Being a Medical Registrar

My thoughts so far

Emma BaileySPR Geriatric Medicine

Disclaimer

• I’m a new SPR/ST3

• It’s my opinion only

“I would like to do (geriatrics, gastro, resp…) but there’s no way I could/would ever be the medical SPR…”

……………………………….DISCUSS

How I ended up here• Graduated 2008

• FY1• Resp, Geriatrics, Surg

• FY2• Gastro, ITU, Oncology

• CMT1• Geriatrics, Neurology,

Community/Rehab• CMT2• Resp, Cardio, Haem

What I am expecting• Registrar training – 5 years minimum – CCT 2017• Moving around hospitals for 5 years inc on-calls/nights• Specialty Certificate Exam at ST5/6• Eportfolio…groan (but is always improving)…revalidation…

• Maybe….• +/- 1 year OOP - ?acute ?stroke ?abroad (more and more

opportunities for these coming up)• +/- time out for further education (?post grad certificate/masters in

ethics/law/palliative care etc)• +/- time out for family (and then ?less than full time – a lot of

geriatric trainees manage this very successfully)

• All adds time on to CCT!

What I was worried about• Medical• Being the (sole) decision maker• Procedures – especially out of hours• Not knowing enough/looking stupid• Missing something• Being in an emergency situation and not knowing what to do

• Management• Delegating/organising the team• Politics

• Workload/Stress• Being so busy• Nights/weekends/long days

The reality…• Medical• Being the (sole) decision maker

• It comes naturally towards the end of CMT

• You begin to become “an expert” in something

• Being the decision maker actually makes things easier

• You don’t have to trawl the wards doing the “****” – the mundane tasks are now someone else’s priority

• Less annoying bleeps (still a lot!)

• Your opinion counts

The reality…• Medical

• Procedures – especially out of hours• LPs• Paracentesis• Chest drain for pneumothorax (often effusions can wait)

• Lots of opportunity to learn, especially if you do specific jobs

• Central lines - continue to be an issue but doesn’t really affect me that much

• It feels good to be the only one around that can do something sometimes!!

What I was worried about• Medical

• Not knowing enough/looking stupid• You are constantly learning

• You will be surprised how much you DO know just from experience alone by the time you are an SPR

• Try not to panic and be resourceful! (internet, BNF, guidelines..)

• You CAN call the consultant• For help or back-up• They have 10-30 years more experience then you• In the day – almost ALWAYS consultant presence

What I was worried about• Medical

• Missing something• That’s why there is a team• Same presentations over and over again• Instinct is really important – go with your gut• If you miss something once, you don’t do it again!

• You can’t fix everything in one night shift – be patient

• Be thorough, then decide what can wait and what will make a difference/change management

What I was worried about• Medical

• Being in an emergency situation and not knowing what to do• You will have seen most of it • Usually too many people doing too many separate

things• Take control (that’s what everyone wants)

• It is easier, in my opinion, to DO something than to NOT DO something

• Leading arrests – either it works or it doesn’t • The arrest is the last bit in a long chain of events

An Example – when enough is enough

• Setting - Night shift, busy-ish, good SHO and FY1 (&H@N)

• EMRT call to ward• 76 yr old man with sats of 70% “End Stage COPD” “NIV

ceiling” but had been reasonably stable on ward• ABG awful – CO2 11• Then starts fitting (PMH epilepsy too)• By the time I get there team are about to give 5mg IV

Diazepam• STOP! Gave 0.5mg Diazepam IV (worried about

respiratory depression)• Fitting stopped….

• …Then breathing stopped• ****!• Gave Flumazenil asap• Started breathing again

• Then started fitting… twitching etc

• Ahhhh!!! • By this time NIV was on. (I knew this was a losing

battle really)• Call family asap• Gave Phenytoin (desperate!)• Still fitting 1 hour later – horrible to watch• Clearly deteriorating• Dw family – decision to give more

benzodiazepines to stop fitting and to remove NIV

• Patient passes away shortly afterwards

What I don’t like about it• Rigid following of protocols/pathways with no common sense

• Feeling out of my depth • Not being able to do a really good job due to workload

• Discharges/returns (or DVTs!)

• Confronting people/disagreeing with people (sort of!)• Irritated by laziness/rubbish clerkings/inefficiency – taking the flack

• Hard work – not eating/weeing regularly!• (Nights/weekends)

• Sometimes it feels like everything is your problem!

What I really really enjoy• Being the “one who can sort things out”• Being an advocate for a patient• Finding the details that can make a big difference

• Teamwork – getting to know people and having a laugh• Leadership/being looked up to

• Having your opinion count• Looking after the sickest patients – actually “saving lives”• Huge diversity• Less of the rubbish jobs! – can actually be easier

• My quality of life is better as an SPR• I don’t spend my time doing boring jobs, generally• More variety – clinics, intermediate care, teaching, meeting families

Why Geriatrics (for me)

• I like older people• I’m nosey

• Diversity – can never assume anything and people surprise you all the time

• Delicate balance between a complex medical background and unique social set ups

• Being good at medicine and basic principles• Being sensible when looking after a frail older patient

• Being able to admit you haven’t got a clue (but it’ll probably settle)

Why Geriatrics (for me)

• MDT/team – working with funny and generally non-pretentious people – no one is trying to be a hero

• Working for people with a subtle brilliance

• Challenging stigma and being an advocate for your patient, and winning small battles

• End of life care – getting it right

• Difficult communication – end of life and NUTRITION– being able to have the conversations that others hate having

• Delirium – when someone really goes for it!

Why Geriatrics (for me)

• The future is geriatrics and the academic and political world are starting to realise this

• Opportunities in research, teaching, travelling etc are growing year on year

• Opportunities to see a problem and fix it both on a small scale and larger scale are there in abundance

• Flexible training is do-able

• The money is good, locums pay well, job security and can work anywhere

My advice• Don’t be put off just because of being the medical SPR – it REALLY

isn’t that bad and a very LOW percentage of your time at work

• All you need for Geri’s is enthusiasm and to be a good doctor, but you do have to love it to be good at it

• As you progress, it all gets easier

• If in doubt do CMT whilst making your decisions – it will do no harm and will only help you in whatever specialty you end up doing

• Shadow me/carry my bleep for the day with supervision and see what you think

• Email me if any questions• Emma.bailey7@nhs.net

My advice

•Don’t be put off by being the medical SPR•Don’t be put off by being the medical SPR•Don’t be put off by being the medical SPR

Thank you• Any questions?