FiY1: A reflective account of the foundation interim year 1 post

Induction

The FiY1 induction was a fast-track of the usual FY1 induction, condensed into one day as opposed to one week (the usual length of FY1 induction at the same hospital). This equipped us with a very basic knowledge of the local trust policy, logins and rota schedules and the fundamentals of life support. We were introduced to the chief registrar, who was to be a port of call for escalating issues from juniors to senior staff. We were taught how to put out a crash call if there was an emergency; however, we were not formally told how to bleep other doctors or who to escalate daily clinical queries to (presumably due to the fact that joining doctors would be based on different specialties and escalation of clinical issues would be taught on the individual wards). The induction did not include protected time shadowing FY1s, lectures on medical emergencies, practical skill sessions or familiarisation with the wards. These are areas typically covered in the traditional weeklong FY1 inductions, which can help reassure many of the joining doctors. A memorable part of the FY1 induction that some trusts have run in previous years is the simulated ‘on-call bleep holder’ sessions, which provide an opportunity for those undergoing full induction to practice prioritising and responding to bleeps. For those on the FiY1 induction this opportunity was not available, and the first time they carried a bleep was on their second day. From a social aspect, having only one day for the FiY1 induction meant that the new doctors began shifts without knowing many of their fellow colleagues. This reduced the opportunity to form the colleague support networks that may be gained from longer induction sessions, but most of the FiY1s were in the same position and joining teams were aware of the situation, which eased the transition into work.

After the FiY1 induction, I found that the most helpful advice was gained ‘on the job’ from the doctors already working on the wards. This included guidance on prescribing medications and completing discharge summaries, and tailored advice on how the consultants run their ward rounds. This is probably not too different from the usual FY1 experience, as it is impossible to prepare new doctors with everything they need to know before starting work. However, I feel the induction could have involved more time shadowing the FY1s on the ward and being supernumerary prior to starting work, although as we were beginning work in the first wave of a pandemic where staffing was already short, this might not have been a realistic expectation. To supplement shortened inductions in future, there are online resources that can aid FiY1 doctors starting in new trusts, with useful suggestions to ease the transition into working.³

The job

The first day as a practising doctor (FiY1 or FY1) is an immediate step up in responsibility from medical school. On my second day as an FiY1 I remember being approached by a nurse who asked, ‘Doctor, can you...’ and I looked over my shoulder thinking they must have been speaking to someone else. The FiY1 post I undertook did not include night shifts, on-calls or weekend shifts. This had the benefit of ensuring some personal time was protected and helped prevent work-related burnout. There were, however, still significant expectations in the FiY1 role, as some of us found ourselves in difficult situations caring for patients with little available support. Often, I found myself to be the only doctor accompanying the consultant on the ward round. I would be expected to document precisely to their individual preferences, complete patient reviews and jobs. This may be comparable to some FY1 experiences, although the COVID-19 pandemic put an obvious strain on clinical staffing and meant that support levels of middle grade or other doctors were sparser in some departments than usual. Although FY1 and particularly FiY1s should not be left unsupported in their role, in practice it has happened on occasion. This made it more difficult at times to escalate clinical problems, as often seniors were not around to review patients. I found the best strategy was to fall back onto the Resuscitation Council's A to E approach for assessing acutely unwell patients.⁴ I found that no one ever criticised this, so if you are in doubt, I would recommend having a safe approach to fall back on such as this. If you assess the patient as stable, it reassures you and the nurses, and any further management is often safe to wait until your senior becomes free.

Overall experience

At the time of writing, there is a second wave of COVID-19 occurring and an FiY1 placement is a possibility for another cohort of final year medical students. There are certain tasks and specific procedures which take time to learn at a new hospital: getting to grips with the computer systems, how to make referrals to different specialties and navigating around the hospital site. In fast-tracked inductions, it is difficult to fit all these tasks in as juniors are expected to begin work in a shorter time period. However, FiY1 (and later FY1) was an excellent opportunity for me to learn how to be a doctor and understand the responsibilities of the role. Furthermore, it meant working at a time where I felt I was making a real difference to the patients I saw and, in a wider view, to the hospital and the NHS. As a result, I found it an immensely satisfying and engaging experience. It is difficult to comment on how this experience might compare to an FiY1 starting in a tertiary centre, or in a similar district general hospital with different structures, but I believe there would be benefits to every FiY1 programme.

By doing FiY1, the theory I learned at medical school could be put into practice in a mostly supported environment. Despite all the pressures, there appeared to be good learning opportunities which prepared me well before starting FY1. I found this eased the transition from medical school to foundation training and, as a result, the start of FY1 seemed like an extension of the job that we had already been doing – especially as many of us were placed on the same ward for FiY1 that we had been due to start on first in FY1. This benefited the hospital in turn, as there were a significant number of FY1s already experienced in their starting rotation. Those that had worked in the trust for FiY1 were particularly useful to the new starters as sources of information and guidance on local policies. This meant that some socialising and support networks came from colleagues reaching out to each other for advice or assistance. With respect to patient care, the doctors who stayed on their wards were able to deliver nearly continuous patient care and the nursing and allied health professionals also benefited from the continuity of a professional relationship.

There may be a place for FiY1 in the future of the foundation programme beyond the pandemic, due to the significant benefits it offers in easing the transition from medical school and creating a cohort of more confident and competent junior doctors. How this would be addressed is a complex issue; it could involve representatives from hospitals and medical schools setting out clear expectations and goals that are achievable in the time frame. I would suggest appointing final year medical student representatives to act as a link between hospitals and their student cohort. That way, there is a clear passage of communication between the students and hospitals and a platform on which their views can be shared. With the resources available through large student national collaboratives, it could be beneficial to collect quantitative and qualitative data from former FiY1s before feeding back to improve the programme.

Support

Providing adequate support for FiY1s is a prerequisite set out by the UK Foundation Programme, as it is normal to feel apprehensive before starting a new job and experience challenges as the job begins, especially if it is brought on earlier than originally planned. FiY1s should have clinical supervisors appointed to them who can provide escalation and support. If this is not in place, it has been beneficial to some FiY1s to know who the British Medical Association junior doctor representative is for their hospital, as this individual can escalate clinical matters on behalf of junior doctors.⁵

Finding a life outside of work is imperative for good mental health – free versions of apps such as Headspace are helpful in winding down after a tough day.⁶ Talking to friends and colleagues can be a good way to deal with stress too; however, I recommend also being proactive and seeking out more formal support systems, eg clinical and educational supervisors, as they can guide you about how to respond to situations or clinical incidents. It is best practice to touch base with your supervisors as early as possible into your placement as they can be invaluable help in times of difficulty.