This is an abridged version of an unofficial guide I wrote to assist RMOs on the cusp of becoming Registrars in our Emergency Department. It represents my opinion and suggestions in making the transition from RMO to registrar that I have developed in consultation with other registrars and ED staff. It is not to be taken as completely true, nor as the opinion of the department or hospital.
It has been a few years since I made this jump myself, and my only memories of it are that being a registrar was a very different role, with more responsibility and accountability. I recall thinking back wistfully to the carefree RMO days gone by, but I got over that fairly quickly.
Serving suggestion: pinch of salt and a stiff drink.
Well done, you!
This is a great step of glory and privilege, that will lead you down the path of enlightenment.
Most of you will be “graduating” from the Resident Medical Officer (RMO) group; this guide is written just for you. It is time to shed the shackles of your RMO years and look ahead into the great beyond of Emergency Medicine.
The first thing to say is that the registrar job is very different from being an RMO. It requires a different mindset and perspective, as well as a higher degree of clinical knowledge and acumen (or so we like to think). You have responsibility for the decisions made, not only by yourself (where the expectations are higher), but by those junior medical colleagues who will be looking to you for guidance, and writing “as discussed with Dr....” in the notes.
Your time on the floor will be increasingly taken over with hearing case presentations from your colleagues of varying vagueness (on the basis of which you are expected to make decisions), reviewing the neverending sequence of ECGs thrust in front of you (once your registrar tag is spotted), dealing with nurses' concerns about potentially deteriorating patients, questionable management plans and bed flow, managing the staffing and bedspace resources in the department, and maybe even seeing a few patients of your own. To quote a recent registrar, you must be more focussed and on the ball, and that means no more hangovers at work.
There are a few important changes in perspective that should be mentioned about the transition:
- Make sure no-one dies
It may sound simple, but as a RMO the focus can be more about making sure everyone is seen, whereas as a registrar you need to be able to spot which patients are genuinely sick or undifferentiated and need further attention. This is mainly done through the stories presented by your colleagues, so you also need to be able to identify which junior colleagues you completely trust with a sick or undifferentiated patient, and those where you need to get more involved.
- Stepping up = more supervision
When the department gets busier, and workload increases, often the way you can improve the situation as a registrar is to increase your level of supervision rather than taking on more patients yourself. Personally taking on more patients can worsen departmental flow as you become less available to supervise and direct juniors, and your own patients are more likely to have delayed disposition due competing demands on your time. You may still want to quickly cast your eyes on patients who need urgent attention, and then allocate someone to be the treating doctor.
- Maintain situational awareness
You need to keep good oversight as to what is happening in your department, especially on nights, when there are no consultants. Keep an eye on how busy each area is (and consider redeploying staff to busier areas), who is waiting (does anyone's triage note make you concerned about how long they'll be waiting?), and who is working or not (where is that intern? They've only seen 1 patient in the last 2 hours). Also, take care of your colleagues – make sure your fellow registrars are travelling along ok (is your resus reg drowning in there, even if they are a “senior” reg), have your fellow registrars and juniors had their meal breaks? Is anyone appearing stressed or overwhelmed? Communicate with your nursing friends about these issues as well.
So why would you want to get yourself into all of that?
Because you love emergency medicine, and you want to improve your skills and knowledge. As a registrar you'll:
- See more interesting things – all of those resuscitations, for starters, as well as a larger number of cases crossing your path as you supervise, and being able to cherry pick some cases as they come in
- Do more interesting things – in resuscitation and trauma, more procedures and new skills
- Have more autonomy to make your own decisions and plans – it's scary at first, but you'll learn to embrace it
- Learn to delegate and manage people and a department
- Use your new title to influence people and gain more respect
- Be on the path to emergency medicine specialisation
Preparing To Be A Registrar
Hopefully, you will have received some degree of advance notice that you are being considered for “promotion” to the registrar roster, or perhaps you just think you're good enough for the job. Either way, you've got your hands on this advice now, so it seems you're ready to start preparing for the job.
There are a lot of expectations as a registrar beyond good clinical skills at the bedside, but these also need to be at a high level. Consider using up some of your hard-earned Professional Development funds (or at least rack up some tax deductions) to do some courses, such as ALS2, EMST or ETM.
Get involved in the FOAM (free open access medical education) movement and all of the great resources available about emergency medicine. Life in the Fast Lane is a great starting place (sign up for their regular review), as well as following #FOAMed on twitter. You'll soon build up a list of resources to follow, and maybe you'd find Feedly a good way to aggregate the websites (search for FOAM). This is also a good way to keep up to date on the literature. Of course, also keep an eye on our website for topical updates and teaching resources.
You will be reviewing a LOT of ECGs. Many, every hour, of every day. Once the nursing staff know you are allowed to sign them, they will track you down. You can try losing your red tag, but they'll still find you.
Most of the ECGs are normal, and most people can spot the ones that are grossly abnormal, so you will need to start getting good at the ones in between. All of those classifications (Sgarbossa, criteria for LVH, types of heart block, bi- or trifascicular blocks) and eponymous syndromes (Wellen's, Brugada, WPW) suddenly become a little more important. Repeat ECGs and dynamic change over time are also important.
So now is the time to start a little self-directed learning in the area. These are some good resources:
- Chan's ECG in Emergency Medicine and Acute Care – the recommended ACEM textbook
- Amal Mattu's ECG videos
- Life in the Fast Lane ECG compendium and guide
- Dr Smith's ECG Blog
If you're uncertain about an ECG, ask someone else to have a look at it as well. Or ask for a repeat ECG, and hope someone else has to look at it (they won't, the nurses will come back to you).
Life (or death) in the resuscitation rooms can be a completely new experience for a new registrar. As an RMO, there is limited exposure to all of the good stuff that happens in there. The only opportunity is really when you're doing the “circulation doctor” role, so start using it to your advantage (our resus team includes an RMO who is the allocated circulation doctor for a shift). Shed the paradigm of just sticking in a needle, running a gas, and then running away. Get involved in the cases, offer to take over some cases, be involved in the discussions and decision-making process. Make it clear that you are interested. Do more procedures. Ask questions of the consultant and registrar about the decisions being made and the management being used, extrapolate cases to more general questions about resuscitation.
Think about a list of common (or uncommon) things you see in resus, and start generating an approach to each of them: the patient in cardiac arrest, shock, respiratory distress, unconscious, agitated or major trauma. Having a structured approach takes some of the initial fear away. You could see if this video helps you.
The other side of resuscitation is team leading and management. This is also something that requires conscious effort, and often forcing yourself to step outside your comfort zone to take a vocal stance and leadership role—consciously extroverting yourself. Again, watch how others are doing it and see what works in general, and what would work for you. You might find Cliff Reid's talk on Making Things Happen a good introduction to this.
Most of the time, there will be a consultant around who will be doing a lot of the departmental management, but as a registrar overnight it will be your responsibility. As mentioned before, it is mainly important to just keep some situational awareness of how the department is falling apart (not just noting that it is). A lot of the time it's about making sure all of the areas are running smoothly (or at least suffering equally), but there is an increasing amount of time required to manage the flow of patients, bed state, and boarding of admitted inpatients in the department.
There's a lot of “behind-the-scenes” departmental management day-to-day, that is becoming a little less behind the scenes, and it is worth starting to get your head around it. A lot of it revolves around workload and capacity and ensuring bed flow to allow for this.
Being A Registrar
Hooray! You're now a registrar! Time to crack out the champagne and get into the detail of what it actually entails day-to-day.
Clinical Shifts and The Roster
There is likely a different roster and shift system for registrars compared to RMOs in your department. You probably should get to know the differences so you don't turn up to work 3 hours late (or, even worse, 3 hours early).
Your first night shift as a registrar may be a source of consternation and concern, as you head in to run your area of the department as the senior doctor, and the weight of all decisions resting firmly on your shoulders. It is important to remember that there is at least one other registrar there to help out (at least in our department), as well as a consultant on the end of a phone. If you are not, your other registrar will be airway competent and experienced, or a system in place for patients requiring urgent intubation.
The first job of night shift, as with being an RMO, is to allocate the roles for the night, if they are not already allocated. The number of registrars rostered on at night will effect this, but the basic roles (in our department) to be covered are Area A/Majors (aka big boss), Area B/Minors and Resus. Each role has its challenges. While it may make sense to have the airway competent person in Resus, this leaves the more junior registrar to run the rest of the department, and also reduces exposure to Resus. I would suggest that once you’ve had a couple of daytime Resus shifts, you should be taking on some night Resus (calling for help early if required).
The second job of the night is to take handover from the evening registrars, who may be a little interested in going home on time. Don’t dive into seeing new patients. If you’re in Area A overnight, you will likely not personally pick up many patients at all—mainly just “quick sort” type presentations—because most of your time will be taken up with supervision, ECGs and departmental management.
As resus reg overnight, you may be busy, or you may not. If not, try to work out where your presence would be most useful, and your absence (when a resus arrives) not too detrimental. You could progressively cover each area so that the other registrars get a break, while making sure a registrar is available for juniors, nurses and the all-important ECG.
As always, number one goal is to make sure no-one dies (unless that is the plan). Make safe decisions including investigating and admitting when you are unsure what is going on. Use your fellow registrars as well as inpatient team registrars for advice. Call in speciality units when they are required, don’t leave it until morning. And, at the end of the day (or night), if someone is not quite ready for discharge, but maybe doesn’t clearly need admission, then use your department's short stay ward.
Try to go through the patient list at around 6am. This gives you 2 hours to ensure all of the patients have a plan, to refer to inpatient teams, to chase up important results or to plan their discharge. At the morning handover have some sort of plan for each patient. If someone is waiting for a test result, give a plan for each possible result. You do occasionally get a patient that you have no idea what to do with, that is okay. Complex patients tend to come at night. That, and the brain does slow down a bit at around 5am.
Supervision Of Junior Staff
One of the biggest changes in your role is now being an esteemed supervisor, guide and mentor to junior staff. In fact, this will become the main role you have, the more “senior” you become. You will become a “Senior Doctor” on HASS (our antiquated Emergency Department Information System), and should make sure you click your name into this box as you discuss patients – this will let you, and all other senior doctors, know which patients have been discussed and reviewed.
In addition, make good use of the clinical comments field in HASS. As you discuss a patient and develop a plan, put this in the clinical comments (maybe even a brief summary of the presentation). This will help you remember the details, and helps the junior and nursing staff all know what is going on.
Supervision skills are a bit difficult to directly teach – everyone will have their own style. You will likely be influenced by the supervisors you have had in the past – think about which ones you respected, and what did they do to achieve that? And the others?
For what it's worth, my bits of advice on “what to be” are:
- Be approachable – you want your juniors to feel comfortable coming to you in good times and in bad. You also want them to be able to discuss with you when they disagree with your plan.
- Be nice – make sure that you're not the reason someone goes home and cries into a glass of wine that night.
- Be prepared to listen – to long stories with variable coherence and direction. Redirect as needed. I find recapping the crux of the story helpful to make sure I've got the gist of it (especially if I've vagued out for a bit in the middle).
- Be sure to use all available information – ask the presenting doctor to bring the patient folder (and risk the ire of the nurses if they don't return it promptly). Make sure you check the nurse-documented history, the vitals, the ECG, and, importantly, the ambulance record sheet. These bits of collateral information are often overlooked and may identify the patient that needs a more urgent review (or a doctor who is not quite thorough enough in their assessment).
- Be prepared to review patients – I almost called this “be sceptical”. We all know how patients' history and examination findings change with time and different doctors, so if something does not compute, sounds concerning, or you have doubts, make sure you get up and see the patient yourself. One consultant once termed it “Trust, but verify”.
- Be sure to follow up results – make sure that critical results are actively chased, even if it means checking yourself (when you get a chance). I also always look at imaging and lab results myself, rather than put faith in the “it's all normal”.
- Be encouraging of diagnosis and plan formulation – let your juniors work out for themselves what they think is going on. I encourage a differential ranging from the simple to the catastrophic for even the most obvious and benign presentations. Amal Mattu gave a talk in which he encouraged discussion of Lions & Tigers & Bears (oh my!): which differentials could kill this patient in the next 5 minutes, 5 hours or 5 days? I then prompt for a plan that will differentiate and treat the differentials.
- Be aware – know what's going on in your department, who is working (or not), and where each of your juniors is up to with their patients. Occasionally check in with each for an update, especially if you haven't seen them for a while (or have been letting them cruise, since you trust their abilities). I run through the list on HASS fairly regularly to make sure I know what's going on, often in order of arrival time so I can easily spot which patients are taking the longest to be sorted. It is easy to lose track of time, and then, suddenly, a patient has been in the department for 6 hours and nothing has been done.
- Be supportive – let people know that you appreciate their work and help, and provide positive feedback (that includes everyone you work with). Make sure you look out for others' wellbeing – are they ok? Have they eaten? Are other things impacting on their work?
- Be an educator – you are now the font of all knowledge, so be generous with it. Use what you have learnt to help improve practice (for instance, the indications for CRP), give summaries on diseases and treatments others have not come across before, explore an otherwise banal case with a “what if...” scenario. Make sure people get to see interesting cases, radiology or results, encourage people to do or observe procedures they have not done before.
- Be decisive – you are the decision maker in the team now. But you do still have other registrars and consultants to discuss with too.
- Be directive – sometimes you'll need to use your rank and position and direct your “staff”, especially in busy times. It may feel uncomfortable, but sometimes someone needs to be told to go see that patient that everyone has been avoiding.
- Be calm – others will feed off your demeanour. If you're calm, it is likely others will follow suit.
Dealing With A Busy Department
At the end of the day, nothing too much should change in your practice in the face of a busy or overcrowded department. You will need to have a heightened awareness of what is going on, and be aware that critically ill patients often get missed or under-treated during these times. Really, the main points during busy times have all been said before:
- Maintain a situational awareness
- Step up your supervision, review sick-sounding patients, chase up doctors for updates and follow up critical results
- Make sure everyone is taking care of themselves, getting their breaks, and not being overwhelmed
- Keep it safe and make sure noone dies
- Be calm
The bulk of the time, the consultants will be dealing with the politics and logistics of improving the situation. You can help by identifying patients you discuss or review that could be moved elsewhere (home, waiting room, short stay, overflow areas, wards), and liaising closely with your area's Team Leader and the shift coordinator to achieve this.
Tips And Tricks
These are some random thoughts from a variety of sources that may offer some support in the role of registrar. They are offered unqualified, with no guarantee of validity:
- You have supports! There are always other regs, and, most of the time, consultants to back you up. You should also make sure that you support others.
- Keep an eye on your time management – it's easy to lose track of your jobs, especially when it's busy and/or you're in resus. One of the main areas that suffers is documentation, so start writing up as soon as you get a chance, even if you know you won't have time to write the whole story.
- At the start of an afternoon shift, make sure the registrar you're taking over from knows you've arrived, and send them on their lunch break.
- If you are uncertain whether you should do something (eg a CT or admitting a patient), it normally means that you probably should – there's obviously enough doubt in your mind that would not be satisfied if you didn't, unless you can get advice from somone who you would trust if they persuaded you otherwise.
For reading this far! I hope it has been helpful.
Thanks, also, to my colleagues and fellow registrars for their tips and suggestions for this guide, and for making our workplace worth working in, and, hopefully, one in which new registrars feel comfortable and well-supported.