Welcome to Gastroenterology. Most people find this a difficult medical job but the seniors and consultants are very approachable and friendly, and are always willing to help you along if there is anything you do not understand. I guarantee you will start to enjoy it after 2-3 weeks!

The Gastro list is split into 3 teams (Gastro 1, Gastro 2 and Intestinal Failure). Each team has a duty consultant (changes every 2-4 weeks), an SpR (changes every 1-4 weeks), a FY1/SHO. Realistically, Addenbrooke's is often short-staffed so you might not have an SHO from time to time. Each team normally has about 10-20 patients.

You can prepare for this job by reading the documents the department has put on Connect for incoming FY1s. These include the Acute Colitis Protocol, and investigations needed for people with UGI bleeds. They can be found on Connect under the Gastroenterology link.

The Gastroenterology home ward is M4. This ward has 22 en-suite bays for patients. The Sisters on M4 are Felicity, Lisa, Katrina, and Mary; occasionally Karolina, Brenda and Ana (three of the S/Ns) act as Ward Manager/Sister when the Sisters aren't around. Dawn, the Ward Clerk, is also very helpful.

Other places your patients will normally be in:

• ATC - Gastro unfortunately takes all General Medicine patients that get a bed in the ATC from A&E. We have recently been able to get PA cover on M4 until 10pm and some of the nurses are wll trained to take bloods, insert cannulas and take PICC bloods which is helpful. On the weekdays, they have a morning phleb round but they sometimes do not do all the bloods. On weekends, L5 and M5 have NO morning phlebs. If bloods are necessary, please let the weekend HO/SHO know they HAVE to personally take the bloods.

Important places: Endoscopy Unit - Level 3 of ATC Histopath MDT - Level 6 of ATC Feeding Issues MDT - Take the stairs from Level 2 in the Medical Staffing block, go all the way up to the top. The MDT is held in Seminar Room 1 on Wednesdays at 1400 hours. Gastroenterology Seminar Room - E7 in main block. Consultant offices - E7 and Endoscopy unit

Consultants: Dr Ewen Cameron (Endoscopy), Dr Miles Parkes (Director of Gastroenterology), Dr Andy Metz (Endoscopy), Dr Young-Mee Lee, Dr Gareth Corbett, Prof R Fitzgerald, Dr Jeremy Woodward (Nutrition/IF), Dr Dunecan Massey (Transplant), Steve Middleton (Transplant, GI motility, IBS), Dr Lisa Sharkey (Nutrition/IF), Dr Tim Raine, Dr Ines Modolell

Other teams you will see/interact with: Nutrition/IF team (the Specialist Nurses deals with all TPN prescriptions, the SpR and Dr Woodward see patients with intestinal failure), IBD Nurses (they handle immunosuppressant prescriptions for IBD patients), Interventional radiologists (Dr Nick Carroll, Dr Winterbottom, Dr See, etc); Radiologists (Dr Sara Upponi, Dr Ed Godfrey)

There are also people that you may not see that often but are essential part of the team - endoscopy fellows, endoscopy nurses, Clinic 12 (gastro clinic) secretaries and nurses, dyspepsia sister, IBS sister

As with all General Medicine rotations, you will have 2 months on Gastro/ward block and 2 months on acute block. You will most likely be clearing your annual leave during your acute block (unless you have pulled some strings over at Medical Staffing).

Acute block consists of about 2-3 weeks of A&E shifts (medical take), 2-3 weeks of being a service needs FY1 (this means you will be allocated to random specialties for a few days), and your annual leave/off-rota days. Enjoy these short breaks while it lasts. Check the Junior Doctor rota on Connect to find out what you are actually doing during this block, most of the time you will have no idea which specialty you're being allocated to (for service needs) until nearer the date.

On the ward block, you will be working every weekday and a few weekends. There are different types of shifts.

• NWD: You start at 0830 hours, go home at 1800 hours if you've finished all the jobs. That usually does not happen so be prepared to stay until 1900-2000. Intestinal failure team typically go around with the nutrition team (nurse specialist and dietitian) to see the intestinal failure patients. It would be helpful to familiarise yourself/ note any issues with PN/ electrolyte and fluid balance for these patients.
• Late- At 1800 hours, you pick up the bleep for the specialties you're covering from the F5/G5 Seminar Room. If you can't find the bleep, call Switchboard and ask them to redirect calls to a spare bleep (easiest way). The Gastro/ID/D&E/MSEU bleep is held by the diabetes FY1s so go to F6 to get it-they will often also give you a paper handover of any of their jobs. It is a very busy on-call evening so try and get as many day jobs as possible done before 6pm. Do jobs and answer bleeps until 2115 when you hand over outstanding jobs at the David Dunn Suite.
• Weekend: It basically sucks. You will cover ALL Gastro patients with an SpR and the Duty Consultant. Start at 0830 hours and the Consultant will see new patients with you. Then you and the SpR will see the rest. Then do jobs and answer bleeps until 2115 when you hand patients over to the night SHO at the David Dunn Suite. Your SpR will have to see new referrals throughout the day. At the end of the weekend you might regret doing Medicine as a career but do remind yourself: one weekend down, one/no more to go!

• Each morning there is a board round with all members on the MDT, this is really useful each patient is gone through, EDD’s and any acute issues are discussed.
• On gastro they are really organized and like the white boards around the office to be kept updated. You need to keep a list of all outliers and update this each day. As well as keeping a list of all patients who have been discharged, about once a week the consultants will go through discharge summaries.
• There is a weekly meeting on Tuesdays in E7, (free food!) where they sometimes like the juniors to present a case. So anything interesting that comes up, keep a note of the patient’s number and then one-week put a few slides together around the case. It’s pretty informal.
• Unordered List ItemFinally, Dawn is the ward clerk, she’ll save your bacon repeatedly- she keeps everything in check on the ward, treat her well.

There are a few special events peppered throughout the week:

Monday

• Radiology meeting at 1230. It is held in a seminar room somewhere in the X-ray department - Level 4 below Berridge room. Follow your team there; if not I guarantee you will get lost.
• Discharge Summaries meeting at 1300 in N2 Doctors' Office. The nice coding lady will go through all discharges from the previous week with you to make sure the Principal Problem for each patient is listed correctly. Make sure to list the diagnosis at the top of the discharge summary.

Tuesday

• Gastroenterology teaching. This is held from 1300-1400 at the E7 Seminar Room. There is always a free lunch! There is sometimes scope for presenting a case if it is particularly interesting, which can boost your CV.

Wednesday

• Feeding Issues MDT at 1400. If any of your patients have been referred, make sure SOMEONE goes to the meeting to present the patient. Also make sure the FIMDT checklist has been done on Epic. If you do not know the patient well enough, force your SpR to go; otherwise, there is a very high chance your patient will not get the PEG he/she needs.

Thursday

• Histopathology MDT. This is where biopsy results from endoscopies get looked at. Make sure this is emailed to the Histopathology MDT email address at least 24 hours before so it will actually be discussed.

If things are slow during any point in the week (highly unlikely), your SHO will try to attend clinics. Let them; they need to complete a certain number of hours in clinic to get signed off every year. The Consultants/SpRs are also very happy to let you join them in endoscopies should you wish to. They are actually very useful - endoscopies can be a mixture of gastroscopies and colonoscopies +/- polypectomies, biopsies, or there are more advanced procedures such as PEG insertion, ERCP etc. They help to put what you see on a daily basis into context. Clinics are also particularly useful (and fun!) - there are general clinics, IBD clinics, nutrition clinics, coeliac disease clinics, etc.

0830: Arrive at M4 Doctors' Office and pick your bleep up. Wait for new patients to be popped onto your team list on Epic. Your Consultant will also arrive at around 0845 with the list of new patients. Divide them so that teams 1 and 2 have roughly equal numbers. Print 8 copies for the team + 5-6 copies if there are students + 1 copy for Matron (to be given to Dawn during Board round at 0900).

0900: Board round with the nurses, PTOTs, secretaries, Matron, etc.

0930: Round patients. Normally a team will start on M4 and the other will go to the ATC. On consultant ward round days consultant will see all the patients. On other days, the consultant sees the new patients and then the registrar may decide to round on all patients or (if he has to rush off to clinic) may split number of patients with SHO / yourself to get around on time. Sometimes you have to round patients yourself; don't worry! Do jobs after ward round.

At random points during the day, you will occasionally get bleeped about prescribing Ferinject or fluids or blood for patients in the Infusion Bay in D5. Don't be surprised; just prescribe them. If they ask for an Infliximab prescription, tell them to contact your SpR (FY1s cannot prescribe Infliximab). If they are asking for some random drug you've never heard of, check the patient's previous encounters/clinic notes to make sure it has been ordered by a gastroenterologist - do NOT prescribe drugs for other specialities. Ferinject is normally 1000mg to be given in 250ml of saline and run through in 15 minutes. Also you might get calls saying a patient needs clerking on D5/PSSU. These are patients who are admitted for PEG insertions, ERCPs or colonoscopies the next day. They only require a very brief clerking note, bloods and cannula (the PAs can do these), and meds to be prescribed. For PEG, there is a protocol where gentamicin has to be given pre-op, and Bactroban and Octenisan prescribed for washing the PEG post-op. Ask the nurses on D5.

After ward round - chasing investigations, referring to other specialities, speaking to family/relatives, speaking to GPs, completing TTOs and discharge summaries. (Make sure to have TTOs completed for the expected discharges the following day so as not to slow down patients' discharge) If there are bloods that need being done over on ATC, do it early on so that results are back before you leave. If possible, do all jobs in one go so you are not constantly going back and forth between ATC and main block.

1630-1700: Around this time, your SpR will check back with you wrt progress of jobs requested in the morning. In either team, the Duty Consultant for the day will do a PTWR for new patients on M4. Make sure bloods are checked - and acted upon if abnormal (pay particular attention to refeeding bloods, inflammatory markers in acute colitis patients, haemoglobin in upper GI bleeds, etc)

1800 or later: Hand over things that NEED to be chased and actioned upon. Do not hand over investigations to be chased (esp routine bloods) if you do not need something to be done depending on result. The twilight/night cover is already bad enough. Order bloods for tomorrow morning.

1. Bleeders: People with UGI bleed p/w malaena or haematemesis. Needs urgent OGD, FBC, G&S +/- transfusion, clotting. If ulcer found on OGD, needs PPI +/- triple therapy.
2. Acute colitis: Needs daily CRP, FBC, U&E. Also needs AXR on admission to exclude megacolon. Depending on progress with IV steroids, might need surgery/infliximab. If patient is to go on infliximab for 1st time, they need CXR, quantiferon, Hep B/C serology, CMV/EBV/HSV/VZV serology.
3. Starvers: Either has IF and admitted to get TPN, or dysphagia and needs feeding tubes. Needs daily refeeding bloods if long period of starvation.
4. Complex patients with chronic sepsis and multiple drains, needing MVTs: Be wary of temperature spikes. Daily bloods till forever.
5. Typical Gen Med patients: Old, frail, has dementia, might have medical problem needing therapy. Once MFFD, they need PT/OT/SW input to getting care or placement. Needs constant chasing about progress with this or they will be stuck in hospital for eons.

Admission - Most patients will be admitted from the acute medical take at 08:15 in the morning. Once the list of new patients arrives from the handover meeting you need to ensure that they are on the list. The on-call consultant will switch between Gastro team 1 and Gastro team 2, so whichever team the consultant is going round with will take all the new patients.

Sometimes the patients will already have been put on the list by the staff at the handover meeting - they usually put all the patients on Team 1. Therefore it is important to re-allocate if necessary.

It is also important to ensure that all VTE assessments have been done for these new patients and that they are under the correct consultant.

Sometimes patients will be admitted from clinic or transferred from another hospital. These patients will need to be clerked and ensure that the ward clerk admits them- they will often come through A&E where the gastro SpR will see them - if you have time it is often useful to go down with them as then you can do the clerking jobs (ie bloods, VTEs and XRs) before they come up to the ward.

Each team will have an SpR allocated to their team - they tend to be around in the mornings and have clinics/endoscopies in the afternoon but normally are contactable - ask for a contact number for if you have any questions in the afternoon. They will usually catch up with you towards the end of the day to make sure there are no issues. As there are 3 teams in gastro, each one usually has a junior- and often one of these is an SHO. They are really useful if you need some senior help and your SpR isn't around, and are usually very happy to help (although remember to return the favour if they are busy with their own jobs). The consultant tends to come back in the late afternoon for a quick board round which is a good time to bring up any issues. The consultants are very approachable, so if you need anything before then and can't contact your SpR, don't hesitate to contact them.

-On evenings you will not have any registrar cover except for the medical registrar (from 6pm-9pm)

-On weekends the consultant will stay until around 12 when the ward round finishes, and the registrar is usually on until around 3pm. Again they are normally happy to be contacted if you have any questions when they have gone home - in an emergency, speak to the medical registrar and/or the rapid response team.

Gastro bleeps

• Team 1 SpR: Mobile
• Team 2 SpR: Mobile
• SpR for Referrals: 156-2000 (incorrect, check switch)
• Nutrition SpR: 152-943
• Team 1: 152-290
• Team 2: 157-372
• Twilight cover for Gastro: 152-409

Other useful numbers:

• Surg SpR: 156-0316
• Rapid Response: 156-0659
• CT SpR: 6718
• CT Co-ordinator: 3219
• X-ray: 2387/3121
• Labs: 3124/3781
• US: 2778
• Micro: 57038
• Endoscopy: 2515
• Transfusion: 3130

Banding for General Medicine is 1A. The job is tougher than most other medical specialties but better than most of the surgical jobs. The rotas are generally fair. There is potential for a bit of work/life balance.

Good Guidelines/ things to be aware of

• Anorexia: there is a protocol on connect that is helpful with how to replace electrolytes, blood tests and teams that need to be contacted and included. To be particularly aware of the need for daily refeeding blood tests and despite appearances of dehydration and poor PO intake, to replace fluid very cautiously, i.e 1L per day in 500ml increments due to low BMI and low albumin.
• Acute colitis protocol. There is a document on connect but EPIC has a really good ‘order set’ for crohn’s and UC if you type in acute colitis. To be aware of, make sure patients get IV methylpred as soon as admitted if acute severe flare. Additionally if they are not responding to steroids and require infliximab, you need to really chase pharmacy for this early in the day as only certain nursing staff can give it and they will only do this when a doctor is around, i.e before 6pm.
• The VIROME study (amongst others that I can’t remember the name of!) are running at Addenbrookes. If you have a new patient who is diagnosed with IBD, even though it is really important to get the steroids running ASAP its really helpful if they can have bloods taken for the study before the administration of steroids. You don’t need to take the bloods, if Dr James Lee (who is running the study) is contacted he’ll be on it!

Just because you're on Gastro does not mean you'll definitely be doing the Gastro twilight cover or weekend cover. Always check the Junior Doctor rota beforehand to find out.

You share the M4 doctors office with the Colorectal team. Makes good fun chatting with fellow FY1s!

Remember to smile and enjoy your job always!