Dr Sean Ninan is a registrar in Geriatric and General (Internal) Medicine in the Yorkshire Deanery. Here he reflects on a recent report from the Royal College of Physicians on the role of the Medical Registrar and how it it compares with his personal experience.
I was on call a few weeks ago and was shadowed by some keen medical students. It was a busy day and I spent most of the day in the resuscitation area of the Emergency Department. There was a handful of patients with COPD and type 2 respiratory failure requiring non-invasive ventilation, a couple of patients with pneumonias and severe sepsis, one who was peri-arrest with anterior T wave inversion and one with S1Q3T3 on their ECG who had a massive pulmonary embolism, and a young man with ischaemic extremities, pleuritic chest pain and a butterfly rash…
The students loved it. They found it fascinating, exciting, intimidating and then…
“I could never be the Med Reg”
It has always been so, yet increasingly trainees seem to be put off by acute specialties and the burden of the general medical take at a time when acute services are under increasing strain.
In this context, I was particularly interested in the recent publication by the Royal College of Physicians “The medical registrar. Empowering the unsung heroes of patient care.”
The report looks at the changing nature of the role of the medical registrar and how this has been influenced in changes in the roles and responsibilities of other grades of doctor.
The increasing workload of the medical registrar is highlighted, as is the amount of “routine” and “non-priority” work that registrars do compared to previous generations. I, like many other medical registrars, enjoy managing complex sick patients, leading on-call teams and teaching junior doctors. But with an increasing workload, medical registrars are often required to do much of the “clerking.” I usually end up clerking more patients than the SHO when on a night shift. This is usually a necessity because of the vast numbers of patients waiting to be seen and perhaps when looking at doctors per patients clerked, my set of night shifts looks “productive” to organisations.
But what is lost? With most of our time spent clerking patients, there is little time for the “senior review.” This is usually where the medical registrar hones the details of the case and hopefully sorts out a comprehensive management plan. As an FY1 and SHO I gained much useful feedback from these reviews and during night shifts I would often spend some time discussing difficult cases with the registrar…..valuable learning time. Night shifts are much busier in terms of number of patients to be seen than they were even 3 or 4 years ago. Now the aim of most on call doctors is to “get through” and “count down” the shifts with little time for learning and discussion of patients. The traditional post take ward round where the night team present their patients to the on call consultant is also becoming increasingly rare. These are all crucial experiences for junior doctors that are being eroded.
I broadly welcome the report as I worry about the perceived unattractiveness of “being the Med Reg”. I did, however, note some criticisms on twitter with some comments from consultants who seem to feel that their increased presence on acute medical units means that registrars may have less to do than before. Many of the issues raised are due to changes in the nature and workload of the acute medical take that have occurred over the last few years.
I remember standing by a trolley in resus, writing in a patient’s notes when his wife asked me: “Do you love your job?”
I replied that “love” was a strong word but that I liked it! It’s more complicated than that of course. I sometimes love it, I occassionally feel like I hate it and mostly I like it.
I do have to say that being a registrar is, in almost all ways, better than being an SHO. These days my weeks are more varied with a mixture of inpatient, outpatient, teaching and acute work. I have finished all my exams, meaning that I have more time to do other things: like playing a proper role in clinical governance, publishing some articles and doing a PGCert in Medical Education.
Being the “Med Reg” isn’t always much fun, but it can be. It’s better than being the medical SHO, who gets bleeped constantly with A&E referrals. It’s better than being the SHO on ward cover up to their eyeballs in cannulas, catheters and drug charts in amongst the sick patients. It’s better than when you were a junior doctor asking the radiologist for a CT, hoping you didn’t get shouted at. People become much more polite to you when you are a registrar. Sad, but true. And it feels really good when you sort out patients, teach your juniors, explain things well to the relatives (because you now know what is going on and what to do) and get a pat on the back from your consultant. It’s also worth remembering that you are only “The Med Reg” around 20% of the time. The rest of your time will be spent in the specialty of your choice, where there is usually more opportunity for training than there was as an SHO.
So, medical students, don’t be put off! Try to go to clinic, spend some time shadowing a specialty registrar and speak to some registrars with a positive attitude before deciding what your career path should look like. Being the Med Reg is not that bad!
If you are thinking about becoming a medical registrar, have a look at my article in the BMJ.
British Geriatrics Society 
The RCP report into the state/plight/predicatement of the Med Registrar is an interesting, illuminating, disappointing and disconcerting read. As with any report, review or inquiry of this kind, there are good intentions to try and improve/highlight shortcomings, problems and deficiencies. The report was probably instigated by grumblings from present registrars and consultants, falling numbers of applications for the med reg post, the perceived drain of talent to GP land and feedback from ARCPs and trainee surveys. The usual old skeletons were drudged up:
· ETWD :- how this is impairing/limiting training and reducing clinical exposure
· MMC:- the experience that current CT1s get is very different and inadequate from the previous Medical SHO training [ lack of attendance in clinics, minimal exposure to managing sick patients in resus, level of clinical responsibility – as in some jobs there is no distinction between house officers and SHOs; lack of opportunity to make clinical decisions]. This does not bequeath them with confidence to act up as the Med Reg
· Too much Service provision as compared to training
· Poor work life balance:- compared to GP trainees/registars
· Lack of felixible training jobs
· 4 hour wait:- increasing workload and as per your previous blog post
· Onerous path to consultant as compared to GPS:- 2 years CT1 training, than 5 Years Registar level Training. 2 sets of professional exams:- MRCP + KBA+ need for research, and PHD – additional 3 year trainings
Some skeletons were not even addressed as presumably they were too scary:
· The lack of consultant jobs for these hard working Medical registrars to apply to. Things aren’t too bad in geriatrics as the speciality is expanding and at the moment you can generally get a consultant job but there are an increasing group of registrars post CCT and PHD who are awaiting for consultant jobs in the UK[ renal, cardiology]. The RCP is well aware that there is a mismatch between registrars nearing CCT and lack of consultant posts. They have highlighted possible shortfalls in consultant jobs in the near future.
· Lack of ability to choose where you are able to work. Nationalization of numbers means you could very easily be given a job in Manchester when u are living in London
· The muted creation of junior consultant role which sounds like the old senior registrar
In suggesting remedies, the report (perhaps quite understandably) was very thin on recommendations/solutions to exhuming the above skeletons as some of these skeletons perennially seem to be drudged on training reviews.
As a medical registrar, I find it very difficult to answer junior questions/career advice whether to embark on a medical career. I don’t thinks its enough just to say “ being Med Reg is not that bad”. The job itself is exciting, interesting and fulfilling but Lack of consultant jobs at the end, lack of flexible training, increased pressures and responsibilities, terrible work life balance all have to be weighed. Embarking on GP training is just 3-4 years to completion, having a great work life balance, good fliexibility in terms of training and ability to specialize in an area of interest. I mean what’s the point of soldering on through 10 years of training, exams and research and not really having a consultant job to go into or being faced with a move to distant parts of the UK or Australia or retraining into other specialities. Not an easy question to answer but one definitely for the RCP to ponder.