From medical student to junior doctor: an A to Z guide
Richard Beasley, Geoffrey Robinson, and Amanda McNaughton give some succinct advice on becoming a junior doctor.
The transition from medical student to junior doctor is difficult for many reasons. These include the content of the undergraduate course (which often covers numerous subjects which have little or no application to clinical practice), the lack of an apprenticeship period with close supervision, and the extraordinary nature of the first year junior doctor's job in terms of clinical responsibilities, horrendous workload, and resulting personal and professional stress.
Resolving this situation is complex. It needs major restructuring of the undergraduate curriculum (as has happened at the University of Southampton, where there is clinical patient contact from the first year), incorporating a "trainee intern" year, in which final year medical students work as apprentice junior doctors (as occurs in New Zealand), and major reform of the duty requirements of junior doctors (as has occurred in many Western countries, with a restriction on the number of hours of work and the recognition of workload as a patient safety issue).
It is important that final year medical students recognise the difficulties that they are likely to face as junior doctors and the ways in which they can overcome them. This A to Z may help.
Alcohol--get the dose right
Alcohol dependency is a major problem for the medical profession. Along with drug abuse, alcohol dependency accounts for over half of sick or impaired doctors. Like all drugs, make sure you get the dose right and keep it right for the long haul.
The boss is always right (but not always)
Although your seniors may have the experience and specialist knowledge, you may have a breadth of up to date "book knowledge" and the advantage of getting closest to the patient. Make sure you do not end up being a clerk--seek responsibility. Aim to become a genuine bedside doctor and not merely the recipient and sorter of laboratory and x ray reports.
Career--take care choosing
There is a huge range of careers, including clinical practice (general to specialist), teaching, research, public health, and administration. Choose wisely and seek advice.
Drugs--first do no harm
Develop the habit of looking up the dosage and side effects when you prescribe any drug.
Ethics--the changing rules
The rules change and so does the emphasis. Two decades ago students had one lecture on ethics; there is now an entire course. However, some rules do not change: personal relationships with patients and accuracy of death certificates (which represented the two key points of the ethics lecture over two decades ago). You will often confront ethical issues in clinical practice. Try to follow two fundamental guidelines that sometimes conflict--respect patient self determination and act in the patient's best interest.
First look--when examining a patient
Before you lay your hands on the patient, first inspect--it is surprising how much you might notice that is clinically relevant. Signs elicited by inspection are the hardest to learn but are often the most rewarding. Before doing a clinical examination, ask yourself what do you want to find out or do. A short focused examination is better than an unfocused general examination. General practitioner--get one
You must have your own general practitioner--you deserve the same medical care as everyone else. Do not treat your family or friends. Do not self prescribe.
History taking--the basis of diagnosis
The basis of clinical diagnosis is the history. The skill of good history taking can be acquired only with much practice, time, and patience. If you cannot make a diagnosis in your patient, it is often preferable to take the history (and examine the patient) again rather than ordering more tests.
Insight--work out what you need to know
Use what is important to learn as the basis for your clinical practice. For example, students need to know the neurophysiology, immunology, and management of myasthenia gravis (to pass the exam). As a doctor you simply need to know how to recognise the disorder and refer the patient to a neurologist.
Judge not--your patients or colleagues
Be non-judgmental and show empathy with your patients.
Knowledge--you cannot know everything
If in doubt, look it up or ask. A textbook on the ward round trolley or in the desk drawer is a useful ploy.
Library--develop the habit
Go to the library whenever you get the chance. Try to read up about your patients' medical problems--the patients deserve it, and it is a great way to increase your clinical knowledge.
Mistakes--errors of omission versus commission
We all make mistakes. Errors of omission are more common than errors of commission--that is, you are more likely to make an error by not bothering to do something than by not knowing something. Try to develop systems in your practice to reduce the risk of errors of omission.
Nurses--treat with respect
Nurses and other health professionals are crucial partners in the care of your patients. Unlike doctors, their salaries and conditions of work may not reflect their expertise and training. Treat them with respect and recognise the essential contribution they can make to the care of your patients.
Overseas--the great medical tradition
Go overseas to live and work at some stage, at any stage. It will be valuable to you both personally and professionally. Your medical degree is a great ticket to travel. Protection--never let it lapse
You don't know what is coming next, so be prepared for it.
Quietly confidential
The confidentiality of the patient-doctor relationship is paramount and must never be breached. Doctors should preserve absolutely secrecy on all they know about their patients because of the confidence entrusted to them.
Relationships--the basis of patient care
Patient care begins with the development of a relationship between the patient and the doctor.
Stress and suicide--beware of the risks
The practice of medicine is stressful. Beware of the effects that stress has on you, your colleagues, and those close to you and seek help if it becomes a problem. Suicide rates in junior doctors are among the highest of any profession.
Teaching--live up to your title
The title "doctor" is derived from the Latin "docere," meaning to teach. Doctors need to share their knowledge with others and be willing to teach what they have learnt to colleagues as well as students of medicine and related professionals.
Uncommon disorders occur uncommonly
Make sure you master the common disorders as a priority.
Variety--the spice of life
Keep up your non-medical interests. It is important for you both professionally and personally.
Workaholism--be careful
Workaholism, the respectable addiction--be careful that work does not completely dominate your life. The warning signs of workaholism are usually diagnosed by those close to you.
X--go the extra mile
Despite V and W, go the extra mile for your patients. Remember the privileged role you have in their lives and what you would want for you and your family.
Y (why)--consider risk factors
Consider the underlying risk factors. Recognising and addressing the underlying risk factors may be more important than treating the disease itself. For example, severe hypertension in a young woman may indicate renal artery stenosis (when no other underlying cause is evident) making one of the most difficult diagnoses relatively straightforward and potentially lead to a cure.
Zzz--sleep deprivation
Recognise the serious effects that sleep deprivation has on your judgment, cognition, and behaviour. Sleep deprivation is an inevitable consequence of your junior doctor's years. Do not get chronically sleep deprived--learn to catnap as you have done in the lectures.
A quick quide
Alcohol--get the dose right
The Boss is always right (but not always)
Career--take care choosing
Drugs--first do no harm
Ethics--the changing rules
First look--when examining a patient
General practitioner--get one
History taking--the basis of diagnosis
Insight--work out what you need to know
Judge not--your patients or colleagues
Knowledge--you can't know everything
Library--develop the habit
Mistakes--errors of omission versus commission
Nurses--treat with respect
Overseas--the great (New Zealand) medical tradition
Protection--never let it lapse
Quietly confidential--the confidentiality of the patient-doctor relationship is paramount
Relationships--the basis of patient care
Stress and suicide--beware of the risk
Teaching--live up to your title
Uncommon disorders occur uncommonly
Variety--the spice of life
Workaholism--be careful
X--go the extra mile
Y (why)--consider risk factors
Zzz--sleep deprivation
Recommended reading
Le Fanau J. The rise and fall of modern medicine. London: Abacus, 2001
O'Hagan J, Robinson G, Whiteside E. Alcohol and drug problems: handbookfor health professionals. Wellington: Alcohol Advisory Council of New Zealand, 1993
Pappworth MH. A primer of medicine. 5th ed. London: Butterworths, 1984
sselbacher KJ, Braunwald E, Wilson JD, Martin JB, Fauci AS, Kasper DL, eds. Harrison's principles of internal medicine. 13th ed. New York: McGraw-Hill, 1994: 1-6
Richard Beasley professor, Medical Research Institute of New Zealand
Email: richard.beasley@mrinz.ac.nz
Geoffrey Robinson consultant physician, Medical Research Institute of New Zealand
Amanda McNaughton physician, Medical Research Institute of New Zealand
studentBMJ 2004;12:309-348 September ISSN 0966-6494
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