Becoming a preregistration house officer

Manoj Ramachandran takes an in-depth look at the difficult transition period from medical student to starting professional life as a preregistration house officer

Your final year as a medical student can be a very stressful time. Wearing a white coat, weighed down by the almost osmotic presence of the two Oxford handbooks in your pockets, you hunt in packs around the hospital wards, undeterred by the constant protests of patients prodded to the point of painful exhaustion. It doesn't really matter if they don't want to see you as you can always come back tomorrow.

You rapidly absorb information but still disbelieve your tutors when they repeatedly inform you that you currently have the greatest breadth (and sometimes depth) of knowledge that you will ever have in your career. Much of the information in your head is above and beyond what is required to pass finals comfortably. The fact that each consultant believes that in-depth knowledge of his or her own (sub) specialty is vital for finals doesn't help. You relieve the boredom of studying at weekends by joining the rest of your year at intensive revision courses, where you find yourself incessantly asking questions such as, "What have I been doing for the past five/six years?" and, "Why didn't they teach us this stuff at medical school?"

Sounds familiar?

Finally, you find out that you've passed.

And slowly, the dread creeps in. Are you ready for that next step? You're going to start working (and getting paid) for the first time in your life. This, you realise, will be your first challenge. You wish that five or six years of medical school had prepared you more adequately for this leap. You will have to deal with clinical emergencies in real life, display your skills at practical procedures, and communicate effectively with your patients, colleagues, and seniors.

Your second challenge will be to try to keep your feet on the ground. You've observed in the past that the responsibilities and urgencies of hospital life have weighed down friends and colleagues in the year above. In fact, most of them spent their year as a preregistration house officer simply trying to get through the day (or night). Many forgot to think about their own futures, aspirations, and career goals during that stressful year. Your aim should be to avoid getting caught up in that quagmire. You should start planning ahead in order to come out of your preregistration year unscathed. You should begin to look forward to your future.

The first few days

Perhaps you've already had experience working as a student locum in the team that you're starting with in your first job. This should stand you in good stead. If you haven't, don't worry. Try to arrange to shadow the house officer who is currently in the post for his or her last few days. Get used to the surroundings and the workings of your team. Learn what the daily routine entails. What is your team's structure? What are your daily responsibilities? When are the regular ward rounds? What equipment should you be carrying with you? How and where can you get hold of blood, x ray, or pathology results by the end of a working day? Who will supervise you during practical procedures? This will ensure that your first few days run smoothly, and that you are prepared for at least some of your initial challenges (see box).

You are not alone

Whenever you feel isolated in your job or in acute or emergency situations, it is important to realise that you are the most junior member of your team and that ultimately, your seniors are directly responsible for your actions. So, ask for help and get your seniors involved. Learn from their decision making and clinical judgment. Get them to supervise you during emergency practical procedures such as insertion of chest drains and lumbar puncture. You may have to be quite pushy if you want to get procedures under your belt, particularly if your firm is very busy during emergency takes. Be critical of your efforts, and learn from your mistakes. Get your seniors to critique your actions, so that you can aim to do better next time. Above all, know your limits in knowledge and practical skill, and learn to recognise when you should be calling for help.

Building bridges

You will soon realise that you are truly part of a multidisciplinary team and that how smooth or bumpy your year is depends very much on the relationships that you build with other health professionals. Very soon after you start, you begin to realise that much of the factual knowledge that you have stored in your head from medical school tends to be less useful in the clinical environment. For example, dealing with a raised concentration of potassium for the first time at the end of a long shift can be nerve racking, even if you have the right books with you to look up all the possible causes. On the other hand, an experienced nurse or sister on the ward should be able to help you locate essential equipment and may even help you in treating the condition (as he or she has no doubt seen it all before and may even have started the appropriate treatment by the time you get there).

Treat nurses, phlebotomists, occupational therapists, physiotherapists, medical secretaries, and all other health professionals with the utmost of respect, and they will try to help you in return.

Time management

This is a skill that can take a lifetime to learn. There are only so many hours in your working day--you cannot possibly do everything that you're asked to do. One possible solution is to try to prioritise your list of tasks into urgent, semi-urgent, routine, and "not my job." For example, sometimes preregistration house officers have to wheel patients down to the x ray department to ensure that they have the necessary investigations performed immediately. In an overstretched NHS hospital, porters can sometimes be hard to come by when you want something done in a hurry. But you have to be careful of how much you do take on as no one will thank you if something goes wrong.

It's important to take adequate breaks, to eat and drink regularly (a good diet doesn't solely consist of chocolates from the wards), and to cultivate a good balance between work and life. Most importantly, if you can manage your time well, you will begin to enjoy your job, increasing your clinical and practical skills, and building long term friendships.

Planning for the future

The last and most important point is the active management of your own career. Some know exactly which career path they are heading down, some are not so sure, and others don't have a clue. Over the past year, I've participated in mentoring around a hundred preregistration house officers. They have been learning how to go about choosing a career, how to improve their CVs, and how to prepare for the interview process to help secure a post or rotation as a senior house officer. The overall feedback is that they have felt more confident in applying for jobs and in making career decisions than their contemporaries.

It's very important for you as a preregistration house officer to plan ahead and critically evaluate your choice of career, as you're about to head down a lifelong career pathway. You will also be competing for jobs in the national market for perhaps the first time--preparation is the key to performing well.

You should seek advice from as many people as possible when planning for your senior house officer posts. Try to ensure that the advice is objective, credible, and preferably independent. I know of several people who have chosen their careers on the basis of limited advice, often from single individuals, and have later regretted their decision. Try to think of what you may enjoy doing in 40 years' time, not just what you enjoy doing at present.

Finally, whatever career you choose to do, remember that the year as a preregistration house officer is simply the beginning of a world of opportunities and possibilities. Go looking for them--don't wait for them to come to you.

Manoj Ramachandran is a director of Career Edge, a company set up by doctors to broaden career training and provide courses in career development.