Author:  Abhi Pal

 

What’s all the fuss about?

A Dummy’s Guide for the Partner or Friend of an adult or paediatric registrar who has just been through #RACPdebacle

Your partner or friend is in tears and heartbroken because they were unable to sit the exam on Monday due to an IT malfunction. You found out on Wednesday that the resit has been organised for 10 days time. What’s the fuss all about? A resit is not the worst thing in the world and it is like a trial mock exam. Doctors seem to be doing exams all the time, why is this one any different?

 

When I was an intern, I thought medical registrars were amazing people – I would look up to them and everyone knew they were the smartest people in the room.  If a medical registrar said something, everyone listened.  They seemed eternally capable, tough, experienced, unbreakable and they were confident.  Clinical medicine was a frightening world with full of deteriorating patients and in some way, those clinical attachments at medical school were not quite the same.  Medical registrars were a source of calm and inspiration.  They were all a bit nerdy, interested in fitness, and ranged from very stressed to mildly stressed.   I knew if I was called to an arrest, a medical registrar would arrive and save the day.

Fast forward six years and now I’m a medical oncology registrar – looking back and across, I still think medical registrars are amazing people.  Every registrar I know loves their job in some deep and specific way, and walks around with about thirty things they think could be done better in their profession.  They work unpaid overtime, spend their weekends doing research projects, enjoy teaching their junior staff and love complaining about the college.  I have enjoyed my time in specific ways and I completed my exam in 2016. 

 

My wife is a paediatric registrar and for the last six months, I have been attempting to provide high level care for my wife as she has sacrificed time with family, her friends, her own interests in order to study for her written exam.  She, along with many other trainees, sat the exam on Monday, only to find out that the exam was called off.  She was disappointed like every other adult or paediatric trainee that day – the outpouring of grief and distress is evident in the Guardian, SMH, Twitter and Facebook.

Sometimes medicine can be opaque and adult and paediatric medical registrars can appear like minor demigods (or at least act like them) in hospitals so here is a rough outline as to why they might look a little bit stressed before the exam and why they are all quite stressed after the recent exam cancellation.

  1. Being allowed to turn up to the exam – Getting a junior medical registrar job is not a simple task and requires prevocational trainees to perform their clinical duties and then find the time to do research, higher degrees, quality improvement projects – just when you start celebrating getting that junior medical registrar job you realise that you now face these two enormous hurdles, the written exam and clinical exam. You must have done three postgraduate years in medicine with the appropriate rotations to be eligible to sit for the exam.
  2. Preparation for the exam – you quickly realise that you are expected to find a study group, and put in a significant amount of time into preparing for the written exam. There are hours of online lectures, online question banks, lectures provided by the hospital, a weekly study group of about 4 – 5 hours is almost mandatory, and then it culminates in a two week intensive course later in the year. 
  3. Sudden and expensive death – The exam is held once a year and costs $1800 to sit. Registration for the RACP costs $3500 per year, the intensive study courses costs $2000.   The exam is tied to employment and failing the written exam will actually lead to the candidate having to re-apply for their job, and usually networks will have difficulty in re-hiring candidates who have failed more than once due to workforce requirements.
  4. Doing a full-time job and then studying on top of this – Being a medical registrar is not easy. Adult and paediatric trainees have to do night shifts, on call shifts for subspecialties (being woken up in the middle of the night and then being expected to come to work the next day), rural rotations where they are taken away from their friends and families.  The first year of being a medical registrar is ironically the hardest because the responsibilities are the same but it is the point of least experience and knowledge.  Trying to climb a steep clinical curve and a steep knowledge curve is a challenge.
  5. RACP – Every trainee has been affected or knows someone who has been affected by the RACP’s extremely strict policies.  They have strict policies around registration deadlines, submission of forms and paperwork, and penalties do apply.  Specialist medicine is a demanding field and the RACP maintains the highest standards for the reputation of the profession, and in this process, it has seen fit to be vigorous in implementing extremely strict guidelines with regards to trainee’s progressing through their training.
  6. Life events – Junior medical registrars routinely plan life events and holidays around their written exam – their lives, their partner’s lives become focussed around the examination dates.  Rescheduling the exam is not that simple – a BPT I worked with had planned an overseas holiday with his wife and son, and now is going to cancel that holiday so he can give himself the best chance at passing that exam.
  7. If the above points 1 – 6 were not enough pressure, keep in mind the following points that every BPT is also carrying with them
    1. If they pass the written exam, then they become eligible to do the clinical exam which is a one day long “live” examination with real patients in another state, and being examined by multiple senior consultants on history taking, examination, synthesis and management. This is equally frightening and nerve wracking, and costs another $2000.  Great candidates can fail this exam just because they have a bad day.  Once again this is a sudden and expensive death situation, with the clinical exam being held only once a year.
    2. If they pass the clinical examination, then they become eligible to apply for advanced training. Surely if they have survived the previous challenges then they will easily obtain an advanced training job? No.  Especially in competitive fields like cardiology or gastroenterology, trainees can miss out on training positions altogether, or may have to do the first year after BPT as an unaccredited year outside of a training program.
    3. Advanced training is another three year period of training in the specialty of choice and carries its own burdens of on call responsibilities, an increase in level of clinical responsibility and rural rotations as well.
    4. Surely at the end of advanced training, they will obtain a job as a consultant? They have just had 10 years of a series of difficult experiences.  The answer is again No. At this point they will have the letters FRACP after their name, but that does not mean they will get a job.  Most newly minted FRACP will likely do an overseas fellowship or a research degree and then, and maybe then, they will obtain that coveted job they have been working so hard for much of their adult lives.

 

 

If you put the above seven points together, you might come close to realising why that person you care about is going through a difficult time.  This is not just another exam, this is not a simple resit – for most trainees it will be the highest stakes exam they have sat, the exam they have prepared for over a year for, and an exam that has had impacts on everyone they care about.  They are on a path to becoming a specialist physician, which right now, is one of the longest and  toughest paths to follow in medicine – they have jumped through so many hoops such as getting into medical school, getting through medical school, getting through internship, residency and getting a job as a junior medical registrar. And they know they have so many more hoops to jump through.  To have something as simple as the opportunity to do the exam be taken away from them is deeply unsettling.

 

What can you do to help a trainee who has been affected by this?

My wife went through this on Monday and I was a personal witness to the months of sacrifice, preparation, anxiety, self doubt she put into this exam.  It is now Thursday – the resit date has been set for March 2nd, and there has been mention of a supplementary date.

I think acknowledging the multiple and varied feelings that trainees might have is crucial

  • Anxiety about the resit exam and whether they will remember everything they had just carried to the exam on Monday
  • Anger at the RACP for the failure to deliver the written exam
  • Loss of opportunity (planned holidays/weddings/family events)
  • Relief at having more time to prepare

It is not as simple as “don’t be angry, move on” or “just do the resit” – if you paid attention to the flowchart, adult and basic trainees have invested far, far more than just their professional identities into their profession.  This is their life and they have involved their entire support network in their decision to train to become a specialist physician. Listen to the stories, be with people and ask how you can help them.

Keeping things in perspective is important – in the acute aftermath of a traumatic incident it is almost unreasonable to ask people to maintain perspective, but in the overall scheme, finding a way through is vital.

 

The amount of support my wife has received from her network was excellent, and seems matched by the social media response.  The loud and strong support from senior clinicians on Twitter has been astounding and I know that not all junior doctors find themselves interesting enough to open up a Twitter account so I have picked some of my favourite pieces that pave the way forward for trainees who have been through the #RACPdebacle

 

Chris Elliot‏ @drcelliot Feb 18

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Bethan Richards‏ @BethanRichards3 Feb 18

 

 

 

 

Winston Liauw gives a different take on the matter and tries to find a message for trainees from an almost entirely negative experience and reflects on the consequences of poor planning in digital health and the experience of terror that trainees went through – The @TheRACP Physicians Exam Debacle as a Teachable Moment for Future Health CIOs

In short think of the BPTs around you who have been through this experience, be kind to them.

This outpouring of grief and sadness is also a good opportunity to reflect on the level of involvement that trainee doctors put into their own education, and the level of emotional commitment that junior doctors have for their training.  Medicine is not a 9 to 5 job, it is a vocation, it takes over our lives at least temporarily, and each of us makes sacrifices for it.  This RACP exam failure has accidentally shown everyone, albeit briefly, just how significant the sacrifices are – this outcome is not just a result of the IT failure on Monday, but also the way the examination is set up and the nature of our training.  Would there have been this reaction if the exam was held four times a year? Would this have been the reaction if the examination did not cost each trainee $2000? Would this have been the same reaction if junior medical registrars had less stressful roles? We should hold on to this moment, look at it carefully and use it to advocate for positive change to make it easier for future junior doctors who will think about becoming a specialist.   For now, when you see that medical registrar who has just been through this experience ask them how they are going.  We are trained to show empathy to our patients but we are not trained to show empathy to each other, and this is as good a time as any to start practicing this.  For the adult and paediatric trainees who have been through this experience, know that there is a significant amount of awareness about mental health issues and medical registrars, and know that there is support all around you.

Your consultant

Director of Physician Training

Your Advanced Trainees

 

 

Useful resources

Doctors’ Health Advisory Service

Employee Assistance Program

Lifeline

RACP Support Helpline

RACP Converge Line 1300 687 327

For direct information, you can email the examinations committee at RACP at [email protected]

 

 

Reviewers:  Chris Elliot, Elie Matar, Evangelie Polyzos, James Edwards