When I left medical school, I thought my only difficulty would be the actual medicine, which most junior doctors will tell you flies out your head as soon as you walk out of finals (it flies back in when you start working though). I somehow assumed that I would always manage to find ways to swerve leaving late and 'comms skills' my way through any difficult situation with colleagues and patients, just like in the OSCE.

It might seem obvious now, but the reality is that it's quite difficult to leave on time when you're not good at judging what you really need to stick around for, especially when a colleague is guilt-tripping you over a constipated patient. It's easy to feel obliged to forego your breaks and your lunch when it's already noon and you're not even a third of the way through your FY1-led ward round because you've not done one before and the overthinking is making you slow. But stack up just a couple too many weeks of abusive patients, working hours for free and being bleeped every five minutes by several different wards wanting their stuff done first and you'll find yourself hating your job.

Burning out is easy, everyone does it. Looking after ourselves is hard, we all need to get better at it.

Keep an eye on your rota
Some rotas are really tough and just working what’s required of you can be enough to burn you out. But working a shift that you didn’t have to do and aren’t even going to get paid for is a truly tantrum-inducing situation that I wouldn’t wish on anyone.

When you start work, you get your rota and your work schedule. Your rota is what you're actually working, but your work schedule tells you what shifts they're going to pay you for. Ideally, there should be the same shifts showing up on both.

I’ve heard lots of stories of trusts quietly adding on-call shifts here and there that don't appear on the work schedule. You're not going to get paid for those extra shifts but they'll do a number on your fatigue all the same.

There have been a few changes with the new contract, but in a nutshell, the rotas should abide by the following (Refs 1,2):
  • You're not supposed to work more than 48 hours average per week
  • You're not supposed to work more than 72 hours in any 7 consecutive days/168 hours
  • You're not supposed to have more than 4 long shifts in a row (by default)
  • You're not supposed to work more than 4 night shifts in a row
  • You're not supposed to have more than 7 shifts of any kind in a row (by default)
  • You're not supposed to work more than 1 in 2 weekends
  • You're entitled to a 46-hour gap after any night shift
  • You're entitled to a 48-hour gap after any run of 5 long shifts in a row or 8 shifts of any kind in a row
  • You're entitled to an 11-hour gap between shifts of any kind (so you can sleep).
Thankfully, my rotas have only needed slight tweaking thus far and getting annual leave has been quite smooth when my departmental seniors did my rotas rather than medical staffing. But, your rota does need checking and you might have to make some assertive phone-calls if you're unlucky.

You can check the rota yourself or you can make use of the BMA online rota checker if you're a BMA member.

Keep an eye on your pay
I was at a training course where a colleague told me he knows of someone who was accidentally paid £50k in a month, which he had to give back but it messed up his tax for the year because the HMRC thought he was suddenly earning loads. Pay is always an issue and there are some glaring mistakes for somebody every single time payday comes round. It shouldn't be the case and it's a pain to sort out, but not nearly as stressful as being strapped for cash.

You can read our detailed article on pay, understanding your payslip & claiming tax relief. Your work schedule tells you how much you would be earning if you worked a year in that rotation (divide that by 12 to get your actual monthly gross income, I don’t know why they don’t just give this to you in the first place). A lot of people don’t really understand their payslips but I would highly recommend getting to grips with the deductions that are going to be taken off your income:
  • Tax
  • Pension (9.3% of your basic pay, which is your pay before any on-call/weekend enhancements; also on your work schedule)
  • National Insurance (12% of anything over £166 a week)3
  • Student Loan (9% of anything over the repayment threshold for your repayment plan) (Refs 4, 5)
  • Mess (optional, usually a tenner)
  • Parking (optional)
This can easily be a third of your income gone before it gets to you, so make sure you know what you should be getting overall each month and call up your trust's payroll (via switchboard) if you don't get it!

Remember to subtract your tax-free allowance for that tax year from the projected annual income on your work schedule so you know what you're actually being taxed on for that rotation. Sometimes your old trust doesn't give your new trust your P45 very quickly, which means you're on the emergency tax code for a while = no tax-free allowance when they calculate your tax = a lot more tax. The HMRC will refund you eventually, but it does mean you'll be short of money for a while and you'll need to chase up your old trust. Keeping all of your payslips on file, so you can track mistakes, is very good practice.

Be bold
You're meant to get one 30-minute break for 5 hours' work, two for 9 hours and three for night shifts (Ref 2). Unfortunately, this doesn’t always happen and you do get some colleagues who regularly try to twist your arm into doing something not strictly necessary that you can’t fit in without skipping your breaks or staying late. This means that saying no and making an independent decision on how urgent a task actually it is a skill you will always be leaning heavily on (I got pushed really hard to prescribe PRN vitamin D on a night shift, which took a surprising amount of effort to turn down). Sometimes, you have a department that throws you out the door at the end of your shift and actively chases you up on your breaks; this is lovely, but it is rare.

Exactly how you do this is up to you, but there are a few general rules of thumb that most doctors I've met seem to go by:
  • If it's time for a break or time to go home and your patient isn't actively deteriorating in front of you, get out of there (if they are really unwell, make sure they're okay, hand over to the on-call doctor and then go)
  • If it's a day job, it can wait until the morning. If it might significantly impact the patient's care before then, hand it over to the on-call doctor.
  • If people are flapping, don't flap with them. Take a breath, consider the facts and make up your own mind about how terrible or urgent a situation is.
  • If you're drowning, resign yourself to leaving a lot of day jobs until the morning.
  • If you're drowning with urgent jobs that might significantly impact a patient's care before then, ask a senior/colleague to help you. I once had a consultant who told me off for not calling her for help when I couldn't fit in an urgent TTO before going home and said that she would have happily written it for me, although I don't know how many other consultants would make the same offer!
Despite how it might feel, not everyone is on the verge of dying the minute you look away and the world isn't meant to be on your shoulders. Don't be fooled! The NHS was running before you got here and it won't blow up just because you take the breaks you're supposed to have.

If for whatever reason you don't get your breaks or you leave late, ignore the guilt and fill in an exception report; it takes seconds.

Keep an eye on yourself
You're going to get tired and when you're tired, it's harder to make sensible decisions and it's harder to be nice. You have 9 days of annual leave per rotation (plus extra days for each bank holiday you work); use them! They don't roll over into the next block. Time them to coincide with zero days and bank holidays to maximise the chunk of time you're not working. Personally, I prefer big chunks on either side of the rotation to frequent long weekends. I've tried both, but three days don't seem to be enough time to recover if I'm burned out. For more information on this subject, read our article on leave.

When you're not working, forget that you're a doctor! Don't even tell anyone! Sometimes, courses and portfolio will get in the way but for the most part, time off is actually time off! In medical school, all time is technically study time and you feel guilty for not studying, but now you are free! Use that salary! Indulge in your unmet childhood needs! Join that dance class! Take that long bath! Find out what scallops taste like! But also be moderate and save up for your house deposit.

General Help
Do read our article on bullying & support. If you ever do get really unhappy, which most junior doctors have at some point already, talk to your clinical/educational supervisor or talk to your other junior doctor colleagues. Usually, they'll have gone through the same thing and will be really helpful. Talk to your family and closest friends; they'll often be the ones who know you best and tell you what you need to hear, even if it’s something along the lines of "take a break"/"take a year out"/"consider a career change".

As a doctor, you can feel obliged to always be the one who solves problems and that might discourage you from seeking help, not that it will stop you wishing someone would bail you out. However, even though a good colleague or a close friend might come up to you and tell you that you look awful, the initial step to seek help is often one you have to take. Looking after ourselves is a skill that we all have to keep practising and developing, because it’s not straightforward and we’re often not great at it. Doctors can suffer very quietly and they do commit suicide (Ref 6), so don't be a hero; let's help ourselves, help each other and remember there is a frequent time and place for being selfish.

References
  1. BMA - Agreed new contract deal for junior doctors in England. Bma.org.uk. https://www.bma.org.uk/collective-voice/influence/key-negotiations/terms-and-conditions/junior-doctor-contract-negotiations/agreed-new-contract-deal-for-junior-doctors-in-england. Published 2020. Accessed February 11, 2020.
  2. Rota Rules At A Glance. NHS Employers; 2019. https://www.nhsemployers.org/-/media/Employers/Documents/Pay-and-reward/Junior-Doctors/Rota-rules-at-a-glance.pdf. Accessed February 11, 2020.
  3. National Insurance rates and categories. GOV.UK. https://www.gov.uk/national-insurance-rates-letters. Accessed February 11, 2020.
  4. Repaying your student loan. GOV.UK. https://www.gov.uk/repaying-your-student-loan/when-you-start-repaying. Published 2020. Accessed February 11, 2020.
  5. Repaying your student loan. GOV.UK. https://www.gov.uk/repaying-your-student-loan/what-you-pay. Published 2020. Accessed February 11, 2020.
  6. Dawnay G. Giles Dawnay: Doctor suicide—how many more? - The BMJ. The BMJ. https://blogs.bmj.com/bmj/2019/06/13/giles-dawnay-doctor-suicide-how-many-more/. Published 2019. Accessed February 11, 2020.
Dr Jinseog Lee (FY2 in ED)