So you want to be a registrar...?
Dr Charlotte Durand
I’m now about to enter my fourth year as a registrar. Most of my time has been spent in the ED but I’ve also had some time as a paeds reg and an ICU reg. Around me, the senior residents are starting to plan to step up on the roster and it got me thinking about my experience of the same leap. Below are some of the things I would tell myself if I could go back to that first day on the job.
You’re going to feel like an idiot, but that’s ok. Give it three months.
Settling into a new job, whether that be in a new department or somewhere familiar, comes with a huge adjustment period. It usually takes me three months to start feeling comfortable and know how the department works. It’s all those little things like knowing which specialty teams are on call after-hours, whether there is a sonographer in-house the weekends, and how each boss likes to run the shift. Maybe you settle in quicker than I do, or maybe you take longer, but no-one is immune to this period. If you’ve stepped up in your local hospital some things will feel easier, but it can take time for the rest of the team to see you as a registrar and not as the resident you were last term. Give it three months.
2. Use this time to ask for help – you only get more senior and independent as time goes on.
When I arrived at my new job as a registrar I came from a hospital where nurse practitioners did most of the plastering and ENT complaints. I felt so inexperienced and already years behind where I should have been with those skills. But I had skills elsewhere, like in paediatrics and interpreting ECGs – the perks of recent terms in cardiology and some consistent paeds exposure. Everyone comes to the job with different levels of experience in certain areas, that’s just how it is. You don’t have to be afraid that people will “find out” you can’t do things without supervision. The first few times I had to put a cast on I just explained my situation and asked the boss to check my work. Nobody minded, the patients left with a cast that was done well and I felt supported and like I was improving my skills in a deliberate way. Don’t avoid your weaknesses, now is the time to work on them.
3. There is a skill to teaching juniors, with different methods for different types of learners.
Some consultants seem to be able to get the best out of you and make you really feel heard, seen and like you are learning. Other times, you feel patronised, micro-managed or totally left without direction. We all want to be able to be the good kind of supervisor to interns and residents, but when I first started supervising, I realised very quickly that nobody was going to teach me how to do the teaching. I bumbled on for a while before I found a few awesome resources that do just that! Have a listen or read the transcript from this podcast from EM Cases. I use these practices as much as I can to try and improve how I am with my team so they feel good about being on the floor with me and we can connect in a way that is both useful and non-traumatizing (I hope!).
4. Stop reminding everyone how inexperienced you are!
Ok this one is for the women who tell me they introduce themselves to the rest of the team every morning by stressing how junior they are. Look, I get it, I really do. But there’s a difference between transparency with your consultant (fine) and knocking yourself down a few pegs to the rest of the team before they day has even started (unnecessary). If you haven’t worked with people before, its reasonable to say, ‘because we haven’t worked together, I might review your first couple of patients and then as we get to know each other you can work a bit more independently.’ As a new registrar there is every chance that the person you are supervising has been a doctor for more years than you have, or who was your equal colleague in the previous term. Work together. Use their experience as an asset to the team, but don’t forget that you are in your role because you have the qualification, experience and knowledge to be there.
5. For God’s sake look at the requirements of your specialty – logbooks, procedures etc
In one of my recent training assessments my supervisor asked me if I was signed up for the dual training pathway that I’d been saying I was doing for the last 12 months. Turns out you actually have to register for it – a fact I would have known if I had looked on the website. There is a lot of information on there about what is due when, so don’t put it off because you might miss out on something important and end up being remediated i.e. having 3 months added to your training time for no reason.
6. Don’t ask nicely.
Ok this is potentially a controversial one, but something I have only started trying in the last 3 months and its WORKING. The first half of my early phase advanced year I got a few procedures signed off because consultants saw me do an intubation or I was assigned to a supervisor for a case discussion. I would occasionally ask if, maybe, if we could find time or there was a lull in patients (ha!) could we maybe please think about finding a patient for a CEX or a DOPS. New flash, there was never a good time because there IS never a good time in the current state of the health system and emergency departments across the country. Then I saw other people being signed off and meeting deadlines and not falling behind and wondered what I was doing wrong. Turns out, you can’t just sit back and wait for the opportunity to fall into your lap. These colleagues rolled in to work, said, ‘I need a DOPS today’ and made it happen. Since this realisation (and with heavy coaching from my mentors) I have had almost one requirement signed off per week because I am actively looking for and seizing opportunities as they arise. Every shift I am on consultants know I am looking for procedures and have thought of me when something comes up. The kicker is, none of these cases/skills are extra things. I do the procedures or manage the patient the same as always, but now I specifically tell people I’d like to use it as an evaluation and follow it up. People want to help you succeed, but the onus is on you.
7. Divide the year into segments with different goals
If you step up to ED Reg from being an RMO, you go from rotating to a new department every 10-12 weeks to spending 6-12 months in the same department. This is great for continuity and comfort but can seem like a loooong time doing the same thing. If I could have my time again, I would divide it into something this:
Term 1 – Settle in and get to know the department, how flow works and all the logistics
Term 2 – Focus on stepping up to running the resuscitations, do hands-on things as much as you can i.e. eye exams, casting, suturing, paeds cannulas, ultrasound etc
Term 3 – Teaching and education focus, supervising juniors on shift, doing some teaching and supervising others doing the skills/procedures you worked on in term 2
Term 4 – Real focus on finishing your WBA requirements
I think having a goal for each term gives me purpose and direction, which is important for my learning and skills development, so it might also be applicable to you.
8. Ask for mentorship
Some departments will assign you a mentor, which can be useful. Sometimes you will naturally gravitate towards someone or multiple people who you want to be more like or who you admire. Chances are, they have no idea that you think they are great and would be really chuffed to know you feel like that. Everyone is busy, so you need to approach them with a specific question or goal for the conversation, rather than just asking them to be your mentor. For example, I recently asked someone if they would mind talking through their experience with being in charge overnight and how to approach the busy ED nightshift in a way that is the safest. I received some wonderful advice, had a chance to build connection with a colleague and not feel like I was alone in my trepidation about nights in charge. It was invaluable advice and made me feel more skilled, more prepared and more supported going into my in-charge shifts.
9. You can learn things at home.
When I first started, I felt like I was standing on a riverbank on one side, looking at the senior registrars on the other side of the river and wondering how the heck they got there. It felt like a huge leap and almost impossible to know how to begin. People said ‘you’ll pick it up as you go’ but I didn’t know what and how I was meant to be looking for. I still don’t really know, but this is what I have found. You don’t go from having no idea about the anatomy of the thorax to whipping in a chest tube with your eyes closed. There are about a million steps in between. The good news is you can do a lot of the early steps at home. If we continue with the chest tube example – you can learn the anatomy, the procedure, the tips and tricks, the troubleshooting, the complications and the finesse of the whole thing from the comfort of your couch. There are so many excellent, reliable resources online for this exact purpose. By doing this learning and practice and mental rehearsal at home, you put yourself in the best place to be truly prepared for the time when the procedure needs to be done. The same can be said for leading a resuscitation, responding to conflict, de-escalating an agitated patient and almost every skill that we hone in the journey from junior to senior clinician.
10. The support systems are actually, well, supportive
I’ve been a part of some intense things in the last few years. Mostly it’s just things that are part of the hectic job we do and a good debrief with colleagues and friends can help you move through it. There have been one or two experiences though that have given me pause. Things where I’ve had a harder time getting back to my usual self in the weeks following. I decided to try the ACEM Assist support service that is run through converge international that offers free telehealth chats for those affiliated with the college. They also cover the ICU college and some other groups so sit outside of ACEM as a separate entity. The person I spoke to was kind, thoughtful and understanding. They helped me walk through the experience and supported me to take care of myself and my colleagues. This is not something that everyone would find useful, but for me it was just the right thing and I’d definitely use them again.
If you are reading this and you’re past this stage, I’d love to hear any additional words of wisdom that you would tell your first-year-registrar self. If you are about to step up, I hope some of these tips resonate and that you enjoy what is one of the most fun, exciting and challenging stages of your career. Don’t forget to be kind to yourself in the process!
Dr Charlotte Durand
“When I first started, I felt like I was standing on a riverbank on one side, looking at the senior registrars on the other side of the river and wondering how the heck they got there. It felt like a huge leap and almost impossible to know how to begin.”