Shadowing in the NHS

After the emotional roller coaster-like experience on the very first day, I was up for my next stage i.e., Shadowing as a supernumerary doctor in the NHS. I learned a lot of things during the period of this 1 month. Even though I had more than 3 years of post-qualification experience as an SHO in Internal Medicine back home, I struggled quite a lot in the beginning. Out of a lot of things that were challenging, understanding the NHS system is the one that I rank at the top. The system and the workflow here, are completely different and not exactly like the one that you might have expected before coming here. I hope this blog will also help you a little bit in knowing a few things about the system here.

Activities in a normal working day

First of all, let me summarise what a normal working day would like in an inpatient ward.

Generally, the work shift starts at 8:30 am in the morning. Once reaching the department, firstly all the SHOs, including the registrar and consultant used to gather in front of the main nursing station of the ward. One of the in-charge nurses then used to do the morning patient briefing. This briefing generally included the information regarding the number of patients in the ward, any significant overnight issues, the number of new admissions to the department, any patient who is NEWSing high, and any potential discharges for the day. After the briefing, SHOs used to divide the patient equally among themselves. There were 32 beds in our wards and most of them were occupied all the time. Since there were 4 SHOs, one SHO had to take a maximum of 8 patients in a day. Once the patient was divided, they quickly then go through the patient notes from their computers and present the same to the consultant one by one. Then with the consultant, they do the bedside rounds and formulate a plan for each patient. After that, they had to input those plans into the system. Generally, the bedside round gets completed in around 3-4 hours. Then, at around 12:30 pm, there is another round in front of the main nursing station back again. This is the time when each doctor briefs the in-charge nurse about the plans that are formulated for all the patients one by one, this is called whiteboard rounds. It is during this round everything regarding the patient gets updated on the whiteboard as well. This lasts somewhere around 30-40 minutes. Then we had a lunch break. Generally, I saw SHOs hardly taking 20-25 mins for this lunch break, because taking a longer lunch break resulted in their work not getting completed by 5pm, though no one would question you if you take a longer break as well.

After lunch for around the next 3 hours, they used to then work on the plans formulated for all the patients. From around 4:30 to 5 pm, if there is some patient who wished the doctors to update their condition to their family members or if there is some patient who doesn’t have mental capacity, it was the duty of the respective SHOs to make a phone call and counsel the next-of-kin. By 5 pm, if the job gets done, it's off for the day, but if it's taking longer, then there is a provision of exception reporting for a longer duration of work. This gets compensated either by extra pay or time-off-in-lieu (TOIL).

Softwares for the daily workflow

Our trust has the following software for the daily workflow of doctors:

1. Etrack for daily patient notes and progress.
2. Sunquest ICE for checking lab reports, referral notes, imaging reports, and as well as ordering tests, and referring patients.
3. Epro for preparing discharge summaries and TTOs (preparing a list of discharge medication).
4. Agfa Xero viewer for viewing X-rays, CT, and MRI films.
5. Nervecenter for observing vitals and NEWS score. All the nurses use trust’s iPods to record and upload the findings from the patient bedside to this software - Nervecenter.
6. Symphony used mainly in ED for patient notes, plans, and referral.
7. Likewise, we also have Trust’s Intranet called “Connect” to view duty rosters, trust’s guidelines, and protocols.

For the first few days, these were also a real struggle for me. However, as I continued watching other colleagues use it many times, I picked up a few skills myself. I also took mandatory IT training for this software and got my own login ID after a week. To be honest, hands-on practice by yourself will help you a lot rather than IT training modules. It will look difficult at the beginning, but let me tell you, you will get used to it in just a few weeks.

Other trainings during the shadow period

In our trust, we also had to do other trainings during this shadow period, which are as follows:-

Point of Care Test Training: This is the training where they teach how to use the ABG machine and handle the ABG sample. ABG machines here are so sophisticated and this training was definitely very helpful to me to understand how to operate them.

Simulation lab session: This is a session exactly like a simman in PLAB 2 exam. Here, the educational supervisor gives you a case, generally an acute one, and asks you to perform the management in a high fidelity simulation mannikin. This reminded me of my days during the PLAB 2 exam practice. Everything during PLAB 2 was making more sense now.

Junior Doctor’s Induction: This is the formal induction program for all junior doctors. In this one-day session we were taught about fire safety, trust’s values, study leaves and budget, annual leaves, a session by the guardian of safe working, general orientation in the trust’s resuscitation protocols, death certification, and filling out cremation forms, etc. We were also told about an app "induction" where we could find the extension numbers and bleep numbers of all the people and departments of the trust.

Final words

Overall, it was a good learning experience for me. After around 2 weeks of shadowing, I started seeing 1-2 patients under the supervision of other fellow colleagues. This helped me a lot, as I always had the comfort zone of asking any silly question about the system and workflow during this time. Slowly, by the end of the month, I felt confident in seeing around 4 patients a day. After this 1 month, I felt more confident in various aspects. Things that were all bouncing across my head in the first few days was making a lot of sense. Hence, this is my strong recommendation to all of you, to ask for at least 2-4 weeks of shadowing before you start working independently. This is going to make your life a lot easier.

Originally, in my rota, there was no 'on-calls' shadowing. Since on-call was going to be a separate set of challenges, I emailed rota coordinators to put me a shadow for on calls for at least 2 shifts and they were happy to put me through that as well. So, I also recommend you to take shadow for on calls to make yourself fully prepared before you start off.

As I am writing this blog today, I have already completed my 1 month of independent work, after the shadowing in my department. I will definitely write about my experience of working independently as an SHO next time in my next blog, until then Ciao!