Ward Rules

Since internship and residency programs have started recently, I’m going to share a few principles and rules I follow in the hospital that I hope might be helpful to those starting out.

These principles vary from person to person and are in no particular order. I’ll be sharing mine here. It’s possible that some might disagree with them, and that’s okay.

I hope these serve as good general practices to have in mind starting out. I’m by no means perfect nor do I claim to be, sometimes I fall short on my own “rules” or principles, we’re only human. I do believe, though, that it is healthy for one to have their own guidelines and rules to aim towards applying consistently. It’s a means to keep oneself in check.

1. It’s okay to be stressed out. Whether it be while taking history, examining, giving your differential or prescribing. We’re all nervous about it when we start, and even down the line. Just don’t hold back and keep exposing yourself to new scenarios, you’ll gain confidence with experience.
2. Work for the patient and advocate for the patient. Always put the patient first. There are many examples for when to do this but an example that I’m always cognizant of is to try to not keep the patient you’re admitting waiting in ED when you haven’t got much else to do in the ward. Push for investigations to be expedited if there’s no need to wait, and so on.
3. Always evaluate patients clinically if there’s a change in status: a spike of fever or a new pain, don’t just ask questions over the phone. Getting up and evaluating the patient will reassure the patient, their care giver and primary nurse that you are aware of the issue, and that you’ve considered all solutions. This is how you practice safely.
4. Never forget to treat pain, never underestimate pain by gender, nationality or ethnicity (a weird existing pattern). Adequate analgesia is the only ethical option. Multimodal analgesia works wonders. Don’t underestimate IV paracetamol, re-assess and upgrade as needed.
5. Escalate care appropriately and raise your concerns. If you’re ever stuck or concerned about a patient, call your senior, even those who might give you a hard time. A hard time is better than a missed diagnosis or mismanaged case. You’re here to learn and ask questions, you are not born with experience.
6. Treat nurses as equals and with respect. Nurses are a patient’s main interface with the system, and they carry out most of the health-“care”. While doctors, dieticians, pharmacists and RTs put plans of care, nurses make those plans happen. Even if you might think that “they’re calling more than necessary”, it’s probably safer for you, them and the patient to answer their questions, no matter how trivial they might feel to you. Learn their names, it’s basic human decency and will create a better team dynamic. This sentiment should of-course be expanded to include all healthcare workers, porters, security personnel and administrators. A hospital is a beehive, and everyone’s role is important.
7. Some doctors complain, and I might have done on occasion, about being called “just for paracetamol” or “just AM lab orders”. While it might feel frustrating to be called for what we might consider “minor issues”, that very small order might be the reason your patient avoid a sleepless painful night or extra hours in the hospital. Optimize orders earlier in the shift to avoid this if you need rest, communicate with your team.
8. Always offer reassurance to patients and never assign blame. Parents and caregivers feel guilt when their loved one gets sick, counteract that feeling and tell them you’re sure they’ve done their best and things sometimes are inevitable or unlucky. Take time to thank them for the work they do because it is truly thankless. They are driven by a sense of duty, but when you express how impressed you are with their care and record keeping, you’ll give them a boost they’re too proud to ask for.
9. Recognize that mistakes do not warrant abuse. Some doctors in certain work environments are mean, and might give out personal insults or be rude, try your best to ignore it. Especially if it sounds personal, because it’s then about their issues, not yours. You’re allowed to ask questions, be slow or not know everything, you’re new (and even when you’re not). If they don't understand that it’s their problem. Even the best residents and interns get that mistreatment despite their best efforts, so it’s not about how good or bad you are at your job. Regardless, you deserve respectful, professional constructive criticism. Report to authority if appropriate. If there’s something you could have done better in that situation then reflect try to learn from it and move on, no point in dwelling or justifying abuse because you might have made a mistake while learning. The whole point of supervision is to prevent and catch mistakes. Break the cycle by treating your juniors with respect and compassion. If you do have the option, prioritize working in places known for a positive work environment, it makes all the difference.
10. Talk to people where they are. It’s really easy to call back the consulting service over the phone, but when an important discussion needs to be had or when the question warrants a back-and-forth, it’s better to find people where they are and talk to them face to face. It shows respect and demonstrates your interest and effort. When you’re trying to push for an MRI or operation theatre spot, visit their respective departments physically. Go up to the lab to push to expedite that urgent lab test. If you need the radiologist to take a second look, go to their office and review it with them side by side, this will facilitate a more level and productive discussion and would, in-fact, be a better learning opportunity. Remember to respect their time constraints while doing so and apply it within reason.
11. Use your hands. Always do procedures, cannulas, NGT, catheters, LPs. Don’t be afraid to try & mess up, everyone starts somewhere, and if you feel like you might’ve made someone uncomfortable with your attempt, think of all the ones you’ll help with this experience. Always ask for supervision.
12. Talk to all patients: even those labeled “comatose”, cerebral palsy, stroke, or sedated ICU patients. We sometimes don’t know who has an element of a consciousness level who would feel the kindness in your voice, or even in some cases, listen. Sedation in ICU settings is not always an absolute on/off switch. I’ve had patients remember me greeting and reassuring them while under sedation in ICU back in COVID.
13. Use your intern privileges: for me, it was having more time on my hand during the shift (varied depending on which department I was rotating in). As an intern, I sometimes felt helpless or even useless at times. Though honestly the thing I had time for more than other hospital staff was to provide comfort and support to my patients, the more I progress through my career, the less of that time I have. I met so many unforgettable characters and heard incredible stories from children, grieving mothers, people on their deathbeds and recovering elderly patients. Patients sometimes spend hours on end without someone to talk to, and having you listen to them for a few minutes might make their day. Moreover, these experiences will serve you well in your career, as they will provide you with firsthand insight into a patient’s experience through the system on a physical and emotional level. This may guide your future approach and will help you practice with more sympathy. Go out of your way to sit down with a patient for 30 minutes, trust me, you won’t regret it.

I’ll be revisiting and adding to this list as time goes by, for my own record at least.

What are your ward rules?