INTRODUCTION
The medical admissions unit (MAU) is a perfect opportunity to hone your skills in history taking, examination, investigations, and management of both the common medical presentations and also rarer conditions. It also provides an environment where you can develop communication and management skills while running the take, delegating to your on-call team, and prioritising unwell patients. You will experience referrals from the community as well as from the accident and emergency (A&E) department. These interactions will be very helpful in improving your telephone consulting skills and referral technique.
As the acute medical team you have a rare opportunity to see a breadth of presentations and conditions, to develop brilliant communication skills, and use them to help your patients and their relatives understand what we're doing to them and why!
This article aims to provide a guide to help you through a typical job on the MAU, that will allow you to feel more prepared for the days ahead and the expectations on you as the senior house officer (SHO).
THE BASICS
1. Your F1/medical student days are over, when clerking you have to ‘hang your hat’ and diagnose! Try to come up with differentials and write them down, it will make you think! Assess the patient clinically, don't just hang on for chest X-rays (CXR) and bloods.
2. Familiarise yourself with the common presentations to the MAU and the immediate management of these patients, in particular chest pain, shortness of breath, sepsis, cough, weakness, ‘off legs’, diabetic ketoacidosis, hyperosmolar hyperglycaemic non-ketotic coma, and renal failure to name but a few.
3. MAU is really important. The time you spend with a patient and their relatives will shape their entire admission. Inevitably, the diagnosis you make will shape the post-take ward round and the course of action for the next few days. The way you treat the family will shape their expectations for the next few years.
4. Remember, hospitals are really scary places, we see them day in, day out so we forget the loss of autonomy, privacy, and sometimes dignity that always go with acute admissions.
5. Undress the patients to examine them.
6. Never document doing stuff you haven't.
7. You're going to be busy. Learn to deal with it. Book holidays early.
8. Consultants can be very useful if mobilised properly.
REFERRALS AND TEAMWORK
9. Listen to the referral before asking questions. You need to know: why does the patient need to come in? What is the possible diagnosis? Most importantly, how sick are they? And, therefore, how soon do you need to see them?
10. If the referral is from A&E ask what appropriate investigations have been done before referral (and if not, politely request these are done before transfer; for example, bloods, electrocardiogram, CXR). If the referring doctor has a specific diagnosis in mind, check if they have started appropriate treatment, as there may be a time delay before you are able to see the patient.
11. Don't be rude to referring doctors on the telephone, it just makes everyone's day unpleasant. Interrupting referrals to make people justify themselves causes the referring doctor to become flustered and annoyed, rapport breaks down, and the information delivery will also break down.
12. ‘Bouncing’ referrals is rare. Another doctor has seen the patient and believes they need to come in for further management. Remember, it is extremely unlikely that, over the phone, you can accurately and safely make a judgement to the contrary. If referrals are noted to be inappropriate, as some are, you have senior colleagues/consultants who can address this. You can always get the A&E team to call/bleep the on-call registrar and remove yourself from the equation.
13. Bear in mind that not everyone is ‘good’ at making referrals, especially early in the process, so try to make their job easier by not getting a reputation for being difficult.
14. Do not venture negative opinions of other doctors to patients, it is unnecessary and unprofessional.
15. You may have several other doctors (and nurses) who you work alongside in acute medicine. One skill to develop early is the ability to delegate effectively, this may be by asking the nurse to get an ECG on arrival to determine how you need to prioritise a chest pain patient from the community.
16. Use the nurses, especially specialist nurses like coronary care. Their knowledge is invaluable.
17. If you do use the nurses, it's still your responsibility when things go wrong.
18. Always listen to concerned nursing staff, if they are worried about a patient, you should be. While it is common practice to see patients in time order, that is not always appropriate, and if a patient looks unwell or has abnormal observations then someone (not necessarily you) needs to see them sooner rather than later.
SKILLS, TRAINING, AND DEVELOPMENT
19. When discharging a patient, make sure you understand the diagnosis and follow-up arrangements for patients. Take 5 minutes to explain to the patient and/or relatives what the diagnosis/suspected diagnosis is, what the investigations have found (if appropriate), and what treatment has been started and why. Patients are much more likely to take medication if they understand what it is for. Also explain what, if any, follow-up is planned, even if that is just to see their own GP if symptoms recur. Patients really appreciate this. Also try to convey this information to the patient's GP on the discharge letter; if your patient hasn't understood what has happened (and in general, few do) then the GP will be their first port of call.
20. Acute medicine is a great opportunity to become competent and confident at a variety of practical procedures. Some people will actively avoid such things, however, at night when there are fewer people around and something needs to be done quickly, it is better to have done it before.
21. Ideally, take every opportunity to observe and assist others, and therefore gain the knowledge and procedural skills yourself in a safe environment, before you do them on your own. Never undertake to perform a procedure you do not feel comfortable doing.
22. As part of the acute medical team, and during on call, you will usually form part of the ‘crash team’. For confidence, the Advanced Life Support Course is very useful. This will help you to develop skills in running arrests when necessary - there is nothing worse than an arrest with no team leader! For practice, ask your registrar if they can lead any arrest calls during a shift, that way they are there to guide you if needed. Confidence, deep breaths, and ABC, that's all you need.
23. Attend medical meetings, for example, grand round, departmental meetings, and SHO teaching. Also look out for relevant courses you may wish to attend. You have a study budget for the purpose of learning. If you see something rare or interesting offer to present it, the more you do, the easier it gets and it looks good on your CV.
24. This job really lends itself to audit projects and completing the audit cycle during your rotation. Express an interest early and let your seniors guide you as to what would be useful, interesting, and easy to audit.
25. There is a huge capacity to learn during your daily job and your knowledge base will expand dramatically. You will rapidly feel comfortable with common presentations and their management, but do take every opportunity to learn from peers, seniors, and your consultants at the bedside or on ward rounds if anything is less familiar. These are skills that you will take with you to your future GP careers, so make yourself open to new knowledge and skills.
26. Most of all, enjoy it!
Notes
Provenance
Freely submitted; externally peer reviewed.
- Received January 11, 2011.
- Accepted January 14, 2011.
- © British Journal of General Practice 2011
