A student’s experience on the Moore-Ridings firm

A medical student who has completed his Moore-Ridings surgical firm year 3 attachment writes here.

(Please note that Mr Moore now leads a different firm with Mr Lamah and that his timetable has changed since this article was written).

Team structure
The RSCH has four general surgical teams, each with two consultants and this particular team works under Mr Moore and Mr Ridings.  The surgical team is comprised of two registrars, one SHO and three house officers (foundation year one doctors).

Teaching ward rounds
Monday mornings consist of a registrar ward round at 8.00am on level 9a before a Mr.Moore teaching ward round straight after. The teaching ward round is one of the most important sessions of the week. 3 in every 4 weeks, there will be no new patients on the ward round, as the firm are on take only 1 in every 4 weekends. However, patients will still need to be presented to remind everyone of the patient’s story to date as well as what has happened to them over the weekend.

There is an opportunity to present patients during the ward round after clerking the patient and looking over their weekend notes. It is important for students to present in this situation as it will give you a good insight into how patients are managed through their inpatient stay as well as common problems that may occur with certain disease states. The second point is that it helps you to develop your presenting skills. I found this invaluable as I got both good constructive feedback on my presentation and it also then provides a platform on which Mr. Moore can provide further teaching.

Not everyone is always comfortable in presenting patients in year 3, however it is important that you try to present as much as you can now, as no one on the team will expect perfection from a year 3 student and will be happy to point out how to improve, where as once you qualify you will be expected to present to a good standard.

Other ward rounds
Mr.Ridings will do a consultant ward round on Tuesday morning, whilst one of the registrars will also do a ward round of the patients on Wednesday and Friday morning. During these ward rounds, you will benefit from observing how patients are managed day-to-day. You can also be a great help to the team if you can find the patient notes beforehand, and sometimes you will be asked to write in the notes or assess the patients’ observations charts. This is all good experience for your training and you should also not be afraid to ask questions to the team regarding what you see, as they will be happy to answer.

Patients are rarely textbook and knowledge required in the end of year exams can be mostly acquired from seeing the cases on the ward and how they are managed.

Endoscopies are also an important learning experience. Firstly, OGDs, and colonoscopies are some of the most commonly ordered tests in GI surgery, and it is important to be there to learn about how patients are prepared for these investigations, what is normal, what is not and patient’s experiences.

Secondly this is also a good place to practice your PR skills, particularly as the patient is more likely to be happy for you to proceed with the investigation they are about to have. One thing you are sure to notice in your attachment to the firm is how a PR exam is routine in surgical assessment and F1s, particularly in GI, will be doing it on a daily basis. This highlights how important it is to be able to identify what is normal and what is not by this stage, and the only way you can do this is through experience.

To do so, you should first consult Mr.Moore or Mr. Ridings to check that they are happy, before consenting the patient. The other good time to practice a PR will be during surgery, in which case you should check with the surgeon before consenting the patient.

On Take
During the 8 weeks of your surgical attachment, you will be scheduled to be on emergency take on two random days allocated to you. Wednesday is when the firm is on take and you can take advantage of the fact that it is the only day of the week where no medical students are scheduled to be on take that day.

You will be encouraged to clerk patients so you can then present on the post take consultant ward round the following Thursday morning. This can be done at anytime on Wednesday, so if you have SSC in the afternoon you can just come in afterwards. Although it is not a signature in the logbook, it is strongly recommended for your own personal gain. To do so you can simply turn up to A&E/MASSU and bleep the surgical SHO (who is not necessarily the firm’s SHO) and ask to see any of the new patients, or if there are none at that time, a patient who has come in earlier in the day. The SHO’s were always very helpful and happy to let you see patients.

This experience is particularly useful in developing your clerking skills and it also allows you to follow the patient right through from there and attend any investigations they may require. Having seen a patient, you can then present to the SHO and discuss differentials and initial management and then present the patient you have seen on the post-take consultant ward round, which is again a very useful learning experience. You will then see how these patients are initially investigated, how the diagnosis and the formulation of a management plan is made. Seeing patients as they come into A&E is a fantastic opportunity to get some clerking experience, as patients will give a detailed history of the complaint and you will then remember how patients with acute conditions such as perforation can present. You may also have the opportunity to take blood or insert cannulas if you are confident enough.  Make sure you ask the team for supervision if you need it.

As well as presenting patients on the post take ward round, you will also learn about CEPOD lists, which basically means the consultant will see the patients from the take and decide who requires immediate surgery and in what order, based on the stability of the patient’s condition. This will teach you how cases are prioritised, for example complete bowel obstruction in an elderly patient who is at a high risk of perforation will usually be high up on the list.

From the ward round, you are able to go to surgery, particularly if it is an interesting case and there is always a chance to scrub in and gain some more practical experience in theatre. During my 4 weeks on GI, I managed to scrub in on numerous occasions and as well as learning how to scrub up and assist, it was also the most enjoyable experience I had in the 4 weeks. It should be stressed however; that the firm will not expect you to attend every operation, and encourage you to do what you think will be most beneficial for your learning.

Another useful learning experience in theatres is being with the anaesthetist during the induction of anaesthesia. Often, they will teach you about the operative complications and their role in surgery. In addition, the anaesthetist may also allow you to get involved with cannulation, intubating and catheterisation under close supervision.

Friday mornings are clinic times for both the consultants, which is unfortunate again as you will miss out through being in symposia. Therefore it is important to try and go to Mr.Ridings clinic on Monday and Mr.Moore’s clinic on Thursday at the PRH. Clinics will provide opportunities to clerk some of the new patients before the consultant sees them and will also allow you to write in the notes, which is good practice for a skill that you will perform frequently at F1 level.

The Moore-Ridings team is a very welcoming one to students and you will be supported all the way through. I greatly enjoyed my 4 weeks attached to the team and learnt a great deal in a short space of time. The most important thing you can do during your attachment is to be there and actively get involved in what is going on as much as possible. There is plenty to see, plenty to do and much to enjoy by showing a desire to learn.

Paul Zeun

3rd year medical student BSMS February 2008