bleep.guide · FY1: The Missing Manual
Thursday, 16 July 2026
The shape of a ward day, morning round to evening handover, and everything in between. What we wish we had known.
# Shadowing Week — session notes
FY1: The Missing Manual · Session 1 of 4 Thursday 16 July 2026 · led by Dr Oliver Devine
You are never solely responsible for the patient in front of you.
A lot of the fear about starting FY1 comes down to a single worry: what if it's just me, and I don't know what to do? So this is worth saying plainly. There is always someone above you whose actual job is to help — an SHO, a registrar, a consultant. Ultimate responsibility for a patient sits with the consultant, and a hierarchy of doctors underneath them. You should never be the only person responsible for a sick patient — there is always someone to escalate to, so keep calling up the chain (and put out a 2222 call if they're sick enough) until help arrives. If that help is routinely slow to come, that's a staffing problem worth raising with your educational supervisor, not a failing on your part — and while you wait, you keep going and keep asking rather than ever standing back.
You will sometimes be the first person on the scene, and the first response for the first five minutes is yours. That part is real. But that's a short, learnable job, and the rest of this is about making it feel manageable.
We asked all ~1,100 registered participants one question — what are you most worried about starting FY1? — and 122 of you replied, from medical schools across 159 NHS trusts. The whole talk was built around your answers.
What came up, in order:
Nights, on-calls and the bleep — by a mile. So much so that they get their own session next week. Then, over and over, one question phrased a hundred ways: how much is actually on me? After that: prescribing, spotting the deteriorating patient, and knowing when to escalate. A few people just wrote "everything." One person wrote a single full stop. That's a normal way to feel right now.
Meet the bleep. It's a little box that runs your on-call. It goes off, you call the number back — that's the whole mystery. In some trusts (like my own) it's a secure chat/app rather than a physical handset, with actual bleeps reserved for crash calls. It feels enormous now. In about two weeks it's background noise.
Expect an acute wave of anxiety — you may physically feel unwell for a few days. That's cortisol, not a verdict on you, and it settles as the fortnight goes on. The advice that matters: show up anyway.
The week itself is a few days of trust admin — exception reporting, Datix, a BLS refresher, IT induction, ID badges and logins — and at some point you get sent to your ward to meet the team and the outgoing FY1s.
The single best move: don't shadow — flip it. Have the current FY1 shadow you. If something needs doing on the ward round, you be the one to do it while they watch. Watching someone document a ward round teaches you almost nothing; doing it yourself, with them next to you to catch mistakes, teaches you the job. The classic trap is standing and observing all week, then discovering on day one that you've never actually ordered a CT, and have no idea how the system works.
Practical procedures — it's normal to be rusty, or to have never done one. Plenty of people start FY1 having done one or two cannulas, no NG tubes, few or no ABGs. That is completely fine and more common than you'd think. If there's a specific skill you're unsure of, grab an FY1 or someone senior this week and ask them to show you — go and practise a cannula in the clean room. Almost nobody will say no, and it's about to be your job. And remember: if you can't get a cannula, there's an SHO and a registrar who are used to doing exactly the difficult ones.
Arrive on time for your rota — usually about half an hour before the consultant, roughly 7:30–8:30. Don't turn up unpaid at dawn; do give yourself a few minutes to get set up. Before the round starts, you want to have:
Do that and, even as a day-one FY1, you look like someone who knows what they're doing.
Then you round — often ~28 patients, frequently split into two teams (say, consultant + FY1 on the new and sick patients; registrar + SHO on the rest).
The ward-round plan is your to-do list. The hardest thing in your first week is documenting fast enough to keep up. So keep it simple: write down what's said and what's examined, and when you get to the plan, it's fine to ask "what should I write for the impression/plan?" — you'll ask it a hundred times and that's normal. Don't try to type the plan and keep a separate handwritten jobs list at the same time; you can't keep up, and you won't trust it. Type the plans during the round, then afterwards sit down as a team, go through the plans, and build the jobs list from them.
Do the critical-today jobs, then have lunch. Very few things genuinely have to happen this minute — usually a blood test or scan a patient needs before discharge. There's no prize for skipping lunch until 3pm; the jobs will still be there. Most rounds end around 12–1, often with a board round (nurses, physios) that's another chance to catch jobs.
The week is front-loaded. Consultants usually rotate weekly (some specialties, like geriatrics, keep the same one for your whole four months). A new consultant who doesn't know the patients is slow — your first ward round might run to 3 or 4pm. That's expected, and nobody expects you to stay till 10pm clearing every job it generated. Monday and Tuesday are busier with more jobs and fewer discharges; Friday to Sunday flips to more discharges, fewer jobs. Pace yourself, and say so if someone insists you finish everything on day one.
The people reading these are GPs with almost no time, and increasingly the patient themselves. Write it as if for a colleague who's never met the patient and is about to clerk them in A&E for something unrelated — do they want two pages, or four lines?
The four-line discharge summary:
Don't paste in reams of results or imaging reports — only the specific result that's diagnostic or relevant to follow-up. And write it just-in-time, not prepped days ahead. "Prepping" a discharge letter means writing it as if the patient goes home today — but if it gets saved and auto-sent later under your name while you're on leave, that's a genuine safety incident. If you're good at the four-line version it takes 15 minutes, so there's no need to write them early.
On time, list printed, sick and new patients identified. Documents the round accurately — enough to be a true record, not everything and not nothing; when unsure, asks "what should I write?" Keeps an accurate jobs list, makes sure it's handed over day to day (if the ward has no jobs list, be the one who starts it — that's a ready-made QIP). And, most important of all, keeps talking to seniors: "taking bloods from bed 3 now," "that's done," "I'll order tomorrow's bloods." Situational awareness runs both ways — but if your registrar knows what you're doing, they can help. The number of times an FY1 stays late doing something a senior would gladly have helped with, if only they'd known — don't let that be you.
Storytime — the first sick patient. A couple of weeks in, a commotion in one of the bays: an elderly patient with sepsis, becoming less responsive, blood pressure dropping. Walking in, the reality wasn't a slick resuscitation — it was an FY1 colleague struggling with exactly the things you'd struggle with (he was trying, and failing, to get an ABG; then two of us were failing to get the ABG). And that's the point: all that's needed in those first few minutes is the bread and butter. Are they talking? Breathing — do they need oxygen? Blood pressure low — give fluids. Get some bloods. Then the cavalry arrives.
On the wards, patients rarely crash out of nowhere. The usual suspects are falls (the single most-viewed page on bleep.guide, which says something about medical school teaching on the topic perhaps), hypoglycaemia (get there fast and start the glucose — a critically low sugar causes brain damage quickly), chest pain / ?ACS, fever / ?sepsis, and fast AF with compromise. Genuine cardiac arrests are rarer than the fear suggests — a big hospital has roughly one a week, spread across every ward.
If a senior is there, let them lead and be a useful pair of hands. If you're alone, two questions: is this patient sick? and have I done this before? If it's beyond you, put out a 2222 call early — help takes about five minutes to arrive, and you use those five minutes on the basics.
First on the scene:
Cover those basics and the team takes it from there. If a medical registrar walks in to find the gas done, pads on, trolley ready — that's an FY1 doing a genuinely excellent job. You already know more than you think. Right now it feels like a disparate web of textbook facts you've never applied; the facts come out with experience. Your job at this stage is not to remember the refractory-hyperkalaemia algorithm — it's to identify that someone's unwell, initiate safe basic management, and escalate. And keep reference material to hand — that isn't cheating, it's how every safety-critical industry works. (bleep.guide has a checklist for each emergency, and an ALS scribe mode for when someone says "can you scribe?" and you're not sure what that means.)
Face the thing that scares you most now, while there's no pressure — the sick patient, the arrest. Find the crash trolley, find the blood gas machine, learn how to turn the defib on; ask an FY1, SHO or registrar to walk you through the drawers (they're different in every hospital). There's an eerie moment coming when you realise you're the only doctor on the ward and everyone's looking at you — meet it having already found where everything is. Download the holy trinity: BNF, MicroGuide, bleep.guide.
Be kind to everyone. Nurses are permanent; you're rotational — the relationship reflects that, and on day one they know far more than you, so treat them as colleagues. Newly-qualified nurses can do bloods, cannulas and catheters, and many want to — if you're being asked to do the whole ward's bloods, that's usually a training/sign-off gap worth surfacing gently, not something to silently absorb. If you're sick, you're sick — don't bring it onto a ward full of vulnerable patients and colleagues; give notice and a realistic return. And have each other's backs: the camaraderie of a whole cohort of FY1s on the shop floor at once is something you never get again once you're the lone IMT or registrar on a ward. It's worth more than you'll realise at the time.
The terrified version of you on day one and the calm, competent version six weeks later are the same person, about three weeks apart. It might take six months, it might take twelve, but it will come, and confidence arrives with experience. You've already done the hard part: you got in, you passed finals, and the GMC has decided in writing that you're safe to start. Every doctor you'll ever work with began on the first Wednesday of August feeling exactly as you do now.
Fast bleep vs MET call vs crash call — how do I choose? If CPR has started, it's a cardiac arrest call. If it hasn't but the patient is peri-arrest / very unwell, it's a medical emergency call. Same number (2222), largely the same team — the label just helps prioritise. If in doubt, put out 2222.
A patient's crashing, I've done what I can, help isn't here yet — do I leave the bedside for the algorithm? Don't deliver what you're not trained to deliver. If you're not ALS-certified, you shouldn't be running ALS — but you can do intermediate life support (30:2 with a bag-valve mask), which you already know. Keep the algorithms on your phone: the RCUK app (search "RCUK" in the app store) has the ALS algorithms; bleep.guide has the wider emergency protocols, so you shouldn't need to leave the bedside to look things up.
Surgical wards — what's common, and how do I handle e.g. peritonitis? Medical emergencies on surgical wards can be worse, because the surgical reg/SHO may not have done acute medicine in a while, so an FY1 can end up the senior medical brain in the room. The approach is the same: A–E, temporise (oxygen if hypoxic, fluids if shocked/septic, antibiotics if septic, blood if bleeding), and escalate — to your surgical SHO for a surgical problem, or the medical emergency team if they're crashing. You're not taking them to theatre or ICU yourself; you're doing the holding measures in the five minutes it takes for the right person to arrive.
Can a nurse give glucose/fluids before I've prescribed it (retrospective prescribing)? In an emergency, yes — a verbal order to start something like IV glucose or fluids is accepted practice while a patient is acutely unwell, and nurses will act on one. Treat it as an emergency measure, not a routine way to save time: write it up on the chart as soon as the immediate situation is under control, keep it to the urgent situations and drugs your trust's policy allows, and remember the nurse giving it is accountable for it too. Outside an emergency, prescribe first.
Fluid prescribing scares me — can someone check it? Yes, and they should — if you're not confident, ask, and it should be cross-checked. It's a bit of a dark art you develop a feel for. Quick steer: look at the patient. Dark urine suggests they're dry; do a proper fluid assessment (JVP, mucous membranes, obs) — if they're shocked, they need fluids. Be more cautious in heart failure or renal impairment, where too much fluid does its own harm — give smaller boluses, reassess after each, and cross-check if you're unsure. Which fluid and how much is a separate, learnable conversation.
Does pharmacy check everything? Largely yes — in most hospitals a pharmacist reviews your discharge TTOs before they go out, and reviews what you prescribe, especially new medicines.
During shadowing, do I do the FY1's job or just observe? Work as normally as you can — ask to scribe the round, do the bloods, do the jobs, with the outgoing FY1 watching. Some teams will nudge you to just observe (especially a consultant-of-the-week keen for a smooth week) — politely push back and get hands-on.
How do I document jobs that can wait until later in the week? A jobs list. If your ward doesn't have one, start it — it makes everyone's life easier.
AMU / what is "post-take"? On AMU you're still doing a ward round as the FY1. "Post-take" means a consultant reviewing a patient who's newly been clerked in (usually with the clerking doctor) to turn the tentative plan into a proper consultant plan. Clerking gets its own session.
Any tips for surgical ward rounds? They're fast, with less attention to the chart — you might round on 90 patients and be done by midday. Documentation is hard to keep up with; accept it won't be perfect, draft the note and go back to it later. You get faster.
Starting in general surgery / on anaesthetics as the only FY1? General surgery: the surgeons round fast and leave, then medical management is largely on you — most of what you'll face is medical problems (sepsis, arrhythmias, retention, blocked catheters). Anaesthetics as a lone FY1 is a relaxed, education-rich job — mostly cannulas, effectively supernumerary, with anaesthetists who are excellent teachers.
How do I do audits/QIPs for a specialty I'm not rotating through (e.g. surgery)? Easy — you'll see every FY1 at the weekly protected teaching (Wednesday lunchtimes). Find the surgical FY1s, ask who their bosses are, and email them. Almost nobody turns down help with a QIP.
Discharge summary when a complication happened in hospital? There's a duty of candour to tell patients when something's gone wrong — but discuss it with the consultant, since it's their name on the letter.
My first shift is a night — is that allowed? It generally shouldn't be, per BMA guidance — raise it with your local BMA rep. If it does happen, ask whether there'll be extra SHO/registrar support; an FY1 should never be holding significant responsibility on their first-ever shift.
Should I shadow a night during shadowing week if I start on nights? If it'll make you less anxious, yes — but you don't need the whole night. Nights are busy from ~8:30 to 1, then quieter; sticking around until midnight to see how handover and the bleeps work is plenty.
On my break, do I hand the bleep over? You're entitled to an uninterrupted break, so hand it to someone else — often the registrar. A crash bleep goes out to multiple people at once, so as an FY1 you're a valued pair of hands but not mission-critical to the crash team. (On a skeleton night team you may need to swap and take your break at a different time.)
How many sick days do I get? As stated in the session: 20 in FY1, 20 in FY2, then 14 as a core/higher trainee. Don't come in sick — it's not worth making a vulnerable patient unwell to avoid an absence day.
Ward cover vs long day vs night — what's the difference? "Long day" and "night" are shift types (alongside normal days, evenings, weekends). "Ward cover" vs "clerking" are roles: ward cover means you're on call for ward jobs and unwell patients; clerking means seeing new admissions. FY1s are usually ward cover, and don't usually clerk overnight.
Imposter syndrome / "I've forgotten all of medicine." Extremely common, and a normal response to an abnormal situation — the design of medical training doesn't give you enough exposure to real responsibility, so anxiety is reasonable. But you passed finals and the GMC says you're safe; that's a better predictor of being a good doctor than almost anything. Stick to the basics. Much of what you've forgotten isn't that relevant to the day-one job anyway.
Any experience of difficult/unkind seniors, and how to handle it? You'll meet people less kind than you across so many teams. No one, especially as an FY1, should make you feel bad or be unapproachable. Remember a consultant-of-the-week is usually there just for the week, and you're on any ward for only four months. If someone clearly crosses a line, go to your educational supervisor — they're separately qualified and registered for the role and are, in practice, almost always supportive.
What's the first day actually like? Hard, and it gets better. Expect a physical stress response unless you're unusually chilled (medical students test slightly higher on neuroticism, so anxiety is normal) — and expect your calves to ache, because you go from mostly sitting to standing for twelve hours. You adapt fast.
Anything to flick through before starting? The emergencies section of the Oxford Handbook is a reasonable start; bleep.guide's emergency checklists are built for exactly this. On apps generally: BNF (look everything up — you'll be the FY1 looking up paracetamol, and that's fine), MicroGuide, and bleep.guide. Flowchart-style emergency apps are less useful in a real emergency, when you want a checklist you can work down.
Thu 23 July, 19:00 — How the bleep? First nights and on-calls. The big one: the bleep, out-of-hours calls, safe first steps and when to escalate. Then clerking (Mon 27 Jul), and a questions-answered session two weeks in (Wed 19 Aug).