Work experience in an Irish Hospital – Part 1

Got accepted in an Irish hospital as an SHO or Registrar? Anxious about what to expect and how to prepare for it? Well, this blog is just for you then.

Firstly, lets discuss from an SHO – Senior house officer point of view. As I’ve worked in medical and allied wards so I will make references to the routine being followed there. However, the general layout should be the same for all specialties.

General layout:

Most of the time, a team consists of a consultant, a registrar, two SHOs and one intern. In the hospital where I worked, the ‘take’ or admitting days of a team were decided by the consultant call rota. For example, Team A’s consultant may have 2 – 3 ‘take’ days in a month. When he’s on take, all the patients admitted that day will go to his team. But there may be a few hand backs too – which means if a patient was previously admitted under a different consultant in the past month or so, then he’ll go to that consultant’s team. Needless to say, hand backs are greatly celebrated as they reduce the team’s burden!

As far as workload is concerned, typically, on a post-take ward round, a team can have anywhere from 15 – 30 new patients along with their old patients. That’s how it was in my hospital which was quite busy and on post-take days, we’d often get free as late as 7 or 8 PM trying to fulfil all the round orders.

In terms of medical records, they are partly on paper and partly on computer software in most hospitals of Ireland. The patients’ charts which contain the doctor, consultation and nursing notes are on paper. The treatment ticket, patients’ vitals, referral letters and other such documentation is also kept in that chart. However, the blood test results and radiology reports can be accessed through different computer software using the patient ID number. The discharge summaries are also made online.

Regular day as SHO:

By this, I mean, a weekday with 9 am to 5 pm duty. The junior members of the team i.e., intern and SHOs are expected to arrive half hour to 1 hour before 9 AM in order to follow up pending investigations from the day before. They get printouts of the new investigation results so that they can be presented when the consultant asks for them during the round. The round usually starts at 9:00 sharp. The patients may be scattered in different wards all over the hospital so a lot of physical activity ensues. The job of an SHO is to write down the round orders and sometimes complete them during the course of the round if need be. For instance, if a patient needs urgent angiography referral, then the consultant will excuse the SHO from the round and ask him to make the referral immediately. As my hospital did not have the facility of angiography so we had to refer the patient to a bigger hospital. For this, first we called the ‘on call’ cardiology registrar in that hospital and explained the entire case to him. Then we filled the referral form and faxed it to him. And after that, we informed the patient’s nurse and she’d follow up the shifting of the patient by liaising with the bed management in both hospitals.

Sometimes, the consults/referrals are made to other teams within the same hospital. This just requires a phone call to the concerned registrar’s bleep and explaining the case to him. He’d then see the patient and give advice accordingly.

In addition, there’s the concept of specialized nurses for different disciplines like diabetes, palliative care, respiratory, heart failure, oncology, stoma/IBS etc. Referrals are made to these nurses if the consultant wants them to educate the patient or make recommendations about a certain aspect of the disease. For example, if a patient’s blood sugar control is erratic then the diabetes nurse is called to adjust the insulin units; to educate the patient about his dietary modifications and to arrange follow up in the diabetic clinic later on. This nurse can take advice from the endocrine consultant if she deems it fit because she’s part of his team. I found this entire practice of specialized nurses very unique yet useful as it reduces the burden on doctors. These nurses are specially trained to do their jobs and are highly competent.

Moreover, another distinguishing feature that I found in Irish hospitals was that of multi-disciplinary teams (MDT) of paramedical staff which included physio therapists (PT), occupational therapists (OT), dieticians, medical social workers and speech and language therapists. The feedback and input of this staff is of paramount importance. For instance, if a patient has suffered from a stroke and has significant neurological deficit, then he cannot be discharged until cleared by PT and OT. The PT will assist the patient in regaining his motor strength and the OT will arrange for any additional equipment he may need on being discharged home like wheel chair or walker etc.

Also, a medical social worker is a key member of this MDT and is called when there is a complex discharge situation. In Pakistan, no matter how sick a patient was, the patient’s family was always happy to take him back home because that is the social structure of our society. Old homes have sprung up but are still not that common. On the other hand, in Ireland, nursing homes, rehabilitation houses, step down hospitals and other such facilities are rampant. Extremely sick and dependent patients and their families prefer these facilities when the acute management has ended. To decide the eventual destination of such patients, medical social workers get involved. At times, MDT meetings are held with the patient and his family to reach a decision. These matters are taken very seriously and a lot of work is put into discharge planning.

One more major member of the hospital team is a pharmacist. His role is extremely significant and he calls the shots in deciding prescription at times. This is unlike in Pakistan, where the suggestions of pharmacists are largely ignored by consultants.

Likewise, a lot of emphasis is laid on the recommendations of the microbiologist for deciding the antibiotic prescription. The team consultant may ask you to discuss the patient’s case with the microbiologist and then decide which antibiotic to prescribe for the patient.

During the hospital stay, most of the blood samples or phlebotomy as it’s called here is done by the phlebotomist. So, the SHO just has to fill in the investigation requests and place them in a designated book. However, there may be days when the phlebotomist is off or over worked so may reduce the number of samples he’ll take. In that case, the SHO will have to do the phlebotomy of his patients. This adds another work to his list. And the nurses will mostly call him to do IV cannulation too. So, my advice is to become proficient in these two skills, they will serve you well. If the SHO fails then he’ll ask his registrar for help. If the registrar also fails then the anesthetist will be called who’s mostly successful as he may use ultrasound guidance for a difficult IV cannulation such as when the patient is in circulatory shock due to active upper GI bleed.

Furthermore, an SHO is expected to make the discharge summaries of patients. These are online and include all the patient details during the hospital stay.

Lastly, once or twice a week, is the clinic day for the team. On this day, round and round orders are quickly completed and then the team heads to the afternoon clinic which lasts for 3 – 4 hours. The team divides so that everyone has one consultation room and then starts seeing the patients individually. The junior members can ask their seniors for advice if they get stuck somewhere. One consultation usually lasts 15 – 20 minutes and is quite thorough. It is completely contrary to the OPD clinics that I have participated in a major tertiary care hospital in Pakistan which were extremely crowded; offered no privacy to patients and each consultation hardly lasted 5 minutes or so because of the extreme patient load.

Piece of advice:

When I started my first job in Ireland, my consultant advised me to focus on two things: documentation and learning the commercial names of medicines. Documentation must be done of everything you do, whether it be phone calls or attending a patient. If you don’t document, it’s like you never did it!

This post is to be continued next week when I’ll discuss the ‘on call’ day for an SHO.