This section is intended to give you a rough idea about the THREE main types of jobs that Interns can be allocated to during the course of the year.
While this section was originally intended to paint a broad outline of the three major types of term on offer to interns, what we didn't expect in 2020 was that COVID would throw all of this into dis-array. So in 2021 there is a new section - COVID - to highlight the fact that what you might reasonably expect, and what the hospital expects, won't always play out in the way we expect.
In 2020, COVID changed everything!
So what should you expect in 2021? The key message is that you will be required to be flexible and adaptable. For all of its disappointments, heartbreak and frustration, 2020 was a year where JMO cooperation and collegiality was at its best, and many JMOs thrived in this environment. COVID has already had a substantial impact on your orientation program and could still disrupt it more profoundly - It is not impossible that you are instructed to dial in from home at the last moment. Other things that changed in 2020 and which may or will have an ongoing impact include:
- PPE: This moved from being a peripheral consideration relevant in certain circumstance to taking centre stage. You must be completely across what is required and expert at donning and doffing. It must be second nature. This saves lives and is not going to change in 2021.
- Hand Hygiene: Has always been of critical importance, but historically, doctors have not been as compliant as they should. Not any more! If you don't know about the "five moments" by now there is a big problem.
- Unexpected Absences and Special Leave: As JMOs got caught up in quarantining, travel restrictions, swabbing and self isolation, it was more likely that positions at all levels could fall unexpectedly vacant for short periods with no capacity to organise relief. In many respects the most important response to this was common-sence and understanding, flexibility and changed work practices. Rapid and reliable communication with RSU was also critical. This problem is not going to disappear in 2021.
- Rostering: In May and June of 2020, the hospital abandoned its traditional JMO rostering patterns and moved to a ward based 12hr roster in a 4 on 4 off pattern. This was designed to allow us to better cope with the influx of patients that thankfully never emerged. BUT, had NSW experienced the same as Victoria, or the experience of any European or North American country, we may still be in such a model. The December Northern beaches outbreak is forcing us to dust off those plans. Who knows what will happen in 2021?
- Term Allocation: reorganisation of rosters in this sort of fashion, completely disrupts term allocation. So even though you've just been given a schedule of 5 terms which we plan to rotate you through during the course of 2021 - you must understand that this could change and that last year it did, through circumstance entirely beyond our control. More so than any other year you need to appreciate that term allocations are not set in concrete and may have to change, even though we will do our best to avoid this.
- Term Structure: Last year even the basic concept of 5 terms per year broke down when the Ministry of Health cancelled term 2, throwing many JMOs plans into disarray. It seems unlikely that this will occur again - but then, the very idea was unthinkable this time last year.
- AHPRA and Medical Registration: In 2020 the disruption to intern rotations and training programs led AHPRA to ease their criteria for progression to general registration, both in terms of the expected mandatory clinical exposure and the number of weeks needing to be completed. However these changes were not universally applied, being limited to only those JMOs impacted by COVID. It is quite likely that the Medical Board will take a similar approach in 2021 to ensure that interns are not disadvantaged by COVID, but as of the moment it is probably best of plan around the historical guidelines - which requires you to satisfactorily complete 10 weeks of a core medical term, 10 weeks of a core surgical term, 8 weeks of a core Emergency term and 47 weeks (excluding leave) in total.
- Meetings and Education: For a while all face to face meeting stopped completely - including our local education programs. Then we started getting proficient at streaming and on line alternatives. Replacing or supplementing education with these alternatives will continue into, and well beyond 2021 and in the long term will have a positive impact on your access to education.
- Career progression: as you probably know the cancellation or delay of exams and other key courses has thrown some specialty career progression into disarray. For our RMOs in 2021 the most significant impact was seen among those interested in surgery, where the log-jam at the more senior levels translated into reduced job offers at the SRMO level. Most other RMOs were only minimally impacted though it is not clear what the long term consequences will be. My guess is that by the time current interns are applying for PGY3 jobs in 2022, the job market will be roughly back to normal.
- Skype interviews: You probably got used to this in a private setting but these have become the norm for most hospital meetings and many job interviews. Skype interviews actually increased the efficiency of annual recruitment so expect this trend to continue.
There are three major types of Intern terms: Ward-based, ED and Relief. Before explaining these, it is worth noting that every term has an official description. This is a requirement of accreditation, overseen by HETI, but some terms also provide additional orientation material.
A ROVER (Rolling Handover) is a document maintained by JMOs and contains useful tips for how to survive the term. JMOs are expected to review and update the ROVER at the end of each term, using it as the basis of a handover with the incoming JMO.
So, in terms of what to expect, these documents are always a good starting point and should be read prior to each new term. You can find Term Descriptions and ROVERs on JMO OnCall
In a ward-based term, you will form part of a clinical team which usually consists of several consultants, at least one registrar (sometimes more) and at least one JMO (Intern, RMO, or both). Some of the larger teams may also include an SRMO or a Fellow.
In some teams, the nature of the work is considered sufficiently complex or demanding as to require an RMO as the junior rather than an Intern. Every pre-vocational term is accredited and will be identified as either PGY1 and PGY2 or PGY2 only. Needless to say, Interns should never be allocated to an PGY2 only term, nor are they allowed to swap into one.
Ward-based terms most commonly involve a fixed length shift, running Monday to Friday throughout the term. The standard working hours at Westmead are 08:30 to 17:00 (i.e. an eight hour day, with an unpaid 30 minute lunch break).There are many variations from this standard shift:
- Most surgical terms at Westmead are 07:00 to 17:00.
- Cardiology is rostered from 07:30 to 17:00.
- Some ward-based terms, such us Upper GI and Neurosurgery, have irregular rotating shifts.
- The Trauma roster is seven days on/seven days off.
- Some teams, such as Vascular and Orthopaedics, have staggered shifts with early- and late-starters.
- Some teams, such as Cardiology, Respiratory and Geriatrics, have weekend shifts incorporated into the global roster for the term.
Regardless of the roster, your day will generally fall into a similar sort of pattern:
- Preparing for and participating in the early morning round.
- Carrying out the tasks arising from the round and ensuring any consults are organised early in the day.
- Facilitating patient discharge, including finalising discharge summaries and medication scripts and organising outpatient bookings.
- Preparing tomorrow's discharge summaries towards the end of the day.
- Handing over to the after-hours ward staff.
Starting out in a ward-based term, it is easy to fall into the trap of thinking that you are not much more than an over-qualified secretary. You may feel that your registrar or consultant makes most of the clinical decisions and your job is to take care of the documentation and administration.
While there is much truth in this, you must never think of this as a bad thing. Excellent organisational skills and communication skills define the best Interns and you can’t be a fierce patient advocate without getting both of these things right. If discharge summaries are not done on time, if tests are delayed, if handover is poor, or if there are gaps in communication and documentation, your patients will suffer.
In every ward-based term there will be opportunities to learn specialty-specific skills, but just as importantly, there will be opportunities to learn generic skills about looking after sick patients in a hospital setting. This is particularly the case in surgical terms, like Orthopaedics or Vascular, where you will be one of the key players in managing the medical comorbidities of surgical patients.
Interns doing ward-based terms with regular shifts will also participate in the general ward after-hours roster. You can expect to be rostered on approximately three to four weekend shifts per term, two to four evenings per term and three to four on-call shifts per term, athough this can be highly variable for different positions.
More information about after-hours is found below.
Emergency terms often give Interns their first taste of what they imagine it is like to be a 'real' doctor. You will be assigned undifferentiated patients to be worked up relatively autonomously, whilst also having excellent supervision and support at all times of the day.
In addition, for almost all of next year, ED Interns will be treated to working in the newest and best equipped emergency department in the state - with the move from the current location to the new hospital anticipated in the first few weeks of 1st Term.
Rosters in Westmead ED are based around 10 to 10.5 hour shifts, starting at 08:00, 13:00 or 22:00. You will be rostered to eight shifts per fortnight, rotating through days, evenings and nights. You are likely to be rostered to nights early in the term, but this is not something to be feared because we have excellent nighttime supervision.
At present Westmead, Interns can be assigned to one of four locations: Acute (Category 1, 2 and 3 patients), Urgent Care (Category 4 and 5 patients), SAFE-T (triage) and ESSU (Emergency Short Stay Unit). It is possible this may change someone in the new hospital but no matter where you are, there will always be pressure to move your patients through the department rapidly. Time management is a highly valued skill in ED. For this reason, many JMOs find that although the absolute number of hours worked in ED will always be less than the wards, the nature of the work is more constant and intense.
Relief is the term that many new Interns fear, because it seems much less structured and more random than the wards or ED. By the end of the term, however, most Interns value the experience having gained confidence in the skills of assessing sick and deteriorating patients. You will be given your relief roster for the whole term, usually two to four weeks commencement. You will usually be asked prior if you have any special preferences with regards to your roster. RSU has to juggle the requests of nearly 50 JMOs when constructing this roster, so if you want particular days off, these should be for exceptional events. If you want to attend your sister’s wedding, for example, RSU will always try to accommodate. If you just feel that it would be nice to have every weekend off, then less so.
You can be rostered to 3 things during relief:
Greater than 95% of interns will take their annual leave during their relief term. It is possible to request leave at alternate times – but this can impact on whether you get enough weeks exposure to your core terms and therefore, whether or not you’ll be eligible to be issued a certificate of completion of internship after 12 months
General Ward After-Hours Roster
where you’ll be rostered to 5 evenings/weekend shifts per week, or 7 night shifts per fortnight. The latter is usually organised in a week on week off pattern. While seven long nights straight sounds daunting, most interns rapidly learn that, in reality, these are little different to the evenings, but come with the added benefit of more rostered days off. The same small group of interns, RMOs and medical registrars are rostered for the whole week and usually form a cohesive and supportive unit. You will also find that the Westmead relief pool is used to staff the Auburn evening after hours, so some relievers may find themselves at Auburn for a few weeks.
You can find more detailed information about after hours shifts from the front page of the JMO App under Quick tips for JMOs
Ward Teams or ED
where you will either be replacing someone who is not available (for whatever reason), or on occasions, assigned as a supernumerary (inevitably to one of the busier teams). Whether you are replacing someone, or you are a supernumerary, it is always wise NOT to assume that the team is expecting you, and to take steps to introduce yourself and explain your presence.
You will find that we tend to have an over-supply of intern relievers in Term 1 of each year, and you may spend more time than usual working as a supernumerary in Term 1.
The information presented below is based on our historical approach to after hours rosters but please be aware that the move to the new building will change the pattern of JMO staffing afterhours. The extent of the change is not entirely clear at present but you need to anticipate that some change WILL occur.
Between the hours of 17:00 and 08:30, medical staffing on the wards drops from hundreds to a few dozen. As Interns, you can be rostered to evenings and weekends during your relief term as your regular shifts, or as overtime, performed after your day shift on a ward-based term.
In 2018, NSW Health introduced the requirement that doctors have a minimum of 10 hours between shifts, meaning that surgical interns who commence at 07:00 am cannot be rostered to overtime which finishes at 22:00. Surgical Interns can therefore only work rostered overtime on Saturdays.
When relievers are rostered to evenings, the shift starts at 14:00 and finishes at 22:00. The first few hours tend to be fairly slow, so we expect the relievers to help out the busiest JMOs on the wards the reliever is covering. If an evening shift is rostered as overtime on a ward-based term, it starts when your usual day shift finishes at 17:00. Weekends are 14-hour shifts for both relievers and ward-based JMOs rostered on overtime. If you can find someone to share the shift with you it is acceptable to split. With the current focus on excessive working hours, this may become more common in the future.
Each after-hours shift has a nominated pager, which should either be picked up from Switch or the outgoing JMO from the preceding shift. Each shift is responsible for a specific grouping of wards, the details of which can be found in the documents below.
Most of the work consists of responding to emergent issues which will either be recorded in the eMR or communicated directly to you via page.
- There is no formal day-to-evening handover meeting so communication between day and evening staff about sick patients should happen one-on-one, by phone or face-to-face communication. In 2021 we will introduce an electronic handover tool to facilitate day to evening medical handover.
- There is an evening handover between evening and night staff, every night at 21:00 in the ICU Conference Room.
- There is a morning handover meeting for all general ward night staff Monday to Friday at 07:30 in the ICU Conference Room.
- On weekends, there is a handover between night and day staff at 08:00 in the ICU Conference Room.
The link below, which can be found on the JMO App, is intended to give you more detailed information about after hours shifts.