This week our specialty guest interview features Facebook’s The Medical Registrar. The traditional ‘workhorse’ of the hospital, we discussed the increasing pressures on medical registrars, the state of training and top tips for the budding med reg.
Could you tell when and why you decided to become a Medical Registrar?
Actually, I toyed with a different specialty before choosing to be a medical registrar. What finally swayed me was a desire to use all of the skills and knowledge I’d picked up over the years, and a desire to stay as general as possible for as long as possible. I wanted a job that would retain the ability to surprise me on a daily basis, and the best way I could envisage this was by becoming a medical registrar.
What aspects of being a Medical Registrar have you enjoyed the most? What has been hard?
When you’re a medical registrar and things are going well, you’re basically being that doctor you thought you were going to be when your 17 year old self decided to go to Medical School. You are a fount of useful knowledge, caring to your patients and colleagues, supporting your juniors, performing complex procedures with one hand, whilst building comprehensive differentials for unusual presentations on the other. Whilst this holy grail is rarely achieved, in those moments when the shit is hitting the fan, all eyes turn to you, and you are able to deliver exactly what is needed, there is a powerful sense of achievement. I have floated home from some night shifts when I know I did it ‘right’.
Equally, there are times when you are expected to do 3 or 4 impossible things simultaneously. The hardest thing is to deal with your internal critic. Actually, if we open our ears to the people around us, very few people have bad things to say about Medical Registrars. The harshest things are said internally, when struggling to cope with things that really are overwhelming. We may be unwilling to accept our own limitations and this can be very destructive. And when someone comes along in the morning with tales of their Herculean competence in times-gone-by, that internal critic can get a real boost. It can be a lonely job at times like this.
What’s the best thing about being a Medical Registrar?
The best thing about being a medical registrar is the instant upgrading in the respect you get from colleagues. It’s far from universal but the sense that the person on the other end of the phone is actually listening to you and considering your opinion is very empowering after time spent at the Foundation and Core medical levels. It leads to the realization that you are now being paid as much for your expertise as your effort.
What’s the worst thing about being a Medical Registrar?
When I lose my temper with someone. If I’m having a very busy shift and things are piling up, it’s entirely possible that I may lose my temper with the next person who calls me up with problems that may seem like a waste of my time. Having a bad shift, with colleagues who are pissed off with you because you are unfairly pissed off with them can leave a bad taste in the mouth for weeks.
Could you share with us your most challenging moment as a Med Reg?
I had a very sick patient to deal with unexpectedly after a vital investigation result had been missed by a referring doctor, despite my documented request that it be reviewed before the patient was moved. Simultaneously I had another patient become unwell with an ST-elevation myocardial infarction despite a platelet count of 5. I was exhausted at the tail end of an extremely busy take and had to manage two simultaneous critical emergencies in different locations. I performed a necessary and life-saving procedure on the first patient but initially I believed I had performed it incorrectly and that, as a consequence, the patient would die. The weight of responsibility has never felt heavier and I really did panic.
However, help was at hand almost immediately and the situation was resolved. Nursing staff brought me tea and toast and my colleagues in various departments made sure that both patients were stabilized and that my terror at having harmed my patient was removed immediately by radiological confirmation that I had in fact done exactly the right thing.
Even before this confirmation, I had been on the receiving end of so much support and comfort from my colleagues in all professions that it was a powerful eye-opener to what help is at hand when it is needed and indeed asked for.
How do you deal with an ever-growing medical take list? What advice would you have for managing all the medical referrals?
You have to be able to prioritise, but also to recognize the priorities of others. The ‘social admission’ at 3h 59ms is really not going to jump up your list of things to do, but for the A+E department it is vital that they deal with this. Not recognizing the priorities of others means that you are unlikely to receive help in return when your own priorities are threatened.
Prioritisation also works at the individual patient level. What is it that the patient really needs right now to keep them moving forwards in terms of their care. Get that done and sort the rest out later. A lot of the important things can be dealt with at the time of referral by an open conversation with the referring doctor. If you know that the septic patient has already had all the correct tests done, the antibiotics administered and fluids written up for the next 4 hours, you can manage your list a little more easily.
My personal advice is to try and avoid clerking the complex and comorbid patients with acute-on-chronic presentations. These clerkings require a focus and attention to detail which your bleep addled brain may struggle to bear on the case. I choose the boring but simpler admissions such as paracetamol OD and pyelonephritis in an otherwise well female for myself.
Also, trust your referring doctors. Don’t reclerk just for the sake of it. Confirm any vital elements and ask the extra questions you wish. It is eminently possible to perform a thorough clerking including relevant history, examination and ordering of treatments and further investigations in 15 to 20 minutes. Being thorough to the point of obsessiveness might be good for the patient you’re seeing, but not so good for the 10 patients waiting.
What do you think are the most critical personality traits that a doctor should possess for a career in medicine?
Curiosity is vital. You must always be able to ask why. A degree of reflection is also vital. It is rare to receive helpful, critical feedback on your performance as a registrar, and also you are often the only registrar performing in your role at any one time, so there is limited ability to learn by comparison to others. You must therefore strive to learn from yourself.
The RCP recently published a report on the welfare of junior doctors which made for harsh reading; what needs to be done to make medical training fit for purpose?
There are the very beginnings of a move away from the idea that healthcare should be explicitly patient-centered and should in fact be person-centered. Recognising that we expect our staff to deliver care and compassion to patients whilst receiving little of this themselves from their workplace is an important first step. Simple things like ensuring that there are adequate and comfortable facilities to rest. Meaningful prioritization of training opportunities. Finding some way to make Human Resources departments administer contracts in a timely fashion and to accept that births, deaths and marriages are just as significant to doctors as they are to other human beings.
The training itself is difficult. The apprenticeship model is fractured, the clinical environment extremely pressured and the capacity for senior physicians to incorporate teaching into their daily practice increasingly limited. We have to find new ways to teach and learn in these environments which constructively use new technologies and unashamedly put the training of the next generation of doctors at the top of the priority list. In my experience, patients do not mind being part of the education of medical professions, in fact many of them relish it. We have to be braver in involving patients and colleagues in dynamic learning in the workplace.
A concern of many trainees applying for medical training is the work-life balance; how do you cope with incessant nights and weekends?
Be good to yourself. A sustainable work-life balance is achievable but requires some effort. Recognise that you will need proper downtime and don’t be hard on yourself for having days when you do nothing. Whilst the nights and weekends mean you miss many regular social events, being free at other times can open up possibilities that would have been otherwise unavailable. Try to do one thing a month that is just for you. Also recognize that whilst these shifts are hard on you, they are also difficult for those around you.
With medicine and training becoming increasingly specialised – is the General Physician dead?
The general physician will never be dead. There will always be a need for this role and as such, this role will always exist in some form or other. It may go under different names and guises but a hospital without some form of continuous general physician presence is not a safe space for patients. Specialists are invaluable but the patient isn’t just a single-organ system, or a single pathology. The ability to see the bigger picture and factor in multiple competing issues in the increasingly complex and co-morbid population we serve will do much to revive the role of the General Physician.
Finally, what’s your number one piece of advice to junior doctors who are considering applying for medical training?
Be nice to as many people as you can be, as often as you can be. You may not know it yet, but you will already have a reputation. This reputation will go with you and may influence the ways in which you interact with others in the future. If you can be as nice as possible, as often as possible, when you inevitably have a bad day and lose your cool, people will generally come to your assistance rather than assume you’re just being difficult.
Also, a mental trick I play on myself is to budget for 2 good days and 2 bad days per month. Whilst the majority of shifts, including on-calls are relatively similar in terms of stress and workload, the odd one comes along that is either really relaxed or really stressful. If you ‘budget’ for these in advance then it feels less unfair and random when they come along, because they will always come along.