Progressing from a SHO to a registrar in medicine
Progressing from a SHO to a registrar can be quite a daunting experience. However with a bit of pre-planning and getting used to showing good leadership and management skills which we all have from day one anyway.
I have mentioned some points here:
LEADERSHIP SKILLS
As a registrar, we often have to deal with rota issues when there are not enough FY1s, SHOs on the acute take on the wards. We have to help struggling colleagues as well.So what can we do as SHOs?
1. Give your contact number to the FY1 on call with you and ask them to call you/text you if they are stuck anywhere - it does not matter how small the task is.
If they ask for help and you are free, you can assist them. This will become a habit. And soon, you will be able to help even when it is busy by prioritizing tasks. This kindness will trickle down and you will see those FY1s do the same when they are SHOs.
2. Help distribute workload when there is understaffing/ too many doctors.
I am not asking you to get involved in making rotas - that is a terrible idea and the management should have rota coordinators who are paid to do this job. However if you see that there are 5 doctors, 15 patients on the ward and you know half of the patients, you might as well ask around if any other wards need any assistance. Or if all is well, ask some of your colleagues to take half the day off for admin.
3. Develop a way of effective communication.
I find WhatsApp groups are the best way to communicate with other colleagues. We had social WhatsApp groups ( pre-COVID) and now we have general WhatsApp groups where people ask for help. Make it a habit of responding if you know the answer and helping out wherever possible.
4. Lead MDT meetings
Ward MDT meetings are an excellent way to start. You learn what relevant information needs to be discussed and what is important to any MDT member as explained below:
What I did as a SHO
NON TRAINING POST
I used to lead morning MDTs on the care of elderly ward which was attended by the consultant, SHOs, FY1s, nurse in charge and therapy team. It took 10 to 15 minutes and I then used to delegate patients to the team for equal work load.
We had a white board on which the following details were mentioned
1. Name, date of admission
2. Last seen by a consultant ( to decide if they need to be seen by the consultant if it has been more than 48 hours)
3. Diagnosis
4. Active medical issues
5. Therapy needs which we can start addressing even if the patient is not medically fit.
6. If the patient is medically fit, what is the delay and how can we escalate it
TRAINING POST - CMT 1
I worked in a small district general hospital with very supportive consultants
1. They allowed me to do lead consultations on ward rounds under supervision ( and then agreed to do assessments). We do this all the time as SHOs however I received some excellent constructive feedback and was able to improve my skills.
2. I led MDTs
3. I presented cases when on call in the handover - I learnt how to be brief and to the point
https://omarsguidelines.blogspot.com/2019/12/handing-over-patients-in-different.html
TRAINING POST - CMT 2
This was also in a district hospital but this was slightly bigger. I was going to be a registrar from the next year hence I decided to become more proactive
1. When on call, I used to give my mobile number to the FY1s and other SHO colleagues to let me know if there is any issue to avoid calling the registrar for things like difficult cannulas and procedures. This way, the registrars were able to focus on unwell patients in ED resus, AMU and on the specialty wards.
2. When the registrars started noticing this, they started trusting me with dealing with more unwell patients. In the handover, I would often inform my FY1 and SHO colleagues to bleep me if there was an unwell patient. I would then manage them and call the registrar if concerned. This reduced the work load of the registrars even more. I would always let them know about what I had done for documentation purposes and so that they knew about the case in case their input was needed at any point
3. I requested the registrars to let me lead CRASH calls to gain confidence and gain effective communication skills.
4. I did regular locums. This not only let me save a substantial amount ( the locum rate was 50 GBP an hour) but I learnt how to clerk efficiently. I could see up to 20 patients in one shift in a safe manner ( remember - quality over quantity, do not make this a competition). This skill helped me a lot - as I could prioritize patients who were unwell, had been here the longest and potential discharges.
MANAGING UNWELL PATIENTS
We all do it all the time.
Unwell patients will be managed in the following way
1. ITU
2. NIV/CPAP as ceiling of care
3. Ward based care only
4. Palliation
After working for 3 years as FY1/SHO, you will all get to know which route an unwell patient is probably going down. We always bleep the registrar as per local and national policy however we can learn what the registrar would like to know. Things like functional status, patient preference, co morbidities help registrars/consultants decide about the escalation pathway.
I have explained it more here:
https://omarsguidelines.blogspot.com/2020/02/teaching-session-ceiling-of-care-in-nhs.html
What I did as a trainee SHO:
1. When on call, we used to divide wards. I ended up working on the acute elderly unit where we had unwell frail patients come from ED and direct admissions. I used to actively clerk and manage them. I would ensure all patients had an escalation plan and if they did not and a DNACPR was warranted, I would discuss it with the patient, next of kin and put one in the patients notes (In that trust, we had DNACPR forms which could be countersigned by SHOs). I did this on a regular basis.
2. Actively made resuscitation decisions and asked consultants this question when I was worried about someone whom we did not have a clear plan for during our regular ward rounds.
3. Attended simulation courses - we had a deanery based ASCME course which helped a lot in developing my communication and management skills.
BEING A SAFE DOCTOR
https://omarsguidelines.blogspot.com/2020/05/working-in-ambulatory-care.html
1. Ambulatory care shifts. SHOs had to discuss each and every case with the ambulatory care consultant and this way, I learnt a lot.
STEPPING UP AS A REGISTRAR
1. Let you assess medical patients in ED resus
2. Let you assess unwell patients on the medical units
3. Lead CRASH calls
4. Let you assess medical issues in patients admitted under other specialties like fast AF in a patient with #NOF under orthopedics', etc
PROBLEM SOLVING
'Do we have a problem'
'Yes?'- 'How can we Fix it?'
'Let's work on fixing it- I have proposed a solution'
I used this everywhere.
Here are some problem solving examples during my career - some of which I was involved in.
Non training post:
Non trainee SHOs felt that they were missing out on teaching and training whereas core medical trainees were getting that. They were seeing the same cohort of patients. So a colleague spoke to the college tutor and proposed that all non trainees are treated equally as trainees. The college tutor agreed - the point that struck the cord was the fact that the SHO pointed out that at the end of the day all of us were seeing unwell patients, were on exactly the same rota and hence we all need to be equally trained. The college tutor ensured non trainees had access to an e portfolio, regular supervisor meetings, bleep free teaching sessions, access to simulation sessions, etc.
Training post:
The registrars rota was too overwhelming
We all discussed this on our WhatsApp group and came up with a solution
Then 2 of us met with management and discussed it and they agreed
MANAGEMENT
Here are a few tips I learnt over the past few years:
For example - there are 10 patients to clerk in AMU and one FY1. There are no patients to clerk in elderly unit (EAU) and there are 2 doctors.
Solution:
Send the 2 doctors to AMU and request one of them to cross cover EAU.
Ensure the nurses make a jobs list on EAU and bleep the doctor once there are a few jobs rather than every hour
You as the registrar can go there every 2 hours and do the jobs as well. You can also help with clerking on AMU if you are free.
2. Listen to the managers and matrons. They have been doing this for ages. They are all reasonable. They would not come to us unless there is crisis ( ie- bed shortage)
KINDNESS AND EMPATHY
This does not come overnight. This is something which we develop slowly. It might start like something as small as letting a tired FY1 sleep for an hour while you carry his/her bleep when you are not too busy, or lending an ear to a crying nurse who is struggling on the ward and making her life easier by helping her if you are free.
And you can always weasel out of situations - I saw some registrar and SHO colleagues do this all the time. I knew they were not busy but they made excuses. They are still the same. Some have even been fed-back by their supervisors as rude behaviors slowly become part of our personality and no one likes a rude person in the NHS. They turn out to be bullies and they are dealt with appropriately as mentioned here:
https://omarsguidelines.blogspot.com/2020/01/bullying-and-stress-in-nhs.html
NO ONE IS GOING TO HOLD YOUR HAND
2. Ask you to lead MDTs
3. Ask you to lead CRASH calls.
4. Make escalation plans
5. Lead consultations on ward rounds
You need to make that effort yourself.
A FEW TIPS FOR NEW REGISTRARS
ACUTE TAKE
1. Clerk patients when you are free. You have done this for almost 3 years now and it will help the workload of FY1s and SHOs
2. Stay in ED when free - you will get the most bleeps from there. I based myself there when I was a ST3 registrar and clerked patients on the clerking proforma
3. When seeing a patient in ED, please fill out a full clerking proforma. It was my pet hate when a registrar had done 2 pages documentation on an ED continuation sheet when (s)he could have filled the clerking proforma.
WARD COVER
1. This can be very busy so make sure your colleagues are not overwhelmed.
2. Help with jobs like cannulas and even discharge summaries when you are free.
3. I usually base myself on the busiest ward when on ward cover ( gastro/CCU) and do all the jobs which the nurses wish to give to the FY1/SHO on ward cover - this way I retain my skills like cannulation, etc and my team is not overworked.
REGULAR DAYS
1. On your regular days, divide patients with your team and see the most unwell patients first
2. No job should be too small for you - if you have seen a patient who is medically fit, do the discharge summary! You know the patient, it will literally take a few minutes rather than waiting for a FY1/SHO to be free from their ward round to do and hence delaying the discharge.
Teach your colleagues whenever you get the chance. Go through interesting cases you have seen and share your knowledge with them.
Do not forget to ask them to fill out an assessment form:
https://www.jrcptb.org.uk/documents/evaluation-form-teaching-and-presentations
Remember, you will still have annual ACRPs and will still have to keep your portfolio up to date. You will get plenty of time at work do that - ie, when the wards are not busy, you are free on your on calls.
Try to work on your portfolio when you are work though to avoid tiring yourself at home.
Remember, you are not alone. You have the consultant on call, critical care outreach team and ITU team to help.
Ask for help early. If ED is getting busy and there are patients piling up there with no beds available on AMU, request your FY1/SHO colleagues to come clerk in ED.
This can become overwhelming at times. Remember when it is becoming too much and ask for help early. You do not have to take the burden on yourself.
TRUST YOUR GUT FEELING
A patient has come in with a fall, the abdomen is bruised, they are now on a medical ward. Get the surgeons involved and get a CT abdomen done ASAP.
TRUST YOURSELF
You have done this for at least 3 years now. You have all the knowledge and skills. All you need is the confidence.
If the answer is no, then put a DNACPR/RESPECT form in after discussion with the patient/next of kin. Do not delay this till the patient actually actually arrests. Do this when clerking patients/doing senior reviews. Make a clear escalation plan:
1. For full escalation
3. Ward based care only
4. Palliate, stop all active treatment
They are clever people. They know what they are talking about. If they do not think a patient is suitable for ITU after they have discussed this with their consultant, put a DNACPR/RESPECT form in after discussion with the patient/next of kin. Do not wait till the patient arrests.
Your documentation should be thorough. I find the SBAR technique the best along with an A to E assessment when I am seeing an unwell patient.
Reflect upon cases you have seen, teaching sessions you have attended, etc.
The criteria is mentioned very clearly here:
https://www.jrcptb.org.uk/training-certification/arcp-decision-aids
My first line to everyone is ' my doors are open. Bring 'em all in' when I am the medical registrar on call. However I do not accept surgical patients but if they have frailty needs and are for palliation, I accept them.
The more obstructive you are, the more difficult your life will be. ED has a breach time of 4 hours. They want the patients out - hence guarding AMU as if it is Fort Knox may not be in your favor and you do not need ED to do every investigation on earth and then wait for the results before you will allow the patient to be transferred.
This is where physically being present in ED helps - I have managed to get urgent CT scans just by suggesting this to the ED team.
Where do a patients with cholangitis. cholecystitis go? The surgical reg refused to take the patient as they do not warrant urgent surgery. So what do you do?
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