Author: Ken Liu
Editor: Paul Hamor
Here at onthewards.org, you will find numerous useful podcasts and blogs on how to survive internship, career advice , how to improve your CV and interview tips, all of which prepare junior medical officers (JMOs) for obtaining that next job. But what happens when you finally get there and obtain that registrar job? How do you transition from being a JMO to being a registrar?
Registrars are not just more efficient versions of JMOs
Just like paediatricians often say “children are not just smaller versions of adults”, registrars are not just more efficient versions of JMOs. Indeed, there are many overlapping qualities required to perform well in either position such as organisation skills, time management and prioritisation, ability to take initiative, effective communication etc. However, since the registrar plays a different role on the team to that of the JMO, he or she must acquire a new skill set. This blog will focus on some specific attributes which are helpful for being (or becoming) a good registrar.
The job of a registrar is a heterogeneous one. Registrars across different streams of hospital medicine face different situations and pressures which may require different skills to handle these. Therefore, the following tips have been kept general and applicable to most hospital registrars. While these tips on being a good registrar are not exhaustive, they are certainly things I wish I knew when I first became a registrar. Best of all, you can start working on them now as a JMO.
Tips on being a good registrar
1. Your job is to be the consultant’s representative for the management of his or her patients
While the treating consultant holds ultimate responsibility for the patient, he or she cannot always be present. Therefore, the job of making decisions for the patients on the consultant’s behalf falls on the registrar. Decisions may relate to:
- Diagnosis (“From my assessment, I think this patient is in pulmonary oedema”) or
- Investigations (“Please order him a chest X-ray”) or
- Management (“Please give a dose of intravenous frusemide 40mg”)
The registrar plays a more active role in the team compared to their previous (largely) reactive role as a JMO. Some new registrars fail to recognise this new responsibility and continue to fulfil the role of a JMO on the team (something they are comfortable with) while they wait for the consultant to make decisions. This reduces the efficiency of the team.
While your consultant wants to know about problems that arise with their patients, they also want to know that a plan is in place. For example, a consultant would rather hear:
- “Patient X has developed a fever and peritonism post colonoscopy. I have kept him nil by mouth, started intravenous fluids and an initial dose of antibiotics while we wait for his urgent CT abdomen/pelvis.”
- Instead of: “Patient X has developed a fever and peritonism post colonoscopy. What would you like me to do?”
Indeed, it may not always be clear to you what the plan should be. Therefore, your decisions (especially the important ones) should be made after discussion with your consultant. Even the smaller decisions you make on your own should be in line with the consultant’s overall plan for the patient (hopefully clarified from previous discussions and ward rounds). The start of each term as a registrar is spent deciphering what each consultant prefers to do in different situations. Remember that being a registrar is a training position. Your decisions may not always be the correct one, however if they are guided by what is best for the patient while recognising your own limits, then harm should not result (see point 2).
It may take some time and reflection to adjust to your new role. Aim to minimise other stressors during this period of transition. For example, you may wish to delay studying for your exams for one month until you have settled into your new role.
JMO tip: You can practise making decisions like a registrar now.
- Try putting yourself in the registrar’s or consultant’s shoes on ward rounds. Before they suggest a plan, think to yourself “What would I do for the patient in this situation?”
- Offer to see ED referrals or consults for your registrar and then report your findings and recommendations to them
- Offer to take the pager and handle phone calls for your registrar (especially if they are in clinic or performing a procedure)
- On after-hours shifts, devise your own management plan for the patient you have just reviewed before calling the after-hours registrar
2. Back yourself but know your own limits
Since almost all registrar positions require a selection process, you have therefore been chosen for the job and entrusted to make decisions. Your prior experience, knowledge and skills have earnt you this role and these same things should give you confidence in making decisions for the patient. As your experience, knowledge and exposure to different situations (and consultants) grow, so will the scope and confidence of your decision making.
Patient safety should always come first. Therefore, it is important to know when you have reached your limit and ask for help. Note the limit of your own capabilities as a doctor (different for everyone) and the limits of your designated role as a registrar might be different – you should stop at whichever comes earlier. For example, you may be comfortable and willing to withdraw active care for a deteriorating patient and begin palliation, however this decision should be made by the treating consultant. Similarly, if the consequences of your decisions (however logically sound) can expose serious risks to the patient, you should also check with a senior before proceeding.
Asking for help or advice is not a sign of weakness or stupidity but rather a sign of maturity and humility.
3. Learn to delegate – You cannot (and should not) do it all yourself
The decisions you make will often generate tasks for the JMO on your team. As it is no longer your primary role in the team to perform these tasks, you need to learn to delegate.
a) Give clear instructions
In order to avoid communication errors, give clear instructions when you are delegating tasks to your JMO. A good way to achieve this is to provide the reason, timeframe and alternative for each task.
For example, the original instruction may be “Can you order an abdominal ultrasound for patient X?” However, a clearer instruction will also add:
- Reason: “Since she is jaundiced with cholestatic LFTs, I am looking for evidence of biliary obstruction.”
- Timeframe: “Can you try to get the scan by midday so that I might be able to add her to our ERCP list this afternoon?”
- Alternative: “If you can’t get the ultrasound done this morning, can you see if you can get an abdominal CT scan instead?”
By doing this, you have now equipped the JMO with an understanding of the context, urgency and ability to troubleshoot for this task.
b) Do not assume that the tasks you have delegated will all get done
Your role as a registrar is not only to make decisions but also to see them through. If an important task is not done correctly or not done at all, the responsibility rests with you. It is useful to perform paper rounds* regularly throughout the day (e.g. one after your ward round, one later in the day and one at the end of the day). This will allow you to see where your JMO is up to with their tasks and whether they are having difficulty or require assistance. The paper round will also provide an opportunity to confirm that the JMO has understood your instructions (i.e. close the loop).
c) Be a team player
If your JMO has a heavy workload and you have time to spare, you should offer to help instead of going for a coffee break or going to the library to study. Registrars are probably best equipped to request consults from other teams or scans from radiology – tasks that take JMOs significantly longer to complete. It should not be beneath you to rechart medications, write in the notes, order investigations etc. Remember that you are working as part of a team. However, doing all the jobs for your JMO will not allow them to grow. Where applicable, you should also find ways to improve their time management and work efficiency. If you do have a consistently struggling JMO, it is best to flag this early. The problem is often multifactorial and time is required to investigate and rectify the situation. It may be wise to also consult other staff such as the JMO’s term supervisor or Director of Prevocational Training (DPET). It is not productive (for you or the struggling JMO) if you deal with it by simply taking on the extra workload of the JMO without addressing the underlying problem(s).
Some other tips for JMO welfare:
- Checking they have eaten lunch
- Prioritising their attendance at teaching
- Thanking and acknowledging them when they have done their job well
JMO tip: Practise by delegating small tasks to medical students attached to your team, particularly during PRINT. Get into the habit of going through a paper round with your registrar.
4. Each term is what you make it
Do not underestimate the value of on-the-job learning. Your training is not about passing exams, but rather shaping you to become a good physician/surgeon/intensivist/anaesthetist/psychiatrist/etc. Even so, in the FRACP written and clinical exams, candidates often find they perform best in the topics or clinical cases related to a term they had previously completed. Therefore, “cruisey” terms are not necessarily the best. Do not rush to the library at the earliest opportunity when your tasks are done. Check if there are opportunities for extra learning such as helping out with a clinic, attending a procedure or theatre list, etc. This will also help in making a good impression with your consultants and term supervisors.
JMO tip: After finishing your tasks, you can attend some of these extra learning activities.
5. Be comfortable with after-hours situations
Depending on where you work, you may be the most senior person in the hospital during after-hours or night shifts. Although support is available, it is usually less accessible during these times. Therefore, it is helpful to be familiar with handling commonly encountered after-hours scenarios. Whilst it is not possible to prepare yourself for every potential situation, thankfully, the common scenarios occur repeatedly. Be aware of avenues to escalate the situation if required (especially if you are rural), such as how to get an ICU review or transfer to a more specialised centre. Know how to recognise, investigate and manage the deteriorating patient and be comfortable with running an arrest call.
JMO tip: Attend an after-hours shift with a registrar to get exposure to common problems that arise and learn how best to deal with them. You can also supplement this with book learning. Attend an Advanced Life Support course prior to becoming a registrar.
6. Health and balance
It can be easy to let work and/or study consume you. Remember that you will not be effective at work (in the long run) unless you maintain your health and a proper balance with the rest of your life. This might include:
- Getting enough sleep
- Scheduling time for exercise, social activities, friends and family
- Making time to see the doctor if needed
- Using annual leave for holidays rather than study
It is also important to look out for your colleagues who are having a difficult time. Help them out by picking up an after-hours shift, sharing study notes, or even with just a kind word of encouragement. Being a registrar certainly comes with its challenges and there may come a time when you yourself will come to rely on the kindness of others.
Although much focus is placed on helping medical students with their transition into internship, we should also remember another transition is just around the corner, when a JMO becomes a registrar. I hope these tips will help JMOs with their own transition into the rewarding role of being a registrar.
*A paper round is an activity where the members of a treating team discuss their list of patients along with each patient’s current situation and tasks required, without visiting the patient’s bedside.