Dear Foundation Training: My Top Tips for Foundation Training

Dear Foundation Training.
I hope this finds you well. You were a really tough cookie to contend with. There were times where I thought we were getting along swimmingly, both in harmony. I understood and enjoyed my role, in fact, I accepted my role and diligently performed my duties to the best of my ability. But, more often than not, I felt like we just didn’t see eye to eye. I felt frustrated at the impervious boundary between responsibility and actual authority. I felt irritated by the fact I wasn’t learning anything, instead repetitively conducting clerical tasks, sensing a slow reversal in brain function, steadily forgetting all those facts I had force-fed my hippocampal apparatus at Medical School. I felt saddened by the fact I was the dumping ground for everyone in the hospital. I felt demotivated by the fact that graduation meant that I no longer deserved a place on the educational pedestal, unlike the medical students I came across in the clinical environment.
Why did I find it so difficult? Is there a light at the end of the tunnel? And how can I make myself feel as though I’m still learning despite the heavy service provision?
I look forward to hearing from you soon to learn the answers to these questions.
Yours sincerely…

It turns out, I’ve found the solution to my own existential crisis. The above reflects just a small summary of my experience of Foundation Training (FT). It is entirely personal and by no means universal. Everything I have described was merely how I felt and not by any stretch an absolute fact. But it’s helped me develop a profound appreciation for Foundation Year (FY) Trainees and the trials and tribulations they endure during this complex period of their career. I aim to outline just some of the things I wish I understood at the start of my own FT; sadly, I feel I never realised many of the more existential elements until much later after I completed my FT.

So, for those of you who are newly graduated and will be officially commencing the Foundation Training Programme (FTP) tomorrow, welcome! For those of you who are currently underway with FT, keep powering on! And for those of you who, like me, are reflecting back on their FT, commiserations! Just kidding, congratulations for making it through and I hope things are going well now!

As I’ve outlined in my introduction, FT is a real conundrum. I never fully understood what the point of the FTP was until much later on post-FT. This meant I constantly butted heads with what was expected of me as a FY Trainee and what my own expectations were of my training. I suppose, in that sense, this is probably the perfect starting point…

What is the point of Foundation Training?

FT is a training programme designed to lay the foundations of clinical work in newly qualified doctors, pretty much as it says on the proverbial tin. It serves to teach newly qualified clinicians the clerical side of service provision, including how a general hospital ward works, how ground level patient care is delivered, and how patient flow works from admission to discharge. These are key aspects of current patient care and underpin everything that takes place in a hospital. As FY doctors progress through the FTP, they build new skills, become more confident in their clinical and clerical judgement, and ultimately progress to becoming well-rounded, multi-skilled trainees in their chosen specialty.

For me, FT represented the only time that I could lay down the foundations of my medical training. Having transferred straight into Core Surgical Training from the second year of FT (Foundation Year 2), all my exams are geared towards surgery, which means the majority of my practical medical and critical care knowledge I now rely upon was gained through my experience during FT. For others, it may be the only time they do Psychiatry, General Practice, or Surgery. This is why it is so important to really maximise your time in FT to gain as much exposure as possible to myriad specialties and clinical scenarios. It may be the only time you will be able to do this and will provide invaluable knowledge in the future when presented with e.g. an acutely unwell patient on a surgical ward whilst you’re the only doctor covering surgery at night. It will also serve to keep your mind stimulated, as your ongoing education is really only limited to weekly FTP teaching. If you’re anything like me, as soon as education grinds to a halt, so does my brain. So take your educational progress into your own hands and make the most of what you see, hear, and feel to keep learning and developing.

As an FY Trainee, you will be an integral member of the multidisciplinary team, and this is truly no understatement. It is so easy to become disenfranchised and feel undervalued as a result of the relentless rigmarole of FT. I felt this acutely during at least 60% of my FT. However, it is so important to uphold the affirmation that the role you play as a FY doctor is nothing but essential. Without you, the clinical operations on a ward are much less smooth and well oiled. FY doctors represent the ground level infantry, the personnel on the shop floor who alert the cavalry when things take a turn for the worst. You will know everything about each patient on the ward: who is unwell, who is doing well, who has been discharged. You are the eyes and ears of the team.

What is expected of a Foundation Year Trainee?

So, what’s expected? Typically, FY doctors are responsible for all the patients on a particular ward. They prepare the patient notes ahead of the ward round and type/write the notes during the ward round. It is good practice to know about the patients prior to the ward round, including their observations, recent blood results, and their progress over the last 24 hours. Once the ward round is complete, FY doctors commence working through the patient jobs that have been generated from the ward round. These jobs can include anything from taking bloods and writing discharge summaries for patients, to referring patients to other specialties for their advice or review. If the jobs are completed earlier than the end of the day, there may be an opportunity to attend a clinic (or theatre session if in a surgical specialty) for additional learning and experience. This is certainly encouraged for FY doctors, however, unfortunately it very much forms a secondary luxury.

On occasion, FY doctors may be expected to conduct the ward round themselves. This may be more likely in a large District General Hospital, where there is a large patient load with less tertiary specialty input. For example, during my 4-month long rotation on Stroke Medicine, I would regularly perform my own ward round, during which I would see up to 15-20 patients and generate my own plans and set of jobs for the day. Whilst this was indescribably terrifying and arduous when I first undertook the task, it provided me with invaluable skills in the independent management of patients. I would know all the details of their inpatient progress, which aspects to optimise next and when a patient was safe for discharge. If and when I needed help or further advice, I would phone the consultant on-call to find out. These skills have helped me to this day and I look back at the opportunity with gratitude, despite practically hating it at the time!

How does the job evolve throughout Foundation Training?

The actual constituent components of the job don’t change massively during FT. However, Foundation Year 1 (FY1) is more clerical, where FY1 doctors are more ward based and are expected to know how to accurately document ward round notes, write patient discharge summaries, and refer competently to other specialties (TIP: ALWAYS use SBAR – Situation, Background, Assessment, Recommendation. It helps your referral sound on point without fail. I used to write all the details down on a piece of paper, using SBAR for structure, before referring).

Foundation Year 2 (FY2), however, brings with it a bit more responsibility through a step-up to the Senior House Officer (SHO) rota. This comprises more complex day and night on-call shifts, where you accept referrals from A&E and other specialties, admit patients into hospital and clerk them in, and cover the wards when the normal working day team finish their shift and leave the hospital. FY2 doctors are also expected to support FY1 doctors and be available for them to escalate to, as an SHO is now the second tier in the escalation hierarchy. Annoyingly for some, the responsibility level is the same as someone who is more experienced with the particular specialty. For example, an FY2 on Trauma & Orthopaedics will hold the same responsibilities as a second year Core Surgical Trainee who has completed all of their surgical exams. However, almost everyone learns the ropes quickly, and there is also less of an expectation of FY2 doctors than there is for the Core Surgical Trainees, which can often be more of a relief!

What can make you a good FY Trainee?

This is a very difficult question and one which is a cause for much contention between different clinicians. However, I have compiled this list of traits based on what I feel I did well/could have done better, along with what I have seen other FY doctors do, who themselves have been recognised as good FY trainees.

1. Reliable

Reliability is an essential trait for any FY doctor, and includes punctuality, something which many people struggle with. Often, in the rush of clinical care in both hospital and community settings, it is inevitable for aspects to be missed. However, by remaining reliable and consistent, you will be able to recognise when such gaps appear, such as a missed medication for a patient, or another patient who is more unwell than they initially seemed. It places you in good stead with the nursing staff on the ward, as well as the rest of the team. In turn, by making a good name for yourself, you can frequently open up more opportunities, such as the chance to be first choice do a procedure such as a lumbar puncture (LP) or scrub into an interesting surgical case.

2. Contactable

Always, whenever possible, answer your bleep. Or, if you are leaving the ward, just politely remind the nursing staff of your bleep number, so they know where you are in case they need to contact you. I used to hate this aspect, as it felt like I was beholden to the ward. But as a FY trainee, you are the doctor who is responsible for the patients and so inevitably, you will be called to review anything that needs a doctor’s input. And, to add more credibility to this point, it’s an actual criterion that is assessed in your Team Assessment of Behaviour, more commonly referred to as the “TAB”, which any staff member nominated by you can answer. Unfortunately, I have been stung here before during my FY1 and it was really inconvenient, albeit a learning point!

3. Efficient

Efficiency is important because of the sheer volume of work that can be present on a daily basis. Knowing how to work through tasks in a time effective manner is hugely helpful, including knowing which tasks warrant more attention than others. We’ve all been there before, running down a rabbit hole into an even deeper and more complex warren behind a random patient echocardiogram from 2005, which has very little clinical relevance, but features on our jobs list so “MUST…. GET…. DONE…..”. This is a prime example of what not to do, as more often than not, it will never be recognised nor hold any relevance by the ward round next morning. Additionally, efficiency is NOT the same as speed. There is a concept known as “Switch Tasking” (full commentary to be released in a future post), which highlights how we actually complete less when we try and multi-task than when we complete each individual task before moving onto the next. By ensuring good prioritisation and completion of each task at a time, you can immediately increase your efficiency (notwithstanding asking for support when you’re snowed under – this is almost as important, if not more).

4. Diligent

Diligence is an important yet understated trait. Speed, efficiency, accountability are all buzzwords which are bandied about with gusto. However, diligence cultivates care and accuracy. There is much interplay between diligence and reliability, in that they frequently complement one another. For example, through diligence, good practice can be achieved, as fewer corners are left unturned. Mistakes are recognised and rectified earlier, and small details such as deranged blood tests, which may otherwise be missed, are identified and appropriately managed. This all serves to increase your reliability, as you are overall less likely to commit minor errors and can therefore perform to a higher degree.

5. Responsible

This goes without saying, however, it is merely the tip of the iceberg, as under the oceanic surface there is a lot more context.

Firstly, responsibility is inherent in patient care. We are dealing with people’s lives, which is no mean feat. This brings with it accountability and necessitates good and safe practice. However, this can feel like a significant burden and so it’s important to keep your mind open to the outside world. It’s so easy to become sucked into the medical world; this will almost always lead to burnout. “Doctor” simply denotes a title and a job. It does not represent your identity.

Secondly, responsibility comes in the form of recognising our own limitations. It’s important to attend to an unwell patient, but it is arguably even more important to know when to escalate. If ever unsure, always ask, as it’s much better to be safe than sorry and it’s never appropriate to be expected to independently manage a situation that’s beyond your capabilities.

Thirdly, responsibility can be at loggerheads with level of experience. One of the most frustrating aspects for me during FT was the lack of experience or credibility due to my juniority, despite the level of responsibility that was expected of me. I would be managing patients more often than more senior members of staff and would therefore know more about the patient and their care, yet my colleagues and nursing staff would always question my decisions. In the end, a senior would come along and make exactly the same deduction and decision! However, it’s crucial to keep in mind that the questioning is not personal – juniority comes with its own risks and sometimes you may not be correct. This in turn simply offers another opportunity to learn. In general, this is just one of those unfortunate things that improves with time, especially time spent in a particular rotation during which colleagues and ward staff steadily gain your trust. It also improves as you become more senior (although it’s still a slow process). The best advice I can give is to bury your ego deep down, remain humble, and accept your juniority whilst completing your tasks diligently and to a high degree. It will get better with time and overconfidence will only backfire (sadly, this is all coming from prior personal experience).

Lastly, responsibility conveys accountability, as alluded to in a previous sentence. However, it is ok to make mistakes. Most doctors have made at least one mistake during their career. Remaining accountable for your mistakes will encourage you to engage in personal reflection and help cultivate the frame of mind which improves with every twist and turn, rather than crumble at the first hurdle. Unfortunately, I learned this the hard way through harsh self-criticism and lack of open acceptance when culpable for even the smallest of errors. It’s something we all struggle with, but at least if you’re prepared for it then the hurt is less.

10 take home messages for a new FY Trainee

So, after this behemoth of an explanation of the purpose of FT and how to do it well, what are the actual take-home messages for a new starter FY doctor? Is it really all just work-work-work?

The answer is no. You are about to start working as a doctor and pursue a career in one of the toughest yet most rewarding jobs in society. You can still be a person, you can still enjoy life. Granted, time may be a bit more limited than it was during Medical School (although it’s not as though there were reams of time there either), but you will still have some weekends free, the odd midweek zero day if on-call, and so many memories to create. So, as a token of good luck to help you on your way, here’s just a small list of my top 10 messages to remember when entering and working in the world of medicine:

1. Work smart not hard – efficiency and accuracy are inversely proportionate to speed.
2. Look after yourself first – arrange time to see friends and family and make sure to book annual leave.
3. Look out for your colleagues – they are your friends, not your competition.
4. Always ask or escalate when in doubt – it is better to be safe than sorry.
5. Thank yourself and your colleagues, including the nursing and heathcare staff – there are too few thank yous in medicine, so be the game-changer.
6. Keep doing the things you love – it’s easy to forget when things get busy, but often it’s what keeps us sane and grounded.
7. Keep the caffeine in check – over-caffeination only serves to increase anxiety and nervous energy instead of alertness and productivity.
8. Regularly remind yourself of the affirmation that you are significant – it’s easy to lose sight of this in the whirlwind of FT when you can often feel the least valued.
9. Stay humble.
10. Keep going – it’ll get better, I promise.