House job is supposed to be the foundation year for recent medical graduates to acquaint themselves with basic skills which are necessary to practice independently as a doctor. It is a transition period between ‘knowing-it-all’ as a final year student to implementing the same knowledge on real patients and noticing how different patients respond differently to your management. Side by side, it is also the first ever job for most of the people, not having been exposed to the atrocities of work life ever before. So it comes with its sets of complexities and technicalities. Understanding what your rights are as an employee and awareness of what you are supposed to do during this year is very important because it helps you draw a line between tasks that come under your jurisdiction and need to be taken care of by you yourself and of things which are someone else’s responsibility but because of the inefficient system, you are held responsible for taking care of these extra chores. So lets begin mentioning some points that you should know before starting your first ever job.
• You are a junior doctor who is beginning to learn how to go about taking care of patients. For admitted patients, you are responsible to take thorough history and perform relevant examination while documenting it in the file and then present the history to your immediate bed senior so that he can tell you what investigations he would like you to perform for the patient and what initial treatment should be given. As you are done with history and exam, do a mental practice of brainstorming the lab investigations and radiology imaging that your resident might ask for and the subsequent treatment that you think is appropriate for this patient. – **
• If the patient has any complains during your duty hours for example, pain, nausea, vomiting etc, inform your senior immediately and ask them the next step in management for symptomatic relief. – **
• For clinic patients, you are again responsible to take history and perform examination and the treatment and investigations will be suggested by your supervising resident.
• As you can see, you are responsible for being vigilant and not missing out anything on the history and exam part and in the initial days, you should ask your resident to tell you if you have missed any important points that he would like to know so that you can go again and ask the patient about it. People often ask whether there is any learning at house job level or not. This is the learning that you are looking for. The awareness of what to ask in a patient with pancreatic, liver or gastric disease for example and what points to not miss in a seemingly normal but critical patient in which your amazing history and examination skills can mean the difference between life and death of the patient. – **
• You are responsible to be able to recognize danger signs in any patient that you are taking care of. The danger signs for a pancreatitis patient might be different from a patient who has undergone appendectomy or a patient with GI bleed. Discuss with your resident the possible complications this patient can have during the course of his stay in the hospital and what possible interventions need to be done immediately when you recognize such a condition developing in the patient and before you can dial a call to your senior. Remember, every second counts. – **
• The patient will have a lot of questions about his disease, about his course of hospital stay and what you are going to do for him in this hospital admission. Counseling is your responsibility but of course you might not know all the knowledge that the patient asks about. Don’t be shy in telling him that you are not aware of the particular thing that they want to know and that you will ask your senior and inform them about it. It is always advisable to stay silent on a question rather than giving out wrong information. – **
• You are responsible for making discharge summaries and counseling the patient about how to take care of themselves at home which will again vary with the kind of disease they are suffering from. Take help from your senior to know what points need to be covered in the conversation with the patient on his discharge. – **
• Tasks that you are supposed to do in the ward which are basically not your responsibility as a doctor
NG intubation, urinary catheterization, blood sampling, vital monitoring, transfusing fluids and blood, administering parenteral medications, fetching blood from the blood bank, transferring patient to radiology for X rays and CT’s. These are basic tasks that you will keep doing for the entire length of your house job in each ward. Remember that you are not doing house job to become an expert at these skills. Fine, you should learn it at this stage how to be able to do these procedures but as you progress further in your career, you will realize that in private hospitals with established systems or rather internationally, these tasks are actually the responsibility of the nurse and only because of a flawed system in the government setup are you being forced to do these tasks where the nurses are not held accountable for what they do and what they don’t do. It is unfortunate that doing these tasks are a part and parcel of being a house officer and 90% of your ward time will be wasted in doing the above mentioned tasks but don’t worry. Become an expert at these things and try to save time by becoming efficient and knowing how to prioritize your work.
• As a house officer, you are directly responsible for any tasks that are employed to you by your senior resident only. Don’t let other residents boss you around for doing the work of their beds too just because their house officer is lazy. Know your rights. Doing stuff for someone once or twice is fine and if you like some resident and don’t mind doing some extra work for them, that is your conscious choice but don’t let anyone abuse you just because you are a friggin house officer and have to listen and follow any commands that are given to you. Per se, residents want their bed tasks to be done by the end of the day. It doesn’t matter to them if house officer A or house officer B does it. So if you get done with your work early and are chilling with your mates, there is a great chance that you will be called upon to do that particular task. Learn to stand up for yourself when you have to. There is nothing wrong in that.
• Often you will see that as you begin your job, there will be some house officers both from your college and on federal seats who will be senior to you, having a few months of house job experience or even some of them who are doing their last rotation of house job. These apparent ‘seniors’ also try to boss you around by telling you to do tasks that are primarily their responsibility. Remember that a house officer is a house officer, even if they have a little bit of more experience than you or not. Don’t succumb to the pressure and keep doing what they tell you to. Learn to say no. Remember the first point, you are directly responsible for any tasks that are employed to you by your senior resident only.
• You will face a lot of problems during this job. Some seniors might not be cooperative enough, some house officers will not be performing their tasks adequately and eventually you have to cover up for them on normal days or while on call. The HO incharge might not be approving your due leaves despite having a genuine reason for it. In any such scenario, follow the chain of command. For any issue among house officers, try to resolve it among yourselves but if things don’t work out, inform your HO incharge and ask him for a solution. If the HO incharge does not respond well, contact the chief resident, he will help you out. If you are still in trouble, try talking to the consultant looking after administrative issues of the ward and residents. If nothing works, going to the head of the department remains your last resort.
• If you have a problem with your bed senior or HO incharge, talk to the chief resident and then subsequently to the consultant and HOD. If the chief resident is doing some injustice with you, the consultant and the HOD are going to be your last resort. Remember, don’t be shy to raise your voice against injustice. If you are right and your senior is overburdening you with extra calls while giving relief to some other house officer on the basis of favoritism, it needs to be brought to the knowledge of the seniors. If you don’t raise your voice today, these people will continue with their atrocities and keep pressurizing you. Learn to say no.
• Taking consent for any surgical or bed-side procedure is primarily the responsibility of a resident. It doesn’t come under the jurisdiction of a house officer. However more often than not, you will be asked to do it by yourself while counseling the patient about the possible complications of the procedure. Remember, counseling is very important, especially for critically ill patients. 90% of the time you will get away with not adequately counseling the patient as his surgery or procedure might go uneventful. However in 10% of the cases, your laziness will cost you really bad and these are the same attendants that will continuously bug you and hold you responsible for even the minutest thing that goes wrong with the patient. So be responsible with pre-procedure and disease counseling. It will make your life easy.
• Document document document. I can’t emphasize this anymore. Whatever you do with the patient, whether it is a blood transfusion or a peritoneal tap or giving contrast for a CT scan, document everything with date and time. It will save your ass when the time comes. Believe me it will. This is about making a good habit starting with your first job. In government setup you might not need as much documentation and not everyone will scold you for writing out the tiniest thing that you did with the patient but in the long run it will help you out when you work with more serious patients in a better setup.
• Politics is a very significant part of the hospital experience. People will bitch about you to other house officers and residents just to gain personal benefits and cause harm to you. Don’t act like a coward that any one can step upon. Be bold and learn to play the game as it is being played with you. Give a rock solid answer to the people involved so that they think twice before messing with you again.
• Use your time in the ward efficiently. 9 am to 2 pm is a sufficient time for you to get done with your morning orders and give a proper over to the on caller with no pending tasks. Don’t be a lazy douche who wastes time all day round and gives a gazillion tasks for the on caller to perform. You reap what you sow. Don’t do anything that you don’t like to be done to yourself. Does it blow your mind when someone hasn’t sent the lab tests and hasn’t gotten the X ray and CT dates that were told to them in the morning round? Exactly the same thing is going to happen with you when someone piles up their work on you and leaves. Get your shit right or be ready to face the consequences.
• Don’t let yourself be used as a personal servant of the residents or consultants. A lot of times guys will be asked to fetch something from the residents car or to bring tea or food from the canteen for them. Girls are often asked by residents to bring and carry their bag from the call room, to serve tea and food for all the seniors, etc. Recall your job description as a house officer. You are not someone’s personal servant.
One of the female house officers shared the following extra tasks that they were told to do,
-“Chai laado. Mera bag say jakay falan chez le ao, cupboard saaf kardo, laptop dena Zara, iPhone hai?, charger dou, chaaat le ao, meri yeh books uthao aur Chalo mere sath neechay”
– “cups me chai dalo, ye humne (seniors) order kiya tha bach gya hai to khaalo”
** = Learning points that need to be focused during house job.