Being a Medical Registrar My thoughts so far

1. Being a Medical RegistrarMy thoughts so far Emma Bailey SPR Geriatric Medicine

2. 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

3. How I ended up here • Graduated 2008 • FY1 • Resp, Geriatrics, Surg • FY2 • Gastro, ITU, Oncology • CMT1 • Geriatrics, Neurology, Community/Rehab • CMT2 • Resp, Cardio, Haem

4. 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!

5. 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

6. 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

7. 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!!

8. 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

9. 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

10. What I was worried about • Bloods • Gas • Give a neb • Find ECG machine • Call XR • Do ECG • Venflon • (squeeze arm) • Find notes • Hand out gloves • Gently stroke pt’s forehead • (EXAMINE pt) • 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

11. 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

12. 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!

13. 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

14. 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)

15. 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!

16. 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

17. 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

18. 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

19. Thank you • Any questions?