My life as a ST6 in Paediatrics
This instalment of “My Life As…” brings us a senior registrar in Paediatrics!
What training are you in?
Paediatric training. I’m currently working at ST6 level.
Where are you working?
Kent, Surrey, & Sussex Deanery, but I’m working in Surrey Hospitals. I’m currently on a year out in London, which is available for KSS trainees at ST6.
When did you decide on your specialty?
I went to medical school in order to do paediatrics, as I’ve always loved working with children. I found medicine on the whole fascinating, but I found it very hard to be excited about adult medicine and I don’t cope well working in a field that does not excite me.
I also believe that medicine as a career is a very tough field so it is very important to do something you love. And If you don’t love it, don’t do it!
I considered surgery for a brief period of time, but soon realised that in order to be a paediatric surgeon I would have to spent considerable amount of time doing adult surgery first and it lost its appeal. The reason for considering surgery was that I always was quite dexterous and enjoyed doing fiddly things with my hands and I thought it would be a good use of my skills.
I’ve wanted to be a neonatologist (paediatric subsepciality in preterm and sick term babies) since my final year in medical school, after I was inspired during a NICU placement. It has a perfect balance of physiology, ethical dilemmas and the all important practical skills that keep you challenged.
What brought you to your decision?
I loved working with kids and particularly wanted to look after babies. I lost a baby brother on NICU in the nineties. I was much younger, and I have seen my parents go through a lot of pain. If I can minimise the experience of losing a child for one family though kindness and holistic care then I feel like I’ve achieved something. Hence, I’m developing a special interest in neonatal palliative care.
How have you found the exams so far? How did you revise for them?
Exams are hard and there is no right or wrong way to revise for them. I have to say I’m really glad exam days are over for me now!
There are 4 exams in paediatrics – 3 are written/computer based and then there is the clinical exam. I think the key is in respecting the exams and taking meticulous preparation. I found it very useful to have a reference textbook to help me revise and I would make notes on each system and associated pathologies.
I would make mind maps and once I had it clear in my head I would subscribe to various question banks and go through them multiple times before sitting the exam. The hardest exam I found was the old Part 1b (now known as Theory of Science) as it is very theoretical. I struggled to pass this (3rd attempt!). I also struggled to see why I needed to know all of this stuff when I could easily just look it up when I needed to know. Now I appreciate it a bit more but found it frustrating at the time.
The clinical exam is fair and is not designed to fail the candidates but to ensure that they would be a safe year 1 registrar by their first day. The key is in preparation for that, too. By the time you take their clinical exam the knowledge is all there. The trick is to nail the examination and presentation skills.
Never make up signs, and get as much practice and feedback as possible. There are multiple courses available, which are rather expensive. The jury’s out on them but most people do find them useful, especially for seeing children with uncommon conditions and being put in a stressful situation with a fake examiner. Some courses run a mock exam at the end which is probably most useful.
Another tip I would suggest is that if the hospital you work at runs the exam fairly regularly it is worth asking if you could come as an observer – it’s a lot easier to relax and get into it once you know the format.
How is your day job split up – when you’re not on-call?
It’s very rare to not be on-call when you’re a paediatric registrar as there are so few of us! On the whole, there are various shifts you do and each hospital manages them slightly differently.
To give you a rough idea: on a normal 8 hour day you would probably be a helpful pair of hands to relieve the long day registrar a little bit. This means that you might be helping out in paediatric A&E and seeing referrals from A&E docs in department without having to send the children up to the admission unit. It’s like reviewing medical or surgical adult patients, but as paediatric registrar you suddenly need to become an expert on all sorts of things.
If AE is well-staffed, you’ll probably join the ward round. This might be either split, so between the registrars and consultants you will see patients separately (with help of friendly SHOs if there are enough) and then meet up at the end to discuss, or you will all go round together. This often depends on how many children are on the ward, how many were admitted overnight and how many have been there for a few days and how complex they are.
RCPCH guidelines require a child to be seen by a consultant within 18 hours of admission so there’s a lot of senior support on the shop floor. If you are helping out then you will probably carry the referral bleep which, once it starts, rarely stops beeping. These are calls from AE and GPs for reviews.
Once the children start coming in, you’ll be supporting the SHO in the assessment unit and reviewing patients, doing procedures and generally being quite busy. Sometimes you might be on a clinic day (if there is enough of you and registrar clinics slots available) in which case you will have a little break from the ward and assessment unit and see children in the clinic, either new or follow ups.
Clinics are usually themed but not always, and there are quite a few general clinics where anything could turn up. Normally you have a brief referral letter from GP. One important thing is to take a very thorough history and examination and if you’re unsure, to discuss it with the consultant before the family leaves the department. If you’re on call then you might have a second registrar with you, in which case you can concentrate on war patients and take over assessment unit and referral bleep later in the day.
If not, then you often run around trying to keep everything together. Consultants in paediatrics are very supportive on the whole and don’t leave you stranded with too many kids to review and unmanageable list of jobs. Sometimes, you do need to ask for help.
What aspects of being a Paeds Registrar have you enjoyed the most? What has been hard?
I love my job. It is very demanding and stressful at times, but on the whole there is always a child or family that will make me smile through something they say or do. I really like being busy as you learn fast and get better quickly. There are plenty of challenges in paediatrics and that keeps me going and my brain ticking. I love teaching and sharing my passion for paediatrics. I think it is quite infectious.
I make it my mission to put SHOs at ease, whether they are paediatric trainees or not. I think if someone is coming into paediatrics for a rotation and expecting to struggle and not enjoy it and at the end they tell me that they actually have learnt a lot and had a great time, I’m very pleased with the job we did.
On the bad side – bereavement on the paediatric ward and neonatal unit is always heartbreaking. You feel helpless that you couldn’t save the child despite your best efforts and you grieve for that loss – in a different way to the family, but nonetheless it is still grief.
However, what I find hardest is child protection and safeguarding. It is an essential part of the job and I do it the best I possibly can but every time it breaks my heart and is beyond comprehension in my brain that people out there would hurt children.
What’s the best thing about being a Paeds Registrar?
I think being a paediatric registrar is pretty cool. It’s very satisfying when you can manage a very sick child and make them better. You have a good amount of independence but at the same time know that your consultant is just a phone call away or watching intently from the end of the room, letting you manage a difficult situation. Kids are a lot of fun and it’s wonderful seeing them bounce back and smile and talk about their favourite superhero!
What’s the worst thing about being a Paeds Registrar?
It is a very busy job and often understaffed. Rotas can be unforgiving but your bosses are always on hand to give you support. The hardest thing is feeling like you are constantly playing catch up, or doing 7 different things at once. Though you do become a master of multitasking.
The hardest thing I found is judging the level of support my junior colleagues need – everyone is so different and has varying exposure to children in their training. You want to get the perfect balance of support without being overbearing and making sure everyone gets the best experience in their rotation and teaching to enable them to look after children effectively in future.
Could you share with us your most challenging moment as a Paeds Reg?
My most challenging moment was on a night shift once at the beginning of my registrar training.
I was about 3 weeks into my first reg job and it was my first night. I spent 9 hours in resuscitation room with a sick young child with upper GI bleed who then deteriorated and became septic from aspiration pneumonia. The medical management was not the tricky bit, but the communication with parents was, as they were very much into alternative therapies and against treatment with various drugs I had on offer.
I had to dig deep to my medical school communication skills lectures to stay calm and bring the parents over to my point of view and the treatment I wanted to give their child. Eventually, I managed, and narrowly avoided having to send the child to PICU. It highlighted for me importance of staying calm and making sure I have all my facts. Of course, I had my consultant come in a help, especially as I had a ward full of children that also needed supervision.
What are your top tips for dealing with ill children as a doctor?
I think the hardest thing to cope with as a children’s doctor is making them upset. Having said that, things that are painful or unpleasant that we do to children (cannulation or blood taking to name a couple) are all well thought through and necessary. We would definitely not do them if we did not have to.
The most important thing is to realise that regardless of how nice and gentle we are, children are going to cry when we stick a needle in their hand (and no amount of numbing cream is going to stop them from crying). Once you get over the cry, you realise that it is a lot better to be firm and get it done quickly than be very gentle and take a long time. And always, ALWAYS get help. It takes at least 3 people to take blood from a child so never ever do it on your own, regardless on how brave they say they are.
Children and their parents are terrified and stressed when they come to hospital so recognising that is very important. This can manifest as a wide array of emotions but everything can be addressed through good communication. I find it very important to talk to the child and hear their voice as well as the parents’. I always explain that to them so that no one feels ignored. When examining children I always talk to them about their friends or school or favourite book or computer game, or the film they just watched so it is important to keep up to date with the newest Disney PIXAR movies, CBBies programmes and fashionable superheroes.
Many junior doctors consider a career in paediatrics but worry that the role is very demanding emotionally. What’s your advice to junior doctors in coping with this when treating children?
It is an emotionally demanding job.
If something happens at work that upsets you and you find it hard to deal with then the best thing is to talk to someone. As an SHO you will always have a friendly registrar with you and they will more than happily take time to make you a cup of tea and talk. Equally, you will have an educational supervisor to talk to but most of the paediatric consultants are friendly and kind and will be able to listen and offer support if you are struggling.
We all do at some point and sometimes it’s not the most obvious things that upset us. Debriefing is really important after a traumatic incident. Over time, your resilience increases and you don’t even realise. That doesn’t mean that you don’t care, because you still care very much but your brain is subconsciously able to process the emotions and compartmentalise it. But ALWAYS ask for help early. We would much rather know than have you struggle.
What do you think are the most critical personality traits that a doctor should possess for a career in paeds?
I think the main thing about being a paediatrician is being kind and friendly. A smile goes a very long way in paediatrics and it is important to be able to make children at ease. You do have to stay on top your CBBeebies TV programmes and be up to date with latest superhero and Disney films released. Talking to children at their level of understanding is crucial.
The RCP recently published a report on the welfare of junior doctors which made for harsh reading; what needs to be done to make paeds training fit for purpose?
Fundamentally, I think we need more doctors in paediatrics. The support on the shop floor is there, most paediatricians are kind people and look out for their junior colleagues.
The trick is to let people know early when you struggle. Rotas are not going to fill themselves if there isn’t anyone to do them. Overall, I think paediatrics doesn’t do so badly with regards to welfare of their doctors but there is always room for improvement.
A concern of many trainees applying for paeds training is the work-life balance; how do you cope with incessant nights and weekends?
I think you just get used to it to a certain extent. It is recognised that paediatrics is a demanding speciality. There is a move to allow trainees to work part-time more and more these days. In fact, there are more registrars working part-time than full-time, and that’s not just for child care reasons. I make sure I plan something nice but not energy-consuming after my nights to have something to look forward to and get me through the hard shifts, even if it is a bath and reading my favourite book all over again. You also develop a network of paediatric friends that you can offload and share frustrations with.
What’s your number one piece of advice to junior doctors who are considering applying for paediatric training?
Do it! It’s hard at times and very busy, but overall very rewarding and well supported. Seeing a poorly child get better and smile at you makes it all worth it!
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