and OGDs
- How to book patients into the theatre
- And most importantly, the registrars and consultants to be careful around
As you can see from the above, it is a lot of information to take in, and very little is related to what you learned in medical school. The above list also gives a good idea of what you will do in the coming four months.
Your First Real Shift
Don’t stress about your first few shifts, as the hospital team will likely pair you with an F1/F2 who will ensure you stay on track. In my department, we were lucky that nearly all new surgical F1s worked the first few days as regular shifts (except for the unlikely couple that had on-calls and nights). This meant that even though we had no idea what we were doing, we knew we could rely on one another.
During your first few days, don’t be afraid of asking stupid questions. Whether in the top or bottom decile of medical school, you will likely all have the same questions.
And don’t just ask your seniors. Ask all the ward staff like nurses, nutritionists, pharmacists and health care assistants; their experience will help you immensely. They will have been working longer than some doctors.
A Normal Day Shift
If you are lucky, you will start your first set of shifts with regular day shifts.
These are typically 8 am to 5 pm with a supposed 1-hour lunch break (usually reduced to 15-30 minutes).
Here is a very rough schedule of how a typical working day is for me at my hospital. Yours will inevitably vary.
|8 am – 9 am||Creating the patient list – My hospital is archaic and has the list on a Word document that the junior doctors have to update at the beginning and end of each day.|
|9 am – 12 pm||Ward round – Your standard ward round that is common to all hospitals. My hospital has at least a registrar as the lead doctor in the ward round (and sometimes the consultant). As the junior, your job is to close the curtains, document everything that occurs, and provide the lead doctor with information like recent blood/scan results, NEWS score, fluid balance and anything relevant for the patient. The length of time depends hugely on the number of patients you have to see. It can range from 1 hour to 5 hours.|
|12 pm -12:30 pm||Break – A well-deserved break. It is occasionally delayed if there are urgent jobs. However, if you have a kind senior, they will usually let you have a quick break before you start your jobs. After a few weeks, you will realise it is your responsibility to take a break. Go when you feel like you are getting tired.|
|12:30 pm – 5 pm||Jobs – The ward round will leave you with many jobs, the most typical being taking bloods, prescribing medications and fluids and booking scans. It is generally more relaxed than the ward round. You mostly get to finish on time; however, this depends on the day-to-day staffing levels. Your SHO can help spread the workload among your colleagues.|
As the rotation progresses, more responsibility will be given to you. For example, you may initially take 30 minutes to take someone’s bloods as you will still be learning the system and where everything is. When you eventually narrow this down to 5-10 minutes, you’ll have time for other tasks.
General Surgery On-Call Shifts
On-call shifts differ from day shifts because you will look after the new admissions that come into the hospital.
The below graphic explains how patients go through a hospital which is essential for understanding the job of on-call vs nights.
The on-call team will see the patients referred by A&E and the GP. They will see and review these patients to either send them home if they are well or admit them to the wards if unwell.
Your job will entail clerking the patients. This means taking a history, doing an examination and starting basic management like analgesia, antiemetics, fluids and antibiotics. In the first few weeks, I wasn’t particularly good at the management side of things and just focused on getting used to taking histories.
After the first month I started to understand when and how to give analgesia, antiemetics and fluids but it took a good three months before I understood when to give antibiotics and which antibiotics to give and where to find the guidelines on Microguide.
General Surgery Night Shifts
Nights are surprisingly more relaxed than I expected.
You can go several hours without needing to do much.
Unfortunatley, you will get bleeped for annoyingly simple tasks like prescribing maintenance fluids and analgesia. However, you will get the odd bleep of an increasing NEWS or new pain which needs sorting out.
Preparing for Nights:
- Get a nap before you leave for work
After the Night Shift:
- Don’t go straight to bed; have a good breakfast. The food will help you feel more sleepy and prevent waking up hungry in the middle of the day.
- Buy a 10,000 lux light (aka SAD lamp). Before the night shift, put it next to you while you get ready or have your “breakfast”. It will trick your brain into thinking it’s morning and help you stay awake the whole night.
- Get some blackout curtains or a blindfold.
A Scary Story
When I started my first week of induction, a doctor lectured the incoming F1s about a patient who had passed away the previous year.
Without giving away any critical information, here is the gist of what happened:
A young male patient had a road traffic accident and was admitted to ITU. There were no significant concerns during the first day, and he was stepped down onto the ward.
Unfortunately, a large number of incidents occurred one after the next, which would eventually lead to the patient’s demise. One of the most important for us as incoming doctors was that at 1 am, an F1 was bleeped and informed about this patient scoring a NEWS of 7.
The thing is, when a patient scores a 7, they should have immediately informed the registrar. The doctor instead asked a few questions over the phone, thought that one of the causes for the high score was a new confusion and told the nurse to stop the PCA (a device that allows the patient to get morphine when needed).
The F1 never went to see the patient in person. They never informed their senior.
After a few hours, the nursing staff called a peri-arrest, and the patient sadly passed awaywards.
The key to learning is to be bold and ask your senior for help. Talk to your senior immediately if you are unsure whether a patient is sick.
Don’t be afraid of being stupid. Even if the NEWS is 3 you can still ask them for help! It’s always better to be safe than sorry.
Dealing With Mistakes
You will inevitably make mistakes.
I have made many over the last three months.
However, don’t worry. It is unlikely any of these mistakes will cause anyone harm. There are several barriers in place for patients. There are pharmacists who check ward medications, nurses who can spot errors, your SHO and other seniors.
The biggest thing with mistakes is that you don’t fret over them. Don’t take them to heart.
Even if the person telling you off is being harsh.
Take it on the chin and move on.
Treat it as a learning opportunity.
The rota is what will dictate your life for the next two years and beyond. It is typically an Excel or Google sheet that gives you your working hours. We also receive a weekly rota that offers more detailed information about which consultants and registrars are working.
You should be receiving your rota six weeks before you start work. When I started this year, I received it one week before.
They said the deanery provided the new staff names too late, and the rota coordinator was going on annual leave. Regardless of the reasons, there is a good chance you won’t get your rota when you should, so email your team and ask where it is.
Above are two screenshots that you won’t see elsewhere – real rotas from a real hospital.
You get 27 days of annual leave, increasing to 32 days after five years of working for the NHS.
There are different policies on how annual leave works depending on the trust you work at; we have to use nine days in each rotation or lose our days off. If you don’t take the leave, you may get paid, but this is at the discretion of the medical education department or equivalent.
Annual leave only applies to day shifts. You also must use your nine days in the rotation (depending on the hospital’s, though).
When allocated nights, on-calls or weekends, you will need to swap your shift to get leave. This means you find a colleague willing to swap their days for yours.
You will get liue days for any bank holidays you work.
A liue day is essentially an extra annual leave day. You can take it whenever you want for any normal shift.
SDT (self-development time) is a new type of leave recently introduced. This is time supposed to be spent in the hospital working on your portfolio and other outside-of-work commitments.
Life Changing Events
Life-changing events are exceptional cases where you need time off regardless of whether you have a standard day shift, nights or on-calls.
Some of these life-changing events include:
- Religious events
As you can see, there is some leniency in the rota whereby if you require time off, they will give it to you. One of your colleagues working as a Locum will fill in for you.
Although the portfolio is less essential and time-critical than some things in medical school, you must keep on top of it.
Don’t worry about it during the first month of work. Focus on building up your clinical knowledge and getting used to the job.
I will not describe the portfolio in detail here as it is a vast topic that will require its own article.
I may write one at the end of the year.
Tips and Tricks
Here are some tips from some of my colleagues:
- Know the common general surgical conditions and have differentials in your head. Don’t get pigeonholed into thinking it’s a condition; keep your mind open.
- Get used to the medications commonly used on the ward in the first week.
- Know what makes a good SBAR and how to make referrals.
- Buy a storage clipboard – it’s a massive lifesaver!
- When on-call and on nights, get all the information about each patient you clerked including name, DOB, hospital number and presenting complaint. You may need to present this to the registrar at some point and the patient will to be added to the list.
In the end, there is little that you can do to prepare for what is about to come. There are still so many things that I didn’t mention that you will find out for yourself when starting; however I have tried to give the most important and note-worthy points above.
You’ll be in the fire for the first few weeks, but when everything settles down, you will start enjoying the job.
And don’t worry about the small things. Be positive and enjoy the journey.
You’re a doctor.
A great resource you can read if you have time: 30 doctors give advice to new FY1s – Zero to Finals