I had been a doctor for about eight hours when I was handed responsibility for around 120 patients.
I had spent the day on geriatrics. At five o’clock, I collected the ward-cover bleep and waited for handover.
Then I accepted every handover I was given—not because I knew it was good, but because I had no idea what a good handover sounded like, or that I was allowed to ask: What exactly are you worried about? What would you like me to do if it happens?
The FY1s handing over were my new colleagues—some of whom would become my best friends—and it was their first proper day too. Between us, we were all new.
I left with a long list of jobs, three sets of paper notes from patients transferred from another hospital and, most pressingly, a lot of work to do on an electronic prescribing system I was still learning to use.
The bleep had already started going off, so I hurriedly wrote down every number because I had not yet worked out—and still have not—how to retrieve the recent ones.
The first transferred patient’s notes contained around thirty drugs.
The number was not really the problem. The problem was that every line required a decision: what to prescribe, what to hold, what needed checking tonight and what could wait for consultant review in the morning. When should I take the gentamicin level? Should we hold the warfarin?
An FY2 from the stroke ward I was covering stayed behind and helped me through the prescriptions and the first clerkings—one decision, then the next.
Then he quite reasonably went home.
Later that evening, the nurse in charge of one of the wards knocked on the office door. A patient’s family had arrived and wanted to speak to a doctor.
Which patient? Which family? What was even wrong with them?
I did not know.
The family had been called in by the day team, but none of this had reached my handover. I found the notes, worked out that the patient was dying and tried to understand what the family had already been told.
About 15 minutes later, there was another knock.
The patient had died.
I had gone from preparing to give an update about someone I had never met to having to tell their family that they had died.
The family room looked out over the Thames towards the Houses of Parliament. The sun was setting across the river as I worked through SPIKES1.
But there was no bell to end the station. No actor would reset for the next student. No examiner would tell me how I had done.
This family might remember that moment and that room for the rest of their lives. I felt an enormous responsibility to get it right.
Until then, medicine had largely been a series of questions to which somebody else knew the answer. You built a web of knowledge, applied it to an exam and waited to be told whether you were right.
In reality, that web has to attach itself to real people with real problems. There is not always a single right answer.
Some of you will have a moment like that this week—some more dramatic, some less—when the job suddenly becomes real.
Not knowing what to do is not the dangerous part.
The dangerous part is thinking you ought to know—and staying quiet because you don’t.
Ask.
As a registrar, I am far more reassured by a new FY1 who asks twenty questions than one who asks none. Questions tell us where we can help.
What other people expect of you on day one is probably much less than what you expect of yourself—and I mean that in the nicest possible way.
You are not expected to arrive complete.
Find the notes. Look things up. Call the right person. Escalate early. Ask somebody to see the patient with you.
Competence does not begin with certainty. It begins with making the next safe decision—and recognising when that decision should not be yours alone.
Five years later, I’ll be locuming as the overnight ward-cover med reg as part of a programme supporting the FY1s who have zero days on Wednesday and Thursday, then begin their first actual shifts on Friday, Saturday and Sunday nights.
I do not remember every job from my first shift. I still don’t know how to cycle back through the numbers on a bleep.
But I do remember the FY2 who stayed behind.
The easiest referral you’ll make all week
The notes I made on ward cover became bleep.guide: a compact, guideline-referenced handbook app with emergency checklists, on-call scenarios, clerking plans, calculators, ALS scribe mode and an ARCP-ready logbook.
Almost one in five new FY1s this year already has bleep.guide on their phone—which feels enormous for our small team. We would quite like the other four, too. If it has helped you, tap the Account button at the top right and share your QR code or link; a colleague can join without Trust verification, and you’ll both get some more free access.
We’ve been improving the app behind the scenes this week. Here is what people are using it for:
Most opened
- Suspected acute coronary syndrome — 462 opens
- Acute severe asthma — 256 opens
- Fast atrial fibrillation — 241 opens
- Hyperkalaemia — 210 opens
- Peri-arrest tachycardia — 203 opens
Most starred
- Post-fall assessment — 8 stars
- The delirious or agitated patient overnight — 7 stars
- Patient spiking a fever — 5 stars
- Asked to write up fluids — 4 stars
- Constipation — 4 stars
- Sepsis — 4 stars
- Diabetic ketoacidosis — 3 stars
- Verifying a death — 3 stars
You do not need to memorise all of this before Wednesday. Just make sure you know where to find a few things before you need them.
Missed our FY1: The Missing Manual webinars?
Useful FY1 reading: how to prepare for FY1 and which apps to install—and in what order.
Good luck
Good luck for Wednesday—whether your first shift is then or on Friday night.
Take a breath. Ask questions. You are capable, trainable and surrounded by people who remember being new.
— Oliver, med reg in Cambridge and one of the doctors behind bleep.guide :)
References
- Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. “SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer.” The Oncologist. 2000;5(4):302–311. Read the paper. ↩︎
