sometimes I find myself at a loss with a keen med student. I don't want to ignore them, but I don't always (or often!) have a structured tutorial to pull out of the hat

this often varies by specialty and ward anyway

EDIT 29/07/2023: to add stuff

Suggested

at the bedside:

• examine a friendly patient
• pt with a rare condition? tell me what you can about it – better, what can the patient teach you about it?
• when asked to review a patient, do an A-E together, or get them to lead the A-E examination
• observe a blood transfusion
• do a MOCA/ACE etc. (other patient questionnaires exist) talk about the advantages and limitations of those tools.

procedures:

• take a postural BP then talk about risk factors for postural hypotension
• take and interpret an ABG
• any other procedure in the GMC core procedures is game obviously
• troubleshoot a catheter/NG tube/cannula

prescribing:

• mock prescribing – antibiotics, gentamicin (grrr)
• let's talk pain relief...
• let's talk antiemetics and their mechanisms...
• let's talk parkinson's meds...
• take a medication history
• do an admission meds reconciliation
• do a meds reconciliation for discharge – why were meds stopped?

teamwork:

• ask a friendly AHP if the student can shadow them – e.g. specialist nurses, therapists, pharmacists
• follow a patient down to scan
• ask a friendly specialist if the student can shadow them
• write a referral together
• calling micro for a specific question
• take a handover

doctoring:

• write a scan request together → discuss why this modality
• chat about on calls
• do they know how “the take” works?
• doing a DNACPR? write the “red form” together

investigations:

• describe an ECG/scan systematically
• look at some bloods, ask them to tell you what it means
• parse reports, historical or otherwise (I was asked to look through 6 years of clinic letters once...)

#teaching #meded

• learned how to flush and remove a chest drain
• went to a suddenly unwell patient
• SHO was surprised that I was so calm with the acutely unwell patient, I attribute it to “request a chest X-ray, do an ABG then have a think”
• spotted a prescription error, carried out duty of candour ** the win not being the error but that I saw it and knew what to do to correct it

#wins

I have two days off after a weekend on call with a steep learning curve, so my brain does need that break.

Just writing some reflections and portfolio sign offs now and thinking

It was pretty fitting that one of my first big learning events was recognising when people were actively dying. That was something I was afraid of, starting off – knowing what was reversibly unwell and what wasn't, and with all the things around that: discussing when people might not survive resuscitation; when to make the call to involve palliative care.

Being in Frailty has helped with making these conversations much more common, and led by seniors used to making these decisions compassionately and sensibly.

Listening to the palliative care team was an education. Listening to how they navigated difficult conversations and family dynamics helped show a way that was calm and clear about uncertainty. In medical school, palliative care teaching was often about generic “breaking bad news” and prescribing. Let's be frank, most of my “palliative care revision for finals” was 80% prescribing, 20% “soft skills”. Learning about palliative care in FY1 has been 20% prescribing, 80% communication skills and styles of patient assessment.... like most other clinical specialties, really!

I have no answers. Coming alongside people and talking about this with them is becoming a bit easier with practice, especially when I know it can be done with compassion and gentleness.

#geris #palliative #death #reflections

small reflections from the other side

I've just finished a run of nights off the delirium ward

I now see delirium everywhere

where before it was “agitated confused” or “drowsy confused” I now recognise “hyperactive delirium” and “hypoactive delirium”... and I see the dangerous transition points where valuable information gets missed, or plans are never actioned.

#geris #reflections

Had a registrar on the ward for the first time since I started – first time in 3 weeks, probably

And she went “I've been on the ward as the only doctor... I'm [grade] and I'm doing all these bloods and NOK updates...”

I feel like I've missed something?? like obv the reg should do the decision making but

idk

I used to be assigned to a bay of 15 patients, most with acute medical problems we were actively treating. Now I have 12 in the ward.

Yet I'm finishing jobs about the same time... leaving late in recent days mostly because of tricky procedures and discharge delays due to medication

._.

#geris

When I moved to this ward, I was struck by how long people stayed on.

But, actually

it's been quite good to know my patients so I could tell other teams about them from memory

And to contact families so regularly that we need only update them on small, granular things – and until they recognise my voice

Continuity, eh

#geris #reflections

Last Christmas, I was self-isolating with actual Covid infection and trying to get takeaways without getting in contact with my vulnerable housemate

This Christmas I will be working

I do observe, I promise, but logistically it is... difficult.

A log for wins at work, because I think I'll need it.

Got drawn into medical take for £40ph with escalated escalated rates after discharge ward round. So having done 10-12 TTAs on the new system, went on the take with a ridiculous number of people to see...

And I've only spent 2 days on frailty, but was immediately given a patient who would clearly benefit – care home resident, came in after a fall, history of dementia. Meaning I knew what sorts of things were good to do for this patient! Had a good conversation re risks and benefits of admission too.

Feels good to have seen and thought about this lots, and be able to apply this in an undifferentiated situation.