How to be a good registrar, part 1.

I know a few people starting this job next year and this is for them.  For those who don’t work in a hospital, a registrar is part of the clinical management structure.  The most junior is the intern (fairly universal in any place of work), a person who is two years out of medical school is a resident, and a registrar can be anyone who is in their third year or beyond.  It varies a bit between states, sometimes a third year out of medical school can be called a senior resident or senior house officer.  A registrar is someone who is embarking on a training program to become a certain sort of doctor – i.e. a surgical registrar will one day be a surgeon, an obstetrics registrar an obstetrician, a GP registrar a GP, and a medical registrar, a physician.  A physician then becomes any of the internal medicine specialties, i.e. a cardiologist, gastroenterologist, geriatrician, endocrinologist etc.  All of the specialties training programs are another 4-6 years after medical school.  It’s a long and quite stressful process!

So for those halfway through, here’s my take on what makes a good registrar.

  1.  Know your drugs.  Learn the classes of the most commonly used drugs and the important interactions with other drugs and diseases, i.e. thiazides and gout.  They’re easy to learn, easy to remember and for some reason, it really impresses the boss when you rattle off a list of dopamine antagonists and rage about all the haloperidol that person who is being investigated for Parkinson’s disease is getting.
  2. Write an issues list, twice a week if you can.  Not at the expense of efficiency though!  Bosses love your issues list and where you’re at for each issue.  Name the issue, the reason (if relevant), what the tests have shown, what tests are pending, and what the plan is.  No longer than a couple of lines though.
  3. Make DVT prophylaxis and resuscitation status their own separate issues.  This reminds you to write up DVT prophylaxis and NFR forms and again, the bosses think you are golden.
  4. Be certain about things as much as you can.  In residency they don’t like it when you’re overly decisive and opinionated.  Ask me how I know this!  But when you’re a registrar, if you have a good sense of what’s going on and sound certain when you say it, they love it.  Say it from the get go, instead of, ‘this lady presents with shortness of breath” and go into her history of symptoms etc, say “This 89 year old lady from home alone presents with pneumonia or likely pneumonia”.  It’s your job as the registrar to make an assessment.  It’s okay to be wrong too, that’s why you’re calling your boss – to offer your assessment, explain why you’ve assessed it that way and see if they agree or not.  If they don’t agree, that’s great!  It’s good learning for you, and they get to offer the benefit of their experience to you.
  5. Be honest, even if it humiliates you.  No, we don’t all do a perfect top-to-toe assessment of our patients.  We get busy, we skip a step, it happens.  If you’re boss asks you ‘what was their JVP, their corneal reflex, their Pemberton’s sign, their lid lag etc’ and you didn’t do it, say so.  Say “I didn’t do that but I can run back and do it now/re-examine them later”.  Even if they’re a bit annoyed, it develops trust.  It means that when they ask if you did something and you say you did, that you’re actually telling the truth.  Trust is hugely important in this game.  So man up and own up.
  6. Look after your junior but  do not do their job for them.  I have run the full gamut of interns and residents from the best to the very failing-internship worst.  Everyone has a different management style, if it’s halfway through the year or beyond I tend to give them just enough rope to hang themselves with.  I don’t offer to do anything for them, I tell them what needs to be done and when it should be done by, and I will suggest how to prioritise their tasks.  If they’re absolutely shockingly drowning I will sneakily do half of their jobs for them if I’ve got the time just to see the look of relief on their face.  I don’t do it too often, and most of the time they’re pretty good.  Make sure you tell them they’re doing a good job when they are, for some weird reason there’s not a lot of praise in medicine but I like to buck this trend by justifiably telling people when they are doing well!
  7. Don’t get too emotionally involved in your patients lives.  I am still learning this.  You do not have the emotional capacity to get involved with the lives of 15-30 patients a day or 4000-8000 people’s lives per year.  You will burn out if you try.  You’re not responsible for their disease or their situation – all you can do is help them as much as you can at this single timepoint in their lives, be caring and empathetic about it, and point them in a direction that is better for their health.  Lots of people complain about doctors being uncaring or the medical profession being evil, it’s not, it’s just too busy.   We all care, it’s why we did medicine, but there’s one of you and 4000-8000 people per year.  You can’t spread yourself that thin.
  8. Be nice to the emergency department.  Don’t be that doctor that bags out the ‘terrible ED’.  It’s low hanging fruit and pretty unfair.  I wouldn’t be an ED boss or a registrar for the world, their job is so difficult.  They have 50,000 people coming through their doors, unsorted, undifferentiated, and it’s their job to make an initial assessment, do some workup, and pass it on to you, all within about 3 hours. The higher up they are, the more people they have to supervise, and the juniors are always so variable.   It’s fine to ask for more workup if you don’t think it’s adequate – my baseline workup for a patient is basic bloods plus a CRP (not usually done but they’re always happy to add it on), a urinalysis, ECG and chest x-ray, plus or minus a head CT or blood cultures if it’s relevant.  If that’s all done or coming, don’t refuse to see the patient because some weird vasculitis test hasn’t been done.  DO refuse if the patient is in kidney failure and they haven’t imaged the ureters because that will be the difference between a medical and a surgical admission!
  9. We are all terrified of pregnant patients.  All of us.  Admit them if necessary, get O&G involved immediately, and make the midwives do dopplers/CTG/anything else that makes you worried.  Know about pre-eclampsia.  Don’t mind the midwives laughing at you because you’re anxious and terrified of Hurting The Baby.  And again, know your drugs, and check that they’re safe in pregnancy, and if they ARE safe, make sure the patient consents because not all pregnant women will consent to safe pregnancy drugs anyway.  Which is their right.
  10. Don’t diagnose a psychogenic disorder without specialist input, and ruling out absolutely every other disease it could possibly be.  And once you have ruled it out, don’t dismiss the patient as ‘putting it on’.  Psychogenic symptoms are real – the patient has no idea that they’re not.  For whatever reason they are unable to communicate their internal distress so their bodies are communicating it for them.  This does not happen on a conscious level and takes a lot of specialist psychiatric input, time, and trust from the patient to be cured or managed.  Be patient.

That’s it for now – I could write a book on this!