Working efficiently and safely as a medical registrar

The job of a medical registrar is the most feared job in the NHS. When I was a CMT year 1 trainee, I was frightened to work as a registrar- mainly because of the anxiety my registrars had. 

As a CMT 2, I started seeing more unwell patients and gained more confidence and started clerking the sickest patients. My fears were alleviated and I actually enjoyed as a ST3 trainee in acute internal medicine. I am now a ST4 trainee and still enjoy my on calls and my regular day job on the COVID wards/AMU/Ambulatory care unit. 

Here are some tips:

BE NICE 

It does not matter whether you are talking to nurses, fellow colleagues, SHOs, FY1s or ward clerks. Be nice! Be the registrar you wanted to have when you were a SHO. If you are having a bad day, take a break ( have a chocolate/biscuit - there are always some in the staff room)

TAKE CARE OF YOURSELF 

You are just a cell on an excel sheet. If you become unwell and are unable to continue working, you will be replaced. So take care of yourself. Enjoy when you leave hospital and leave all your worries at work. Go out, enjoy the lovely outdoors. 
http://omarsguidelines.blogspot.com/2017/11/the-pursuit-of-happiness-in-uk-for-img.html

ENJOY YOUR SHIFTS 

This is your life - you spend at least 8 hours on a daily basis in hospital. Remember that medical registrar on call shifts are for 5 years only and then you will be a consultant in your dream specialty.  

WORK WITH COLLEAGUES AND NOT AGAINST THEM 

If the matron wants you to assess patients in ED to decide whether they can be outlied to a medical ward, then see them! The matrons are not against you. They are trying to help patient flow and we need to work with them to avoid patients building up in ED. 

WORK IN ED,WITH ED

As a medical registrar on call, I always base myself in ED. It helps a lot! I get to take a handover directly from the ED health care professionals and am able to advise on management they may have missed - like requesting ketones, CT head, adding on a D dimer ( any test which will acutely change management - we should NOT expect to do a full vasculitic screen/non invasive liver screen which can also be done on the wards). 

This makes their life easier and you get to learn a lot of acute management which improves your training. The ED team also learns this and they will do it next time when they have a similar patient. 

The ED teams job is to do an A to E assessment, treat, discharge or refer to relevant specialties within 4 hours. Being present and giving them advice helps a lot. 

BEING A REGISTRAR DOES NOT MEAN YOUR LIFE IS EASY 

This is very important which people sometimes do not understand. You are still supposed to clerk patients, do discharge summaries, bloods and cannulas when your colleagues are busy. 

Your sole responsibility is not to sit in an office during your shift waiting to be bleeped for an unwell patient but being available in ED, AMU and any other wards they might need you. 

ASSESSMENTS 

Loads of FY1 and SHO colleagues will discuss cases with you. Appreciate their efforts. Thank them for their hard work and the best reward a trainee could ask for is feedback. So offer to fill out CBDs, mini-CEX, DOPS or any other assessments they can send to you which are relevant and give positive feedback. 

ENSURE YOUR TEAM IS WELL RESTED 

Ask how your FY1 and SHO colleagues are doing. Ask how your other registrar colleagues are. Offer to help. For example, if you are on ward cover and the wards are fine but the clerking shift is busy, offer your services and help the team. 

COMPLAINTS 

We work very hard. We see loads of unwell patients. We treat and cure loads. Out of the thousands of patients we see, sometimes 1 will not have a good outcome. We forget that we were not the only healthcare professional in the picture and sometimes a complaint does come through. This is normal, this is a high risk field and not everything goes to plan. So , always document like you will have to present your documentation in court. When things do go wrong, talk to your consultant and usually, they are very supportive. 

COMMUNICATION 

We see unwell patients, then leave. We sometimes forget to inform our other colleagues about our plans. Unfortunately, our the quality of our handwriting is inversely proportional to our number of years we have trained as a doctor- ie our handwriting gets worse with career progression ( I guess it has something to do with us thinking faster than we are able to write) and not everyone can understand our lovely handwriting. Therefore, always inform the nurses/you SHOs/FY1s about your plans and what you would like them to do. Speak! Do not only write.  
http://omarsguidelines.blogspot.com/2018/01/nurses-in-nhs.html

MANAGING UNWELL PATIENTS 

Always do an A to E assessment, CXR, bloods, ABG - you will be able to identify the cause within a few seconds of doing your A to E assessment.

An unwell patient is either for:
1. Full escalation - in which case get ITU involved if warranted. 

2. NIV/CPAP ceiling of care - do an ABG and decide, if they are known COPD, in T2RF with low pH despite nebulizers and IV steroids, antibiotics for an hour, then start them on NIV. Get support from critical care outreach and respiratory nurses. 

3. Ward based care only - in which do the basics, treat them for a HAP/CCF/PE/sepsis of unknown origin etc or whatever the cause is 

4. Palliation - This is the most important thing. Recognize when to stop. Involve the nurses who have been caring for the patient and have noticed a significant deterioration in let's say, a 90 year old frail lady on day 5 of IV antibiotics over the past 6 hours and feel she is approaching the end of her life. Get the family involved, move the patient to a side room to allow visiting, get chaplaincy ( if appropriate) and palliative care team involved. The family really appreciate this when they are holding the hands of their loved ones while they pass away gracefully and peacefully. 

DNACPR/RESPECT FORMS 

If you think that CPR/intubation will be futile and as a team leader, will not continue CPR if the patient crashes, then make a decision early. Before they deteriorate. Before they are unable to share their opinion, before they undergo a process which will prolong their agony/distress.

Discuss it with the patient/NOK and put it in the notes. 
https://omarsguidelines.blogspot.com/2020/02/teaching-session-ceiling-of-care-in-nhs.html

TAKE ADVICE 

We, as medical registrars give so much advice to other colleagues and sometimes forget that we can get advice. ITU SpR, medical consultants on call, specialist consultants on call, nurses in charge, matrons, out reach nurses are all there to help us in case we are with an unwell patient and are unsure of what to do. It helps not only with your decision making but also for documentation purposes.

LISTEN TO COLLEAGUES 

Listen to the nurse who says that a patient does not look right and review the patient thoroughly. If ITU do not think a patient is suitable for intubation/CPR, put a DNACPR/RESPECT form. If your SHO is concerned about a patient, come and see the patient ( I usually take a handover in a SBAR manner- https://omarsguidelines.blogspot.com/2019/12/handing-over-patients-in-different.html and ask the person telling me about the unwell patient to do the basics and I come immediately) 

LOCUM WHEN POSSIBLE 

Locum whenever you can. I usually locum when I can get at least 2 days off a week - combined with annual leaves/bank holidays. Put that extra money in a sub-account for a deposit towards your house/fancy car/a nice trip. 

Locuming not only helps you financially but also helps you gain confidence. 

NEVER BE TOO OVERCONFIDENT 

Mistakes happen when we become overconfidence, when we do not trust our ' gut feeling' that something is not right. So be a safe doctor. Follow the local guidelines. Do not be rash. Remember, it is someone's life in your hands. Treat them like you would treat your family members. 

DO NOT CHASE NUMBERS/CLERKING BOARDS 

Patients will continue to come constantly. Try to clerk as many but you do not need to clerk everyone without taking a break. Give yourself frequent breaks. See as many as you can - as a registrar I can see up to 15 patients in 12 hour shift but if it is busy on the wards/in ED , I see far less. However I do not worry about handing over a lot of patients to the next team as I know I have tried my best and it is important to ensure the patients have been managed thoroughly. 

MENTAL WELL BEING 

Sometimes, a rotation can be too intense, a consultant can be mean or your shift can go really bad. Take a break if you feel overwhelmed. It happens to the  best of us and sometimes, it is okay not to be okay. Talk to people about this. It helps. 

FOCUS ON YOUR TRAINING NEEDS 

With the regular on calls, we forget that we have our own things to sign off. So keep on top of your portfolio, follow the decision aid here:
https://www.jrcptb.org.uk/training-certification/arcp-decision-aids

Remember, you need to get both GIM and your specialist training signed off so ensure you have everything for both before the ARCP. 

MANAGERS

Work closely with management. If you identify a problem, think of a potential solution and talk to people. You will  be surprised at how grateful management feels when doctors on the frontline give suggestions. This can be a face to face discussion or a quick email to the relevant people. You will also build some excellent leadership and management skills. 

QUALITY IMPROVEMENT 

There are so many things we can improve on - so make a quality improvement project out of it. Involve SHOs who need this for their CVs/portfolios and go ahead with it. 

HELP IMGs

Remember the first few days? When a random registrar told you that it will all be okay when you were stressed? Or when you really wanted to hear it? Be that pillar of support for new IMGs. Talk to them, help them, be their friend, be the support you needed when you started in the NHS. 

As a SHO, I observed by registrar colleagues and tried to gather as many good points I could and then tried to implement them as a registrar myself. I am far from perfect but try my best. I do feel like all of us can improve ourselves by being kind, friendly, taking care of each other and ourselves because at the end of the day, happy doctors equates to better patient care.

I personally try to think of myself as a glorified FY1/clerking monkey/cannulation robot/ discharge summary typer at the rate of 10 summaries/ 30 minutes ( well, I try to meet this target- always fail). 

I love my job as a medical registrar, and I try to help everyone around me. Despite this, I come on time and leave on time and ensure that everyone else with me goes home on time as well. My whole team is relaxed, happy and well looked after. They appreciate the effort and I see them adopting the same habits I adopted from observing others- so be part of this chain reaction.