The Student Room Group

FY1 - general surgery

Hi everyone,

I'm wondering if I could ask for some advice and experience from any doctors on here. I am feeling a little nervous about starting FY1 if I'm honest and my first rotation is general surgery.

I am therefore wondering if I could have some insider-tips from any doctors who have already 'been there and done it', so to speak.

Is there any particular advice you would have for an FY1 before starting a general surgery rotation?

For example:

1) What would you say are the most common on-call queries / requests that you get asked to do in surgery?
2) What would you say would be the most essential or key surgical topics to revise before starting FY1?
3) Any other hints or tips to make like on general surgery a bit easier?
4) Anything you would have done differently with hindsight?

Any advice would be very much appreciated, especially as I feel as if I have forgotten every bit of surgery I knew at med school!

Thanks for reading, I appreciate your time.

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Original post by theepw
Hi everyone,

I'm wondering if I could ask for some advice and experience from any doctors on here. I am feeling a little nervous about starting FY1 if I'm honest and my first rotation is general surgery.

I am therefore wondering if I could have some insider-tips from any doctors who have already 'been there and done it', so to speak.

Is there any particular advice you would have for an FY1 before starting a general surgery rotation?

For example:

1) What would you say are the most common on-call queries / requests that you get asked to do in surgery?
2) What would you say would be the most essential or key surgical topics to revise before starting FY1?
3) Any other hints or tips to make like on general surgery a bit easier?
4) Anything you would have done differently with hindsight?

Any advice would be very much appreciated, especially as I feel as if I have forgotten every bit of surgery I knew at med school!

Thanks for reading, I appreciate your time.


1: As an FY1 your most common stuff is the bog standard ward jobs. That being writing up medications, IVT, cannulating people, doing bloods etc. After that you have the reviews of anyone getting sick overnight and that can be a myriad of things depending on the departments you're covering, but sepsis is the commonest.

The other thing you do as a surgical FY1 is clerk in new admissions, in my hospital and others nearby its just patients referred in by GPs that are seen by FY1s though. So you need to take a good history, do a good exam, form a differential and do basic investigations before discussing with a senior and getting them to review. However this can take hours to happen if your reg is scrubbed, so you need to do the right things for the patient in the meantime.

2: You don't need to revise anything really. Be good at practical procedures (bloods, cannulas, catheters, ABGs, NGs etc) and know how to do a basic clerking and a good ABC review. If you can do all that and you're fairly well organised then you'll be a good FY1.

You also need to be able to write in a set of notes legibly whilst updating your jobs list, checking the obs chart, closing/opening the curtains, wheeling along a computer, carrying another 5 sets of notes in your other arm and listening to what your reg/consultant is saying. Being a good scribe is actually an art.

3: The patient list is your god. Keep it up to date, relevant and succinct. If you don't have a good patient list ward rounds will be (more) hellish and you'll lose track of who's who and who needs what. Also, when you're doing the ward round, make a clear and ordered jobs list so you don't lose track of things you need to do.

In my hospital the colorectal team can have up to 75 patients at any given time, and they're often spread around 7-8 different wards, and move beds frequently. You cannot keep track of all of those people in your head, so you need the list.

4: Not much. I'd have practiced cannulas more in medical school i suppose.
I'd also like to tell early FY1 me that he doesn't need to jump into reviewing a patient he's been called to straight away. Now i always take 5-10 minutes to sit with the notes (after a cursory glance at the patient to ensure they're not actually imminently dying), and get a good idea of the patients background, history of current admission, look at the bloods, obs and fluid balance etc.

Those 5-10 minutes spent getting your bearings will in all but a very small handful of situations (peri-arrest people being the exception) lead to better patient care because you'll know what you're doing//looking for.
The actual 'medicine' involved is relatively straightforward. You have to be really organised, quick and efficient with the jobs though, especially if you have any desire to go to theatre. You have to be your bosses eyes and ears with your patients because you'll spend more time with them when they're awake. "Call the medics" isn't usually a valid plan.

This is assuming it's a busy surgical job. A lot of dgh surgery is not busy and will be a gentle induction to fy1
Original post by basit282828
OMG i wish to have this convo one day in my life. I've just done my GCSE's, and i have a long way to go till i do medicine. However, this just made me day! Thank you!

Posted from TSR Mobile



Aww keep working at it and hopefully it'll work out for you :h:
I've just finished my first year of medicine and all the hard work, stress, tears from GCSEs and A-levels were totally worth it :smile:
Original post by fishfacesimpson

This is assuming it's a busy surgical job. A lot of dgh surgery is not busy and will be a gentle induction to fy1


That's true actually - here surgical jobs have a super stressful ward round 8-9, then jobs until 11 or so, then they're finished and spend the rest of the day in the mess. Even on calls you'll probably spend more than half the time sitting around...
Original post by theepw
Hi everyone,

I'm wondering if I could ask for some advice and experience from any doctors on here. I am feeling a little nervous about starting FY1 if I'm honest and my first rotation is general surgery.

I am therefore wondering if I could have some insider-tips from any doctors who have already 'been there and done it', so to speak.

Is there any particular advice you would have for an FY1 before starting a general surgery rotation?

For example:

1) What would you say are the most common on-call queries / requests that you get asked to do in surgery?
2) What would you say would be the most essential or key surgical topics to revise before starting FY1?
3) Any other hints or tips to make like on general surgery a bit easier?
4) Anything you would have done differently with hindsight?

Any advice would be very much appreciated, especially as I feel as if I have forgotten every bit of surgery I knew at med school!

Thanks for reading, I appreciate your time.


Congratulations on finishing medical school and starting as a new F1!!

I am currently a F1 on General Surgery in a very busy DGH and have very loved the placement (and F1 in general) :smile:

So I have a few tips that I have found useful…..

1. Come in early and prep the list. Even if it's just 15mins early - double check the location of the patients (our trust moves patients overnight all the time due to bed shortages) and check key findings e.g CT reports, how your really sick patient is etc

2. Write down the jobs of the ward round as you go around with the boss.

3. If the boss requests any scans know why you are doing them! Radiologists will want a reason for example USS ?gallstones for RUQ pain….saying because the consultant said so won't cut it!

4. Unless you have a really sick patient to manage I find the most effective way to prioritise main tasks are request/vetting scans, taking bloods and then discharge summaries. That way you bloods are processed by the lab as you do your discharge paperwork.

5. Chase all the investigations you order - bloods, scans etc - if it isn't back by the end of your shift then hand it over to the next F1 :smile:

6. If when assessing a patient you think….maybe they need a PR exam or an ABG then do it! Nobody will tell you off for doing them but if you miss it out you might miss a key finding.

7. Breath! Especially when you are stressed! It will be ok!!!

Let me know if there is anything else you want to know if you have found this even slightly helpful! Good luck!
Reply 6
Avatar for dooodles
dooodles
This is so helpful everyone! I'm starting on general medicine at a DGH - any tips specific for that? :smile:
General medicine will be hell, and is so in pretty much every hospital. The on calls, unlike general surgery, will see you getting bleeped left, right centre, front and back. You will be on the ward busy working your way down your list of jobs whilst nurses continues to add to that list. You're likely to end up working 12 hours straight with no food or water or loo break even for your first few on calls.

Then few months down the line and you would have mastered the art of filtering out rubbish jobs and prioritising your jobs. All of a sudden that woman with a BP of 95/50 isn't worth an immediate review anymore because her HR has remained stable and in fact her BP has always been low and is currently chatting to her neighbour with a cuppa in hand. You'll learn these things over time but it's a right of passage after all. You will enjoy it. Really. And you will learn that it is OK to take a break, as long as nobody is dying as you sip your cuppa.
(edited 8 years ago)
Reply 8
Avatar for Ceryni
Ceryni
18
Original post by fishfacesimpson
The actual 'medicine' involved is relatively straightforward.... A lot of dgh surgery is not busy and will be a gentle induction to fy1


Original post by Da CorrupteD KiD
General medicine will be hell, and is so in pretty much every hospital. The on calls, unlike general surgery, will see you getting bleeped left, right centre, front and back. You will be on the ward busy working your way down your list of jobs whilst nurses continues to add to that list. You're likely to end up working 12 hours straight with no food or water or loo break even for your first few on calls.

Then few months down the line and you would have mastered the art of filtering out rubbish jobs and prioritising your jobs. All of a sudden that woman with a BP of 95/50 isn't worth an immediate review anymore because her HR has remained stable and in fact her BP has always been low and is currently chatting to her neighbour with a cuppa in hand. You'll learn these things over time but it's a right of passage after all. You will enjoy it. Really. And you will learn that it is OK to take a break, as long as nobody is dying as you sip your cuppa.


Thanking God that I'm only a 1st year atm because this escalated so quickly.... :ahhhhh::unsure:
(edited 8 years ago)
Reply 9
Avatar for Helenia
Helenia
20
Original post by Da CorrupteD KiD
General medicine will be hell, and is so in pretty much every hospital. The on calls, unlike general surgery, will see you getting bleeped left, right centre, front and back. You will be on the ward busy working your way down your list of jobs whilst nurses continues to add to that list. You're likely to end up working 12 hours straight with no food or water or loo break even for your first few on calls.

Then few months down the line and you would have mastered the art of filtering out rubbish jobs and prioritising your jobs. All of a sudden that woman with a BP of 95/50 isn't worth an immediate review anymore because her HR has remained stable and in fact her BP has always been low and is currently chatting to her neighbour with a cuppa in hand. You'll learn these things over time but it's a right of passage after all. You will enjoy it. Really. And you will learn that it is OK to take a break, as long as nobody is dying as you sip your cuppa.


This, basically. After my first day as a gen med F1 (and this was after a fairly gentle 3 months of paediatrics, so I had already worked out basic stuff about how the hospital worked etc) I cried, worked out how many more days I had to work in that job, and kept a religious countdown until it was over. Some general surgical jobs are really awful, but the ones in my hospital (London DGH) were generally ok, rarely more than 20 patients on your list and usually fewer. The ridiculous way medical takes worked in my hospital meant that you sometimes had 60 patients in 10 different wards.

A few tips that may help, but you'll learn to find your own way:

1) The List is your key to success or failure. Keep it up-to-date, put jobs on it as you go along and DO NOT LOSE IT.

2) Work out how best to organise jobs, it will depend on your hospital. In some places it's easiest to keep a stash of request forms (radiology, specialty referrals, echo etc) in your folder, try to scribble them as you go, or after the WR depending on its pace/how many scribes there are, and then drop them all off afterwards. If you have electronic requesting, and especially if you have portable computers for your WRs, you can do more requests as you go along. Still write them all on your list, so you remember to check they've been done and get the results.

3) Work out a list of important phone/bleep numbers, saves lots of time having to go through switchboard each time. Sometimes you can put these as a header/footer on your patient list, or just save it on your phone/in your folder.

4) Make sure all your patients on things requiring daily dose adjustment e.g. warfarin, gentamicin, have had their prescriptions done before you go home. Likewise if anyone is on IV fluids, ensure they have enough prescribed for the night. These little jobs take up an enormous part of your on-call time and you will make your colleagues lives easier, and hopefully set a good example!

5) Make friends. With the nurses, with AHPs, with other F1s and with your team. It will make your experience better and help you get stuff done. It can be a really difficult balance if you have to exert your "authority" when an experienced nurse wants you to do something you're not comfortable with - they probably know loads more than you (but don't always assume this) but if you put your name on something, it's your neck on the line. Don't be a cocky git, and if you're really struggling with someone trying to force you do something you're unsure of, get your SHO/reg involved.

6) Use your seniors. Don't be afraid to ask for help, even if they are all busy. You might need a thick skin but most of us are usually quite approachable*.

7) Contrary to what you may feel initially, you are almost never too busy for lunch. You will feel much better after even just a 15 minute sit-down and something to eat than if you try to power through. If you can have lunch with your team, it can be a good time to catch up with jobs etc - though be careful talking about patients in public places. If you are using a bag, carry a small bottle of water with you, so at least you don't get dehydrated.

Good luck!

* Unless you call the Anaesthetic SpR at 3am because a patient needs a cannula and they "look difficult" or you haven't escalated it appropriately up your own team. Then I'm not so approachable.
(edited 8 years ago)
Original post by DoctorInTraining


6. If when assessing a patient you think….maybe they need a PR exam or an ABG then do it! Nobody will tell you off for doing them but if you miss it out you might miss a key finding.



before jumping in with the PR exam please consider how many this patient is likely to have - ( and may have all ready had ) - but don;t let that put you off if the patient has not all ready had one ...

another PR related point it is not 'Against the Law' for RNs to do PR exams to check for impaction or to perform digital removal of faeces ... worth checking what the hospital's policy is ...

if you want to know the reasons for this common misapprehension it dates from poor practice in the old long stay geriatric / psychogeri 'hospitals' which were a hang over into the NHS of the poor law.
Original post by zippyRN
before jumping in with the PR exam please consider how many this patient is likely to have - ( and may have all ready had ) - but don;t let that put you off if the patient has not all ready had one ...

another PR related point it is not 'Against the Law' for RNs to do PR exams to check for impaction or to perform digital removal of faeces ... worth checking what the hospital's policy is ...

if you want to know the reasons for this common misapprehension it dates from poor practice in the old long stay geriatric / psychogeri 'hospitals' which were a hang over into the NHS of the poor law.


The sad reality of PRs when you're considering doing one is:

1. You can't assume they've been already been done, even when they ought to have been.
2. You can't assume they will be done, even if they ought to be.

3. You're utterly screwed in court or in front of the GMC if there is something wrong PR and you haven't done a PR exam because you didn't want to inconvenience the patient or because you delegated the task inappropriately. Even if you believe they've had a PR already, if in any doubt whatsoever you should do one again; if not for the sake of diligence then at least for medicolegal reasons. It's just not worth avoiding it or putting it off in the hope that someone else has or will do one (see 1. and 2.)

4. Like in almost all things, repetition is probably better medically, if not for comfort. What the PRHO doesn't pick up the SHO might; while that PRHO won't learn what he's missing unless he actually does the damned PRs in the first place...


I think it's a bit risky to warn us new juniors against over-PRing people! :lol: Chances are we're going to be trying to avoid PRs already, we don't need any encouragement that might see us unconsciously edge just over the line into negligence.


Post Scriptum: I also suspect the nurses probably wouldn't appreciate you trying to pass off as many PRs as possible onto them :mmm:
(edited 8 years ago)
Original post by Friar Chris
The sad reality of PRs when you're considering doing one is:

1. You can't assume they've been already been done, even when they ought to have been.
2. You can't assume they will be done, even if they ought to be.

3. You're utterly screwed in court or in front of the GMC if there is something wrong PR and you haven't done a PR exam because you didn't want to inconvenience the patient or because you delegated the task inappropriately. Even if you believe they've had a PR already, if in any doubt whatsoever you should do one again; if not for the sake of diligence then at least for medicolegal reasons. It's just not worth avoiding it or putting it off in the hope that someone else has or will do one (see 1. and 2.)

4. Like in almost all things, repetition is probably better medically, if not for comfort. What the PRHO doesn't pick up the SHO might; while that PRHO won't learn what he's missing unless he actually does the damned PRs in the first place...


I think it's a bit risky to warn us new juniors against over-PRing people! :lol: Chances are we're going to be trying to avoid PRs already, we don't need any encouragement that might see us unconsciously edge just over the line into negligence.


Post Scriptum: I also suspect the nurses probably wouldn't appreciate you trying to pass off as many PRs as possible onto them :mmm:


I'm on the fence with this one- I think it all depends on the context. If you are looking after a patient who has with an unexplained Hb drop ?UGI bleed or a history of fresh rectal bleeding ?cause or obstructed ?rectal mass ?empty rectum etc etc then you must absolutely a) conduct a PR and b) consider conducting serial PRs especially in the context of suspected bleeds because the fact that it has been documented that the patient did not have melana on examination when they were clerked in by your SHO 24 hours ago does not mean that you won't find melana now...

However, if the reason why you are doing the PR is to assess whether your (stereotypically elderly, medical) patient is impacted and would be a candidate for supps/enema for their constipation, and you have no other concerns that there's something else going on, then I see no reason why a RN can't do it, especially as they may well have an opportune moment to quickly perform the exaamination while washing/ changing/ generally nursing the patient.
(edited 8 years ago)
Original post by twmffat_twp
I'm on the fence with this one- I think it all depends on the context. If you are looking after a patient who has with an unexplained Hb drop ?UGI bleed or a history of fresh rectal bleeding ?cause or obstructed ?rectal mass ?empty rectum etc etc then you must absolutely a) conduct a PR and b) consider conducting serial PRs especially in the context of suspected bleeds because the fact that it has been documented that the patient did not have melana on examination when they were clerked in by your SHO 24 hours ago does not mean that you won't find melana now...

However, if the reason why you are doing the PR is to assess whether your (stereotypically elderly, medical) patient is impacted and would be a candidate for supps/enema for their constipation, and you have no other concerns that there's something else going on, then I see no reason why a RN can't do it, especially as they may well have an opportune moment to quickly perform the exaamination while washing/ changing/ generally nursing the patient.


I agree. The one occasion when a PR must be done is when an UGI bleed is suspected. There is simply no excuse in this situation. Multiple PRs imo is perfectly defensible in the context of a suspected UGI bleed. With regards to constipation I generally just work my way up the 'laxative ladder' starting with lactulose and if patient is BNO for a week and is obviously not obstructed then enemas. Don't think I've ever PR'ed anybody for suspected impaction except new patients during the surgical take.

By the way I didn't know that RNs could do PRs?! Where I work the new RNs don't even know how to bleed people these days.
(edited 8 years ago)
I didn't PR anybody ?impaction whilst I was a surgical FY1 (although I did do plenty for other reasons!), however as the houseplant on gerries I've had to step up to the task a few times- there's no use in using supps if there aren't any faeces there to soften and you don't really want to use a simulant if your patient is completely bunged up with hard dry stools. But it definately isn't a diagnositic dilemma that needs a medical degree/ something I can remember receiving any real teaching on in med school. The nurses are way more in tune with the bowel movements (or lack of) of the patients
(edited 8 years ago)
Original post by twmffat_twp
I'm on the fence with this one- I think it all depends on the context. If you are looking after a patient who has with an unexplained Hb drop ?UGI bleed or a history of fresh rectal bleeding ?cause or obstructed ?rectal mass ?empty rectum etc etc then you must absolutely a) conduct a PR and b) consider conducting serial PRs especially in the context of suspected bleeds because the fact that it has been documented that the patient did not have melana on examination when they were clerked in by your SHO 24 hours ago does not mean that you won't find melana now...

However, if the reason why you are doing the PR is to assess whether your (stereotypically elderly, medical) patient is impacted and would be a candidate for supps/enema for their constipation, and you have no other concerns that there's something else going on, then I see no reason why a RN can't do it, especially as they may well have an opportune moment to quickly perform the exaamination while washing/ changing/ generally nursing the patient.


True, but then even in the latter scenario the PR still needs doing. It's fine if the nurse has the time, training and is willing but that's not always going to be the case, and it's probably not good practice, nor significantly better for the patient (or the already busy nursing staff!) to avoid PRs to the extent that you're literally relying on the nursing staff to do any which you can possibly excuse yourself from.

Plus I'm of the attitude that we shouldn't be too lazy from the starting line, we've got plenty of time to learn how not to do work for ourselves :rolleyes:
Original post by Friar Chris
True, but then even in the latter scenario the PR still needs doing. It's fine if the nurse has the time, training and is willing but that's not always going to be the case, and it's probably not good practice, nor significantly better for the patient (or the already busy nursing staff!) to avoid PRs to the extent that you're literally relying on the nursing staff to do any which you can possibly excuse yourself from.

Plus I'm of the attitude that we shouldn't be too lazy from the starting line, we've got plenty of time to learn how not to do work for ourselves :rolleyes:


Out of interest- are you FY1 going on to FY2 or 5th yr going to FY1?

Its just that I'm definately not a work-shy FY1, but I've had nurses conduct PRs for ?impaction and I haven't felt the need to repeat them. We rely on the nurses to document bowel movements any way, and they would be the ones putting the supps in, and in this context its literally a question of is there poo there or not, and is it hard or soft.

One general tip I've found with FY1 is that the best way to cope on a busy ward is to delegate the jobs that you can to others able to do them, to free you up to do the things that only a doctor can do. This means finding out if the nurses can do bloods, catheters and venflons; using your phlebotomy service; and so be it, trusting nurse PRs in this context if they are able and willing to do them. You WILL burn out otherwise if you don't make the most of the skills of those around you.
(edited 8 years ago)
i think it is worth having a basic idea about scans as an FY1 in surgery would be helpful.

i would generally order either an ultrasounds or an abdo x-rays before registrar sees the patient with abdo pain depending on the presentation.if the patient is so sick you think they need an urgent CT scan, you had to get the reg to come and review from theatre.

maybe if you are new you will need some more support, however, also as i posted a thread before and it seems many hospitals have now stopped surgical registrars working resident on site, it may not be readily available as it once was.

the harder part when you start as a doctor is management as you dont have exposure to it as a student. scans are generally impossible overnight unless very urgent in DGH so they probably will say no.


in hours there are too many unnecessary scans - half of AAU has CTPA, CT head and some surgeon ask for CT abdomen on every patient - so often when you need an urgent scan in the afternoon there are no slots and your very sick patient cannot be done and yet the surgeon shouts at you if the scan is not done.

nightmare. but hopefully if you read a bit of scans you will be better prepared. when i started i used to feel like a tool every time i went to radiologist consultant and i could not explain why a scan was needed. maybe your place will be more supported but perhaps if you are too supported you dont develop.

try not to stress too much, to be honest it took me about 2 months to feel slightly competent ! i wish you the best x
Original post by Da CorrupteD KiD
I agree. The one occasion when a PR must be done is when an UGI bleed is suspected. There is simply no excuse in this situation.


I did wonder about the PR I had to do just an hour after the patient had opened their bowels, and we'd all seen the stool. I can perhaps understand that you can't take the patient's word that their stools aren't black (everybody lies?) but when you've seen it for yourself I'm not sure what sticking your finger in is going to achieve.

Also the patients who have been frequently opened their bowls but their abdomen is a bit distended (read: fat) and the medical consultant asks you to PR ?obstruction. Happened many times, and if you object you just get ridiculed and told you don't want to "put your foot in it". Haha yeah funny brb just going to strip this young patient of any dignity they had left.

Original post by Friar Chris
True, but then even in the latter scenario the PR still needs doing.


Does it though? If you want to find out whether a suppository will work then just give it and see what happens. Is not like they're expensive.

Plus I'm of the attitude that we shouldn't be too lazy from the starting line, we've got plenty of time to learn how not to do work for ourselves :rolleyes:

I'd say that learning to 'be lazy' ie. prioritise tasks and determine which ones need doing now and which don't, is the key thing that will save your sanity as an FY1. Doing the overdue RIP discharge letter the ward clerk asked you to do that no one will ever read when you're day 9 or 10 of 12, its 6pm, you still have 3 EDLs to write and you have to be in for 7 the next morning? Pointless.
(edited 8 years ago)
Reply 19
Avatar for dooodles
dooodles
Strange what you all say about gen med.. I know some current f1s at the DGH I'm going to and they said the busiest jobs are acute med and gastro, and all the other jobs are absolutely fine. They definately didn't say anything particular about gen med being "hellish". Apparently there are two F1s and you get your own bays to look after so get to know your patients well. Still expecting it to be very hard work but wasn't expecting that extreme! :wink:

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