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JMO Charter 2009

5. What is my Role? - Working in the WA Hospital System

The scope of a JMO

As a junior doc, you are part doctor, part administrator, part secretary, and often the main source of contact for the families. On a usual RMO job, you are required to:

Write in the notes
Ward jobs (cannulas, bloods outside of phlebotomy rounds, med charts, investigation request forms, consult forms to other specialties, discharge summaries)
In some teams, clerk patients (e.g. the acute assessment unit at SCGH)

It is important that patients are seen every day, and that results are reviewed everyday (be wary, sometimes your team may forget about an outlying patient). Adequate documentation is paramount; the notes pertaining to the ward rounds needs to be written every day, along with relevant conversations with other teams, nursing staff, allied health, registrars/consultants, and family members.

Additional surgical responsibilities:
Consent: see Section 5.4
Pre-admission clinic: Often, a pre-operative assessment requiring a brief history, examination, and basic investigations (CXR, ECG as required; bloods; remember G+H for large operations, or ones where bleeding is expected). There are written guides on recommended investigations for each specialty in the clinic rooms.

Workload

Entirely variable, depending on the job: expect base hours between 38 and 50 hours/week, including a roster of Sat morning ward rounds. In addition, there is a roster for after hours ward cover. You are paid for your lunch breaks (no doubt implying that it is common to not be able to take one; but at least always make yourself stop for 15 minutes to eat).

In every term (apart from those involving shift work, e,g. ED, and the acute assessment unit at SCGH) you will be rostered to work “ward cover” shifts on weeknights, and weekends. On average, these occur once every 1 – 2 weeks. This involves responding to issues after the patients’ day teams have left; you could find yourself sitting in the common room most of the night, writing the odd med chart and putting in some cannulas, or you could be paged all night, occupied with ill patients. How busy you are often depends on if the day intern/resident has finished all their jobs or not! If you need to, it is generally, possible to swap these shifts amongst yourselves.

*Remember, help is always available, even if at times there appears to be none; there is always a medical and surgical registrar in the tertiary hospitals, and you can always call ED; and if all else fails, and things are looking dire, you can call a medical emergency; there’s no quicker way to get help!

Boundaries

Remember that although you are a vital cog in the medical machine, you are not the driver; the ultimate responsibility for the patient’s care lies with the consultant, and a significant amount lies with the registrar. If you are unsure, or feel out of your depth, always seek senior advice; inventing an answer is often precarious. The intern year is a learning one; like in all of medicine, you will not always know the answer.

You should not feel pressure to perform a task that is above your level of training, e.g. making a decision that a patient should be not for resuscitation / Medical Emergency team call (MET), and obtaining consent from the family for this decision.

Obtaining informed consent

Obtaining informed consent and whether or not one is appropriately trained to do so is an issue that commonly affects JMOs. With the aim of maximizing patient safety, PMCWA had developed a policy statement (in line with the 2006 WA Department of Health ‘Consent to Treatment Policy for the Western Australian Health System’) regarding informed consent:

Consent is always taken in the context of patient safety.
Prior to obtaining informed consent, the prevocational doctor should be satisfied that he/she is aware of the material risk. He/she should also be able to understand that material which can be reasonably withheld in the patient’s interest.
The prevocational doctor should know the patient well enough to appreciate the specific risks to that patient. A patient may have special needs or circumstances that may in some cases, require special or additional information.
The prevocational doctor should have sufficient knowledge of the procedure to explain it to the patient.
For each placement, there should be an opportunity for an agreement between the term supervisor and prevocational doctor about those procedures that they are comfortable to obtain consent, those that they would not, and those which may vary depending on the individual patient and the prevocational doctor’s experience.
Hospital process must not allow unfair retribution to a prevocational doctor from a supervisor for reasonably refusing to take consent.
Consent is sometimes taken at the last minute when more senior staff are not readily available. There should be policy to generally obtain consent during preadmission clinics or equivalent. Where appropriate it may be reasonable to not allow a case to be booked unless consent has been obtained
Where appropriate, consent may not be able to be delegated and must be taken only be a senior resident, registrar or consultant.

If you do not feel that you are adequately prepared to obtain consent from a patient for any given procedure, it is important that you express this to your supervisor/s (registrars/consultants).

If you at anytime feel inappropriately pressured to carry out consents for procedures you should contact either your term supervisor of DPGME.

The full PMCWA statement upon “Prevocational doctors obtaining consent to treatment” is available on the PMCWA website.

Handover

Handover is ‘the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis.’

Handover is one of the most important skills that you need to acquire as a JMO. It was recently reviewed and further developed by the Education Committee. Most hospitals have a handover guideline to follow which you should commit to memory, but some JMO prefer to design their own template.

There are basically two types of handover:

when you are handing over patients (ie. at the end of the shift) and
JMO to JMO handover (end of term changeovers).

When handing over patients (eg. at the end of the shift) it is firstly essential to know before your shift begins where and what time you need to meet the next working doctor. If it is a ward patient on your team then it may easier to hand over the patient to the after hours doctors via phone. For afterhours or on-call shifts, you should handover patients at the handover meeting, which will occur at a set time and place at the different tertiary hospital (often in the DCR). It is essential to detail the urgency for review of the patient (ie. 30 minutes versus ‘sometime during your shift’) as the next doctor may become very busy with other jobs.

End of term JMO handover is also very important and needs to be comprehensive. Both the incoming and outgoing doctor have a responsibility to ensure an effective handover occurs. It should be done in person. As part of accreditation requirements, the HOD of the unit should provide an orientation and orientation documentation for new JMOs to ease transition.

An excellent reference for clinical handovers is the Australian Medical Association’s ‘Safe Handover: Safe Patients’.

Professional standards

Patients expect a high level of professionalism from doctors. It is good to start a relationship using Mr/Mrs, however, this often changes to a first name basis depending on the circumstances eg. young patients and long term patients. Try not to swear in front of patients.

Be polite to all members of staff, your job relies on all their hard work. You are required to answer your pager promptly. However, if you’re in the middle of a cannula, just get it done and then answer. If you stopped all your jobs to answer every page within 30 seconds then you won’t get anything else done.

It is important that you are punctual each day when arriving at work. It is often expected that junior medical staff will know the results of the previous days blood tests etc. so it is often useful to arrive at work 10 minutes early to check on these before the rounds. You will be speaking with other junior medical officers, registrars and consultants on a daily basis. It is important that you have all relevant information available when making a referral and that you treat other staff with professional courtesy and respect.

If you find you are left to deal with a situation that is beyond your capabilities, always call your senior. It is important to know your boundaries and when you have to ask a silly question; you just can’t know everything. If you don’t agree with a decision from another doctor, don’t be afraid to question it, although do it tactfully.

Privacy and confidentiality

To keep patient details strictly confidential you should always be aware of who may be able to see your notes, where you leave them, where you throw them away, what you say and who may be listening. This can be tricky, especially when your team takes the lift during a round and continues to discuss the patients while members of the general public share the lift. Remember, the general public occasionally take the stairs too. When talking to a patient in their room, make sure the curtains are always shut. Every ward has a confidential paper bin near the ward clerk; throw your lists away there once you’ve finished with them.

If you take a phone call regarding a patient, ask politely who is calling and their relationship to the patient. If there are guests in a patient’s room, ask the patient if they are happy for you to continue talking about their medical conditions. With patients who are unable to communicate, there can be multiple family members involved. Try to convey all information through one family member (usually the next of kin) so that it is clear to all the staff who can be given confidential information.

Dress code

Dress code is essentially smart office attire. Closed-in shoes are expected as part of occupational health and safety. There are some rotations and some hospitals that allow junior medical staff to wear scrubs to work, but this depends on which area you are working in. It goes without saying that dress should not reveal cleavage/midriffs. Weekend ward rounds/ward cover is usually more casual with some areas happy for you to wear smart jeans. If in doubt, follow the adage of “when in Rome, do as the Romans do” or simply ask.

Equipment

Equipment for the ward:

At least 3 pens... your registrar will borrow them... forever.
Clipboards are useful to hold your patient list.
Extra things in your clipboard such as blank inpatient notes, med charts, radiology forms etc so you can be efficient on the ward round.
Stethoscope, always on surgical rounds. Surgeons always need them but never carry them.
Pager... especially useful when switched on.
ID Badge to prove that you are no longer another medical student.
More pens.
On Call by Cadogan, Brown and Celenza. A book written by WA doctors for covering the wards. Everything you need to know as an intern, but failed to get taught in medical school.

Medical Student Placements

Firstly, remember this was you not so long ago! Try and remember the horrible experiences from when you were a student….being ignored, getting in the way, never knowing when to be where, and improve these for students attached to you.

Medical student placements are becoming a more common trend in hospitals due to increasing tertiary numbers. They vary in clinical experience from their first term in the clinical setting to final year pre-interns. It must be remembered that students are there to learn. Those that are most experienced should be encouraged to work simultaneously with the intern/resident in the day to day management of the ward and other duties. Medical students should also be encouraged to participate on ward rounds, clinical meetings, theatre, clinics, ward work and on-call duties, but they should be allowed free time to attend tutorials and work on assessments. They are mainly under the supervision of the clinical registrars and consultants, and should present patients regularly to senior medical staff for feedback. However, most students really appreciate tutorials from the interns and residents, and also opportunities for practical skills such as cannulation and venesection.

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