Registrar Ruminations

Gilly Fleming

I was recently awarded an Outcome 6, and by the time this Blog goes live, I’ll have taken up a consultant post in the unit I’ve wanted to work in since I was a medical student. I’m very fortunate to have had an excellent training experience, which I know has prepared me well for this transition, but to be honest, it’s all a bit surreal and it has rather crept up on me.  It’s the strangest mix of excitement and absolute terror, all in the same breath.

I haven’t felt this way since my first few days as a registrar in ICM. I can so easily recall the strange mix of excitement and terror that I’m feeling now.

So, if you’ll allow me the self-indulgence, I was hoping to pass on a few things I’ve learned as a registrar in ICM training, to the incoming ICM trainees, in an attempt to reduce that first-day feeling of terror. These are all just my personal opinions and reflections – feel free to challenge these reflections and to create your own personal set of registrar ruminations as you progress through training…

Find Your Own Path

Find the things you are interested in and pursue them. Whilst it’s important to have a broad base, and you need to fulfil curriculum requirements, don’t commit yourself to projects / opportunities you have no interest in, just because you feel you should. Work in a unit that’s POCUS heavy, but you’re interested in ICU follow up? That’s ok, consider it a service development opportunity! Find your contacts and develop your niche.

It sounds silly, but I spent quite a bit of my early training dipping in and out of things that didn’t really interest me. It was tiring, and not surprisingly, none of those things came to fruition.

When I started focusing on the things I was interested in, success came more easily, and I was able to build a CV which diversified me and made me more employable in the long term.

Don’t feel the need to fit the mould – the strongest units have a consultant body with a diverse range of specialist interests!

Progress is in the small details

I remember as a foundation doctor being in awe of the intensive care registrar as they turned up to emergency situations. I remember thinking to myself, wow, this is life saving stuff.

But the more ICM I did, the more I realised that often, progress for patients isn’t to be found in emergency situations and moments of pace, but in small details and clear goal setting.

I’d argue that the true life-saving stuff in ICM often isn’t found in a resuscitation setting.

It’s all very well if you can perform a slick RSI on a very sick patient, and put in lines, but you need to formulate a weaning plan to get that patient off a ventilator. Are they suitable for a sedation hold today? Have you addressed the noise issues on the unit that are disrupting their sleep? Patients who are constipated are never clear headed, and if your patients aren’t getting feed to match their nutritional requirements they are almost certainly aren’t getting the nutrition they need to get through a critical illness. Does the line look a bit crusty?  How do you know when it’s the right time to de-escalate the antibiotics?

Pay attention to the small things, do them well, and value the input of each of the members of your specialist multi-disciplinary team who will help you get it right for every patient.

Decisions are rarely clear

Reflecting on my time as a junior registrar, I often viewed patient management decisions as black and white, right, or wrong, and at times I found myself a bit frustrated when I wasn’t able to follow the decision-making process of the Consultant I was working with, when I thought a decision was really clear and they appeared to be taking time to think about it.  On reflection, I was just totally lacking an appreciation of the nuances of complex decision making.

The reality is that whilst a few decisions are plainly straightforward, many are grey, and lie on a spectrum of many, totally acceptable decisions.

In everything we do there is a balance of harm and risk, and there is often not a right or a wrong thing to do, just the most appropriate option, having integrated evidence-based practice, experience, and discussions with colleagues into the picture.

Watch your bosses – you’ll see them ask for advice several times a day, from other Consultant colleagues or other specialist members of the MDT. This doesn’t demonstrate uncertainty, it is role modelling, a very important professional behaviour of collaborative decision making which we know is good for patient safety and driving quality of care.

If you aren’t sure why someone has made a decision – ask. I think it’s useful to approach this in an inquisitive way, with genuine curiosity, to avoid people thinking you’re in some way challenging/criticising decisions. I find the following phrase useful:

“I’m interested to hear more about your thought process behind X. I think it might be useful for my development to hear the different considerations that went into making that decision”

The “default to safety” trick 

Need to make a decision overnight?

Firstly, don’t worry about phoning and asking for advice (see above point). You aren’t expected to cope with every situation.

Acting up in a consultant role this year, I’ve realised I’m considerably more on alert with the trainee that doesn’t phone for help than those that do. It’s well established that Consultant input into care leads to better outcomes, and it’s a given that we need to provide the best quality care to patients. Phone your boss, and don’t be apologetic about it. You’re doing the best for your patients when you call the boss. It’s extraordinary to think that it took me several years to get into this mindset – and in retrospect, in my last year of training I’ve probably called for advice or help more than I have at any point during my training, and I know my patients have benefitted.

But, in making decisions out of hours that I feel competent to make, I often found myself defaulting to the simple mantra “What is the safest thing for this patient?”.

In the middle of the night, when I’m swithering about getting that surgical review, or thinking about requesting that scan, I find it a useful reset and it helps to organise my thoughts and allows me to manage risk.

Be honest with yourself and your colleagues

Dedicate time, in both formal and informal ways, to openly reflecting on your clinical practice. Some things will go well; some things might not go as well as planned, the important thing is to learn and develop from your experiences and interactions. Use all your reflective opportunities – from informal discussions over cups of tea to formal feedback as learning and development opportunities.

Acknowledge mistakes when you make them, give genuine apologies, and be transparent. Remember, it is very rare that a single poor decision leads to an adverse outcome – most often these occur due to a weakness/ flaw in our complex system within the NHS and should be dealt with in a blame-free way using a risk management framework.

Never, ever attempt to minimise or cover things up – mistakes can be learned from, and systems improved, but dishonesty is more challenging to forgive.

Find your mentors and learn from them

This is simple – find those that nurture you, develop you, and those that challenge you. Heed their advice.

There’s often the bit of advice given about “becoming” your mentors. I don’t think this is true. The people that will act as your true mentors throughout training might not be like you at all, which is completely ok – but with their actions and support they will allow you to become a more rounded, shiny version of yourself.

Similarly, as you move into your role as an ICM registrar, you need to start acting as a mentor and a role model to some of the other doctors-in-training in your unit. Lead by example with your practice, setting expectations for professional behaviours and standards of care.

So those are a few ruminations on my experiences, which you may or may not find helpful as you enter this period of transition into ICM training. I wish you all the best in your training and I hope you all have the same positive training experience that I’ve been fortunate enough to find. In a nutshell, if you get to know your colleagues, use their expertise, ask for help, and always put the patient at the centre of care, you’re almost guaranteed to have a rewarding and successful time during training.